Serious injuries to a 6-year-old child in 2018. History of domestic abuse between Child R's parents, resulting in a Child in Need Plan and Child Protection Plans until parents separated. Child R had experienced 13 injuries over a nine-month period, mainly in the form of bruises to his face. In 2017 and 2018 Child R made disclosures about being hurt by mother's partner. Child protection medical examination found that one injury was non-accidental and caused by someone hurting him but no protective action was not taken. Injuries were attributed to poor parental supervision, but this was not in line with the medical findings. In October 2018, Child R attended the emergency department with a serious head injury and significant bruising, which later required neurosurgery. Mother's partner was sentenced to nine years for grievous bodily harm against Child R; Mother charged with neglect. Ethnicity or nationality not stated. Learning focuses on compliance with child protection procedures and the arrangements for the child protection medical examinations; assessment of risk, the impact of confirmatory bias and misunderstanding of terminology; the transfer of cases. Recommendations include: ensure that multiagency child protection procedures are effective in respect of strategy discussions and child protection medicals; chronologies should be completed as part of the referral to Social Care to highlight patterns of physical injury; consider an awareness raising campaign within the wider children's workforce focused on physical harm in children and consider whether the terminology around non-accidental injuries should be changed.
      
 Title:  Serious case review: Child R. LSCB: Nottingham City Safeguarding Children Partnership Author: Hayley Frame Date of publication: 2021  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1           Serious Case Review Child R  Author: Hayley Frame       Completed:  22.08.2019 Published:  01.04.2021   2  Forward  This Serious Case Review was completed in the summer of 2019. The content remains as written by the author and as signed off by the Childrens Safeguarding Board which was the governing body for Serious Case Reviews at the time.  Publication was delayed whilst we awaited the conclusion of associated criminal proceedings.   In the intervening period, in response to Working Together 2018, there have also been statutory changes in local safeguarding arrangements, with the introduction of Statutory Partnerships and the disbandment of Safeguarding Boards.   Due to the extended delay and statutory changes a decision has been made to publish this report without attempts to update or amend in any way.  This allows for full transparency and reflects the learning and actions undertaken in response at the time.                      3  Contents   1. Introduction   2. Purpose and Principles of the SCR  3. Methodology  4. Time period for SCR  5. Parallel processes and investigations   6. Overview report structure  7. Summary of Historical Information  8. Summary of Information Known to Agencies and Agency Involvement in Respect of Child R  9. Analysis including lessons learned   10. Changes in Practice and Actions Already Taken  11. Conclusions   12. Recommendations        4  1. Introduction  1.1. Serious Case Reviews (SCRs) are always carried out by a Local Safeguarding Children Board (LSCB), when a child dies or is seriously injured and abuse or neglect is known or suspected to be a factor. This procedure is laid out in the NCSCB Safeguarding Children Procedures and is in accordance with the expectations set out in the Government guidance, ‘Working Together to Safeguard Children’ 2015, chapter 4. This SCR has been commissioned following the completion of a Rapid Review compliant with Working Together 2015 (as per current DfE transition guidance published July 2018).    1.2. This report summarises the findings from the SCR that was established to consider the professional interventions in respect of a child, who will be referred to as Child R, who was seriously injured whilst in the care of his mother and her partner. In October 2018, Child R attended the emergency department with a serious head injury and significant bruising. This later required neurosurgery.   2. Purpose & Principles of the SCR  2.1. The purpose of the SCR is to establish any lessons to be learnt from the case; to identify how these will be acted on and lead to sustainable improvements, the prevention of death, serious injury or harm to children.   2.2. The NCSCB and partner organisations will translate the findings of this SCR into programmes of action, which lead to sustainable improvements in practice and service delivery, to improve outcomes.  2.3.  The following principles will be applied to this SCR:  a culture of continuous learning and improvement across partner  organisations identifying learning and promoting good practice;  the review will be proportionate according to the scale and level of complexity of the issues being examined;   the review will be led by an individual who is independent of the case under review and of the organisations whose actions are being reviewed;   professionals will be involved fully in the review and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;   the final report of the SCR will be published, including the NCSCB’s response to the review findings, in order to achieve transparency, unless a reason not to do so is identified within the process   improvement will be sustained through regular monitoring and follow up so that the findings from the SCR makes a real impact on improving outcomes for children  recognition will be given to the complex circumstances in which professionals work together to safeguard children 5   the review will seek to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  the review will seek to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  the NCSCB and partner agencies will be transparent about the way data is collected and analysed; and  relevant research and case evidence will be used to inform the findings   3. Methodology   3.1. An Independent Reviewer, Hayley Frame, was commissioned to undertake the SCR. Miss Frame is an independent safeguarding consultant and as such is independent of all agencies contributing to the SCR. She has 24 years’ experience within safeguarding, as a practitioner and as a manager at various levels, and is a qualified and registered Social Worker. Miss Frame is experienced in completing serious case reviews, safeguarding adult reviews and domestic homicide reviews.  3.2. This SCR was commissioned following the completion of a Rapid Review and submission to the National Panel which agreed with the recommendation for a Serious Case Review. As such the project plan and methodology took into account:    That there was already a detailed rapid review report available that highlights key learning and practices episodes which has been used to inform this report.  That organisations had already completed and submitted internal case review reports.  That the SCR needed to be proportionate in recognition of learning already identified and potential for additional learning.  That there was a need to engage the workforce, specifically those involved with the family in the process, via the convening of a reflective learning event.  There was a need to engage the family in the process subject to police approval given ongoing criminal investigations  That the process was compliant with Working Together 2015, (as per current DfE transition guidance published July 2018.)  3.3. Agency submissions were provided by:  Nottingham City Council - Children’s Integrated Services  Nottingham CityCare  Nottingham City Clinical Commissioning Group (for GP contracted services)   Nottingham Emergency Medical Services (NEMS)   School   Nottinghamshire Police 6   Nottingham University Hospital NHS Trust  East Midlands Ambulance Service    3.4. In order to ensure that the SCR considered not only what happened but why, the NCSCB SCR standing panel agreed to adopt an approach that engaged directly with practitioners involved in the case. As a result, a practitioner event was held, to which all practitioners and their line managers who had direct involvement in the case were invited. The practitioner panel ensured that opportunity was given to fully understand practice from the viewpoint of the individuals involved at the time.   4. The time period over which events were reviewed  4.1. 1st October 2017 to 2nd October 2018 (date of incident that led to the decision to hold a SCR)    5. Parallel processes and investigations  5.1. The involvement of family members has not been possible at this stage due to the ongoing criminal investigations, which includes Child R’s mother. The CPS have authorised a charge of neglect on Child R’s mother on the grounds that she left her son with a known dangerous man.  The mother’s partner was sentenced to 9 years for Grievous Bodily Harm against Child R.   5.2. There are no other reviews currently taking place in relation to this case.  6. Overview Report Structure   6.1. The Overview Report provides a summary of the information contained within the agency submissions, ensuring that key events and issues are captured and analysed. Author’s comments are set out in bold, including findings ascertained from the practitioner event held as part of the review.   6.2. The analysis includes a summary of the author’s comments, analysis of the case against the identified key issues and the themes that have emerged from this SCR.   6.3. There have been a number of developments and actions already taken and these are set out in section 11 prior to the conclusions and recommendations of the report.  7. Summary of historical information  7.1. In 2012 concerns were raised regarding domestic abuse between Child R’s parents. This led to a Child in Need Plan commencing. In January 2013, a child protection enquiry 7  under section 47 of the Children Act 1989 was undertaken which concluded that the children were at ongoing risk due to domestic abuse.  An Initial Child Protection Conference took place and the children were made subject to child protection plans under the categories of physical and emotional abuse. This plan remained in place until April 2014, when the case closed as the parents had separated and it was felt that the risk of domestic abuse had reduced.   7.2. In November 2014, it was confirmed that the couple had resumed their relationship and in May 2015, the children were again made subject to child protection plans. The child protection plan ceased in November 2015. Following the child protection intervention, the family continued to receive support and intervention from the Children’s Targeted Family Support Team until January 2017.   7.3. The parents were no longer in a relationship during the scoping period for this review.   8. Information Known to Agencies and Agency Involvement in Respect of Child R  8.1. On 30th November 2017, Child R informed school staff that his mother’s partner had punched him in the arm ‘the other day’ and given him a ‘dead arm’. A concern form was completed by the school and the mother was spoken to who said that she did not recall her partner punching Child R’s arm and stated that having previously been in a violent relationship that she would not condone this kind of behaviour. The review has concluded that in the circumstances the school’s response was proportionate however it is of concern that Child R may have felt disbelieved and that his voice went unheard. There was no change in his presentation however following this incident to trigger further concern.   8.2. Similarly, on 31st January 2018, Child R informed school staff that his mother’s partner had shot him with a nerf gun (a toy gun that fires foam darts) causing a bruise to his cheek and a cut to his forehead. Again, a concern form was completed and his mother was spoken to.   It does not appear that this injury was considered in the context of the previous injury. The school have acknowledged that they could have done more to ascertain who the mother’s partner was. Had this injury been referred to Children’s Social Care, the details of the partner could have been established.    8.3. On 14th February 2018, Child R had bruising to his face which was allegedly caused by play fighting. A concern form was completed and his mother was spoken to who agreed to take Child R to the GP.   8  The review has established that Child R’s mother came into school in the morning, saying that she was thinking of taking Child R to the GP due to the bruising.  The school have reflected as part of this review that they should have made a referral to Children’s Social Care but the explanation seemed reasonable and they were reassured that she was taking him to the GP.   8.4. Child R was seen by the GP that day, at 6pm, who made a referral to Children’s Social Care the next day after having reflected upon the presentation and feeling concerned about Child R’s injuries. The GP informed the mother.   The review has questioned whether the GP had considered whether Child R was safe to go home that night and whether a referral should have been made to the out of hours Emergency Duty Team.   8.5. The referral was screened by Children’s Social Care on 15th February 2018 upon receipt and it was agreed that there was a need for a child protection investigation and that the child needed to be seen that day.  .  Despite this, no strategy discussion took place with the police and s47 (child protection enquiries) did not commence.   Expected practice is that the social worker will speak with the Police and health professionals to have a strategy discussion. The police are based in the same office. In situations where it is not clear-cut whether a child protection medical is needed and therefore the social worker will go out to see the child first, they will still have a discussion with the Police beforehand. This ensures that S47 enquiries have already been agreed in advance with the Police and that any child protection medical occurs within that framework.  In addition, a strategy discussion provides an alert to the police of an injury to a child and allows them to consider the potential for a police investigation at the earliest opportunity. In this case the police were denied the opportunity to consider the need for a police investigation as they were unaware of Child R’s injuries.  8.6. The child was seen by a social worker and attempts were made to arrange a child protection medical. However the Non Accidental Injury clinic was closed and so it was agreed that a child protection medical would occur the following day.   The review has considered what should happen when a child protection medical is required but the clinic is closed. It would be essential to ensure that a risk assessment was agreed through a strategy discussion; that the child was medically safe and that a safety plan was in place given the potential for non-accidental injury. In this case, there was no adequate safety plan in place as it was assumed that the mother was a safe person.   9  8.7. The child protection medical occurred on Friday 16th February 2018 and it found that the injury was non accidental in nature, as the bruises were in areas  of soft tissue that are not usually injured accidentally. The information was recorded on a summary form and handed to the attending social worker which she signed. This was a different social worker to the one who had visited Child R at home, due to her being on annual leave. The form states the views of the Paediatrician: ‘I am concerned that this is a non-accidental – i.e. that this was caused by someone hurting him’.   The review has established that the social worker took this paper form away with her. The Paediatrician has informed the review that the mother walked out of the clinic in distress and that the social worker was intending to speak to her manager. There is no record of any discussion taking place, or of the paper copy of the report being shared with the Team Manager.  However, the tone is set by the safety plan agreed on 15th February 2018, which assumes that Child R’s mother is a safe person, and so she leaves the hospital with Child R.   Expected practice would be that after a child protection medical, the Team Manager would record on the child’s file the outcome of the medical examination; the immediate safety plan for the child and why they have determined it is safe for the child to go home.  8.8. It wasn’t until Monday 19th February 2018 that the Team Manager informed the social worker that a strategy discussion with the police was required. In addition, the Team Manager ticked the relevant boxes on the child’s electronic file for a strategy discussion to be held and S47 enquiries to commence.   This strategy discussion did not occur. The review has established the allocated Social Worker subsequently cancelled the strategy discussion from the electronic file on 5th March 2018.  This cancellation is not easily visible to a Team Manager when closing a case. This has been raised with the system provider Liquidlogic as a risk within the system.   The review has not been able to establish why the Social Worker cancelled the strategy discussion. In addition, this must question the administration rights within the system that allow a Social Worker to cancel an action that has been initiated by a Team Manager.  8.9. On Wednesday 21st February 2018, the full child protection medical report is emailed to Children’s Social Care. It was electronically copied to the GP. The report is clear regarding the concerns that the injuries are likely to have been caused non-accidentally. The report also details that Child R was to be subject of an s47 enquiry.   The full medical report was emailed to the Children and Families Direct inbox. At that time the business support officers would then email the report to the social worker. There is no record of a Team Manager having seen either the interim report (paper copy the social worker would have been given at the end of the medical examination) or the full report once it was received later. This protocol 10  has now changed in that the report is emailed to both the social worker and team manager to ensure management oversight.    8.10. On 28th February 2018, the school recorded that the social worker shared the outcome of the medical with the school as being ‘NAI due to poor supervision’.   The review has considered the issue of terminology across the wider workforce, and the school have reflected that not all school staff would fully understand that NAI means the child has an inflicted injury.  Also, the injury was not due to poor supervision – the medical report was clear that the concern was that someone had harmed the child.    8.11. On 15th March 2018, Child R was seen at school with further bruising to his head, allegedly from falling from his bed. The school informed children’s social care but no action was taken. On 20th March 2018, he had bruising to his waist. The school informed Children’s Social Care and a social worker visited Child R and felt that it appeared accidental and that she was intending on closing the case.   On both occasions, a medical view should have been sought regarding Child R’s injuries.   8.12. The following day, 21st March 2018, Child R was seen at school to have fresh bruising to his face. The social worker was informed but she was unable to visit until the following day. Also on the 21st March the social worker contacted, and spoke with the GP. The GP advised that there was no medical condition that would suggest a predisposition to bruising. The GP was of the belief that s47 enquires were being undertaken.   8.13. On 26th March 2018, the children’s assessment was concluded and the case was closed to children’s social care. The authorising Team Manager wrote that ‘The assessment has not raised any further concerns since the medical that was undertaken from the referral. Agency checks have not raised concerns. No concerns raised about the children in the home. Appropriate supervision of the children has been raised. Mother has taken on board all concerns and worked with the assessment.’  It is of note that the Team Manager made reference to the medical yet did not identify that this had occurred outside of established safeguarding procedures, and specifically that a strategy discussion and s47 enquiries had not taken place.   In addition, the case was allocated to the social worker from 19th February 2018 until 26th March 2018. No supervision between the social worker and team manager occurred during this time, which should have been monthly as per the supervision policy, and there is no recorded management oversight.  11  8.14. The following day, 27th March 2018, Child R had further facial bruising which was referred by the school to children’s social care. He was seen in school by the same social worker who felt that it was accidental.   This was the third report of bruising in 6 weeks.  8.15. On 29th March 2018, Child R was tearful in school and limping. The social worker visited him in school again but no action was taken. School records show that they discussed with the mother that Child R should be taken to the GP.    8.16. Child R had further facial bruising on 16th April 2018. The information was recorded by the school staff and his mother was spoken to. Again on 23rd April 2018, a mark was seen to Child R’s back and the school spoke to his mother.   The review has established that the school did not refer these injuries to children’s social care because the assessment outcome was that the injuries that occurred had resulted from poor supervision and not inflicted harm.  They felt that the mother was plausible in her accounts.   8.17. On 15th May 2018, Child R had bruising to his face and neck. His sister informed the school that she threw a car at him. A concern form was completed.  8.18. On 17th May 2018, the social worker finalised a second assessment and stated that the case should be transferred to Targeted Family Support Services. The authorising Team Manager wrote that ‘It is a concern that Child R has presented with a number of different injuries, however there have been consistent explanations for this and there is a concern regarding a lack of supervision within the household. I am therefore in agreement with the social workers recommendation for the case to be stepped across to TFST for the identified work to be completed. Should there continue to be concerns regarding injuries to the children following work being completed with mother a referral to CSC to be made and consideration to S.47 enquires being initiated’.  The social worker report does not identify the pattern of bruising and the view taken is that the bruising is caused due to a lack of supervision. The first and second assessments are virtually identical however they were signed off and authorised by 2 different Team Managers.    8.19. The case was considered by the Targeted Family Support Manager who felt that the case would be best met by Early Help services (a lower tier of intervention).  The review has considered that this should have prompted a discussion between the Children’s Social Care Team Manager and the Targeted Family Support Team Manager due to a differing view regarding the threshold met for services.  12   8.20. On 7th and 12th June 2018, further facial bruising was seen at school. After the second incident the school contacted the social worker who stated that the case was going to be allocated within Targeted Family Support Services, which was inaccurate information.  School records show that the social worker spoke to a staff member and informed them that the case was closing and transferring to Targeted Family Support Services– when the case was actually fully closing with no further action.  The social worker is also reported to have said that a discussion had taken place with the Team Manager and they agreed that if an adult was intentionally harming the child, that they would have hurt the child on their body and not their face so as to hide the abuse.  This provided the school with reassurance. The Team Manager was present at the practitioner event held as part of this review and was clear that this conversation did not occur and that the Team Manager does not agree with the view that people who hurt children would never hurt a child on the face in order to avoid detection.  8.21. Despite the Targeted Family Support Team Manager’s earlier view, a home visit was undertaken by a Family Support Worker on 22nd June 2018, however the mother refused Targeted Family Support Services and the case was closed.   There was no referral made to Early Help, no consideration of escalating the case to Child in Need status given the mothers refusal to engage with Targeted Family Support Services, and as such the case was closed to all of Children’s Integrated Services.   8.22. On 25th June 2018, Child R was seen by the GP with back ache. No marks or bruises were noted.   This was a different GP to the one that made the earlier referral to Children’s Social Care.   8.23. On 11th and 24th July 2018, Child R was seen at school to have bruising to his arms. The mother was spoken to by the school and the explanation given by the mother and by the child himself was that he had been wrestling with his cousin and it caused the bruising.  The school advised not to wrestle and to find alternative ways to play.  The review has established that the school were not fully convinced that the injuries were linked to poor supervision but as Child R was known to be a boisterous and clumsy child at school there was some plausibility that he had sustained the injuries due to poor supervision. At this point school were not aware that the case would not be transferring to Targeted Family Support Services as planned, and still believed that a family support worker would be allocated.  13  8.24. Child R attended the Urgent Care Centre on 25th August 2018 with an ankle injury and multiple facial bruising. The GP was informed. The explanation that he had fallen from his bike was accepted.  The urgent care worker had a very clear memory of Child R as he was limping badly and as his mother was heavily pregnant, the worker carried Child R down the corridor. The worker did not have any concerns about Child R’s presentation and he appeared happy and boisterous. In hindsight, the worker has reflected that bruising to both sides of his face would be unlikely after a bike fall. The urgent care worker also looked at the safeguarding note held on the system, and saw that the case was closing to social care, and felt reassured by this. The presentation was not referred to children’s social care as would be expected practice.   8.25. On 2nd October 2018, Child R attended the emergency department with a head injury and significant bruising. This later required neurosurgery. Following disclosures, the mother’s partner was arrested for assaulting Child R.   9. Analysis including lessons learned  9.1. Compliance with child protection procedures and the arrangements for the child protection  medical examinations   9.1.1. As was established within the rapid review, it is clear that the social work response to the concerns raised for Child R was not in line with both national and local safeguarding procedures. This was compounded by a lack of management oversight. It has been established that there were no contextual issues such as the allocated social worker’s caseload being high that might have provided some explanation for the failure to comply with established procedures. Unfortunately the social worker is no longer employed by the Local Authority and therefore it has not been possible to engage her in the Serious Case Review.   9.1.2. As part of the Rapid Review process, an individual reflective session was held with the social worker with regard to the case management and responses to Child R’s repeated presentation with injuries. This was held prior to the social worker leaving the Local Authority and the notes of the session were made available to the Independent Reviewer for this Serious Case Review.  The social worker is recorded as having stated that the mother was very engaging and that she spoke to the children alone who had not made disclosures, and had also undertaken direct work with Child R in school. She could not recall why a strategy discussion did not occur and did not mention that she had cancelled it. She confirmed that she had undertaken visits that had not been recorded. She was able to articulate the process for child protection enquiries but was not able to explain why the process had not been followed in this case.  An audit of twenty cases held by the same social worker was completed to ascertain if these practice issues were present in other cases. No practice concerns were identified through this audit.  An audit of 10 cases for each Team Manager was also completed to ensure that there were no practice concerns about their decision making.  14   9.1.3. The strategy discussion is a pivotal part of all safeguarding procedures. It allows for information sharing between key statutory agencies and ensures agreed decision making where there are concerns regarding a child experiencing significant harm. It also allows for consideration at an early stage for the potential for criminal investigations to be undertaken by the police. Despite this Serious Case Review, it remains unclear why a strategy meeting did not occur in this case.    9.1.4. In November 2018, Ofsted undertook an inspection of the Local Authority and found that ‘child protection enquiries are swift and well-coordinated, including when concerns are received out of hours. Co-location of police, health and probation agencies with children’s social care supports timely strategy discussions and appropriate decision-making. Children at risk of significant harm are urgently seen and risk is quickly assessed. A small minority of enquiries take too long. This leaves some families with prolonged uncertainty. Social workers’ timely assessments of children’s needs are thorough and provide a clear view of risks to children. They are informed by good-quality direct work, which means that children are contributing to and influencing their own plans’. These inspection findings support the view that the failures in this case relate to individual practice errors rather than systemic difficulties within children’s social care.   9.1.5. The child protection medical examination that was held should have occurred within the context of agreed s47 enquiries with the police following a strategy discussion held with them, and health colleagues. It is not clear, despite this review, why this did not happen in this case and how the child protection medical examination occurred outside of agreed pathways. The review has considered how child protection medical examinations are arranged and the process is that the social worker will call the on call paediatrician for advice and if agreed that a medical is required, then the social worker completes a form and sends it to business support staff at the hospital. The review has suggested that the form is amended to include whether a strategy discussion has been held and whether s47 enquires have been initiated. If not, then a child protection medical cannot go ahead and be booked.   9.1.6. Arrangements have been made to ensure that the full medical examination report is now given social care team management oversight as they receive an emailed copy, within one working day There is currently no similar way to ensure that the hand held paper copy of the interim report completed at the time of the examination is seen by the Team Manager as it is given to the attending social worker. However the form itself could be amended to include the details of the interim safety plan and the name of the Team Manager who has agreed it. If this is completed by the on call paediatrician this will ensure that there is discussion of the findings immediately, appropriate management oversight and a safety plan for the child agreed between the paediatrician and the Team Manager.   9.1.7. Standard safeguarding procedures were not followed when Child R presented to the Urgent Care Centre and social care were not informed of his attendance. The GP who was in receipt of the information regarding the presentation did not inform social care either however the information would likely have been filed in the GP notes by an 15  administrator and without reference to safeguarding concerns is unlikely to have been flagged with the GP.  9.1.8. The review has recognised that within the Urgent Care Centre there is, by the very nature of the work, a fast turnaround and workers have very little time to look at the history of a presenting patient, and even if they did would not necessarily understand all the acronyms and terminology used. The Urgent Care Centre have completed work with staff on different social care terminology and acronyms to support them when looking at notes, have compiled a ‘top tips for bruising in children information sheet and have also considered how they use body maps. This may have assisted the worker in considering fully whether the mechanism reported was in line with the presenting injuries.    9.1.9. The school have acknowledged that there were several occasions where multiagency safeguarding procedures were not followed and they should have referred Child R’s injuries to Children’s Social Care. They have reflected on how they accepted the position of the social worker in that the injuries were due to poor supervision and that they were reassured by the mother’s presentation. In addition, they believed that the case was awaiting allocation of a family support worker yet did not pursue when this was going to occur.   9.1.10. Despite the review process and the scrutiny of the Independent Reviewer and the NCSCB SCR Standing Panel, it has proved to be very difficult to understand and make sense of the sequence of events and agency responses in this case. As the Review has not been able to seek the contribution of the social worker nor the mother, this has also made the challenge of understanding why even more difficult.   9.1.11. There is a clear failure to recognise a catalogue of injuries suffered by Child R. Within the practitioner event held as part of this Review, the Independent Reviewer compiled a basic list of all injuries sustained by Child R. This made for stark reading and the impact of this upon those in attendance was significant.  Had a similar brief chronology been completed as part of Child R’s case management, this may have led to a different conclusion of the assessment and response as the evidence is overwhelming.     9.2. Assessment of risk, the impact of confirmatory bias and misunderstanding of terminology  9.2.1. The assessments completed by the social worker were not of a high standard. Although two were completed they were virtually identical. The assessments did not clearly identify the worries and what was expected to keep the child safe, in line with well-established Signs of Safety guidelines. Child R’s father was not approached as part of the assessment and there was no information regarding the mother’s partner. It appears that the social worker developed some fixed thinking in relation to the cause of injuries for Child R, believing them to be due to poor supervision. This bias then impacted upon her decision making and the actions taken. More robust management oversight could have challenged this stance. In addition, the use of a chronology listing all of Child R’s injuries would have been a key tool to challenge fixed thinking.   16  9.2.2. The review has established that there were opportunities for escalation of concern regarding Child R. Professional challenge is a key safety net in the delivery of multiagency safeguarding procedures. The paediatrician undertaking the examination did not have input into the proposed safety plan despite their findings. The school were informed wrongly by the social worker that the outcome was ‘NAI due to poor supervision’ - yet this is clearly a contradictory description for the cause of an injury to a child.    9.2.3. The review has discussed the impact of the misunderstanding of terminology and that the term Non Accidental Injury is not particularly helpful, although widely accepted within the child protection arena. To reconsider rewording the term to be that of ‘inflicted or deliberate injury’ would alleviate any confusion regarding injuries that arise as a result of poor parenting such as poor supervision,  and put the focus upon who caused the injury and not just how. New categories have been established within the paediatric service, yet these specialist categories would not necessarily be easily understood by the wider workforce.   9.2.4. The review recognises that it takes time to embed new terminology across a multiagency safeguarding partnership, yet this has been seen already to be successful with regard to ‘DNA’s’ now being referred to as ‘was not brought’; which again is a good example of where a change in terminology can lead to a change in focus, the focus being upon the child’s experience. To change widely accepted terminology will be a strategic challenge however the driver for this comes from the practitioners themselves who were clear that a change to ‘inflicted or deliberate injury’ would leave no room for misunderstanding or ambiguity, and it is imperative that this Review listens to the voice of the practitioners on the front line.    9.3. The transfer of cases   9.3.1. Previously when a case was being transferred from children’s social care duty teams to the Targeted Family Support Teams, and Targeted Family Support Team decided that the case should not sit with them then the case would electronically be referred back to the social worker.  This has now changed so there would be a discussion between the Social Care Team Manager and the Targeted Family Support Team Manager or Family Support Practice Specialist. If TFST are not going to take the case then it will be for the Social Care Team Manager to decide on what to do next. This will ensure that the case can be escalated where needed and not result in case closure to all parts of Children’s Integrated Services, as occurred in this case.   9.4. Child R’s lived experiences  9.4.1. Child R was, at the time of the significant injury, a 6 year old child who had experienced thirteen injuries over a nine month period. These injuries were mainly, though not exclusively, in the form of bruises to his face, often in areas that are not commonly injured during accidents. A child protection medical determined that one of these was likely to be non-accidental. He had been seen and treated by medical professionals for back pain 17  and ankle pain. He has also received a serious head injury, requiring neurosurgery, and all current available evidence indicates that this was the result of a serious assault. Child R is a child that has experienced significant pain, apprehension and fear as a result of these injuries. Despite good support in school, access to a specialist counsellor and direct work with the allocated social worker, Child R was not able to tell professionals involved with him how he received the injuries.   9.4.2. All indications are that Child R enjoyed school. He was a popular pupil with a solid friendship circle. He presented as happy and confident in class and had excellent attendance. He was seen to be an active and sometimes boisterous boy who engaged well in school life. Observations of him with his mother raised no concern in the way they related to each other. His mother’s presentation also served to reassure professionals in contact with her, apart from that of the consultant paediatrician who undertook the child protection medical as it would appear that she saw a different presentation of the mother, who was not accepting of the medical findings regarding the cause of Child R’s injuries.   10. Changes in Practice and Actions Already Taken Childrens social care have completed the following activity:   A development session has taken place with all team managers from the duty service in respect of section 47 procedures, strategy discussions and child protection medicals.    In addition, it has been reinforced to social care staff that following a safeguarding concern any safety plans implemented are discussed with a Team Manager and that when a child protection medical has confirmed child abuse, before the child leaves the hospital, the social worker must agree the safety plan with the Team Manager and place this on the child’s file.  The Children’s Integrated Services case transfer policy has been updated to capture the actions to be taken if a family do not engage after the case has stepped across to Early Help or Targeted Support services.   The School:   The school involved have already implemented some procedural changes. This has included the use of provision mapping which identifies the school’s key vulnerable children, and the application of signs of safety to the weekly safeguarding meeting; in order to provide a better oversight and monitor progress. This will also provide the opportunity for the regular review of children’s chronologies to identify any patterns of concern. Each child will have an action plan which will be regularly reviewed.    The school has a weekly staff briefing where safeguarding is a standing agenda item.    The school have altered their policy so that only a Senior Designated Safeguarding Lead can close down an internal concern form. This will provide appropriate management oversight.   18   This learning is to be shared within the DSL wider schools network.    Team Around the school:    Children’s Integrated Services have developed their offer to schools where the school may be worried about children who attend their provision. All schools have been given the contact details for the Targeted Family Support Team Manager and Family Support Practice Specialist in their area.  All schools across the city will have a named Family Support Worker who will meet with the school on a termly basis (three terms a year) to look at the most concerning children, and offer a Family Support clinic if require to offer advice and support the school if a request for a service or a referral is required. The managers and specialist will have on average 16 schools per Targeted Family Support Team area and they will meet with the schools on a termly basis to look at concerns and emerging themes.   Health agencies    The designated safeguarding professionals for Nottingham City CCG have produced a communication to remind all health professionals about their responsibilities to promote the welfare of all children. This will also include challenges to the outcome of contacts that are disputed and should this not be resolved the escalation process must apply.    Within the Urgent Care Centre, when professionals see children with marks/ bruises (multiple in nature, following a late presentation, not consistent with the mechanism of injury or raises any concerns) a body map should be completed as it is considered to be a tool to promote good practice of record keeping. The body map should also be part of any referrals made to assist in the understanding of what has been visualised.   The Nottingham CityCare Partnership have also compiled a terminology/acronym glossary to be used across all agencies.   11.  Conclusions   11.1. It is evident that Child R has experienced significant physical harm. He had multiple bruising to areas that are uncommon for accidental injury. Child protection procedures were not followed and despite a clear medical view regarding one injury being non accidental and caused by someone hurting him, protective action was not taken. The belief that the injuries were caused by poor supervision was not in line with the medical findings and the evidence/assessment completed to support this hypothesis is weak. The individual practice issues of the allocated social worker shaped the progress of the case and there was an absence of management oversight to challenge her beliefs.  11.2. Measures were taken following the incident to provide assurance that case management within the relevant social work teams was effective and of the required standard. The 19  Ofsted inspection of Children’s Social Care in 2018 supported the view that the systems within the duty teams were effective. There is no evidence to support a view that the failures within this case are as a result of organisational or systemic issues.   11.3. However, it would appear that Child R’s positive presentation and the plausibility of his mother influenced the decision making. The application of the framework for child protection, its associated policies and procedures, should have provided a safety net to challenge fixed thinking and look objectively at the evidence. This did not occur and Child R remained at risk of, and suffered, significant harm.    12. Recommendations  12.1. The LSCB should be assured that the existing multiagency child protection procedures are effective in respect of strategy discussions and child protection medicals. This should include:    A review of access rights within the social care electronic case management system    That no Child protection medical examination can take place without a strategy discussion being held and S47 enquiries having been agreed as per established procedures.    A review of the arrangements for child protection medical examinations is completed. This should include the means by which safety plans are agreed by all relevant agencies.   12.2. Chronologies should be completed as part of the referral to Social Care to highlight patterns of physical injury. Chronologies should also be completed by social care as part of the children’s assessment and shared with the Community Paediatrician where appropriate to ensure that they have all relevant information.    12.3. The LSCB should consider an awareness raising campaign within the wider children’s workforce focused upon physical harm in children and consider whether the terminology used within the workforce should be changed.    