Murder of a 1-year-old male child in 2021. At the time of his death, the child was in the care of the local authority and was placed with prospective adopters. The female prospective adopter was found guilty of his murder and child cruelty. Learning includes: medical assessments of potential adopters require a thorough consideration of their medical records and include information from specialists and providers of mental health support; the system would be more robust if these assessments were updated at the point of matching and before an adoption order is made; improvements are required regarding seeking, sharing, and considering any adult vulnerabilities that could be a risk to children; adoption systems and practice must ensure that there is improved consideration of the lived experience of other children in an adoptive household; when it is apparent that there are issues with prospective adopters bonding with a child placed with them, a robust and timely professional response is required that recognises the emotional impact on the child and the pressure on carers. Recommendations are embedded in the learning. Additional national recommendations include: the Child Safeguarding Practice Review Panel to ask the Department for Education to review adoption guidance considering the learning from this review. Makes a number of local recommendations.
      
 Title:  Child safeguarding practice review: Leiland-James Michael Corkill: review report. LSCB: Cumbria Safeguarding Children Partnership Author: Nicki Pettitt Date of publication: 2022  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           FINAL   1    Child Safeguarding Practice Review Leiland-James Michael Corkill REVIEW REPORT Report Author: Nicki Pettitt            Contents 1 Introduction to the case  Page 1 2 Process Page 2 3 The case being considered Page 2 4 Analysis and identification of learning Page 3 5 Conclusion and Recommendations Page 17     1  Introduction to the case  1.1 This Child Safeguarding Practice Review (CSPR) was undertaken to identify learning for the Safeguarding Partnership by considering the case of a one-year-old child who died in 2021.    1.2 At the time of his death, Leiland-James was in the care of the local authority and was placed with prospective adopters. He had been living with the couple for five months when he died. The female prospective adopter has since been found guilty of his murder and child cruelty.    1.3 Leiland-James was described by those who knew him as an alert and inquisitive child, who was beginning to explore his environment. He was showing signs of a particularly close relationship with the older birth child of the prospective adopters. His eyes would reportedly ‘light up’ when they came home from school, and they would play happily together.   1.4 Following Leiland-James’s death, actions were taken to safeguard the older birth child. They were spoken to by police officers as a potential witness and disclosed use of physical chastisement by the prospective adopters to both children. Other witnesses in the police investigation state that the children were often shouted at, and family members were aware that the prospective adopters used smacking as a punishment, although this was not shared with professionals at any time prior to Leiland-James’s death.   FINAL   2    2       Process   2.1 It was agreed that the review would be undertaken using the SILP (Significant Incident Learning Process) methodology, which engages frontline staff and their managers who were involved with the families in question, avoids hindsight bias or individual blame, identifies opportunities for improvement within systems for safeguarding children and promotes good practice. An independent lead reviewer was commissioned to undertake the review1. Due to Covid-19, engagement with professionals was predominantly via video technology, however a face-to-face event was held in September 2021.   2.2 The review has considered in detail the period from the start of the assessment of the prospective adopters until Leiland-James’s death. Detailed case information that is known and was considered will not be disclosed in this report2 unless it is relevant to the learning established during this review.   2.3 The partnership will be sharing the learning from this review with Leiland-James’s mother. The lead reviewer requested meetings with the prospective adopters to potentially identify additional learning from their point of view.  They did not respond to this request.   3    Case information   3.1 Leiland-James was the subject of care proceedings and was placed with foster carers following his birth. This was due to significant concerns about the ability of his birth parent/s to care for him. The agreed care plan for Leiland-James was adoption and he was placed with the prospective adopters when he was seven months old3.  3.2 The prospective adopters in this case had been unable to have a second birth child and applied to adopt to increase their family. They underwent an assessment and were approved as adopters in 2019. The match with Leiland-James was made just less than a year later.  3.3 There had been no known concerns about the prospective adopter’s care of their older child. They had used IVF4 to conceive and said that they did not wish to undergo treatment again, due to the financial, physical, and mental health impact. The adoptive mother had said during her assessment to adopt that she had suffered with low mood and anxiety in the past, initially linked to her infertility and then due to her reported tendency to ‘over-think’ and ‘worry.’ Her GP was involved in the assessment of the adopters and stated at the time that there was “no reason or medical conditions that may affect her ability to care for a child”.   3.4 New Covid-19 restrictions were implemented not long after Leiland-James was placed.   4 Analysis and identification of learning  4.1 The rapid review undertaken shortly after Leiland-James’s death outlined the initial learning from this case. This CSPR built on this and will identify additional learning for the systems in Cumbria. It is unusual to be undertaking a review of this type on a child placed for adoption,  1  Nicki Pettitt is an experienced safeguarding professional and lead reviewer who is entirely independent of CSCP and all agencies  2  Statutory Guidance expects full publication of CSPR reports, unless there are serious reasons why this would not be appropriate 3 Both Leiland-James and the prospective adopters are white British. There was no learning identified regarding culture 4  Fertility treatment - In vitro fertilisation FINAL   3  and the impact on the birth family and the professionals of this tragic case has been taken into consideration throughout.  Thematic analysis The adoption processes Support and emerging concerns Impact of Covid 19           The adoption processes 4.2 While it is the responsibility of the local authority to assess prospective adopters and to place children in their care for adoption, multi-agency involvement is required in the process. The assessment and approval of the prospective adopters in this case was described by those involved at the time as ‘unremarkable’. The Adoption Assessment followed the Cumbria County Council ‘Assessment and Approvals of Prospective Adopters’ Policy and Procedure. This is closely based on the Department of Education ‘Statutory Guidance on Adoption’ (July 2013). The assessment of the adopters included references, medical information, and police checks. The prospective adopters attended the required training and group sessions. The adoption panel scrutinised the case and recommended that the couple were suitable adopters. They later recommended the match with Leiland-James. Both decisions were considered and agreed by the Agency Decision Maker (ADM) who had no concerns about either the assessment or supporting information. The chair of the adoption panel and the ADM are both independent of the management of the case and attended the practitioner events and reflected that in their opinion the written adoption assessment report (PAR) and the supporting evidence was of good quality and provided what was required for a decision. The written PAR includes strengths and vulnerabilities and fulfils the purpose of providing evidence of the assessment undertaken and concludes whether the couple are suitable adopters.  Following Leiland-James’s death there was a thorough audit of the quality of the PAR in this case and learning was identified, particularly regarding areas where there could have been more challenge and exploration of what the adopters reported. This learning will be used in training and auditing activity. 4.3 The Adoption Social Workers analysis of the prospective adopters was that they presented as a “united couple” with a “strong and solid relationship.” This was confirmed by those friends and family members who provided references. Interviews with personal referees for potential adopters are undertaken in face-to-face meetings by the assessing social worker, and written references are also requested and provided. They are specifically asked about any safeguarding concerns.  The references included questions about the parent’s relationship with their birth child and specifically asked if they are aware if the prospective adopters use smacking, physical chastisement, or inappropriate discipline. All were positive about the prospective adopters and shared nothing of concern.  It was seen as a benefit that the couple had close family and friends living near-by who categorically stated that they would support a placement.   4.4 The CoramBAAF form AH adult health report is an important part of the adoption process. It is requested by the adoption team and is completed at Part A by the prospective adopters and their GP then undertakes a physical medical and completes Part B. The assessment is then returned to the adoption team and is considered by them and by the adoption panel medical advisor. It is then the role of the advisor to give an opinion based on what has been shared by the prospective adopter/s and the GP.  There were gaps in the health information shared with FINAL   4  Children’s Services by the prospective adopters during the assessment and again when Leiland-James was placed.  This has been found to be a significant learning point in this case. 4.5 At the time of the assessment some issues had emerged in relation to how much alcohol the couple consumed. The ‘Summary Report from the Medical Advisor’ commented that their drinking was above the healthy recommended limit and that this should be explored further by their social worker. The female adopter had stated on her form that she drank two bottles of wine a week and the male adopter had stated that he drank around 10 cans of cider a week, both wrote ‘on and off’ on the handwritten forms. The assessing social worker undertook a further exploration of the couple’s drinking and evidence of the challenge and additional assessment was then included in the PAR. This was acceptable to the adoption panel who approved the adopters and later the match. The social worker concluded that the couple had a ‘healthy and informed approach to alcohol’.  However, information which the prospective adopter had shared with First Step5 at the time shows that she was drinking significantly more than this. This was not known by any other agency at the time. (See 4.11 below)  4.6 The female prospective adopter had disclosed a physical health issue6 and said that this was managed with medication. This was confirmed by her GP during the assessment. As the condition can be painful, this was discussed with the prospective adopter by their assessing social worker as living with pain is a vulnerability that professionals working with Leiland-James and with his prospective adopters needed to be aware of and consider. It is now known that the female prospective adopter had historically suffered with juvenile arthritis, which was not shared on the health form and not identified later as the GP recorded “nil” in the musculoskeletal system section of the AH form, so this was unknown by the assessing social worker or the adoption panel medical advisor. The review has found that in this case the GP did not appear to have thoroughly considered the medical records to ensure that they provided independent verification of what the patient reported about their medical history. This was due to not all the information having been received and recorded and the limited time available for the GP to thoroughly complete the medical assessment, leading to a potential risk in the system that important information will be missed7. The review also found that there is a common feeling among GPs (and most professionals) that prospective adopters are likely to be open and honest about their past and current medical issues, and that when there is an older child in the family and no known concerns, this potentially also gives false reassurance.  4.7 The view of the family GP is significant in the adoption assessment, as they are specifically asked on the CoramBAAF form to comment on health and lifestyle issues which may impact on the applicant’s ability to care for a child.  In this case the GP had written on the female prospective adopters AH form that there were ‘no reasons or medical conditions that may affect her ability to care for a child.’ This is a clear statement, but the medical advisor could and should challenge this if they believe it is required. The medical advisor to the Cumbria adoption panel has since devised a questionnaire that is being completed by all potential adopters. It asks much more detailed questions about their medical history and medication. While this is helpful to the assessment process and decision making, it must be acknowledged that this relies on the prospective adopters self-recording, and there is still a need for rigorous professional curiosity  5 First Step was part of Cumbria Partnership Foundation Trust, providing free talking therapies to adults, at the time the service was accessed by the adopter  6 Swollen intercostal muscle in her rib cage 7 While the medical assessment in this case was undertaken prior to the 2020 COVID 19 pandemic, it is noted that there have been more recent concerns highlighted in 2021 about the challenges GPs are facing in completing medicals for prospective foster carer and adopters. The RCGP and BMA issued a joint statement to the DforE supporting GPs regarding the pressure they are experiencing in this area.  FINAL   5  about the information shared from the assessing adoption social worker, the GP and the medical advisor.   4.8 There is also a need to consider how the medical assessment is updated if there is a delay in a child being matched with the adopters. There needs to be a system in place to ensure that any new medical issues that emerge can be considered at the point that a match is made and then during the placement prior to an adoption order being made. In this case this was a significant issue, as the female adopter was diagnosed with rheumatoid arthritis in September 2020, weeks after Leiland-James’s placement with them. Those working with Leiland-James or with her in respect of the adoption were not aware that she had been unwell or of the diagnosis. It was not disclosed by the family and the GP did not share any information with CSC.  There was no indication at any visit that the female carer was unwell or in pain. The current national system does not have in place an expectation that updated medical reports are provided at the time of matching, during the child’s placement or prior to an adoption order being made. This gap is an issue that requires changes to national guidance, so a recommendation has been made. This new information was particularly significant as a concern had been raised by the consultant in his letter to the GP regarding the prospective adopter’s alcohol consumption, as outlined below at 4.14.  4.9 The GP told the review that they were not formally informed that a child had been placed with the family, and that they only knew because the family registered Leiland-James at the surgery. No ‘flag’ was added to the patient records for either the child or the adults. Strengthening Families dispute this. They told the review that they informed the GP surgery that Leiland-James was a child in care placed for adoption and provided information including the contact details for the allocated social worker. CSC also had a record of this notification to the GP which was placed on to Leiland-James’s electronic case file. Single agency learning for primary care has been identified about the need for significant information to be formally flagged on patient GP records.   4.10 It is now known that the female prospective adopter was struggling with her mental health around the start of the adoption assessment. An Initial Visit Form was completed by the assessing adoption social worker at their first visit to the couple in January 2019. The screening questions include “have you ever needed support, advice or medication for depression, anxiety or stress and other mental health problems.” Nothing was disclosed by the applicants during the first meeting. When the medical form was completed, it emerged that the female prospective adopter had spoken to her GP about anxiety and low mood in 2011 and 2018. It was reportedly linked to her infertility both before and after she had her child. The matter of not disclosing this information was later addressed with the prospective adopter who stated that she felt that the question at the initial visit only related to whether she was experiencing current mental health difficulties, so she had answered in the negative. The adoption social worker and her supervisor told the review that it is not uncommon for applicants to fail to disclose all information at the ‘Initial Visit’ and that if there were no subsequent attempts to “cover up” this information or to avoid talking about it, they were not concerned. This was therefore not viewed as a lack of potential openness and honesty. The prospective adopter presented her mental health issues as historic, and no indication was given that they were as recent as it is now known they were. 4.11 The criminal investigation into Leiland-James’s death identified that the female prospective adopter was receiving ‘talking therapy’ support from First Step at the time of the adoption assessment. This information was not known to the assessing social worker and was not shared by the GP in the adoption medical report other than a sentence that she had ‘reported anxiety FINAL   6  and depression and received counselling in 2011 and 2018’ and which had ‘settled on its own’. First Step informed the GP of their involvement in the early months of 2019 but did not include any details regarding what was discussed with the female adopter. During the review, First Step confirmed that they had worked with the female adopter from December 2018 – April 2019. The couple’s application to be assessed as adopters was made in January 2019, so this on-going work was relevant to the assessment. The adoption team did not request permission to make checks with First Step as they had been under the impression from the adopters and from the GP information that the involvement was historic and related to the female prospective adopter’s feelings about the couple’s infertility. This was not in fact the case. The information held by First Step shows that the prospective adopter had issues with her low mood, anxiety, and anger management. This included her self-report that she was often irritable and short tempered, including shouting too much at her young child.  She spoke about feeling judged by other parents and that she avoided company. She also reported drinking six bottles of wine a week which impacted on her motivation and mood, although she denied it had an impact on her parenting.  4.12 The initial assessment by First Step was completed and it was agreed that ‘talking therapy’ was required. The assessment was a telephone appointment, and the treatment appointments were face to face, following their guided self-help model. At the prospective adopter’s request, the focus of the work was on her anxiety and mood. No consideration was given to the impact on a young child of her reported issues and no safeguarding or clinical supervision was sought by the assessing mental health worker and the information shared by the mother was not considered through a safeguarding lens. First Step were not aware that the couple had applied to adopt a child and that an assessment was being completed. They did share with the GP that they were working with her, although no detail of what was discussed with the prospective adopter was included.  In April 2019, the work with First Steps stopped at the client’s request and again the GP was informed.  This correspondence was not reflected in the GP information shared during the adoption medical assessment and was not shared with or sought by CSC.   4.13 The male prospective adopter was spoken to about his wife’s mental health by the assessing adoption social worker, and it was stated that he presented as a supportive and understanding partner, who was clear that he balanced his wife’s reported tendency to ‘worry’ and ‘over-think’ things. The fact that the female adopter reported that her GP was supportive was seen as a positive support and safety factor, as was her reported good experience of CBT in the past. Once the placement was underway her social worker continued to speak to the female adopter about how she was feeling. There was no indication that any of the symptoms reported to First Step early in 2019 were an issue, but as those involved were not aware they were not specifically discussed. It is not current practice for an adoption assessment to contact an agency that has provided counselling for information. A recommendation has therefore been made.    4.14 As stated above at 4.8, following Leiland-James’s placement the female prospective adopter had further health concerns. She was diagnosed with rheumatoid arthritis and during the process of diagnosis was referred to a consultant gastroenterologist by the GP and seen in September 2020, around a month after Leiland-James was placed, for a separate health condition. During the consultation a concern was raised with her about her alcohol intake by the consultant gastroenterologist, which at that stage was reportedly 27 units a week8 and was thought to be having an impact on her health condition. This information was shared with the GP in a letter but neither the health issue or the alcohol use was shared with any other agency,   8 UK Chief Medical Officer’s advice is to consume no more than 14 units/week.   FINAL   7  so it was not considered in respect of the potential impact on Leiland-James or the older child. The prospective adopters did not disclose this new health issue to their own social worker or Leiland-James’s.  4.15 The assessment of prospective adopters also includes a financial assessment. They are asked to complete a finance form and to provide bank statements and other financial documents to corroborate their information. The review has had access to the handwritten form that was completed in this case and was then considered during the assessment. The review was informed that it was found out after Leiland-James’s death that the family had significant loans and credit card debt without having the income to service this debt. It was apparent that the design of the form did not clearly ask for the total money owed, rather it asked for how much money was being spent each month on loans and credit cards.  This does not give the full picture and enabled the family to disguise what they owed and that they were only paying the minimum amount each month, leading to the debt increasing. Changes were made to the form in 2019, but after this couple’s assessment. Adoption managers have since undertaken a piece of work to reconsider all the other financial assessments undertaken at the time.  There is also a plan to review financial assessments at the time of a match being considered to ensure that information is up to date.  4.16 A Placement Order had been agreed by the court in July 2020, Leiland-James was effectively free to be placed for adoption. Several meetings were held to consider the potential match with these adopters in the month that followed, and the required reports were written. The adoption panel that considered the match was held in August 2020 as an additional panel. This was a pragmatic and timely response to ensure that the proposed plan of introductions could start, and Leiland-James could be with the family prior to his new sibling starting school. The panel’s recommendation for the match was agreed by the ADM and an adoption support plan was drawn up by staff from CSC responsible for Leiland-James and the prospective adopters.   4.17 There had been a gap of nearly a year between the prospective adopters being approved and them being matched with Leiland-James and him moving to their care. This is not unusual. During this time the adopters attended courses and a support group where they met other prospective adopters, some of whom they then had informal contact with outside of the group.   They also had contact with their adoption social worker monthly and received a regular adoption newsletter with relevant updates. Along with all prospective adopters in Cumbria they were offered membership to a site for therapeutic support.9  The couple shared with their support worker that the waiting was hard. Those with extensive experience of working in adoption spoke during the review of the need to manage approved adopter’s expectations about the potential for a long wait for a placement if they want a baby, and this family was no exception. The first national lockdown response to Covid-19 was implemented around six months after their approval and much of the support available was moved to virtual platforms.  It is noted that all approved adopters have an annual review if they are approved but waiting for a placement. This is an opportunity to consider any changes and to renew checks. The timing of the placement meant that these prospective adopters were not subject to an annual review as the placement was made 11 months after their initial approval.   4.18 After the potential match was identified, the prospective adopters were given information about Leiland-James and his wider family history. This included consideration of the issues they may face in the future. They had a consultation with the community paediatrician who is the medical advisor to the adoption panel when the match was being considered. This is an   9 The membership of the National Association of Therapeutic Parenting was a specific service funded by ASF Covid money to give additional support during Covid.  FINAL   8  important meeting for all adopters, as they are provided with medical information about the child and their parents/siblings and is an opportunity to know what may lie ahead. In this case the adopters appeared to understand what health needs Leiland-James may have and they were reportedly not overly concerned.  A ‘Chemistry Meeting’ between Leiland-James and the prospective adopters was held in July 2020 at the foster carer’s home, which was reportedly positive.   4.19 The plan made for the introductions included a combination of time spent at the foster care placement, outside of the placement, at the adopter’s home and with the older birth child as appropriate. Sessions were observed by the social worker for the child. All plans had to be Covid-19 aware even though during August 2020 there were fewer restrictions than previously or than were to come, and the plan was subject to a Covid-19 risk assessment. The male prospective adopter had time off from work on adoption leave when Leiland-James moved into his new home. He had recently returned to work after a period of furlough and worked on permanent nights. The prospective adopters later reflected that they wished that the introductions had included more time spent at their home to ease the transition for Leiland-James, although at the time they were incredibly positive and voicing their wish for him to move to their home as soon as possible.  4.20  The adoption service in Cumbria had previously learned from other cases that gradual and focused transitions tend to result in more successful adoptions. This was found when work was undertaken to consider learning from adoption breakdowns around four years ago.  In Leiland-James’s case there were valid reasons for the matching decision to be made at an additional panel meeting and for the introductions to be completed slightly more quickly than the adoption service would ideally like. Despite the norm in Cumbria being a longer period of introductions, the eight days of introductions in this case is around the national average.  4.21 A planning meeting is always held as soon as possible after a match has been agreed to plan the introductions. Usually, it includes both the existing foster carers and the prospective adopters, the social workers for both sets of carers and the social worker for the child. This case has shown that there is a case to be made for it also including the health visitor for the new placement, to ensure information sharing and to include the support that could be required from the health visitor - who is likely to be a Strengthening Families (SF) worker as was the case with Leiland-James. The newly allocated SF worker for Leiland-James visited him in his prospective adoptive placement within three weeks of him being placed, having telephoned the week before. They told the review that ideally they would have visited sooner, but that they don’t tend to be told until the day of the placement. Learning has been identified about the requirement for the health visitor / SF worker and the child’s GP being informed of the proposed placement as soon as a match is agreed. (Ten days earlier in this case.) Wishing to improve practice in this area, SF are considering the feasibility of undertaking the adoption equivalent of ante-natal visits to prospective adopter’s pre-placement, to consider what advice and support is required. For example, with the potential issues of Leiland-James having a milk intolerance and possible developmental delay. There have been recent changes in the local authority adoption service to ensure improved information sharing with SF, which includes them being invited to matching meetings10.  4.22 Less than 20% of children in Cumbria who are placed for adoption are placed in a family with a birth child. A larger number of families have already adopted a child previously (over a third)   10 It is acknowledged that it is more complex when a child is placed outside of Cumbria, but as the child remains ‘looked after’ until the adoption order is made, corporate responsibility for the child should ensure that there is good information sharing and an expectation of multi-agency support across areas, as part of the care plan.  FINAL   9  so considering the impact on another child is common when planning for introductions and placement. During Leiland-James’s matching process, there had been careful consideration given to the impact on the birth child and awareness that they would be starting school around the time of the placement. This was taken into consideration for the introductions and the plan for when Leiland-James should move in. At the time of the adoption assessment, the adoption social worker had spent time with the birth child as part of this assessment and they had been able to talk about what they liked doing, showing the social worker their bedroom and toys. This was felt to be age appropriate at the time. By the time the match was proposed they were around 18 months older. While there is no expectation in guidance that they would be formally engaged with to explore their view of the family and lived experience at this stage of the process, this would have been good practice. The review believes that there is a benefit of undertaking this as a specific piece of work in all cases after a child has been placed. Where to record this information about a birth child needs consideration. A recommendation has been made. Following Leiland-James’s death, the sibling was able to give a very clear account to police officers and social workers about what was happening at home.  Learning  If a prospective adopter has had contact with a service providing mental health support or counselling, consideration should always be given to requesting consent to contact the agency during the assessment to request information.   Those providing therapeutic interventions to the parents of children should consider the impact on a child of what is reported, and clear information should be shared with the GP about reported alcohol consumption.    It is important that the prospective adopter health assessments undertaken by GPs, are allocated sufficient time to consider and record historic and current health information.   Any known potential vulnerabilities, including the physical and mental health of prospective adopters, should be formally reconsidered at the point of matching and at the child looked after review following placement, to confirm if there have been any changes.   The new health visitor / SF worker who will be involved following a move to adopters and the prospective adopter’s GP should be immediately notified about a planned placement. The new health visitor / SF worker should be invited to the meeting planning introductions and the move. The health visitor / SF worker and the GP should consider what pre-placement support they can provide and share any concerns or issues that they are aware of.   It is important that all professionals across agencies understand the importance of their consideration and involvement in the cases of children who are in adoption placements. They remain children looked after until the adoption order is made and require a focus from all professionals at this time of transition.   Information must be sought and considered in assessments to ensure a full understanding of a prospective adopter’s financial situation, which includes a clear and achievable plan for how any debt is to be managed.  When prospective adopters have another child, that child should be engaged with in an age-appropriate way to understand their day to day lived experience, at each stage of the process.     FINAL   10  Support and emerging concerns 4.23 After Leiland-James went to live in his new home, small but potentially significant concerns began to emerge. The older child had a pre-arranged operation which was not disclosed to the local authority. The family also appeared to be calling Leiland-James by his middle name despite them agreeing they would not do so. Then, against clear advice and unbeknown to the social workers, it was shared that Leiland-James was spending significant amounts of time, including overnight stays, alone with his soon to be adoptive grandparents and aunt and uncle. The experienced staff involved acknowledged that Leiland-James’s placement was vulnerable to breakdown, and that there was likely to be an impact on his attachment to his new parents. Local levels of pre-adoption disruptions are low, with just one disruption in the four years prior to Leiland-James’s death. However, those involved with Leiland-James recognised the signs and were concerned that the information emerging was an indication that the placement was at risk of breaking down, and they planned to increase support to the family.  4.24 The head teacher at the older child’s school had been told by the local authority that the family were hoping to adopt and had provided a reference both in writing and verbally as part of the assessment. The school was not updated at the time that the match was made, as this is not usual practice. The family informed their social worker that they had informed the school themselves, as is expected. This was not the case. The school may have been well placed to support the birth child at the time of the placement. They told the review that, with hindsight, they believe the placement possibly had an impact on the adoptive sibling’s behaviour at school, as they presented as ‘emotional and very needy’ at this time.  4.25 The older child’s planned operation in November 2020 involved the family having to isolate at home for a week and the older child missing school for two weeks. Afterwards the older child reportedly needed extra care and attention from the parents and was particularly clingy to their mother, struggling with Leiland-James getting attention.  This was at the time that Leiland-James was reportedly to be particularly in need of developing a close relationship with his adopters and this dynamic would have added to the family stress.  The prospective adopters had not informed either their own social worker or Leiland-James’s social worker, so there was no opportunity to consider the impact on Leiland-James of this period of isolation and the birth child’s likely reaction to the operation. 4.26 There was a degree of anxiety shared by the adopters at the time of matching about the name given to Leiland-James when he was born, which was distinctive and spelt unusually. The prospective adopters asked if they could just use James instead. This was not agreed, as it is good practice to ensure a child retains their birth name to assist them in the transition as it is the name they are accustomed to, and later when there is a need to understand their identity.  It was agreed that it was in Leiland-James’s best interests to change the spelling to make him less identifiable as he grew up. A lot of work was undertaken with the adopters about the need for him to retain his birth name, including being clear that if they didn’t like or accept the name they shouldn’t progress with the match.  The social worker for Leiland-James and the adopter’s social worker later found out that he was being referred to by James by the older child and other family members. This was denied by the adopters, but there was a suspicion that it was their intention to call him James going forward, despite advice to the contrary. The school was able to confirm during the review that Leiland-James was known to them as James, including on a pre-school application. This shows a degree of ‘disguised compliance’ by the adopters, where they agreed with what the professionals said in meetings but did not comply with this advice. While this may have been one of the only areas where this was the case, it shows that the adopters did not entirely understand Leiland-James’s (or any adopted child’s) needs and FINAL   11  leads the review to question both the meaning of the child11 to them and their commitment to working with professionals.    4.27 Despite advice to the contrary, it emerged in December 2020 that Leiland-James had been cared for by extended family members, including overnight stays, on around four occasions. The first six months of an adoption placement are crucial to the child attaching to their new parents and there is an expectation that this time is invested in the child by their immediate carers. While wider family members are crucial in supporting the placement, the early months need to focus on the child being part of the nuclear family. When discussing concerns about how the placement was going, the prospective adopters shared that they had been feeling let down by some family members who were not supporting them as much as promised. This perceived lack of support may have been due to Covid 19 and the hard to decipher Government advice about what mixing was allowed. There may also have been a view from the wider family that initially Leiland-James needed to be with his new parents.  4.28 Network Meetings were held during the assessment and when the match was confirmed. They were well attended by extended family and friends, who were reportedly very willing to help support the family with Leiland-James. There is no requirement to have these meetings, but in Cumbria they have become part of the process and are best practice. There is no process of review of these meetings following the placement however to ensure that the support offered is happening, and to enable family members and friends to share any concerns.  Family members are expected to contact the allocated worker if they are worried, and the adoption service is now specifically outlining at the network meetings that the network have a responsibility to make this contact. Although the meetings held are called Network Meetings – a term used in the Signs of Safety methodology, they are not used in their pure sense where the network have some accountability to make sure that the plan is working. When used in adoption, they are a meeting where information is shared with the wider family and friend’s network and where the support available is clarified and agreed.  4.29 When Leiland-James was placed in August 2020, there had been some issues with feeding and reflux. He had been on a ‘milk-ladder’12 at the foster carers and this was transferred with him when he was placed for adoption. Leiland-James was slightly overweight and had not progressed with his expected mobility. This was thought to be in large part due to him being carried a lot in the previous foster care placement. (It was acknowledged that there were two carers and several much older children in the placement and that they tended to hold Leiland-James a lot, particularly when they were all at home during the Covid-19 lockdown.) As well as having an impact on his mobility, this meant he was not always easy to settle by the prospective adopters who were unable to hold him as much as he had become used to. 4.30 As the months progressed, while there was communication between professionals and with the prospective adopters, direct social work home visits to Leiland-James were largely limited to statutory visiting frequency13. The social worker for the adopters and the social worker for Leiland-James spoke to each other regularly and there is evidence that the case was discussed in supervision. Leiland-James was only seen once in placement by his allocated social worker, once by another member of the child’s social work team, and on three occasions by the social worker for the prospective adopters. Considering the concerns about the possibility of placement breakdown, learning has been identified about the need to have more direct   11 The meaning of the child in the case of adoption is influenced by the adoptive parent’s expectations of adoption and their motivations to adopt. This is not always determined by the child’s needs but by the expectations of that child.  12  A plan for increasing a child’s exposure to cow’s milk gradually, to build up their tolerance. 13 Statutory regulations state that a child looked after must be visited within one week of the start of any placement, then at intervals of no more than six weeks during the first year of the placement FINAL   12  contact with a child in a vulnerable placement than the minimum expected, and a recommendation has been made.   4.31 At the approval stage there had been some questions regarding the in-depth understanding of adoption from the prospective adopters. There was no doubt at the time of their wish to be committed adopters and to love and care for an adopted child, but they appeared to have a limited understanding of what adoption really means for a child. This limited insight was identified at the adoption panel that they attended when they were approved. While they had clearly been provided with a lot of detailed information, they came across to the panel as “slightly limited in their understanding of adoption”. Following Leiland-James’s placement and a lot of detailed information being shared about him and his needs, this limited knowledge and understanding of adoption may have exacerbated the situation. Those who work in adoption told the review that not all adopters have a lot of understanding of therapeutic parenting and need support. Many adopters are ordinary people who must learn and build skills over time. In this case the adoption assessment led those involved to believe that the couple had both the time and the commitment to develop as positive carers of an adopted child. It is now clear that the professionals were lied to during the assessment and after Leiland-James was placed, and that the processes and practice did not lead to the disclosure of concerning information that was available.   4.32 From the start of the placement until he died, Leiland-James remained a child in the care of the local authority. This means he still had statutory reviews and statutory visits. Two review meetings14 were held on-line during the time he was with the prospective adopters. The focus of a CLA (Child Looked After) review is on the child’s health, emotional and behavioural development, family and social relationships and identity. Consideration will also be given to contact arrangements with birth family, and potentially with the foster carers he initially lived with. In Leiland-James’s case there was no health representation at the CLA reviews held when he was placed with the prospective adopters. This was an area where the attendance of the SF worker would have been helpful to provide reassurance and support with issues such as his feeding, development and crying. There is no evidence that the SF worker was formally invited or asked to attend the review. The IRO service confirmed that they previously invited SF until a child is placed for adoption and will ensure they do so again.  4.33 There is a need to always consider the child’s lived experience and ensure that their voice is heard above that of their carers, both in reviews and when visiting. This is essential even when the carers are prospective adopters. It is acknowledged that prospective adopters also require the support of professionals and there is a need for them to develop an effective and respectful relationship with professionals. In this case, Leiland-James’s voice was heard, particularly regarding whether the placement was the right one for him. He did not seem to be settling as would be hoped and there was evidence that the adopters were struggling to bond with him and love him as they stated that they wished to do. However, there was also evidence of him as a sociable little boy who was babbling, smiling, clapping and laughing. He made good eye contact with both adopters and appeared to have a positive and developing relationship with the older child. This was pointed out to the adopters along with other encouraging signs that had been noted by those involved. At the time the professional focus included the relational aspects of care as the worries were about whether the placement could meet Leiland-James’s emotional needs and whether the carers, with support from the therapeutic worker, could   14 An Initial CLA Review meeting will take place within 28 days of a new placement, then within a further period of 91 days, and most future reviews will take place within a further period of 183 days if an adoption order is not yet made FINAL   13  connect with him enough to give him a safe, positive and loving home for the rest of his childhood.  4.34 A social worker from the children’s team visited the placement on 4 November 2020 as a statutory visit to a child looked after and met with Leiland-James and the female prospective adopter. The social worker, who had not met the family before, said that the prospective adopter had shared that she was struggling and was worried that she did not love Leiland-James as she had expected to. Her mood was described as ‘flat’. The social worker told the review that she had no concerns for Leiland-James’s care on the day but did recognise that support was going to be required. The social worker ensured that the prospective adopter had emotional support from her network over the next few days and suggested she speak to both social workers involved. She was reassured that the carer remained child focused despite her concerns. She came across as open, honest and straightforward. Leiland-James was reported to be showing signs of good attachment at this early stage in the placement and was noted to be appropriately snuggling into his prospective mother’s embrace. The social worker who visited shared information from the visit soon afterwards with the social workers with responsibility for Leiland-James and the adopters. There is no evidence that the male prospective adopter was alerted to the concerns or spoken to by CSC. The agency report also found that this visit was not recorded at the time but after Leiland-James’s death, and action has been taken about this.  4.35 The review considered the impact on the case of this visit, which was undertaken by a social worker who was not the child’s allocated social worker and who did not have an existing relationship with the child or the carers. If a social worker is unable to undertake a statutory visit, another worker from the team may do this on their behalf. This can be positive as it can provide a fresh pair of eyes, but it can also mean that continuity of relationship and the ability to compare with previous contacts is lost. In this case this was the first visit to Leiland-James and the carers by the child’s social work team since the first week after placement. The Local Authority has undertaken further work to establish how common this is in the case of children placed for adoption and has assured the review that it is not regular practice for visits to be undertaken by a social worker who is not allocated to the child.  4.36 The social worker who visited reflected, with hindsight, that ‘post adoption depression’ (PAD) may have been an issue. Post Adoption Depression Syndrome was first written about by June Bond in 1995. It describes the stress, anxiety, and depression that many parents experience following adopting a child.  Estimates suggest that up to 65% of adopters experience it at some point after having a child placed with them.  It describes a mental health impact which may be from ‘the stress inherent in parenting, attachment/bonding challenges and when the needs of the child are more significant than expected’.   It can also be due to unresolved grief and loss due to any infertility issues that resulted in the application to become adopters. All adoptive parents and professionals need to know and understand that low mood following a child being placed is normal and to be expected, and that support is available and will help. In Leiland-James’s case this may have been an issue that would have impacted on his lived experience. The female prospective adopter’s known and admitted history of low mood and anxiety may have made her more susceptible to PAD. The adoption social workers in Cumbria are experienced in guiding adopters through the possible responses to what can be the overwhelming experience of caring for an adopted child. The review has found that there are benefits if this support is multi-agency however and that it is essential to ensure that the second carer in the family is made aware of any concerns. It is acknowledged that the extent of the carer’s mental health issues and her negative feelings about her own child, told to First Steps in 2018, were not known or shared at the time.  FINAL   14  4.37 Those involved reflected, that concerns about bonding do emerge as an issue in an adoption placement, and that resources are available to work on this. In this case, when their social worker spoke to them on the telephone after the November visit described above, the female carer was more positive and accepted the work proposed.  The social workers formulated a plan to provide support from the therapeutic service which they hoped would address the concerns about an absence of bonding / attachment. An initial appointment was arranged and held on 16 December 2020, around 6 weeks after the duty social workers visit.  This meeting was held at the time of the statutory visit15 to Leiland-James undertaken by the adoption social worker, and this was the first time that Leiland-James had been seen in person by CSC since the previous statutory visit early in November by a social worker from the child’s team. A plan was made for more work to be undertaken in the New Year. This perceived delay was due to the expectation that this is a longer-term piece of work rather than an emergency response. It was not due to capacity issues or limited resources within the therapeutic service. The review identifies learning for the service regarding the lack of a timelier response.  4.38 The workers involved were experienced adoption professionals and they planned a conversation with the carers about potential adoption breakdown. Not all adoptions go smoothly and the social workers who work in the adoption teams understand this. They are used to having difficult conversations with prospective adopters, and in this case they did ask, in the meeting held in December, whether the adopters wished for Leiland-James to be removed from their care. The adopters were clear they did not want this. Having an emotional connection with the child is important in an adoption, and it can take time and support for this to develop. When this is absent, as at times it appeared to be with Leiland-James and his prospective adopters, professionals are always concerned that the placement will fail.  However, it was noted that the family were looking forward to Christmas and Leiland-James’s first birthday. It was the plan to work intensively with the family to see if the therapeutic service could have a positive impact and improve the outcome of the placement. Those involved reflected that a prospective adopter admitting they are struggling and need help is seen as a positive. The review was told that planned work rather than an immediate response is what is generally required in cases where bonding is an issue.     4.39 There were concerns about how the adopters were managing with caring for Leiland-James, although not to the degree that it was of concern for his short or medium-term wellbeing. Due to teething at the time of the move, Leiland-James was crying a lot and his social worker stated that he had a particularly high-pitched cry. He liked to be held and screamed if the carers left the room. It was reported that he had settled to a degree by mid-November, but the early issues likely had an impact on the placement. It is noted that the male prospective adopter worked night shifts and slept during the day. Over the winter this must have been difficult for the children and for the family to manage. COVID restrictions would have limited the opportunities to leave the house and have a positive social life.  4.40 The SF worker was aware of some tensions in the family. The female prospective adopter stated that she found it hard to be so scrutinised by professionals and described her relationship with Leiland-James as ‘like baby-sitting’ rather than parenting. This was not shared with CSC at the time. The prospective adopters appeared to be open and honest with strengthening families and with CSC about the difficulties they were having and in voicing their concerns regarding the impact on their birth child. This was seen as positive and a sign that they would accept support and therapeutic intervention. However, there was also a degree of child blaming in  15 CSC have undertaken a piece of work to see whether the practice in this case, where the adoption social worker undertook a statutory visit to a child in care, to understand whether this was a wider issue that requires consideration. They have concluded that it is not a wider issue and is not general practice.  FINAL   15  their language, with Leiland-James being described as ‘clingy’ and ‘resistant to affection.’ Those involved were concerned about this and recognised the need for intervention from the therapeutic social worker, who was to work on promoting attachment and therapeutic parenting.  4.41 In November 2020, the female prospective adopter spoke to her GP about her arthritis as she was struggling with some basic tasks such as opening jars due to pain in her hands and feet. There is no indication that there was a discussion about how this could impact on her ability to care for the baby, or that the information was shared with other professionals by the adopter or by the GP.  Leiland-James was described as a ‘heavy’ baby, and it is known that he wanted to be carried a lot. This may have been painful or at least uncomfortable for the female prospective adopter who did most of the childcare. The GP service has identified the need to place a flag on GP records stating that a person is applying to adopt. This will allow a GP to consider sharing information if anything new emerges, as it did in this case. A recommendation has been made to ensure that this happens across Cumbria. Prospective adopters are told that they need to share with CSC if they have any new health issues. In this case the information was not shared by the prospective adopters or their GP.  4.42 As stated above (4.40) the first meeting between the adopters and the therapeutic service was held on 16 December 2020. The adopter’s social worker was with the carers in the home and the therapeutic worker joined via video link due to the result of a COVID 19 risk assessment required at the time. After the session the social worker and the therapeutic worker had a conversation to reflect on the session. They agreed that the carers appeared to be negative about Leiland-James and found it hard to show any joy about parenting him during the meeting. They were described as tense and ‘flat’. It was concluded that work was required, and that while they should join a therapeutic group starting in February, they would require support from all involved prior to that. The social worker spent time with the family that day and recorded afterwards that while there were issues, there were also positive interactions observed and indicators that Leiland-James appeared more settled. The review was told that following the meeting there was consideration in the adoption social workers supervision that support was needed. There was no plan made for increased visiting in the days and weeks that followed, however. The social worker who was present did not assess that this was required as she had noted that Leiland-James was well cared for physically, that he engaged happily in peek-a-boo, and that he appeared to be meeting his developmental milestones. His warm and positive relationship with the older child was also noted.  4.43 It was of concern at the time that the female prospective adopter stated during the meeting in December 2020 that she wanted a break and required ‘respite’ from Leiland-James. It appears this was in response to challenge when information was shared that Leiland-James had stayed overnight with family members, against advice. It was agreed that Leiland-James’s social worker needed to be made aware of this concern. Emails were sent16 and an agreement made that there needed to be a care planning meeting. No meeting was held prior to his death.  4.44 Leiland-James was only seen once more by a professional on 23 December 2020, when he attended the GP surgery with the male prospective adopter for routine immunisations which were undertaken by the practice nurse. The response to Leiland-James’s injuries and then death the following month was appropriate. There were no identified delays in information   16 These emails were sent on 31st December. The delay following the visit on 16th December appears to have been in part due to due to Christmas bank holidays, leave and part time working.  FINAL   16  sharing, correct processes were followed and there was appropriate safeguarding of the birth child.   Learning  When a child who is in the care of the local authority is placed for adoption, there should be a multiagency plan, to include health and schools17   That the wider family and friends’ network are explicitly made aware of their responsibility to share any concerns with the local authority. Information about how they do this must be shared during the network meetings and in writing afterwards18  That the support of the health professionals involved with the child is requested to ensure that updated health information about the adopters is available for consideration at key stages in the process, such as child looked after reviews   When a prospective adopter/s presents in a way that leads to concerns about the emotional care being provided to a child, there needs to be provision of an appropriate, more timely and robust response  Impact of COVID-19 4.45 Any review being completed that considers systems and practice from March 2020 needs to consider if there was any impact due to the COVID-19 pandemic. Leiland-James’s case is no exception. There had been a delay in the final hearing in the care proceedings due to a court backlog during the first lockdown. It was not significant however and Leiland-James was 7 months old when he was placed with the prospective adopters. There were other areas where Covid-19 potentially had an impact on the case. They included the limited availability of community activities and parenting support such as mother and baby groups and play activities, and some limits to the support the family could request from family and friends. For example, visiting from mixed households was not allowed in December other than on Christmas Day 2020, unless there was a clearly defined support bubble. The review was told that despite the restrictions in place, some childcare support was provided by the extended family.  4.46 There was a need at the time for questions to be asked of all families receiving support from agencies about the impact of Covid-19 on their family and on them as individuals. It is now known that the male prospective adopter had some time on furlough during the first lockdown. This had a significant financial impact which was not shared with the social workers at the time. The family also struggled with isolation during lockdown. None of these were unusual for any family in their situation, but with the female prospective adopter’s known history of anxiety and low mood and her long-term health issues, this required robust consideration. It is noted that at the time Leiland-James was placed in August 2020, things were less restricted and there was a feeling that life was getting back to normal. The further lockdown in November 2020 and news that a further lockdown may be implemented in early January 2021 would have had more of an impact. The family was still adjusting to having a new baby, it was winter, and the potential need for the older child to be home schooled from January may have had an impact.  4.47 There had been a shorter than usual (in Cumbria) period of introductions for Leiland-James. Although this was largely due to the need for sufficient introductions to happen before the older child started school, it was also due to COVID-19 and the wish to limit the frequency of face-to-face contact between those involved in the move. While the plan was similar to those common  17 When there is an older child (either a birth child or an adopted child) who attends school, including the nursery class prior to statutory schooling, consideration should be given to the best way of including the school in any planning to support an adoption placement. The school’s assistance in capturing the ‘voice of this child’ is an important part of the process.  18 Action has been taken in respect of this.  FINAL   17  in the UK as a whole, in Cumbria they had seen the benefit of a longer period of introductions and preferred to do this when possible. All the meetings held as part of the matching, introduction planning and child in care reviews following the placement were held virtually (on-line). Professionals had become used to this by August 2020 and they told the review that it did not have an impact on the quality of the plan/planning. One exception to this was the therapeutic social worker who had her first consultation with the couple around a week before Christmas. She reflected that the start of a therapeutic relationship was impacted by not meeting the prospective adopters face to face for the initial appointment.  It is difficult to know if the lack of face-to-face support groups had any impact on how the prospective adopters were managing.   4.48 There is increasing research about the impact on children of the COVID 19 restrictions, and a view that it may affect their development and ability to adapt to different environments and people. This was likely to be an issue for both Leiland-James and the older child in the family.  The prospective adopters told the adoption social worker that they missed having regular visitors to the home and going out as a family. They liked to eat out and have day trips, but this was impossible at the time. Leiland-James himself needed to adapt from being in a home with a lot of people, to living with a small family, with a father who slept during the day due to night shifts and limited or no visitors due to the new lockdown restrictions. This and the resulting stressors needed to be factored into the support being offered.   Learning  The many impacts of Covid-19 on children and families cannot be underestimated and will require robust consideration by professionals during assessments and contacts for some time   5 Conclusion and recommendations  5.1 Leiland-James died while being cared for by a couple who had been successfully assessed and who were being supported by professionals and their own network. Following his move, indicators emerged that it might not progress to be the right placement for Leiland-James, and that his longer-term emotional needs may not be met. There were no known indicators that Leiland-James was at risk of physical harm from his carers, however. What was not known at the time was that the prospective adopters had not been honest about their debt, their mental and physical health, their alcohol consumption and use of physical chastisement during the assessment, at the time of Leiland-James being matched with them or during his time living with the family.  Learning has been identified that information in these areas should be robustly sought, shared, and considered. This is significant, as had the information held by First Steps and the gastroenterologist been known, along with the understanding that the prospective adopters were hiding these issues, the assessment could have better reflected the vulnerabilities and potential risks.   5.2 The learning from this review has been clearly set out above, but has identified the following pivotal findings regarding systems and practice which were considered when making the recommendations below: The medical assessments of potential adopters require a thorough consideration of their medical records and include information from specialists and providers of mental health support. The system would be more robust if these assessments were updated at the point of matching and before an adoption order is made FINAL   18  Improvements are required regarding seeking, sharing, and considering any adult vulnerabilities19 that could be a risk to children Adoption systems and practice must ensure that there is improved consideration of the lived experience of other children in an adoptive household When it is apparent that there are issues with prospective adopters bonding with a child placed with them, a robust and timely professional response is required that recognises the emotional impact on the child and the pressure on carers 5.3 Ongoing service improvements in the Cumbria adoption service, unrelated to this case, include a pilot with the University of East Anglia ‘Moving to Adoption’ Model. This outlines three key stages ‘getting to know each other’, ‘making the move’, and ‘supporting relationships’ after the move. Each stage has key principles that need to be achieved and so is not prescriptive about timeframes and details on the planning. The focus is on outcomes for the child and being flexible to their needs’. Those involved in the review believe that these changes will contribute to improvements for children who are to be adopted, and hopefully enable them to thrive and have a successful placement.  5.4 CSC informed the review that they recently commissioned the Local Government Association to undertake an in-depth independent review of practice in the adoption service. This review has provided assurance about adoption practice. Positive improvements reported in the adoption service include additional management oversight, seeking information from providers of mental health support and inviting Strengthening Families workers to key meetings.  5.5 The following additional recommendations are made to ensure that the Partnership can be confident that any areas identified as being of particular concern are addressed.   National recommendation: 1. The Child Safeguarding Practice Review Panel to ask the Department for Education to review adoption guidance considering the learning from this review. Revised guidance should include:   the need for all health information for adopters and children in the family to be updated and reconsidered at key points in the case, such as at matching, at Child Looked After Reviews and when an adoption application is made  seeking assurance that medical assessments do not rely on the self-report of the prospective adopters  the need for flags to be placed on the GP records for prospective adopters/adopters  the need for financial information, including the total of any debts, to be robustly assessed during any assessment of prospective adopters. Local recommendations: 1. Due to the likely delay in changes to national guidance, relevant partner agencies in Cumbria to be told to raise awareness of the importance of adoption health assessments, and to ensure that health information is requested, analysed20, and shared at the key adoption process stages to inform decision making, such as when agreeing a match21.   2. The CSCP to ask partner agencies to determine how they will ensure that ‘systems’ identify a person as a prospective adopter, so that professionals are aware of this. Additionally, all  19 To include physical and mental health, alcohol consumption, and financial issues. 20 Including the role of the medical advisor.   21 In this case it is health information that is relevant. It is acknowledged that this could also include the need to consider updating all checks undertaking at the matching stage, including police and local authority checks.  FINAL   19  GP records locally should have a flag placed on the record of prospective adopters, with the expectation that GP’s share any information that pertains to changes in health or lifestyle that may have implications for a child in their care. 3. That the CSCP asks all relevant partner agencies to determine how they will ensure that all professionals are aware that children placed for adoption remain in the care of the local authority until an adoption order is made, to ensure an improved awareness of their potential vulnerabilities and the need for professional oversight.  4. That Cumbria CSC, the CCG and the Adoption Panel Medical Advisor are asked to provide assurance regarding the need for all information to be sought, shared, and considered thoroughly in adoption assessments to enable a full understanding of a prospective adopter’s health and mental health.  5. That Cumbria CSC are asked to provide information and assurance in the following areas: - That all necessary information is sought and considered in assessments to enable a full understanding of a prospective adopter’s financial situation  - That the voice of other children in the household is sought at regular points in the assessment and placement - That there has been a review of visits to children in adoption placements to ensure that those with allocated responsibility for the child visit the child in placement at least in line with statutory requirements, and more often when there are concerns about the viability of the placement   - That there is an appropriately timely and robust response in cases where there are concerns about bonding with a child placed for adoption. 