Death of a child in spring 2018. Child V died following an acute asthma attack. Learning includes: neglect strategies and assessment tools can help practitioners assess the degree of neglect and clarify what the focus of intervention should be; the risk of parents' needs overshadowing or distracting practitioners from considering the child's experience; when a father/male carer seen as posing a risk moves out of the family home, it cannot be assumed the risk has been reduced; when there are long- term concerns about a child, there is a risk that reports will be lost in the wealth of information; assessment of parenting capacity is particularly challenging if a child has complex needs; in neglect cases, there is risk of over-optimism if improvements are looked at in isolation; for children with additional needs, learning disabilities or medical conditions, there is a need to look beyond the diagnosis and consider a holistic assessment of the child's needs. Recommendations include: assessment practice, especially in neglect cases and if there have been multiple referrals, is robust and always includes analysis of parenting capacity; that practitioners are aware of the available neglect assessment tools and confident with their use; neglect training and practice development is supported by reflective supervision and robust management.
      
 Title:  Serious case review: S33 – Child V. LSCB: Pan-Dorset Safeguarding Children Partnership Author: Karen Tudor Date of publication: 2020  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.                           29.09.2020         SERIOUS CASE REVIEW         S33 – CHILD V     Independent Reviewer Karen Tudor August 2019  Serious Case Review, Child V Page 1     CONTENTS  PAGE INTRODUCTION   Events leading to this Serious Case Review Method Family Participation in the Review Summary of Child V’s Background   SUMMARY OF INTERVENTION           Education            Health   GP Involvement  Child and Adolescent Mental Health Service (CAMHS)   Long Term Health Conditions   Early Help Children’s Social Care  Police  Housing    FINDINGS AND LEARNING         Asthma Management       Recognising Neglect Adult Focus       Working with Fathers        The Child Protection Procedures Understanding of Parenting Capacity       Early Help and Effective Planning  Application of the Threshold Document  Diagnostic Overshadowing The Value of Reflective Supervision Understanding the Child’s World        SUMMARY OF LEARNING    CONSIDERATIONS FOR THE SAFEGUARDING PARTNERSHIP  APPENDICES       Serious Case Review, Child V Page 2    INTRODUCTION  Events leading to this Serious Case Review 1. This Serious Case Review (SCR) was commissioned following the death of a child in the Spring of 2018. The child, known as Child V, died following an asthma attack.    2. Child V had been receiving treatment for asthma, for a number of years, and because the cause of death was a known health condition, at the time of Child V’s death a SCR was not considered appropriate or necessary. As the Child Death Process1 progressed over the following year, further information emerged about the involvement of numerous agencies over many years with Child V and the family; this suggested there may have been unidentified neglect and that there were opportunities for learning.   3. The local Safeguarding Board carried out a Rapid Review2 which concluded the case met the criteria for a Serious Case Review. The recommendation was endorsed by the National Panel3 and the SCR process began.   Method 4. The local Safeguarding Children Board had not yet fully implemented the new arrangements, set out in Working Together 2018, therefore the method and terminology is that described in Working Together 2015. The Serious Case Review sub-group oversaw the process and commissioned an Independent Reviewer.   5. The SCR Panel4 decided that the Review would consider the whole of Child V’s life. This is unusual for a SCR and was felt to be necessary because of the long-term involvement of practitioners with the family, which seemed to have produced very little change.   6. Written reports were requested in the form of chronologies and analysis of events and conversations were held with the agency authors and practitioners. Learning was identified  1 Child Death Overview Panels (CDOPs) are responsible for reviewing information on all unexpected child deaths. They record preventable child deaths and make recommendations to ensure that similar deaths are prevented in the future. 2 Rapid Review – Safeguarding Boards are required to undertake a Rapid Review into all serious child safeguarding cases within fifteen working days of becoming aware of the incident. 3 The National Safeguarding Practice Review Panel decides if a Serious Case Review (WT 2015)/ Local Child Safeguarding Practice Review (WT2018) is required and informs the local LSCB/Partnership of their decision.  4 See Appendix for membership Serious Case Review, Child V Page 3    and considered in the light of current research and relevant evidence from other Serious Case Reviews.   7. The Reviewer also considered changes and developments in policy, procedure and practice which have taken place in Dorset during Child V’s life; whereas learning can come from past experience, recommendations are based on current practice.     Family Participation in the Review   8. Child V’s family were invited to participate in the Review and Child V’s mother, and maternal grandfather met with the reviewer. Where relevant to learning, their views are represented in the report.    Relevant Family members are:  • Child V – Subject of the Review • Ms CM – Child V’s mother • Mr CF – Child V’s father  • Siblings 1, 2 and 3, all primary school aged children.  • Ms VGM – Child V’s Maternal Grandmother    Summary of Child V’s Background   9. Child V and three younger siblings lived with their mum.  The father had moved out of the family home when Child V was about 6 years old, although there was still some contact. Both of Child V’s parents were thought to have had troubled childhoods and both were described in the records as having “mental health” difficulties, including Ms CM having post-natal depression following the birth of her children.   10. Mr CF described himself as a regular cannabis user with associated health problems, he had sought help for anger issues. Ms CM was a teenager when Child V was born.  11. During their early life, Child V had witnessed a number of traumatic incidents over a period of a year, including domestic abuse, which may have continued after the father had left.  Serious Case Review, Child V Page 4    During the late preschool period, Child V also witnessed a close family member attempting suicide by hanging..   12. Child V was diagnosed with asthma as a young child and there was a history of excessive prescriptions of asthma inhalers which suggested poor management of the condition.   13. Child V exhibited challenging behaviour at home and at school, which included anger, violence and soiling. Child V had been known to CAMHS since 4 years old. Child V was permanently excluded from primary school, when 8 years old, and after some time spent in a Thrive base5, was offered a place at a new school for a “fresh start” and was given 1:1 support as part of an EHCP6.   14. The underlying causes of Child V’s behaviour were thought to be related to early life experiences and attachment difficulties.  In addition there was a formal diagnosis of being on the autistic spectrum (ASD) a year before death. Following the diagnosis, there was an offer of a place at a school for children with additional needs, where one and half terms were spent.   15. Child V died at home in the spring of 2018.     5 The THRIVE base is a small nurture-based intervention for the children in our school who need additional help with their social and emotional needs. The aim of the THRIVE base is to provide a therapeutic teaching and intervention programme to support children with their social and emotional difficulties.   6 Introduced in September 2014, an Education, Health & Care Plan (EHCP) is a document which sets out the education, health and social care needs of a child and the support that is necessary to cater for those needs. Serious Case Review, Child V Page 5    SUMMARY OF INTERVENTION Education • 2010 – 2015 School 1  • 2015 – 2017 School 2  • 2017 – 2018 School 3 (up to the time of Child V’s death) • 2017 – Educational Psychologist  Health  • 2006 – 2010 Health Visiting • 2009 – 2015 Steps to Wellbeing (adult mental health service)                          Intermittent involvement with Ms CM • 2006 – 2018 GP  • 2010 – 2018 CAMHS, intermittent involvement • 2010 – seen by dietician, poor diet • 2011 – Paediatricians, 2 emergency admissions for exacerbations of his medical condition; asthma  • 2014 – Enhanced School Nursing, liaison with Children’s Social Care   Early Help • 2010 – 2017 Chesil Education Partnership – Early Help. (education run service de-commissioned in 2017) •  2017 – 2018 Family Partnership Zone – Early Help provided by Dorset County Council. (up to time of Child V’s death)   Children’s Social Care  • 2010 – 2017   18 referrals, 8 progressed to assessment. • October 2012 – May 20014 active involvement, Child in Need case.  • 2014 – 3 assessments, no ongoing role identified  • 2017 – Most recent referral about poor parental supervision, no response recorded, Police • 2009 – report of poor parental supervision • 2011 – domestic abuse report x2 • 2013 – report of poor parental supervision and report of an injury to Child V • 2014 – domestic incident • 2017 – reports of poor parental supervision x3   Serious Case Review, Child V Page 6    Housing  • 2006 – 2017 – intermittent support, 12 moves in 11 years   Education  16. In 2010, Child V started in the reception class at a local school, for the purposes of this report known as School 1. The school identified that Child V needed additional support primarily with issues of diet and school attendance and convened a CAF7. At this point Child V was said to be toilet trained, however by 2012 soiling was a persistent problem.   17. Although the CAF appeared to have had some success, in 2012 and again in 2013 the school referred Child V to the CAMHS service who began working with the family to try and address Child V’s challenging behaviour.   18. Despite substantial efforts and resources, Child V’s violent behaviour towards other children and to staff, became increasingly difficult to manage. There was an exclusion from school for increasingly long periods until there was a permanent exclusion in February 2015 when aged 8 years old.   19. Child V was out of school from February 2015 until November 2015 and then gradually integrated into mainstream education, School 2, supported by staff from the Chesil Education Partnership8 through the Thrive Education Zone.   20. At School 2, Child V’s behaviour continued to be a challenge for staff at school and also at home. For example, the refusal to comply with instructions, throwing things, damage to property and sometimes violent towards other pupils. On at least one occasion, Child V was curled up on the floor sobbing and was extremely distressed.   21. There was soiling at school and there were no clean clothes or wipes provided. Hygiene was compromised by soiling; Child V was described by a member of staff as “always  7 Common Assessment Framework (CAF): this is a process for gathering and recording information about a child for whom a practitioner has concerns identifying the needs of the child and how the needs can be met.  It is a shared assessment and planning framework for use across all children’s services and all local areas in the UK.  Sometimes referred as Early Help, it helps to identify in the early stages the child’s additional needs and promote coordinated service provision to meet them. 8 The Chesil Education Partnership was formed in 2004 as a partnership of local schools and colleges. Its aim was to provide early, multi-agency support to children with additional needs. It was decommissioned in 2017 and all Early Help services are now offered under the Council umbrella through Family partnership Zones. (FPZ)  Serious Case Review, Child V Page 7    smelling like that.” In 2016, Child V told staff that they hated their own teeth, as “they are dirty” and also said that they didn’t clean them and never used the toilet at home.   22. Child V refused to be in a school photograph “because their t-shirt was dirty and hair was a mess”. In October 2016, Child V reported to staff feeling tired because all the family (four children and Ms CM) were sleeping in the “girls’ room with the TV and films on until late.” There were reports that the asthma was affecting Child V at school, but medicine was not available for use.  23. It is clear, from discussions, that the school worked hard to engage Child V and help manage emotions.  Child V was in a small class of six children with three staff who knew Child V well and formed a relationship with Child V. They were keen to avoid an exclusion and, in December 2017, Child V returned to the Thrive Zone with a plan for a managed move to a specialist provision, School 3. Child V had been at School 2 for just over a year.   24. From 2015, discussions were taking place about whether Child V might be on the autistic spectrum. In 2017, a formal diagnosis was made of Autistic Spectrum Disorder (ASD)9 with traits of Attention Deficit Hyperactivity Disorder(ADHD);  School 1 and School 2 were given advice about how to manage Child V and in September 2015 an Education Health and Care Plan (EHCP) was agreed.   25. In 2017/18 Child V attended School 3 for one and a half terms in the period leading up to the time of death; the school is a specialist provision. Child V’s behaviour continued to be a challenge for staff and there was still soiling and not being given incontinence pads to bring to school.   26. Not long after starting this school Child V felt unwell and had symptoms related to asthma, but Child V had no asthma inhaler and Ms CM reportedly said she had not picked one up from the GP. The school were concerned that Ms CM did not appear to be taking the situation very seriously.   27. The school shared their concerns with the Family Partnership Zone (Early Help) who were providing support to the family.  Child V’s school attendance was dropping, there were problems around the use of Child V’s asthma medication and the school felt there were “clear issues around neglect.” FPZ and Child V’s school discussed the case and collated their concerns with a view to making a referral to Children’s Social Care however, they decided  9 ASD, more recently described as ASC, Autistic Spectrum Condition. Serious Case Review, Child V Page 8    that a referral would not meet the threshold for intervention by Children’s Social Care and did not pursue this.   28. The decision not to refer at this point was based on the past response of Children’s Social Care and the staffs’ feeling that they had insufficient evidence of harm, as the situation was much the same as before. There is no evidence that the school staff (who have since retired) consulted with their own designated Safeguarding Lead.    Health  GP Involvement 29. During the period of this Review, Child V, the siblings and mother were registered at two practices, moving from one to the other.  A close relative of Child V worked at one of the practices as a Health Care Assistant.   30. Mr CF was registered at a different practice. In 2010, he asked for help with his anger, and disclosed domestic abuse and cannabis use. The GP records about his mental health are incomplete, with no documentation of any significant events that might have impacted on Child V.  31. In 2008, when Child V was a toddler, the records refer to Child V’s asthma. In 2016, the notes refer to Child V’s asthma control being poor “due to autism.”  32. In 2010 a GP became aware of Child V’s emotional well-being when Ms CM described Child V’s behaviour towards a younger sibling, which appeared to be a copy of a traumatic incident witnessed involving the father.  The GP made a referral to CAMHS and on their advice, to Children’s Social Care.  33. In 2016/2017, numerous prescriptions for Child V’s asthma medication were issued, more than one a week.  At the first surgery, these were written by Child V’s relative and signed by a GP without question.  When the family changed surgeries, the practice of repeat prescriptions continued.  Only one asthma review is noted in the record, this was in 2015. There was no standard approach to the assessment of this common childhood condition at either surgery.   34. The Practice, where the relative worked, were aware that she was able to access Child V’s medical file, issue prescriptions and by-pass the overdue asthma checks. In addition to this Serious Case Review, Child V Page 9    Review, the CCG10 carried out a thorough review of the GP surgery’s intervention with   Child V.   35. The conclusion of the CCG Review was that Child V’s asthma monitoring was well below an acceptable standard; they would expect to see clear policies in place about access to records and monitoring of prescriptions.   36. Since these events, the structure of the GP practices has changed and appropriate disciplinary measures have been taken to ensure prescription practices are satisfactory. At the newly configured practice, all children have an Asthma UK Care Plan11 in keeping with national guidance and all the nurses undertaking routine asthma checks for patients with this condition are fully qualified specialists.  Child and Adolescent Mental Health Service (CAMHS)  37. In 2010, CAMHS received their first referral about this family, from a family centre worker, who expressed concerns about the impact of domestic abuse on Ms CM and Child V. An assessment identified that Child V had severe emotional and behavioural difficulties with attachment problems. Ms CM reported she was suffering with mental health difficulties which made it difficult at times for her to go out.   Child V was referred to the local children’s centre for therapeutic input and parenting work; Ms CM did not fully engage with the services, attending about half the appointments offered.   38. In 2012 and 2013, there were referrals from the school about Child V’s soiling and anger, the outcome was that it was not the right time for any parenting work, as the family were not settled in a suitable environment; they were experiencing multiple house moves.   39. In 2015, the school referred Child V again, because of problems with soiling and allegedly not having used the toilet during the past 4 years, questions were raised about possible Autistic Spectrum Disorder.   40. The team agreed a programme of work for both Child V and Ms CM.   10 Clinical Commissioning Groups (CCGs) were created following the Health and Social Care Act in 2012 and replaced Primary Care Trusts on 1 April 2013. They are clinically-led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area.  11A written asthma action plan is an important method of supporting people to take the right actions at the right time. There is evidence that people who are given a written asthma action plan are four times less likely to need hospital care for their asthma. Serious Case Review, Child V Page 10    41. In 2016, the CAMHS team contributed to the Education Health and Care Plan and discussed setting up a Team around the Child (TAC) meeting, and bringing in some additional parenting support to help establish household routines. CAMHS were working with Child V to help address hygiene issues and help with emotional regulation.   42. In 2016/17, CAMHS were seeing Child V at school, where the environment was quiet and calm.  There was one home visit in September 2017.  43. In November 2017, there was a review of Child V’s needs, a sensory attachment assessment was underway12 and the plan was to consider therapeutic options once this was complete. Child V had recently started School 3 and was described by CAMHS as “withdrawn and reclusive with separation anxiety.”  44. In December 2017, the TAC meeting suggested Ms CM ask CAMHS to refer her to the Mental Health Team, as she had been having some counselling which had brought on difficult feelings. Child V was described by their mother as pulling out hair leaving “open sores on their head” and making references to taking their own life.    Early Help 45. During Child V’s life, the family were offered “Early Help” from two providers. From 2011 until 2017 the service was provided by a multi-agency team from education known as the Chesil Education Partnership. This service was de-commissioned in 2017 and no-one was available to contribute to this review.   46. During 2017/18 Child V and the family worked closely with the Early Help service run by the Council known as the Family Partnership Zone (FPZ).  The focus of work was Child V’s soiling, the family’s inadequate housing, supervision of the children and Ms CM’s struggles to get Child V to school; this included encouraging Ms CM to sustain her commitment to the work.   47. In early 2018, the professionals working with the family, including the school, were concerned that there had been very little change. CAMHS indicated it was not appropriate to offer trauma-based work to Child V at that time because the family were too unsettled.  12 Sensory Attachment Intervention (SAI) is an integrative approach to the treatment of children and adults who have suffered abuse or severe neglect. Negative experiences in the womb and in early childhood impact on one's capacity to cope with stress throughout life and the model of intervention aims to target the areas of the brain which are the source of a dysfunction response. Serious Case Review, Child V Page 11    (This was partly due to the number of house moves) Ms CM was encouraged to address her own issues and CAMHS continued to offer sensory attachment work.   Children’s Social Care  48. There were 18 referrals to Children’s Social Care. The first one was in 2010, after that they were fairly evenly spread, the most recent was in 2017, twelve months before Child V died.   49. The content of the referrals is similar; the common themes are Child V’s behaviour, Ms CM not coping, risk of eviction, school attendance and poor supervision of the children placing them at risk of harm. There were three referrals about injuries to the children allegedly caused by their father. Of the referrals, 8 led to an assessment of need.   50. The assessments have been reviewed by Children’s Social Care and are described as varying in quality, as adult focussed with emphasis on Ms CM’s status as a victim of domestic abuse and Child V’s difficult behaviour. There is little information about what life was like at home for Child V. The possible underlying reasons for the behaviour are discussed and were thought to be a response to witnessing domestic abuse and Child V’s father’s suicide attempt. This is not considered in any analysis or decision making. It seems to have been assumed that once Mr CF had left the family home, there was no further risk of domestic abuse.   51. The three referrals about (minor) injuries to the children in 2012/13 were not progressed as each time the cause of the injury was described, either by Child V or Ms CM, as accidental. With one exception, the outcome of the referrals was to continue to work with the family within the framework of Early Help.    52. In 2014, there were three referrals which coincided with the one period of active intervention from Children’s Social Care (October 2012 - May 2014.) During this period the case was open within the Child in Need framework and allocated to a Social Work Assistant. There were regular CIN reviews and a parenting service was providing support to the family. It is notable that although Mr CF was said to have left the family home, he was still in regular contact with the family and Ms CM was advised to seek a Restraining Order.   53. In 2017, the police raised a PPN13 advising that “the children had been playing in the street at night, crossing between cars with little parental supervision.” There is no Children’s  13 Officers who attend incidents complete a Public Protection Notification document (PPN) which summarises the vulnerabilities of children. These are shared with Children’s Social Care and Health and Education where appropriate to enable partner agencies to make decisions about risk assessment and take action as required.   Serious Case Review, Child V Page 12    Social Care’s response to this information; the TAC (Early Help) arranged a meeting for the family with the local police to inspire and engage the children and address the anti-social behaviour which was affecting the local community.   54. A referral was also made by a member of the public who observed a similar incident a month later; there is no record of a response from Children’s Social Care.     Police  55. Child V came to the attention of police in 2009, when three years old, following a report indicating poor parental supervision.   56. There were three contacts about domestic abuse, two in 2011 and a further contact in 2013.   57. In 2013, the police also visited the family home following a report from a neighbor that Ms CM was not coping and the children were “screaming.”  58. From 2014 - 2016 there were no police reports until, in 2017, when the family got caught up in some neighbourhood unrest and the police were working to address issues on the estate. The family subsequently moved again.   59. When the police are made aware of a domestic incident where there are children present, they issue a Public Protection Notice (PPN) to Children’s Social Care; the expectation is that Children’s Social Care will decide whether or not the information should progress to be seen by the Multi-Agency Safeguarding Hub (MASH) and a decision made about referral for assessment.   60. If the incident concerned is not one of domestic abuse, for example if the report is about poor parental supervision, PPNs are not automatically copied to health professionals or education.    Housing 61. Child V and the family moved eleven times in twelve years and from 2012 until Child V’s death, had intermittent support from the Council’s Housing Department. The records Serious Case Review, Child V Page 13    indicate that the Housing Department only became involved if Ms CM was unable to find accommodation herself or needed financial help with rent and a deposit. The family experienced a period of homelessness in 2016 when they were provided with temporary accommodation.   62. The Housing Department were unaware of the number of moves or the reasons for them except to note that landlords had not extended the tenancy agreements.   63. The Housing Department were not aware of any domestic abuse and never had any safeguarding concerns about the children. At Ms CM’s request, a Housing Officer attended one TAC meeting, a month before Child V’s death.    Serious Case Review, Child V Page 14     FINDINGS AND LEARNING   64. Child V died at home following an acute asthma attack. There was no delay by the family in seeking medical help and the treatment provided was prompt and appropriate. Sadly, Child V’s life could not be saved.14   Asthma Management 65. There were however issues identified, during the Child Death Review process, with the asthma medical management.15 These were about the high number of prescriptions dispensed16, the role of a family member in the dispensing of the prescriptions and the lack of regular and effective asthma reviews. (It is important to note that there was one asthma review shortly before Child V’s death and the medication prescribed was entirely appropriate.)  66. All of these GP issues have been explored in detail in the individual agency review and reassurances provided that this situation cannot occur again. Internal disciplinary processes are complete; the GP surgeries where Child V was being treated are now under different management.   67. The implications of the prescribing practices, the lack of scrutiny and regular asthma reviews are that the number of prescriptions being issued was never questioned and the opportunity to consider what this meant, why Child V needed so many prescriptions and what this might mean in terms of his care at home was never considered. The opportunity for this information to contribute to any multi-agency risk assessment was lost.    Recognising Neglect 68. When this case first came to the attention of the SCR Panel, the key question discussed was whether there were missed indicators of neglect, which had never been properly assessed, and what could be learnt from this case.     69.  The definition of neglect from statutory guidance, Working Together to Safeguard Children, Department of Education (2013), is:  ‘the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect  14 In 2017 (the most recent data available) 1,484 people in the UK died from an asthma attack in the UK (Asthma UK) 15Child Death Review process, See CDOP  16 The record states that prescriptions for 65 inhalers were issued in the last calendar year Serious Case Review, Child V Page 15    may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:  • Provide adequate food, clothing and shelter (including exclusion from home or abandonment);  • Protect a child from physical and emotional harm or danger; Ensure adequate supervision (including the use of inadequate caregivers); • Ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs’  70. Even with this precise definition, in day-to-day practice neglect can be hard to identify. In this case the Review identified that although practitioners observed for example, Child V poorly supervised, hungry, dirty and being without asthma medication, the possibility of neglect was never properly considered or assessed.   Neglect Strategy  71.  The local Multi-Agency Safeguarding procedures include a Neglect Strategy; when asked about this none of the participants in the Review were familiar with its contents. The strategy sets out both “child risk factors” and “parent risk factors” many of which were present in this case. It promotes use of the “The Neglect Toolkit” which includes the Graded Care Profile Tool and tools to assess:  Clutter   Home conditions  Parenting daily hassles  Strengths and difficulties  Understanding the Child’s World    Learning Points: • Interventions will be more effective and produce better outcomes for children if they are based on evidence and if progress can be measured. Knowledge and understanding of the Dorset Neglect Strategy can help practitioners, from all agencies, assess the degree of neglect, and whether a referral to Children’s Social Care is appropriate.   Serious Case Review, Child V Page 16    • The tools can help clarify what the focus of intervention should be and can also help practitioners decide when intervention should be stepped-up if there is insufficient change, or stepped-down if positive change is sustained.   72. From the reports and conversations with practitioners and managers about barriers to recognition of neglect, the review has identified the following learning themes:  Adult Focus  Understanding of Parenting Capacity  Application of the Threshold Document  Diagnostic Overshadowing  The Value of Reflective Supervision  Child Focus  Adult Focus 73. From the outset of this case, Ms CM was seen as vulnerable; the professionals knew she had had a difficult childhood yet how her own experience of being parented might impact on her parenting capacity was never considered. Most agencies saw this case as a vulnerable young mother, a victim of domestic abuse, with obvious love for her children, struggling to cope in a chaotic environment with a child with additional needs.   74. Ms CM was a teenager when Child V was born and she was living in an abusive relationship. After Child V was born, Ms CM had three more children, this meant in 2011 she had four children under 5 and was diagnosed with post-natal depression. Mr CF’s abusive behaviour contributed to their precarious financial and housing situation and the family moved 12 times in 11 years.   75. Ms CM did not seek to hide her struggles and actively sought help. The GP prescribed medication to address her mental health difficulties and Early Help set out plans to address the practical problems the family were experiencing.   76. Ms CM is described by practitioners as having a good understanding of how Child V’s early experiences had impacted on their behaviour and an “enthusiasm and willingness” to take advice. When the Child in Need plan came to an end in 2015, one of the factors which influenced the decision to close the case was Ms CM’s willingness to work with professionals, this was mistakenly perceived as a “protective factor.”  Serious Case Review, Child V Page 17    77. It is understandable that the focus of attention was on Child V’s parents, primarily the mother.  What was missing from the practitioner view was the potential impact of their experiences on Child V. For example, when Child V spoke about distress due to dirty teeth and hair, or the allegation that the father used degrading punishment methods, the focus was on how to help the mother with these issues.    Learning Points • Parents own needs have to be acknowledged and addressed, but there is a risk of them overshadowing or distracting practitioners from considering the child’s experience.  The definition of neglect makes it clear that it is not necessarily intentional.  Loving parents can still fail to meet a child’s needs.   • All assessments must ensure the impact of events and parenting on the child is fully understood and explained. Seeing and listening to children, separately from their parents/carers and, if necessary, alone, is more likely to enable their voice to be heard.    • Enthusiasm and willingness to work with practitioners is not an indication of a parent’s capacity to protect a child or meet their needs; intentions must be supported by a professional assessment of parenting capacity and evidence of change.   • Asking the question “what is life like for a child in this family?” will help practitioners retain a child focus.  Working with Fathers  78. Mr CF was a teenager when Child V was born. There is limited information on the records about Mr CF although he too is said to have had adverse childhood experiences; he had requested help from his GP with anger issues and had described himself as a regular cannabis user.     79. There are reports of three domestic disputes between Ms CF and Ms CM, which were attended by the police,  There were also descriptions about Mr CF’s behaviour at home, which was destructive and violent and which led to the family having to move and accruing financial problems.   Serious Case Review, Child V Page 18    80. In 2010, in what was assumed to be a suicide attempt, a family member attempted to hang himself in the family home, in the presence of Ms CM and the children. This had a dramatic impact on Child V who, for a time, copied the behaviour in play and is likely to have contributed to their “attachment difficulties.”   81. From this Review the records indicate Mr CF was seen as a perpetrator of domestic abuse and, in 2011, Ms CM was advised to seek a Restraining Order to keep Mr CF out of the family home. Despite her best efforts, the record show he continued to be present and, when he eventually moved out, he maintained contact with Child V.  82.  Yet once Mr CF “moved out”, the “risk” was viewed by professionals as minimal.  The detail of when and where he was seeing Child V and if any abusive behaviour was continuing, was not explored.   Learning Points • Research and Serious Case Reviews indicate that the role of fathers in families is often less well understood by practitioners. Fathers/Male Carers must be included in assessment of risk and information from the resident parent (in this case Child V’s mother) should be checked or regarded as unsubstantiated.  • If a father/male carer is seen as posing a risk to a child and moves out of the family home, it cannot be assumed the risk had reduced. There should be an up- to-date risk assessment to consider the changed circumstances.    The Child Protection Procedures 83. During her discussions with practitioners, Ms CM described Mr CF’s treatment of Child V including his use of degrading punishment methods. In 2012/13, there were three reports of physical abuse of the children by Mr CF. Ms CM was asked about them and reassured the practitioners that the injuries were caused accidentally. (A neck injury, scratches and a burn) Children’s Social Care closed the contact without further action because there was already a CAF (Early Help) in place and there was “no reason to disbelieve Ms CM.”     84. Given that these incidents were after the Restraining Order had been granted and what was known about Mr CF, his violent behaviour, his drug use and anger issues, and that Ms CM was herself a victim of domestic abuse, it is concerning that there was no further enquiry made about these incidents.   Serious Case Review, Child V Page 19    85. The Child Protection Procedures are designed to provide an incremental approach to an allegation, a multi-agency discussion and information sharing, a plan about how to investigate the reports and, if there is any evidence or risk of harm, a Child Protection Conference.       86. These were missed opportunities to consider Child V’s experience within family and the nature of family relationships.    Learning Point: • The Child Protection Process enables a structured, multi-agency response to allegations of child abuse. Failing to follow the procedures means that opportunities are missed to establish the nature of any risk. When there are long- term concerns about a child there is risk that reports will be lost in the wealth of information or that each incident will be seen in isolation and the cumulative nature overlooked. The use of chronologies can help mitigate this risk.     Understanding of Parenting Capacity 87. In the course of this review, it became clear that although neglect was mentioned from time to time, none of the practitioners had a clear idea of the capacity of Child V’s parents to meet Child V’s needs or why the improvements in the quality of care were not sustained.   88.  In addition to the work being done through Early Help, Children’s Social Care carried out eight assessments. These were judged by the agency as “varying in quality and lacking any real assessment of parental capacity”, only the last notes that Child V was seen alone.  The assessments do not provide a picture of what life was like for Child V, the focus appears to be on “unwanted behaviour.”   89. The assessments are adult focussed and are described in the agency review as “over optimistic about Ms CM’s ability to protect Child V and take on board the advice offered.”  90. What was missing in this case is the use of tools to assess the degree of neglect, along with an assessment of parenting capacity. This would enable an understanding of both parents, to establish their strengths and areas for development, followed with what the aim of intervention should be and, most importantly, to be able measure change.   Serious Case Review, Child V Page 20    91. Ruth Marchant17 sums up one of the challenges for practitioners. ”Knowing what is involved in a child’s day-to day care can operate powerfully on our expectations about what is good enough parenting. One possible consequence of realising the demands is a downward shift in our assessment standards...”   Learning Point:  • Assessment of parenting capacity is particularly challenging if a child has complex needs; they may need more skilled parenting than other children in the same family. Understanding a parent’s ability to meet the needs of an individual child and their potential for change is essential. A robust assessment, which is evidence based, will enable a base line to be established and outcomes evaluated.   Early Help and Effective Planning  92. The agencies and individuals who worked with the family were responsive to the family’s needs. Over the period of this Review, hundreds of hours were spent considering how to make changes to improve the quality of Child V’s life, but without any lasting change.   93. From as early as 2010, when Child V started school, a multi-agency plan was in place within the Early Help framework, which focussed on specific tasks. For example, the plan in September 2017 included addressing the children’s anti-social behaviour, Ms CM setting boundaries for the children and sorting out the family’s housing situation.    94. CAMHS were involved intermittently, from 2010, to address Child V’s emotional needs, which were considered to have arisen from early life and attachment difficulties compounded by ASD diagnosis.   95. The plans did have some success and, if the tasks are viewed in isolation, would be seen to have been effective; for example, Child V’s school attendance improved, was better dressed and housing moves were achieved. As Ms CM matured as a parent, she became better able to establish boundaries for the children.    17 Making Assessments work for Children with Complex Needs, Ruth Marchant, in The Child’s World, Jessica Kingsley 2019  Serious Case Review, Child V Page 21    96. Brandon et al18 refer to one of the difficulties of recognising neglect as the tendency of practitioners to look at events in isolation. The report says: “Neglect can in some cases be challenging to identify because of the need to look beyond individual parenting episodes and consider the persistence, frequency, enormity and pervasiveness of parenting behaviour which may make them harmful and abusive.” 97. This means that a report of poor parental supervision, or an inappropriately dressed child on a particular day, can easily be seen as an isolated event, especially if there are periods of improvement in general parenting.   98. There is a risk that Individual improvements, for example, Child V bringing nappies to school, are reassuring and can distract from an overall pattern of long-term neglect when improvements are not sustained.     99. Looking back at Child V’s life, it is striking that there was little lasting change and in the last year of life was still distressed at times and on occasions, coming to school hungry, inadequately dressed and at aged 11, still soiling.   Learning Point: • Although task focussed plans are useful, in cases where the plan is relatively unchanged over a long period, it is necessary to consider any underlying factors which might inhibit progress. In neglect cases there is risk of over-optimism if improvements are looked at in isolation.    Application of the Threshold Document  100. Brandon et al in Missed Opportunities of Neglect – what is ignored, why and what can be done? states that:  “a number of high profile child deaths have shown that it is extremely difficult for professionals with safeguarding responsibilities to identify indicators of neglect, to assess whether what they have observed is sufficiently serious for them to take action and to decide on the most appropriate course of action.” 19   18 Missed opportunities: indicators of neglect – what is ignored, why, and what can be done? Brandon et al, Research report November 2014, DfE 19 Brandon et al, Ibid Serious Case Review, Child V Page 22    101. To ensure the right action is taken at the right time, in common with all authorities, multi- agency guidance was available to all agencies in the form of a threshold document.  102. In this case, there were eighteen referrals to Children’s Social Care, eight led to an assessment and one to a period of ongoing work.   103. The evidence indicates that each referral was viewed in isolation, without consideration of the number of previous referrals, and what this might say about what was happening in Child V’s life. Although each referral might appear to be about a relatively low risk incident, for example, poor parental supervision, when viewed as part of a bigger picture the possibility of long term chronic neglect must be actively considered.   Organisational Climate 104. From 2013-2016, when Child V was designated as a Child in Need, Children’s Social Care were undergoing a major re-organisation, many permanent social workers left the authority and one practitioner described the team responsible for Child V as “in chaos.” One of the social workers, who knew Child V during this period, was supervised “by at least four different managers” during that time.  The impact of the organisational climate might also account for the reason a case review by a manager at that time, which recorded concerns about the quality of the recent assessment, lack of planning and failure to follow up on safeguarding concerns was never acted on or reviewed.    105. Threshold decisions were also influenced by a management directive, in 2015, instructing staff to reduce the number of Child in Need cases. This was designed to reduce case-loads during a period of high demand on social work teams; however practitioners who were working with Child V at the time, report that the practice led to inconsistency in applying the concept of threshold to referrals and a general reluctance of other agencies to refer to Children’s Social Care.     106. Towards the end of 2017, the Early Help team (FPZ) and Child V’s school were considering making another referral to Children’s Social Care.  There were a number of indicators of possible neglect and his physical needs were not being met, for example the school observed  Child V coming to school with no breakfast, having holes in shoes, to be wet and cold and to be falling asleep at school.   107. The practitioners discussed the referral process, but did not take action because they were aware that previous referrals had not met the threshold for intervention and had been passed back to Early Help. The practitioners advised Ms CM to take Child V to the GP and agreed if this was not done, they would then make the referral.  Serious Case Review, Child V Page 23     108. The practitioners agreed that the focus at that time had been on “meeting thresholds” rather than on a child’s needs. Also relevant was that previous referrals had been made by Early Help expecting intervention from Children’s Social Care and the management decision was to pass it back. This indicates that further work is needed on the stepping-up and stepping-down process, to ensure the process is well understood and children and families are getting the right help.   109. Brigid Daniel20 in her research on neglect and what works says:  “There are many children about whom a range of professionals may be concerned and who are known to communities and professionals but who are not actually receiving adequate direct help. We often hear concerns about “slipping through the net” but in fact it happens rather than slipping through the net they are in effect “stuck in the net.”   110. The stepping–up process would have prompted discussion about the constraints of Early Help, to consider whether Child V was “stuck in the net”  and whether there was a role for Children’s Social Care to assess and work with family within the Child in Need framework.   Learning Points:  • When multiple referrals are received about the same child, consideration should be given to the history, in order to determine if there is a pattern emerging. When there are a high number of referrals, even if the information is similar in nature, this should raise questions about why there are so many referrals and what is known about the child’s day to day life.    • For those making referrals, knowledge of the history (and including it in the referral) will help improve the quality of a referral. Chronologies are an effective tool to enable practitioners to build a picture of a family life.   • At times when systems are stressed, or likely to be overloaded, it is particularly important that managers provide effective oversight and decision making.    20 Brigid Daniel, Why have we made neglect so complicated? Taking a fresh look at noticing and helping the neglected child, Child Abuse review, Vol 24, 2015. Serious Case Review, Child V Page 24    • Effective professional challenge is an important part of the safeguarding process. Practitioners from all agencies should be aware of the Conflict Resolution Policy (Escalation Policy) and feel able to challenge or question decisions made.    Diagnostic Overshadowing 111. The term Diagnostic Overshadowing was first coined to highlight the risk of failing to recognise health needs in people who had been diagnosed with a learning disability. In this case, the term provides a useful reminder of the risk of seeing a medical diagnosis/condition, autistic spectrum condition, (ASC) as the main reason for a child’s behaviour, obscuring the child’s voice.   112. In their paper Pathways to Harm, Pathways to Prevention, Sidebotham et al21 state:  “While the primary focus for intervention remains the child’s disability or health needs, indicators of abuse may be misinterpreted and the risk of significant harm go unrecognised. Such signs as physical injuries challenging behaviours developmental delays, poor growth and unhygienic living conditions can all be left unchallenged or attributed to the child’s disability rather than identified as symptomatic of abuse or chronic neglect. In some cases, this may be compounded by parents actively deflecting attention from safeguarding concerns...”   113. For those working with Child V there were obvious indicators that the diagnosis of ASC did impact on behaviour and the way Child V viewed the world.  There was also the very real challenge for Ms CM to get Child V to school in the morning, which should not be underestimated. CAMHS were working with Child V on managing emotions; in 2017 Child V was making references to killing themself and pulling out hair making the scalp bleed.    114. During this review some practitioners expressed the strong view that ASC is not an excuse for a child being dirty, inadequately dressed or hungry. The practitioner’s approach was that in order to help Child V manage the behaviour, Ms CM needed help with her own issues; at the time she was expressing concern about her own mental health.  115. This a reasonable view however the documents suggest that, again, the focus of attention was on the adult and Child V’s voice was lost.    21 Pathways to Harm, Pathways to Prevention, Sidebotham et al, a triennial analysis of serious case reviews 2011 to 2014, university of Warwick, University of East Anglia Serious Case Review, Child V Page 25    Learning Points:  • For children with additional needs, learning disabilities or medical conditions, there is a need to look beyond the diagnosis or label, and consider a holistic assessment of the child’s needs.   The Value of Reflective Supervision 116. All agencies who worked with Child V and the family had access to supervision and/or safeguarding advice; however there is little evidence that this provided an opportunity for practitioners to reflect on this case, to step back from the day-to-day pressures, to observe the bigger picture and think about the quality of interventions and Child V’s childhood experience.   117. Supervision also enables discussion of relevant policies and practice guidance, for example, the Neglect Strategy and how tools might be used in assessment. When there is a risk that parents own needs might overshadow the child, supervision can provide constructive challenge and ensure the “voice” of the child is not lost.    118. For some practitioners, organisational pressures, staff changes and sickness meant that supervision wasn’t as regular as the policies prescribe. For all agencies, there is insufficient time to discuss all cases at every session and effective supervision relies on cases being brought to the attention of the supervisor. When considered in the context of high caseloads and concerns about significant risk to children, this case did not stand out and was not seen as a priority for supervision time.  Plans were in place, agencies were working together and the general consensus among practitioners was that everything that could be done for Child V was being done.     Learning Point: • Supervision, and management oversight, provides an opportunity to reflect on a case and think systemically about cases. This is especially valuable in long term work when there is little change and in cases where there have been multiple referrals.    Serious Case Review, Child V Page 26    Understanding the Child’s World   119. Hundreds of hours were spent with Child V and the commitment of the practitioners to improve Child V’s quality of life is without question. Child V’s needs were assessed, analysed and diagnosed based on childhood experiences and observation of behaviour. CAMHS assessed Child V’s needs and provided direct work in the context of mental health.   120.  The documents and reports which formed part of the Review include comments about      what Child V saw and had done to them.  For example, domestic abuse, family member’s      suicide attempt and the experience of father’s degrading forms of punishment. There are     descriptions of Child V’s behaviour at school and these events and observations culminate     in planned interventions. The evidence is that the direct work from CAMHS was well       thought out and delivered to a high standard, although little progress was seen.  Other      interventions were process driven, for example, poor behaviour at school led to exclusion,      observations of possible neglect led to Early Help and homelessness led to financial help      for the family.   121. These actions were all appropriate and Ms CM reported that generally she felt listened to and supported; what is missing from the narrative is an understanding of how Child V saw the world and what was important for Child V.   122. The challenge for practitioners is how to ensure that amongst the diagnosis and clinical formulations, the practitioners’ voice does not overwhelm the child’s voice; Ruth Marchant describes this as the risk of seeing the child in “a pathologising, deficit model where the child is tested against some concept of normality”22. She goes on to say... “Some children are very clear about the focus of this kind of assessment: “It’s always about what’s wrong with me.”     123. Ann Bannister in “Entering the Child’s World”23 describes a study where children were asked about their views of harm and what support they would like. The study found “that children often have strong opinions about their needs and ways in which these can be met and are able to express their views and feelings if professionals create the right atmosphere” it goes on to say... “despite the Children Act 1989 emphasising that practitioners should ascertain the wishes and feeling of children and what the child wants to see happen, parents and carers remain the main source of information on children’s views.”    22 The Assessment of Children with Complex Needs, Ruth Marchant, in The Child’s World, Jessica Kingsley, 2018 23 Ann Bannister in “Entering the Child’s World Serious Case Review, Child V Page 27    124. When one of the practitioners had the time and opportunity to get to know Child V, the description which emerged contrasts vividly with the description of Child V throughout the records as a child “with problems.” “Child V was an extremely special child and it was the word ‘special’ that came up over and over again, when you heard from people who knew Child V well.  Child V didn’t let everyone in but, for those that were, they reported Child V’s most infectious smile and laugh that you couldn’t help but respond positively to.  Child V was protective and caring towards their family…I recall stories of particular kindness to an extended family member who was much younger and had additional needs. Child V was also thoughtful, for example, choosing the most woolly, fluffy scarf as a present for you because they knew you always got cold in the classroom. Child V would enjoy beating you at computer games, but would be thoughtful about winning and sometimes, just to be kind, let you win whilst pretending not to. Child V was cheeky too, for example, always choosing football as a reward time activity and chuckling away to themself because Child V knew I hated it! I will always remember the joy brought to the room when things were going well and Child V was doing something they enjoyed.”   Learning Point:  • In order to understand the child’s world, and to ensure work is done with the child and not just to them and for them, requires direct work in the right atmosphere. To reassure the child their views are important, and will be taken into consideration, requires building rapport with the child and establishing appropriate age-related means of communication. In long term work, when multi-agency meetings and reviews are being held, identifying a practitioner who can be an advocate for the child will help ensure their voice is heard.     Serious Case Review, Child V Page 28    SUMMARY OF LEARNING   a. Interventions will be more effective, and produce better outcomes for children, if they are based on evidence and if progress can be measured. Knowledge and understanding of the Dorset Neglect Strategy can help practitioners, from all agencies, assess the degree of neglect, and whether a referral to Children’s Social Care is appropriate.   b. The tools can help clarify what the focus of intervention should be and can also help practitioners decide when intervention should be stepped-up, if there is insufficient change, or stepped-down if positive change is sustained.   c. Parents own needs have to be acknowledged and addressed, but there is a risk of them overshadowing or distracting practitioners from considering the child’s experience. The definition of neglect makes it clear that it is not necessarily intentional and loving parents can still fail to meet a child’s needs.   d. All assessments must ensure the impact of events and parenting on the child is fully understood and explained. Seeing and listening to children, separately from their parents/carers and, if necessary alone, is more likely to enable their voice to heard.    e. Enthusiasm and willingness to work with practitioners is not an indication of a parent’s capacity to protect a child or meet their needs; intentions must be supported by a professional assessment of parenting capacity and evidence of change.   f. Asking the question “what is life like for a child in this family?” will help practitioners retain a child focus.  g. Research and Serious Case Reviews indicate that the role of fathers in families is often less well understood by practitioners. Fathers/Male Carers must be included in assessment of risk and information from the resident parent (in this case, Child V’s mother) should be checked or regarded as unsubstantiated.  h. If a father/male carer is seen as posing a risk to a child, and moves out of the family home, it cannot be assumed the risk had reduced. There should be an up-to-date risk assessment to consider the changed circumstances.   i. The Child Protection Process enables a structured, multi-agency response to allegations of child abuse. Failing to follow the procedures means that opportunities are missed to establish the nature of any risk. When there are long- term concerns about a child, there is a risk that reports will be lost in the wealth of information or that each incident Serious Case Review, Child V Page 29    will be seen in isolation and the cumulative nature overlooked. The use of chronologies can help mitigate this risk.    j. Assessment of parenting capacity is particularly challenging if a child has complex needs; they may need more skilled parenting than other children in the same family. Understanding a parent’s ability to meet the needs of an individual child, and their potential for change, is essential. A robust assessment, which is evidence based, will enable a base line to be established and outcomes evaluated.  k. Although task focussed plans are useful, in cases where the plan is relatively unchanged over a long period, it is necessary to consider any underlying factors which might inhibit progress. In neglect cases, there is risk of over-optimism if improvements are looked at in isolation.    l. When multiple referrals are received about the same child, consideration should be given to the history in order to determine if there is a pattern emerging. When there are a high number of referrals, even if the information is similar in nature, this should raise questions about why there are so many referrals and what is known about the child’s day to day life.    m. For those making referrals, knowledge of the history (and including it in the referral) will help improve the quality of a referral. Chronologies are an effective tool to enable practitioners to build a picture of a family life.   n. At times when systems are stressed or likely to be overloaded, it is particularly important that managers provide effective oversight and decision making.   o. Effective professional challenge is an important part of the safeguarding process. Practitioners from all agencies should be aware of the Conflict Resolution Policy (Escalation Policy) and feel able to challenge or question decisions made.   p. For children with additional needs, learning disabilities or medical conditions, there is a need to look beyond the diagnosis or label, and consider a holistic assessment of the child’s needs.  q. Supervision, and management oversight, provides an opportunity to reflect on a case and think systemically about cases. This is especially valuable in long term work, when there is little change, and in cases where there have been multiple referrals.  Serious Case Review, Child V Page 30    r. In order to understand the child’s world, and to ensure work is done with the child and not just to them and for them, requires direct work in the right atmosphere. To reassure the child, their views are important and will be taken into consideration, requires building rapport with the child and establishing appropriate age-related means of communication. In long term work, when multi-agency meetings and reviews are being held, identifying a practitioner who can be an advocate for the child will help ensure their voice is heard.   Serious Case Review, Child V Page 31    CONSIDERATIONS FOR THE SAFEGUARDING PARTNERSHIP  125. This Serious Case Review is about the recognition and response to neglect, in particular, evidence based assessment, intervention and the evaluation of progress to prevent and reduce the impact of chronic neglect.   126. Although some of the practice in this case took place years ago, at the time of his death Child V was known to a number of agencies who were actively working with him and his family. The learning themes resonate with some of the findings of the recent Joint Targeted Area Inspection (JTAI) in particular premature closing of cases, work with children who are at the cusp of early help/statutory social work threshold for intervention and the use of chronologies for children with complex needs and histories.   127. The commitment of the staff is beyond question and, during the review, practitioners were thoughtful about their practice and open to learning. It is notable that when the “bigger picture” was exposed, without exception, the practitioners identified how this case could have been managed differently.   128. There is no new learning, the points raised in this Review are all about promoting good day-to-day safeguarding practice, which is underpinned by the Dorset Neglect Strategy. The challenge for the Pan-Dorset Safeguarding Children Partnership is ensuring that strategic documents, policies and practice developments are embedded into practice and observed in improved outcomes for children.   In particular, the Partnership should ensure that:   A. Child focus is not overshadowed by adult needs and the impact of events and parenting capacity on children is noticed, recorded and responded to appropriately:  B. Assessment practice, especially in neglect cases, if there have been multiple referrals, is robust and always includes analysis of parenting capacity; that practitioners are aware of the available assessment tools and confident with their use:  C. Neglect training and practice development is supported by reflective supervision and robust management;   D. Reports of physical and emotional abuse are thoroughly investigated, and the child and alleged perpetrator are spoken to. This is especially important in neglect cases Serious Case Review, Child V Page 32    when long-term poor parenting can distract practitioners from noticing other forms of abuse.   E. The ongoing work to develop the concept of thresholds being seen as a barrier and view as an intervention on the continuum of need.      Serious Case Review, Child V Page 33     APPENDICES  Agencies Participating in the Review  • Children’s Social Care – Dorset Council • Family Partnership Zone – Dorset Council • Dorset County Hospital • Dorset Healthcare – inc CAMHS • Dorset CCG – inc GP • Dorset Police • SWAST – sent briefing report and summary of involvement  • School 1 – Education • School 2 – Education • School 3– Education • Alternative Education Provision – Dorset Council • Housing – Dorset Council  Membership of the SCR Sub-Group  • Service Manager- Dorset Combined Youth Offending Service (Chair)  • Detective Chief Inspector, Child Protection – Dorset Police • Consultant Paediatrician – Dorset County Hospital • Designated Nurse Consultant for children – Dorset CCG • Designated Safeguarding Manager – Dorset Council • Named Nurse and Service Manager for Safeguarding Children/Safeguarding Children Advisor – both with Dorset Healthcare • Senior Advisor and Virtual School Head – Dorset Council • Business Manager - Pan Dorset Safeguarding Children Partnership (formerly DSCB)           