Neglect of three siblings aged 0-1, 5 and 3 years, who were removed from mother and mother's partner in December 2015. The family had been known to children's services since April 2013, after moving to Manchester from the south of England six months earlier. There were 4 children in the family at the time. Home conditions were poor, and the children had complex needs. Father moved out with two of the siblings in March 2014. In April 2014 the children became subject to child protection plans under the category of neglect. An initial child protection conference was held in September 2014 in respect of the unborn child (Child I1), the child of mother and mother's partner. Mother's partner is described as a transgender person and identifies themselves as female. Mother identifies as male. In May 2015 the children were removed from the child protection plan but continued to receive support under a Children in need plan. In December 2015 ChildI1 and siblings were removed from the home following an unannounced visit by a social worker. Methodology: a systems methodology approach focusing on multi-agency professional practice. Findings include: there was a fixed and overly optimistic view of the case by some of the professionals; at times the parents' needs received more professional attention than those of the children; professionals did not always feel confident in their responses to some of the issues, particularly around gender roles and transgender issues. Recommendations include: the voice and daily lived experience of the child should be the primary focus of all agency interventions; agencies should work closely together in cases of long term neglect, especially if there is concern about disguised compliance.
      
 Title:  Child I1: serious case review. LSCB: Manchester Safeguarding Children Board Author: Valerie Charles Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                               CHILD I1  SERIOUS CASE REVIEW This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 14th December 2017    INDEPENDENT LEAD REVIEWER: Valerie Charles  April 2017  MSCB Child I1 SCR Page i   Contents Section 1: Introduction .......................................................................................................................... 1 1.1 Context of the serious case review .............................................................................................. 1 1.2 Decision to conduct a serious case review .................................................................................. 2 1.3 Brief background and summary of contacts ................................................................................ 2 Section 2: Serious Case Review Methodology ....................................................................................... 3 2.1 Systems methodology .................................................................................................................. 3 2.2 The Review Team ......................................................................................................................... 4 2.3 Scope of the Review ..................................................................................................................... 5 2.4 Key lines of enquiry ...................................................................................................................... 6 2.5 Structure of the review process ................................................................................................... 6 2.6 Status and ownership of the overview report ............................................................................. 6 2.7 Parents contribution to the Serious Case Review ....................................................................... 6 Section 3: Analysis of agency involvement and Key Practice Episodes ................................................. 9 3.1 Key Practice Episodes ................................................................................................................... 9 3.2 Key Practice Episode 1: April 2014 – Initial Child Protection Conference ................................... 9 3.3 Summary appraisal of practice within Key Practice Episode 1 .................................................. 12 3.4 Key Practice Episode 2: July 2014 - Review Child Protection Conference ................................. 15 3.5 Summary appraisal of practice within Key Practice Episode 2 .................................................. 16 3.6 Key Practice Episode 3: September 2014 - ICPC for Unborn Child I1 ........................................ 19 3.7 Summary appraisal of practice within Key Practice Episode 3 .................................................. 20 3.8 Key Practice Episode 4: May 2015 - De-escalation from CP to Child in Need ........................... 22 3.9 Summary appraisal of practice within Key Practice Episode 4 .................................................. 24 3.10 Key Practice Episode 5: Child in Need Planning & Review - June to December 2015 ............. 25 Section 4: Conclusion ........................................................................................................................... 30 Section 5: Findings ............................................................................................................................... 32 5.1 Finding 1: Voice of the Child ...................................................................................................... 32 5.3 Finding 2: Assessments in cases of neglect ............................................................................... 33 5.5 Finding 3: Multi-agency working ............................................................................................... 33  MSCB Child I1 SCR Page 1 of 35 Section 1: Introduction 1.1 Context of the serious case review 1.1.1 This review concerns three children within the family who experienced significant harm through neglect. Concerns were highlighted about the ways in which agencies worked together to safeguard the children.   1.1.2 There are also two older siblings who went to live with their father and paternal grandparents during the period under review.   1.1.3 The three children were removed from mother and mother’s partner on 24th December 2015 when the social worker visited the home unannounced and found the house and circumstances in a very poor condition. Some areas of the house including the kitchen and bathroom were unusable. All three children were accommodated under Section 20 Children Act 1989 agreements. 1.1.4 The task of the review is to establish what lessons can be learned, for the purpose of learning and improvement in safeguarding services and in inter-agency working, in order to better safeguard and promote the welfare of children in Manchester.   1.1.5 The extent and quality of professional involvement and support given to the children and their family over a two-year period, from February 2014 to December 2015, has been considered by the review. The involvement of agencies during this period of time was in response to concerns about poor home conditions and parents not meeting the significant health needs of the children. The children became subject to child protection plans in April 2014 in the category of neglect.   1.1.6 In the months leading up to the incident in December 2015 the children had been removed from child protection plans and were subject to Child in Need (CiN) planning. During the period prior to the incident there had been deterioration in the home conditions and in the level of engagement from parents.  1.1.7 The review found evidence of good practice and some success in working with the family, but also areas that the review felt could be improved upon. These have been presented within this report as findings for Manchester Safeguarding Children Board to address.   1.1.8 This report was presented to the Manchester Safeguarding Children Board in August 2017.  1.1.9 Throughout the report the use of acronyms for the various people involved is kept to a minimum.  The three children are referred to as CHILD I1 (aged 0-1 year during the period under review), SIBLING 3 (aged 5 years old), and SIBLING 4 (aged 3 years old). The older siblings are referred to as SIBLING 1 (aged 8 years old), and SIBLING 2 (aged 7 years old). Members of the family are referred to in terms of their relationship with the children – i.e. mother, father, mother’s partner, paternal grandparents etc. In this case there are two biological fathers. The biological father to the four eldest children is referred to as father. The MSCB Child I1 SCR Page 2 of 35 biological father to CHILD I1 is referred to as mother’s partner. Professionals are referred to in respect of their professional role.   1.2 Decision to conduct a serious case review 1.2.1 The Local Safeguarding Children Board Regulations 2006 (regulation 5) requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with the statutory criteria and procedures that are set out in Working Together to Safeguard Children, 2015 (chapter 4)1.   1.2.2 The LSCB should always undertake a Serious Case Review (SCR) where abuse or neglect of a child is known or suspected and either the child has died or the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.   1.2.3 The rationale for undertaking this review is that the three children were seriously harmed by neglect and concerns were highlighted about the ways in which agencies worked together to safeguard the children.   1.2.4 The case was reviewed by the Serious Case Review Subgroup at two meetings and, based on the collation of information received from agencies, it was agreed at an extraordinary meeting held on 22nd April 2016 that the criteria for a Serious Case Review were met.   1.2.5 The independent chair of the MSCB approved the recommendation for a SCR on 22nd June 2016.   1.2.6 There was some delay before the review was commissioned. The review did not get underway until January 2017. This was due to a review of the commissioning processes taking place and a high volume of serious case reviews being managed at that time.   1.3 Brief background and summary of contacts 1.3.1 The family had been known to Manchester Children’s Social Care (CSC) from April 2013. An anonymous referral to NSPCC led to an unannounced home visit by CSC. It was identified that the family had moved from the South of England into the Manchester area six months previously. Since that move, the family were unknown to all agencies, including Health and Education. They were not registered with a GP or a dentist.   1.3.2 Home conditions were very poor and unsatisfactory. The home was unclean with food on the floor and furniture was piled high blocking doorways and windows. There were three beds in the living room with no bedding on these beds.   1.3.3 There were four children in the family at the time. Following child protection medicals the community paediatrician identified that all four children had complex needs which had not previously been recognised.                                                         1 Working Together to Safeguard Children, 2015 HMSO. MSCB Child I1 SCR Page 3 of 35 1.3.4 The eldest child, SIBLING 1, was aged seven years old and had a severe squint and had never been to school. The second child SIBLING 2 was aged five years old and did not speak and was still in nappies (subsequently diagnosed with autism). The third child SIBLING 3 was aged 2 years old and had walking difficulties (subsequently diagnosed with cerebral palsy). The fourth child SIBLING 4 was aged 11 months old.    1.3.5 Various Health referrals were made to address all the children’s health needs and a referral to Families First2 was made.  1.3.6 Families First began a six-week assessment and intervention programme with the family in July and August 2013 to work on parenting and living standards of the family. The three goals identified were: to attend all health appointments for the children; to address the children's educational needs; and the home conditions to be addressed i.e. clutter and mice infestation.   1.3.7 The outcome of the Families First intervention identified that the family had worked hard to make changes with some success. However, concern remained that without support or instruction, or if the family experienced any major setbacks, matters could deteriorate again. Further support and assessment of their ability to maintain the changes was required.    1.3.8 A period of Child in Need (CiN) planning was then put in place until February 2014, when due to a significant deterioration in the case it was decided to escalate to child protection.   1.3.9 In April 2014, the four children became the subjects of child protection plans under the category of neglect.   Section 2: Serious Case Review Methodology   2.1 Systems methodology  2.1.1 This review is based on a systems methodology approach3 focusing on multi-agency professional practice. The goal is to move beyond the specifics of the particular case – ‘what happened’ and ‘why’ – to identify the ‘deeper’, underlying issues that are influencing practice more generally. It is these generic patterns that count as ‘findings’ or ‘lessons’ from a case, and changing them will contribute to improving practice more widely. A systems approach uses a particular case as a ‘window’ on the whole system.                                                         2 Families First is a city-wide service and is part of the Family Recovery Team. The team provides up to six weeks of intensive intervention for families experiencing crisis. When their usual ways of dealing with problems stop working, Families First practitioners will explore the family’s own solutions and guide them through the process of change. The family’s own social worker commissions the service, and remains closely involved throughout the six week period. 3 Recommended best practice developed by SCIE. Learning together to safeguard children: developing a multi-agency systems approach for case reviews, SCIE (Social Care Institute for Excellence) 2009.  MSCB Child I1 SCR Page 4 of 35 2.1.2 Using a systems methodology approach for studying a system in which people and context interact requires the use of qualitative research methods to improve transparency and rigour. The key tasks are data collection and analysis. Data comes from involved professionals and others including family members, case files and contextual documentation from organisations.  2.1.3 Due to particular time constraints in order to complete the review in a concise timescale i.e. within three months, it was decided that the review would be based on a systems methodology approach, but would be proportionate to the timescale set. Instead, for example, of conducting individual conversations with the involved professionals (which can be very involved and time consuming) it was agreed that a structured practitioner and manager’s learning event would be held over the course of a full day.   2.2 The Review Team  2.2.1 The membership of the review team includes agencies from Manchester multi-agency child protection system and is represented by senior and specialist agency representatives to oversee the collation and analysis of information and outcomes of the review, as follows:   Homelessness Service  Service Manager, North District, Children’s Social Care  Named Nurse for Safeguarding Children (CMFT)  Head of Safeguarding CCGs  Designated Doctor CCG   Specialist Protective Services, Greater Manchester Police (GMP)  Case Worker, Education.  2.2.2 The Manchester Safeguarding Children Board (MSCB) commissioned Valerie Charles an independent lead reviewer with appropriate experience and training to co-ordinate and manage the review.   2.2.3 Valerie Charles works as an independent consultant and is registered with the Health and Care Professions Council (HCPC). Valerie has been qualified since 1991 and has a professional social work qualification and MA in Child Protection. She has extensive experience of working in children’s services in both the local authority and voluntary sector. She was a senior manager for NSPCC from 2006 to 2012. Valerie has worked in different roles within local safeguarding children boards, including chairing and authoring serious case reviews and has experience in systems methodology case reviews. Valerie has undertaken training for independent reviewers.   2.2.4 Key lines of enquiry were identified from the combined multi-agency chronology. Individual agencies were asked to provide a summary of their agency learning to the review.   2.2.5 The review team identified the ‘case group’ which comprised of practitioners and managers from services that would provide information and participate in the review.   MSCB Child I1 SCR Page 5 of 35 2.2.6 In March 2017, a practitioner and manager learning event was held. Group discussions with the case group were undertaken, facilitated by members of the review team and the independent lead reviewer. The staff roles of those involved in group discussions was as follows:    Social Worker x 2  Specialist Resource Team officer  Team Leader, Homelessness  Support Worker, Homelessness  Greater Manchester Police officer x 2  Deputy Head, Specialist Support School  Teacher, Specialist Support School  Nursery worker x 3  Health Visitor  Health Visitor Manager  Speech and Language Therapy (SALT) worker x 2  School Nurse  Physiotherapist x 2  Midwife  Occupational Therapist Manager   Occupational Therapist  Consultant Child Psychiatrist – Child and Adolescent Mental Health (CAMHS)  Officer, Manchester Safeguarding Improvement Unit, MCC  Consultant Paediatrician.  2.2.7 The independent lead reviewer used the information from the combined multi-agency chronology to identify key practice episodes for particular learning in this review.   2.3 Scope of the Review  2.3.1 The scope and timetable of the review were agreed. The time period under review is from February 2014 when the decision to convene an Initial Child Protection Conference (ICPC) was made, up to the children being removed on 24th December 2015.     2.3.2 The following agencies have provided information and contributed to the serious case review in accordance with Working Together to Safeguard Children (2015), Chapter 4 and the associated LSCB guidance and relevant learning and improvement frameworks:   Central Manchester Foundation NHS Trust (CMFT)   Pennine Acute Hospitals NHS Trust - midwifery services (PAHT)  Manchester NHS General Practitioner – CCG    North West Ambulance Service (NWAS)  Manchester Education Services   Greater Manchester Police (GMP)   Manchester Children and Families - Children’s Social Care (CSC)  Homelessness Team, MCC  NSPCC (did not provide any services to the family) MSCB Child I1 SCR Page 6 of 35  Greater Manchester Fire and Rescue Service (GMFRS) (did not provide any services to the family).  2.4 Key lines of enquiry 2.4.1 The review team identified and agreed key lines of enquiry for consideration in addition to analysing individual and organisational practice, as follows:  1. The extent, to which the impact of neglect was recognised, assessed and acted upon. 2. The adequacy, level and quality of risk assessments and interventions, including, the escalation and de-escalation of the case.  3. The adequacy of child protection plans, the functioning of core groups, the attendance and impact of non-attendance by agencies, oversight and challenge of the child protection case conferences, including robustness of decisions to cease child protection plans.  4. The quality and robustness of child in need assessment, planning and decision making. 5. How effective was inter-agency working, communication and decision making. 6. Professional’s roles and responses when attending a neglect case.  7. The ‘voice of the child’ and ‘daily lived experience’ – were the children spoken to/listened to? Were their views, wishes and feelings appropriately sought and taken into consideration? What factors impacted on this issue. 8. The extent to which mothers/parents own health needs had an impact on parenting capacity.  2.5 Structure of the review process  2.5.1 Over the course of this review, between January 2017 and April 2017, the review team met on three occasions. The review findings were presented to the Manchester Safeguarding Children Board in August 2017.   2.6 Status and ownership of the overview report 2.6.1 The overview report is the property of the Manchester Safeguarding Children Board (MSCB) as the commissioning board.   2.7 Parents contribution to the Serious Case Review  2.7.1 The parents were made aware of the Serious Case Review (SCR) by letter and were invited to make a contribution to the review. Mother and mother’s partner have not made contact. Father attended a meeting involving the independent reviewer in April 2017. Father attended a further meeting in November 2017, when the independent reviewer shared the findings of the review.  MSCB Child I1 SCR Page 7 of 35 2.7.2 The meetings with father provided an opportunity for him to discuss some of the services provided to the family from his perspective.   2.7.3 Father confirmed that he moved out of the family home with SIBLING 1 and SIBLING 2 in March 2014 and that his marriage had broken down.   2.7.4 Father said that initially regular contact was maintained and SIBLING 1 would stay with mother at weekends. In 2015, father saw less of the family and SIBLING 1 and SIBLING 2 had contact with their mother only 2-3 times in that year. Communication between father and mother became non-existent.  2.7.5 Father stated that he was concerned about the lack of contact and was intending to contact the social worker to see if there was anything he needed to be aware of. When the younger children were taken into care at the end of December 2015, father described being shocked and did not understand how the situation had deteriorated to such a degree when agencies were involved. 2.7.6 In 2013, when Children’s Social Care became involved with the family, father stated that the social worker was excellent and the help and advice given to them was invaluable. Father felt that they were given a chance at a time when they were really struggling as a family. Father stated that he has since been able to make positive changes in his life. Father stated that the social worker was courteous and struck a good balance between support and being clear about expectations.  2.7.7 During the period under review, father felt that he was not told enough, about his younger children SIBLING 3 and SIBLING 4, by the agencies involved. Father did acknowledge that he could have been more proactive and should have contacted Children’s Social Care himself.   2.7.8 Father stated that it was always made clear to him that Children’s Social Care were focussed on the children. Father confirmed that he has his own mental health issues and that a separate social worker or department to support him may have been helpful.  2.7.9 During the meeting when the findings were shared with father, he clarified from his perspective a number of points made within the report. Father stated that at no time was there any domestic abuse between him and mother. In relation to the reference, within the report, that an incident at the house in 2015 may have been an indication of domestic abuse, he stated that at that time he had not visited the house for a long period.  2.7.10 Father clarified that he had not stated that SIBLING 1 was bisexual. There had been a conversation between parents when they said that they would not be surprised if SIBLING 1 became bisexual when older. Father shared this conversation within a core group.  2.7.11 Father has no recollection of mother making a planned arrangement with him to care for the children when she went into labour.  Mother did contact him at the time of delivery, MSCB Child I1 SCR Page 8 of 35 to ask if he could care for the children, but he declined as he felt that he would not be able to manage all of the children together. 2.8 Diversity considerations of the family 2.8.1 The family’s cultural and ethnic heritage is white British.  2.8.2 Mother’s partner who is the biological father of CHILD I1 is described as a transgender person – who identifies themselves as female. 2.8.3 Mother now identifies as male.     MSCB Child I1 SCR Page 9 of 35 Section 3: Analysis of agency involvement and Key Practice Episodes  3.1 Key Practice Episodes 3.1.1 An important tool in the organisation and analysis of data using a systems methodology case review approach is the identification of key practice episodes. These are a selection of practice episodes that were key, in that they were significant to the way the case developed and/or was handled. These were identified by the independent lead reviewer with the benefit of their overview perspective of the case and provide a useful way of summarising the most significant agency contact and involvement during the period under review.  The information cited within the key practice episodes has been sourced from the group discussions with practitioners and managers, documentation and the combined multi-agency chronology.  3.1.2 The five key practice episodes that have been identified for more detailed analysis are:  April 2014 – Initial Child Protection Conference  July 2014 - Review Child Protection Conference  September 2014 - Initial Child Protection Conference for Unborn Child I1  May 2015 - De-escalation of Child Protection to Child in Need  Child in Need Planning and Review - June 2015 to December 2015.  3.2 Key Practice Episode 1: April 2014 – Initial Child Protection Conference  3.2.1 An Initial Child Protection Conference (ICPC) was held on 10th April 2014 in respect of the four eldest children (CHILD I1 was not born at this stage). The conference was held due to the deterioration of the home conditions (which were poor and unclean with mouse droppings, flies, clothes piled high, bin bags, newspaper on the windows, beds and sofas covered in clothes with nowhere to sit, and large furniture stored inside and outside the property), missed children’s health appointments, the complex dynamics of the adult relationships and parental mental health.  3.2.2 A friend of the parents (described as a transgender person – who identifies themselves as female) had moved into the family home. Mother reported that the family friend was her girlfriend. There were arguments and disagreements between the adults which resulted in a high degree of discord. Subsequently, the family friend became mother’s partner and biological father of CHILD I1.  3.2.3 The decision to convene the ICPC appears to have been prompted by concerns being raised with the social worker on 3rd February 2014, relating to deterioration in the home conditions and the relationships between the adults. There had been a significant period under Child in Need (CiN) planning without sufficient progress.  MSCB Child I1 SCR Page 10 of 35 3.2.4 On 5th February 2014, a referral was made to the police by Children’s Social Care (CSC) for a strategy meeting/discussion as part of Section 47 enquiries4. A telephone strategy discussion took place on 10th February 2014. Information was exchanged and it was noted that there had been a previous referral for neglect in April 2013. Police had not visited the address or seen the children but were in agreement for the matter to proceed to ICPC.  3.2.5 It is unclear whether the children or the house were seen as part of the Section 47 enquiries, as the recorded visit by the social worker is dated 27th February 2014, which is outside of the timescale for section 47 enquiries.  3.2.6 On 27th February 2014, SIBLING 2’s school raised concerns about poor hygiene and a rash on the child, in addition to lack of stimulation and poor home conditions. The paediatrician expressed concern that the carers were unable to meet the children’s needs but felt that a medical was not necessary as the evidence of neglect had been seen by the school. 3.2.7 The same day, 27th February 2014, an unannounced joint visit was made by the social worker and CSC team manager. Home conditions were poor, the social worker gave the carers (father, mother and mother’s partner) five days to ‘clean up the house’, change the hygiene standards of the children and sort out the living arrangements so the children were better cared for, stating a consequence of not complying would be legal advice being sought. 3.2.8 A follow-up unannounced visit was made by the social worker on 7th March 2014, and the home conditions had improved somewhat.  3.2.9 By the time of the ICPC, mother was eight weeks pregnant to her new partner. Father had moved out of the family home with the two eldest children to live with paternal grandparents in a neighbouring authority. Neither parent attended the ICPC but did submit reports detailing some of their health issues. 3.2.10 The ICPC identified the risks as follows:   The children had been living in chronically neglectful conditions, albeit there had been some recent improvement in the home. It was questioned how long this could continue, as the family had had previous interventions, over a twelve month period, where improvements could not be sustained and there was little evidence of change.    The three youngest children all had significant developmental delays and there was a lack of stimulation for the children:   o SIBLING 1 had a squint that had not been treated at an early stage.                                                        4 Section 47 Children Act 1989 requires a local authority to make enquiries they consider necessary to decide whether they need to take action to safeguard a child or promote their welfare when they have reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm.  These enquiries should start within 48 hours.   MSCB Child I1 SCR Page 11 of 35 o SIBLING 2 had significant developmental delay (delayed speech and language development), a diagnosis of autism (13.1.14), and was still in nappies. All of which has been impacted by a lack of early assessment.  o SIBLING 3 had cerebral palsy and significant learning and social communication difficulties and immunisations were outstanding. Physiotherapy appointments were cancelled nine times, and progress in eight months had been slow. Parents did not follow the physiotherapy programmes they were given for SIBLING 3.                              o SIBLING 4 was significantly developmentally delayed and presented as autistic. Immunisations were outstanding and appointments were missed for orthoptics. SIBLING 4 had been witnessed banging their head against the window in distress and there was possible lack of stimulation.   The parents had not demonstrated insight into their children’s learning and development needs, and physical disabilities. They had a lack of understanding of their children’s needs and consistently had failed to act on advice given to them.    Both parents had been reluctant to engage with professionals and when they had, the focus was on themselves and not their children. Home visits were monopolised by mother and her own issues, and she failed to act upon advice given to her. Parents were both said to suffer mental health problems - father had stated he had a counsellor for depression and was ‘bipolar’ (not formally diagnosed) and mother suffers from anxiety. Mother was diagnosed with chronic fatigue syndrome, was seen regularly by GP, and also had fibromyalgia and endometriosis.   Mother was not acting appropriately or taking the children to medical appointments. There had been approximately twenty three missed health appointments in eight months.    Minimal protective factors in the family home - no risk assessment had been completed.     There was concern about the role and background of mother’s new partner.  The nature of parents’ work was also a cause for concern and requiring further exploration – mother was said to work in ‘web fantasy’ and father worked within the pornography industry.  3.2.11 It was a unanimous decision of the ICPC that all four children should be made subject to child protection plans under the category of neglect. A comprehensive outline child protection plan was drawn up, identifying the need for Health to complete a chronology of all the families’ health needs, including attendance and non-attendance, with reasons for this, to assess patterns of behaviour. It was also stated that CSC should combine this Health information into a social work chronology. Significant assessments were required to be undertaken – including risk assessments in respect of parents’ apparent mental health problems, further parenting assessments, a risk assessment in relation to mother’s new partner, and a risk assessment in relation to paternal grandparents.   3.2.12 It was a recommendation of the ICPC that a strategy meeting involving the police needed to take place within 24 hours – this was to discuss the current home conditions, and MSCB Child I1 SCR Page 12 of 35 the concern that the family were a possible ‘flight risk’ (parents had not attended the ICPC and they had talked of moving house) and to explore the nature of both parents’ employment.  It was specifically stated that following the conference there needed to be a joint home visit by police and social worker to the family home. A strategy meeting was held, but it did not take place until 24th April 2014.  No joint visit with the police ever took place.  3.2.13 Due to the level of concern at the ICPC, and the recognition that there had already been significant drift in the case, a recommendation was also made that the social worker should consult about a legal planning meeting.   3.2.14 A first core group took place on 14th April 2014. Minutes of the ICPC were not received by Health for 5 months (19th September 2014) – significantly outside of timescale. 3.3 Summary appraisal of practice within Key Practice Episode 1 3.3.1 This key practice episode is particularly significant as it marks the escalation of the case from child in need status to child protection.   3.3.2 There is some evidence of attempts at multi-agency working within this key practice episode - the liaison between professionals to convene the ICPC, and to formulate a child protection plan. There is recognition that there had been some drift. There is clear identification of the many areas of concern, and there is recognition that the plan needed to be based on thorough assessment. There was also some references to the need for legal planning and advice to inform planning – both in the ICPC, and in the direct interactions with the family. These are the more positive and appropriate aspects of the interagency working identified in this key practice episode. 3.3.3 At the same time, there are many aspects of the interventions which are of significant concern. This includes examples of further delay and drift, not following procedures, poor recording and communication, and some loss of focus on the experience of the children. 3.3.4 The CiN plan had been in operation for a year before a CiN meeting concluded that the case should be escalated to an ICPC. The review has seen evidence of some good, task-focussed work carried out within the CiN plan. At times there had been some areas of improvement, although there was also a lot of evidence that any (temporary) improvements (such as in home conditions, or health appointments being made) were always reliant upon professionals taking responsibility, rather than the parents.  3.3.5 It is not clear to this review why the decision was taken at this point, in February 2014, to proceed to ICPC, rather than some months earlier. Deterioration in the already poor home conditions is cited. A deficit in the agency interactions and recordings in this key practice episode (and elsewhere) is in lack of specifics or details about these poor home conditions. An indication of the extent of the ‘clutter and mess’ in the house is in the fact that the family and professionals had been referring to the need to get a skip to help with a clear up since the previous summer (indeed this continues to be referred to throughout the period under review). 3.3.6 Analysis of the agency recordings and the professionals’ comments about the process of the section 47 enquiries, strategy discussion and the convening of the initial conference MSCB Child I1 SCR Page 13 of 35 indicates some confusion about these processes. It remains unclear why there was a significant delay between the concerns being raised on the 3rd February 2014, and the conference being held on 10th April 2014. This two month period was marked by a lack of urgency and lack of focus on the experience of the children, and there are clear examples of the agencies not working effectively together in a timely manner. The family was not visited in this period by CSC until 27th February 2014, and whilst the children were seen then and in the follow up visit a week later, the recordings do not include the voice of the child, or the daily lived experience of the children. 3.3.7 It has been suggested to the review that a culture had developed – particularly within the police and CSC - of responding in a very process-driven and routine way to requests for strategy meetings/discussions. This meant that they became seen as a necessary step to be taken in order to trigger an ICPC, rather than an opportunity to properly consider the facts and plan enquiries. In the record of the confidential discussions in the ICPC, the social worker explains that, on advice from the team manager, it was felt that a phone call to the police was adequate as they only wanted agreement from another agency to go to ICPC. There were a lot of agencies involved – particularly from Health – and they should have been invited to be part of the strategy discussions, and that this should take the form of a face-to-face meeting with full consideration of the need for home visits/the children being seen, etc. Indeed, it is notable that there was no apparent consideration at this point (or at any other point throughout the timeframe of this review) of the need for a police visit to the family home as part of an investigative process into possible neglect. Similarly, there is no indication that CSC or other agencies considered requesting police visit the house when conditions were deemed to be inadequate – particularly on the CSC visit on 27th February 2014.  3.3.8 Police have advised this review that key learning is that in circumstances where there is a request for a strategy meeting in relation to neglect, they should be involved in joint visits to the address to ascertain if the threshold for criminality has been reached.  3.3.9 The interagency working within the ICPC itself led to recognition of the complexity of the situation, identifying the many areas of risk. The voice of the child was not adequately captured (the consultation booklets ‘Have your Say’ were not completed at this point – or indeed for subsequent core groups). Whilst this booklet may not have been appropriate (given the children’s needs) guidance from the specialist agencies involved could have helped with obtaining the children’s views on their daily lived experience. There was, however, an appropriate identification of important actions to be taken within the outline child protection plan, not least the recommendations for a further strategy meeting and joint visit with police, the need for clear assessments and chronologies, and the recommendation for a legal planning meeting. It is of real concern that none of these was adequately followed up and that the failure to complete actions did not result in escalation by any agency.  3.3.10 In relation to the recommended strategy meeting, Health have recorded that the CSC team manager appears to have made a unilateral decision not to proceed to a strategy meeting without giving any explanation. There is no evidence of any consideration about this being challenged or escalated. A strategy meeting was held on 24th April 2014 - not within 24 hours from conference as the agreed plan. The health visitor attending the case conference was from another clinic and was not able to attend and the CSC report to this review states that it was unclear from notes what the purpose of this strategy meeting was, and little MSCB Child I1 SCR Page 14 of 35 information was exchanged.  Concerns about parents work were not recorded as being discussed in the meeting, and there was no consideration of the need for a joint visit involving police.  Police records show that a recommendation of this strategy meeting was for a legal planning meeting to be convened.  3.3.11 The handling of the issue of legal advice (at this stage, and throughout the timeframe of this review) appears particularly significant, not least because it seems to give an insight into the way the case was perhaps perceived by some professionals (as not meeting the threshold for legal intervention). It also serves to highlight some of the ways in which interagency working was not effective, with some indications of what the barriers to this may have been – some difficulties in professional relationships, coupled with lack of understanding of roles and responsibilities amongst some of the professionals. There was a lack of understanding of the issue of legal thresholds and the responsibilities of each agency. Professionals appear not to have adequately recognised their role in evidencing their concerns and following escalation procedures as appropriate. Instead, there was an over reliance on CSC having responsibility for case planning decisions. 3.3.12 Given the gravity and complexity of the many concerns identified at the ICPC, and the fact that over a long period of intervention no adequate change could be sustained, it was right that legal advice needed to be sought, carefully followed and reviewed throughout any proposed interventions. A decision to seek legal advice is for CSC to take rather than other agencies. Despite the various references to the need for this (at this point and elsewhere), the only contact with CSC legal services at this point was a planning meeting with the legal service on 23rd June 2014.  3.3.13 It is interesting to note that in the referral form for the legal meeting the social worker stated that the majority of the Health professionals believe the children should be removed – there is no other reference to this view of the Health professionals in the CSC case notes or recordings of interagency meetings. There was no evidence provided to the legal planning meeting as to why Health professionals held that view. The minutes of that meeting indicate that it was noted that ‘had the case come to legal planning at an earlier stage’ then it would have been a ‘Public Law Outline (PLO)5 case’. However, at the point of the discussions the social worker advised that the child protection plan was being effective and was addressing areas of concern, and therefore it was decided that PLO was not indicated. It was made clear that if there were any further concerns raised or care of the children slips again then it should ‘come back for legal planning swiftly given the history and children’s health needs’. 3.3.14 It has been commented to the review that CSC professionals (social worker and CSC team manager) did not view this as a case that was serious enough to merit legal action being taken. It is interesting to note that the message given to the other agencies involved was always that the case ‘did not meet the threshold’. There was never any significant challenge or escalation from any other professional to evidence that a different basis of intervention was required, or that the threshold may have been met.  Legal advice was not sought again until the children were ultimately removed from the family home.                                                         5 Public Law Outline (PLO) - this formal meeting is often known as a “pre-proceedings meeting” or “PLO meeting”. In some cases the social workers may feel that the risk of harm to a child is so great, or the case is so urgent, that the case should go straight to court. MSCB Child I1 SCR Page 15 of 35 3.4 Key Practice Episode 2: July 2014 - Review Child Protection Conference 3.4.1 A Review Child Protection Conference (RCPC) took place on 3rd July 2014. Three core groups had taken place since the ICPC. The CP Chair for the RCPC was different from the CP Chair who had chaired the ICPC. 3.4.2 It was decided that the meeting would take place in two parts to reflect the living arrangements for the children. Part one therefore considered SIBLING 1 and SIBLING 2 who had been living with their father in a neighbouring Local Authority area since before the ICPC. Part two of the meeting considered SIBLING 3 and SIBLING 4 who remained living with their mother and mother’s partner in Manchester. The same professionals were in attendance for each of the two parts of the RCPC. Parents again did not attend the meeting. 3.4.3 Part one of the meeting identified that:   SIBLING 1 was doing well at school.   Father was said to be taking action to address the children’s health needs.  Since separating from mother some difficulties were said to have been removed and this had had positive effects for the children.  There was regular contact with mother – although this needed more structure.  Health services from the new Local Authority needed to be obtained for SIBLING 2 without further drift/delay.  SIBLING 1 no longer at significant risk – SIBLING 2 needed a plan to prevent drift and to prioritise the services required.   3.4.4 A majority decision was taken to remove SIBLING 1 and 2 from child protection plans and to continue managing the case under CiN. The children were felt to be no longer at significant risk. The case was transferred to the neighbouring Local Authority on 14th August 2014 and closed to Manchester.  3.4.5 Part two of the meeting identified that:    There had been some improvement in home conditions.  There was progress with some tasks on the child protection plan – such as immunisations for the children, attending some appointments, and accessing some nursery and Stay and Play provision.   Mother had taken the children to a dentist but it was said that SIBLING 4 and SIBLING 3 would not cope with treatment at the time so the paediatrician was asked for a referral to specialist dentist service.  Mother and mother’s partner had been spoken to about behaving inappropriately (embracing/kissing) in the reception area – example of their lack of social awareness.  Mother’s partner has poor hygiene and was inappropriately dressed (‘see-through nightie’)   when the health visitor visits.   The social worker was completing a family assessment which other professionals were contributing to.  No problems with mother allowing professionals into the home.  MSCB Child I1 SCR Page 16 of 35  Mother was still anxious, pre-occupied by her concerns and stresses and could present as stressed and tearful. In respect of the children, mother tends to focus on the smaller concerns rather than the main ones.   There was mention of mother showing signs of disguised compliance and being likely to ‘revert’ if not under scrutiny and services are withdrawn.  The CP Chair challenged the social worker about the children’s poor daily lived experience and how long this could continue. It was the CP Chair’s view that a substantial and sustainable improvement was needed. The CP Chair also commented that improvements can only be sustained when a child protection plan is in place.  The social worker stated that CSC would always be involved to some extent – risks could be reduced but the need for services would not.  Discussion took place with CSC team manager and a legal planning meeting was held on 23th June 2014 - plan is effective/making good progress to date, no immediate safeguarding risks of harm, no role for legal as the threshold for proceedings/PLO was not met.    Concerns about the two older children when visiting mother's address.  Mother 20 weeks pregnant - referral to midwifery team and ICPC required.  Daily lived experiences of the children needed to be assessed further.  Father labelling SIBLING 1 as bi-sexual.  3.4.6 In Part two the unanimous decision was for SIBLING 3 and SIBLING 4 to remain subject to child protection plans.  3.5 Summary appraisal of practice within Key Practice Episode 2 3.5.1 The decision to hold the meeting in two parts, and the way it was organised, meant that there was decision making in respect of two of the children before there had been full information sharing about all aspects of working with the family. Indeed, it is notable that in the second part of the meeting (after decision had already been reached to discontinue the child protection plans in respect of the two older children who were in father’s care) there was further information fed in to the conference specifically about the care of these two older children – including they regularly stay with their mother, and as well as information about their father identifying that SIBLING 1 (six years old) is ‘bisexual’.   3.5.2 It appears that significant aspects of the original child protection plan had been ‘lost’ at this RCPC. There is in the minutes, for example, no mention of the fact that the ICPC identified the need for strategy meeting to happen within 24 hours to consider a joint visit with the police. The issue of looking into the parent’s work/employment does not feature in the minutes of the RCPC. Risk assessment of mother’s partner was said to be ‘on going’, and that ‘there appear to be no concerns’ – yet there are concerns expressed at the meeting about mother’s partner being young and lacking experience as well as concerns about being inappropriately dressed for visits and having poor personal hygiene. It was stated that the social worker was preparing a chronology in connection with the family assessment. No timescale was discussed for these assessments. There is no mention of a parenting assessment.   MSCB Child I1 SCR Page 17 of 35 3.5.3 It is notable that some information given to the RCPC conflicts with information recorded in minutes of Core Groups that had taken place. One example relates to the combined health and CSC chronology that had been requested as part of the child protection plan at the ICPC. Whilst the social worker said to this review meeting that a chronology was being prepared, they are recorded as having said in a preceding core group that a chronology is not necessary – stating that health had already completed a ‘comprehensive chronology’ presented at ICPC, and that CSC only had two referrals to add to it. This was not challenged in the core group. Health information to ICPC was, in fact, in the form of various reports, not a full chronology, and the CSC had a great deal of information about their involvement (as well as referrals) to include in a chronology. No combined chronology was ever produced, and this could have been crucial in enabling people to see how the case had progressed over a long period. Health and neglect concerns needed to be mapped, and issues in relation to parental health also needed mapping.  3.5.4 The social worker advised the RCPC that there has been no problem with mother allowing professionals in to the house – as this had been recognised as a significant issue. The Health chronology for this review, however, states that mother would not allow the health visitor access due to anxiety caused by unplanned visits, and the health visitor visit on 2nd July 2014 (day before RCPC) had to be a doorstep visit for about forty minutes. It is not clear why this appears to not have been challenged in the meeting – the health visitor was present. It was commented in the RCPC that the health visitor has not been allowed upstairs in the house.   3.5.5 The child protection plan included that an assessment was needed of the parents’ mental health issues. This was reviewed in the core group on 6th May 2014. The core group record states that neither parent had suffered with their mental health to a point that emergency steps have had to be taken and that both parents had sought advice from their GP. It states that the onus was on Health professionals to identify if any safeguarding concerns arose and to advise CSC of their risk assessment. At that point the social worker would undertake a risk assessment of the children’s needs. There is brief recorded discussion of the issue of mother’s mental health in the RCPC. The outreach worker (from the GP surgery) reports that the doctor wanted to make conference aware of concern for mother’s mental health. The social worker advised that she lacked sufficient knowledge in this area to be able to say how much of mother’s presentation is due to ‘personality and social and communication skills rather than actual mental health issues’, stating that this would need to be evaluated by someone with that expertise. However, there was no plan for any such assessment to take place, and no apparent challenge (from the CP Chair or anyone else present) about the lack of any plan for this assessment.  3.5.6 Given the history of the children’s basic needs not being met and changes not being sustained, at this point there needed to be a clear focus on carefully evidenced assessment from the various professionals. This needed to include each child’s individual welfare and development needs and robust assessment of the carers’ motivations and capacity to meet these needs. In response to concerns from the health visitor about parenting in the mother’s household, the social worker agrees there are ‘doubts’ (about parenting capacity) but that she needs to ‘establish all the evidence before considering legal’. In the confidential section of part two of the RCPC the social worker states that she has spoken with the legal department, but ‘cannot say there are immediate safeguarding risks of harm’. She goes on to MSCB Child I1 SCR Page 18 of 35 comment that the next step will be to see how mother copes with the extra child and if not ‘whether the response to the plan contains evidence for removal’. One of the two changes made to the child protection plan at the RCPC was for ‘focus to be on the daily lived experience of SIBLING 3 and SIBLING 4 as a contingency that legal planning is needed’ – it is not clear to the review team what is meant by this. What is clear is that no agency challenged the lack of adequate and evidenced assessment to inform the on-going risk management and intervention.   3.5.7 The review has heard repeated comments from professionals involved at the time indicating that they did raise, in core groups and other discussions, concerns about the nature of the risks. It has been said that whilst some progress was being made and tasks within the child protection plan were being achieved, the level of progress appeared small, and the daily experience of the children was not good enough, leading them to talk about whether the children should be left in these home circumstances or removed by legal action. The apparent response (from the social worker) was said to be that legal advice was that ‘the threshold was not reached’. The review can find no such record of these discussions within the records of meetings or discussions presented to the review. Indeed, it is noticeable that core group meeting records, record little in the way of comment from other agencies – they are recorded by the social worker. As highlighted earlier, however, the referral to legal department by the social worker does include comment that most Health professionals want the children removed.   3.5.8 It is notable that within the minutes of the RCPC the social worker makes reference more than once to their view that CSC would ‘withdraw from case at some point’. Considering the early stage in the child protection process, and particularly that this view is not informed by the completion of any assessments, and that there are still lots of concerns about the needs of the children not being met, it seems premature and overly optimistic to be expressing such a view.   3.5.9 There appears to have been little in the way of management oversight from the CSC team manager. Certainly, there was little or no CSC management presence at multi-agency forums – did not attend the ICPC or the RCPC’s. The CSC team manager did attend the legal planning meeting in June 2014, but was again reliant on the social worker for all information and perspective on the progress of the case.   3.5.10 The CP Chair did comment about how long the poor daily lived experience of the children could be allowed to continue – and did highlight how that experience for the children needed to be assessed further. The CP Chair has an important role in ensuring there is an appropriate plan in place, overseeing the working of the core group and challenging practice. There was not sufficient challenge to the loss of focus on important aspects of the child protection plan – such as the assessment of mental health, of parenting capacity, of the need for a comprehensive chronology, or any attempt to evidence or escalate concerns about progress within case planning. It cannot have been helpful that – due to resource issues – that the CP Chair chairing this RCPC had not been involved in the initial ICPC.    3.5.11 A summary of the analysis of the interagency working at this point would be that over-optimism was based on some progress with specific tasks and mother being quoted as MSCB Child I1 SCR Page 19 of 35 acknowledging the problems and the need to make ‘significant changes’. Insufficient attention is on the actual evidenced daily experience of the children. The overall understanding of the situation needed to be based on clear assessments – assessments of parenting capacity, informed by a good understanding of the parent’s backgrounds and abilities - including a formal specialist assessment of the mental health problems that they had presented as having and the impact of these - and underpinned by a clear combined chronology.    3.6 Key Practice Episode 3: September 2014 - ICPC for Unborn Child I1  3.6.1 An Initial Child Protection Conference (ICPC) was held on 12th September 2014 in respect of the unborn child (CHILD I1). Mother was approximately thirty-one weeks pregnant. The pre-birth assessment was completed on 5th September 2014.  3.6.2 The CP Chair who chaired this meeting was a different CP Chair to the two previous conferences.  3.6.3 The decision was made that the child be made subject to a child protection plan, under the category of neglect. 3.6.4 An outline child protection plan was completed and a core group was held to develop the child protection plan on 22th September 2014. The following actions were identified for mother and mother’s partner: to attend parenting course and implement the tools learned; to ensure that when born the baby’s health, emotional and developmental needs are met; to take on the support offered.  3.6.5 A midwifery detailed care plan was in place from 23rd September 2014, stating that a discharge planning meeting must be held prior to mother and baby’s discharge and that key professionals must be notified of the birth of baby. Additional information was included that mother’s partner (the biological father) is transgender and intended to use an artificial aid to feed the baby whilst as an inpatient.  There was no plan to address how the two other children would be cared for (or by whom) when mother went into labour and how the emotional impact on them would be managed.  3.6.6 Recording from the social worker’s visit on 17th October 2014 indicates that the house was ‘smelly’ but ‘clean’ and that planned work on the children’s daily lived experience would happen after the baby was born. It is not explained why it was felt this work should be further delayed, and there is no record of this delay having been discussed within core groups.      3.6.7 Midwife home visit on 20th October 2014 identified poor living conditions, unclean, upswept floor, crisp packets, no curtains at the windows (sofa cushions used instead) and unable to sit on the sofa due to the hygiene level. Mother made clear she wanted to be referred to as "dad" and mother’s partner as "mum". 3.6.8 On 23rd November 2014, CHILD I1 was born at home at 17:00hrs. A call had been made to the North West Ambulance Service at 17:10, the ambulance arriving at the home at 17:19. This was after CHILD I1 had been born – the call had not been made during labour or delivery or after the membranes had ruptured, as is usual. As mother was declining to come into hospital and there were concerns that the placenta had not been delivered, a midwife MSCB Child I1 SCR Page 20 of 35 attended the home arriving at 18:00.  Mother’s own hand-held midwifery record could not be located until just leaving the home (possibly further avoiding professional linking details). It is also thought significant that when the call was made the family gave a completely different name for mother – which had not been used before. There was reason to think that the family had been covertly preparing for a home delivery – for example, they had purchased a shower curtain to protect the bedding or flooring. Previous discussions with mother (7th July 2014) had made it clear that a hospital birth was appropriate as there was a significant risk to both mother and baby - as mother had had two previous caesarean births, and SIBLING 3 has cerebral palsy. Amongst the concerns noted on the day of the birth was that SIBLING 3 and SIBLING 4 were distressed, crying and agitated by the activity – and were not comforted by the adults who stated that SIBLING 3 was best ignored.  3.6.9 On 24th November 2014 mother and CHILD I1 were discharged home without the discharge planning meeting taking place. The mother wanted to return home as SIBLING 3 was upset without her and was smearing faeces. It was said that mother’s partner could not cope with looking after the two children and their distress was apparent.  The decision to agree the discharge of mother and CHILD I1 without the discharge planning meeting was taken with the involvement of the Local Authority Emergency Duty Service (EDS) social worker. The EDS social worker took the decision that the discharge meeting could take place the following day at home, and in the meantime mother and CHILD I1 could go home – this was on the basis that the main risks were identified as neglect rather than domestic violence or substance abuse.  3.6.10 There was a midwife home visit the following day, and the social worker also attended the home and explained the need to tidy up the clutter, as there was difficulty in moving around the room freely (described as untidy, smelled, two pushchairs, large cardboard boxes in the hallway). Mother appeared restless and was tidying up on arrival of the midwife. The midwife observed mother’s partner to appear childlike in manner and demeanour, required simple instructions, and was seen to sit on bed, stare and rock periodically. It was questioned by the midwife whether mother’s partner had some degree of learning disability.  3.6.11 Over time (eight post-natal home visits were made by the midwife), the midwife observed the environment to look less cluttered, more space in room/on floor, ammonia smell persisted (later the smell reduced and the smell of cleaning products was apparent) smell did later return as SIBLING 3 was reported to be potty training. When the midwife queried the smell in the house a problem of mice were mentioned.  3.6.12 On 3rd December 2014, a health visitor new birth visit was undertaken and the home conditions were recorded as satisfactory. 3.7 Summary appraisal of practice within Key Practice Episode 3 3.7.1 Given that the pregnancy was known about in April 2014 the timing of the pre-birth ICPC was late (outside of timescale). The social worker’s assessment was completed on 5th September 2014, giving no time for input from other agencies before the pre-birth ICPC. Indeed, the assessment appears as a single agency assessment, is brief, does not give any voice to the children, did not clearly identify risks to the unborn child and, given the history, appears over-optimistic. The assessment does signpost the need for other assessments to take place, such as a parenting assessment.    MSCB Child I1 SCR Page 21 of 35 3.7.2 The need for planning to be based on careful assessment – particularly of parenting capacity - is starkly demonstrated around the time of the birth of CHILD I1. There are clear indications from the observed behaviour of mother’s partner at the time, from comments made by mother that her partner could not cope, as well as from the distressed presentation of the children, that mother’s partner was not able to manage alone to meet the needs of two children with disabilities. There had been reason to be concerned about the abilities and vulnerabilities of mother’s partner previously, and indeed at the pre-birth ICPC on 12th September 2014 there are concerns that mother’s partner gets angry with people if confronted about behaving inappropriately, is said to be ‘quite volatile’, and is felt to have Asperger’s syndrome. It is perhaps most concerning that, even with this new information from the time of the birth no assessment of parenting capacity took place until much later (when the case was in proceedings). It has not been possible to understand why the planning around the birth of CHILD I1 did not include a practical plan about how the two other children would be cared for (and by whom) when mother went into labour and how the emotional impact on them would be managed (subsequently the RCPC in December 2014 was informed that father had agreed to look after the children but then let mother down – although there is no record of this agreement being part of the plan). 3.7.3 Parents chose not to seek assistance from medical professionals at the time of the labour and delivery, thus ignoring the risks that had been clearly highlighted. It appears they had been planning for a home delivery, and they then gave a false name when they did ring midwifery services. It is apparent from agency records, as well as from comments to this review, that professionals at the time recognised that the circumstances around the birth of CHILD I1 were of real concern. However, there appears to have been little or no consideration – by any agency - of how to respond to the risks. At very least, in such circumstances for children subject to child protection plans, there should have been consideration of triggering s47 enquiries, and having formal multi-agency discussions.   3.7.4 There is real concern about functioning of the core group at this time. It has been commented that the circumstances of CHILD I1’s birth were not discussed within the core group, and indeed a core group meeting held on 25th November 2014 (the day after mother returned home) even includes comments (from the social worker) about the fact that the monitoring that was needed for the family could be done under a CiN plan led by Health, rather than a child protection plan. The recording on the core group documents is brief in the extreme – not only is there no mention of the circumstances of the birth, there is no focus on risks. The review has been told that the core group document was updated by the social worker each time and this was not routinely then circulated to the other professionals, although sometimes the social worker would bring the record of the last meeting to the following core group (but not routinely). It was stated to this review that core group members were raising concerns within core groups – about the state of the house, the needs of the children, and the capacity of the parents to meet these. It has further been stated that ‘the core group wanted the children removing’– yet this is not reflected within any records of core groups.  3.7.5 Repeated comments to the review about working with the parents of CHILD I1 indicate that professionals found them at the time to be very ‘self-absorbed’, and wrapped up with their own pre-occupations. An example given of this, which is also borne out by some of the MSCB Child I1 SCR Page 22 of 35 agency recordings at the time, is that they regularly wanted to make clear to professionals how they wanted to be called (that CHILD I1’s biological father was to be called ‘Mum’ and biological mother was to be ‘Dad’), and that this was highlighted above the needs of the children. It has been further explained that the parents of CHILD I1 brought discussions about the needs of the children back to their own needs.  3.7.6 In the pre-birth ICPC there was some discussion of the fact that mother’s partner was planning on using an artificial aid to feed the baby. The CP Chair did question whose need this was meeting – that of CHILD I1 or of mother’s partner. It was left that this would be followed up in a joint visit with both the social worker and midwife. It appears no such follow up occurred about this.  A housing Connect support worker was asked about having this conversation, but understandably felt it was not their remit. Practitioners have commented that issues around gender identity, sexuality and CHILD I1’s parent’s preoccupations with their roles often clouded attempts to address issues around the needs of the children. There was some challenge to the comment from father that SIBLING 2 (at 6 years old) was ‘bisexual’ at an earlier core group, and professionals did have some concerns about sexual and social boundaries and the emotional impact on the children of issues that were potentially confusing to them. However, professionals were apparently fearful that by exploring some of these concerns there was the potential for appearing discriminatory. This may go some way to explaining why these issues were never appropriately addressed.     3.7.7 Repeated child protection visit recording indicates that the children are not being seen alone by the social worker or any member of the core group, and indeed some recordings of visits do not mention the children, which falls below expected practice. On a number of occasions family are on the point of leaving when professionals visit, and it is speculated that this was a deliberate strategy by the family to avoid the house being seen properly.   3.8 Key Practice Episode 4: May 2015 - De-escalation from CP to Child in Need  3.8.1 A RCPC took place on 14th May 2015. This was the third review for SIBLING 4 and SIBLING 3 and the second review for CHILD I1. Monthly core groups had been held.  The children’s mother attended this conference – this was the first conference that any of the parents had attended. Yet again there was a different CP Chair chairing the RCPC who had not been involved in any of the previous meetings.   3.8.2 Information was presented to the RCPC from professionals that there were no safeguarding concerns raised in the review period and there was progress and engagement from CHILD I1’s parents. The social worker reported that there were no escalating risks. Mother had ‘changed her life’ since the ICPC, mother and mother’s partner presented as a happy loving couple and put their children first. Furthermore, mother was said to be proactive in getting support for the children and addressing concerns. An example given of this was mother removing excess furniture from the house.   3.8.3 Tasks on the child protection plan were explored. There was progress with getting appointments – dates were in place for some more immunisations, a dentist was due to visit SIBLING 3, parents had taken SIBLING 3 for physiotherapy, CHILD I1’s health needs were being met and weighed monthly.  It was stated that parenting assessments were completed as part MSCB Child I1 SCR Page 23 of 35 of pre-birth assessment and Children and Parents Service (CAPS) completed an assessment which did not raise any concerns.   3.8.4 One aspect of the plan was for risk assessment of parents’ mental health to ascertain if future support was needed.  This action was said to be completed as an Edinburgh Post Natal Depression Scale6 had been completed in March 2015 with mother and she had shown no signs of low mood or depression. It was further stated that no concerns had been identified in the review period with parents’ mental health.   3.8.5 In relation to the voice of the child, it was stated that SIBLING 3 expressed their wishes through noises, smiling or leading you by the hand to what they were interested in. SIBLING 4 was happy in the home, CHILD I1 smiled and seemed happy and had toys. It was noted that the three children were not seen on their own due to their ages and learning needs.    3.8.6 There was talk about home conditions. The family had got a skip to get rid of some furniture. The house was said to be very dark (mother stated sunlight can make SIBLING 3 distressed), and the social worker reported on-going concerns about mice infestation in the property, and that it was difficult to keep the home clean and tidy because of the children’s particular needs.  3.8.7 The CP Chair gave a very positive summary of the RCPC and recommended that there was no evidence of significant harm, but a need for on-going support under a CiN plan for a minimum of three months. It was the unanimous decision of the RCPC that the children should be removed from the child protection plan.  A CiN meeting was arranged for 11th June 2015.  3.8.8 In the period leading up to the RCPC, there was evidence of some concerns and a pattern of missed appointments and difficulty in contacting the family was beginning to emerge. It is unclear if this was fully recognised and discussed within the core groups. In January 2015, core group minutes and child protection plan show little evidence of update since the last meeting. The child protection plan states that professionals believe that parents were doing all they can to meet the children’s needs (which seems to be a shift from previous conference discussions).  3.8.9 In February 2015, the home conditions were described as ‘could be better’ and within the CSC recordings there are contradictory comments, ‘mother must do more to meet the complex needs’ and the ‘child protection plan has been completed’.    3.8.10 In March 2015, the social worker reports having to take a ‘hard line’ with mother as the home conditions were a ‘little messy’ and the next RCPC will be to ‘de-register the children’.  3.8.11 In April 2015, the children were recorded by CSC as ‘thriving’.  3.8.12 In May 2015, the week before the RCPC, the family were said to be hiring a skip and were going to re-decorate. The home condition was still ‘variable’, but (as is the theme                                                       6 Cox, J.L., Holden, J.M., and Sagovsky, R. (1987) Detection of postnatal depression: Development of the 10 -item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150: 782-786.  MSCB Child I1 SCR Page 24 of 35 throughout) there is little detail about what this means. Mother was reported to be wearing dark glasses and had a puffy eye. Mother was reported to attend school and was seen by health staff wearing dark glasses and had a puffy eye. Mother said that something had happened at the weekend and father was not allowed in the property. This information was shared with the social worker, school and the health visitor.  It appears this may have been an indication of a domestic abuse incident which was explored at a home visit by the health visitor to which mother denied.  The information was not raised in the RCPC.      3.9 Summary appraisal of practice within Key Practice Episode 4 3.9.1 This was a very significant stage in the handling of the case as the decision to discontinue the child protection plans for the three children signified that they were not at risk of significant harm, and that their parents were able to meet their needs with the support of a CiN plan.   3.9.2 There had been areas of significant progress. The core groups had happened regularly, and mother had attended all of these in this review period. The family were being seen regularly, and some areas which had been a cause for concern had been addressed.  3.9.3 The RCPC was a long meeting and many areas were discussed, and in most of these some progress was highlighted. However it appears – from analysis of the records at the time, and from comments from the practitioners involved - that the concerns about lack of full information sharing, consideration of all the facts and any real challenge that was a feature of core groups, were also a feature of this RCPC.  3.9.4 Professionals involved have considered why it was felt appropriate at this time to discontinue the child protection plans. Comments have highlighted that there were still concerns about issues such as the state of the house, and indeed, that this fluctuated generally over the months of involvement, and that this was not significantly better or worse at this time, than at any other. Tasks on the child protection plan had been ticked off and others that remained could be followed up within the CiN process.  Again, it has been stated that different professionals were concerned about whether the parents had the capacity to meet the needs of the children, and that this had been raised repeatedly (which is not reflected in recordings), but the response was always that the case did not meet the threshold for legal action to be taken. 3.9.5 The CP Chair’s summary of the situation, in reflection of the discussion at the meeting, was a very positive one. Having different CP Chair’s chairing each meeting clearly gives scope for different approaches as well as a potential loss of issues or themes. It is notable, for example, that the CP Chair who chaired the previous RCPC (in December 2014) put emphasis on some of the aspects of the case that had not been assessed (such as the role of mother’s partner, and mother’s own mental and physical health), and highlighted the significance of the history which showed that the adults have struggled to meet the needs of the children.  3.9.6 It is clear that throughout the handling of this case much more weight is attached to completing specific tasks than to overall assessment which took into account history and MSCB Child I1 SCR Page 25 of 35 evidenced how the needs of the children were being, and could be met, by the adults7. There had been no real assessment of mental health of mother – the assessment quoted as happening in March 2015, is not an assessment of mental health needs, is used to identify the possibility of post-natal depression. Despite concerns about mother’s partner’s functioning and talk of possible learning disability or autism, there had been no assessment of this8. There was no challenge to the statement that the pre-birth assessment had included assessment of parenting capacity.   3.9.7 Many of the tasks that were achieved within the child protection plan could be seen to be very largely due to professional involvement (rather than parents) – availability of a chronology or clear history might have shown how this mirrored time when there was some progress before it became subject to child protection planning. There was some challenge by the CP Chair in this meeting to the fact that it took two health visitor visits before mother did take CHILD I1 to the doctor for a chesty cough as advised, but this pattern of professionals having to take responsibility for tasks happening is not drawn out. There was no mention, for example, in the meeting of the fact that the stated (and somewhat questionable) improvement in the home conditions was due to professionals taking a ‘hard line’ with mother in order to achieve the ending of the child protection plans.  3.10 Key Practice Episode 5: Child in Need Planning & Review - June to December 2015  3.10.1 The first CiN meeting was arranged for 11th June 2015. The CiN plan was developed and meetings were held every six weeks.  3.10.2 The case was re-allocated to newly qualified social worker on 24th June 2015. At the point of re-allocation of the social worker there was no formal handover of the case and it was allocated on the understanding that it was ‘low level CiN’ case and would close in 2/3 months. The CSC management records show a plan to de-escalate to universal services. 3.10.3 On 25th June 2015, the health visitor was informed that mother had repeatedly cancelled home visits with speech and language therapy (SALT) over recent period and had given medical reasons.  It was agreed that the health visitor would discuss this with mother. By July 2015, the health visitor had last seen the home in May 2015.  3.10.4 A joint home visit by Health professionals took place on 8th July 2015. This detailed a number of concerns indicating a significant deterioration had taken/was taking place. These included: prolonged waiting for door to be answered; window not fixed as previous visit; strong chemical smell (felt to be an attempt to mask other smell of dirty laundry); food in the buggy; being ‘ushered’ into the back room so not seeing other part of the house; bed in the room; conditions had deteriorated, more toys and clutter, visible dirt and rodent droppings, rodent observed in the living room and a skip filled with father’s belongings.                                                        7 The review has been advised that the use of Signs of Safety (SOS) approach (The Signs of Safety, developed by Andrew Turnell and Steve Edwards, 1994) in case conferences may be a beneficial approach to risk assessing.  8 A visit was completed with the PAM’S (Parent Assessment Manual - PAM) assessor, who did not appear to identify learning difficulties. CSC records are unclear about what kind of parenting assessment was carried out involving the PAM’S assessor, but it should be recognised that CSC did attempt to get a learning disability specialist involved.  MSCB Child I1 SCR Page 26 of 35 3.10.5 At the next CiN meeting on 16th July 2015, it was recorded that all professionals expressed that parents ‘need to keep on top of housing conditions and liaise with landlord regarding the ‘damp’. It is not evident that there was any discussion about the fact that significant Health appointments were being missed and was difficulty in contacting the family. Indeed, it was recorded that mother ‘continues to attend meetings and is working with professionals (and that mother) has ensured that the children's health needs are being met by attending appointments and allowing professionals access’. 3.10.6 The pattern of missed appointments/difficulty in seeing the family continues over the following period with a number of cancellations of home visits by mother.  Mother was using emails to communicate with Health professionals.  3.10.7 A CiN meeting took place on 1st October 2015. There was discussion about the fact that there had been three failed health visitor home visits and the non-attendance for CHILD I1’s nine months’ developmental assessment (which was subsequently attended on 15th October 2015). It was identified that the health visitor had not seen the home since May 2015.  3.10.8 There was an unannounced social worker visit on 5th November 2015. The three children were seen in timescales and described as well. The family had a skip and were de-cluttering the house and redecorating. 3.10.9 On 9th November 2015 a SALT report confirming SIBLING 3’s progress since starting school over twelve months, interactions had improved. On 12th November 2015, a further health visitor appointment was cancelled via email from mother due to family sickness. 3.10.10 On 10th December 2015 in supervision the CSC team manager considered whether CHILD I1’s case should remain open as there had been no concerns about their care and no additional needs were identified, and it was that closure of CHILD I1’s case would be considered subject to information from Health and other professionals about needs and developmental progress. However, in the CiN meeting the following day (11th December 2015), it is identified that CHILD I1 had missed immunisations again and it is not clear whether they had been weighed recently. Professionals queried what support could be put in place if the case was closed to social workers. Mother referred to having had a seizure and was going to a GP appointment.  3.10.11 On 15th December 2015 a planned home visit was cancelled as the health visitor was off sick. Mother was advised that she could contact the duty health visitor if she required any support in their absence. On 16th December 2015 the GP advised mother to go to A&E regarding blood results. Mother wanted to consider this as she was worried about the children. On 18th December 2015 there was a telephone consultation between GP and mother to discuss blood results, which showed increased concerns about mother’s health due to increased infection markers. However, mother was not keen to go to A&E, despite medical advice, due to childcare issues.  A further GP consultation the next day advised mother that she needs A&E attendance as she could have serious illness, and it was said that she understands that she may be putting her life at risk if a significant infection. 3.10.12 On 24th December 2015 there was an unannounced social worker home visit. It was felt that the children were evidently suffering from neglectful parenting. There was a vermin MSCB Child I1 SCR Page 27 of 35 infestation with mice clearly running around the floor and excrement on the floor. There was no running water, no flushing toilet and rubbish overflowing from the bins. There was limited, if any, walking space on the floor, and rubbish, including dirty nappies cluttering the house. There was no edible food in the house. The three children appeared to be in distress and were rocking and upset. CSC removed the children with agreement of mother under Section 20 of the Children Act 1989. 3.10.13 The incident on 24th December 2015 was attended by police response officers. The incident was coded incorrectly, which meant that the appropriate updates were not made on the log and the attending officers provided no risk assessment of the matter. As a result, the incident was not escalated to the Public Protection Investigation Unit (PPIU) by the attending officers and therefore crimes were not submitted, Police Powers of Protection (PPP)9 was not utilised and medical examinations of the children do not appear to have been requested10. However, the children were safeguarded and removed from parental care. 3.11 Summary appraisal of practice within Key Practice Episode 5 3.11.1 There had been some recognition in previous meetings that the important time for seeing whether the adults could meet the needs of these children adequately might be when the framework of the child protection plan was withdrawn and there was not so much support, scrutiny or pressure from the professionals. In addition to any message that the decision to end the child protection plans may have given the family, it does appear from comments from the professionals involved and analysis of agency records, that that decision also had a significant impact on how the professionals viewed the case and their role.   3.11.2 It is clear that there had been emphasis by some professionals on trying to achieve ‘de-registration’ (the ending of the child protection plans). Once this had happened, it seems that the focus was on providing a level of support to the family – notably to mother – and not so much on the daily lived experience of the children, and whether this was good enough. 3.11.3 This was always a complex situation. There were three young children who had multiple needs and were not able to communicate verbally, and the CSC team manager had rightly identified at an earlier stage that they would require parenting that was above the expectation for most parents. Whilst there had not been clear assessment of the histories and parenting capacities of the adults, it was very apparent that the parents themselves had their own complex needs – mental health needs, possible hoarding behaviours, possible learning disability, some physical health concerns, poor histories, etc. There were difficult dynamics between the adults, a mother who was articulate but with a clear history of avoidance and not working openly with professionals, and above all a history of not being able to make and sustain the necessary change and to prioritise the needs of the children. Whilst it is not well                                                       9 Section 46 provides the Police with Powers of Protection to take children into police protection where a constable has reasonable cause to believe that a child would otherwise be likely to suffer significant harm. 10 GMP have already identified learning in relation to the inactions of the initial responding officers on 24th December 2015 and this has been addressed via the PPIU Detective Sergeant and their line manager in relation to the submission of crimes once offences had been disclosed.   MSCB Child I1 SCR Page 28 of 35 documented, there had been numerous discussions about whether the children should be with the family, and consideration of legal action.  3.11.4 Despite this context, it is clear that the case was at this point seen as a straight-forward, and ‘low-level’ case. It was therefore felt appropriate to allocate to a newly qualified social worker. The new social worker inherited the case from an experienced colleague and was then managed initially by the same CSC team manager who previously was responsible for the case, who had the view that the case was heading towards the CSC withdrawal. The social worker received very little in the way of management supervision at this time – the review has been advised that there were no formal supervision sessions for nine months. The social worker was not experienced in working with children with disability, and it has been highlighted to the review that they therefore lacked confidence to challenge an articulate mother who was used to confidently asserting her views, and came across as knowing her children and what they needed. It is also would seem that the social worker was unlikely to find it easy to challenge the prevailing view of the case within CSC.   3.11.5 This optimistic view of the case appears to have been shared by the other agencies involved. Certainly, there is no indication of any significant challenge, or anyone highlighting that there was reason to be very concerned about a possible deterioration in the circumstances for the children. There was a clear pattern emerging  – about mother avoiding professionals, missed appointments, deterioration in the conditions within the house – all of which ought to have triggered concern about whether the needs of the children were being prioritised.  3.11.6 The fact that all of these problems were clearly present within a very short while (i.e. with the first two months) after the ending of the child protection plans, should have alerted those involved to the need for a robust response, and a clear plan to tackle the issues such as the home conditions and meeting specific appointments to meet the health needs of the children. There is no evidence of any consideration about the case being re-escalated at any point within this key practice episode.  Instead there was an acceptance that various appointments were being cancelled or missed – there appears to have been little communication between the professionals about this, as well as no real challenge of the family.  3.11.7 With regards to the lack of response to the deterioration in home conditions within this period, it has been commented that the professionals felt that the daily demands on mother – such as taking the two children to nursery, to appointments etc. – meant that there was some ignoring of how bad home conditions were.  3.11.8 It appears that there was no lack of communication with family, but much of this was by email. It is (now) recognised that mother may have been deliberately using emails to keep dialogue going with professionals, to be in control of what was said (it is stated that emails would be about her issues rather than the needs of the children) and at the same time this was communicating without allowing access to the home.  3.11.9 It is notable that most of the interaction that took place in this time was with mother. There is little reference to the role of mother’s partner and their role. In the discussions with the GP mother gave indications that she did not feel that she could leave the children in the care of her partner. This was significant information that should have been explored further MSCB Child I1 SCR Page 29 of 35 and been made known to the other professionals working with mother. It appears the GP did not inform other professionals of the risks to mother’s health in the late stages of this period, or of the reasons why mother would not get medical help (going to A&E) as she was being advised. Other professionals were concerned about mother’s health – particularly following her disclosing she had had a seizure – but this did not trigger any liaison with GP.    MSCB Child I1 SCR Page 30 of 35 Section 4: Conclusion  4.1.1 It will be apparent from the foregoing analysis that the case under consideration was a very complex one and posed significant challenges for the professionals involved over the timeframe of this review. The process of trying to understand what influenced decisions and practice – and the systems in which these operated at the time has also presented some real challenges. Whilst there are undoubtedly some significant questions about professional actions and influences which have not been fully understood, there are some clear themes that emerge from the scrutiny of agency actions within the five key practice episodes identified as the focus for this review. These include poor communication between agencies, poor recording, loss of focus on the voice of the child and the daily lived experience, focus on task-completion rather than on on-going assessment of impact of the work being done, lack of recognition of the importance of chronologies to show the context of previous history, lack of challenge, and lack of healthy scepticism amongst the professionals working on the case.  4.1.2 There has been much scrutiny of interagency working in situations where children are subject to neglectful parenting – indeed, neglect has been a factor in sixty per cent of recent serious case reviews11. The work in such situations is rarely a simple or straight forward process. Adults who neglect children often have their own complex needs, and have entrenched patterns of behaviour and are very resistant to change12. Undoubtedly, working with this family at the centre of this review was always going to present real challenges to the many professionals involved.   4.1.3 A fixed and overly optimistic view of the case - that the children’s needs could be and were being met by the parents - quickly came to define how the case was seen and responded to by key professionals in the core group. This view did not change in response to new information. It has been identified that the social worker was influential in the development of this over-optimistic view, but it is also clear that other professionals also shared this view and contributed to the over emphasis on the perspective of the parents, rather than on the daily lived experience of the children. This view, which was never effectively challenged within the core group, can be seen to drive decision making and influence how the case was handed to the new social worker. The focus of much of the work was on completion of tasks within the child protection plan, rather than on assessment of the outcomes, or of the impact of completing these tasks. 4.1.4 The multi-agency core group did not function effectively. There were real deficits in information sharing – both within and between meetings – which included significant information not being shared. Comments from practitioners have highlighted that significant professionals were not always invited to core groups – and it seems, were not sufficiently proactive in ensuring their input to these meetings. There were significant deficiencies in the way multi-agency meetings were recorded – being very brief, not reflecting discussion,                                                       11 Brandon, M. et al. (2013) Neglect and serious case reviews: a report from the University of East Anglia commissioned by NSPCC. 12 Working Effectively with Neglected Children and Their Families – What Needs To Change? Farmer & Lutman (2014). MSCB Child I1 SCR Page 31 of 35 disagreement or challenge that did take place, not highlighting the risks or impacts on children, and not being circulated in a timely or useful way.  4.1.5 The CP Chair service has a crucial role in overseeing and quality assuring the multi-agency working. There were examples of good identification of risks and issues by CP Chairs in particular meetings and of some good challenge of the prevailing view of the core group. However, the overall challenge provided by the CP Chairs - particularly to the loss of emphasis on intervention being informed by careful and on-going assessment of the experience of the children within an appropriate overall context - was not sufficiently robust or consistent.  The fact that there was no consistency of CP Chair throughout the period was undoubtedly a contributory factor to this.  4.1.6 The parents’ needs were, at times, more evident and a greater focus of professional attention, than those of the children. Within conferences there had been recognition of the need to undertake some assessments of parental mental and physical health problems, assessment of the role and background of mother’s partner and, most significantly, of parenting capacity. Perhaps the most significant deficit in the interagency interventions in this case over the timeline of this review is the failure to carry out evidenced based assessment, which could inform the interventions, and might have identified whether there was capacity for change.  4.1.7 The different ways in which the parents acted to deflect professional attention from what was happening for the children have been highlighted. It is understandable that individual professionals did not always feel confident in their responses to some of these issues. More than one comment was made to the review, for example, about professionals not feeling comfortable in discussing with parents some of the issues they presented with around gender roles/transgender issues, and sexuality. However, more effectively functioning multi-agency working would have helped identify how far these issues might be impacting on the children, or indeed, on the agencies’ attempts to work with the family. There is little evidence that the professionals were able to challenge each other effectively and to consider all new information with a greater degree of healthy scepticism. This meant that despite some reference to disguised compliance by the parents, there was never any appreciation of the significance of each missed visit or health appointment.  4.1.8 The review notes that during the period of under review the latest Ofsted inspection identified significant concerns about how children were being safeguarded at the time. There is an improvement plan in place, which addresses issues highlighted by Ofsted13.  4.1.9 The analysis of these key practice episodes has led the review team to produce three significant recommendations in the form of Findings that it is felt the Manchester Safeguarding Children Board should address.                                                        13 The Ofsted overall judgement is that children’s services and the Local Safeguarding Children Board are both inadequate - Manchester City Council Inspection of services for children in need of help and protection, children looked after and care leavers and Review of the effectiveness of the Local Safeguarding Children Board Inspection date: 25 June 2014 – 16 July 2014 Report published: 01 September 2014.  MSCB Child I1 SCR Page 32 of 35 Section 5: Findings 5.1 Finding 1: Voice of the Child 5.1.1 In examining reports and records, and the comments from professionals, there is a marked absence of reference to the perspective and the daily lived experience of the children. The children through age and complex needs had difficulty with communicating. This creates an imperative to look closely and with healthy scepticism - and with clearly evidenced observations - at what the daily lived experience of the child might be in order to better understand their views and ensure their voice is heard.  5.1.2 One illustration of this failure to highlight the daily lived experience of the children is the absence of any recognition of the specific needs (such as routines, response to change and environmental impacts) of a child with autism within the plan that was in place. Indeed, there was little attempt to illustrate within the planning – through SMART plans – what improvements were being sought in terms of the daily lived experience of the children throughout the interventions.  5.1.3 Whilst services were provided to the family, without the necessary focus on the child’s experience and specific improvements in outcomes, it is hard to quantify whether the daily lived experience of the children was ever good enough.  5.1.4 In instances of work with children with disabilities and complex needs the process of understanding their daily lived experience is necessarily more complex. The involvement of practitioners specialising in work with children with such needs would be beneficial in helping to assess their needs and perspective.  5.1.5 In contrast to these concerns about the voice of the child not being sufficiently heard, it is apparent that there was significant professional focus on the perspective of the adults, particularly mother. These concerns – too much focus on working with parents and insufficient emphasis on the voice of the child – reflect the key findings from an evaluation of other serious case reviews14.  5.2 Issues for MSCB to consider in regard to learning and improvement  1. The MSCB needs to ensure that consideration of the voice of the child and the daily lived experience of the child is the primary focus of all agency interventions.  2. Is the MSCB satisfied that there are arrangements in place for the involvement of practitioners with particular experience and expertise in working with children with disabilities and complex needs to ensure that their views, needs and daily lived experience are fully understood? 3. Is planning sufficiently SMART, and do the plans focus on the required improvements in terms of quantifiable outcomes for the children?                                                        14 The voice of the child: learning lessons from serious case reviews, Ofsted, 2011. MSCB Child I1 SCR Page 33 of 35 5.3 Finding 2: Assessments in cases of neglect 5.3.1 In cases of neglect interventions need to be informed by thorough multi-agency assessment based on clear understanding of history, for which a combined multi-agency chronology is an essential tool. Assessments must always focus on children’s needs and required outcomes to ensure that progress of plans can be regularly and realistically reviewed.     5.3.2 In this case the need for various assessments was recognised, but no adequate multi-agency assessment ever took place. In the absence of assessment there was significant drift, a failure to recognise the importance of previous history, and interventions became overly focussed on the parental perspective. Planning and reviewing relied on the completion of tasks rather than on on-going assessments of impact on the children.  5.4 Issues for MSCB to consider in regard to learning and improvement  1. Is the MSCB satisfied that professionals undertaking assessments are supported by appropriate and robust frameworks and tools?15 2. Are assessments in cases of neglect being informed by the completion of comprehensive multi-agency chronologies?  3. Is the MSCB satisfied that there is sufficient management oversight and quality assurance in place for these assessments? 5.5 Finding 3: Multi-agency working  5.5.1 In cases of concern about long term neglect it is important that the agencies work closely together to ensure there is good sharing of information and consideration about the progress of interventions. This is particularly important in cases – such as this - which involve difficulties in engaging with families, and especially where there is reason to be concerned about disguised compliance16 17.  5.5.2 There were significant difficulties and deficits in the multi-agency working in this case. At times there was poor sharing of significant information between professionals. Meetings were not always appropriately attended. There were times when there needed to be multi-agency meetings (including strategy meetings in relation to significant concerns), to reflect on information and plan work, but instead there was brief, (process-driven) discussion between just two key agencies.                                                       15 For example: - CANDO Health Neglect Tool and the Graded Care Profile a tool for assessing neglect.  16 Disguised compliance involves a parent or carer giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention - Disguised Compliance NSPCC Factsheet, 2010. 17 Disguised compliance by parents was a common feature in cases reviewed by Ofsted in their national report on professional responses to neglect. The report noted that there was significant variation to the extent to which clear strategies were adopted to manage such behaviour - In the child’s time: professional responses to neglect. Ofsted, March 2014.  MSCB Child I1 SCR Page 34 of 35 5.5.3 One key issue identified was the repeated failure of the multi-agency group to provide appropriate challenge. Some of the child protection conferences did include some challenge to the prevailing view of the case by the professionals, and questioning of whether alternative plan was appropriate. However, there is no evidence that other multi-agency meetings routinely included the group questioning whether the view about the concerns and risks posed, or the progress of the interventions was sufficient or appropriate. Whilst there are comments that within meetings there was some discussion and challenge (which apparently included repeated reference to whether the children’s needs could be met by the parents), these concerns or challenges were not appropriately robust or persistent and are not reflected in the records of core group meetings.  5.5.4 Records of core group meetings were of poor quality, showing little detail of discussions and often do not make clear where the information and plan has been updated from the previous meeting. Records of meetings were not routinely circulated in a timely and useful manner.  5.5.5 One issue that illustrates many of these concerns about the multi-agency working is that of the agencies’ discussions and understanding around legal planning. At various points, including in child protection conferences, the need for the work to be informed by legal advice was indicated. It has been stated to the review that on a number of occasions various professionals expressed their view that the children should not be in the care of the parents, but they report being told by CSC that the threshold (for legal action) was not met. However, what was required was for agencies to work together sharing their areas of expertise to highlight evidence of the capacity of the carers, of the welfare and development needs of each child and their daily lived experience. This could have led to more appropriate risk assessment and management, or else to appropriate escalation if the response to this assessment was not felt to be adequate. Similarly, there was little consideration (by any professional) about the need for police investigation and what this would have required – particularly for a home visit involving the police to look at evidence for a possible prosecution.   5.5.6 Professionals were unclear about their roles and responsibilities as part of the multi-agency group. There appears to have been some power imbalance in terms of how different professionals felt able to contribute to the meetings and share their views and concerns. Individual practitioners have said that they felt uncomfortable about discussion in relation to transgender and sexuality issues, and the response seems to have been to avoid raising the concerns that they (legitimately) had about how these might be impacting on or obscuring the needs of the children. 5.5.7 There was no attempt at escalation and professionals have reported being unclear about escalation processes. There was a lack of management oversight and support to ensure there was appropriate reflection about the handling of the case. Management oversight within individual agencies should have highlighted how the MSCB Multi-Agency Escalation Policy18 could be implemented, but this did not happen.  5.5.8 Whilst the review has noted some positive practice from the many CP Chairs who chaired the meetings, the overall input from the CP Chair service did not provide the required                                                       18 MSCB Multi-agency Escalation Policy issued by the MSCB in June 2015 as supplementary guidance to the Greater Manchester Safeguarding Partnership (GMSP) Escalation Policy. MSCB Child I1 SCR Page 35 of 35 level of consistent and robust challenge to the planning and loss of focus on the important aspects of the children’s experience. 5.6 Issues for MSCB to consider in regard to learning and improvement  1. The MSCB needs to satisfy itself that professionals across all agencies are confident and empowered in their contributions, roles and responsibilities within multi-agency working. This includes their responsibilities in respect of challenging considerations, decisions and planning made by the multi-agency team.  2. Is the MSCB satisfied that professionals across all agencies are aware of the multi-agency escalation policies and procedures and in what circumstances these should be implemented? 3. In cases of neglect where there is a request for a strategy meeting, should the MSCB review its procedures to ensure that a full multi-agency, face-to face meeting MUST take place? Should a request for a strategy meeting in such cases of neglect always involve the police in a home visit to ascertain if the threshold for criminality has been reached?   4. Should the MSCB consider a review of the multi-agency paperwork/tools and the way they are used, and circulated?   5. The CP Chair service has a key role in overseeing the effectiveness of multi-agency working. Is the MSCB satisfied that workload and management support to CP Chairs enables them to effectively fulfil their statutory duties to monitor and quality assure this work – including monitoring progress of cases between meetings and appropriate escalation as required? 6. Is the MSCB providing adequate training and support to member agencies specifically around transgender and sexuality issues (and how they may or may not impact upon the parenting) to ensure that professionals feel confident in raising any concerns they might have when working in cases where such issues add to the complexity of planning? 7. Does the MSCB agree that there is a need for a programme of training and support to ensure that professionals across member agencies have an adequate understanding of their roles and responsibilities in relation to risk management and legal planning? Specifically, such training and support could focus on professional roles and responsibilities in relation to ensuring that assessments are informed by clear evidence, and in relation to agency escalation processes in situations where there is drift or delay in the response to such evidenced assessments.  