Death of 3-year-old Child S, cause unknown, in summer 2014, six months after moving to a London Borough. Child S had lived for most of his/her life in another Local Authority. Child S's mother had a history of long term substance misuse. Child S, a sibling Child Y, and the mother were known to Children's Social Care (CSC), universal and specialist health and disability services, pre-school support services and drug support services in both local authorities. Child S had been the subject of a Child Protection Plan in 2013 but removed from the plan in the same year. Child S had serious health concerns from birth, eventually identified as cerebral palsy. Contact with all agencies was sporadic and featured many missed appointments. When the family moved to the London Borough there were concerns about the lack of support for Child S's health in the transition. Learning points focus on: coordination and leadership; escalation of concerns; core and follow up assessments; continuity in social work practice; healthy scepticism about long term drug use; reporting and sharing information in drug services; experience of the child; transferring information between areas; hidden men; safeguarding children with disabilities; police sharing information. Recommendations for the two LSCBs include: pre-birth planning and assessment appropriate with drug using parents; Children in Need meetings properly recorded and CSC assessments up to date; compliance with 2009 guidance on safeguarding children with disabilities; review compliance on transferring cases; embedding healthy scepticism about long term drug using parents
      
 Title:  Serious case review into services provided to Child S and Family. LSCB: Waltham Forest Safeguarding Children Board Author: Alan Bedford Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                                                                                                                                                                                        SERIOUS CASE REVEW INTO SERVICES PROVIDED TO  CHILD S and FAMILY                                  Final    Nov 2015  updated May 31 2017                                                                                           Independent Reviewer- Alan Bedford  Section  Page 1 INTRODUCTION 1 1.1  Background to the Review  1.3 North East Lincolnshire  1.4 Terms of Reference  1.6  Review Process  1.10 Independent Reviewer 2 1.11 Family Involvement  1.12 Anonymity  1.13 Agencies Participating  1.14 Report Structure 4 1.16 Family Structure  1.17 Care Proceedings  1.18 Detail     2  HISTORY  and APPRAISAL 5 2.1 Introduction  2.4 Before the pregnancy with S was revealed  2.18 The pregnancy and birth 8 2.30 2012 11 2.46 2013 15 2.72 2014 and the move south 22 2.80 The arrival in London 23 2.85 Services in Waltham Forest 24 2.105 S’s death 29 2.109 Summary     3  LEARNING and WHY 32 3.1 Introduction  3.2 Coordination and leadership  3.10 Escalation 34 3.12 Assessments  3.16 Continuity  36 3.19 Tolerance, and drug use  3.26 Drug services 38 3.32 Scepticism 39 3.34 Thinking about what it was like to be S 40 3.36 Transferring between areas  3.44 Men 42 3.46 Safeguarding and disabled children 43 3.52 Police 44 3.55 CSC organisational context 45    4 CONCLUSION 48    5 RECOMMENDATIONS 51    Appendices  3 App1 H,,,,   Collated Learning Points         52 App 2 Agencies Updates on Progress 583  56 App 3 Acronyms   72  1  1 INTRODUCTION  1.1 Background to the Review: In late 2014, the Chair of the Local Safeguarding Children Board (LSCB) concluded that the circumstances of this case met the statutory requirements for a Serious Case Review (SCR) as set out in statutory guidance.1 These are that there should be an SCR for every case where abuse or neglect is known or suspected and either a child dies or a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child.   1.2 The child in this case died. Although a specific cause of death has not been identified, as this was a case with considerable complexity, covering two local authorities, where there had been concerns about neglect, and the child had been in the past on a Child Protection Plan, there was sufficient to meet the criteria for a Review. The history of neglect and parental drug use, made it important to examine the case carefully.    1.3 The outcome of the Police investigation was that the CPS made the decision not to prosecute anyone in relation to Child S’s death.   1.4 The child had been living in the host borough for less than six months before the death a few days after arriving in the borough in which the family had previously resided in. This preceding area had been the family home for a number of years and for the subject child over 2 years before the move to the receiving borough. The SCR whilst commissioned by the receiving borough as the most recent home area has had the necessary support from the originating area’s LSCB and  the Review’s inquiries  have been mirrored in both areas  1.5 Terms of Reference: The 2013 guidance (which applied when this Review was begun) no longer provides core terms of reference for SCRs, but says that final SCR reports should  provide a sound analysis of what happened in the case and why, and what needs to happen in order to reduce the risk of recurrence.  1.6  This SCR will :  Appraise the quality of work in this case  Establish what lessons can be learned about the quality and effectiveness of      agency and multiagency working  Identify the key themes that characterised work with this family  Make proposals for improvement where any shortfalls are identified  Involve front line staff and family members in the Review  There is a key underlying question:                                             1 Working Together to Safeguard Children (DfE, March 2013).  2   Could the death have been prevented?  If so, why, and what can be learned from this to help other vulnerable children, and staff, in the future  1.7 Review Process:  The Review used the flexibilities contained in the guidance to follow a methodology that fitted local needs. In both local authorities, with 1-2 representatives from the other area, scoping days were held, chaired by the independent reviewer, with front line staff and managers involved in the case. The groups, which saw summaries of each agency’s involvement, identified the key points of agency interaction with the family for specific focus, and also identified key themes for the Reviewer to explore. This was a helpful way in both engaging staff in thinking about the possible learning, but also making best use of Review time by agreeing focus. As will be seen in the Review, there were some differing issues and perceptions between the areas and the cross participation proved very valuable in understanding the case  1.8 Thereafter, the independent reviewer met the staff involved with the case, examined agency files, and the dialogue between reviewer and reviewed about what happened and why, and what might be done better, provided rich material for this Review.  1.9 To support the process there was a small Reference Group of senior staff from involved agencies which the reviewer could use as a sounding board, and if necessary to facilitate any stumbling blocks in the process. The host authority’s LSCB’s standing SCR Panel quality assured the final draft before presentation to the Board. The report has also been agreed by the preceding authority’s LSCB.   1.10 The staff groups reconvened to consider the draft SCR, to advise on whether it was describing appropriately the facts and issues, and to consider what recommendations would be most helpful for their work. Both meetings were well attended, and the Review would like to thank staff for their openness and commitment to the learning process. All key staff were fully cooperative.  1.11 Independent Reviewer: Alan Bedford was asked by the LSCB to undertake this Review. He has a background in child protection social work with the NSPCC, where he was also national training manager. Following this is spent 18 years in the NHS, the majority of the time as a CEO in Trusts and Health Authorities. He has worked independently as Alan Bedford Consulting on a range of issues from infection control, to emergency health care, to safeguarding. From 2009-11 he was Director of Safeguarding Improvement for NHS London, leading a London wide peer review programme, and from 2009-13 was chair of the Brighton and Hove Safeguarding Children Board. He has conducted a number of SCRs, is accredited as a SCIE Systems Reviewer, and completed the 2010 and 2013 national training for SCR authors/chairs.  1.12 Family Involvement: Towards the end of the Review the mother agreed to meet the Reviewer to discuss her views on services and her views are reflected in this report. The Reviewer also met her in February 2016 to go through the findings of the  3  Review. She was pleased the findings might help other families in a similar situation in the future  1.13 Anonymity: As the focus of SCRs is about learning, it is inappropriate to identify the children and family concerned. This Review which will be published will not therefore describe the family in any detail which could lead to identification, especially of the surviving sibling. Some facts may be altered slightly to enhance anonymity.    1.14 Agencies Participating: All involved agencies participated. These included:  Host Area  Local Authority and Council  Children’s Social Care  Education/Academy  NHS Foundation Trust  Health Visiting  Community Paediatrics including therapy services  Bart’s Health NHS Trust  Paediatrics  General Practice  Preceding Authority  Local Authority and Council  Children’s Social Care   Children’s Centre  Health Visiting  Children’s Disability Service  Education/School  Home Options and Home Choice  Police  NHS Foundation Trust  Midwifery  Acute and Community Paediatrics, including therapy services  NHS Clinical Commissioning Group   4  NHS Foundation Trust (RDaSH)  Drug and Alcohol Services for Adults          General Practice  Two surgeries  Children’s Hospital NHS Foundation Trust  Addaction  1.15 Report Structure:  This report describes the history in Section 2, appraising professional practice in key events. In Section 3 there is ‘Learning and Why’ which identifies the key themes of professional practice and why those patterns of work occurred. It is in understanding the ‘why’ that needed improvements can be identified. The ‘Conclusion’ in Section 4 summarises the learning, and answers the key question about whether protection could have been quicker.  1.16 There are in Section 5, recommendations for the LSCBs to consider. They are addressed to the Boards rather than each agency separately, given the Boards’ collective responsibility for assuring the quality of child protection systems.  1.17 Family Structure:  The mother was unmarried, with two children. S was not yet 3 at the time death, with another child, Y, three years older.   1.18 Care Proceedings: The surviving child is subject to Care Proceedings.   1.19 Detail: The planned intention is to focus on what is most important in the story and for priority learning. However, it has been necessary in this case to describe much of the detail for two reasons. Firstly, to illustrate and inform the appraisal of work. Secondly, because a shared grasp of the detail was so important to case management. How professionals and agencies handled the detail about this family is a key part of the learning, and seeing what was known or could have been known will assist that learning.              5  2  HISTORY AND APPRAISAL  2.1 Introduction: This section only covers key events, rather than all professional contact with the family. It focusses on the areas from which there can be learning, but also limits information which might threaten anonymity. This section looks at ‘what’ happened and appraises the quality of the work. Section 3 analyses the events in more detail and looks at the ‘why’ questions.  2.2 While it will be seen that some professional practice may have been better, this Review will conclude that there is little to suggest that S’s death could have been prevented by immediately prior professional action. For example, although there were issues of coordination of work, and questions about the strength of assessment of the parental capacity to cope with a very disabled baby (and the robustness of the transfer of information about this between areas) there were no indications in the months immediately leading up to the death that could have led to any protective action. Indeed, the historical poor parental cooperation with services was not seen in the host authority. However, that does not mean there is nothing to be learned from the case for the two areas involved, and there are questions about whether S should have been subject to child protection procedures before the family moved to there.  2.3 The Review will conclude that the only way to have avoided the sad ending to the case would have been if S was no longer in the mother’s care. It is necessary therefore to look in more detail than might normally be necessary to assess whether proper assessments were made and action taken during S’s life.  2.4 Before the pregnancy with S was revealed:  This section is covered in some detail as it is necessary to know the history and what was known or not known, in order to assess the quality of service around S who later died.  2.5 The mother had come to this country from Europe some time ago. There is a record of termination counselling in early 2007. This must have been related to a different pregnancy as her first child Y was not born until early 2008. The mother had longstanding drug issues. She referred herself to the local NHS drug and alcohol service in September 2007 as a heroin user and was put on the substitute methadone in October. She soon stopped attending reviews, and stopped collecting the methadone in December 2007. It seems unlikely that the drug and alcohol service knew she was pregnant when they last saw her, around 3 months before Y’s birth, although the GP did as he had referred her to hospital with a termination request. The drug and alcohol service closed the case in January 2008 a few days before Y’s birth as mother had not been accessing services.  2.6 In October 2007, she was refused a termination at the hospital as she was 22 weeks pregnant and it was suggested she saw the British Pregnancy Advisory Service to see if they could help. The GP, recognising she was on methadone and pregnant, referred her to midwifery but she did not keep the early November appointment with the midwife, and received no antenatal care until 36 weeks pregnant. She arrived 5  6  hours late for a scan, and gave birth the following day. Maternity records do not indicate knowledge of her drug problems, although mother was in receipt of NHS drug services at the time.   2.7 This was drug using mother with limited English, with a late booking, who had asked for a termination, who had stopped receiving drugs services, and who was not seen by any professional responsible for her or the un-born’s safety for over two months before the day before giving birth. In these circumstances, there must be questions as to why no one took action to locate her (even taking into account that she was hard to contact) or referred the matter to Children’s Social Care (CSC). She had no antenatal care at all, used drugs, and must have been ambivalent about the baby to be.    2.8 This links to a recurring theme in this Review of lots of professionals being involved, but it being far from clear as to who was in charge or leading. Around the time of the late pregnancy no one took charge, and without CSC being involved there were no obvious candidates. It is hoped, should a similar situation arise today, that a referral to CSC would be made at the point mother was both heavily pregnant and thought to use hard drugs, but also in receipt of no care. There was enough cause to have a multiagency meeting to assess the future well-being of the baby.  2.9 Discharged at 3 days, Y was visited 5 times by midwives, showing the recognition of mother’s vulnerability.  The health visitor HV1 started visiting before the midwives stopped which was good for continuity of care. Remarkably, given that the GP and drugs services all knew she was a drug user, the health visitor was unaware of this until Y was over a year and a half old. Then, unlike now, there was no standard question about substance use for health visitors to use during early visits. Y’s development was not of any significant problem. Mother needed advice on smoking, feeding, diet, sleeping safety etc, but nothing that would warrant any referral to CSC. S was taken many times to the well-baby clinic at the local Children’s Centre in the first year (and then after a gap for a 2.4 year check in 2010). There were many missed appointments for immunisations that continued into 2009. For example, a reminder in March 2009 about a missed jab was not remedied by the mother for 6 months. There were moves of house, and conditions were spartan.  2.10 At 14 months, Y was treated for a cut head at A&E with a history of a fall from a push chair.  The A&E discharge letter was extremely poor and gave no detail that would help any other professional think about the implications and the A&E medical record was equally unhelpful. A&E records have been a problem for some time and improvements are underway. HV1 did not visit after this incident.  2.11 In August 2009 the GP recorded mother’s heroin use again2, and her not wanting methadone. In September 2009, the GP records daily heroin injection. The following                                              2 There is no record of mother having any contact with the GP in her own right from Jan 2008 to Aug 2009 , nor any drug services - so her drug status in this period is unknown,  7   day, the drugs nurse providing shared care with the GP practice told the new health visitor, HV2, about mother’s drug use (she was using heroin and methadone). It was agreed the drugs nurse would inform CSC. Three days later HV2 visited to explore this, and mother assured HV2 that her use did not affect her child care. An untidy flat, with incomplete bedding, and a ‘broken and dismantled cot, were noted. The drugs nurse properly shared the information with CSC, recorded that the referral was ‘not accepted’, and that a Common Assessment Framework (CAF) was recommended. The CSC chronology says checks were undertaken before this decision, but there is no indication in other agency chronologies of such checks. HV2 also spoke with CSC and, on hearing that an assessment was unlikely, said as a single drug using parent she thought ‘an assessment was still required’. The health visitor recorded that the social worker said there would be a discussion with a supervisor about an assessment and would let her know the outcome. Nothing further is recorded by any agency.   2.12 Current LSCB guidance3 makes it clear that an assessment ‘must’ take place when there are ‘concerns by practitioners’, and regardless as to whether such advice existed in 2009 it was inappropriate for CSC not to assess. Had they asked the GP  and heard about daily heroin injection, and all the missed appointments, in addition to the concerns of HV2 and the drugs nurse, surely at least an initial assessment would have been justified. There is no evidence a CAF was done.   2.13 In October 2009 HV3 took over, and the following month advised the mother to see the GP about the missed immunisations and the clinic re weight loss. Some immunisations were promptly done, but by January 2010 the GP is concerned about those outstanding, and Y also missed the 2 year health development check. (HV3 visited the next day). The following month mother is advised to bring the child when she next attended the GP for her methadone prescription. The chronology dwindles, with no health visitor contact from April 2010 to January 2011 with HV4.  2.14 Contact with drugs shared care continued in 2010 where appointments seem to have been kept. In January, March, April, June, July, mother tested positive for opiates or admitted use. No test is recorded until December 2010 when it was negative.   2.15 Y was admitted to school in January 2011. The next month a substance misuse appointment is missed. From February to May 2011 mother visits the drugs counsellor/nurse at the GP’s three times - at times tearful, at others concerned about no family support and poor housing. By this time she would have been pregnant with S. More appointments were missed, and in July (with the practice not knowing she was pregnant) she claimed her drug and alcohol use was not excessive. In August, Y was seen in clinic and the weight was average.                                              3 The LSCB Procedures Manual Contents (Sept 2014)  8  2.16 The same month, mother asked the GP for a termination (TOP) and was referred for one.4 The GP practice, via the chemist where she got her drugs, encouraged her to return for more discussion, and a month after seeking the TOP she changed her mind. Help with housing set up by the surgery lapsed as she was uncontactable.   2.17 By the point mother’s pregnancy was known there had been no multiagency assessment of family functioning, even at the lowest level of assessment, so there was no shared view to guide the approach to a second baby.  2.18 The pregnancy and birth: Late revelation of pregnancy is not uncommon for drug using mothers. As the statutory guidance at the time (Working Together to Safeguard Children 2010) said “Unfortunately, some pregnant problem drug users do not seek ante-natal care, either because the drugs affect menstruation and leave women uncertain of dates, or because they fear that revealing their drug use to health professionals will result in judgemental attitudes, the involvement of children’s social care services and the possible loss of the baby once it is born.” The first knowledge was the request for termination at about 20 weeks, then the change of mind a few weeks later, when the surgery (through the Addaction shared care worker) informed the local drugs and alcohol service which worked with the specialist substance misuse midwife.   2.19 It is worth looking at the contacts specifically around the pregnancy from revelation to birth.          15.8.11 Mother seeks termination at GPs, and is referred 12.9.11 At drugs shared care at GP’s changes mind. Referred by the Addaction worker to the local drugs and alcohol service for pregnancy support. Addaction notes indicate the case already referred to drugs midwife  9.10.11 Children’s Centre worker and health visitor encounter the pregnant mother by chance. Mother said she had got midwifery appointments at the local drug and alcohol service. Children’s Centre inform drugs midwife. Health visitor tells ordinary midwife.  10.10.11 Drugs midwife notes plan to see in a week  The local drug and alcohol service and Addaction have a ‘brief discussion’ about a possible need to refer to CSC 11.10.11 Mother arrives too late to see a doctor at local drugs and alcohol service. Nurse tells Addaction worker of maternity appointment 17th Oct, and notes she should speak to the midwife about a referral to social services 17.10.11 Mother DNAs for her maternity scan and consultant appointment at the drugs and alcohol service. Addaction alerted. Rebooked for 24, and 31 October (ultrasound). Midwife’s notes she will tell safeguarding 19.10.11 Long call between mother and Addaction- issues of non-attendance discussed 24.10.11 Mother saw midwife at the local drugs and alcohol service and was booked for consultant led maternity care. She does not want to transfer her drugs care from shared care to the local service 26.10.11 Mother tells Children’s Centre she has a scan appointment 30.11.11(Did she mean 31.10.11?) 31.10.11 No record of appointment being kept but… 1.11.11 Mother attended antenatal clinic Drugs use noted 3.11.11 Addaction tell the drugs midwife that mother’s pregnancy is more advanced than                                             4 The mother told the Review that she did not hide the pregnancies, but was not aware she was pregnant for a number of months. This is not unusual in drug users  9  thought 1.11.11 Safeguarding at the hospital alerted to pregnancy ( and again 3.11.11) 7.11.11 Midwife tells Addaction that mother could not make 4pm appointment. Addaction agrees to contribute to the drugs midwife’s CAF ‘referral’ 9.11.11 Attended shared care and reminded of maternity appointments 14 and 21.11.11 14.11.11 DNA maternity appointment 21.11.11 Seen in antenatal clinic by paediatrician 28.11.11 Seen for scan  and booked for an induced birth 1.12.12 Drugs midwife tells Addaction of hope for a pre discharge CAF meeting  2.20 This highlights a number of issues. As soon as mother decided to keep the baby, should there not have been immediate home visits by a range of staff to ensure she was locked into services? There are though quite good records of staff keeping each other informed   2.21 The chance encounter with mother about 7 weeks before the birth (when HV4 and the Children’s Centre (CC) parental engagement worker had come across the pregnant mother living with another family which had known illegal drug use) was fortuitous. There were no items for the unborn baby, conditions were overcrowded. The CC worker called the specialist midwife, and HV4 returned later that day to explain about links with the specialist and area midwives. The specialist midwife arranged a scan. The two workers who found mother did well to spot the risks and make appropriate links (such as getting her registered with the local CC).  2.22 Much work was done by professionals in the weeks leading up to the birth - the timing of which was unclear as mother had had no antenatal examinations. What is striking is the absence of any referral to CSC or even any record of a check with CSC, and no indication that anyone considered calling a pre-birth case conference to assess the risks. Given that this was a second late booking, mother was known to be still using regularly, she was missing drugs appointments, was living in overcrowded accommodation with a drug using  family, and  had a long history of missing health appointments for Y, there were strong grounds for getting people together to assess the situation.   2.23 The mother by no means missed all the appointments, but one would have thought the hard work necessary to ensure she attended some of them would have been enough to warrant referral to CSC at any time from August onwards. Arrangements were made to do a CAF. Its origin is unclear, with several workers indicating to the Review that they started it. Deciding to do a CAF is not a referral to CSC. There are indications that the specialist midwife wanted to avoid drug using mothers being stigmatised and to avoid interventions that might seem heavy. It is right to avoid any assumption that drug using parents will always have problems, but this mother- and even more importantly the baby- would have needed the very best support.  2.24 The shared drugs care at the GP Practice was in association with Addaction, and almost all the work was done by two full time Addaction workers. The local drug and alcohol service says now that mother should have been under the full time service  10  with them, but she declined to transfer.  It was good practice that the NHS Trust named nurse for safeguarding was informed of the pregnancy and the appropriate notification was sent to various maternity, paediatric and community staff so all were alerted to the risks. Mother was finally booked in for the birth and was found to be 35 weeks pregnant. This was 2.5 months after she first told the GP of the pregnancy.  2.25 The birth was induced - with mother arriving late for this as she had not sorted child care arrangements for Y. Maternity services were well prepared for the possible impact on the baby of maternal substance misuse  and  the stay in hospital was unremarkable in the circumstances, with all proper advice given. Maternity, on the day of birth, record the specialist midwife saying the mother had ‘plenty of support’ although she would speak again to the named nurse for safeguarding. Maternity also recorded the specialist midwife’s view that the previous child was well cared for and no referral (presumably to CSC) was necessary, as a CAF was being done. However it also records her saying she had discussed the case with CSC and there were no concerns other than housing/overcrowding, and no need for a discharge meeting. CSC have no record of this discussion, but either way the assessment of the drugs midwife was too low key, and if CSC were indeed asked they formed a view without any assessment.   The ‘good support’ is hard to fathom in an overcrowded, dishevelled home with another family where drug use was a big issue. The drugs midwife recorded that CSC was satisfied a CAF was the appropriate action. The mother told the Review that she would have liked CSC support at the time of the birth (by which she meant on practical matters).  2.26 After 3 days, mother and baby were discharged and midwives visited regularly, with S losing some weight initially, and then gaining. S was not taken for the required BCG injection. Less than two weeks after arriving home, the mother left S outside Y’s school unattended and poorly clothed/covered. When mother was located she expressed no emotion and said she had forgotten. The school referred to CSC who commenced an assessment.   2.27 The next day a CAF meeting was held with school, Addaction, the CC, and HV4 present, but no one from CSC. The pattern of missed appointments and being hard to contact was shared. Mother was not there, later saying she was unsure of the venue. By Christmas, mother was on methadone (which can be taken with breast feeding), there had been some weight gain, and for simplicity the Children’s Centre was to be used for S’s health appointments.   2.28 The social worker (SW1) who led the assessment saw the family at the home she shared with the other family, but was unaware they used drugs too. An Initial Assessment (IA) was completed by SW1 at the end of 2011. It strangely describes S as two months old when not yet at one month. Mother explained the termination request as being related to the ethnicity of the father which would have been frowned upon in her community. Mother had not attended drugs services during the assessment so there was no up to date information as to what drugs were in her system. Deciding she could provide safe care in the absence of this was a  11  weakness. It was recommended that social workers from the Family Safeguarding Service provided long term support. This was appropriate, but the magnitude of ‘forgetting’ a two week old baby and leaving the baby alone does not seem to have been given sufficient weight. Mothers of such young babies tend to have the closest concern for them and forgetting them in the street is the extreme opposite - and was probably related to current drug use. The IA also says mother was ‘shocked’ with professional concerns- which in itself was a warning sign. A strategy meeting and possible case conference would have been a more robust response. Also, records suggest no contact with school, GP, or Police during the assessment as would have been expected and proper. The mother told the Review that she was used to taking Y to school and going home alone, so she went home alone as usual - which illustrates the risks.  2.29 At the very beginning of 2012, the family with whom the subject family lived told the CC of mother finding it hard to contact a GP re S. (He had been taken to an out of hours GP with drowsiness and not feeding, and advice was given).  Mother was encouraged to bring the baby to the CC, and there advised to get to a GP quickly. S was admitted to hospital with a bloody nose and being unresponsive to feeds, and stayed in for several days. S fed well in hospital. CSC was informed by the ward and S was discharged as better, but with a referral to the local paediatric hospital for a hernia repair. A heart murmur was also to be followed up.  2.30 2012:   Describing the rest of 2012 chronologically would be too lengthy, so the history is told by service. This is the year in which concerns about S’s development began to surface and became a serious issue.  2.31 Children’s Social Care:  This section is affected by recording appearing to be poor in places, with some CSC action only seen by this Review through other agency files. SW1 went twice after the discharge from hospital, then the case was transferred to the Family Safeguarding Service, SW2.  There was a CIN meeting5 at the end of Jan where HV4 recorded the social worker as saying agencies were over-concerned about missed appointments as there were not many. However the record said mother was warned that if S was left alone again the council would consider Care Proceedings. The record says that at the meeting S was seem to have a swollen eye. Strangely, it was the drugs worker who was tasked with assisting with a GP appointment re the eye, so it must not have been seen as having potential safeguarding implications. It was also strange that the record makes no reference to S being in hospital that month with failure to thrive. It says there were no concerns at S’s ‘first weighing and development check’. The Review has been provided with no record of any other CIN meeting in this case.                                               5 There was a ‘Record of CIN Meeting and Plan’ on each of S and Y. Neither said who was present, although it seems that it included two social workers, the HV, the drugs worker, the Children’s Centre, and head teacher- plus mother and baby.   12  2.32 After the meeting, six of the next seven home visits were by an experienced unqualified worker from the Family Resource Service6 who helped mother with practical/housing issues. No safeguarding concerns were noted, it was noted the Family Resource service would stop as Addaction were supporting mother with her drug problems. The next CIN meeting in April was not quorate as no other agencies were present, and one in May was attended by several agencies but does not appear in CSC records.  There was not a CIN meeting until July which failed as whilst other agencies were there, the social worker was not. Oddly, on one recorded a week later in July, it says it was ‘brought forward’ as a paediatric appointment had been missed.  This was 5.5 months after the first CIN meeting, against a policy of one every 3 months. Only the school was there in addition to SW2, so not really quorate again and there was no pooled multiagency view as was needed. A note said the plan was for mother to keep the health appointments. No other agency has recorded this meeting.  2.33 There were no social work visits, despite the 6 weekly policy, from the CIN meeting in July until mid- October (3 months) and then only after HV4 had expressed very serious concern about S’s development problems (see below). A Home Start worker who went with SW2 arrived first and found Y (then 4) home alone, and mother arrived before the SW got there. SW2 visited in November and twice in December, where ‘no concerns’ were noted.  Mother named the family friend with whom she lived when S was born as Y’s father.   2.34 A Core Assessment (CA) was done on S and on Y following HV4’s concerns. The reason was to ‘fully investigate’ the root cause of S’s poor health as well as the needs of Y. “It is concerning that various concerns are now being raised about S’s health, therefore assessment of (S) and (the sibling) and the wider family is vital’. Only one home visit is noted during the 6 weeks the CA’s were being done, there were no multi-agency meetings and no records in the composite chronology of discussions with other agencies.  It is hard to see how the CA can be thorough. Many key areas of assessment around the baby and mother are word for word the same as in the Dec 2011 Initial Assessment when S was one month old and not then known to be disabled. S was now nearly a year old, and now known to have serious disability. Even the concluding analysis of risk is almost the same, so in no way can the CA be seen to robust. It recommended the case staying open to the Family Safeguarding Service.  2.35 It was decided at a December 2012 CIN meeting (attended only by SW2 and school) to close the Y case as there were no concerns about him. One wonders whether, given the additional pressures mother was under with a child by this point diagnosed with cerebral palsy, it was necessary to ‘close’ the Y case. Pressure on mother to attend health appointments continued. It is interesting that the CA on Y signed off in                                               6 Who were not social work qualified (although they are all PAMs trained and are qualified as either nursery nurses, or to NVQ level 4 in Child Care, and are directly supervised by an FRS Social Work Qualified Team Manager).  13  December 2012 recommended that ‘this case should continue to remain open to the Family Safeguarding Service for further social work support’. This meeting (with no one from any branch of health present) was also recorded as saying “ S to close to Family Safeguarding Service if Barnardos can support the family” - again at odds with the CA.   2.36 Drugs Services: In 2012 mother’s drug care was ‘shared care’ with a GP (GP1) prescribing methadone and support from a drugs nurse.  Mother tested negative for drugs at the start of January, but GP records show her  not attending 9 scheduled appointments between January and June 2012 (although Addaction record a ‘medical review’ of her drug use- which included heroin again). She then moved to another prescribing practice with GP2, where in due course all three of the family were registered. She was initially a temporary patient and as such was not prescribed methadone. In August, a call from the previous surgery said there were rumours the mother had dealers at the house, and was ‘selling herself’ with the children in the house. The mother told the nurse that when she used heroin she got a friend to care for the children. The information was passed to SW2, but apparently was not recorded. Mother was seen the following month for shared care, HV4 was contacted after mother described S’s developmental delay. This was helpful and led to a HV visit and speedy referral to hospital. In October, mother’s urine was positive for cocaine, methadone and morphine. Mother was seen 3 more times by shared care in 2012, with S. On one of those occasions she had missed a pick-up of methadone so had used heroin. In December 2012 her urine was positive for opiates and methadone.   2.37 GP Services: In relation to non-drugs related issues, mother appears to have had no contact in 2012 with either GP1 or GP2. There is one note on Y- not attending a scheduled appointment. In addition to hospital letters on file, S was weighed in January at mother’s request at a drug appointment, and was seen with an upper respiratory infection also in January. In September, S was referred to paediatrics following HV4’s concerns. In December, an appointment for immunisations was missed.   2.38 Health Visiting: In January 2012, what would have been a useful joint visit with SW1 led to no access. The January CIN meeting was attended by the HV. An assessment visit was done in February, where mother scored low on the depression test. Also the Family Resource worker called about mother’s confusion with hospital appointments. A March planned visit failed as mother had ‘gone to the school’, and a second visit was done jointly with the Family Resource worker which was good practice. No health visiting contact is then recorded until September, a  gap of over seven months, despite, in June, the Children’s Centre calling to report that a family friend had expressed that mother had a ‘houseful of adults smoking and taking drugs’ and expressing what the notes describes as ‘grave concerns about the health and well-being of both children’. The CC told the Review that they told CSC, but this is not in CSC’s chronology. S’s 7-9 month assessment at the CC in July was also not attended.   14  2.39 In September, HV4 did that assessment at home, and found ‘global developmental delay’ to fine and motor skills, hearing, speech and vision. This was so bad she wondered if the child was deaf or blind. S was referred to GP2 and on for hospital assessment. HV4 also shared concerns with the drugs nurse who was also concerned about development. A nursery nurse weighed S later in September and the baby was found to be in the bottom 1% of babies at that age. Despite this no further health visiting contact is recorded in 2012, indeed not for a year.   2.40 School: There were no especial concerns about Y, or anything noted by the school nurse.  2.41 Children’s Centre: In January and February 2012 mother attended CC sessions and used the laundry facilities. The parental engagement worker attended the January CIN meeting and one in July where there was no social worker. In February, mother collected a donated pushchair. In March she did not attend two pre booked sessions but did visit to collect some donated clothes. In September, mother attended with S to collect a ‘7-9 month care pathway gift’ having received a gift card from the HV, This enabled the assessment to take place. Between then and the end of the year mother attended three times, once for the laundry and twice in relation to Christmas gifts.  2.42 The Hospital: After the early January 2012 admission, S was discharged with several appointments and all relevant professionals updated. In early February, the heart murmur concerns were dismissed, a community paediatric nurse visited about the BCG scar and S was seen in outpatients where weight was around the 2nd centile. A month later, at outpatients, S was ‘beginning to thrive’ but there were concerns about head size and muscle weakness around the throat. A skull x-ray was normal. There was nothing then until July when S was not taken to outpatients, and was ‘discharged for no attendance’, although S would be seen on re referral. In September, following the health visitor’s extreme concern about poor development the GP made a referral and the baby was seen at outpatients a month later.  2.43 S’s weight was still around the 2nd centile. There were concerns about microcephaly (a medical condition in which the circumference of the head is smaller than normal because the brain has not developed properly or has stopped growing), and an MRI showed significant damage within the brain, thought to have been caused before birth. This made S at increased risk of cerebral palsy, so the child was to be seen again in three months, and referred to physiotherapy- the first appointment for which mother and baby arrived 90 minutes late. The physio wondered how S could have been so extremely neurologically disadvantaged and it only noticed when nearly a year old. This appointment was some two months after HV4 had identified the deficits in September.   2.44 By mid-November, the paediatric OT was involved too and she did a joint home visit, and was concerned by muscle tightness and vacant episodes where S seemed not    15  to respond to any stimuli. This was discussed with SW2. At the end of the month a physio appointment was missed, and in December mother ‘forgot’ an OT home visit, although the OT delivered a bath chair the next day. Mother had had a letter from the consultant about the diagnosis. She couldn’t see that there could be a serious problem as she ‘hadn’t taken a lot of drugs during pregnancy’, saying she knew regular heroin takers whose babies were normal. At the December CIN Meeting the OT recorded mother as being late and very down.   2.45 Summary at the end of 2012: The overall impression gained by the Review of events in 2012 was of a continued lack of any real multiagency approach. None of the meetings were comprehensive in attendance, some quite the opposite. Given concerns about weight and development, mother still using a variety of drugs, missed appointments, and mother’s lifestyle, the absence of any real overview meant there was no assessment of S’s overall well-being. Despite being a Child in Need, no leadership by CSC can be seen, and gaps between CIN meetings were allowed. Across the year there was a seven month gap in health visiting contact before the baby is seen to be in the bottom half of 1% of all children in weight, to be followed by no health visiting contact for many months- with the occasional outpatient appointment no compensation. There also need to be questions about whether such extensive disability could have been seen earlier, and therapeutic care begun earlier.  2.46 2013:   This was a year which started with growing concerns about missed appointments which led to S being put on a Child Protection (CP) Plan, and Y back on a CIN Plan – only for the CP Plan to be removed after less than 3 months after better appointment keeping. Cooperation soon deteriorated again, and by the autumn was almost non-existent as mother planned a move to London. Plans to reconvene the case conference due to very high health concerns were not implemented before contact with the family was lost and they were found to be in the host authority in February 2014. Again, the history will be told by agency, with a summary pulling it together.  2.47 Children’s Social Care: Despite the CA recommendation that the case be continued, there was a January CIN Meeting at which Y’s case was closed, even though on the workers’ arrival the 5 year old Y was alone with a 9 year old, mother having locked them in while she went out with S. By February, senior managers were agreeing a strategy meeting to discuss possible child protection action following missed health appointments for S. The meeting was held, and a Section 47 investigation/CA was commenced. There was one home visit between the strategy meeting and the CP Conference which placed S on a CP Plan and reinstated Y as a CIN. An initial CP Conference was held in March, with community nurses, physio, Police, SW2 and mother present- plus a non-involved chair. Apologies from the drugs nurse and OT. There was no mention of hospital, school, Children’s Centre, or GP in the attendance details. The physio had not seen S since before Christmas 2012, and there was great concern about development and the absence of therapy. All the professionals agreed to a CP Plan, and for Y a CIN Plan. With a range of professionals involved  16  there was a good, frank discussion of risks and the right decision made. Oddly, nine days after the CP Conference a supervision record says ‘Y to close at CIN due to no unmet needs’.  2.48 Significant parts of the CA (which was completed during the CP Plan in April) are the same as the one written when S was two weeks old and 90% is the same as the CA written in 2012 following the health visitor’s concern about the level of disability. This included copying a line about keeping all appointments when the reason for the CP Plan only a month before was missed physio appointments! This Review can see no way this was a current fresh assessment that matched its description as ‘vital’. What was important was for how things were at that moment to be fully assessed and described.  2.49 There were three home visits in April by SW2 at which no concerns were noted, and in May a Core Group meeting was held with SW2, health visitors, a ‘key worker’ from  the Council Children’s Disability Service, and the physio. There was no reference to the GP.  There seem to be no minutes, but a case note of the meeting (in response to two months cooperation from mother) says that the case was to be discussed by SW2 with the line manager to consider ‘de-Plan of S’, and to transfer S from safeguarding to the disability team.   2.50 The children were seen once more before, in early June 2013, a review CP Conference took Y off the CP Plan, less than three months after it started. Only SW2, the physio, disability key worker, and a health visitor who did not know the case, were there. Apologies from HV4 and no reference to GP or school. Mother remained on methadone and was using heroin, she said, twice a month. The key worker input (see below) was clearly helping. Whilst improved care of S is to be applauded, the haste with which the CP Plan was removed was rather optimistic, and not fully informed. The CSC case note shows the optimism. “Mother’s substance misuse continues but it is not thought this has any shortfall in the care of S or the sibling Y’s care’.  The minutes said nothing on S’s admission in April with failure to thrive. A key piece of information which influenced the outcome was a report from the drug and alcohol service which was said to have said that mother had kept all appointments. The drug and alcohol’s service’s chronology for the period of the CP Plan shows four appointments, the first where mother admitted current heroin use, and two in May which were DNA’d,  and one on the day of the Conference where she again admitted using. So it was actually only 50%, not ‘all appointments which is a vast improvement’ as the minutes quote SW2 as saying. Presumably the social worker was not using an up to date report. The Police also reported activity which suggested dealing in stolen goods to support the drug use.  2.51 Another issue which seems to have been given little thought was that at the review it was clearly stated that when mother used drugs (in the bathroom) she made sure her one of her friends was watching the children. The previous Conference minutes identified these two as fellow drug users, so hardly the greatest reassurance!    17  2.52 The mother was asked by the Review about what made a difference for her in that the attendance somewhat improved. Her response was that it was because she was ‘more scared’ by the implications of the CP Plan and that it gave her an incentive to collaborate, which went when  the CP Plan was removed.  2.53 After this, the case seems to have been given little attention by social work, with no recorded visit to the children from late June to mid-October when SW2 did a joint visit with the disability key worker. This was the only successful social work visit achieved before the confirmation in February 2014 that they were in London. The gap in the social worker seeing a child on a CIN plan was not acceptable7. The mother was aware of this gap and told the Review that ‘after a while it was, like, very quiet. She said that the pressure being off made it easier to slip back. In September, the key worker  and Portage worker appropriately reported to SW2 a new man in the household, and at the October visit permission was gained for a Police check, but there is no record this was ever done. The physio records a “CIN” meeting with mother present in August8, and HV4, Portage, and the KW record one at the hospital that mother failed to attend in October, but these meetings do not appear in the CSC chronology of events for this family. The Portage worker recorded that at the October meeting attended by SW2, HV4, the KW, physio and Portage, SW2 said she wanted to raise the case back to child protection, and would consult her line manager. Like the others this meeting was not minuted, nor had any resulting plan been seen.  HV4 noted at the October CIN meeting ‘suspicious activity and maybe controlling mother’ about the new man.  2.54 This limited social work involvement needs to be put in the context of nearly all the very important physio appointments being missed from June ‘til when they left for London. As this was fundamental cause of the CP Plan, and the social worker was informed in writing of most of the DNAs, it is inexplicable that there were not urgent meetings to review the decision about a CP Plan- or even to consider whether S was safe at home. There were also missed appointments for OT, dietician, GP, and drugs care, and numerous emails and letters were sent first to SW2 and them also to the Principal Social Worker (PSW).  None seem to have been recorded on the CSC electronic records and were not in CSC submissions to this Review. Initially the correspondence was to inform of missed appointments, but later demanding to know when the strategy meeting or CP Conference (which SW2 clearly indicated in October was being planned) would happen. None happened before the move to London. In submissions to the Review, staff reported getting no responses to most communications. Some of the strongest concerns were from relatively junior staff working (without whose help few appointments would have been kept) and their persistence is to be applauded. A multiagency child protection review of the status of the children, particularly S, was warranted by late summer 2013.                                             7 The key worker from the disability service, who was also from the Council did see them 9 times during this gap in social worker visits, but was not a qualified social worker. Also, she was unable to make contact with the family for the month prior to the social worker’s first visit in 16 weeks in mid-October. 8 No other agency records this, so possibly not a CIN meeting  18   2.55 It is interesting to note that the disability key worker (see below) who was active in seeking proper review and action was part of the same organisation as the social worker- the Council.  2.56 Positively, after the October visit by SW2, the social worker emailed key health staff about mother’s intended address in London (with another male) and a phone number. The email says S is a CIN ‘due to the conference not being held as yet’ which implies an expectation of a CP Plan being re-introduced. The address proved to be an accurate one. It was thought mother was moving between London and that area, but no warning was sent to the host authority. It is unlikely she moved permanently until February 2014. It is then surprising that her being increasingly difficult to locate towards the end of 2013 did not lead to frantic searches for S as it was known how disabled S was and how vital to care was the missing therapy.  2.57 Children’s Disability Service- Key Worker: From April 2013, when S was on a CP Plan, until late November, a ‘key worker’ (KW) provided practical and emotional support to the family, and for example facilitated appointment keeping in a very practical way. In the opinion of the Review the KW did a remarkably determined, practical and child-focussed job, and she was largely responsible for any appointments that were kept. (The mother told the Review how helpful was the key worker). She also liaised with other agencies and, as seen above, was most persistent in alerting the social work service to problems, and then chasing for action. She also alerted her own manager, who assumed her senior social work colleagues would respond, but in hindsight she could have used her seniority to escalate more strongly. She also pointed out the mother would keep an appointment or two after a gap and that seemed to lower concerns. A PSW in the disability service did alert CSC in December to the KW’s extended absence on sick leave, that the Portage worker couldn’t locate the family, and to staff absence over Christmas.  2.58 Health Visiting: Other than incidentally seeing S at the May 2013 core group and June CP Conference there is no  record of any health visitor involvement in 2013. This seems inappropriate given the serious worries about S’s health. It is true that many other health professionals were involved but in the absence of comprehensive multi-professional meetings there was no evidence that their combined input made up for no health visiting engagement.  2.59 Portage: More practical support was provided through the Portage, a pre-school home teaching service for children with additional needs. It took some months after referral before, via the KW, mother cooperated and from September 2013 there were weekly visits. The worker spotted feeding problems and arranged a speech therapy assessment, also arranging OT help with seating. After 5 visits, mother was never at home, and SW2 was regularly informed of failed visits. The worker alerted CSC to the presence of a new man (as did the KW) and shared his questioning of services. She also emailed the social worker about her progress and that visitors were  19  banging on mother’s door. The worker was very concerned about the lack of response from CSC. 2.60 Children’s Centre (CC): Despite being part of the local Children’s Services the CC was not invited to the March 2013 CP Conference. This was not an uncommon event at the time. When the parental engagement worker did an 18month assessment at home two days after the conference she would not have known the outcome. From May to August mother visited the CC three times to use a free phone service, and in November information was provided to the family about eligibility for 2 year early education funding.  2.61 School: Y had a school entry health assessment in April. Y’s height was in the lower quarter of children and weight below average. Letters were written to mother about regular short absences in the autumn of 2013 which seem to have been connected with advance trips to London. There seemed to be an assumption by agencies that the family had moved toward the end of 2013, but Y remained in school until the end of January. In the absence of the key worker no one seemed to take the practical step of locating mother through school pick up times.   2.62 Drugs Services: In January 2013 mother failed three appointments at the local drug and alcohol service, but attended with S in March where clothes were dirty and S smelled, although clean himself. Mother said she used crack via a pipe. Two days later, SW2 told the nurse about Y being locked in alone, and the cerebral palsy diagnosis. Mother failed an appointment in March, and the nurse provided a report for the March CP Conference. The report identified that the family she lived with are also clients of the shared drugs care service at another practice. An appointment the day after the CP Conference was failed, but one was kept at the end of March when S was chesty and given antibiotics. In April she attended shared care again, but S was so unwell the GP referred him for admission. The nurse asked the drug user whom mother lived with (who was probably Y’s father) to care for Y while she attended hospital. Two appointments were failed in May, but there was no mention of these in the Conference in June which decided all was well with appointments, and there is no sign from the minutes any update was sought.   2.63 In July SW2 was asked to call about mother’s non-attendance and not picking up methadone. The notes indicate there was no response, and the drug and alcohol service closed the case in August. (The mother remained under the GP for general health needs).  2.64 GP Services: In 2013 there is no record of mother or Y, receiving any general care from the GP. S did not attend for immunisations in February, but was seen as very wheezy in March and April when antibiotics were given. Detailed hospital letters were received outlining the various diagnoses and test results about S’s disability. S was not seen in the surgery after April 2013.   2.65 Hospital: At the beginning of 2013 it was the missed or late attending appointments with physiotherapy and or the OT which led to the strategy meeting and the CP Plan.  20  After the Plan attendance improved and mother appeared to be ‘cooperating well’. At the end of April, S was admitted for two days as an emergency by the GP. (Mother had taken S to her drugs appointment). A dietician became involved as S was seen as failing to thrive, and feeding advice given.  Weight was at the 0.4th centile (i.e. only 4 in 1000 children would weigh so little). After discharge two appointments were kept including a consultant paediatric assessment. The resulting consultant letter about the diagnosis of cerebral palsy went to numerous health staff but not SW2 despite the CP Plan. Mother was to be helped with disability living allowance. It is not clear if the consultant knew S was on a CP Plan9. There was a positive assessment about chest and daily exercises in May, but S was not in for a planned OT visit. Most appointments were kept in May and until late June. In early July, S had a planned admission to hospital for an endoscopy of the upper airways.  2.66 From July, attendance dropped off at therapy appointments or home visits, and as stated above therapists would notify CSC of this when it happened. In August, S was discharged from dietician services for non-attendance and the consultant and social worker was informed. Absences included from the mother and baby sessions at the child development centre. Across September and October, most sessions were missed. S was assessed in October by speech and language therapy and described as ‘significantly physically compromised which will impact on …feeding skills’. The plan was for a series of visits, but none could be achieved and S was discharged from speech therapy. The OT described very tight limbs and limited response to stimuli. S was seen in paediatric outpatients in November. Mother was positive about progress. There was a viral infection, which was given antibiotics. The importance of linking in with London services was impressed on mother   2.67 In early November the physiotherapist shared concerns with the named safeguarding nurse, and advised her to tell the school of the move plans so Y’s transfer could be arranged. There were more missed physio and OT appointments mother ‘forgetting’ or saying she was in London. At the end of November S was seen and ‘his body smelled of damp and smoke’. New appointments were given to mother. In December, the KW and consultant spoke about the ‘great concern this baby will be lost with no contact number or address’. This was several weeks after the social worker has sent round an address- but maybe there was no certainty that was where the family would go.  2.68 Police: At the end of December, Police attended an incident involving mother and two men. Both children were present. There was a scuffle between two men, with mother hiding in the bathroom. No offences were revealed and advice was given to the adults. Mother had been in a relationship with one of the men who it was understood thought he was helping her move to London. Mother said she was expecting to go alone. The Police risk assessment was ‘standard’. CSC was not informed. As ‘no child protection concerns had been identified’ the Police say that ‘a                                             9 Medical files are now colour coded so clinicians will always know if a CP Plan is in place  21  decision was taken not to inform CSC’ even though the Police record of the event notes the former CP Plan. See 3.53 below.  2.69 This event shows that mother was still in the originating borough, as it did three weeks later when twice mother arrived at properties where Police were executing a drugs warrant.   2.70 Summary at the end of 2013:  This was a year when more and more support and care were provided to the family related both to the disability and to address the problems which required a CP Plan. The Plan was removed with undue haste, and when the circumstances which led to the Plan were soon replicated no steps were taken to review the safeguarding implications. Both for social work and health visiting there were long gaps between contact, and without full multiagency discussions (or at least any recorded meetings) no one could be sure other professionals were filling the gap. S’s disability was profound and the needs for regular therapy input were great.  Whilst not minimising the load on this single mother, S missing so much therapy amounted to parental neglect and should have led to a serious new assessment and maybe action. The fact that it was understood the family was about to move made that more not less essential. The non-response of CSC to the concerns of various health staff was not acceptable. That no agency escalated concerns to a high level was weakness shared by many organisations or departments, as will be discussed in the following chapter.   2.71 Finally, there should have been more effort to trace the family to ensure S was treated, involving the Police if necessary. All professionals knew S’s development was significantly at risk from the lack of regular health care but there was no search and it turned out Y did not leave the school until the end of January 2014. If an address had been given by the mother, and people believed they had moved to London, why wasn’t that borough’s CSC asked to see if they were there – given S’s urgent need for regular therapy?  2.72 2014 and the move south:  There was no clear picture of the family’s whereabouts. Specific dates are given to demonstrate the picture. On 3rd January another physio appointment was missed. The physio emailed the social worker and KW, and noted a ‘plan to contact the hospital safeguarding for advice on action as no response from the social work team’. This was repeated on the 7th. On the 9th  (on the advice of the safeguarding team) the senior staff nurse at the Child Development Centre wrote to the PSW (copy to the CSC Safeguarding lead) referring to five colleagues from different professions having concerns for the length of time S had been without care, and that each had alerted the social worker to missed visits and appointments. It also referred to the lack of information from CSC, and the lack of the planned CP Conference. It pointed out that SW2 had emailed to say she thought they had moved - but the nurse added that Y was still in school so they had not moved! The Review has not seen any reply.    22  2.73 Y was indeed still at the local school, as Portage confirmed on the 9th and also told CSC, and a planned safeguarding missing persons alert by the hospital named nurse was cancelled. Portage noted getting no response from the social worker or PSW.    2.74 On the 10th  the physio records concerns about CSC informing staff the family had gone (Y was still in  school) – and the risks of S’s medical needs not being met, and three days later the speech therapist is noting no response from the liaison health visitor whose advice had been sought two weeks earlier. The physio failed twice over the next couple of days to track down mother. On the second of those days, the 17th, the Police encountered mother twice when doing drugs raids, but no link was made with her being the mother of a child formerly on a CP Plan. SW2 had failed home visits in 13th and 23rd.  2.75 On the 14th, health visiting recorded they had moved out of the area, and on 28th they were informed by the hospital liaison health visitor that speech therapy appointments had been missed and a home visit had been arranged. (On 27th the named nurse told the speech therapist that a letter had been sent to the social worker asking for help in making an appointment. A few days letter, on 3rd February, the therapist found no one in at that home visit and discharged S from therapy, the same day). HV3 made an un-appointed visit on 5th February No one was in and SW2 was emailed for an update.  2.76 S’s GP recorded missed appointments on 10Th January, and 5th and 21st February  2.77 Portage had a call from the school on 3rd February to say the family had just left for London, but that Y had been in school until then, and this was shared with the KW who had just returned from sick leave. CSC was informed but got an ‘away’ (for the next 8 days) reply.  2.78 The detail described above shows that no one was pulling together the overall position and assessing the risk. In January 2014, the situation was far worse than when S was given a CP Plan, but there was no meeting of any kind to share information and create a plan. There was every justification for a Strategy Discussion and CP Conference, and a Police search for the family. (The Police were completely unaware about the concerns on this case).  During the month there were varying levels of uncertainty about where the family were, but with the eldest child still in school presumably it would not have been hard to find mother (probably with S) twice a day. So even if she was not at home to visits she could have been spoken to. It is hard to understand why this did not happen.  2.79 This was a child with serious disability, who by the last week of January 2014 had not been seen by any health professional for 2 months, had had physio once since August, had not seen the speech therapist for 2.5 months, had not seen the GP for 9 months, and had had no contact with health visiting (other than coincidental to  23  multiagency meetings) for 7 months. S had been seen at paediatric outpatients in November 2013. The absence of the Conference, and any clear shared multiagency assessment had an impact on how the family was viewed in London.  2.80 The arrival in London: On 13th February, ten days after being told they were in London the originating CSC referred the family to the receiving Children’s Services by email. Given the urgency of S being located and treated, taking ten days seems far too long. SW2 informed other professionals that they had gone and been referred to the local CSC. The email (according to a receiving agency) said she had ‘referred all the information we have regarding S and the history of mother’s lack of engagement’. The address was the same as that circulated the previous October, and the name of the man there was given.   2.81 The information in the email, and recorded in the receiving authority’s referral record, was inadequate. It mentioned the former CP Plan but did not say when that was or for how long. It did say, ‘mother was informed that CSC would once again10 be looking at CP and PLO11proceedings’. It includes the words, ‘This the first contact in respect of S….’, which came from the IA written in December 2011! There is hardly anything in the transfer email about the current situation, and the last paragraph about benefits, housing, sleeping arrangements, is taken from the Initial Assessment written over 2 years previously when S was 2 weeks old. S was now nearly 2 years 3 months old. Also, the strongest comment in it on health appointments is the drugs midwife denying a problem with appointments in 2011, so the criticality of the last few months missed appointments was not clear. This section was also directly taken from the December 2011 report. The next day the receiving CSC phoned originating CSC and left a message. Presumably there was no reply as 5 days later, the 19th  February,  the  CSC team manager emailed for the dates of the CP Plan, and asking for confirmation that Y had ‘not been subject any planning at present’. It also asked for details of health professionals ‘so specialist health services are set up as soon as possible’. A manager recorded that after further information from the originating borough they would decide if a strategy meeting was needed. It was also noted that ‘key documents which given the more recent concerns e.g. chronology or copy of the assessments would facilitate appropriate risk assessment, were not sent with the referral’. The case was opened for assessment on both children. Six days after referral, a record of the ‘Managers Directions’ noted being unsure if a strategy meeting or Section 47 12 had been held in relation to the recent concerns, and tells SW3 to contact SW2 ‘to enforce the request for further information’.(This may have meant ‘reinforce’?). It advised an unannounced visit as the manager understood the family to have ‘fled’ CSC, and to ask what action the originating borough’s health agencies had taken to inform London.                                              10 No reference to this being done before has been seen by the Review 11 Public Law Outline- an warning of possible legal proceedings 12 Section 47 of the Children Act 1989 places a duty on LAs to investigate and make inquiries into the circumstances of children considered to be at risk   24  2.82 The allocated receiving borough social worker (SW3) visited 8 days after the referral. Given what is known in hindsight about the longstanding treatment deficit, this could have been quicker but the urgency was not clear from the incoming referral. SW3 visited  again two days later, and mother was advised about registering promptly with a GP (which was done early March), about seeing Housing about accommodation, about the need for a cot for S, and to encourage Y to read more and be on the computer less. Mother reported no physiotherapy since the move, but seems not to mention that S only had physio once since August 2013.  2.83 The originating borough’s Children’s Development Centre (CDC) was ‘very relieved’ to be called by SW3 a week after she had visited the family (again a week seems a long time) quoting to the receiving CSC the lack of shared communication with CSC in the originating borough.  The CDC nurse gave the contact details for physio, OT, and speech therapist. The physio also emailed SW3 –‘great to hear someone is finally involved with the family, we have all been struggling to know what is going on”. The Portage worker emailed a transition sheet of contacts and failed visits, including failed joint visits with speech therapy.   2.84 SW3 produced a Child and Family Assessment, which talked of there having been no physio for 4-5 weeks, when it had been three times as long. It referred to a dated 2013 CA in the originating borough, and reports from therapists there so must have had more information from the originating authority (although a 11th March supervision note still referred to ‘significant gaps’). It was a pretty up to date summary, and recommended a CIN Plan. However, the receiving CSC manager said her view was that the case ‘is hitting the threshold for Child Protection’ noting that S still didn’t have access to specialist health services- correctly identifying that Y had not been receiving the heath care needed ‘for at least 5 months’. The manager wanted more information before deciding and asked for more information from the originating area’s drug services, and noted the worker was assessing to see whether mother appearing ‘obliging’ was ‘superficial compliance’. It referred to two unannounced home visits, but the chronology identifies only one. The manager asked SW3 to contact the safeguarding lead doctor about access to services. The Review has seen no record this was done.   2.85 Services in receiving/host area: Compared to the preceding borough, services in the host area (Feb-July 2014) gained the impression of a cooperative mother, away from drugs, not missing appointments, and engaging well with services. Numerous health professionals became involved once they had received referrals. There does seem to have been some delay in those referrals being made. This was a period when the severity of S’s disability especially around feeding and swallowing became clear, leading to more intensive health involvement. The history over this period will be told by agency.  2.86 Children’s Social Care (Disability Team): The second recorded home visit was in mid-March. The social worker recorded: ’My concern is S needs urgent physiotherapy for the tight skin’. Y was bored and wanted to go to school. Mother  25  said she was off methadone now. (ie drug free.) The case note referred only to having a Feb 2013 CA and an ‘outdated’ CIN Plan from the originating borough’s CSC. Mother had linked with a GP and was to be referred to specialist services. Both the GP and CSC referred S to the specialist health services with mother signing CSC’s referral to indicate her consent. This referral did not mention that S had been subject to a CP Plan, nor did it mention safeguarding. In mid-April management agreed to CIN status, and noted the referral for specialist services. The next visit was on the last day of April 7 weeks after the first, just outside the 6 weeks of the CIN Policy. However, in the circumstance it was far too long as it needed to be confirmed that S was getting healthcare- the nub of CSC engagement- and the closeness to Child Protection had been noted on allocation. A week later, an ad hoc visit was made to check if a cot had been delivered, and the timing of various health appointments was checked.  2.87 Towards the end of May, taking into account health reports, a CIN Plan was agreed by the disability team manager (mainly about accessing services) and the need for a CIN Meeting. This was circulated to involved staff. The child was not then seen by a social worker (SW4) until mid-July, an unacceptable gap since 8th May 2014- over two months. The fact that one social worker left and another took over is not sufficient explanation. A CIN meeting was planned for the end of May but was postponed (and never re-scheduled) as S was in hospital. The hospital stay seems actually to be rather good timing for such a meeting.  S was an inpatient with chest and feeding issues, and had two A&E attendances earlier in the month with respiratory issues, leading to a referral for feeding issues.   2.88 The final involvement was SW4’s only contact – a home visit 6 days before S’s death.  SW4, who prepared by calling the consultant community paediatrician, specifically looked for evidence of drug paraphernalia, but saw none. Mother agreed with some keenness for S to be  a pilot subject of the new Education and Health Care Plan (which was to replace statementing) and  they were due to discuss this again the following week. SW4 appropriately looked equally at Y’s needs, and found him happy and communicative. Mother was advised about summer activities. SW4’s overall impression on child care was ‘positive’.  2.89 It is a pity that what seemed to be a robust response to the referral, a good assessment, and an appropriately cautious management response, was weakened by a long period with no social work involvement before SW4’s visit and no multiagency meeting to bring things together. See also the following paragraph.  2.90 Education: Y entered school in London at the end of March, so nearly 2 months without schooling, and the signs of this were evident. Y tended to arrive at school late. The male friend helped with pick-ups. The school only knew of the prior social care involvement when the originating borough’s school forwarded some information. The school asked SW3 for background information and had a reply nearly seven weeks later outlining mother’s substance misuse and that S had been on a CP Plan.  This delay was not acceptable. Y did not attend school from five days before the  26  sibling’s death. Three days later SW4 rang to discuss Y and said he thought they had moved north.  2.91 General Practice: The mother told the Review that she tried to register the family with the GP immediately in arrival so S could get treatment. She says the surgery would not accept them for reasons relating to being unable to prove their address. Given that the GP made a speedy referral once registered this could mean that S’s health care was delayed for several weeks. She said she was grateful to the social worker for making sure she got registered. The children were registered at the beginning of March 2014, just before CSC advised mother needed to be registered too, and handed in an initial physio assessment form. The Practice also got copies of letters about missed appointments at the originating borough’s hospital. Mother and baby were seen a few days later and referred promptly to community paediatrics and therapy. The GP’s referral said ‘no CP issues’. For the rest of March there were failed attempts to contact mother so the failed hospital appointments could be discussed ‘to exclude any safeguarding concerns’. S was seen early April, and again early May for breathing problems and mother was advised to take the child to A&E for stridor13. The GP requested mother’s child health record (red book) and originating borough’s GP records were received on 12th May. The practice was aware of speech therapy involvement from mid-May as special feeds were requested. S was seen later in May for a cough, and was sent to hospital for admission. Twice in June, S was seen for respiratory conditions.   2.92 Drugs Services and Police: There was no reported involvement with drugs services or the Police. Throughout, mother’s word was taken about not using drugs, and the Review has not seen any referral to drug services. The mother was found to have a number of drugs in her system after S’s death, and told later the Review she was  indeed using during her time in the receiving borough.   2.93 The Hospital: These services were provided by Bart’s Health NHS Trust. S attended A&E with breathing problems at the beginning of May. Three weeks later, S was admitted via A&E with a virus, and needed IV drugs, and steroids. S was in for eight days, seen by speech and language therapy, and assessed as having an unsafe swallow. A nasogastric tube (tube into the stomach via the nose) was inserted. The child was discharged when well and mother as deemed able to cope with the tube feeding, with a referral to the feeding clinic, and for further tests. Nursing staff saw mother as caring. Mother kept the appointment with the paediatric dietician a week later, but the next day the dietician was called by the speech therapist, concerned S was aspirating (food going into lungs) and the advice was to minimise food by mouth. In the second week of June mother was late for the next appointment and it was rescheduled for a month later. The dietician did call mother to emphasise the importance of using the tube feeds, not food by mouth. The rescheduled                                             13 Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Airflow is usually disrupted by a blockage in the larynx (voice box) or trachea (windpipe).  27  appointment (eight days before S’s death) was not kept and rescheduled for four days later to coincide with the feeding clinic, but there is no record that was kept.  2.94 Community Health Services:  These services include universal health visiting, and the Specialist Child Services which include the Child Development Team (CDT) community paediatric nursing, community paediatrics, and therapies such as physiotherapy and speech and language therapy.   2.95 Health visiting learned of the case via a copy of the CSC referral to specialist health services mid-March, and not direct from the originating borough. Records were requested. The health visitor (HV5) told the Review that she was not aware at referral of the former CP Plans, nor that there was consideration of reconvening a case conference to consider S going back on a Plan just before the move south. HV5 eventually made contact with mother (the first of three home visits) in the second week of April, four weeks after the first notification, and made very full and good report in her findings. A nurse from the child development services also attended. Practical help was offered, and mother said she no longer took drugs. She agreed to a referral to speech and language therapy, and to the local children’s centre. She updated the social worker. The child development nurse made referrals to wheelchair services and ENT  2.96 In mid-April HV5 liaised with SW3 about mother missing a child clinic appointment. (Mother said she had forgotten). S was seen at the beginning of May at clinic and referred to the dietician. Height was ‘well below’ the 0.4 centile. In mid-May HV5 visited again and was working hard to link mother with the children’s centre. By this point mother was linked with Portage, OT, speech therapy and wheel chair services, so it seems that much was being put in place. A report was sent to SW3 for the CIN meeting (which did not happen) pointing out that S was on the 0.4 centile for weight and height. The report read positively in terms of mother’s care and commitment. Mother agreed to meet the health visitor at the end of June at the clinic but she did not attend. However, S had been examined at a major outpatient’s assessment clinic the day before.   2.97 In addition to the universal health visiting service, Community Health Services also provided specialist services such as community paediatrics, physio, OT, and speech and language therapy which are grouped together as a ‘Child Development Team’ (CDT). The CDT also includes the Portage worker, although the post belongs to the local Council. The Portage worker visited from early May, initially with the specialist community nurse from the CDT. Mother was described as ‘very engaging’, and ‘a good bond/interaction between mother and S’ was observed. The first 4 appointments were kept, but one where the worker was due to take mother and S to S’s prospective school was cancelled with mother saying she was not in London. (It is understood she moved that day or the day before).  2.98 Both the GP and CSC referred to the specialist children’s services mid-March. The GP focussed on the cerebral palsy and associated issues, asking for physiotherapy  28  and community paediatrics but added ‘no child protection issues’. The CSC’s referral covered the drugs, disability, and a pattern of missed appointments. Although it mentioned the initial CP Conference, it did not say that S was a CIN or had been once subject to a CP Plan. It said there had been no therapy since the move, but did not say there had been hardly any for months. This may have been because the information from the originating borough’s CSC had not been clear about this. The CDT did have the originating borough’s reports from Portage, speech therapy (Oct 2013), physio (Nov 2012), Portage (March 2014) and a hospital letter describing an outpatient assessment (Nov 2013) - none of which mention the former CP Plan14. The impact was that there was no real understanding given to health of just how long S had been without specialist health care, nor how seriously the care deficits had once been taken. For example, the speech therapist and physiotherapist told the Review they were not aware of the former CP Plan, only that of historic social work involvement, but not how recent or extensive.   2.99 Although mother was told at the end of March 2014 that S was on the ‘waiting list’ for the CDT, services (although not physio) sprung into place  It is clear from the records that the health professionals liaised well between each other, bringing in other specialists as  necessary and providing a comprehensive service, recorded well. The overall impression of health staff was of a caring mother, committed to cooperation with S’s care, enhanced by the presence of S’s grandmother from early June. However, the period of cooperation with health was less than two months, from early April to late June, then declined in the weeks before S’s death. There was a major ‘joint assessment clinic’ involving the CDT, consultant paediatrician, OT, physio, and speech therapy  the end of June which S attended with mother and grandmother, but no appointments with health were then kept until S’s death three weeks later.  2.100 The speech and language therapist saw S several times in May and June. She made thorough assessments of feeding, providing complex advice about what and how S should eat before and after the feeding tube was fitted. Firm advice was given in June about minimising food and drink by mouth. The therapist was very concerned about aspiration risks. S was to have a video fluoroscopy15 to assess the swallowing on mid-June but mother arrived too late for it to happen.  2.101 The specialist community nurse from the CDT saw S several times from early April to June, bringing in wheelchair and speech therapy services, working jointly at times with Portage. At a home visit shortly after S’s discharge from hospital with the feeding tube extensive advice was given about feeding. Community paediatric nurses provided phone advice about feeding and visited twice, on consecutive days, just before the missed fluoroscopy as the nasogastric tube had been pulled out by S.                                              14 The 6.3.14 ‘Referral for Paediatric Physiotherapy’ from the originating borough’s Physio did refer clearly to the CP Plan, but although it went to the receiving area’s social worker on 6.3.14 it is unclear if it was attached to CSC’s referral to specialist child health for physio 7 days later. 15 A Videofluoroscopy is a moving X-Ray image of swallowing recorded on videotape/DVD that allows an individual’s swallow to be viewed … It is an essential diagnostic tool for the assessment and management  29   2.102 The OT did a thorough assessment in late May, and provided help with aids, and advice about housing.  At the joint assessment clinic, at the end of June, a further OT assessment was planned, as was a referral to orthotics. There was more complex assessment and discussion about the specialist feeds, the anti-reflux medication, about how to get help administering a drug through the tube. After this appointment only SW3 saw the family. Appointments for feeding assessment and OT were missed in July, as the planned visit to S’s intended school. It is also understood that the grandmother has returned home so one less support.  2.103 The absence of physiotherapy is perplexing. It is hard to understand why the child was offered no physiotherapy, when the originating borough reported a weekly need, and there had been a long gap in such therapy. The mother was disappointed that it did not happen as she found the therapy eased S’s body, but S was not seen by a physio for 3.5 months after the referral by the GP for physiotherapy. This must have provided very mixed messages for the mother who had been subject to CP processes for missing physiotherapy for S, yet was given none for so long after the need was registered in the receiving borough.  The Review has made further inquiries about the physiotherapy delay. It seems that when Specialist Children’s Services discussed the referral in late March 2014 the only physiotherapy report it had was from November 2014. They did not seem to understand that the originating borough’s physiotherapy was desperately worried because S needed regular physio and had missed it for months. Community Health Services say that their physio service is an acute service and therefore do not provide physiotherapy in an emergency16. No referral to an urgent service was made, probably because physiotherapy was not realised to be urgent. In fact, in Community Health Services terms, S was treated as ‘priority’ and planned to be seen (at the Joint Assessment Clinic) ‘within 8 weeks’. Community Health Services told the Review that ‘our usual wait for initial assessment is 8 weeks’.  It turned out to be 12. Community Health Services has looked at waits around the time of S’s referral and they were around the 3-4 months.   2.104 With both receiving authority’s CSC and the GP referring for physiotherapy, and mother being concerned about its absence, it is disappointing that nothing was provided for so long. The mother said this was the one thing about services that she was unhappy with. The fact that the meeting to discuss the referral had only a Nov 2012 physiotherapy report is not sufficient explanation as the CSC Referral form said “Mother did not make S available for weekly physiotherapy which was vital”. (Review underlining). Even the Nov 2012 assessment which the meeting did have said the plan was ‘weekly physiotherapy’. Surely this should have led to an urgent request for more information from the originating borough and S being seen quickly, not in 3 months’ time?                                              16 This may not be right as originating borough’s Physio records ‘forwarding’ the ‘referral for paediatric physio’ in London to the receiving area’s social worker on 6th March A copy was found in GP files and it referred to the CP Plan ( and why) the absence of needed equipment, drug use and so on.  30  2.105 S’s Death: It is not the role of Serious Case Review to look into the cause of death. That is for the Police and courts. However, some information emerged after S’s death which raises questions about prior work. Mother told Police she left the originating area in November 2013, but returned in December because she had concerns about the man she went to live with (platonically she said) and his chastisement of Y, but he persuaded her to go back over Christmas. (But Y was in school in NEL in January 2014). She said the return from London to the originating area in July 2014 was for the same reason- the man’s chastisement of Y. The man’s relationship with her appears to have been exploitative and controlling. It emerged after the death that he may have been violent with mother and one if not both of the children. The man concerned was the man whose name SW2 circulated in October 2013.   2.106 Apparently the move back was without possessions or clothes beyond what they were wearing, and mother stayed with the drug using friends she was with at the time S was born. S was said to have pulled out the feeding tube in the originating borough the day before being  found dead, but she was not worried as she  carried syringes given to her (she said) to feed S if the tube came out. She also said she had sought no advice as S was taking foods orally. (The originating borough’s speech therapist told the Review S should have been virtually nil by mouth). There was no medication for S at the house. There was evidence of recent drug use, with drug paraphernalia in the room used by the children, and tests showed mother had used diazepam, the ‘designer’ drug mephedrone17 and heroin. S’s blood also contained a low level of mephedrone.   2.107 These post death findings highlight the lack of any assessment of the men in mother’s life, in either boroughs. There is no assessment of male friends in the originating borough’s Assessments, and no mention of the man concerned, or reference to asking about who she was living with in any of the receiving area’s CSC visits. The receiving borough’s Child and Family Assessment merely said she was living with a male friend ‘who has been helping her with shopping and transport’. The findings that mother was likely to have been using drugs while in London highlights (and her later acknowledgement of this) the acceptance without evidence that she was no longer a hard drug user.   2.108 Summary: The key issues will have more analysis in the next chapter. This was a family with which the public sector had very significant involvement in both local authorities. It is hard to think in terms of the range of people involved that more could have been offered (except physio). Many of those staff worked very hard to get help for the family, which was not easy to engage. However, there seems to be a theme in both areas of there being insufficient pulling together of views and risks, and weaknesses in coordination of effort. This meant that toward the end of their time in the originating area when S was more at risk than when subject to CP Plan, there                                             17 The user is reported to experience stimulant and euphoric effects comparable to those of cocaine, ecstasy or amphetamine.    31  was no leadership from CSC and there was no multiagency assessment of the risks, nor resulting action. In the receiving borough (whilst the picture was of much greater cooperation from the mother who seemed to be linking well with health staff) there was again no multiagency meeting – which had it happened might have alerted staff to just how long S had been without care.  2.109 The quality and timing of information transfer north to south was variable, and many staff in London did not really understand the extent of the gap in health care or the CP background. It is possible, that had there been a better shared understanding of scale of earlier neglect of S’s health needs that there may have been a more active response to mother’s sudden non-cooperation just before the death. This does not mean  that had there been a quicker reaction S would still be alive, as the reason mother has given for the sudden move was well hidden from professionals  2.110  It is also important to consider pressures on the mother. She had two children as a single parent, with one of them not only disabled but often ill. At times in excess of a dozen types of staff were simultaneously involved, with numerous home visits and appointments on top of the emotional recognition of S’s impairments and what this would mean for them both. The drugs may have been self-choice, but once caught up in that it is no surprise that the effort and rigour needed to handle her family’s needs was often beyond her, when they would have taxed the most super parent.  2.111 The history leaves the question as to whether there was at any time sufficient evidence to protect S from the inconsistencies of the care received, and related risk?                         32  3 LEARNING and WHY  3.1 Introduction: This chapter will identify the key issues from the preceding history and appraisal, and where there is a problem, look at why this occurred. The views of the front line staff at the staff meetings and interviews were very helpful in preparing this section. It will also identify ‘Learning Points’. These are issues for consideration by the LSCBs and agencies/professionals, and can be used in a range of ways.  A learning point does not necessarily imply that something is not in place. (A smaller number of formal recommendations are in chapter 5). There will be comment by issue, but also where appropriate by agency.   3.2 Coordination and Leadership: The combined input from services to this family was very extensive in the originating borough and (once aware of the family) in the receiving borough where an array of services was put in place quickly. The scale of service is to the credit of both areas, but what stands out was a weakness in coordination and an absence of leadership around this family. A CAF seems to have been started around S in 2011, but the Review has seen almost nothing to indicate what resulted, nor seen any reference to a lead professional which might at least have given some indication of who was overseeing the collaborative effort. When the children became Children in Need (CIN) the CIN meetings were usually unrecorded, with sometimes no one other than CSC there, with key professionals missing, and once the social worker not attending. There was no sense of the meetings pulling together the evidence necessary for ongoing assurance about one of both children’s safety. Only one CIN meeting seemed to have drugs services present. Minutes were conspicuous by their absence18.  3.3 There was little evidence of thorough gathering of evidence from other agencies when successive core assessments were done (see Assessments below). When a CP Plan was properly given to S in 2013, the only core group meeting had no input from GP/drug services despite drugs being seen as the main cause for mother not keeping appointments. The review CP Conference that took S off the plan after less than three months was attended by a health visitor (who did not know the family) physio, key worker, and social worker, and minuted inaccurate information about mother keeping drugs appointments which was a key factor in the decision.  3.4 After the removal of the CP Plan there was virtually no social work contact for four months, at a time when health concerns were quickly rising again at missed appointments. As the previous chapter concluded, there was every reason to reconvene the CP meetings by late summer but there was neither co-ordination of concerns, nor any action by the agency which led on child safety.  3.5 Throughout the autumn of 2013 concerns mounted further. There were still no multiagency meetings, and although the need to have one was acknowledged by                                             18 Apparently minutes were not required by originating borough’s CSC, only a record of the plan or amended plan. This seems insufficient for interagency understanding.  33  originating area’s CSC, none occurred. Worse, the period was characterised by non-response from CSC to other agencies concerns, or other departments within the council. What was needed was a strong coordinating and rigorous approach by CSC to ensure information was pooled, risks assessed, and if necessary protective action needed. However (as will be seen in ‘Escalation’ below) this is not solely a problem with originating area’s CSC as other agencies did not escalate concerns in a way that would have made them undeniable. For example, CSC senior management had no idea about the concerns or their level.  Receiving area’s CSC also failed to pull together agencies by having no CIN meeting between taking on the case in February 2014 and July. There was in London far less concern, but had there been at least one thorough meeting there would have been more shared knowledge about the historic risks, and possibly a more co-ordinated response to the sudden change in co-operation at the end of June.   3.6 NHS services should also use the history of this case to consider co-ordination around children with disability where there are also safety concerns.  In both local authorities there was a similar structure around services, but in neither could this Review see how the very wide range of services were coordinated, and how a plethora of appointments are ‘managed’ to avoid family overload etc. The staff were enthusiastic, caring and skilled, but with a child like S with failure to thrive and many health issues it must be important that there is coordinated information about, say, weight, feeding regimes, safety and so on. This is particularly important when there are safeguarding concerns where such information is crucial evidence. The joint assessment in the receiving borough in June 2014 was the closest to a health wide assessment. The key worker role in the originating borough also seemed to be a good role to help with this. It was positive that, in both areas health staff were good at keeping CSC posted on concerns about the children, especially about the key safeguarding issue of missed appointments.  3.7 There is a need in complex health cases to have a lead professional to pull together health information, have a complete overview of health needs, coordinate caring inputs, and who can liaise closely with the social worker in CIN or CP cases.  Health staff discussing a draft of this report also identified a need for more joint assessment in such cases, and where necessary involving social care and education too.   3.8 It is also easy when so many are involved to assume someone else is covering a particular issue, or had the overview. For example, the health visitor did not see S in 2013 other than at meetings and this may relate to a view that so many other health staff were seeing the child. This can be a risky assumption without active checking.  3.9 Learning Points:  In complex case like this there must be clarity on who takes responsibility for leading overall the multiagency process  Where a child is a CIN or on a CP Plan this has to be CSC  34   This role is crucial, and needs high priority, with other agency concerns getting clear prompt responses  However across health there should be a lead professional (sometimes called a key worker)  who maintains the overview of the child’s progress, key information , and ensured collated information is shared with the multiagency groups  CIN meetings and Core Groups must have good multiagency attendance, up to date reports, and be minuted clearly with wide circulation.  Professionals must not assume without evidence that another is doing something  3.10  Escalation: This was primarily an issue in the originating area. The strength of feeling about the social work non-response in 2013 came over in written submissions, and Review meetings and interviews. Yet at the time, whilst the Principal Social Worker was included in some correspondence, no agency went higher and as far as the Review can see no manager in another agency (or even another council department) made formal approaches to counterparts or higher. There is an LSCB policy about disagreements between agencies, with a detailed procedure, but this was not overtly used and one wonders how many front line professionals knew about it. By and large, front line staff battled away on their own to try and get a response from CSC and their child care concerns acknowledged. This was to their credit, but another time the value of manager to manager discussions, and indeed going up the line until a satisfactory response is received, must be appreciated. In this case, had say a senior health manager insisted on a CP Conference and S had been put back on a CP Plan, then S would have arrived in London with that Plan. It may not have made a difference, but the receiving borough’s staff would have had a higher level of alertness and scepticism about mother’s self-report.   3.11 Learning Points:  Front line staff with serious concerns about another agency must engage their own managers in resolution, going up the line as necessary  Managers must seek appropriate responses from their counterparts, or higher as necessary  The  originating borough’s LSCB disputes policy19 must be used to ensure speed of resolution and appropriate managerial involvement  Even where the policy is not formally used, professional concerns need to be respected with prompt responses  3.12 Assessments: The receiving area’s CSC did one assessment, to inform the decision after the referral from the originating borough. There was only one home visit recorded to assess the situation20, and it was signed off before specialist health services were involved. It was largely based on the information from the originating borough. Indeed, it is impossible to tell which were current views and which were                                             19 Originating borough’s LSCB: Resolution of Professional Disagreements, in the LSCB Procedures Manual 20 … Although the manager appraising the assessment refers to two.  35  taken from that borough’s reports. This makes it difficult for a manager to assess the assessment. The receiving area’s manager quite properly postponed the decision on S’s status for more information, and saw it as being close to a child protection case. The manager therefore compensated for the weak assessment.  3.13 In the originating borough, the assessments are of concern. The Initial Assessment, not long after S was born appears to be pretty thorough, although no sign of information from drugs services or any check with Police (especially given the longstanding drugs use). All the key issues that faced professionals later were identified. The recommendation to take on the case was correct.  Unfortunately, the thoroughness of this initial look was misused later when large extracts were used in CA’s by the next social worker (some even appeared in the transfer information to London two years later) and were presented as current assessments.   3.14  The first CA, concluded in December 2012, was informed by only one home visit from start to finish, and took large amounts from the December 2011 IA, which was before S was even known to be disabled. It was not a meaningful current assessment when a very up to date assessment of family functioning was needed. Another was done as a result of the 2013 Strategy Meeting and subsequent CP Plan, and again it was largely cut and pasted from the previous assessments. It was not fit for purpose, and had little up to date information. Reading them cold, without the prior assessments to hand one might see them as thorough. It is in seeing them together that one sees how poor they are. Supervising managers might also get the impression of ‘current-ness’ but  they do need to focus on what is different from before and test out what they are reading in discussion with social workers.  The CA’s are also light on evidential issues such was weight progress and drug use. Also none make any real assessment of mother’s male friends.   3.15 Learning Points:   While it is inevitable, and for continuity proper, that core assessments draw on previous assessments, it must be clear what is a current view and what is an historic view  There is a duty to ensure that such assessments are up to date, are evidence based and have current multiagency views  Similarly assessments done after transfer in must be clear what is a view from the previous area, and what is a locally verified view.   Supervisors must be alert to the temptation to use old assessment material rather that evidence based new information  Supervisors, when quality assuring assessments, should satisfy themselves that information is new, focus on what things are like ‘now’, and have taken current wider agency views into account.  3.16 Continuity: In a case like this where consistency and continuity of care for the child is crucial, and where the opposite is the key reason for intervention, professional action needs to mirror the continuity expected from the family. With the exception of  36  the lack of the originating borough’s health visiting contact through 2013 (after being the prime mover in getting S’s disability needs assessed in 2012) health services in both areas were persistent and recognised the need for that and continuity. With CSC in the originating area, and to a far less degree in London, there were issues where continuity was questionable. This applied to meetings and visits. In 2012 there was a 5.5 month gap between two CIN meetings, which increased the impact of the very limited attendance as described earlier. In the same year there was a 3 month gap between social worker visits, and then only because triggered by a health visitor. In 2013, there was no recorded social work visit for 3.5 months June to October. These gaps reduced still further the quality of ongoing assessment, and the role the social worker could play in holding the ring. In the receiving borough, S was not seen by a social worker for 9 weeks until mid-July during a time when there were major health problems and a much higher level of care required from the mother.  3.17 Related to this was the need to maintain the line with mother that she must be responsible with S’s health needs. The mother told the Review her attendance at appointments was better during the CP Plan as she was scared of the consequences of not improving. We know now she had not improved as much as thought, but she was able to contrast this period with when there was soon after no social worker visits, and no pressure/threats etc. While it cannot be proven that such an approach would have made a difference, the mother was aware, when discussing this with the Review, that given her overall circumstances she was less likely to do the right thing without such pressure. The absence of any qualified social work input for months shortly after the CP Plan came off must have significantly reduced the impression given to mother about what she needed to do.  3.18 Learning Points:  Continuity of social work oversight is important in any CIN or CP Case,  but where the key issue is the ability of a drug using parent to provide all the care needed for a disabled child  then close supervision needs to be undertaken  Supervisors need to monitor visit frequency and challenge when this is not at least within agency policy  Supervisors need to monitor visit frequency, the regularity of CIN meetings and challenge when this is not within agency standards  If a universal services such as health visiting steps down visits because many other health professionals are involved, there needs to be clear written clarification of the plan.  A CP Plan coming off does not mean there are no issues remaining, and parents need to be given an ongoing understanding of what is required.  3.19 Tolerance, and drug use: It is always easier to see things in hindsight, but there were several occasions in this case where things do not seem to have been taken as seriously as they might. Some of this relates to how one views parents who use illicit drugs. In 2009, with drugs services and health visiting concerned about mother’s regular drug use, CSC did not see a role and recommended a CAF. It may have  37  been thought that there had to be more to a referral than simply a mother using drugs, but it is safer to at least do a preliminary assessment- especially with fellow professionals concerned. The same happened in 2011 at S’s birth, although it seems the drugs midwife was not pressing CSC action. The incident which led to CSC involvement was mother forgetting a 2 week old baby outside a school until alerted to what she had done. It led to no strategy meeting or CP Conference (although taken on as a CIN). The author has not heard of a similar case in 40 years in child protection and it really was quite exceptional. It is interesting to consider whether had the mother not been a drug user whether it would have led to a strategy meeting and even a formal investigation for neglect The Police were not even told. This was very serious neglect.  3.20 Twice at home visits Y was found alone on arrival, yet on one occasion Y was taken off CSC’s books by having the CIN status removed at the end  of that visit.  3.21 Similarly, one might ask if the mother’s drug use was seen as a mitigating factor with the many missed appointments, rather than vivid confirmation of the risks. There was plenty of confirmation in the originating authority that the mother was topping up methadone with heroin, and it is hard to see that this was given the attention it needed in assessing child care.   3.22 When mother began missing appointments again after the CP Plan came off (probably to a greater degree than when the Plan was put on) CSC did not return to child protection processes. It is hard to tell if that was simply poor practice, or that a tolerance to this had developed because mother used drugs. It is interesting that the mother says she found the CP Plan helpful as she felt she had to comply, but this feeling went when the Plan was removed.  3.23 This dynamic can also impact on assessments around the time of birth. There are comprehensive policies around concealed pregnancy and substance using mothers now in the originating borough, but there was less in place in 2008 and 2011. Whatever was in place, there should have been a pre-birth assessment. This was a mother with a second concealed pregnancy, with no obvious support in her home to balance her drug taking ( the other adults were users too), a single parent known to be an illegal drug user, with English as a second language, with housing issues etc. If the late booking made pre-birth meetings impractical then a pre discharge meeting was warranted. It is hard to understand why the drugs midwife did not push for such multiagency involvement. The CAF, which seemed briefly to begin, would not be a substitute for a safeguarding assessment. Had CSC become involved and a multi-agency assessment taken place this would have been much more informative and robust than just the midwifery view.    3.24 There was a different form of not recognising risks around just how neglectful was the care of S. Firstly, and health staff were very aware of this,  the duration of no therapy in the originating area before  the move south was clearly at a level that was damaging, but no action was taken. Secondly, after the move, it was initially thought  38  (as the transfer information was weak) that S had only been without care for some weeks, around the moving period. In fact, S had been without healthcare for 5 months. By the time that became clearer, the family was responding well to London services. No one ever stepped back and said … ‘This child, 5 months with virtually no therapy… this is dreadful, what does it tell us about the parent, the risks?’ etc.  To all intents and purposes, the receiving authority started again.   3.25 Learning:  In assessing the risks from drug using parents it is important to be very child focussed and not see  the drug use as mitigating factor when there are child care deficits  While it might be wrong to stereotype drug using parents as automatically a problem, it is also wrong to allow that to lessen what needs to be strong vigilance for the child/children or…  …With past behaviour being the best predictor of the future, staff (with their supervisors) need to remember past examples of neglect (or any other form of abuse) when noting positive improvements, and not reduce alertness until much longer periods have passed.   The type of drug used, and  the frequency/method of taking it, must be considered when assessing parental behaviour and the risk to a child  Pre-birth and/or post discharge meetings can be a good way of ensuring a comprehensive assessment and should not be dismissed for fear of alienating the parent, or being unfair to users. The child must be the prime focus  3.26 Drug services: There was no known involvement with drug services in the receiving authority, but in the originating one mother was known 2007-13. Some of the service was at the local drug and alcohol service, part of an NHS Trust, but it was mainly in ‘shared care’-a partnership between a GP who prescribes the alternative drug, e.g. methadone, and a worker from a drugs agency. In this case, the agency was either Addaction or the local drug service, and one of two GP Practices where the family was also registered for routine health care. The Review found it difficult to get a clear history of drugs care, which was commissioned by the CCG (or predecessor), and for the GP is separate from the GP’s primary care contract. It is not clear to the Review how issues of accountability are addressed in shared care, and clarification would be helpful- especially when there are safeguarding connections. For example, where regular updates on a parent’s test results are key to a safeguarding assessment, whose duty is it to supply that information?   3.27 Where the shared care GP is also the family GP that must be advantageous as the practice is in a position to link parental and child health. It is important that GP views are taken for assessments. It is hard to find any sign of the GP perspective in the initial or core assessments, of the CP Conference minutes, and there is no indication of them being asked. SCRs have shown that there is often as assumption that other health staff are bringing Practice information, an assumption often proved not to be the case.  39   3.28 The regular testing of users in shared care or NHS Trust care provides key information about what a user is taking, how much, and the degree to which they are complying with treatment plans. When this is related to child safety there must be a clear agreement about who is to be told the results with what frequency, and what results should be regarded as significant concern for immediate passing on. This should also apply to an agreed number of DNAs.  3.29  We know now that mother was using drugs whilst in touch with services in London, and they were in her system at the time of S’s death less than a week after being last seen by SW3 in London.  The receiving authority’s services relied wholly on self-report, and there could have been more scepticism that a person who had used drugs for so many years would suddenly stop both illicit drugs and methadone simply by moving home. It may well have been difficult, given her denials and apparent cooperation, to press mother to demonstrate she was off drugs or link her with drug services, but it does not seem that either was considered.   3.30 It does seem remarkable that the health visitor for Y, the first child, was not aware of mother’s involvement with drugs until over a year after Y’s birth, when Y’s GP was well aware.   3.31 Learning Points:   In shared care, accountability for safeguarding issues should be clarified  Obtaining GP views is very important, especially when providing both shared drugs care and primary care for family members  Reporting arrangements for test results , and DNAs should be clarified between drug services and CSC  There should be a healthy scepticism if a very long term drug user and parent  is claiming total abstinence  3.32 Scepticism: In the meetings to discuss draft findings, involved staff identified how the case showed a lack of scepticism that would have been more appropriate. For example, the lack of challenge or inquisitiveness around how the children were kept safe during drug use,   the acceptance that mother had suddenly stopped using drugs, the lack of inquiry about men, to which might be added some of the reasons given for not attending appointments. Staff often find being more challenging hard, especially when trying to maintain a tenuous relationship with clients, but challenge in this context is not about spoiling for a conflict (one definition of challenge) but simply the professional duty around seeking more information in the interests of children.  3.33 Learning Points:  The value of being reasonably sceptical about a case, and especially self-report should be part of professional culture in safeguarding.  40   Supervisors can help staff with this by modelling challenge done well in supervision  Supervisors need to be alert to the signs that staff are finding challenge hard with a particular family  3.34 Thinking what it was like to be this child: Related to the lack of inquisitiveness, staff also identified when considering the draft SCR  that there was, looking back, insufficient thought given to what it must have been like to be S. This was likely to lessen the realisation of just how bad was the neglect. For a baby, young toddler, to have such disability and not to have the discomfort and motor development subject to regular treatment must have been distressing. To have problems with feeding and swallowing as well, would mean something we all take for granted was often less than pleasurable.  As well as the inconsistency of care and attention that would come from a drug using parent. The staff also said that Y was also, ‘not in many people’s minds’.  3.35 Learning Points:  Overtly thinking through what it must be like to be a child in such circumstances is a necessary discipline  Such thinking needs to be done on a multi-professional basis so a rounded view is formed  3.36 Transferring between areas: It is likely that one of the reasons CSC did not convene a late 2014 child protection meeting was the understanding that the family was to move soon. This case illustrates perfectly why such a view can be harmful. It is far harder for a new area to form a considered view on arrival than it is for the ‘exporting’ area to form an assessment of where things are at transfer. On S, staff including the originating area’s social worker seemed to think that the child should be considered again for ‘child protection’, but it never happened. The result was a very poor transfer out document from CSC, and a range of health reports of varying dates which the receiving area had to piece together into some sort of whole. What the receiving borough had was an April 2013 Core Assessment, which itself was largely copied from earlier assessments - written before S had even come off the CP Plan.  3.37 Within London, there is agreement between authorities that the exporting authority remains responsible for a month post move. This would not be practical with a 200 mile distance, but the spirit of this procedure would have been useful in the S case so the originating authority had a greater responsibility initially, thus reducing the need for the receiving one to start again.  To a degree this is enshrined in existing LSCB procedures (of the originating authority) which say the following: ‘Where a child moves across local authority boundaries, and a Section 47 Enquiry is being considered or is in progress and/or a Child Protection Conference is proposed but has not yet taken place, the local authority where the concerns originated should make decisions as to how to proceed. In these circumstances, therefore, the originating authority must continue with the Section 47 Enquiry and should convene  41  a Strategy Discussion Meeting - this should take place within 72 hours of notification of the child’s move. Timescales may be varied depending on the individual circumstances e.g. proximity of the two areas and/or the gravity of the situation. In all circumstances, however, the Strategy Discussion/Meeting will always involve representatives of both the originating and the receiving authority and their respective roles and responsibilities will be agreed. The Strategy Discussion/Meeting should consider how the timescales for the completion of the Section 47 Enquiry and holding of the Child Protection Conference (if appropriate) will be met. The social worker from the originating authority will attend and provide a report for the Child Protection Conference’.21  3.38 This should have been applied in this case. A Child Protection Conference had indeed been proposed but had not yet taken place. Its non-arrival was being challenged inside and outside the Council. The social worker was recorded at telling the CIN meeting in October she would discuss with her manager taking case ‘back to safeguarding level’. The Health Visitor recorded as action from the meeting ‘SW2 to seek advice and potential removal of S’. Later in the month the social worker emailed the key worker’ ‘I am awaiting the strategy meeting being arranged by my PSW and them this will allow me to raise this to CP and Planning for a case conference’ In November she  emailed health staff saying ‘… due to the conference not being held as yet.’  There can be no doubt that such safeguarding steps were in the pipeline, and indeed should have happened under the LSCB procedure.   3.39 The referral to the receiving authority CSC from originating CSC did not describe this plan for safeguarding meetings, nor acknowledge they should have happened, nor say how much other professionals wanted it. It said much more vaguely that mother had been informed that CSC would ‘once again be looking at CP and PLO procedures’  and did not say when  this was. As a result, even had the receiving area known the originating area’s procedure it is unlikely it would have realised this case fitted, as the level of current concern was not conveyed.   3.40 The SCR’s meeting with involved staff from the receiving authority was clear that the transfer information simply did not convey the level of concern that abounded in the originating area.  The receiving authority’s CSC rightly realised they had weak information and postponed deciding if CIN or CP. However, by the time they got to that re assessment mother had already created a good impression and was cooperating well. The CIN decision was then based more on what the receiving CSC found than on the history, and the magnitude of the history which had not been conveyed well was lost. This shows the risks of new assessments not having a clear history. Had it been clearer there would have been more likelihood that of a more sceptical approach when things seemed to have improved.  3.41 Most health information was transferred quickly, the originating area staff being so relieved the family had been located by services, although some hospital records                                             21 Originating authority’s LSCB Procedures  42  arrived after S had died. There were also discussions between therapists and the receiving area’s social worker. What the transferred information highlighted was the absence of any ‘health overview’ of Y.  The Review is not proposing a specific way of doing this but will recommend that in both areas the NHS considers how with especially complex cases there can be somehow a collated assessment from time to time which sets out the overall position and a plan across professional boundaries. This would make it much easier for say receiving authorities than having to piece together numerous reports and try and work out what the overall picture is saying. This would not remove the responsibility of social work to carefully log key health indicators in CIN and Core Group meetings and CP Conferences.  3.42 Had S been subject to CP Plan before leaving the originating area (which this Review thinks should have been the case) it would have triggered various aspects of the London CP Procedures22 which would have required enhanced standards of liaison between the two authorities,  matching  the requirements in the originating procedure. The receiving area staff would also have been more alert, and sceptical. However, this does not mean there would have been a different outcome, especially as mother created a good impression, but it might have done. The poor transfer from the originating borough was exacerbated by the receiving area’s CSC and the GP not mentioning child protection issues in their referrals to specialist children’s services.  3.43 Learning Points:   If multiagency meetings are needed to review the safeguarding status of children, this must not drift simply because the family may be moving…  .. indeed as the originating area LSCB policy indicates it raised the responsibility of  the transferring authority  Transfer information has a huge impact on receiving professionals and must be given high priority   The originating area staff need to be reminded of the LSCB policy and the very significant responsibility it gives even if the family have moved  The originating CSC especially should ensure its staff understand and implement the policy  New assessments which seem positive can be risky if not properly informed about past behaviour which is the best predictor of the future  The NHS in both areas should consider how in such complex cases there can be an overall health assessment  both to help monitor progress but also aid multiagency assessments  3.44 Men: Many SCRs have identified weaknesses in assessing the men in the lives of children at risk. This case is another. At times mother had various male associates and friends and yet no assessment by any agency makes any analysis of them or, as far as the Review has seen, any check. There was a commitment to check one                                             22 ‘Children and Families moving across Local Authority boundaries’. Section 6, London CP Procedures. (London SCB) http://www.londoncp.co.uk/chapters/chi_fam_bound.html   43  male in the originating area but there is no record that was done. One male in a family with whom mother and children live in the originating area, and where S died was deemed to be supportive but he was also a drug user, and after S’s death was jailed for an intra-family assault. According to mother (and a child) the man with whom she moved to London and lived with assaulted her and the children and was the reason she moved to and from London – but there is no reference in the receiving authority’s assessments or case notes about this person. It is good practice in any child case to get a good understanding of significant adults, and especially so with drug using and the lifestyle and associates that can come with that.  3.45 Learning Points:  Professionals must take active steps to assess the men in the lives of parents of children in need, or on CP Plans  Supervisors should look for this in assessments they appraise  Seeking out information about sometimes shadowy or aggressive figures is not easy work and staff need good training and support to deal with it  3.46 Safeguarding and disabled children: The national guidance is ‘Safeguarding disabled children: practice guidance’23. This emphasises the increased vulnerability to abuse of children with disability, as do both authorities’ Safeguarding Boards’ Procedures. The national guidance sets out the duty of LSCBs to ensure their member agencies ‘take seriously their responsibilities to protect disabled children…’ Both areas LSCB procedures list ‘deliberate failure to follow medically recommended regimes’ as an indicator to look for with the care of children with disability. The originating area guidance twice warns about the need for child focus and not making allowances for parental problems; ‘Children with disabilities should not be left in situations where there is a high level of neglect or other forms of abuse, because a practitioner  feels that  the parent, carer or service “is doing their best”. Carers will need to be challenged in the same way as carers of non-disabled children’. The London guidance has a link to the 2004 National Service Framework ‘Disabled children and young people and those with complex health needs’24 which says that ‘Diagnosis and identification of disability or complex health needs which may not be a single consultative event) is followed quickly by a multi-agency comprehensive needs assessment’.  3.47 Looking at how practice adhered to these key points, this Review has already speculated (in ‘Tolerance, and drug use’ above) on whether the mother’s drug use was a factor in not giving sufficient weight to episodes of neglect. The originating area’s LSCB guidance about not leaving a child exposed to neglect because the parent is ‘doing their best’ is an important reminder that the well-being of the child comes first. And the warning indicator about not following ‘medically recommended regimes’ links to this. The originating borough’s CSC took no action when this started happening again soon after the CP Plan came off and, partly due to poor transfer                                             23 Department of Education, 2 July 2009 24 Department of Education/Department of Health, 2004  44  information, neither CSC focussed on the fact that S had been without the ‘medically recommended regime’ for many months, and not just over the move period.  3.48 When S’s disability was first identified in September 2012 there was not a multiagency comprehensive needs assessment. CSC did a core assessment, but as noted above there was little new in it from one done 9 months earlier when S was a few weeks old. The only potentially multiagency meeting around that time was a CIN meeting in December, but only the social worker, school and OT were present. With S’s disability now being recognised as so serious and mother’s continued drug use, surely this called for properly comprehensive core assessment with significant overt input from other agencies- and well represented multiagency meeting would have been most useful in the originating borough.  Even in the receiving area where things seemed to be going so much better, there was no multiagency meeting, and the ‘joint assessment clinic’ was only joint within some parts of health.   3.49 With a family like this with so many professionals involved and tricky issues of judgement about maternal capacity, and the impact of illicit drugs, there needs to be a forum to lessen the chance of something being missed, and enhance the chance of all information being pooled.  3.50 The staff from this case raised the issue of the possibility that with a child being a CIN for ‘disability’, this may somehow be seen as a less worrying CIN - as not a CIN for ‘safeguarding’. If this was ever the case, it would be risky as it is well known that children with disability, and non-verbal children with disability are more at risk of abuse or neglect- not least from the simple truth that parenting is so hard.  3.51 Learning Points:    The LSCBs need to review their work against the 2004 guidance, which is still current and listed in Working Together 2015   When it becomes clear that disability is to be a major issue, national guidance that there must be a ‘comprehensive multiagency assessment’ should be followed.  With complex cases like this, there is no substitute for face to face multiagency meetings especially when safeguarding is an issue   Disabled children should not be left in neglectful circumstances just because, to quote the originating authority’s guidance, “the parent, carer, or services is ‘doing their best’ “.  Failure to follow ‘medically recommended regimes’ is from the child’s perspective neglect, regardless of intent or mitigating factors.  Care should be taken to be sure children classified as CIN for disability have no less rigour about their safety.   3.52 Police: The Police had no involvement with this case until the initial CP Conference in March 2013. The Review has seen no evidence of checks with the Police for the initial assessment or two core assessments that preceded this Conference. (By  45  chance this did not matter as at the March Conference there was nothing of note reported by the Police. The Police were not members of the Core Group which met once, and did not attend the Review Conference in June ‘in accordance with Force policy’, but a report was provided which was recorded as an ‘inference’ mother was dealing stolen goods to feed her drug habit since the previous meeting.  3.53 At the domestic incident attended by Police in Dec. 2013 (when some thought the family had left for London) it was risk assessed by the attending officer and a supervisor as ‘standard’. The LSCB procedures use ‘moderate’, ‘moderate to serious’, and ‘serious’. The Police are rating the abuse between adults, the LSCB the risk to children. Is there a need for standardisation of risk levels? Even though the record of the event noted the former CP Plan, CSC was not informed as there were ‘no CP issues’25. The Police must have been aware that S was still a CIN, and sharing the information with CSC would have been much better. It would at the very least told social work that S was still local. When 19 days later mother arrived twice at buildings where drugs warrants were being executed, this would again been useful information for CSC as confirmation of continuing involvement with illicit drugs-at a time when S was receiving no health care.   3.54 Learning Points  Even if the incident was not especially serious, Police sharing the information with CSC when  there are children present may well prove very valuable in the context of that case  If the child is known to be an open case (and especially if recently on a CP Plan), CSC should always be informed of a Police domestic abuse visit.  The originating authority’s LSCB should satisfy itself that the procedures around domestic abuse always lead to appropriate sharing of information.  3.55 CSC organisational context: This report has identified a number of weaknesses with the social work performance in the originating authority. Twice there was NFA (no further action) when other agencies sought social work support with Y and the S, and it might be argued on both occasions some assessment might have been done. With S the issues  included recording, poor assessments, inadequate checking with other agencies, gaps in visiting and long gaps between review meetings, poor responses to other agency concerns, failure to review safeguarding concerns in late 2013 and weak transfer information. It is also implicit that there must have been weaknesses in supervision for little of this to have been seen at the time. The balance between individual performance and inherent system weakness is often difficult to assess. For example, similar weaknesses in recording were later identified in other cases managed by the social worker, and had not been seen at the time by the PSW. On the other hand, various reviews by Ofsted of the originating authority                                             25 Police procedures at the time (from 2004) did not require notification to CSC unless children were involved in the event or there had been at least 3 ‘minor incidents of actual domestic violence’. The May 2015 procedures include greater scrutiny of the need to refer, and more judgement to be used.  46  identified problems which showed up in this case. Ultimately it is for CSC and the LSCB to be assured that whatever the balance was, things are improved now.   3.56 The Ofsted findings set out here have been public information26, so are not new findings. This SCR covers 2008 onwards, and 2011-14 on S so evaluations across this period are relevant. In 2009, Children’s Services were said to ‘perform well’. However, in January 2010 an unannounced inspection listed a number of strengths but also listed a number of areas for improvement: decisions on NFA without sufficient evaluation of the range of possible risks; inconsistent recording or approval of assessments by managers; the quality of assessments being too variable; insufficient use of chronologies; and the case recording being weak on documenting and understanding affiliations. All these issues could be seen in the S case.   3.57 Another unannounced inspection later in 2010 said the issues of NFA27 and chronologies were still not addressed, but assessments had improved. However it added new areas for improvement: insufficiently robust management of contacts requiring closure of progress; and the quality and timeliness of recording on the electronic system. The 2010 grading was reduced to adequate, as was  the 2011 assessment which was still listing the closure of cases without sufficient analysis of risks, and poor use of chronologies. The last major inspection was in April 2012 by Ofsted and the CQC - not long after S’s birth. Safeguarding services and outcomes, and safeguarding provision were deemed ‘adequate’, and the contribution of health agencies to keeping children safe ‘good’. The inspection report asked for ‘‘immediate action’ to ‘ensure managers in referral and assessment services record on file clear management directions as to the level of assessment to be undertaken, the purpose of assessment, checks to be undertaken and the risk and protective factors that should be addressed’. It also asked strategy meetings and section 47 inquiries are recorded in sufficient detail to enable ‘coherent easy understanding of risks and progress’. It also referred to decision making records not being robust enough on the evidence for decisions. The CQC produced a simultaneous report 28 confirming the ‘good’ assessment of NHS safeguarding, but requiring higher adherence to mandatory training.  3.58 This Review was not designed to assess the degree to which the issues raised by Ofsted have been dealt with. Some were clearly visible in this case in 2013. The LSCCB needs to be satisfied that CSC processes around assessment, recording, and continuity of care are improved and that there are good governance processed to monitor compliance with required standards.  3.59 In the receiving authority’s CSC the case was managed by the disability team, which at the time was part of the safeguarding service with the team manager managed by the head of service for safeguarding. Asked about the preparedness of disability                                             26 All Ofsted reports can be seen at http://reports.ofsted.gov.uk/local-authorities/north-east-lincolnshire  27 No further action 28http://www.cqc.org.uk/sites/default/files/old_reports/20120810%20NHS%20North%20East%20Linco lnshire%20CQC%20Final%20Report.pdf   47  social workers for safeguarding cases, the Review was told that whilst a few years ago there were safeguarding deficits in the disabilities team, this had been addressed and they would expect social workers to be alert to and know what to do with safeguarding concerns. The social worker interviewed said his training on safeguarding was the same as for mainstream social work. The receiving authority had an Ofsted inspection of child protection in 2013 where the overall effectiveness of CP was assessed as ‘adequate’. The areas for improvement included the numbers of social workers, and the robustness of supervision and recording of supervision around decisions. On the latter issue, this was not evident in the S case, with good written managerial views and decisions. The inspection also required that children’s plans are specific and measurable, and regularly reviewed to ensure timely interventions are based on an understanding of current risk. There was also an inspection by Ofsted in November 2014 of children in need of help and protection, and of the LSCB. This was just a few months after S left the originating borough. It refers to follow up in cases being delayed by high work volumes and limited capacity, with high turnover of staff. In many cases …practice requires improvement due to delays, limited consideration of risk, and/or poor action planning and recording’. It also mentions the need to ensure children are visited at the required frequency.   3.60 In the receiving authority, after a good start the planning process drifted in the gap between social workers with no CIN Meeting or clear plan along the lines Ofsted required. The visit frequency was also missed.    3.61 To a large extent the sorts of problems described above do seem to be reflection of weaknesses known to have been in the originating authority’s CSC in most of the period covered by the Review, and should not now be a surprise looking back at those years. Any weakness in the receiving authority’s CSC was for a small proportion of a brief period responsible for the case, but again seems to relate to a known issue. In both areas, the CSC response to this SCR will need to demonstrate what has changed now.  3.62 Learning Points: The learning points have been covered in the specific section earlier in this chapter               48     4 CONCLUSION  4.1 This is a complex case in its own right, but even more so as two different areas were involved in S’s care. There are three overall questions: was the death preventable; what was the quality of service; and, what can be learned?  4.2 Determining whether the death was preventable when the cause and manner of S’s sad death is not known is not easy. The only way to be sure of prevention would have been if S was no longer in mother’s care. As until just before the death the mother was cooperating well with services in London, was creating a good impression on professionals, and had shown no current warning signs, it cannot be argued that services in the receiving area could have prevented the death. Just before leaving for the originating borough mother was enthusiastically discussing future work with the social worker, and gave no indication of impending departure. However, there is an issue as to whether the receiving area’s agencies would have done anything different if they had received better transfer information, or if S had arrived (as S should have done- see below) on a CP Plan.  4.3 The information that arrived from the originating borough was inadequate from their CSC, with no clarity about former CP concerns, or how current was the strong desire for new CP processes at the time of the move, and extracts from old assessments. Health information arrived promptly from involved professionals but was mainly the last assessment, with no overall statement of S’s care needs at the point of the move, or missed treatment.  This Review has no doubt that as the circumstances were worse in the autumn/winter of 2013 than at the time of the CP Plan there should have been CP meetings and a new CP Plan was needed.   4.4 Had the transfer information been good and proper transfer processes followed (the originating authority’s procedures require a case with a CP conference imminent to be subject to rigorous transfer arrangements)  receiving authority staff would have been more alert, more sceptical about mother’s self-report, with greater awareness of why S was on a Plan and how long without treatment.  The receiving authority’s CSC was concerned about what it didn’t know, thought hard about whether child protection was the right level, and did not rush to a view- but, by the time they decided, mother’s current good response became the accepted view. With better information there would have been even more contact, maybe more challenging, probably more thought about the drugs, and so on. However, other than what mother said after the death about her male relationship, it seems unlikely that it would have led to any action that would have removed S from the mother’s care.  4.5 If there was to have been a point at which S was provided alternative care it was in the originating authority. The child had already been on a CP Plan once, the non-treatment soon after the CP Plan was removed, quickly reached a very serious level  49  (worse than before) and there was a need stated by all involved that child protection processes should be reinstated. It was just that the originating authority’s CSC did not implement them. And other agencies did not escalate concern sufficiently highly. One cannot be sure, but its seems quite probable that had there been good ongoing assessments over S’s life, good monitoring data collated, and the drugs and treatment deficits properly studied that there would have been a CP Plan and at least a conditional threat of Care Proceedings, if not actual proceedings. Mother did of course have a hard life, but looked at just from the child’s perspective there needed to be very significant change. There needed to be a greater focus on what it was like to be S in that family  4.6 It is implicit above that the quality of work in the originating authority’s CSC was not acceptable. There were issues with the quality of assessments, insufficient collation of multiagency views, continuity, response to other agency concerns, poor or missing CIN meetings, and the failure to reinstate CP processes. Many of these points were seen more generally in various external reviews, and Appendix 2 outlines what is different now. The receiving authority’s CSC did well at the beginning with a good sceptical assessment, and quickly engaging other agencies, but the gap between the first and second social worker was too long, and a CIN meeting should have been held.   4.7 Health work was characterised, in the main, by enthusiastic child focussed work providing a wide range of care for S. in a professional way. The weakness in health was not of the quality of any individual work, but of not having processes which provided coordination or overall leadership of the health input. The health staff are keen to learn from this case and work on how this collaboration could work in practice. The joint assessment clinic in the receiving borough was good practice, but only a partial solution to the need to pull together the needs and care of such a complex child. However, it was delayed even by that authority’s normal non-urgent standards, and it is an illustration of the importance of good interagency and professional communication that the urgency of S’s need and extremely long period S had been without physio were not recognised by the receiving authority’s health, mainly due to the weak transfer information. Nothing however should have stopped the receiving authority asking for more up to date health reports from the originating authority, particularly as information they did have referred to weekly physiotherapy.  4.8 The staff groups which have worked with the Reviewer on this SCR have agreed that there is major learning from this case regardless of whether or not the death was the result of some sort of abuse or neglect, or whether or not the death was preventable. Chapter 3 has set out many ‘learning points’ for LSCB and agency consideration, and Chapter 5 will set out some overarching recommendations for the LSCBs.  The list that follows summarises the key learning. (All the learning points are collated in App 1).Some may seem very obvious, but if the points are (in one or both areas) not embedded strongly there is no harm in repetition. These points are around cases like S where there are complex health and social care needs and safeguarding implications.  50    The need for clear CSC leadership of  the multiagency process  The need for a lead health professional in complex cases  CIN and CP meetings in such complex cases need wide multiagency attendance, face to face if at all possible.  Escalation of interagency concerns must be pursued up the line internally and externally  until resolution, with the LSCB involved if dissatisfaction remains  Assessments must be current ( being clear where they lean on old findings), and supervisors must ensure that up to date and well evidence assessments are being presented  Families moving should enhance the need for current assessment, and ensuring safety, and not as a reason to leave to the next authority  After transfer, assessments must be clear what is a former view, and what is currently evidenced locally  Staff need to be more proactive in understanding and assessing the role of men  in the lives of mother and child(ren)  Staff should be aware of the risks from developing a higher threshold for concern  based on parental problems: eg drug use must not mitigate an assessment of parental capacity, or reduce the significance of an abusive event  Staff should, where drug use is a significant concern, seek evidence of subsequent abstinence and not rely just on self-report  Professional scepticism about progress and self-report is very important  Accountability in shared drugs care needs clarifying, and responsibility for collation and sharing  of test information clarified  Disability raises  the risk of abuse: LSCBs should be sure Boards and members are following national guidelines on safeguarding and disability  Complex disability, and especially with safeguarding concerns, requires comprehensive multiagency assessment.  Neglect from the child’s perspective should not be accepted because parents are ‘doing their best’ – which may not be sufficient to protect  In such cases, there needs to be a very specific effort made to consider what it must be like to be a child in the family  4.9 The most worrying aspects of case management were quite some time before this Review is published. It will be important for agencies and the LSCB/s to be confident things are different now.            51    5 RECOMMENDATIONS   5.1 The SCR recommendations are around a number of key areas which cross agencies.  They are in addition to the ‘learning points’ (collated in App 1) which will also need consideration by agencies and the LSCBs.  The recommendations are all addressed to the Safeguarding Boards for work with member agencies, and are there to assist the Boards have the necessary degree of on-going assurance about areas highlighted in this Review.  5.2 It is clear from this Review that there is more to learn from this Review in the originating borough than in the receiving one, but all the recommendations are made jointly to both Boards as the good practice sought by the recommendations applies generally. Each Board can decide the priority it gives locally to each recommendation. The recommendations are written in a way that largely allows Boards to decide how they are implemented.  5.3 RECOMMENDATIONS: The LSCBs should:   i. Seek assurance that pre-birth planning with drug using parents is appropriately undertaken, and that  the threshold for CSC involvement with children of such families as correct level ii. Consider how thorough training and supervision, the risk of drug use being seen as a mitigating rather than conformation of risk factor can be avoided iii. Review escalation procedures and their application in practice iv. Seek assurance that CIN meetings are properly recorded, appropriately attended, and held at required regularity v. Commission reports from the local CSC on how it will ensure that  assessments are up to date, and sufficiently consider the views of other agencies vi. Should comply  with national 2009 guidance on safeguarding disabled children vii. Ask the local NHS to review how the wide ranging services around complex cases are coordinated, and information about development and risks is pulled together, and…. viii. … ensure agreement between agencies on how such collated information is fed into CIN and CP processes ix. Review the compliance with local policies on transferring cases in and out to ensure that receiving agencies are very clear on current assessments and prior safeguarding concerns x. Consider how a  greater culture of healthy scepticism can be embedded, and how staff can find process of challenge to parents more comfortable for them      52    Appendix 1 Collated Learning Points  On Coordination and Leadership  In complex case like this there must be clarity on who takes responsibility for leading overall the multiagency process  Where a child is a CIN or on a CP Plan this has to be CSC  This role is crucial, and needs high priority, with other agency concerns getting clear prompt responses  However across health there should be a lead professional (sometimes called a key worker)  who maintains the overview of the child’s progress, key information , and ensured collated information is shared with the multiagency groups  CIN meetings and Core Groups must have good multiagency attendance, up to date reports, and minuted clearly with wide circulation.  Professionals must not assume without evidence that another is doing something   On Escalation  Front line staff with serious concerns about another agency musty engage their own managers in resolution, going up the line as necessary  Managers must seek appropriate responses from their counterparts, or higher as necessary  The  originating authority’s LSCB disputes policy29 must be used to ensure speed of resolution and appropriate managerial involvement  Even where the policy is not formally used, professional concerns need to be respected with prompt responses  On Assessments  While it is inevitable, and for continuity proper, that core assessments draw on previous assessments, it must be clear what is a current view and what is an historic view  There is a duty to ensure that such assessments are up to date, are evidence based and have current multiagency views  Similarly assessments done after transfer in must be clear what is a view from the previous area, and what is a locally verified view.   Supervisors must be alert to the temptation to use old assessment material rather than evidence based new information                                             29 Originating authority’s LSCB: Resolution of Professional Disagreements, in the LSCB Procedures Manual  53   Supervisors, when quality assuring assessments, should satisfy themselves that information is new, focus on what things are like ‘now’, and have taken current wider agency views into account.  On Continuity  Continuity of social work oversight is important in any CIN or CP Case,  but where the key issue is the ability of a drug using parent to provide all the care needed for a disabled child  then close supervision needs to be undertaken  Supervisors need to monitor visit frequency and challenge when this is not at least within agency policy  Supervisors need to monitor visit frequency, the regularity of CIN meetings and challenge when this is not within agency standards  If a universal services such as health visiting steps down visits because many other health professionals are involved, there needs to be clear written clarification of the plan.  A CP Plan coming off does not mean there are no issues remaining, and parents need to be given an ongoing understanding of what is required.  On Tolerance, and drug use  In assessing the risks from drug using parents it is important to be very child focussed and not see  the drug use as mitigating factor when there are child care deficits  While it might be wrong to stereotype drug using parents as automatically a problem, it is also wrong to allow that to lessen what needs to be strong vigilance for the child/children or…  …With past behaviour being the best predictor of the future, staff (with their supervisors) need to remember past examples of neglect (or any other form of abuse) when noting positive improvements, and not reduce alertness until much longer periods have passed.   The type of drug used, and  the frequency/method of taking it, must be considered when assessing parental behaviour and the risk to a child  Pre-birth and/or post discharge meetings can be a good way of ensuring a comprehensive assessment and should not be dismissed for fear of alienating the parent, or being unfair to users. The child must be the prime focus  On drug services  In shared care, accountability for safeguarding issues should be clarified  Obtaining GP views is very important, especially when providing both shared drugs care and primary care for family members  Reporting arrangements for test results , and DNAs should be clarified between drug services and CSC  54   There should be a healthy scepticism if a very long term drug user and parent  is claiming total abstinence  On Scepticism  The value of being reasonably sceptical about a case, and especially self-report should be part of professional culture in safeguarding.  Supervisors can help staff with this by modelling challenge done well in supervision  Supervisors need to be alert to the signs that staff are finding challenge hard with a particular family  Thinking what it was like to be this child  Overtly thinking through what it must be like to be a child in such circumstances is a necessary discipline  Such thinking needs to be done on a multi-professional basis so a rounded view is formed  Transferring between Areas  If multiagency meetings are needed to review the safeguarding status of children, this must not drift simply because the family may be moving…  .. indeed as the originating authority’s LSCB policy indicates it raised the responsibility of  the transferring authority  Transfer information has a huge impact on receiving professionals and must be given high priority   The originating authority’s staff need to be reminded of the LSCB policy and the very significant responsibility it gives even if the family have moved  The originating authority’s CSC especially should ensure its staff understand and implement the policy  New assessments which seem positive can be risky if not properly informed about past behaviour which is the best predictor of the future  The NHS in both areas should consider how in such complex cases there can be an overall health assessment  both to help monitor progress but also aid multiagency assessments  Men  Professionals must take active steps to assess the men in the lives of parents of children in need, or on CP Plans  Supervisors should look for this in assessments they appraise  Seeking out information about sometimes shadowy or aggressive figures is not easy work and staff need good training and support to deal with it  55   Safeguarding and Disabled Children  The LSCBs need to review their work against the 2004 guidance, which is still current and listed in Working Together 2015   When it becomes clear that disability is to be a major issue, national guidance that there must be a ‘comprehensive multiagency assessment’ should be followed.  With complex cases like this, there is no substitute for face to face multiagency meetings especially when safeguarding is an issue   Disabled children should not be left in neglectful circumstances just because, to quote the originating authority’s guidance, “the parent, carer, or services is ‘doing their best’ “.  Failure to follow ‘medically recommended regimes’ is from the child’s perspective neglect, regardless of intent or mitigating factors.  Care should be taken to be sure children classified as CIN for disability have no less rigour about their safety.   Police  Even if the incident was not especially serious, Police sharing the information with CSC when there are children present may well prove very valuable in the context of that case  If the child is known to be an open case (and especially if recently on a CP Plan, CSC should always be informed of a Police domestic abuse visit.  The originating authority’s LSCB should satisfy itself that the procedures around domestic abuse always lead to appropriate sharing of information.              56     Appendix 2   Agency Updates on Progress – as of May 2017         These updates are in the words of the agencies involved, as opposed to being findings of the SCR. They address what is better now since the time of this case. Receiving authority Children’s Social Care: Children’s Social Care has an established and embedded Pre Birth Assessment Procedure. In conjunction with Thresholds Criteria ( Making a Good Referral) all agencies are informed of what CSC considers to be an effective referral, what threshold criteria the authority uses and what the expected outcomes should be from referral to Multi Agency Safeguarding Hub (MASH). The MASH is the front door for Children’s Social Care and Early Help which support a Think Families approach and secures a more joined up response across the partnership. The local authority provided an 18 month comprehensive programme of training for social work Practitioners and managers. Called Strengthening Practice, the programme provided SWs and their managers with a comprehensive programme of a range of social work theories, risk assessment models to apply to decisions making and social work practice. These models address evidence based practice around substance misuse and other principle social care concerns. We published ‘Practice Standards for Excellence’ which outlines how we provide structures and processes, through multi-agency forums, partnership working with key agencies that provide pathways for concerns to be appropriately escalated. Across Children Social Care there are regular Performance Dashboard Meetings that review the reports and data generated Framework I, the current CSC Data system. These meetings identify deficits in performance regarding compliance with Child In Need and Assessments timescales. Individual managers are required to account for their teams’ performance. The Data reports also allow managers to monitor and take action to cover data gaps and patterns of poor performance. The local authority undertook a review of services for Disabled Children. In undertaking this review senior managers and partner agencies are guided by Safeguarding Disabled Children (DFE 2004) as part of the Think Families agenda enabling the whole partnership to understand and accept responsibility for safeguarding. Following the implementation of the SEND (special educational needs and disability) reforms and the development of Education and Health Care Plan, we have established a Disability Enablement Service co-located with the Child Development. The local authority has an established MASH. The MASH provides a system for managing and triaging referrals to CSC and ensuring that appropriate safeguarding  57  decisions are made and case is allocated to the appropriate Early Help team, CSC team, Disability Enablement Service. The MASH is best placed to address issues regarding insufficient information in referral and is guided by our thresholds criteria. In conjunction with Strengthening Practice Training Programme we have established a series of practiced forums led by the Principle Social Worker, in order to provide SWs the opportunity to address challenging practice issues and create a learning environment. North East London Foundation Trust (NELFT): The SCR highlighted a number of areas in which the service took steps to address, including managing more effectively the dissemination of communications from the assessment clinics. There is also a more robust process of tracking appointments and ensuring that staff are familiar with the NELFT Missed Appointments Policy (previously referred to as ‘Did Not Attend’). This will be updated in the summer of 2017 to reflect the current shift away from ‘Did Not Attend’ to ‘Was Not Brought.’ However, this has already been embedded in safeguarding children processes and training. The process of transfer of records is under review moving to an electronic transfer method for children subject to a child protection plan. This will ensure a timely transfer of information and records to the receiving area. NELFT have a robust paper process which will be used until the new electronic process is embedded.  The process for the receipt of records for children whom there are safeguarding concerns into NELFT was reviewed locally and where necessary strengthened. Where records are received at the Safeguarding Office the Safeguarding Nurse Advisor currently undertakes a series of checks following which the records are signed off and forwarded to the child health department. Child health administrators will then open a referral for the child on the electronic RiO system. The signed off record is forwarded to the practitioner.  In order to strengthen the process we added 2 additional steps. These additional actions have further reduced any risk of a practitioner not noting safeguarding concerns.  •   When safeguarding records are received directly to the safeguarding office, the safeguarding admin will open the referral on RiO. (The paper records will be sent to child health for them to update the immunisations and development history etc)  •   When the Safeguarding Nurse Advisor has quality assured the records she will make telephone contact with the practitioner to advise that the records are being sent and document this in RiO. The electronic health record continues to be updated in relation to capturing information on who is in the family home and the household makeup.   Males in the household and their roles in relation to children and young people continue to be a focus in safeguarding supervision. The NELFT Safeguarding  58  Children’s Supervision policy was reviewed and strengthened in May 2015. As part of this process ‘prompt questions’ were introduced as part of the supervisory process. Whilst these do not explicitly ask about males in the household, the prompt questions do give considerations to the question as to what is influencing or affecting the way the parents look after the child. The supervisee is prompted to give consideration to “complicating factors” such as drug or alcohol misuse, domestic violence or mental ill health which affect the way they (the parent/careers/partner) look after the child?  In addition the prompt questions also capture the question raised in the SCR about ‘what it is like to be the child in that environment’.   In children with complex health needs care, the Child Development Team (CDT) nurses take on the care coordination and link with different teams/agencies.  Regarding transfer in and information - at the point of referral to Specialist Children Services all referrals for children with complex needs go through a clinical triage process. If the supporting clinical information is not robust enough or information from clinical teams is missing, the Single Point of Access (SPA) administrator will request this from the referring agent or from the service/team the child was previously known to - if that information is available. The referral would then proceed to the weekly MDT panel for allocation to the appropriate pathway - their responsibility for chasing up the required information would then fall to the individual team to support clinical care delivery – it has to be recognised that this can take some time as it is not always clear who to contact.  Similarly when children transfer out of our local services, if NELFT have been informed of the transfer and provided with the address the family are moving to, teams involved in the child’s care will be alerted, they will review the clinical information and send to the receiving service.  Clinical Commissioning Group (CCG): The CCG safeguarding team have ensured that lessons are learnt and embedded within frontline practice in Barts Health Trust (BHT), North East London Foundation Trust (NELFT) and GP practices in a number of ways. The CCG designated nurse provides safeguarding supervision to the Looked after children’s Nursing Team, Named nurses across NELFT, Barts Health and the Safeguarding Lead for the Neighbourhood Midwives Project. The CCG has established a local safeguarding health economy meeting, attended by key safeguarding leads from NELFT and BHT and specialities including the Family Nurse Partnership.  Two quality assurance visits have taken place to the Health component of the Multiagency Safeguarding Hub (MASH). MASH health practitioners receive joint supervision with their counterparts in Redbridge MASH. This allows for peer review and shared learning.   59  The CCG has supported and facilitated GP visits to the local MASH. Invitations for GP colleagues to visit the local MASH have ensured that GPs are fully conversant with the MASH process and thresholds. MASH Health practitioners have also been invited to participate in GP Training and plans are in progress to simplify the current information request form. Secure generic mail boxes have been introduced to support safe and timely exchange of safeguarding information between MASH, the Child Protection Service and Primary Care. This process is underpinned by a Standard Operating Procedure and the access by GPs to Bypass numbers by MASH and the Child Protection Service has also provided a failsafe mechanism.  The comprehensive GP Training offer delivered by the Safeguarding Team within the CCG has included Lessons learnt from local serious case reviews. The CCG safeguarding Team also circulates regular safeguarding updates via the GP Newsletter.GP training has been facilitated and learning from local serious case reviews has been disseminated. There is evidence of the impact of these measures in improved engagement and a marked increase in requests for support and protection from GPs totalling 147 by the end of February 2017.  The CCG has successfully recruited a Clinical Lead GP for safeguarding children and adults thereby promoting a ‘Think Family’ approach.  Originating authority Children’s Social Care:  Due to the significantly reduced caseloads we are now able to progress the focus on the quality of our work within Common Assessment and Safeguarding Service (CASS)  and across CSC. We began a 3 year implementation of the Signs of Safety Framework (SoS) in January 2014. This approach is based on the use of Strength Based interview techniques, and draws upon techniques from Solution Focused Brief therapy (SFBT). It aims to work collaboratively and in partnership with families and children to conduct risk assessments and produce action plans for increasing safety and reducing risk and danger by focusing on strengths, resources and family networks. Many studies have identified substantial benefits that the SoS approach delivers, and these benefits from the over-arching objectives of what we aim to achieve through SoS implementation locally include:  Better outcomes for families: increased safety and permanency  Improved relationships between practitioners and families  Increased family involvement in identifying solutions to improve safety for children  Improved organisation, efficiency, and standardisation in children social care practices  Increased practitioner clarity and decision-making  Improvement in frontline staff morale  60   Improved partnership-working and collaboration between child protection and other professionals  Contribution to a longer-term reduction in the local Looked After Children population  Reduction in the duration cases are open to Children’s Social Care  Improved identification, management and support for children and young people at risk of sexual exploitation  Improved early identification, management and support for children and young people at risk from domestic violence  Quality Assurance: We also have a robust QA process in place across the services. The Quality Framework is a series of measures and arrangements to ensure that vulnerable children’s services are timely, of a high quality, appropriate to meet identified needs, give value for money and safeguard the welfare of children and young people leading to improved outcomes for vulnerable children and their families. We have a robust Audit and Observation Calendar now established in CASS. Audits are undertaken by internal managers and an external auditor. We also have recently undertaken several multi agency case file audits. The results of all audits are shared on a quarterly basis with the Deputy Chief Exec and the Director of Children’s Services, Head of Safeguarding, Head of LAC and CDS and Head of Integrated Services. Audits highlight strengths and areas for improvement and discussion is held as to how we will meet the unmet need. Within the audit meetings data is also interrogated to inform all parties of what the data is telling us and to aid discussion to shape a collective response as to how we will strengthen practice. Performance Data is used in the form of work books for the service as a whole and also work sheets which the case supervisors receive on a weekly basis in order to manage cases and develop their staff group. The workbooks will now form part of a Performance Monitoring and Accountability Framework which is a proactive tool for social workers to ensure that their work is timely. This sits alongside the Quality audits already on-going within the service. The PM and AF details for the social worker what visits, meetings, assessments etc. are due for completion so that they can proactively manage their case load.  Should any aspect of case work not be completed as required there is a clear escalation process through all tiers of management to ensure the required work is completed. Should issues not be resolved through escalation to the case supervisor, Service Manager and Head of Service the Assistant Director will meet with the social worker and their manager to discuss capability, ensuring also that the social worker has been well supported to meet the expectations of their role. CASS Panels: The CASS Service has also established a number of panels to review cases within the service; these are: CIN, Closure, CP and Looked After Children  61  panels which were introduced in January 2014. The purpose of these panels is to map cases (under the SoS framework) with the social worker and their manager to ensure that the right decisions are being made at the right time for children and their families. A representative from Early Help also attends these panels to ensure that services outside of statutory intervention are responding appropriately to meet a child and family’s needs. We will ensure that there is a team around the family at all times whether at a Universal, Targeted or Statutory Intervention level. Case Conferences: These will now also follow the SoS approach to ensure that harm and complicating factors are evidenced. CP Plans ensure that actions are appropriate and timely to ensure the safety of the child and build on strengths and safety through the family and professional networks. Multi agency attendance at Case Conference, Strategy Discussions and Core group progresses the plan for the child, verifying and evidencing that the child is safe and when it is appropriate and proportionate to either step-up or step down the plan for the child. The Families First Access Point (FFAP): The case supervisor in FFAP is the key decision-maker on all new referrals to the service. Extensive work has been undertaken to ensure that all management directions are recorded by the decision-makers including the level of assessment required, the purpose of the assessment, checks still needing to be undertaken and risks and protective factors to be addressed by the social worker in the assessment. FFAP referrals also take into consideration the full history of the family and information from involved partner agencies. In the FFAP we have a number of partner agencies with whom we work alongside our Early Help advisors and all referrals come through the FFAP to ensure the right level of support and protection is provided. The FFAP replaced the MASH in January 2017.  We are also undertaking a series of visits to partner agencies, particularly focusing on adult services, to make additional virtual links to the FFAP to ensure that referrals to CSC are timely and thorough and that there are key partners involved in the decision making of a case from referral through to closure. This is to further strengthen our already strong links with partner agencies. FFAP has further strengthened the recording of referral information at the front door using the SoS approach. This produces a firm evidence base for decision making at the front door and incorporates Early Help Assessments to ascertain what further support and/or intervention is appropriate for the child and family to inform assessment planning. Single Assessment: On 3rd September 2014 we launched the use of the Single Assessment. This gives a maximum of 45 working days for completion but with built in reviews (management decision) of progress at 10 days and 25 working days. These reviews are undertaken by a manager. This ensures that assessments are thorough but remain timely to avoid drift and delay with clear managerial direction.  62  Our electronic social care system has been upgraded to include the new Single Assessment. The upgrade is already enabling improved quality of recording in assessments and in the case files in general. Social workers have also been provided with social work guidance, using the SoS framework, to assist them to meet the expectations of quality within their recording. QA Audits throughout the last year demonstrate that case file recording is improving within the service. The local authority has launched a further pathway to ensure that children and families receive help at the right time. The Prevention and Early Help pathway encourages the assessment by multi-agency professionals of children and families where worries may be raised but there is no substantiated evidence or risk of significant harm. This will ensure that children and families will receive the right support at the right time to attempt to prevent escalation to statutory social care. This includes pre-birth. The local authority has a number of decision making points in place to aid decision making on cases by multi-agency professionals and prevent drift and delay. These include Universal plus and Early Help cluster meetings, FFAP, panels at CIN/CP/LAC and step down within CSC and RAM panel to aid decision making in terms of  progressing cases (or not) into the court arena. These points of step up and step down will also be enhanced by the creation of the FFAP (Families First Access Point) to ensure that children and families are supported appropriately at every level within the Local Authority, once again ensuring that the right support is available at the right time and providing clear routes of escalation to avoid drift and delay. The FFAP is the front door to CSC. The FFAP is recently launched and includes CSC, EH, Police Health and virtual partners.  Recording of meetings: Plans for CP cases are updated on a monthly basis by Core group members and CIN plans are updated as per the CIN meeting guidance by multi agency professionals. All plans are saved on CCM and distributed to partner agencies working with the child and family.  CSC have introduced the Performance Monitoring and Accountability Framework (PMAF). This is a proactive tool for social workers to manage their work and also confirms the clear expectations in respect of work to be carried out with a child and family and the timeliness of recording. The PMAF is a tool that will support social workers to complete the work that is expected of them through restorative meetings to assist the social worker and their manager to identify barriers and solutions to get work completed.  The PMAF also offers challenge when support has been provided but expectations remain unmet. The PMAF reviews only Quantative elements of work and it is important to note that the PMAF is supported by the Quality Assurance Framework which reviews cases thoroughly to ensure that case recording does not become a tick box exercise. CIN meetings are required to be undertaken within a Child in Need case by multi agency professionals. CIN meetings are part of the PMAF and QA reviews. Should attendance at meetings not be what is required from the Team Around the Family,  63  this would be escalated to the LSCB if an approach at any other level was not successful in improving attendance of partner agencies. Assessments: There are robust systems in place to make sure that all professionals within the Team Around the Family (TAF) are fully involved from an early stage. There is an expectation that the TAF will attend CIN meetings and Core Groups. Early Help and CSC have further engaged partner agencies in multi-agency cluster meetings, mapping sessions (SoS) and panels  in order that, even in the most complex of cases, there is full representation from professionals to identify and address all of the needs of the child and family. Supervision: Supervision is focused on ensuring the child is safe and that the plan for the child is driving the case forward. Supervision is timely and we have the addition of the Single Assessment required management oversight and CASS panels to prevent drift on cases as discussed above. We are ensuring that our first line managers have the required skills and knowledge to supervise cases effectively. We are building on their strengths through a programme of bespoke Assessment and Development that will see their leadership skills enhanced in order that they can continue to support social workers within the service and progress cases effectively. Case Transfer: The LSCB has an overarching process of the transfer of cases to another local authority, specifically Child Protection. Internal transfer procedures, owned by CASS, also detail the transfer of any case to another Local Authority and the transfer of supervisory responsibility. These processes have been in place for a number of years and were reviewed alongside all of the LSCB procedures to ensure that they are in line with Working Together 2015. Guidance for social workers is complete and embedded, there is good practice in respect of the transfer of CIN cases across Local Authority Boundaries. Team Meetings within CASS have reaffirmed to staff the importance of sharing information and all relevant information at the point of transfer. This is undertaken under the Signs of Safety Framework and all cases are “mapped” at the point of transfer. SoS safety plans and danger statements are shared alongside current CIN plans for the family. Internal transfer procedures owned by CASS also detail the transfer of any case within the service and therefore the transfer of supervisory responsibility, and the prevention of drift.  Pre-birth planning: The LSCB has a robust and recently updated policy which CSC supports. This ensures that multi agency plans are made for children prior to birth and avoids confusion and delay once the child is born. All children pre-birth are assessed where the child is already known to the local authority through their siblings or family circumstances and were concerns already exist. Those children pre-birth where new concerns are expressed and evidenced will be assessed through a Single Assessment by CSC. Joint pre-birth planning and review meetings are now held between foundations, midwifery and CSC.  64  Professional Disagreement Protocol: The LSCB Escalation Procedure has been revised and re-published. The Procedure covers both LSCB and the Safeguarding Adults Board. The need to escalate and challenge where there is disagreement was reinforced at the SCR Practice Forums in May 2015.  The professional disagreement Protocol remains within the LSCB procedures online, and can be accessed and followed by any professional wishing to raise a disagreement. The interagency protocol is designed to assist and guide all practitioners working with children and young people in the borough in finding a resolution when they have a professional disagreement/issue in relation to the safeguarding of children and young people All arms of the children’s workforce are encouraged to appropriately challenge decision making through conversation, the Professional Disagreement Protocol, panels and Service Challenge, support and solution meetings. Challenge Support and Solution meetings will be jointly facilitated by the FFAP with partner agencies invited to offer external challenge in respect of thresholds. Culture of Scepticism: The local authority is embedding a whole system approach across the Children’s Workforce to support professionals, and the community, to work together in an honest, supportive but healthy challenge environment. The Creating stronger communities model uses the approaches of SOS, Restorative Practice, Outcome Based Accountability and Family Group Conferencing to work with each other in an open and honest way to identify need, evidence concerns/ worries and work together to find solutions to prevent escalation. This is a much more engaging approach for children and families in that we are working with them rather than doing to. Approaches such as SOS also assist professionals to develop skills such as appreciate enquiry, which is a positive approach to change, which will enable professionals to be confident in probing further with enquiries and support families to respond positively to those enquiries. Resistant Parenting training is available to practitioners in supporting practitioners to be aware of associated factors and how to challenge these. Safeguarding and Disability: The LSCB has reviewed and updated local practice guidance in respect of safeguarding children with disabilities and has revised the Disability Safeguarding training against the Safeguarding Disabled children practice guidance.   Child Health Services: Since the death of Child S changes in Children’s Health Provision (CHP) and the Health Visiting Service have been implemented. These have been made to improve services and reflect some of the issues identified by the SCR. Recommendations made will be taken seriously by the organisation to strive for best practice. Record keeping is continuing to improve and training sessions have been delivered to ensure staff think and record appropriately, most significantly is the analysis of any involvement or intervention and the impact that this has on the child  65  as identified by a local record keeping audit in 2014 by CHP. Moreover, any gaps in care need to be evidenced why, within the record.  The Signs of Safety Approach, rolled out locally is now fairly embedded within our service, a tool that ensures all agencies are working similarly. Supervision is robust, supervisors have access to support from the Safeguarding Team and receive three yearly refresher training, with more intensive supervision for newly qualified staff. Supervisors are actively encouraged to professionally challenge supervisees to analyse, think critically and record effectively and this has been audited by the Safeguarding Team.  A FFAP (MASH) health post is now established allowing a swift response for gathering and sharing information, attending strategy meetings and ensuring professional discussion and challenge is a two way process. Moreover, when there are complex cases or drift, prior to the Resolution of Disagreement Policy (if with CSC) there is opportunity for Health Safeguarding to discuss with FFAP/CASS manager at a Complex Case Meeting. A process is also in place that changes the way that safeguarding records are transferred out of the area, eliminating a layer of checks that result in speedier transfer of information.   Another positive change is that families wherever possible, and especially if involved with safeguarding, keep the same health visitor (as long as they live within the authority) – this eliminates dilution of information and ‘start again’ syndrome.  Education: In respect of Education locally, a Safeguarding in Education Sub Group was established in July 2013 with representation across all education sectors in the borough. In relation to transition between internal educational establishments and other local authorities, the group has undertaken a particular piece of work pertinent to this case on developing guidance and exemplar documentation for the recording and evidencing of child protection concerns and handover at transition.  This includes child protection recording guidance and child protection file documents which include: front sheet; chronology sheet, transition document and handover record.  The documentation was reviewed in 2016 which included a clearer reference to any special educational needs and / or exclusions. These example documents have been shared with all education establishments in the borough and are available on the education section of the LSCB website.  NHS Foundation Trust (community health services):  Since the time of this SCR, we have continued to develop process in line with lessons learnt and recognised best practice. The post of substance misuse midwife no longer exists as the duty to work with substance misusing parents is part of every midwives role. A lead responsibility for ensuring that substance misuse issues are included in planning for pregnancy (including the associated risks) now sits within the role of the Named Midwife (safeguarding) and the capacity of the named midwife role has been doubled in order to embed this into their role.   66  Midwifery cases which have a substance misuse component all have a separate family file in addition to normal documentation and midwifery safeguarding supervision is now embedded within normal practice, led by the named midwives and recorded on a central system in the Trust which enables easy review and audit. Work continues to embed Early help assessments across clinical areas where there are identified needs for children / unborn and this includes areas of complex needs and substance misuse. Within Paediatrics, a process for children who do not attend has been developed which ensures that children are not discharged purely due to none attendance and escalation to the safeguarding team is made based on the lead clinicians concerns. Follow up is then made by the safeguarding liaison nurses either directly with the family or via the most suitable professional known to the family. The trust has embedded the LSCB escalation policy within its practice and this is discussed during supervision and followed with appropriate senior manager intervention as the case dictates. The safeguarding team also attend the Local authority challenge meetings which allow for direct escalation of live cases and resolution of professional conflicts.  Police: Local Police, in conjunction with our four local authorities, have agreed a Policy for the sharing of Domestic Violence Incidents with Children’s Social Care. The policy has been agreed by Senior Managers within the Police Service and each local authority area. The policy details how cases that reach a threshold for safeguarding will be shared with Children’s Social Care and also a process for identifying cases that qualify a need for Early Help intervention.   The Domestic Violence Form (F913) has been amended and now asks attending Officers to record whether a child has been seen and spoken to, including the demeanour of the child in relation to the incident.  There is also a reminder on the Form that whilst at the scene intelligence and Child Protection checks must be carried out in order to identify any existing Child Protection concerns. Work is also on-going regarding access by DV staff to CSC systems to identify those cases which are open and allocated. Domestic Abuse incidents are now shared directly to a range of agencies across the Force area this includes midwifery and health professionals either through direct routes or via Multi Agency Safeguarding Hubs.   A pilot has now commenced in locally where domestic abuse incidents are shared directly with schools and education establishments – this is known as Operation Encompass.  Work is currently underway to embed this process within the other local authority areas and a Force wide Conference was held in March which was attended by a range of professionals and agencies progress this process across the Force area.  67  The Police now have a process in place within the HUB where additional research is undertaken on incident logs where vulnerability is identified as a factor.  The outcomes of this research, which includes previous incidents and safeguarding concerns are recorded within the incident log and notified to the Officer dealing which ensures they are aware of all relevant history to inform their decision making.   All DA incidents are reviewed by a Supervisor, and they also review the relevant F913 for including the rationale and risk assessment made by the attending Officer.  High risk cases are identified quickly and relevant safeguarding is put in place and the case can be referred to MARAC if appropriate.  A standard e-mailing template has been implemented to identify those DA incidents where children are/are not in the household or living in the relationship – this ensures that those cases which need early notification to partner agencies are readily identified. Local Police have invested greatly in the delivering of DA Matters training since the commencement of this review.  This training was delivered by external trainers across the Force area and included bespoke training on coercive control. Local Police have successfully had a victimless prosecution on the new legislation around coercive control and knowledge on this area of abuse has greatly increased. We are one of 3 Forces currently undertaking a national pilot in relation to a 2 year review of the DASH.  This is being led by the College of Policing in accordance with extended research from victims, Practitioner’s and support agencies.  This pilot is due to take place until May 2017. We are introducing a new IT system – CONNECT – from June 2017. This will result in DASH Risk Assessments being automatically populated within Connect when completed at by the attending officer this will free up DA Unit staff capacity to focus more time on DASH Risk Assessment triage, secondary assessments of incidents and victim support.  GP services- from Named GP for Safeguarding: The following points are related to the recommendations made that apply to general GP services rather than the specialist GP who works with drugs services. Over the last 2-3 years, we have begun to roll out a comprehensive teaching program to GPs. We initially began by making adjustments to level III training and putting on special sessions with lunch time. This allowed more GPs time to access the training and the vast majority of GPs are now trained. We provide a series of training updates to GPs on topical issues such as child sexual exploitation. We have a session in neglect coming up shortly which will address the importance of issues such as DNAs and the impact of parental substance misuse.  As the lead GP for safeguarding it has become apparent that GPs are considering safeguarding issues more within their work, but these are usually as the result of contacts with children. The LSCB has placed an emphasis this year and getting  68  professionals to "think family". The training that is currently being delivered and will be delivered in the future will reflect this. All local practices now have a lead GP for safeguarding and these leads are identified to the staff within the practices. We hope this will lead to increased care support within the practice setting. We have also increased the emphasis on non-clinical staff and nurses also receiving regular safeguarding training updates. Coordination of cases where children have complex care needs and there are safeguarding concerns: A meeting was held on 19th January 2016 with attendance from Clinical Commissioning Trust, NHS Foundation Trust, Children’s Health Provision, Children’s Disability Service and Children’s Complex Care. The meeting considered mechanisms to coordinate cases and ensure information is shared where a child has complex needs, there are safeguarding concerns and there are a wide range of services involved.   It was recognised that in most cases where a child has a disability, it is likely that a Consultant Paediatrician is involved, and would act as the lead “health” professional. However, where there are safeguarding concerns, health services must not have separate processes for the oversight of arrangements.  Instead, where children have complex needs, and there are safeguarding concerns, there should be a multi-agency Team Around the Family, and that coordination and information sharing must be facilitated via Early Help, Child in Need, Child Protection or LAC processes. NHS Foundation Trust Foundations: In July 2014 a new provider was commissioned from Public Health for drug and alcohol treatment services, with significantly reduced the budget and altered remit which merged all the previous treatment requirements, including criminal justice and Young person’s services within one new team. This new provider was a joint partnership. The impact of the required savings was a significant reduction of experience within the team. The emerging service has needed to re-establish a governance reporting structure and be operationally delivering services whilst merging teams and structures and workloads within a significantly reduced service. Challenges have included merging clinical records- accessing single electronic record keeping, establishing a fundamentally new service model, local polices and operational procedures and new performance monitoring reporting.  The governance for the new service is agreed by a partnership board representing all 3 agencies with a proactive approach to work to the highest level arrangement, therefore the safeguarding policy and monitoring replicates the NHS Foundation Trust policy and since the SCR, serious case review training has been delivered to all staff at the service as an internal update in Oct 2015.  To provide safe clinical care with fewer resources the new service has moved to a non-medical prescribing (NMP) led service, with all the clinical staff employed by the  69  Trust, and full medical updates are sent to each GP for regular updates after each prescribing review. The new service works with strategic partners and  has established internal processes to link in with the child sexual exploitation, domestic violence and neglect priories for the LSCB with representation  at the multi-agency health board forums.  All pregnancies to have consultant oversight at Foundations and to be discussed at monthly maternity meeting, and minutes a shared with Children’s Social Care (CSC) and wider audience, for appropriate membership from the MASH for this multi-disciplinary working: The names of the children are now linked to the adults in the electronic record. We have moved from a targeted treatment model towards a single treatment model where the access process promotes safeguarding from the first point of contact. It has been agreed that the new service is to have nominated roles that can access CSC records from first point of contact. The risk assessment tool was reviewed and the Face risk assessment model has been in place for 12 months and is  fully integrated.  All Staff are adequately trained and supported to recognise the signs and symptoms of substance misuse and be able to identify and respond to risks including recognition of disguised compliance and professional over optimism, whilst including parents in this process.  Safeguarding is a priority for  eliciting information, interpreting the risks,  demonstrating critical thinking to agreed thresholds and remaining objective so  not  to become desensitised to the  risk for the family whilst building on strengths where possible. The signs of safety approach was adopted by the new service over a year ago with the support of the best practice framework for recognising and sharing relevant information in parental substance misuse to support case escalation. This is linked to the Trust’s safeguarding guidance. The named doctor role supports all aspects of safeguarding within the Trust.    The new service has a robust pregnancy pathway a good working relationship with midwifes, breastfeeding groups and are building good relationships with health visitors and school nurses. Staff all received updates on safeguarding adults and children, modern day slavery and coersive behaviour.  We are also completing more single assessments and attending far more initial meeting, early help and child protection conferences.  We have made links with the family hubs and have completed a piece of work around the children whose parents or carers are involved in services to liaise better with family hubs. The staff receive regular supervision on safeguarding and are encouraged through supervision to raise concerns.  Addaction: Addaction have been able to elicit key points of learning from this Serious Case Review locally and other reviews nationally (both those we are party to and those we are not but provide opportunities to learn). Key learning included ensuring we ask the right questions at the right time, following through on questioning situations that don’t seem quite right, and ensuring we triangulate our information by working in partnership with other agencies.   70  Following key recommendations, Addaction reviewed our local and national risk and assessment paperwork. Where identified, we ensured our questions at assessment, continuing through care planning, were targeted towards offending and thoroughly exploring wider family networks.  Addaction’s internal training for front line workers was assessed and revised. This ensured that our organisational learning would have a greater impact on our workforce nationally, while providing timely benefits to our local workforce locally. Key recommendations included for our workers to exhibit more ‘professional curiosity’. In practice, this means our workers are asking more probing questions, repeated at recovery or treatment plan reviews, to capture whether safeguarding risks have changed over time. Consequently, risk assessment has become a more dynamic, active process of enquiry, in order to steer away from one-off data collection at assessment. Professional curiosity is a theme that Addaction will continue to champion in our work nationally going forward.      In addition, our workforce follows the ethos of making every contact count, which informs the process of continual assessment and taking action where concerns are identified or raised. By doing this, Addaction as an organisation is clear in our communication and training of our workforce, ensuring a widespread understanding of the interdependencies that exist and how we relate to other professionals and agencies in the greater care pathway.  In addition, we recognise our responsibility to ensure we gather enough appropriate information to effectively assess and manage risk. Crucially, continual assessment is conducted in partnership with the wider care pathways in place locally and we are active in managing risk, so that our workers are equipped to confidently challenge, appropriately. Addaction has recently put in place a new national transfer of treatment policy to strengthen our practice when transferring individuals from our services to a new provider. Key lessons learnt are ensuring we:   Ask and receive information around risk from those agencies that refer in to our services, as well as from the service users themselves.   Triangulate risk information with partner agencies and where appropriate other sources of information such as that from family members.  Make appropriate referrals to specialist and/or statutory agencies when we identify high levels of risk and keep them updated of changing situations.   Escalate problems of low or inadequate official response through our management structure and that of the other agency concerned.   Play an active part in the overall care and management of risk with our partner agencies in respect of our service users where there is identified risk, while being clear on the reasonable limits of our involvement due to being non-specialists in child safeguarding.     71  Practical things we do:   Ensure that all staff use ‘professional curiosity’ to follow through on information they feel intuitively doesn’t ‘add up’. Where possible, triangulate this information with others involved.   Ensure that our comprehensive assessments and risk assessments are robust, thorough and regularly reviewed.   Ensure that we ask our partner agencies for full details of risk at referral and keep this information updated as we work with a person.   Ensure we have robust working relationships and care pathways in place to meet the wider needs of our service users and their families.   Ensure that when we refer people on, we give all appropriate information to aid the new agencies to manage risk. When there is significant risk present, we must also ensure that we do all we can to support an individual in the transition period until the new service is in place. This is even more important when the referral is being made to a service out of our area. We must do all we can to make sure individuals don’t ‘fall through the gaps’ in service provision due to poor handovers of care.   Ensure that work conducted around risk is clearly recorded in a timely manner.                  72   Appendix 3   Acronyms  BCG Vaccine against Tuberculosis CA Core Assessment CAF Common Assessment Framework CC Children’s Centre CCG Clinical Commissioning Group CEO Chief Executive CIN Child(ren) in Need CP Child Protection DNA Did Not Attend GP General Practitioner HV Health Visitor IA Initial Assessment IT Information Technology KW Key Worker LSCB Local Safeguarding Children Board NFA No Further Action OT Occupational Therapist PSW Principal Social Worker S The subject child of this SCR SCR Serious Case Review SW Social Worker TOP Termination of Pregnancy Y S’s older sibling     Final 8 June 2017 