Injuries indicative of physical and possible sexual abuse of a 7-year-old boy in May 2019. Learning includes: practitioner knowledge and beliefs about children and families from different ethnic groups or migrant backgrounds can influence their ability to address children's needs; when a school records safeguarding concerns in the CPOMS electronic system, used by many schools, to report, record and track safeguarding concerns, they should notify key professionals and record any discussions and plans made between agencies; the need for clear terms of reference for safeguarding teams in schools; seek out information about significant people in a child's life in order to recognise risks posed by some men; information about commissioned services proposed by schools should be provided to parents; designated safeguarding leads should have access to opportunities to develop their practice; well-kept records in schools are vital to keep children safe; professionals need to be supported to remain curious about children's lives. Recommendations for the safeguarding partnership include: assurance sought through the local workforce safeguarding strategy, that agencies provide briefings and access to training supporting culturally competent practice; seek assurance that all professionals, including safeguarding leads in schools, are well equipped to work with diversity, culture and ethnicity in safeguarding work; explore how supervision, team learning, training and programmes can help professionals improve their skills as professionally curious practitioners in relation to relation to 'significant males'; ensure a robust system for quality assuring safeguarding audits and action plans in schools and partner agencies.
      
 Title:  Serious case review – Jacob 22. LSCB: Manchester Safeguarding Partnership Author: Linda Richardson Date of publication: 2022  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1    Manchester Safeguarding Partnership Serious Case Review – Jacob 22  This report was commissioned and prepared on behalf of the Manchester Safeguarding Partnership  Independent Reviewer: Linda Richardson  Published 25th May 2022                  2  This page is left blank   3  Contents  1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews   2. The circumstances which led to this review  3. Family Involvement   4. The approach used  5. Parallel proceedings  6.  What was known to agencies   7. Significant Dates   8.  Analysis of Practice  KLoE 1:  How well agencies understood threshold criteria and adhered to multi-agency safeguarding procedures? • Immediate response to the discovery of Jacob’s injuries • School’s awareness of Jacob’s previous injuries  • The role of Commissioned Service Provider  in School1 • The response of health colleagues • Jacob’s immunisation history KLoE 2: What influences may have impacted upon professional-decision-making • Understanding school’s response • School’s understanding of Jacob’s needs • The role and function of Designated Safeguarding Leads (DSLs). • The role of males in families • Professional bias and cultural relativism1  KLoE 3: The extent to which professionals collaborated and worked together • Liaison between agencies  • Collaboration between professionals • School’s relationship with CSC  KLoE 4: Managerial Oversight and Supervision  • Accountability and Governance • Supervision and support for DSLs • Keeping and maintaining records    1 Cultural relativism is the idea that a person's beliefs and actions  should be understood based on that person's own culture, rather than be judged against the criteria of  for example, the culture and practice within the UK.   4  KLoE 5: Jacob’s voice and the extent to which professionals were curious about his lived   experiences  • Keeping the child in focus  9. Concluding remarks   10. Summary of Learning Points  11. Recommendations    Appendix 1: Agencies represented on the review team.  ---------------------    Key:  Subject:   Jacob (not his real name) Mother of Jacob  MJ Birth Father of Jacob  BFJ Partner  of mother   PMJ  Children’s Social Care    CSC Primary School    SCH1 Primary School (DSL LEAD)   DSL1  Designated Safeguarding Lead    DSL2 Designated Safeguarding Lead   DSL3 Designated Safeguarding Lead   DSL4 Designated Safeguarding Lead  DSL5 Class teacher    CT1 Teaching Assistant   TA1 Commissioned Service Provider  CSP CSP1 Social Worker    CSW1 Health Visitor Area1    HV1 Health Visitor Area2   HV2 General practitioners   GP1, GP2, GP3, and GP4 Practice Nurses    PN1, PN2, PN3, and PN4.          5   1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews (SCRs) 1.1. From June 2018, under revised legislation2, LSCBs, set up by local authorities, began their transition from LSCBs to safeguarding partner arrangements. LSCBs were required to carry out all of their statutory functions, including, where the criteria was met, commissioning SCRs until the point at which the new arrangements began to operate in their area.   1.2. The main responsibilities of LSCBs at the time this SCR was commissioned were to co-ordinate and quality assure the work of member agencies to safeguard children. The statutory guidance, which accompanied legislation and underpinned the work of LSCBs, set out its expectation that LSCBs should maintain a local learning and improvement framework so good practice could be identified and shared.  1.3. In situations where abuse or neglect of the child is known or suspected and children die or are harmed, LSCBs were required to undertake a rigorous, objective analysis of what happened and why, to see if there are any lessons to be learnt which can be used to improve services in order to reduce any future risk of harm to children. There was an expectation that these processes known, at the time, as Serious Case Reviews (SCRs) were transparent, with the findings shared publicly.  1.4. Manchester Safeguarding Children Board (MSCB)3 commissioned this SCR in September 2019 in line with statutory guidance in place at the time.4  The statutory guidance has now been updated and arrangements for undertaking local reviews where a child has died or been seriously injured have been amended. Local reviews in future will be referred to as local Child Safeguarding Practice Reviews.   2. The circumstances which led to this review  2.1. Jacob is thought to have been around one year old when he and his mother (MJ) moved from Eastern Europe to the UK in 2013. They moved to join Jacob’s father (BFJ) who was already resident in the country. Jacob came to the attention of statutory agencies in May 2019 when he was 7 years old and his mother MJ, and her then partner, PMJ, took him to A&E, with a leg injury.  2.2. Due to significant discrepancies in the accounts given by Jacob, MJ, and PMJ, hospital staff contacted police and Children’s Social Care (CSC) to report concerns about possible non-accidental injury. A further medical examination found Jacob to have a number of injuries indicative of physical and possibly sexual abuse. MJ and PMJ were arrested and charged under section 5 of the Domestic Violence, Crime, and Victims Act 2014. Both adults were remanded in custody and Jacob was accommodated5 by the local authority.   2 Children Act 2004,  amended by the Children and Social Work Act 2017, 3 Now referred to as Manchester Safeguarding Partnership (MSP) 4 Working Together to Safeguard Children 2015 HMSO, 5 A local authority has a duty to accommodate a child, when there is no one with a legal responsibility able to care for the child.    6  2.3. Jacob was not known to children’s services but he did attend primary school (SCH1) and agency records indicated a number of absences from school for what appear to be typical childhood ailments. According to medical records, health professionals saw Jacob only occasionally but neither they nor SCH1 recorded any concerns about Jacob’s behaviour, well-being or safety.    2.4. Such were the concerns about Jacob’s injuries, seen in May 2019, that a decision was taken in June 2019, endorsed by the independent chair of MSCB at the time, that the criteria for a Serious Case Review (SCR) was met. It was agreed that the period under review should be from January 2018 around the time when MJ was believed to have started a relationship with PMJ, to May 2019, when the extent of Jacob’s injuries came to light. Agencies were asked to include any relevant background information, which was pertinent to the review.  3. Family Involvement  3.1. The Safeguarding Partnership Coordinator from Manchester Safeguarding Partnership (MSP) contacted MJ to explain the purpose and process of the serious case review. In June 2020, MJ indicated to Jacob’s social worker that she would like to contribute to the review. 3.2. MJ was contacted by the independent reviewer and, in light of Covid 19; a WhatsApp video call took place in July 2020. As agreed with MJ, the independent reviewer took notes of the conversation and these were copied and sent in an email to MJ a few days later. MJ was encouraged to share these with her sister and/or her legal representative.  3.3. The independent reviewer initially established the extent to which MJ was able to converse in English and offered the services of an interpreter, but MJ indicated she was keen to continue the conversation and both parties were able to communicate without any difficulty.  3.4. Comments made by MJ have been incorporated into this report at key points in the narrative. However MJ clearly indicated she felt she had good relationship with staff in school and she did not feel that any professional could have done more to help, as no one suspected PMJ of hurting Jacob.  4. The approach used 4.1. An independent lead reviewer with no links to any of the agencies involved was commissioned to work with a review team. This reviewer was also tasked to write an independent report and identify any findings, which could help to improve practice when working with children and families.  4.2. A review team of senior professionals representing the agencies that were or had been involved with the family was established. Their role was to provide a source of high-level strategic information about their own agency and their involvement with Jacob and his mother through their contributions to the SCR process and the submission of an Agency Learning Report. The review team analysed data, appraised practice, and are in agreement with the content and findings of this report. The agencies represented on the review team are listed in Appendix 1.  4.3. Members of the review team also identified practitioners from their own agencies who knew Jacob and/or his mother and other significant members of the household. The review team met with some of these practitioners to explain the SCR process and held conversations with four professionals from  7  SCH1 and CSP. Whilst, the onset of the Coronavirus impacted upon the direct and ongoing involvement of professionals, the review continued, albeit at a slower pace than planned.  4.4. The review team identified some initial lines of enquiry as the review team began to pull together information about agency involvement. This approach allowed a wider exploration of events rather than a pre-determined focus on very specific issues without understanding what happened, when and why. The review team agreed that key  areas to explore were:   • To what extent agencies demonstrated understanding and adherence to multi-agency safeguarding procedures and was there a common understanding and application of threshold criteria?  • What training and had been delivered and how effective was this? • What were the indicators that abuse was happening and were these well understood? • How did opportunities to understand the child’s lived experience inform professional curiosity and thinking?  • Were there any specific organisational challenges to information sharing?   • Were there any aspects of diversity that impacted upon the approach to the child and family?   5. Parallel Proceedings   5.1. Jacob now lives with his father and father’s partner and is subject to 12 month Supervision Order. He has supervised online contact with his mother. PMJ is currently serving a custodial sentence for neglect offences against Jacob.  6. What was known to agencies (taken from Agency Learning Reports, the integrated chronology and conversations)   Greater Manchester Police (GMP)   6.1. There is no evidence to suggest that GMP were involved with this family or with PMJ prior to Jacob presenting at hospital in May 2019.  NCA Pennine Acute Trust-Hospitals  6.2. When Jacob was 3, he was taken to hospital by his birth parents with an injury to his thigh, staff at the hospital were told he had fallen from a trampoline. Jacob was found to have a fracture of his thighbone and was treated with an above-the-knee cast. Agency records indicate there were no concerns or queries about the nature, site, or explanation of the injury. Jacob was seen at follow up visits at the outpatient’s clinic in June and July 2015 as expected6. Jacob was also taken to hospital in September 2016 by his parents with ear pain and fever. He was treated at the time with antibiotics. 6.3. In May 2019, Jacob was taken to the hospital by MJ and PMJ with a leg injury. Explanations for the injury were inconsistent and statutory agencies were swiftly contacted in line with child protection procedures. Health Visiting (Area1)  6 Having made further enquiries about this accident, the review team made a decision not to include this incident in the review.  8  6.4. Jacob was in receipt of universal health services in Area1 where he initially lived with his birth parents. Agency records indicate the family engaged well with HV1. The family moved to Area2 in September 2015.     Health Visiting (Area2)   6.5. The Health Visiting team in Area2 received health records from Area1 in September 2015. The first visit to the family by HV2 took place one month later. Given there were no concerns noted in medical records, this was in line with expected practice. Jacob was seen in the presence of his mother, his maternal aunt, and an unnamed friend of his mother. Jacob was noted to have fully recovered from his accident earlier in the year and was described as ‘bright, alert, and playful’. He was heard to speak only his mother’s first language and records refer to the positive interaction that was observed between Jacob and his mother. There was no information recorded about BFJ. Health advice was given about Dentists, GP, and local services. MJ did not have a ‘red book’, the Parent Held Child Health record and according to agency records, when asked, MJ said she was taking Jacob’s immunisation history (from his birth country) to the GP. HV2 referred Jacob for his BCG vaccine.  6.6. Jacob was assessed and was noted not to have any unmet health needs so health visiting took place as would be expected for a child receiving universal health services. HV2 was notified of Jacob’s visit to A&E for ear pain and fever in September 2016 and that he was treated with antibiotics. In line with expected practice, no follow up visit by HV2 was made.   School Health Service7 6.7. Jacob was transferred from the Health Visiting service to the School Health Service in February 2017. At this stage, any concerns held by health visitors about the child or family circumstances are usually shared with the school nurse. There were however no concerns shared about Jacob and neither was there any reference to, or discussion about, Jacob’s immunisation history.   6.8. In July 2017, when he was five years old, Jacob received full health screening checks including vision and hearing, both of which were satisfactory. This is standard practice and offered to all children on school entry. Jacob had also taken part in the National Child Measurement Programme (NCMP), which is provided as part of the universal school health programme, his height, weight and body mass index (BMI) were recorded on 3 occasions. Jacob’s height was noted to be above average and his BMI within healthy limits. Jacob’s immunisation history was, unusually, not picked up when he had his health screening checks.   GP Practice  6.9. According to the integrated chronology, the family first registered with a Group Practice (GPP1) in June 2014. Jacob’s medical records appear to have been accessed by GP1 in August 2015, 14 months after the family registered with the practice, but there are no notes to suggest any consultations had occurred. The review team were advised that records can be accessed for a number of reasons, data collection, follow up checks, but as GPP1 has now closed and records provide no additional detail, it has not been possible to verify why Jacob’s records were accessed then and on other occasions too.  7 Manchester School Health Service is part of the Children’s Community Health Services Directorate and consists of School Nursing and Healthy Schools and Healthy Weight Project Team   9  It is possible that records were consulted in response to queries about Jacob’s immunisations, but this cannot be verified with any certainty.    6.10. In September 2015, the first letter was sent to the family by GPP1, reminding them about Jacob’s immunisations. Jacob was then 3 and half years old. Medical records were accessed again in November 2015 by Practice Nurse (PN1) but again no entries were made to explain why the records were accessed. One week later, Jacob was seen with his mother by the TB nurse at a local medical centre and was given a BCG vaccine. Upon checking Jacob’s medical record, the TB nurse noticed that Jacob was not up to date with immunisations and promptly and appropriately contacted PN2 at GPP1 to bring this to their attention. There is, however, no evidence that this communication prompted any action by the practice.   6.11. Records suggest it was not until October 2016, that another letter was sent to parents regarding Jacob’s immunisations. Jacob was seen a few days later by GP2 because of his ongoing cough and sore throat. Notes do not specify who brought Jacob to surgery and there are no observations recorded about Jacob. His outstanding immunisations were not picked up at this consultation.   6.12. According to agency records, GP3 telephoned MJ from the surgery three weeks later, but received no answer. A few days later, another letter was sent to the family requesting that Jacob be brought to the clinic for a flu-jab. His immunisations were not mentioned in the letter. In March 2017, medical records indicate that BFJ took Jacob to the surgery because his cough and cold were not clearing up. Jacob was seen at that time by GP4. Notes from the consultation indicate that BFJ was advised that Jacob’s symptoms could be viral but there was ‘nothing to worry about’. One week later, records refer to BFJ bringing Jacob back to the surgery for his immunisations. He was seen by PN3 who recorded that Jacob continued to have ‘loose stools’ and ‘looked pale’; he was not however referred back to the GP, which would, given his age, be expected practice. Jacob’s immunisations were appropriately postponed and another appointment made for two weeks later. The appointment was not kept.    6.13. By April 2018, Jacob, age 6 years old, had still not received his immunisations. According to agency records, the GP practice tried, unsuccessfully, to make contact with MJ again by telephone. Contact was also attempted, to no avail, two months later in June 2018.  6.14. In September 2018, the family was sent a letter informing them that medical services would in future be provided by a different medical practice – GPP2. The review team was able to establish that GPP1 was closed following significant and ongoing concerns reported by CQC8 around quality and patient safety.   6.15. Medical records indicate that Jacob was seen at GPP2 in March 2019 by PN4, when MJ took him to the surgery because of ear pain and, according to agency records, ‘bleeding from both ears’. Jacob was diagnosed with an ear infection. Bi-lateral bleeding from both ears was observed alongside a note in the medical records, which confirmed that bleeding had not happened with any of Jacob’s previous ear infections. There is no record of his immunisations being discussed.   8 Care Quality Commission monitors, inspects and regulates health and social care services.    10  Primary School: SCH1 6.16. Jacob started in reception class in September 2015. In his first year, Jacob’s attendance at school was 91%. School records indicate he had 33 authorised absences due to ill health. This pattern was repeated in Years 2 and 3, although his attendance was then in the region of 94%. Whilst references have been made to holding conversations with MJ about Jacob’s attendance, there are no records, which capture the content of these discussions.    6.17. Jacob was described as a quiet child who initially struggled with language and academic work. Although not assessed, as would be expected, Jacob was placed on the SEN register and received one to one intervention to help with his academic progress.   6.18. In March 2017, Jacob was found during afternoon play in the playground with his trouser and underwear down to the floor. There are no further details provided about this incident and nothing to suggest Jacob’s behaviour raised any concern or that it was discussed with MJ.   6.19. A CPOMS9 entry on February 2019 refers to Jacob being seen at school with a ‘cut/bump’ on the back of his head and ‘red marks’ above and below his eye. Records state that when asked, Jacob said he fell against a cupboard but did not know how the ‘marks’ on his eye had happened. Jacob was apparently then seen by DSL1 and said he had fallen against a wall. School records also refer to Jacob talking about a ‘strong man’ who looked after him when his ‘mummy was at work’. Agency records note that MJ was contacted and told about the injury, which in their view needed treatment. MJ came to collect Jacob from school. It is unclear from records what conversations, if any, were held with MJ about PMJ who was apparently looking after Jacob that morning. The CPOMS entry also referred to Jacob, saying on the previous day, he was hungry and had not had breakfast. He was given something to eat that day by school staff. No further details are recorded.   6.20. In March 2019, school records refer to TA1 noticing ‘blood’ coming from Jacob’s right ear. Jacob was seen by DSL2 but she told the lead reviewer that she did not see any blood only ‘a yellowish red discharge’. According to records, Jacob said that ‘the man’ had ‘stuck a stick’ in his ear and ‘dried blood’ was also seen in Jacob’s other ear and Jacob confirmed the man had ‘put a stick’ in that ear on another day. Records refer to Jacob clearly being distressed and wanting reassurance that MJ would come to take home and that if the ‘man’ came to take him home, Jacob did not want to go with him. MJ collected Jacob from school and later contacted DSL2 to confirm that Jacob had been seen by his GP and had been diagnosed with an ear infection.   6.21. DSL2 spoke with MJ a few days later to ask about Jacob describing her partner as ‘that man’ and was apparently told by MJ that Jacob and her partner ‘do not get on’. MJ explained that her partner had changed rules in the home and Jacob had never settled with him. Records suggest that MJ gave her verbal consent for her details to be passed to the school’s commissioned social work service, so the family could receive social work support from CSW1 around the relationship between Jacob and PMJ.   6.22. According to school records, Jacob attended school every day between 3 May and 24 May 2019 when school broke up for the half term holiday.    9 CPOMS is an electronic system used by many schools, to report, record and track safeguarding concerns.   11  After School Club (ASC)   6.23. Jacob attended after-school club usually three days per week. According to records, Jacob was ‘quiet’ at after school club but this was in line with how he presented at school during the day. Jacob was described as ‘quirky’ although there is no additional information provided to explain more about this description. He was also described as being mischievous at times. Jacob was noted to be always hungry and staff often wondered if he had eaten school lunch. There are no records to indicate that staff noticed any marks or bruises on Jacob which gave rise to concern.   6.24. Jacob was observed by staff at the after school club to have a warm and reciprocal relationship with his mum who usually collected him after sessions. PMJ apparently collected Jacob from school only on 2 or 3 occasions and only when they had been previously informed by MJ. Staff noted there were no outwards signs of affection between Jacob and PMJ on those occasions. Agency records were not available to confirm the dates when PMJ picked him up from school and notes shared with the review team refer only to ‘the man’ who picked him up after school. No other details are provided and the absence of these records is not in line with expected practice.     Commissioned Service Provider (CSP) 6.25. CSP is a charity which, under the auspices of a larger organisation, provides a commissioned social work service to schools in the Manchester area and works with families and children who may be experiencing difficulties.   6.26. According to CSP records, CSW1 was invited into school in April 2019, to attend a meeting with DSL2. At the meeting, CSW1 was asked to make contact with MJ to discuss the CSP service and offer to do some work around family relationships, given that Jacob referred to PMJ as ‘the man who lives with us’. The DSL confirmed that MJ had given her consent to SW1 making contact. The record of this conversation does not contain any detail of what information was shared with CSW1 and how much CSW1 knew about the two previous incidents. In speaking with the review team, CSW1 advised that DSL just mentioned that SCH1 felt some work around family relationships would be useful, and no other details were shared or sought. At that stage CSW1 agreed to only make contact with MJ to tell about the services the agency could offer.   6.27. Agency records suggest that CSW1 made at least three attempts to speak with MJ by telephone but her calls were not returned. CSW1 later spoke with DSL and it was agreed that MJ would be invited into school after the half term holiday to discuss what support CSW1 could provide and to obtain MJ’s written consent for any work that might take place.   7. Summary of significant dates  (taken from Agency Learning Reports, the integrated chronology and conversations)   2013:   Jacob and his parents moved from Eastern Europe and came to live in Area1   June 2015 Injury due to ‘fall from trampoline’ Aug 2015 Family moved from Area1 to Area2 Sept 2015 Jacob started in reception class at SCH1 2017 Relationship between MJ and BFJ ended. MJ met PMJ  Late 2018 PMJ moved into the family home with MJ and Jacob.   12  Feb 2019 Jacob found to have a wound at the back of his head. When asked he said he was spinning around and fell. He was noted to also have a ‘red mark’ above and below his eye. MJ was advised to take Jacob to A&E. Mar 2019 Jacob was noticed to have a ‘bleeding ear’ and told CT1 that ‘the man’ had put ‘a stick’ in his ear.’ Dried blood was also seen in Jacob’s other ear. Jacob became distressed when he thought he would have to go home with ‘the man’.   Jacob was seen the same day by a Practice Nurse at the GP surgery and an ear infection in both ears was diagnosed.  Mar 2019 MJ told DSL2 that Jacob had not settled with PMJ. MJ agreed to DSL2 passing on her details so CSW1 could get in touch to offer support with family relationships, MJ did not respond to messages left by CSW1.  May 2019 School broke up for half term holiday. (24th) May 2019 MJ and PMJ took Jacob to hospital (29th) with a leg injury. Multiple and relatively recent injuries were discovered on Jacob’s body, limbs, face and neck.   8. Analysis of Practice  8.1.  The purpose of SCRs is to support improvements in safeguarding practice. This means it is not enough just to describe professional activity in a case or to identify elements of practice that were problematic without seeking to understand why they occurred. The analysis needs to explore what systems were in place and what may have influenced professional activity and decision-making at key points in work with the family.  8.2. It is also important to be aware how much hindsight can distort judgement about the predictability of an adverse outcome. Once a serious injury or harm to a child is known it can become easy to look back and conclude that certain actions or the absence of these, were critical in leading to that outcome. The review team was mindful of the dangers of hindsight bias but wanted to understand why certain actions and decisions would have made sense at the time and importantly, what systemic factors in place then, might still be impacting upon practice in Manchester in 2020.   8.3. The analysis is structured around five key lines of enquiry (KLoE), which provided a framework with which to appraise practice. The KLoEs are listed below and an appraisal of practice under each key line of enquiry follows.    KLoE 1:  How well agencies understood threshold criteria and adhered to multi-agency safeguarding procedures KLoE 2:  What influences impacted on professional judgements and decision-making  KLoE 3:  The extent to which professionals collaborated and worked together KLoE 4:  Managerial oversight and supervision KLoE 5: Jacob’s voice and the extent to which professionals were curious about his lived experiences        13  8.4. KLoE 1: How well agencies understood threshold criteria and adhered to multi-agency safeguarding procedures?   Immediate response to the discovery of Jacob’s injuries  8.4.1. Manchester Safeguarding Partnership’s procedural guidance for agencies who have concerns about a child’s development, welfare or safety, identifies five levels of need. Levels 1 and 2 relate to needs which can be met by universal services or by a single agency, whilst Level 3 and 4 relate to the needs of children or young people who would benefit from a coordinated programme of support from more than one agency, perhaps using a multi-agency early help assessment. Level 5 is where the local authority receives or gathers information which suggests that a child or young person is at risk of, or suffering from, significant harm due to abuse and/or compromised or absent parenting.  8.4.2. When Jacob was taken to the hospital by his mother and PMJ in May 2019, it was the middle of the half term holiday and Jacob had not been in school since the previous week. As MJ worked, Jacob had been left in the care of PMJ, as had happened previously.  8.4.3. An X-ray showed that Jacob had a fractured tibia. However, the radiographers acted swiftly and demonstrated best practice when they noted bruising on Jacob’s face and became concerned about the conflicting and changing accounts by MJ and PMJ as to how the injury had happened. They shared their concerns about possible non-accidental injury with paediatric colleagues and this led to a child protection referral in line with child protection procedures. The response by the police and CSC was prompt; Jacob was subject to a full medical examination, which found evidence of a number of injuries suggesting physical, and possibly sexual, abuse. Both MJ and PMJ were arrested and Jacob was accommodated by the local authority and placed with foster carers.  School’s awareness of Jacob’s previous injuries  8.4.4. As part of the police investigation, various graphic images and video clips were obtained from PMJ’s phone and these included photos and concerning videos in which Jacob was seen being humiliated, sometimes naked and sometimes with what appeared to be excrement on his hands, mouth and buttocks. According to Police records, these images and clips had been sent to MJ but it has not been possible to confirm which had actually been seen by MJ, who indicated that those she had seen did not cause her alarm.  8.4.5. Information presented by CSC to support a rapid review meeting, referred to a video clip on PMJ’s phone, showing Jacob with a ‘black eye and in school uniform’. Further enquiries by the review team confirmed however that these details were in fact incorrect. The information shared by police actually referred to Jacob being seen on a video clip on a Sunday in January, ‘clothed’ but with ‘an injury to the left side of his cheek bone towards the eye area’. The review team was satisfied that the reference made to Jacob wearing a school uniform was a recording error.   8.4.6. There are no entries in school records to suggest that Jacob attended school with a facial injury in January 2019. From information in the attendance register, Jacob was in school every day that month so it would be expected that any injury to the face or around the eye would have been observed and recorded. The video clips and images are, at the time of writing this report, in possession of the Criminal Prosecution Service (CPS) so it has not been possible to clarify these details at present.   14  8.4.7. The medical report seen by the review team describe numerous bruises on Jacob, ‘too many to count’. Some were recent, over his right and left cheek, ears, and shoulder with tiny red spots 10 evident on the skin, other bruises showed evidence of yellowing and so were of differing ages. Some bruises were found in usually protected areas such as ears, trunk and cheeks and some had a clear pattern suggesting inflicted or non-accidental injury. The examining doctor also found right cheek bruising typical of a blow with open hand with pale finger spaces in-between. Both ears had bruising front and back, suggesting a forceful blow or pinch. These features also suggested non-accidental injury.  8.4.8. There were some injuries to Jacob around his genitals and buttocks, but the cause of these could not be established. Although indicative of possible sexual abuse, this could not be confirmed evidentially and without any disclosure from Jacob then or since, evidence of sexual abuse was found to be inconclusive.   The review team queried to what extent Jacob’s language and/or learning difficulties may have impacted upon his ability to express himself during his interview with the police and social worker following the arrest of MJ and PMJ.  This was considered an important point and the review team queried whether Jacob would have had the language to describe what may have happened to him. The review team was reassured by police colleagues that Jacob’s cultural background and his ability to communicate in English were carefully considered prior to his ABE11 interview. The possibility of using an interpreter had been carefully considered but the interview team were confident in Jacob’s ability to express himself clearly.  8.4.9. Most of Jacob’s physical injuries appeared underneath his clothing and would, it seems, not easily have been seen when at school. Many, although not all, of the bruises appeared to have been inflicted over a period of a week or two and some perhaps only a few days earlier. From records seen by the review team, bruising to Jacob’s face and neck may have occurred in the days since school had broken up, with the exception of four small, fading circular bruises on Jacobs’ jawline, indicative of him being gripped by his jaw.  These bruises would likely have been noticeable whilst he was in school.  There are however no record of these marks in Jacob’s record on CPOMS and neither CT1 nor TA1 can recall noticing anything to cause concern and indicated that had they done so it would have been reported.  8.4.10. It was confirmed that children undressed for PE in the classroom and DSL1 advised that any obvious bruises on Jacob’s limbs would have been seen and recorded. Neither CT1 nor TA1 can recall seeing any marks or injuries on Jacob which caused concern, although as was pointed out, with a class of 30 + children, unless very obvious and brought to their attention, they would not necessarily have noticed any bruises. DSL2 told the review team that she could remember TA1 expressing some  10  These small red or purple spots on the skin, called petechiae are caused by a minor bleed from broken capillary blood vessels and are associated with bruising and are a known indicator of abuse. British Medical Journal  ‘Bruising in children who are assessed for suspected physical abuse’ (2014)     11 Achieving Best Evidence (ABE) interviews are conducted in line   with government guidance  when police and social workers  are investigating allegations of abuse  against children.    15  concern about Jacob; TA1 told the lead reviewer this would have been in February  when she shared her concern with DSL2 in relation  to Jacob’s head injury and recorded this on CPOMS.  8.4.11. There are no records in CPOMS of any bruises or marks seen on Jacob other than those noted on body maps in February and March 2019. The ‘red’ marks seen on Jacob’s eye, when the cut on his head was noticed, did not spark any curiosity as to what these might be or how or if they could be linked to his head wound. There was no discussion with MJ as to whether she had taken Jacob to A&E and no follow up conversation when Jacob did not appear at school the following day. There were no further enquiries by either of the DSLs, as to what may have happened to Jacob, and his head wound and the ‘red marks’ on his eye were just noted in CPOMS and no further action was taken.  8.4.12. School staff spoken to as part of the review, were adamant that they had no reason to suspect that Jacob was at risk of harm by PMJ or by anyone else. The lead reviewer was told that Jacob seemed  happy at school and when he occasionally  talked of PMJ, he  did not give the impression  of being fearful of him, TA1 recalled that Jacob would often do press ups to show staff how ‘strong’ he was and it was assumed  that this was something that came from PMJ. Staff were unaware that PMJ was not a long standing partner of MJ and said they had no reason to be concerned about his relationship with Jacob. MJ was observed to be a caring parent and her responses to what had happened  to Jacob seemed appropriate.  Both CT1 and TA1 indicated an  understanding of what to do if they were worried about any child in school.  8.4.13. It was clear from speaking with the DSL1 and DSL2 that they understood the process for making referrals, but had developed a very clear view as to which referrals would be accepted by CSC and which they would be advised to manage at a lower threshold level.   The review team was given examples by DSL2 of where, in her view, concerns and referrals, with   firmer evidence than was apparent in Jacob’s case, had not received the expected response from CSC and it was apparent that this influenced the actions taken.  8.4.14. It was this perception which seemed to have led all five DSLs in SCH1 to conclude in February and in March that CSC would not progress their referral as the threshold for intervention had not been met. This conclusion was reached based on the lack of any prior concerns about Jacob’s well-being or behaviours; the school’s positive view of MJ and her observed warm and caring relationship with Jacob and the ‘plausible’  explanations of the circumstances surrounding Jacob’s head injury, and the fact that MJ had later said his  ‘bleeding’ ears   had been seen by the GP.  Both DSL1 and DSL2 said they believed the ‘stick’ to which Jacob referred, was a cotton wool bud, used to clean his ears; they suggested that  Jacob would not know what these were called, hence his description  of a ‘stick’. MJ later confirmed to SCH1 that they used these buds at times to clean Jacob’s ears. DSL1 and DSL2 told the review team that they did not have any evidence to suggest Jacob was at risk of harm and neither did they believe him to be so. 8.4.15. There are no records which offer a rationale for the decisions taken or details of exactly when these discussions took place, but the review team was told that all five DSLs agreed that the threshold for a referral to CSC was not met, calling into question their understanding of thresholds and the role of CSC. The responsibility for deciding on the significance and implications of injuries to a child lie with the statutory authorities, and what happened to Jacob - injuries to the back of his head and to  16  the face, - should at the very least have sparked a degree of ‘respectful uncertainty’, especially given the presence of a ‘new’ male in the family who, it seems, was previously unknown to SCH1.   8.4.16. The concept of  ‘respectful uncertainty’ should lie at the heart of all professionals working with children where parents are asked to account for their children’s behaviour, or in Jacob’s case, injuries, or absences from school. The term was first used by Lord Laming12 almost two decades ago but it continues to be as relevant to current professional practice as it was then. It reminds professionals of the importance of critically evaluating information given to them by parents and keeping an open mind before accepting, at face value, what they are told. Jacob’s injuries should have led to, if not a referral, then certainly a conversation with colleagues in CSC.  8.4.17. Alongside the incident in February, was Jacob’s distress the following month at the thought of going home with PMJ, a relatively unknown male. This should have prompted the DSLs to question  what  might   be happening at home  for Jacob and what it meant when MJ said that her partner and her 7 year old son ‘did not get on’. It was clear to the review team that MJ’s comments were of some concern to DSL2 which is why CSW1 was asked to work with the family and ‘assess and review relationships in the family’.  Despite the agreed protocol between SCH1 and the commissioned service that no work would begin with families without a signed contract, CSW1 agreed to make contact with MJ to talk about CSP and the services on offer.  This information should have been readily available in school. MJ did not respond to CSW1’s attempt to make contact and this meant that no direct work was undertaken with the family,  during what is now known as a critical period,  between March and May 2019.   8.4.18. MJ told the independent reviewer that she could not recall any conversations about, or contact with, a social worker from CSP, neither  could she remember any conversations with DSL2  about  needing help with relationships in the family.  MJ told the lead reviewer that PMJ and Jacob got on very well and were always doing things together, and there had been nothing in her life with PMJ which caused her concern which is why she never suspected him of hurting Jacob. MJ said she enjoyed good relations with school staff and Jacob was very happy at school.  8.4.19. Making a judgment call about what might be happening in a family is not easy for any professional working with children. It is especially challenging for school staff that have hundreds of contacts with children every day and yet need to pick up and respond to any cues, which suggest a child might be struggling or hurting. The challenge of making these judgment calls should not be underestimated. The review team understand that all five DSLs in SCH1 discussed whether a child protection referral to CSC was required and this would indicate that there were some questions about Jacob’s care and well-being. The DSLs were however, clearly reassured by the agreement of a qualified social worker  - CSW1 -  to make contact with the family, but the lack of clarity about the status of that contact and the absence  of any written agreement  with MJ about what the work should entail meant important information was not shared and this  left Jacob vulnerable.   8.4.20. The DSL’s believed that Jacob was not risk of  harm and concluded  therefore  that there was no need to liaise with CSC, or even make contact  with the cluster group in their locality to discuss whether a  child protection referral  should be made. If, as was the case with Jacob,  schools  do not refer or make contact with CSC, because they believe a case will not meet the required threshold,  12 Victoria Climbié Serious Case Review Lord Laming  17  divergent views will not be explored, DSLs will not be supported and some children may be left at risk.  8.4.21. During the course of this review and in response to learning emerging from it, front door arrangements for agencies to make contact with CSC to explore child safeguarding or safety concerns have been strengthened through the development of an Advice and Guidance Service.. This provides professionals in all agencies  with easier access to more informal advice and guidance from CSC. This development is to be welcomed, offering as it does, opportunities to further enhance partnership working, especially between schools and CSC.  Learning Point 1: When concerns about children arise and agencies are considering whether a referral to CSC should be made, or are uncertain about next steps,  the starting point should always be a dialogue with CSC so agencies can make informed decisions about the appropriate  course of action.     The role of CSP in SCH1  8.4.22. Like many other schools in the North West, SCH1 contracts CSP Schools Service to provide social work and therapeutic services to pupils in need and their families. Referrals for social work support are made to CSP with the written consent of parents after which  the usual procedure is for the CSP worker assigned to the school, to approach the parent and discuss and agree  in more detail, a tailored package of support.  8.4.23. It is important to note that, although most of the staff working for CSP are social work qualified, their role in the charity is to offer support to families under Level 1 or 2 and only very occasionally under Level 3. CSP social workers, the review team was told, are not used as a substitute for contact with statutory agencies whose role is to investigate and assess risk of harm to children. Both DSL1 and DSL2 confirmed they did not use CSW1 to assess risk in families, and acknowledged that if CSW1 identified risks in work with families, these would be recorded on a [CSP] Safeguarding Report Form, discussed in detail with the DSL, and shared with the CSP manager. CSW1 would also report directly to CSC.  8.4.24. Although there are no details of the conversation, the review team was told by DSL2 that MJ agreed that some support to help with Jacob and PMJ’s relationship might be helpful and she gave verbal consent for her details to be passed to CSW1. CSW1 advised the review team that without any written agreement, she was only intending to make contact with MJ to explain what support might be available to the family. Whilst, aware that Jacob had talked about the ‘the man in the house’, had an ear infection and a ‘stick’ had been put in his ear, she was not made aware  of any safeguarding concerns but neither is there evidence that she questioned this or sought to clarify if Jacob was open on CPOMS, only believing that her initial role was to talk with MJ about  her role in  CSP.   8.4.25. CSW1 told the review team that she had worked for the school for around five years and had confidence in DSL2 so the request in March to help with family relationships was in line with  other work she had  undertaken in that school and others. CSW1 told the review team that she would not have begun any work with the family without a written agreement. When MJ did not respond to her overtures,  CSW1 was not concerned as not all families respond when first contacted. A  18  discussion with DSL2 in early May, the details of which are not recorded, led to a decision that MJ would be invited into school by DSL2 to meet CSW1 after the school half term break.  8.4.26. CSW1 was very clear about the thresholds for referral to CSC but indicated there was nothing in her conversation with DSL that alerted her to any risk for Jacob and had any such information been shared, she would not only have urged contact with CSC before she became involved with the family, but would also have suggested the school arranged an earlier meeting with MJ. CSW1 was not aware that Jacob was open on CPOMS, which would have highlighted some safeguarding concerns. CSW1’s manager told the review team that CSW1 referred more families to CSC than any other workers in the team and was confident that she both understood thresholds for referrals and consistently worked to multi-agency safeguarding procedures. In this case, however her practice fell below expected standards.  8.4.27. In response to learning from this review, CSP has now improved its systems to ensure that any contact their social workers have with families or are asked to have with families, even to explain the services the agency can provide, are documented regardless of whether the case is ‘formally’ opened to the agency.  The response of health colleagues   8.4.28. When Jacob was seen by PN4 in March 2019 because of ear pain and ‘bleeding’ from both ears, medical records indicate he was diagnosed with an ear infection. Whilst ear bleeds can be a characteristic of ear infections, bi-lateral ear bleeding is unusual and can  be  symptomatic of trauma in response to a physical injury. There is no evidence to suggest that PN4 looked for or noted the presence / absence of other features such as bruising which may have supported  or dismissed trauma as a possible cause for the ear bleeds. This was a missed opportunity to query with MJ in more detail, and possibly Jacob, what had happened to cause both  ears to bleed. Medical notes do not however indicate any safeguarding concerns and PN4’s diagnosis and treatment appear to have been endorsed by GP5 with whom PN4 consulted. The issue of bilateral ear bleeding and the potential link with injury and trauma has been identified  as a learning point from this review which will be taken forward in the agency action plan.  Jacob’s immunisation history 8.4.29. As part of the Healthy Child Programme (HCP) Health Visitors and School Nurses are commissioned to promote immunisation and GPs are responsible for the provision of the immunisations. As a child becomes school age, school nurses would expect a one to one handover from the HV if there are any health or safeguarding concerns and sharing information about a child’s immunisation history would usually be part of that discussion. There is no evidence to suggest that HV2 raised Jacob’s lack of immunisation with the school nurse as might be expected or that Jacob’s immunisations history was picked up at his health screening checks in July 2017. MJ was asked to complete  a parental questionnaire and answered ‘No’ to the question  ‘Has your child  had all their immunisations’. Yet, this  was not followed up with MJ. 8.4.30. It would be expected that when any child attends for a medical consultation, immunisation histories are checked but it appears this did not happen when Jacob was brought to either GPP1 or GPP2 surgeries. These were missed opportunities and the review team was unable to determine why Jacob’s immunisation history was not addressed by health and medical practitioners.   19  8.4.31. There is no evidence to suggest that MJ contacted the surgery any time to cancel Jacob’s appointments or to inform them she would not be attending. If she did get in touch these contacts are not recorded. Cancelled and ‘did not attend’ appointments are common, especially in GP settings, but without a system to flag up their cumulative significance, Jacob’s medical needs relating to his immunisations, somehow got lost along the way. The absence of any medical records from his home country, clearly led to drift, further compounded by the family transferring from one medical practice to another. However, there is little to evidence that MJ was actively encouraged to have Jacob vaccinated or that either  medical practice sought to involve as might be expected,  the health visitor or later the school nurse to find out a little more as to why Jacob was not  being immunised.  8.4.32. The GP role in safeguarding children who are or may be neglected is underpinned in some practices by alert systems that provide good oversight and tracking of risks to children who fail to attend hospital appointments, miss their immunisations or who are not brought to routine appointments.  There is no evidence to suggest that GPP1 had such systems in place. Expected practice would be for Jacob’s immunisations to have  been discussed within the medical practice by the wider multi-disciplinary team (MDT)13 to agree a way forward and also to consider the possibility that this could be neglect and possibly  a safeguarding issue.   Learning Point 2: Without robust systems in place for  a child’s immunisation history to be flagged in medical records,  the  health needs of some children may be overlooked. Where a child does not have an immunisation history, professionals should always explore the reason for this with parents.   8.5. KLoE2: What influences may have impacted upon professional-decision-making    School’s understanding of Jacob’s needs  8.5.1. Hindsight bias can seriously affect people's appraisal of a decision when it is followed by an adverse outcome, but the quality of decisions made by professionals in all agencies is inevitably affected by the many influences to which decision makers are subject 14. The review team explored the influences existing at the time to better understand the rationale for the school’s decision not to refer or liaise with CSC about Jacob’s family situation when it would have been appropriate to do so.  8.5.2. SCH1 is a large primary school, with staff managing complex situations and challenges on a daily basis. The school has a number of children from Eastern Europe and are fortunate in that they also have a teaching assistant that speaks the same language as MJ and who, the review team was told, has a good understanding of the culture from the region where she lived. At the beginning of 2020, there were 4 children in school on Early Help programmes, 6 children on Child in Need plans but no children on child protection plans. Given the demographic and the challenges of working with such a large and diverse group of children, the review team, thought this number seemed unusually low. According to agency records, SCH1 made 12 referrals to the MASH team between Sept 2016 and March 2018, 10 of which led to assessments by CSC. This would suggest that not only were most  13 Multi Disciplinary Teams (MDTs) work with GPs to provide enhanced access to health and social care services within a primary care setting.  14 Decision‐making under uncertainty in child protection: Creating a just and learning culture. Munro: Child and Family Social Work  (2018)   20  referrals deemed appropriate by CSC, it also brings into question the view  expressed by the DSLs, referred to earlier in this report,  that many of their safeguarding concerns were not shared by CSC.  8.5.3. Records suggest that Jacob was placed on the Special Education Needs (SEN) register at a time when the SEN Coordinator (SENCO) was on maternity leave. There is no evidence that he was ever formally assessed and it is therefore unclear whether Jacob’s perceived difficulties were to do with a learning difficulty or the fact he was using English as a second language. Jacob was, however, provided with one to one support until he reached Year 3 when focused support was given in small groups with other children.   8.5.4. The review team was told that Jacob was a quiet boy but as his language skills developed he began  to talk with  staff and play  more confidently with other children but there was it seems, never any indication he was troubled. His relationship with his mum was observed as being warm and affectionate and MJ would frequently attend events and parents evenings at school.  MJ herself said she believed that  Jacob loved school and she appreciated the calls she received from  staff to let her know how he was doing.  8.5.5. Despite the significant number of absences from school, the review team was told that MJ always kept the school informed and would contact school by text, phone or occasionally visits to explain why Jacob would not be in school on a particular day. When MJ occasionally reported she had taken Jacob to the GP, she was asked to provide evidence of prescribed medication for Jacob, although this request does not always appear to have been followed up by school. On one occasion records indicate that MJ came into school, with a bottle of Amoxyicillin, showing Jacob’s name but the date was obscured and could not be seen. There is little to suggest that Jacob’s absences, his frequent bouts of colds, coughs, sore throats and  tummy upsets, were seen as anything other than the usual childhood ailments.  8.5.6. Staff spoken to as part of the review were asked to reflect on why Jacob’s absences did not generate greater concern.  The review team was told by DSL2 that she believed there was a view held by some staff, supported by their experiences of working with other families from Eastern Europe, that parents  from these countries were ‘known’ to ‘mollycoddle15’ their children and keep them off school for longer than necessary. If this view did indeed hold sway, then it could explain why Jacob’s regular absences were not considered concerning enough to discuss formally with MJ or refer Jacob to the school nurse, who was in school for a few hours every week and easily contactable. The need to be sensitive to cultural differences is an essential component of best practice but the possibility that Jacob’s frequent absences from school were attributed to a cultural norm, rather than considering other explanations was of concern to the review team.  8.5.7. SCH1 is a primary school with a diverse pupil population. The review team was told that SCH1 prides itself on its cultural competence, being respectful of, and responsive to, the beliefs, practices, and cultural and linguistic needs of the children and families who attend the school. Interpreters are regularly   used to overcome any communication barriers and although Jacob began school with very limited English, it appears that MJ could communicate reasonably well and there were never any concerns about communication between school and family. The stereotyped assumption that families from Eastern Europe ‘mollycoddle’ their children would certainly not have helped to raise  15  ‘mollycoddle’  means to treat someone in an over-indulgent and over-protective way  21  concerns about Jacob’s persistent ailments and this,  together with  the unusually small number of children known to statutory services suggests some work may be needed with staff in school to improve understanding about the impact of stereotyping and bias, especially  in relation to safeguarding and vulnerable  children. The  issue  of professional bias  is further explored  later in this report.  Learning Point 3: Without challenge, a practitioner's knowledge and beliefs about children and families from different ethnic groups or migrant backgrounds can influence their ability and willingness to address the health, safety and well-being  needs of children.   8.5.8. The school nurse (SN1) in post during the period under review has now left her employment. At the time, SN1 was contracted to work 4 days per week for the Trust and spent 3 hours on a set day each week at SCH1. She would also have been available via email or phone at any time during the working week. Whilst it would not be expected that a school nurse  would be aware of every child who was poorly and absent from school, Jacob’s frequent absences due to ill-health could usefully have been brought to the attention of SN1. Certainly, best practice would have been that SN1 was notified when Jacob was ‘opened’ on CPOMS but SCH1 did not appear to have any formal system for discussing, on a regular basis children about whom there were concerns and where input from SN1 could be of benefit.   Neither is there evidence that the GP  sought to consult with  a  School Nurse about Jacob’s immunisations.  8.5.9. Jacob’s ‘accident’ in February and his  ‘ear infection’ in March were, according to agency records, discussed with MJ. Although not recorded in any detail, the explanations given were seen as plausible. Staff at SCH1, referring to their own experiences of parenting, agreed that given Jacob’s language difficulties, the ‘stick’ to which he referred was probably a cotton wool bud used to clean the discharge from his ears and MJ indicated as much when she was contacted. Jacob’s distress that he would have to go home with ‘that man’ was attributed to him being poorly and wanting to be with his mum. This may well have been the case but school staff made a comfortable ‘fit’ with  what they observed and what they were told and  by doing so,  avoided  having to consider  another and  possibly harsher reality.  8.5.10. A degree of healthy sceptism would have been expected at this point, given the research about risks posed by some non-related males who come to live in families where there are children. Unchecked assumptions can inhibit professionals from focusing on the child and family and this limits communication and exploration about what may be happening for a child in their family.  8.5.11. Although MJ gave the independent reviewer different information, CPOMS  records indicate that MJ told DSL2 that Jacob  ‘did not get on with her partner’. Jacob’s needs at this point were clearly recognised by DSL2 and were appropriately recorded on the school’s safeguarding reporting and recording system. However, DSL2’s conversation with MJ about the involvement of CSP was not formalised through a signed contract and  MJ’s ‘agreement’ was accepted at face value. The ensuing discussion with CSW1 was  on a similar ‘informal’ basis and consequently the work that may well have been helpful to Jacob was not prioritised by CSW1 so drift and delays  occurred and   DSL2 believed contact was being made with the family.   22  Learning Point 4:  When safeguarding concerns lead to children being ‘opened’ in CPOMS, key professionals should be notified and any discussions and plans made between agencies, should be formalised and recorded  so there is clarity about who is doing what, when and why.  The role and function of DSLs  8.5.12. The role of the Designated Safeguarding Lead (DSL) in schools is specified in the Children Act 2004. This states that every school has a ‘named’ DSL  who holds responsibility at both a strategic level within the school and on a day-to-day basis and ensures  that effective arrangements are in place to safeguard the welfare and safety of children and young people.  Whilst the activities of the designated safeguarding lead can be delegated to appropriately trained deputies, the ultimate lead responsibility for safeguarding and child protection, must remain with a named designated safeguarding lead and this responsibility should not be delegated.16   8.5.13. In SCH1, the lead DSL was the Headteacher, DSL1, whilst DSL2 had operational responsibility for managing safeguarding issues on a daily basis. Three other members of the senior management team were also identified as DSLs and had apparently been trained at the required level to take on the DSL role. The review team understood that these five individuals essentially worked as the safeguarding team and were each expected to offer guidance and support to school staff and keep abreast of any safeguarding concerns, which staff recorded on the CPOMS system.  8.5.14. The review team did not find any evidence that a clear system was in place for quality assuring this process or ensuring the checks were done systematically and on a daily basis. DSL1 was of the view that their arrangements worked well and information was shared and discussed appropriately. The rationale for having five DSLs, described in the school’s safeguarding policy, was to ensure decisions could be discussed within the team , thus creating a shared responsibility. The  importance, however,  of having a lead DSL who  makes the final decisions and leads on action is well researched and is explicitly described in the statutory guidance produced  specifically  for education. 17  Although DSL1  formally held this role, the review team were informed that some safeguarding decisions were delegated to DSL2.  8.5.15. The review team was told that all five DSLs met on a weekly basis as part of the Senior Leadership Team. Safeguarding issues were apparently discussed on a regular basis and were, it seems,  always a standing item on the agenda. There were however no minutes of these safeguarding discussions available or provided to the review team and none were recorded on the CPOMS system.   Learning Point 5: Safeguarding teams in schools, whatever their size,  should have  clear terms of reference to provide focus and structure for the ‘team’ and to ensure that decisions and discussions about safeguarding concerns are carefully considered,  properly  recorded and regularly  monitored. A system should also be in place to quality assure records and decision-making.   Skills and knowledge base of  professionals  8.5.16. The review team was told that all DSLs had received specific training for their role in 2018, provided by the local authority. All staff had also received safeguarding training from an experienced external  16 Keeping Children Safe in Education (2018, 2019) 17 Keeping Children Safe in Education (2019)   23  training provider, well-known to, and quality assured by  MSP. The s17518 audit for 2017-2018 was completed by SCH1 in line with statutory requirements and highlighted training needs around the use of CPOMS and monitoring actions when concerns about children emerged.  There does not seem to have been an action plan produced following this audit which would have been best practice and would certainly have strengthened safeguarding practice in SCH1.   8.5.17. In the UK, it is not a legal requirement for a parent to have a child immunised. Whilst parental refusal to vaccine, in itself, may not constitute medical neglect, it could be an early indication of neglect and/or that the family need access to support services and healthcare professionals need to be particularly alert to and curious about, a child’s immunisation history. The CQC19 expects all healthcare providers, including GPs, School Nurses and Health Visitors  to protect children and young people from harm, and help improve their wellbeing. Current guidance 20 sets out ‘minimum training requirements’, emphasising the importance of maximising flexible learning opportunities to acquire and maintain knowledge and skills, drawing upon lessons from research, case studies, critical incident reviews and analysis, and serious case reviews.  8.5.18. MSP seeks assurances about training  from partner agencies through three pathways: Section 11 audits, annual reports from partner agencies and  feedback and evaluations of training opportunities through a training report produced by the multi-agency Learning and Development group.  In effect, the partnership relies on self-reporting from agencies as to the quality and effectiveness of the training offered to, and taken up by the workforce.  The role of males in a family  8.5.19. Men play a very important role in children’s lives and have a great influence on the children they care for or with whom they are in regular contact. Despite this, research and SCRs suggest men are too often ignored by professionals who sometimes focus almost exclusively on the quality of care children receive from their mothers and female carers. A repeated finding21 is how often fathers and male figures are absent in recordings, assessments and care plans. When protecting and supporting children, practitioners in all agencies need to proactively assess and where possible engage with all significant men in a child’s life, understanding that some ‘may pose risks, some may be assets to the family, and some may incorporate aspects of both’.  8.5.20. Staff at SCH1 were clearly curious as to why Jacob referred to PMJ as  ‘that man’ and the ‘ ‘strong man’ who took care of him when ‘mummy was at work’. The curiosity did not however extend to finding out more about him – even to the extent of checking out his correct name with MJ, which remained misspelt in school records and on CPOMS. The review team had a sense from documents and conversations that school staff held a view that MJ’s partner, whoever he was,  not their concern.   18 The S175 section of the Education Act 2002 requires School Governing bodies to carry out an annual review of their School’s Safeguarding practice and to provide information to their Local Authority regarding how the duties set out in the guidance have been discharged.  19 Care Quality Commission (CQC) monitors, inspects and regulates health and social care services. 20 Roles and competencies for child safeguarding training are outlined in ‘Safeguarding children and young people: roles and competences for health care staff (2019) 21 Hidden men: learning from case reviews. NSPCC April 2015  24  8.5.21. There can be a reluctance on the part of professionals in agencies to ask or seek information about partners  or other adults who are living in the family and/or who may be significant figures in a child’s life; asking about the status of key relationships can be seen as intrusive. The review team was told by school staff that if the practice of checking out family relationships and who is who in families was to be adopted, they would be altering records on a weekly if not a daily basis. However, this is less about repeatedly changing school records,  rather it is about knowing what is going on in a child’s life and being aware of the well-researched risks that are posed to children by some  ‘new’ or relatively  unknown partners or adults  in families, some of whom can wilfully inflict physical and sexual harm on children with whom they have contact.  8.5.22. It cannot be known that if SCH1 had sought to discuss MJ’s partner with MJ, Jacob’s abuse at the hands of PMJ, could have been avoided. However, had more information been gathered about his relationship to Jacob and  there had been greater  curiosity about his role within the family,  staff may have been better equipped to talk more purposefully with  Jacob about what might be happening at home.  Learning Point 6: If professionals in contact with children do not purposefully and intentionally seek out information about who are significant people in a child’s life, the specific risks posed by some men are more likely to go unrecognised and this will leave some children vulnerable.    Professional Bias  8.5.23. Whilst staff were curious about why Jacob did not use PMJ’s name, they were less curious about PMJ himself and his role within the family. Professional curiosity is the capacity and communication skill to explore and understand what is happening with an individual or family. It is about enquiring deeper and using proactive questioning and challenge and understanding one’s own responsibility and knowing when to act, rather than making assumptions or taking things at face value.   8.5.24. The term ‘rule of optimism’ is used to describe the tendency of professionals working with children to favour the most positive interpretation of a parent or adults’ behaviour. This was evident when SCH1 accepted MJ’s explanation about Jacob’s head wound in March 2019, even though she was not present at the time and there were inconsistencies in the accounts provided by PMJ and Jacob. MJ’s description that PMJ had probably focused more on clearing up the coffee that Jacob had spilt, rather than checking to see if he was OK was readily accepted by SCH1  and was recognised and described as a ‘male thing’.  8.5.25. Given the nature and location of Jacob’s injuries – one on the face and the other on the back of the head, Jacob’s response and the involvement of an unknown male in the household, school staff should have demonstrated greater  curiosity about PMJ, but were it seemed reassured by MJ’s response in coming into school and offering an explanation about what had happened. When Jacob on another occasion did not want go home with ‘the man’ staff assumed that he wanted his mum because he was poorly. This may well have been the case but at that time, given what had happened only 2 or 3 weeks earlier, staff should have been alerted to other possibilities and explored the extent to which they were willing to acknowledge  some uncomfortable warning signs.  8.5.26. The review team was told that Jacob was very attached to his mum and the affection between the two was evident. MJ was described as always pleasant and cooperative with staff and was able to converse reasonably well in English; she apparently always attended school activities. DSL1 and  25  DSL2 agreed that, on reflection, this possibly drew them away from any thoughts that Jacob might be at risk from unsafe parenting. The review team was told that there was never any evidence to suggest that MJ avoided contact with school and it was never considered a possibility that Jacob was being kept off school to avoid scrutiny of any bumps or bruises. The  view that MJ was being overly protective of her son, if this view did indeed exist,  would certainly have influenced staff into believing that mum was very much a protective factor.  Research22 suggests that initial impressions of a parent, such as whether they are ‘cooperative and responsive’ influences the perceived engagement by the parent and this can reduce a professional’s perception of risk leaving children unseen and unheard.  8.5.27. A key theme in the existing research on professional reasoning and judgement is a tendency towards confirmation bias where professionals arrive at a conclusion about an individual and fail to see evidence, which challenges that initial view. The review team acknowledged that in a busy school, with lots going on and a reasonably responsive parent, who was cooperative and involved in school activities, staff, without any challenge, could be less likely, to adopt a questioning approach and therefore continue to take what they were told by MJ at face value.  Learning Point 7:  A cooperative and responsive parent has considerable power to disarm and distract professionals from exercising professional curiosity and questioning what may be happening a family  and this can leave children at heightened risk.    8.6. KLoE 3: The extent to which professionals collaborated and worked together  Liaison between agencies  8.6.1. Multi-agency working is about providing a seamless response to vulnerable children and their families. Jacob was in receipt of universal services and seen regularly by school and occasionally by health colleagues.   8.6.2. Given the number of absences from school on health grounds, 33 in Year 1, 15 in Year 2 and 18 in Year 3, expected practice would have been for SCH1 to make contact with their school nurse to establish if Jacob had any ongoing health needs which were not being met. This did not happen as SCH1 were reassured by MJ always keeping the school informed Jacob about  why he was not at school and Jacob’s school attendance did not meet the threshold for monitoring absences. Jacob was under regular review through the SEN process and did not, it would seem,  present as a ‘poorly’ child.  8.6.3. School nurses deliver universal and targeted services working across education and health, providing the link between school, home, and community. They are responsible for delivering programs to improve health outcomes for school age children and young people aged 5-19. This includes school entry screening and immunisations, therefore  had contact been made with SN1 by SCH1 or by GPP2, Jacob’s immunisation history would undoubtedly have been highlighted.    22 Making Threshold Decisions in Child Protection: A Conceptual Analysis. Platt and Turney (2013)     26  8.6.4. The role of the school nurse has changed significantly over the last decade. Research23 suggests that the role is exceptionally diverse, and many have described the service as being  stretched, over burdened and under resourced with most of their work focusing on safeguarding and child protection. However, there  is no evidence to suggest in this case, that SN1  was unavailable and although not able to contribute directly to this review, there  is little to suggest any attempts were made by SCH1 to make contact with the school nursing service, or that SN1 was asked to make contact with Jacob and MJ.  8.6.5. As part of the Healthy Child Programme (HCP)24 Health Visitors (HV) and School Nurses (SN) are commissioned to promote immunisations which GPs provide. When Jacob moved into the Manchester area, expected practice would be that the GP shared  ‘movement in’  information with the HV and when Jacob attended school, this information would be shared with the SN. There is no evidence of this in the HV or SN records and the review team was unable to determine why this information was not shared. It would have been helpful if the medical practitioners when trying to fix up appointments for Jacob’s immunisations had made contact with HV1 and later SN1 to find out whether they were aware of the family and were able to offer any insights into Jacob’s situation. Had there been any communication between the GP surgery, HV1 or HV2 and SN1, Jacob’s immunisation history would have emerged. The review team was unable to clarify exactly why contact was not made with SN1.  Learning Point 8: The significant changes in the remit and function of school nurses together with an overwhelming demand for their service may have left some professionals less clear about the  valuable service  these  professionals  continue to provide and the additionality  these roles  bring to multi-agency working.   8.6.6. CSW1 had worked with the school for almost 5 years and working relationships were described as good. The review team understood that the commissioned service is used to provide a support service for children and families and although the service, as mentioned previously, is not intended to provide supervision to staff in school, advice and guidance is occasionally sought from CSW1, especially when CSC referrals are being considered. The review team understand the work undertaken by CSW1 was discussed with the DSLs at termly review meetings. Records from the termly review in April 2019 refer to CSW1 making  ‘contact with [MJ] in Year 2 to offer parent’s support’.   8.6.7. Speaking with the review team CSW1 reflected that with hindsight, Jacob’s reference to ‘that man’ and MJ’s comments about him never settling with PMJ should perhaps have ‘rang alarm bells’.  When CSW1 was unable to make contact with MJ over a period of several weeks, this did not raise any concerns for CSW1 or DSL2 but for different reasons. CSW1 was not concerned about non-contact because her initial task was only to talk with MJ about CSP1 services. CSW1 was also aware that it was not unusual for families not to respond immediately to initial contacts even when they had agreed for their contact details to be passed on.   23 BMC Nursing s’ perspectives on the role of the school nurse in health education and health promotion in England: a qualitative study (2016)  24 Manchester Local Care Organisation (MLCO) Document 2018 – “Communication between General Practitioners and Health Visiting Guidelines  27  8.6.8. DSL2 was unaware, at least initially, that MJ was not responding to CSW1 but even so, having discussed the family with CSW1, she was reassured that CSW1 was ‘involved’ and was attempting to make contact. Whist there was very clearly mutual respect between DSL2 and CSW1, the  informality of this arrangement meant that no one held responsibility for progressing work with the family. The absence of any clear plan, focus or agreed timeline meant that no work was undertaken with the family or Jacob by any professional during the 8 weeks following MJ’s assertion that PMJ and her son ‘did not get on’.  The circumstances which led to the involvement of CSW1 was recorded on CPOMS and discussed with other  DSLs,  the agreement should however  have also been overseen by DSL1.   8.6.9. The dilemma of how to engage with resistant families whilst also maintaining a critical focus on whether parental avoidance is happening is found in research25 and suggests that professionals can often place too much reliance on ‘knowing’ the parent and fail to consider that families can be resistant to contact from professionals and are able to develop skilful strategies for keeping them at arms length. DSL2 and CSW1 did not consider the possibility that MJ may have deliberately been avoiding contact with CSW1 even although she appeared, in the words of DSL2 ,  to have been ‘open and honest’  about Jacob and PMJ and appeared keen to receive support to improve the relationships in the family. MJ’s lack of response to CSW1 was not seen by either professional as in any way significant and highlights the problems that can occur when the nature and status  of agreements  about interventions are unclear.  8.6.10. The reason for the involvement of CSW1 was not as well considered as it might have been and the lack of any signed agreement by MJ allowed work with this family to drift.  Without any clearly defined plan there was no ongoing focus on what was happening in Jacob’s life but the  apparent co-operation of MJ and her willingness to meet with CSW1  clearly  provided some reassurance to DSL2, an issue already highlighted in Learning Point 7.  Learning Point 9: Where schools propose parents engage with any of their commissioned services, clear information about that service should be provided by the school so parents can make an informed decision as to whether they wish to engage with that service  and for what purpose. Any agreement should be captured in a written contract.   School’s relationship with CSC 8.6.11. SCH1 described their relationship with CSC as good, with DSL2 having regular contact with colleagues in that agency. There was an awareness of the wider pressures on the front door of children’s services which in SCH1’s view meant that sometimes children and families did not get the help they needed early enough to prevent difficulties escalating. SCH1 considered they were fortunate in having their own resource, provided by CSP, to provide early help to families at levels 1 and 2. Nevertheless, there was still a frustration that when SCH1 had shared concerns with CSC, the responsibility for working with the child and the family had been passed back to them. In the light of that experience, SCH1 considered they acted appropriately by  commissioning  CSW1 to work with the family.    8.7. KLoE 4: Managerial Oversight and MASH   25 Ofsted, 2008, Evaluation of 50 SCRs  28  Accountability and governance   8.7.1. Governing bodies and proprietors in schools are required to have a senior member of the board take leadership responsibility for their school or college’s safeguarding arrangements and ensure that a senior manager within school has lead responsibility for safeguarding and child protection, i.e. a senior DSL.26   In SCH1, the Headteacher held this role. The school was inspected by Ofsted in November 2017 and was rated as ‘Good’, with effective safeguarding arrangements in place.  8.7.2. In 2018, CSW1 was asked by DSL1 to sit on the board of governors, which, with the support of her line manager, she agreed to do. Although she did not hold the role of lead safeguarding governor, she nevertheless brought her social work background, knowledge and expertise to her governor role and in any other circumstance, such an individual would be a welcome addition to any board of governors. However,  the obvious conflict of interest of  CSW1 also being a commissioned provider to the school was not  as well understood as it might been even though it had been explored by CSW1’s line manager, the agency HR manager and DSL1. In effect this meant that as a governor CSW1 was  quality assuring safeguarding arrangements in school and her own practice. The situation has now been rectified and CSP have ruled that staff working in schools cannot sit on the board of governors of any school commissioned by the agency. This issue did however, raise questions for the review team as to how well governors understood their safeguarding responsibilities and, notwithstanding the Ofsted report from 2017, how well they were able to discharge these with confidence. Learning Point 10: Governing bodies in all schools have a responsibility to ensure they are well equipped to discharge their safeguarding responsibilities and that  robust systems are in place to quality assure  safeguarding arrangements  in their school.   Supervision and support for DSLs 8.7.3. Although an analysis of schools in Manchester who completed the 2018/2019 s175 safeguarding audit indicated that 90% of staff received supervision, the  review team was made aware that the DSLs in SCH1 did not receive any formal supervision sessions from DSL1. Neither did DSL1, as the lead,  have access to supervision or support around her own practice and decision-making. School staff have more access to children than any other social care provider and are well placed to pick up on mental health issues, trauma, neglect, abuse and generally safeguard children. Whilst other emotionally intense professional roles such as social workers and health care practitioners have structured opportunities to reflect with an experienced senior colleague, on their practice and decision-making, the support needs of DSLs have not always been recognised.  8.7.4. Supervision ensures cases don’t drift, maintains the focus on the child, and helps professionals to find out the evidence base for assessment and intervention. Whilst forthcoming statutory guidance  does not, worryingly,  refer to the importance of supervision for DSLs in schools, there is nevertheless an acknowledgement by well-informed professionals, that DSLs  should be given the time, resources and support to effectively discharge  their safeguarding responsibilities. There is a Safeguarding in Education team in Manchester who provide this support to Manchester schools  and who facilitate  meetings for DSLs,  but SCH1 had not availed themselves of the support offered.   26 Keeping Children Safe in Education 2019  29  8.7.5. The review team was struck by the impact on DSL1 and DSL2 of what happened to Jacob and their sense of bewilderment that, despite their training and considerable experience, they had, on this occasion, not believed that Jacob was a child at risk of harm. Both professionals were able to helpfully reflect on this and concluded that they had, with hindsight, accepted MJ’s explanations too easily and had not considered Jacob’s life from his perspective as well as they might have done. It should be noted that the review team were advised that actions of DSL1 and DSL2 to seek the involvement of CSP without reference to CSC were supported by other DSLs in school.  8.7.6. The role of CSP in supporting families in SCH1 is to be welcomed, but it might be helpful if the role is more clearly defined as access to the ‘CSP social worker’ may be seen as a shortcut to help DSLs with their decision-making and assessment of ‘risk’ in families. This is not appropriate and is not in line with the service level agreement seen by the review team. CSW1 confirmed she has regular supervision with her manager who has oversight of her work and case records. As she did not get to meet MJ or Jacob, her manager was simply informed that she had not been able to make contact with the family and no further discussions took place around her role with the family or the purpose of her involvement.  8.7.7. CSP has now strengthened their referral process to ensure that the information shared is detailed and accurate and there is greater clarity around roles and respective responsibilities and the purpose of any contact with families is discussed in supervision. These changes will, going forward, strengthen existing relationships between SCH1 and CSP and lead to improved  outcomes for families.   8.7.8. All education staff struggle at times to deal with the complexity of their pupils’ lives, alongside the requirement to achieve the required academic outcomes and the subsequent workload and associated stress that comes with that. However, some roles, such as DSLs need to make difficult decisions and are more likely to regularly encounter incidents of high emotional impact, this means that supervision for these key roles is essential if children are to be well-protected  and  the need for early intervention responses recognised.  8.7.9. During the lockdown period, the Safeguarding in Education team have been consulting with DSLs on a weekly basis to offer support and pick up any complex safeguarding issues. Such an approach is to be welcomed and clearly recognises  the support that DSLs  require so that they can  discharge their safeguarding responsibilities effectively.  Learning Point 11: Without systems and formal opportunities to reflect on their practice and decision-making and be helpfully challenged about their thinking, human errors are more likely to occur. Best practice means DSLs have access to opportunities to develop their practice, and be both challenged and supported  in relation to the professional judgements they make.   Keeping and maintaining records  8.7.10. There are no records in either CSP or SCH1, which capture in any detail the discussions held between DSL2 and CSW1. The review team understand from CSW1 that although she kept notes for herself as to the work required, she was unable to upload these onto Lamplight27 because there was no consent form or referral to  ‘open’ the case on the CSP system. The CSP procedures seen by the review team did allow for contact to be made with families without this document although  27 This is the recording system used by CSP  30  social workers were required to obtain signed consent forms before any actual work began. In this respect CSW1 did not work outside of her agency’s  procedures. 8.7.11. However the system in place at the time provided no means by which the details of initial pre-referral contact with families could be recorded without the family being ‘opened’ on the system and the only way of ‘opening’ the case was via a signed consent form. This effectively left some contacts with family’s undocumented and not subject to managerial oversight or discussion.  8.7.12. CSP have now changed their procedures to ensure that all initial or informal conversations about families are documented and their recording systems have been adapted to make this possible, ensuring that any amendments to the system are GDPR compliant. Case file audits   have also been strengthened to ensure that all relevant and significant information is recorded on case files. 8.7.13. Well-kept records are essential to safeguarding children and young people. It is easy to overlook the significance, value, and complexity of case recording, and to treat it merely as an administrative task. Good record keeping, as a key aspect of a school’s accountability to children and their families help  DSLs meet their  responsibilities  to respond appropriately to concerns for children. The review team was told that reporting concerns is the responsibility of every member of staff and some training had been given to staff about the CPOMS system, introduced in 2017, to ensure they know when and how to record concerns about a child, however small or apparently insignificant.  8.7.14. CPOMS is an established and effective case management system if used properly. It allows for staff to add any concerns to the system, within a restricted area and for the DSL to ensure that all entries are noted, addressed and actions, and the rationale for these, recorded. The records kept in relation to Jacob, where they existed were minimal. PMJ’s first name was spelt incorrectly in all the entries, implying that no one had been curious enough to find out some basic information about this individual. The absence of any records of meetings with MJ or minutes of the weekly DSL discussions, which can easily be stored on the CPOMS system, demonstrated practice that fell well below expected standards. This should have been addressed by DSL1 whose responsibility it was to maintain managerial oversight of the   records on CPOMS, and to be assured that decisions and actions were appropriate and/or followed through.  8.7.15. The need for the lead DSL to monitor records and reflect on what is or might be happening to children about whom there are concerns is a key aspect of the lead DSL role, providing as it does, a check and challenge function which helps to avoid professional complacency and drift. The review team found no records or evidence of a system, which demonstrated that the lead DSL regularly monitored CPOMS28 entries, but neither was there evidence that the safeguarding school governor had oversight of how well the CPOMS system was being used. The roles of the 5 DSLs in SCH1 were not well defined and therefore, responsibilities of who was doing what in terms of recording were not clear.  8.7.16. Despite a very positive Ofsted report in 2017, which stated that the leadership team in SCH1 ‘has ensured that all safeguarding arrangements are fit for purpose and records are detailed and of good quality’, the review team are of the view that in this case, record-keeping did not meet expected standards. Practice around recording practice has however now been reviewed and strengthened    31  with staff being skilled-up to make better use of CPOMS and  systems  introduced to ensure concerns are appropriately addressed progress monitored.  Learning Point 12: Well-kept records are tangible products of concerns, interventions, and actions taken to safeguard and protect children and it is vital that they are recognised as such. Without systems in place in schools  to ensure these records are kept up to date and carefully maintained, work to keep children safe will be compromised and likely to be less effective.    8.7.17. Recording practice can be viewed by professionals as a time-consuming activity but it is only by keeping accurate, relevant, and up to date records that patterns and cumulative information emerge and the child’s experiences can be understood and shared when necessary with other agencies.  8.8. KLoE 5: Jacob’s voice and the extent to which professionals were curious about his lived experiences  Keeping the child in focus 8.8.1. Much of the existing research and evidence on communication with children and young people comes from inquiries into child abuse and serious case reviews. A persistent finding in reviews  of cases where children have been seriously harmed is that professionals have not adequately engaged with, or related to, the children concerned.29  These reviews have invariably contained scenes where professionals were in the presence of abused children, but they did not get close enough to discover what was happening in their lives.  8.8.2. The review team has not been provided with any first-hand information about Jacob - what he looked like, who his friends were, what he enjoyed doing at school - other than the comments he apparently made in response to questions about injuries. By February 2018, Jacob had attended SCH1 for eight school terms and until then, there had been no significant concerns raised about Jacob, his well-being, safety or how he was parented.   8.8.3. The review team was informed that all children attending SCH1 receive a home visit when they first begin in reception class and although these visits are not recorded, any observed or emerging concerns are  shared with the SEN/DSL as appropriate. Jacob received 1-1 intervention in his first year to help with his language and academic progress and this continued in Year 2. Although Jacob remained on the SEN register, he was never formally assessed, but by being on the register, the review team was told, his progress was supported and monitored.  8.8.4. The references in agency records to Jacob being ‘quirky’ and having indicators which could indicate he had a form of Aspergers 30 would suggest that Jacob was seen in some way as being ‘different’ but even given the diverse population of children on roll at school, the review team was told he did not ‘stand out ‘in any way.  8.8.5. The fact that Jacob was on the SEN register, together with his frequent absences on ill health grounds, and the fact that from March 201731, he was open on CPOMS, would however suggest a  29 How children become invisible in child protection work: Findings from research into day-to-day social work practice, British Journal of Social Work, (2016) 30 Asperger’s syndrome is a developmental condition characterised by significant difficulties in social interaction and nonverbal communication, along with restricted and repetitive patterns of behavior and interests.  31 Previous incident when Jacob was found in the playground with trousers and underwear pulled down.   32  vulnerability that was not recognised by school staff as well as it might have been. It would have been helpful had school staff been a more curious about Jacob’s continued absences and sought to understand more about his lived experiences.  8.8.6. There is no evidence to suggest that staff at school sensitively reached out to Jacob to find out what his life was like at home. Jacob’s voice is not evident in any school records seen by the review team and there was a sense from conversations with some staff that these types of sensitive conversations were regarded as belonging in the social worker’s domain. In fact, any ‘trusted adult’ in school could have taken time to establish a rapport with Jacob and learnt a little more about his lived experiences; what he saw, heard, and experienced at home  on a daily basis.  8.8.7. School staff are understandably anxious about initiating these types of conversations with children, being acutely aware of the danger of treading into investigative territory. Whilst acknowledging the caution needed before any child is spoken to about home and family, the review team was of the view that staff in school could have done more to talk with Jacob and listen to what he was saying and importantly, perhaps what he was not saying. The notion of ‘invisibility’ does have some explanatory power in how Jacob was not ‘seen’ by school staff in the most rudimentary sense even though he was right in front of them. Any reservations the DSLs might have had about adopting this course of action could easily have been allayed by contact with CSC. Instead, MJ’s account, and not Jacob’s,  became the narrative which described Jacob’s life at home.  Learning Point 13:  Unless practitioners are supported to remain curious about the lives of children and  recognise the importance  of trying to understand what is happening in a family rather than making assumptions or accepting things at face value, harm that some children are experiencing  may not be recognised.   9. Summary  9.1. This review provides a reminder for all professionals of how easy it is to lose sight of a child’s day-to-day life.  There were some fundamental weaknesses in the safeguarding systems in SCH1, which meant that what might have been happening to Jacob at home was not well considered or explored.  9.2. The central and universal positioning of schools is key to effective safeguarding practice, located at the heart of the community,  schools provide a consistent, accessible, and supportive environment throughout a child’s schooling. Staff are able to observe a child’s development, witness interactions between the child and their parents either end of the school day, and monitor their health, safety and wellbeing. They are in a particularly advantageous position for children to seek help and support from adults they may trust. This makes the safeguarding role of school staff and particularly DSLs,  as a collective group, highly valuable in the effective delivery of collaborative safeguarding practice.  However without appropriate checks and balances, good partnership working with other professionals and crucially,  without opportunities for reflective and challenging supervision, errors in professional judgment can too easily occur and this can leave some children, like Jacob, vulnerable.   9.3. The review team appreciated the extent to which key staff in SCH1 and CSP talked openly and honestly about their practice and decision-making. Their reflections and insights indicated personal  33  learning which alongside changes within their organisations can serve only to strengthen safeguarding arrangements  in their respective agencies.   34   10.  Summary of Learning Points  Learning Point 1: When concerns about children arise and agencies are considering  whether a referral to CSC should be made, or are uncertain about next steps,  the starting point should always be a dialogue with CSC so agencies can make informed decisions about the appropriate  course of action.     Learning Point 2: Without systems in place for  a child’s immunisation history to be flagged in medical records,  the  health needs of some children may be overlooked. Where a child does not have an immunisation history, professionals should explore the reason for this with parents.  Learning Point 3: Without challenge, a practitioner's knowledge and beliefs about children and families from different ethnic  groups or  migrant backgrounds can influence their ability and willingness to address the health, safety and well-being  needs of children.   Learning Point 4:  When safeguarding concerns lead to children being ‘opened’ in CPOMS, key professionals should be notified and any discussions and plans made between agencies, should be formalised and recorded  so there is clarity about who is doing what, when and why  Learning Point 5: Safeguarding teams in schools, whatever their size,  should have  clear terms of reference to provide focus and structure for the ‘team’ and to ensure that decisions and discussions about safeguarding concerns are carefully considered,  properly  recorded and regularly  monitored. A system should also be in place to quality assure records and decision-making.    Learning Point 6: If professionals in contact with children do not purposefully and intentionally seek out information about who are significant people in a child’s life, the specific risks posed by some men are more likely to go unrecognised and this will  leave some children vulnerable.    Learning Point 7:  A cooperative and responsive parent has considerable power to disarm and distract professionals from exercising professional curiosity  and questioning what may be happening a family  and this can leave children at heightened risk .  Learning Point 8: The significant changes in the remit and function of school nurses together with an overwhelming demand for their service seems to have left some professionals less clear about the valuable service  these  professionals  continue to provide and the additionality  these roles  bring to multi-agency working.   Learning Point 9: Where schools propose parents engage with any of their commissioned services, clear information about that service should be provided by the school so parents can make an informed decision as to whether they wish to engage with that service and for what purpose.  Any agreement should captured in a written contract.  Learning Point 10: Governing bodies of schools have a responsibility to ensure they are well equipped to discharge their safeguarding responsibilities and that robust systems are in place to quality assure  safeguarding arrangements  in their school.   Learning Point 11: Without systems and formal opportunities to reflect on their practice and decision-making and be helpfully challenged about their thinking, human errors are more likely to occur. Best practice means DSLs have access to opportunities to develop their practice, and be both challenged and supported  in relation to the professional judgements they make.  35   Learning Point 12: Well-kept records are tangible products of concerns, interventions, and actions taken to safeguard and protect children and it is vital that they are recognised as such. Without systems in place in schools to ensure these records are kept up to date and carefully maintained, work to keep children safe will be compromised and likely to be less effective.    Learning Point 13:  Unless practitioners are supported to remain curious about the lives of children and  recognise the importance  of trying to understand what is happening in a family rather than making assumptions or accepting things at face value, harm that some children are experiencing  may not be recognised.   11.  Recommendations Multi-Agency Recommendation 1:  MSP should consider how it can be assured that the Advice and Guidance Service (AGS) is working well and agencies are accessing the service responsibly and within appropriate timescales.   In relation to:  Learning Point 1: When concerns about children arise and agencies are considering whether a referral to CSC should be made, or are uncertain about next steps, the starting point should always be a dialogue with CSC so agencies can make informed decisions about the appropriate  course of action.      Multi-Agency Recommendation  2:   MSP should seek assurance, through the current Workforce Safeguarding Strategy,  that all agencies provide their workforce with  briefings and access to training which  supports awareness and the development of culturally competent practice. Specifically, MSP should seek assurance that all professionals, including safeguarding leads in schools are well-equipped to work with diversity, culture and ethnicity in safeguarding work.   In relation to:  Learning Point 3: Without challenge, a practitioner's knowledge and beliefs about children and families from different ethnic groups or migrant backgrounds can influence their ability and willingness to address the health, safety and well-being  needs of children.    Multi-Agency Recommendation  3:   Learning from this review echoes  repeated findings from  national serious case reviews in relation to ‘significant males’ and the need for professionals to  have a healthy scepticism about the what they are told by parents/carers about significant adults in their family.  MSP should explore in some depth how supervision, team learning,  training programmes,  and  other approaches,  can  be utilised to help professionals improve their skills as professionally curious practitioners in ways  that  are safe,  supportive and  challenging.     36   In relation to: Learning Point 6: If professionals in contact with children do not purposefully and intentionally seek out information about who are significant people in a child’s life, the specific risks posed by some men are more likely to go unrecognised and this will leave some children vulnerable.    Learning Point 7:  A cooperative and responsive parent has considerable power to disarm and distract professionals from exercising professional curiosity and questioning what may be happening a family and this can leave children at heightened risk  Multi-Agency Recommendation  4:   MSP should promote awareness across the partnership of the importance of immunisations for children and the necessity of exploring with all parents, whatever their culture or background,  their child’s immunisation history.   Learning Point 2: Without systems in place for  a child’s immunisation history to be flagged in medical records,  the  health needs of some children may be overlooked. Where a child does not have an immunisation history, professionals should explore the reason for this with parents.  Multi-Agency Recommendation  5   a) MSP should ensure the system in place for quality assuring safeguarding audits and action plans  in schools and partner agencies,  is  robust.  b) MSP should seek  confirmation how the learning points below and which relate specifically to schools  will be addressed.    In relation to: Learning Point 4:  When safeguarding concerns lead to children being ‘opened’ in CPOMS, key professionals should be notified and any discussions and plans made between agencies, should be formalised and recorded  so there is clarity about who is doing what, when and why  Learning Point 5: Safeguarding teams in schools, whatever their size, should have clear terms of reference to provide focus and structure for the ‘team’ and to ensure that decisions and discussions about safeguarding concerns are carefully considered,  properly  recorded and regularly  monitored. A system should also be in place to quality assure records and decision-making.    Learning Point 9: Where schools propose parents engage with any of their commissioned services, clear information about that service should be provided by the school so parents can make an informed decision as to whether they wish to engage with that service  and for what purpose. Any agreement should  be  captured in a written contract.   37  Learning Point 10: Governing bodies in all schools have a responsibility to ensure they are well equipped to discharge their safeguarding responsibilities and that  robust systems are in place to quality assure  safeguarding arrangements  in their school.   Multi-Agency Recommendation  6   MSP  should consider whether any  actions are needed to ensure that professionals in all agencies  fully understand the role, remit and function of School Nurses    In relation to:  Learning Point 8: The significant changes in the remit and function of school nurses together with an overwhelming demand for their service may have left some professionals less clear about the valuable service  these  professionals  continue to provide and the additionality  these roles  bring to multi-agency working.     Recommendation: Clinical  Commissioning Group   Actions should be taken to remind health professionals about a  link between bi-lateral ear bleeds and trauma. (see para 8.4.28)     End/ 38  Appendix 1   Agencies represented on the Review Team   Diocese /Commissioned  Service Provider  Greater Manchester Police (GMP) Manchester City Council – Childrens Social Care (CSC) Manchester City Council – Education Team Manchester University NHS Foundation Trust (MFT) Manchester Health & Care Commissioning (MHCC) Northern Care Alliance (NCA)  