Serious non-accidental injury of a 6-week-old boy in August 2013 suspected to be a result of shaking. Child Y was in the care of his father for the weekend when he was admitted to hospital with bruising and cerebral haemorrhage resulting in significant disabilities. Father was charged with Grievous Bodily Harm and found not guilty. There had been previous reports of neglect, physical injuries and multiple visits to hospital with injuries for Child Y and his siblings, including cigarette burns and an overdose. Father did not live with the family; he had previously taken overdoses and was known to police for domestic abuse and possession of drugs. Mother was known to alcohol and drug services. Key issues identified include: gaps in communication between agencies specifically around mother's alcohol misuse and sharing safeguarding concerns that could affect siblings; individual referrals not meeting the threshold and cumulative patterns not identified; lack of continuity of professionals working with the family; limited involvement with the father; lack of professional curiosity; not following up non-attendance of appointments. Highlights effective practice in school staff engaging both parents to address children's needs and health visitor following up on missed appointments. Recommendations include; review of multi-agency practice around parental alcohol misuse and neglect; improvements to maternity booking forms to include space for father's details and psychosocial concerns; children's services to conduct regular audits of repeat contacts; and safeguarding to be considered in cases of child obesity.
      
 Title:  Overview report on the serious case review relating to Child Y. LSCB: Surrey Safeguarding Children Board Author: Helen Davies Date of publication: 2014  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               Overview Report on the  SERIOUS CASE REVIEW  relating to  Child Y    Helen Davies September 2014   2    TABLE OF CONTENTS                   Page No  1. Introduction               3 2. Arrangements For The Serious Case Review         4 3. Methodology Used to Draw Up this Report          5 4. Brief Chronology of Key Events           6 5. The Family               9 6. The Agencies             11 7. Key Issues              22 8. Conclusions and Lessons Learned          29 9. Recommendations from this Serious Case Review        31 Appendix A              34 Appendix B              35 Appendix C              36 Appendix D              38 Appendix E              39  3 1. INTRODUCTION  1.1. On 27 August 2013 child Y was taken to hospital with bruising and a cerebral haemorrhage suggestive of shaking.  He was transferred to a London hospital in a life threatening condition.  The father was subsequently charged with grievous bodily harm.  1.2. This matter was referred to the Local Safeguarding Children Board in Surrey where child Y lives.  In September the Strategic Case Review Group (SCRG) of the Surrey Safeguarding Children Board (SSCB) met to consider whether the criteria for a serious case review were met.  1.3. There is a legal requirement, as defined in statutory Guidance, Working Together to Safeguard Children 2013, to undertake a serious case review when abuse or neglect of a child is known or suspected and  - either a child has died,  - or a child has been seriously injured and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.  1.4. At its September meeting, the SCRG concluded that further information was required in order to make a decision about whether the criteria for a serious case review were met.  More information was gathered and considered by the SCRG in October 2013.  The Group members were split in the recommendation they made to the Independent Chair of the Board, Alex Walters, about whether the criteria for a serious case review were met.  The decision of the Independent Chair was that, although it was not clear if the serious case review (SCR) criteria were met, the case required a review process.  1.5. Therefore, in order to inform further consideration of the SCR criteria and to begin the process of a review, the SSCB Chair requested that further information and analysis were sought through the completion of Individual Management Reviews (IMRs) by two Health Care Providers, (one providing hospital services and the other providing community services), and by the local authority’s Children’s Social Care and Schools and Learning Services.  1.6. These four reports were considered by the SCRG in November 2013 when the Group recommended to the Independent Chair that the criteria for a serious case review were met. The Chair of the Board decided on 22 November 2013 to initiate this Serious Case Review, as child Y had been seriously harmed and the information gathered from Board partners  4 indicated cause for concern about how they had worked together to safeguard the child.  1.7. The purpose of a serious case review, as set out in statutory Guidance, Working Together 2013, is to identify improvements which are needed and to consolidate good practice in order to prevent similar deaths or serious injury.  2. ARRANGEMENTS FOR THE SERIOUS CASE REVIEW  2.1. The SSCB decided that its Strategic Case Review Group would be the reference group for this review.  It was chaired by Alex Walters, the Independent Chair of the Board.  Its function was to manage and oversee the conduct of the review.  The membership of the SCRG is set out at Appendix A.  The Board appointed an independent reviewer, Helen Davies, to lead the review and to write this overview report.  She was assisted by Angie Tregoning, SSCB Case Review Officer.  Further details are at Appendix B.  2.2. As indicated in paragraph 1.5, four internal management reviews (IMRs) had already begun in October 2013. In total nine IMRs were requested from the following agencies which had substantial contact with child Y and his family:  - Health Care Provider that provides hospital services - Local Clinical Commissioning Group (Surrey general practitioners) - Health Care Provider that provides mental health services and community alcohol and drug services - Health Care Provider of community services providing health visiting, school nursing, and speech and language therapy services - Surrey County Council Schools and Learning - Surrey County Council Early Years and Childcare Service - Surrey County Council Children’s Services (SCS) - Surrey Police - Local Borough Council  2.3. In addition, background reports were requested from agencies with less significant or less recent information:  - South East Coast Ambulance Service - Homestart  2.4. This report was written in anticipation that it will be published. Consequently, the information in the report is limited so as to:  5 a) take reasonable precautions not to disclose the identity of the child or family b) protect the right to an appropriate degree of privacy of family members  Some of the health services involved and the local borough council are anonymised in order to avoid revealing in which part of the county the family lives.  2.5. Terms of Reference for this SCR are at Appendix C. Child Y was the main subject of the review and its principal focus was from 1 May 2012 (when Children’s Services began its assessment of the family) until 27 August 2013 (when child Y was admitted to hospital). However, all agencies were asked to provide a summary of all significant events and relevant family history outside the specific timescale and to consider any safeguarding issues for child Y’s older siblings.  2.6. All internal management reviews addressed the terms of reference. All the authors of the internal reviews were independent of the case management, and all bar one conducted interviews with staff involved with child Y and his family. 23 members of staff were interviewed in total.  2.7. Following consideration of the combined chronology of events and the internal reviews, the independent reviewer and the SSCB case review officer met at a learning event with fourteen professionals who had worked with child Y and/or his family. They included midwives, health visitors, speech and language therapist, social work manager, children’s centre manager, and staff from the nursery and school attended by child Y’s siblings. This provided a valuable opportunity to gain their perspectives of their work with child Y’s family and to consider lessons learned.  2.8. After the first draft of this report had been compiled, the independent reviewer and the SSCB case review officer met with IMR authors and key professionals in order to seek their views on preliminary findings and on recommendations. Five IMR authors attended this meeting along with seven of the professionals who had attended the earlier learning event. This group suggested some helpful recommendations, which are addressed in paragraph 9.1.2  3. METHODOLOGY USED TO DRAW UP THIS REPORT  3.1. This overview report relies on:  - the agency IMRs and background reports  6 - subsequent discussions with the SSCB case review officer and with the SCRG reference group - dialogue with the IMR authors - discussion at the learning event in March 2014 - discussion at the follow up meeting in April 2014 - the views of Child Y’s parents and grandfather, discussed in section 5   3.2. This report consists of:  - a factual context and chronology - commentary on the family’s input to the SCR - analysis of the part played by each agency - closer analysis of key issues arising from the review - conclusions and recommendations  3.3. The conduct of the review has not been determined by any particular theoretical model.  However, the review has been carried out in keeping with the underlying principles of the statutory Guidance, set out in Working Together 2013.  These are at Appendix D.  4. BRIEF CHRONOLOGY OF KEY EVENTS  4.1. This section of the report briefly describes key events from the birth of child Y’s oldest sibling.  Further detail is then provided at appropriate points throughout the report.  4.2. Child Y lived with his mother and her three older children, all of whom are white British.  The father of the older children did not live with the family but was involved in the children’s care. During her pregnancy, the mother told health professionals that child Y had a different father, but divulged no information about him.  After child Y’s birth the older children’s father was involved in his care and, more recently, the mother has confirmed that he is, in fact, the father of child Y.  Throughout this report he is referred to as ‘the father’.  4.3. In March 2005, the father smashed up property in the mother’s flat.  Surrey Police were called and notified Surrey Children’s Services (SCS).  In the same month the father took an overdose and had brief involvement with psychiatric services.  In June 2005 the first child (then a toddler) was taken to paediatric A&E with a cigarette burn, reportedly caused by running in the park into a cigarette held by an adult.  The injury was accepted as accidental.   7 4.4. In June 2007, the second child (aged four months) was taken to paediatric A&E with a head injury, which was accepted as accidental.  These two children were taken to A&E on six occasions between June 2005 and March 2008.  4.5. In September 2008 there were concerns about the first child’s behaviour at school and at home, so a home school link worker (HSLW) became involved with the family (until November 2012).  4.6. In July 2009 an art therapist in mental health services contacted SCS because a client was concerned about the children being neglected due to their mother’s alcohol use.  In November 2009 the same art therapist contacted SCS again as the same client had reported that the children were neglected and unsupervised.  4.7. In the same month a behaviour support teacher became involved with the family and worked with the mother alongside the HSLW.  Later in November 2009, the police were called to the family home following violence from the father to the mother, witnessed by the children.  The police notified SCS of the incident and reported that the home was untidy with evidence of cannabis use.  SCS contacted the children’s health visitor who agreed to follow up.  However, SCS closed the case before the health visitor had been able to make contact with the mother or see the children.  4.8. In February 2010 a voluntary organisation, Homestart, became involved with the family. In April 2010, the second child (aged 3) went missing while playing outside.  The child was found quickly and the police notified SCS.  4.9. In October 2010 the father took an overdose of paracetamol after an argument with the mother and had brief involvement with psychiatric services.  In the same month Homestart involvement ended when the volunteer left and the first child (aged 6) went missing after climbing out of a window.  The child was found unharmed and the police notified SCS, who asked the HSLW to follow up.  4.10. In November 2010 the third child started nursery and the second child (aged 3) was taken to A&E after taking an accidental overdose of antibiotics.  4.11. By March 2011 a CAF (Common Assessment Framework) had been completed for the third child because of concerns about developmental delay, especially communication.  The HSLW was the lead professional. In April 2011 the mother attended part of a positive parenting course at the local children’s centre.   8 4.12. In April 2011 the mother told her general practitioner (GP) that she was drinking three bottles of vodka per week.  She was referred to the community drug and alcohol service.  The service contacted SCS in May 2011 after an initial assessment of the mother, to query if the children were known to SCS.  4.13. In July 2011 the HSLW spoke with a member of the public who reported that the mother was drinking heavily. The HSLW told the head teacher of the children’s school. In August 2011 the mother was discharged from the community drug and alcohol service because she had not engaged. The service notified her GP.  4.14. In May 2012 SCS received an anonymous referral alleging that the children were neglected due to the mother’s alcohol use, they were poorly supervised, and both the home and children were unkempt.  SCS started an initial assessment.  In July 2012 the father was cautioned by the police for possession of cannabis.  4.15. A core assessment was completed by SCS in August and the case was transferred to the children in need team for ongoing support of the family.   4.16. In September 2012 a student social worker was allocated to the family. There were concerns about rubbish rotting outside the family home and the local borough council was involved.  In the same month the second child’s class teacher completed a cause for concern form as the child had a black eye.  The head teacher at that time did not notify SCS.  4.17. In October 2012 a children in need meeting was held, attended by key professionals and family members.  In November 2012 the mother revealed to the health visitor that she was pregnant with child Y, and the HSLW left her job after working with the family for over four years.  4.18. In December 2012 a children in need review meeting took place where SCS planned to close the case and end their involvement. I n the same month, the mother had her first ante natal appointment.  4.19. In January 2013 SCS closed the case and the third child finally attended an appointment for speech and language therapy assessment.  All three older children had numerous DNAs (did not attend) for medical appointments between 2005 and 2013.  In January 2013 another cause for concern form was completed by a teacher for the second child who had a burn on the hand.  The head teacher at that time did not notify SCS.   9 4.20. Child Y was born in July 2013. On 30 July he was taken to A&E after a reported fall from his mother’s knee.  There was no injury and it was accepted as an accident.  4.21. On 27 August 2013 child Y (aged 6 weeks) was taken to a local hospital with injuries suspected to be non accidental.  He was later transferred to a London hospital and was dependent on life support for a few days.  It was considered likely that his injuries were due to shaking while in the father’s care.  His mother had gone away for the weekend and left him in the care of the father.  4.22. The father was arrested for causing grievous bodily harm (GBH) to child Y and for possession of an offensive weapon. He was subsequently charged with both offences and remanded in custody. He stood trial in February 2014 and was found not guilty of GBH and convicted of possession of an offensive weapon for which he received a custodial sentence.  4.23. Child Y and his three older siblings were made subject to care proceedings in September 2013.  Initially, they lived with relatives during the proceedings and now all four children live with their mother subject to interim supervision orders.  5. THE FAMILY  Child Y’s mother  5.1. Child Y’s mother was invited to contribute to this review.  She chose to speak with the author of this report by phone.  She explained that child Y now has significant disabilities.  She confirmed that he has the same father as his three siblings.  When she went away for the weekend, she did not believe that child Y would be at risk in his father’s care, as he had been involved in caring for him nearly every day since his birth and he had never harmed the other children, all of whom adore him.  5.2. The mother has found the older children’s school helpful as well as the input from the home school link worker, with her focus on routines and setting boundaries.  5.3. She did not experience health visiting as helpful as she did not see the health visitors often, and they changed frequently.  The mother explained that she finds it difficult to ask for help and to trust people, so she does not like changes of workers.    10 5.4. The mother explained that she did not engage with the children’s centre because their activities were age specific, so she could not take children of different ages at the same time.  5.5. She did not engage with the community alcohol team in 2011 because they were asking questions about her past. She acknowledged that her heavy drinking at that time was because she was feeling low following a stillbirth and traumatic events in her childhood. However, she was not ready to have counselling then. She commented that she had counselling recently and found it very helpful.  5.6. The mother considered that the social work involvement in 2012 was too short. The focus was on improving the state of the house, supervision of the children and setting boundaries for the children. She felt that it was too short a period for her to show improvements. She values the current social worker because she listens, is honest, is not judgmental, and makes her think. She has helped her improve daily routines for the children.  Child Y’s father  5.7. The father was also invited to contribute.  He agreed to speak with the author of this report by phone.  He confirmed that he lived with the mother and his children intermittently.  He had very little involvement with professionals visiting the family home as he was usually out at work or elsewhere.  When he was interviewed, the focus was on how he dealt with the children, and how involved he was in bringing them up.   5.8. He understood from the mother that the focus of social work involvement in 2012 was on household routines, boundaries for the children and improving the state of the house.  He perceived it as generally helpful for the mother.  5.9. The father was positive about how much their school has helped his children.  Child Y’s grandparents  5.10. The maternal and paternal grandparents were contacted, with the agreement of the parents, and invited to contribute to the review. The paternal grandfather agreed to speak with the author by phone. He confirmed that he and his partner have had considerable involvement with child Y and with his siblings, who have stayed overnight with them on many occasions.  Before the incident in August 2013, they had no contact with any agencies working with the family. He did not think the injuries to child Y  11 could have been prevented but would like lessons to be learned about involving members of the extended family in assessments and plans.  5.11. He appreciated the social work involvement with child Y’s siblings since the incident, especially direct work undertaken with them.  He was also pleased that he and his partner were able to look after the siblings immediately after the incident and during the subsequent assessment period, as this kept the children together and provided continuity for them.  6. THE AGENCIES  6.1. Surrey Police  6.1.1. Surrey police had no involvement with child Y until his injuries were reported on 27 August 2013.  They then checked that his siblings were safe (in the care of relatives) and began a criminal investigation.  They had previously received two notifications of domestic abuse by the father towards the mother/her property in 2005 and 2009, both of which were notified to Children’s Services.  They had also been involved with child Y’s older siblings when two of them were reported missing for a brief period in two separate incidents in 2010 (both were aged under 7 at the time).  These incidents were also reported to Children’s Services.  All the actions by Surrey Police were appropriate.  6.2. The General Practitioners  6.2.1. The three older children, the mother and the father were all registered at the same GP practice.  It is a large practice and no one doctor at the practice saw any of the family members on a regular basis.  The father was registered at a different address to the mother and children, and there is no record that he was the father of these children.  At the time of the critical incident on 27 August 2013, child Y remained unregistered at the practice.  He had been seen by a GP once on 8 August 2013 when he was ‘snuffly’ but otherwise well.  This consultation was recorded in his mother’s notes.  The IMR author commented that this is common practice before very young babies are registered with GP practices, and it is not unusual for this to be the case at four weeks of age.  6.2.2. The older children had attended the practice since infancy and had been seen for minor ailments. Significant issues were that several immunisations had been given late, all three children required audiology follow up and some appointments were missed, as were  12 the third child’s speech and language therapy (SALT) appointments. There is no evidence that this pattern of non-attendance at medical appointments in both primary and secondary care was reviewed by a GP. The Surrey- wide named GP for safeguarding children, who compiled the GP IMR for this serious case review, noted that this issue has previously been identified in another recent Surrey SCR. Therefore, there is an ongoing piece of work between the named GP and the individual practice safeguarding leads, which aims to improve follow up when children repeatedly fail to attend for medical appointments. This is scheduled for completion in the spring of 2014, followed by audit in autumn in 2014.  6.2.3. The mother’s most significant contact with a GP was in April 2011 when she was recorded as having ‘non-dependent alcohol abuse’.  She reported drinking three bottles of vodka per week (120 units) and, whilst not drinking every night, could drink up to a bottle of vodka in one sitting without ‘losing control’.  The GP recorded that she was a single parent to three young children, which she found very stressful.  She drank only after the children were in bed.  The GP recorded discussing her concerns for the mother’s own health and the potential safety issues for her children.  The mother agreed to referral to a community alcohol service and the health visiting team, which the IMR author concluded was an appropriate response.  The GP record states that the health visitor was notified, but there is no record of this on the health visiting notes.  6.2.4. The mother did not engage with the alcohol service, which duly notified the GP.  However, there was no follow up by primary care to reassess any potential risks to the children.  No reason for this is recorded in the GP notes.  The IMR report concluded that more should have been done to review if the mother’s heavy drinking was continuing, and what impact it could be having on her children.  Also, in the light of her non-engagement with specialist services, consideration should then have been made as to whether a referral to Children’s Services was necessary.  In response to this review, the named GP for safeguarding children plans to review the current level 3 training for GPs, with a plan to incorporate training on alcohol misuse from a safeguarding children perspective.  6.2.5. The GP did not raise any concerns about alcohol misuse and the social circumstances (having been notified in October 2012 that the three children were subject to a child in need plan) at the time of the mother’s referral to maternity services in November 2012.  The IMR  13 report concluded that this was partly because the maternity referral form provides limited opportunity to record psychosocial concerns or substance misuse (and no mechanism for the recording of the father’s details and whether he is present at that point in the pregnancy).  Nevertheless, it was a missed opportunity for relevant information to be shared at the start of the mother’s pregnancy with child Y.  As a consequence, the named GP plans to meet with named midwives for safeguarding children to review current maternity booking forms by September 2014.  6.2.6. The father had very little contact with the GP practice.  It is recorded that he had taken two drug overdoses in 2005 and 2010 and suffered from a brief episode of low mood in January 2011, when he spoke to a GP over the phone seeking advice as he felt that he was ‘blowing things out of proportion’ and was taking it out on his mother and his partner.  It was recorded that he was father to three young children.  He was advised to make contact with a talking therapies service and no further GP contact was recorded.  6.3. Health care provider of hospital services  6.3.1. The community midwifery service provided by the local hospital was involved with child Y’s mother during her pregnancy with him.  She attended regularly for ante natal care and saw several different midwives.  While the midwife who completed the ante natal booking recorded on the summary sheet the mother’s history of alcohol misuse and involvement with Children’s Services, this history was not known by midwives who saw her subsequently, as they only looked at the hand held record where the history was not recorded.  The summary sheet recorded the history and the mother’s assertion that she had stopped drinking and that Children’s Services’ involvement had ended.  There is no evidence that either of these statements was verified by communication with the GP, health visitor or Children’s Services.  The community midwife responsible for the booking confirmed awareness of the hospital Trust’s safeguarding policies and procedures, and was not able to justify why further enquiries were not made and acknowledged that further enquiries into the history would have been beneficial.  6.3.2. Following his birth, child Y and his mother were visited at home on five occasions in two weeks, the majority of which were completed by the same midwife.  They had no concerns about his care.  The level of midwifery engagement in both the ante and post natal periods was appropriate and exceeded NICE recommended visiting  14 post natally.  However, some of the midwives were not aware of significant family history.  At the professionals’ meeting convened in April 2014 as part of this review, it was confirmed that, as result of learning from this case, changes to recording have been made whereby the hand held record now contains information on the summary sheet.  6.3.3. The paediatric A&E department of the local hospital had contact with child Y on 30 July 2013.  His mother reported that he had fallen from her knee onto the floor.  They were triaged very quickly by a nurse, child Y was assessed by a junior doctor and, due to his age, he was then reviewed by a paediatric registrar.  The mother’s explanation was deemed consistent and was accepted, and, following a period of observation, he was discharged, as he appeared well.  A health visitor referral form was completed in line with the hospital Trust’s Safeguarding Children Policy, but no referral was made to the community midwife, who was responsible for child Y at that time.  The IMR stated that, as a result of learning from this case and another recent serious case review, information is now routinely shared with the named midwife for safeguarding if a baby under 28 days old attends A&E.  The named midwife then contacts the relevant midwifery team with the information.  This change was confirmed when the independent reviewer met with community midwives at the learning event in March 2014.  6.3.4. The same A&E department dealt with child Y on 27 August 2013.  The IMR author reported that there was a clear plan for his clinical care and evidence of review by consultant paediatricians.  However, there was significant delay of around five hours before contact was made with the Children’s Services Emergency Duty Team, and this was just to share information.  It was another four hours before a formal referral of possible non accidental injury was made to the emergency team. Hence, there was a delay of around 9 hours before any action could be taken to safeguard child Y’s older siblings. This was a breach of compliance with Surrey Guidance for ‘Bruising in Children who are not Independently Mobile’.  The A&E paediatric staff explained to the IMR author that this was partly due to breakdown in communication within the team caring for child Y, partly because the staff were also dealing with another very sick child simultaneously, and partly because there was a fear of misdiagnosis.   6.3.5. The IMR author has confirmed that since August 2013, in response to this and another recent SCR, safeguarding supervision is now  15 facilitated on a weekly basis in paediatric A&E.  In addition, the safeguarding children team visit A&E daily and staff are reminded to make contact if they have any safeguarding concerns or queries.  Also, two more consultant paediatricians have been employed at the hospital, providing more support and oversight of safeguarding cases.  6.3.6. The same A&E department had many contacts with child Y’s older siblings.  They attended on 16 occasions between 2005 and 2013.  The presentations were reported as accidents or were emergency medical problems.  None of the incidents, which included a cigarette burn on a toddler and an overdose of antibiotics by a three year old, were viewed as potentially suspicious or indicative of poor parental supervision.  The IMR author concluded that professionals appeared to be affected by the rule of optimism and explanations were accepted too readily without further examination of the child or further consultation with named safeguarding professionals.  There is no evidence of communication with other professionals who knew the family, while notification to the health visitor was inconsistent.  Improved systems have been put in place as indicated in the above paragraphs.  6.3.7. The local hospital had information about many DNA (did not attend) appointments for the older children in outpatient departments.  This was particularly significant for the oldest child who missed nine appointments between 2010 and 2013.  The IMR author stated that there was some evidence of information sharing following missed appointments, but follow up with the GP was not consistent.  There was no evidence of named safeguarding professionals being alerted to the DNAs nor was there evidence of practitioners contacting the mother directly to remind her of the importance of attendance.  The hospital’s named doctor for safeguarding children is reviewing the hospital’s safeguarding policy in relation to missed appointments for children.  The revised policy is due to be completed by May 2014.  6.4. Local health care provider of community services  6.4.1. The health visiting service had four contacts with child Y and/or his mother in late July and August 2013.  The same health visitor saw them at home on two occasions.  She was aware of past concerns about possible neglect of child Y’s older siblings.  She recorded positive growth and development and good interaction between mother and child and had no specific concerns.  She also  16 discussed the fall that resulted in A&E attendance in July.  Two other health visitors had phone contact with the mother in August about breast feeding while the allocated health visitor was on leave.  She had planned to undertake child Y’s six – eight week check on 28 August, by which time he was in hospital.  An updated family health needs assessment had not been completed.  As the mother remained in safeguarding supervision during her pregnancy with child Y, a health needs assessment should have been started before his birth, with the aim of completion by the age of eight weeks.  However, due to a change of health visitor in May 2013, the assessment was not started pre-birth.  6.4.2. The health visiting service had been involved in the CAF (Common Assessment Framework) for child Y’s third sibling in 2011 and in the child in need plan for the three older children between September and December 2012.  The allocated health visitor was receiving safeguarding supervision because of the  child in need plan, mother’s repeated failure to engage with health services for her children, especially audiology checks and speech and language therapy for the third child, concerns about hygiene and consistent boundaries in the home, and the unknown status of the mother’s alcohol use.  When the case was closed by Children’s Services in January 2013, the health visitor felt strongly that this was the wrong decision, as she did not believe that all the concerns about neglect had been fully addressed, and the mother was pregnant.  She expressed her views to the allocated student social worker, who duly reported back that she had discussed the concerns with her supervisor, but the decision to end Children’s Services involvement stood.  The health visitor escalated her concerns to her safeguarding supervisor but there is no evidence that the supervisor approached Children’s Services.  The latter understood that the health visitor would address her concerns with Children’s Services.  6.4.3. The health visitor was tenacious in ensuring that the third child did eventually receive the speech and language therapy (SALT) that she needed, persisting in overcoming administrative obstacles posed by the SALT service.  6.4.4. The speech and language therapy (SALT) service finally provided a service to the third child from January 2013 after many months of delay.  The IMR author commented that the SALT service’s response to parental disengagement appears to have contributed to the child not being able to access the assessment and necessary support within reasonable timescales.   17 Administrative barriers were put in the way, which the child’s health visitor was tenacious in challenging.  Eventually, the SALT service overcame the mother’s failure to keep appointments by working with the child at school and engaging the school staff in the therapy.  The school staff duly engaged the mother, and the child finally received the necessary help.  However, it was around a year from referral to initial assessment, and a further five months before the child, assessed with a moderate-severe speech disorder, received regular therapy sessions at school.  The SALT managers have recently changed their processes, whereby a manager now reviews the case of a child whose parent has failed to keep appointments for assessments in order to ensure that a needy child receives the required service.  6.4.5. The school nursing service had very limited involvement with the family.  Two of the older siblings were identified as overweight in their school medicals in April 2013 but the records state that, as their mother did not respond to messages from the nurse, there was no intervention to address their weight.  The IMR author commented that school nurse involvement in this case accurately reflects the targeted nature of the service; school nurse caseloads only permit support of clearly identified health needs and safeguarding concerns.  Neither child was subject to a child protection or child in need plan or in safeguarding supervision, so the minimum requirement of review of health needs, communication of same to parent, discussion and further support was offered.  There is an apparent anomaly, as the mother remained in safeguarding supervision during her pregnancy with child Y but this was not extended to her children, resulting in no intervention to address their weight.  Obesity was not viewed as a potential indicator of neglect.   6.5. The Health Care Provider of mental health services  6.5.1. This Provider had limited involvement with the mother.  She was referred by her GP to the community alcohol team in April 2011 and she attended an initial triage assessment within two weeks of referral.  However, the mother did not attend two further scheduled appointments to complete the assessment process.  The service appropriately made an enquiry to the Children’s Services contact centre and notified the GP of her non attendance.  There is no record that the service notified the health visitor, but it was understood that the GP had done so.   18 6.5.2. The Provider also had very limited involvement with the father.  There were referrals to the Drug and Alcohol Team in his late teens due to cannabis use but he did not engage with the service.  There were also referrals to a psychologist and to psychiatric services following overdoses in 2005 and 2010, but there was no ongoing intervention due to non engagement in 2005 and risk of suicide being assessed as low in 2010.  6.6. Surrey Early Years and Childcare Service  6.6.1. This service provided information about the third child’s attendance at nursery and the family’s contact with the local children’s centre.  The nursery attendance for nearly two years on a part time basis was 100%.  It followed a CAF referral from the children’s centre citing concerns about speech and language delay.  Therefore, the child was allocated a free place under the Free Entitlement for Every Two Year Old scheme.  The nursery staff had regular contact with the mother and noted a few concerns – about the child’s diet and weight, and aggressive behaviour on one occasion.  They were addressed appropriately with the mother.   6.6.2. The family was registered at the local children’s centre from September 2009, but the mother only attended part of a positive parenting course (in April 2011).  There was no outreach worker employed at this time so there was no follow up.  6.7. Surrey Schools and Learning  6.7.1. This IMR provided information about the local primary school attended by the three older children and outreach services.  The staff at the school recognised the children’s additional needs and ensured that they received the necessary support for their learning and social development.  This included attendance at the breakfast club.  The same reception class teacher taught the three children and made positive efforts to engage both parents in supporting their learning.  Although the father was not seen regularly, the school staff perceived him as a positive influence.  6.7.2. In September 2008, a home school link worker (HSLW), employed by the school, became involved with the family to address concerns about the first child’s behaviour at school and at home.  The HSLW continued her involvement until November 2012 and provided practical and emotional support to the mother to support her parenting.  She engaged several agencies to support the family and  19 coordinated their involvement.  She put in place the CAF for the third child in 2011 and was the lead professional.  6.7.3. In November 2009 a behaviour support teacher worked alongside the HSLW to assist the mother in managing the oldest child’s behaviour.  Her involvement continued until April, and it is recorded that the mother considered that the programme had resulted in improvements.  6.7.4. Specific concerns about the children were reported to the previous head teacher of the primary school on three occasions by members of staff.  On the first occasion, the HSLW reported in July 2011 that a member of the public had told her that the mother was drinking heavily.  On the next occasion, a class teacher completed a cause for concern form in September 2012 about the second child as she had a black eye and the explanation was inconsistent. The third occasion, in January 2013, also involved the second child. The class teacher completed a cause for concern form about a burn on the child’s hand. There is no record that any of these concerns was reported to Children’s Services. The latter two events occurred when the school was experiencing significant personnel changes. The new head teacher has undertaken safeguarding training and is aware of the correct action to take if such a concern should arise in the future.  6.8. Homestart  6.8.1. In February 2010 a Homestart volunteer became involved with the family, and it is reported that the mother valued this.  However, the volunteer was changed in October 2010, and the mother was unhappy about the change, so the contact with Homestart ended.  6.9. Surrey Children’s Services (SCS)  6.9.1. In May 2012 there was an anonymous referral to Children’s Services (SCS) alleging that the children were neglected because of their mother’s alcohol use, that her supervision of the children was poor, and that the home and the children were unkempt.  The SCS contact centre had received seven previous notifications or contacts between 2005 and 2011.  Two were from Surrey Police reporting domestic abuse in 2005 and 2009 (the latter also reported that the family home was untidy with evidence of cannabis use lying around); two were from the police reporting incidents in 2010 when two of the children went missing for brief periods; two were in 2009  20 from an art therapist in mental health services whose client reported that the children were neglected and unsupervised due to their mother’s alcohol misuse; one was from the community alcohol team in May 2011 after their initial assessment of the mother, querying if the children were known to Children’s Services.  6.9.2. Prior to May 2012 the SCS contact centre had responded to the police notification about domestic abuse in 2009 by contacting the health visitor, who agreed to visit the family.  However, the SCS contact centre closed the case even though the health visitor had been unable to make contact with the mother or see the children.  The SCS contact centre had also responded to one of the missing incidents in 2010 by contacting the HSLW and asking her to follow it up with the mother.  It appears that each reported incident was viewed separately rather than identifying the pattern of possible neglect/emotional harm that they might indicate cumulatively.  This practice by contact centre staff has been noted in previous reviews in Surrey.  6.9.3. SCS began an initial assessment in May 2012, which progressed quickly to a core assessment.  The IMR author commented that the core assessment was not of good quality.  However, the social worker did see the two oldest children alone in school as part of the assessment and did meet with the father.  It took longer than the recommended 35 days for such an assessment because the assessing social worker had difficulty in making contact with the father and also took a period of leave.  The core assessment was completed in August and recommended that ongoing support should be provided as children in need.  6.9.4. The case was allocated to a student social worker in September 2012.  A child in need meeting took place in October attended by the mother, her stepfather, the paternal grandmother, and professionals working with the family – health visitor, HSLW, student social worker and her supervisor.  The meeting developed further the child in need plan, which the IMR author described as possibly having too many objectives, including some for the father, who was not engaged with it.  6.9.5. The student social worker visited the family home seven times between September – December 2012, and the children were seen on their own on one occasion at school.   21 6.9.6. There was a meeting to review the plan in December 2012, attended by the mother, her stepfather, the health visitor, school staff and student social worker (the HSLW had left her job in the November after supporting the family for four years).  The student social worker recommended that the case should be closed, but the IMR author reported that it was unclear what had changed significantly for this to be considered appropriate, other than the threshold for child protection was not deemed to have been met and the work that SCS had agreed to undertake under the child in need plan had been completed.  The children’s attendance at school was good, but the mother was not engaging with recommended services, and there did not appear to be enough evidence that the home situation was significantly better.  However, the mother was assessed to be able to understand the risk factors and take action to minimise them.  The assessment of the father’s capacity to parent remained unknown.  6.9.7. At the point when the case was closed by SCS in January 2013, it was known that the mother was pregnant and it was unclear who the father was.  The mother had experienced a stillbirth in 2005, so was anxious about the pregnancy.  There were still concerns that the home was unclean and that the mother was failing to take the children to medical appointments, and the health visitor raised her concerns that issues of neglect and emotional harm were still prevalent and little had really changed for the children.  There was no formal step down plan and no lead professional was identified, but the school staff and health visitor continued to work together.  6.9.8. The SCS staff involved in the core assessment are no longer working in the service so could not be interviewed.  Likewise, the student social worker was not available.  However, her supervisor was interviewed by the IMR author.  She explained that the student was in her final year and was deemed to be a good student, so her judgment of the family functioning was accepted.  However, at the time when the supervisor agreed that the case should be closed, she was supervising up to eleven staff due to vacancies and sickness.  This was an unfortunate combination of circumstances and is not usual practice.  SCS supervisors normally supervise 5 – 6 social workers. I n this case, the consequence was that the supervisor was not aware of all the background information when making the decision to close the case.  6.9.9. When the SCS emergency duty team was notified late in the evening by the A&E paediatrician of the injuries to child Y on 27  22 August 2013, the social worker duly notified Surrey Police who checked the safety of the older siblings.  They were all safe in the care of members of their extended family.  6.10. The local borough council   6.10.1. The council was the mother’s landlord.  Its only significant involvement during the period of this review was to issue a notice to the mother requiring her to remove rubbish from the property.  She duly complied. The council also ensured that essential works were undertaken by its contractors and liaised with the HSLW as necessary.  The council officers did not see the children on any visits to the family home and had no evidence to suggest that the mother was not looking after the children properly.  7. KEY ISSUES  7.1. Communication  7.1.1. This review has identified a number of gaps in communication between agencies and within agencies.  7.1.2. During the mother’s pregnancy with child Y, the midwifery front sheet (completed during the first ante natal appointment) noted that she had had a problem with alcohol and had also been involved with Children’s Services, but this was not on the hand held record, which midwives who saw her subsequently looked at. Hence, they did not know about past concerns.  7.1.3. The GP records indicate that she did notify the health visitor of concerns about the mother’s drinking, but there is no record on the health visitor notes.  The two health visitors, who between them were responsible for the case between June 2011 and May 2013, state that they were not aware of the mother’s reported alcohol misuse to the GP in May 2011.  The GP did not notify the midwifery service of historic concerns when the mother was referred in 2012.  7.1.4. The health care provider of community services kept the mother in safeguarding supervision in the health visiting service during her pregnancy with child Y because of past concerns, but did not keep his siblings in safeguarding supervision in the school nursing service.  This meant that there was no assertive action to address obesity.  23  7.1.5. The Drug and Alcohol Service appropriately notified Children’s Services of their initial assessment of the mother but did not notify the health visitor.  The staff understood that the GP had notified her.  7.1.6. The local hospital paediatric A&E staff did not notify the health visitor consistently about the older children’s attendances, nor did they notify the community midwifery service after child Y attended in July 2013.  However, they did notify the health visitor of this attendance.  7.1.7. The hospital paediatric A&E staff did not notify Children’s Services of their concerns that child Y had suffered a non accidental injury for five hours, at which point they made contact to check if he was known to Children’s Services.  The referral was nearly four hours later.  This delay potentially put his siblings at risk.  7.1.8. There is no evidence that the previous head teacher of the children’s school reported concerns to Children’s Services about information received about the mother’s alcohol misuse or about two separate injuries noted on one of child Y’s siblings, one of which occurred when the child was subject to a child in need plan.  7.1.9. Children’s Services notified the GP practice in October 2012 that core assessments of the three older siblings had been completed two months earlier and the need for ongoing support through a child in need plan had been identified.  There is no record that the GP was contacted to contribute to the assessments or notified of the reasons for the plan or how long it continued.  7.1.10. At the time of the core assessment the third child was attending nursery, but there is no record that Children’s Services contacted the nursery for information about the child.  7.1.11. The consequence of these gaps in communication was that the professionals in direct contact with the family did not have the full picture of how it functioned and of the children’s experiences.  7.1.12. There were, however, examples of positive communication between agencies, notably coordinated by the home school link worker.  She was the lead professional identified in the CAF for the third child and liaised between the school and the mother, along with the behaviour support teacher, Homestart, the health visitor, the nursery and the local borough council.  24  7.1.13. Some agencies, notably the hospital and the school, have acknowledged the failings in communication and taken steps to remedy them, as indicated earlier in this report.  7.2. Professional Standards  7.2.1. There was variability in professional standards across agencies in relation to the quality of assessment, identification of neglect, decision making, and exercise of professional curiosity.  Assessment  7.2.2. Health needs assessments undertaken by the health visitors lacked depth, did not explore fully the extent of domestic abuse and alcohol misuse, and contained limited information on the father and his role in the family.   7.2.3. The GP dealt appropriately with the mother’s disclosure about her alcohol misuse in 2011, but when the mother failed to engage with the community alcohol service more should have been done to assess if her heavy drinking was continuing and what impact that could be having on her children.  7.2.4. The core assessment undertaken by Children’s Services in 2012 was not of good quality and did not gather all the background information known to Children’s Services or all the information known to other agencies.  There was no chronology, and there was limited assessment of the father’s role in the family and any risks he might pose to the children.  The lack of engagement with the father meant that his mental health issues and substance use were not explored.  There was no contact with grandparents, who were identified as significant in the children’s lives but were not part of the assessment.  The IMR author commented that the assessment did identify the risk factors well and appropriately recommended the need for ongoing support for the family.  However, the recording of the assessment was lacking in detail.  7.2.5. The first midwifery contact with the mother in December 2012 took at face value her assertion that she no longer drank alcohol and that her contact with Children’s Services had ended.  There was no professional curiosity or attempt to explore these matters in any depth.   25 7.2.6. The children attended A&E at the local hospital on many occasions between 2005 and 2013.  However, none of the injuries or an accidental overdose was viewed as potentially suspicious or indicative of poor supervision.  Again, the mother’s explanations were taken at face value, with a lack of professional curiosity.  7.2.7. By the time of child Y’s birth, it was believed by the health visitor and community midwives that his mother had stopped drinking.  Also, child Y’s paternity was unknown to the health professionals, and there was very limited assessment of the parenting capacity of the father of the older children and what part he might play in parenting child Y.  7.2.8. It should be acknowledged that all agencies were in a difficult position in trying to assess the father.  The mother consistently maintained that he did not live with her and the children, and in later years, was adamant that their relationship was over.  The father was evasive when attempts were made to contact him (for example, by the social worker).  Identification of Neglect  7.2.9. The staff of the children’s school considered that the three older children experienced some neglectful parenting.  However, it was not considered to be at the threshold of significant harm.  Therefore, they ensured that they received additional support (eg breakfast club) and allocated the home school link worker to support the mother.  She focused on improving hygiene and conditions in the home, assisting the mother to manage the children’s behaviour, and enabling the children to access services (eg nursery).  7.2.10. When the core assessment was undertaken in 2012, a specialist assessment tool to identify neglect was not used, as this was not the practice in the service.  The subsequent intervention by the student social worker appeared to focus on practical matters (eg state of the home) without addressing the potential neglect indicated by so many missed appointments.   7.2.11. Overall, the issues of neglect were not fully understood or addressed.   26 The children’s voices  7.2.12. Child Y was only six weeks old when the critical incident happened, and the records of the community midwives and health visitor make positive observations of his development and interaction with his mother.  7.2.13. The older children had regular attendance at nursery and school so were observed and spoken with on each school day.  In all the reports and chronology compiled for this review, there is only one record of a child making an adverse comment when the second child told nursery staff in 2011 that no one cared for her at home.  The school staff reported that the children spoke openly about what they did at home.  7.2.14. During the core assessment, the assessing social worker spoke with the two oldest children on their own at school, and the student social worker also saw all three children on their own at school and engaged them in activities using direct work tools to facilitate communication.  Decision making and risk analysis  7.2.15. There were seven notifications to or contacts with the Children’s Services contact centre between 2005 and 2011 highlighting domestic abuse, the mother’s alcohol use impacting on her capacity to parent, and concerns about her supervision of the older children.  None of these resulted in a referral for assessment because it was not considered that they met the threshold.  While this may have been a reasonable judgment for each individual contact, the cumulative pattern that they revealed would suggest that an initial assessment should have taken place sooner.  A similar pattern has been noted in previous case reviews in Surrey.  It has been addressed by developing a central countywide multi-agency safeguarding hub, which operates a partnership approach to child protection and safeguarding contacts and referrals.  The county council’s contact centre no longer receives contacts for Children’s Services, and referrals are now passed to area duty and assessment teams for decisions about the threshold for undertaking an assessment.  7.2.16. Children’s Services closed the case after three months subject to a child in need plan.  This was because the student social worker and her supervisor judged that the issues had been addressed in that  27 the home was cleaner and some practical tasks had been achieved.  The student social worker took the mother’s word that she had stopped drinking heavily because no professional had reported seeing her under the influence of alcohol.  She also took the mother’s word that the father did not live in the family home and that domestic abuse was no longer an issue without apparently considering the increased risks of domestic abuse after separation.  In the course of this review, the supervisor has acknowledged that she was not aware of all the background information held by partner agencies, and she would not have closed the case if she had been aware of it.  7.2.17. There was no joint risk assessment by the professionals in the child in need network to inform the decision to end the child in need plan.  It was known at the time that concerns remained about supervision of the oldest child, about missed appointments for the children, about cleanliness within the home, and about the children’s diet.  7.2.18. A formal written step down plan was not put in place after the child in need plan ended and no one was designated lead professional. However, the health visitor and school staff continued to work together.  Surrey Children’s Services is about to implement a different model of working in an attempt to improve service delivery to vulnerable children below the threshold of child protection.  It is intended that the ‘step down’ process will be more rigorous, and a family plan will be developed and a new lead professional agreed.  Effective professional practice  7.2.19. There were some examples of effective professional practice.  7.2.20. The school staff made strenuous efforts to engage both parents in supporting their children’s learning and to address the children’s needs for additional support.  7.2.21. The home school link worker was proactive in engaging several agencies to support the family and remained committed to providing practical and emotional assistance to the mother for over four years.  7.2.22. The health visitor was tenacious in ensuring that the third child received speech and language therapy despite the mother’s reluctance to attend an assessment meeting.  She ensured that  28 administrative processes did not prevent the child receiving a service.  7.3. Organisational Issues  7.3.1. In Children’s Services, there was a delay of a month or so in allocating the case after completion of the core assessment in August 2012 and it was held on duty during this period.  The delay was due to staff shortages.  7.3.2. Also, in Children’s Services, the supervisor of the student social worker responsible for the case for three months was, at that time, supervising up to eleven staff due to sickness and vacancies.  This is not usual practice.  However, the consequence was that the supervisor was unaware of all the background information when making the decision to close the case in January 2013.  7.3.3. There was lack of continuity in the community midwifery service during the mother’s pregnancy with child Y and after his birth.  The mother kept all her appointments but saw several different midwives, which contributed to gaps in their knowledge of her background.  During this review, the service has reported that it is now fully staffed and providing improved continuity of care.  7.3.4. There was significant health visitor turnover during 2011-13, with five different individuals being allocated to the family.  This may have had a negative impact on appropriate management of the risks in this case and in the mother’s engagement with the service.  The lack of continuity was due to staff shortages, increasing caseloads and organisational change.  7.3.5. There were issues in management oversight of the health visiting service.  Safeguarding supervision is provided separately from line management and recommended that the mother should remain in safeguarding supervision during the latter part of her pregnancy with child Y even though health visiting involvement had ended with the third child who was by then in school.  The health visitors’ view was that, as this was an ’enhanced’ case, there should have been extra visits to the mother, commencement of an updated family health needs assessment, and additional supervision.  However, because there was a change of health visitor in May 2013, this did not happen.  The operational managers of the health visitor caseloads did not have specific case knowledge, and there was no recorded handover between professionals.   29  7.3.6. The key issues identified were delays in allocation of enhanced cases and gaps in communication between the line managers of health visitors and safeguarding supervisors.  The IMR author stated that, as a direct result of the learning outcomes identified within this review, there is now a protocol of substantive recorded handover between professionals when reallocation of enhanced cases is necessary.  Managers are also informed when cases of safeguarding concern are transferred between professionals and team bases to ensure continuity of involvement.  7.3.7. The health visitor did not agree with the decision by Children’s Services in December 2012 to close the case.  She raised her concerns with the student social worker and escalated her concerns to her safeguarding supervisor.  However, they were not escalated across agencies to Children’s Services.  This action may have been different if a well promoted escalation policy had been in place.  Surrey Safeguarding Children Board is developing an inter-agency escalation policy which is due to be in place by May 2014.  7.3.8. The speech and language therapy service response to parental disengagement appears to have contributed to the third child not being able to access the necessary assessment and support within reasonable timescales.  Changes have now been made by the manager of the service to ensure that needy children are able to access the service.  7.3.9. There was no system within Health agencies to keep oversight of the numerous DNAs at medical appointments by child Y’s older siblings. This had two consequences: - delays in them receiving necessary services/health care - lack of appreciation of the possible neglect that it indicated  As already indicated in this report, the named GP and the named doctor for safeguarding children at the local hospital are developing policies to address this issue.  8. CONCLUSIONS AND LESSONS LEARNED  8.1. At the time of the critical incident, child Y was only 6 weeks old.  During this time, he had been seen at home by a community midwife on five occasions and by a health visitor on two occasions.  His mother had also received phone advice from two other health visitors.  None of these professionals  30 had any concerns about his growth and development or about his mother’s interactions with him.  He had been seen by a GP once because he was snuffly.  He had also been taken to paediatric A&E after a fall from his mother’s lap, which was accepted as accidental and resulted in no adverse effects.  8.2. The mother did not divulge the identity of child Y’s father during her pregnancy and professionals working with the family understood that child Y had a different father to her three other children.  Therefore, no assessment had been made of any father figure or of the role that the father of the other children would have in respect of child Y.  No professional was informed that the mother planned to be away on the weekend of the critical incident, leaving child Y in the care of the father when it is believed that the injuries occurred.  8.3. There was evidence, known to Children’s Services, that the father had been violent to the mother/her property on two occasions in the past, that he had taken two separate overdoses and that he used cannabis.  This information was known to the GP, but not known to the other health professionals involved with child Y and his mother.  Otherwise, very little was known about him or about the nature of the relationship between the parents.  The mother maintained that they did not live together and that the relationship was over by the time of her pregnancy with child Y.  He was clearly involved in the care of the three older children, as social workers, health visitors and the home school link worker had seen him in the home.  The school staff also saw him bringing and collecting the children at times.  He was generally viewed as a positive influence in the children’s lives, and there is no evidence that any child expressed negative feelings about him.  Critically, there was no assessment by health professionals or social workers of his parenting capacity and any risks he might pose to the children.  However, it must be acknowledged that this would have been difficult to achieve as the mother revealed little about him and he had very little contact with agencies, apart from the school.  8.4. Although there were no specific concerns about the mother’s care of Y in the first six weeks of his life, there had been past concerns about her vulnerability as a lone parent, about the impact of her alcohol use on her parenting, and about neglect of her older children.  There was no updated assessment during her pregnancy of how these past concerns might impact on her care of child Y.  8.5. There was insufficient evidence to predict that child Y would suffer significant harm while in the care of the father.  However, there were missed opportunities to undertake a comprehensive assessment of his parenting  31 capacity and any risks he might pose to child Y and to update the assessment of the mother’s capacity to parent four children.  8.6. This review has revealed many themes common in serious case reviews, such as the lack of assessment of peripheral male figures, poor identification of neglectful parenting and its impact on children’s life experiences, ineffective assessment of parental substance misuse, and a lack of professional curiosity.  8.7. It has also revealed issues that have occurred in previous serious case reviews in Surrey, notably gaps in sharing information across agencies, identification of non accidental injury at the local hospital, lack of a system to collate DNAs when children miss medical appointments, and failure of the Children’s Services contact centre to respond to repeated notifications of concern about children.  The partner agencies of the Surrey Safeguarding Children Board have acknowledged these issues and are taking action to address them.  Therefore, they will not be repeated in the recommendations below.  However, the recommendations address necessary systems for the Board to oversee rigorously the implementation of the planned changes and an audit process to check their effectiveness.  9. RECOMMENDATIONS FROM THIS SERIOUS CASE REVIEW  9.1. Introduction 9.1.1. These recommendations reflect the key issues arising from this review. Agencies have not awaited the completion of this review in order to address issues arising from this case.  Some of these recommendations, or aspects of them, have been identified and addressed already.  9.1.2. Some of the recommendations below address helpful suggestions made by practitioners at their meeting with the lead reviewer and SSCB case review officer in April 2014 – an enhanced consultancy role for the community alcohol team, development of a shared multi agency chronology during assessments, updated multi agency risk assessments before children are ‘stepped down’ into early help, and proactive involvement of children’s centres in early help plans.  9.2. Recommendations to the Surrey Safeguarding Children Board  9.2.1. The Board should ensure that reported improvements by the local hospital in consistent recording on maternity records, in consistent notification of midwives and health visitors when children attend  32 A&E, and in safeguarding children lead professionals maintaining enhanced oversight of children attending A&E, are embedded.  9.2.2. The Board should ensure that the reported improvements by the local health care provider of community services in management oversight of health visitor case transfers and in access to speech and language therapy by needy children are embedded.  9.2.3. The Board should ensure that the review of maternity booking forms and the policies currently being revised, by the named GP for safeguarding and by the named doctor for safeguarding at the local hospital, on children failing to attend medical appointments, are completed in a timely manner and implemented fully.  9.2.4. The Board should ensure that the policy on escalation of concerns across agencies is fully implemented.  9.2.5. The Board should review multi agency practice with neglectful families and consider ways in which it can be improved, drawing on evidence about what works.  9.2.6. The Board should review multi agency practice with children affected by parental alcohol misuse and consider ways in which it can be improved, including an enhanced consultancy role for the community alcohol team.  9.2.7. The Board should ensure that all agencies enhance their engagement with and assessment of peripheral fathers.  9.2.8. The Board should ensure that an updated multi agency risk assessment is undertaken before children are ‘stepped down’ into the early help system.  9.3. Recommendations to Surrey County Council  9.3.1. Surrey Schools and Learning should ensure that all school Child Protection Liaison Officers have received updated safeguarding training.  9.3.2. Surrey Children’s Service (SCS) should ensure it undertakes regular audits of repeat contacts to the multi agency safeguarding hub and repeat referrals to the duty and assessment teams and reports the findings to SSCB.   33 9.3.3. SCS should set standards for the quality of assessment, including a shared multi agency chronology and involvement of extended family members who have a significant role in children’s lives, and ensure that all managers and supervisors uphold the standards.  9.3.4. SCS and Surrey Schools and Learning should consider how children’s centres can be actively involved in child protection and early help processes, where relevant.  9.4. Recommendation to Community Health Care Provider  9.4.1. The health care provider of community services should review its policy on childhood obesity to ensure that safeguarding is considered.  9.4.2. The health care provider of community services should review its policy on safeguarding supervision with a view to achieving a consistent approach across all its services.  34 APPENDIX A  Composition of SCR Panel   Alex Walters      Independent Panel Chair Designated Nurse NHS Guildford and Waverley Clinical Commissioning Group Deputy Director Children, schools and Families Surrey County Council Head of Youth Support Services   Surrey County Council Head of Safeguarding     Surrey County Council Surrey Local Delivery Unit Director Surrey and Sussex Probation Trust Partnership Support Manager Surrey Safeguarding Children Board Area Education Officer (North East)   Surrey County Council Detective Superintendent, Public Protection,  Surrey Police   In attendance  Case Review Officer Surrey Safeguarding Children Board  Helen Davies      Independent Reviewer   35 APPENDIX B  Details of the independent reviewer/author of this report  Helen Davies trained in social work and worked in local government in a range of social work and management positions, including thirteen years as an assistant/deputy director of children’s services.  Since 2011, she has worked as an independent consultant and been involved in a number of reviews in respect of children and adults.  She has never worked in any of the agencies involved in this review, but has contributed to three previous reviews undertaken by Surrey Safeguarding Children Board.   36 APPENDIX C  Terms of Reference for this Serious Case Review  The serious case review primarily considered events in the period from May 2012, when Children’s Services began its assessment of the family, to August 2013 when the critical incident happened to child Y.  However, all agencies were requested to include relevant background information about his older siblings, so the relevant chronology of key events dates from 2005.  The agencies were asked to draw up their individual management reviews around the following issues:  - Did agencies communicate effectively and work together to safeguard and promote the children’s welfare.  - Was the level and extent of agency engagement and intervention with the family appropriate?  Were assessments undertaken in a timely manner, was the quality adequate and did they include fathers, extended family and historical information?  - Was any information known by any agency about parental mental health issues, domestic abuse, substance misuse or parental anti social behaviours or concerns re neglect?  If so, was appropriate consideration given to how these impacted on parenting capacity and were appropriate referrals made?  - Were the decisions and actions that followed assessments appropriate and were detailed plans recorded and reviewed?  Were multi agency ‘step down’ plans in place and agreed by agencies following the closure of the CIN plan in Jan 2013?  - Were the children’s views and wishes sought and taken account of in assessments and planning?  Did this include the presentation of young non verbal children being fully considered?  - Were any safeguarding issues in respect of child Y and his siblings identified and acted on appropriately and in a timely way by all agencies?  - Were missed appointments and failure to engage considered as indicators of neglect?   37 - Was race, religion, language, culture, ethnicity or disability a factor in this case and was it considered fully and acted on if required?  How was the uniqueness of this particular family recognised?  - Were there any organisational or resource factors which may have impacted on practice in this case?  - Were appropriate management/clinical oversight (supervision) arrangements in place for professionals making judgments in this case?    38 APPENDIX D  Principles Underlying this Serious Case Review  The conduct of this review has not been determined by any particular theoretical model.  It has been carried out in keeping with the underlying principles, set out in the statutory Guidance, Working Together to Safeguard Children 2013:  - There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children. Identifying opportunities to draw on what works and promote good practice;  - The approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined;  - Reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed;  - Professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;  - Families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process;  - Final reports of SCRs must be published, including the LSCB’s response to the review findings, in order to achieve transparency. The impact of SCRs and other reviews on improving services to children and families and on reducing the incidence of  deaths or serious harm to children must also be described in LSCB annual reports and will inform inspections;  - The review will recognise the complexity of safeguarding children and seek to understand not only what happened but why individuals and organisations acted as they did;   39 APPENDIX E  References  This report has been generally informed by the following publications   Working Together to Safeguard Children  (Department for Education 2013)  A Study of Recommendations Arising from Serious Case Reviews 2009 to 2010 by Marion Brandon et al (Department for Education 2011)  New Learning from Serious Case Reviews: a 2 year report from 2009 to 2011 by Marion Brandon et al (Department for Education 2013)  In the Child’s Time: professional responses to neglect (Ofsted 2014)     