Severe neglect and abuse of a large group of siblings by their mother and father over many years. Care proceedings concluded in 2017 and the children are no longer under parents' care. Six of the siblings are now adults. Evidence of the children suffering significant neglect and abuse by their parents between 2007-2017. Home environment was overcrowded, chaotic, dirty and unsafe. Evidence of physical abuse, domination and coercion, and failure to prevent physical and sexual abuse between siblings. Failure to ensure that the children received medical care or attended school regularly. Parents were uncooperative; aggressive to professionals with some disguised compliance and manipulative behaviour. Several of the children made subject to child protection plans for neglect in 2007-2009; in July 2016 police protection was taken on all the children under 18 living with the parents and interim care orders were granted. Learning includes: overwhelming nature of the complexity and scale of the problems and of the oppositional, hostile behaviour of the parents; responses from all agencies to concerns and interventions were generally short-lived and episodic; children's lived experience was not fully appreciated. Ethnicity and nationality not stated. Recommendations include: develop a model for interagency practitioner supervision for complex cases where working together closely and consistently is of paramount importance; ensure that the use of the Public Law Outline is being used effectively to give local authority and social workers sufficient leverage with families which are deliberately obstructive by clarifying their concerns in a 'Letter before Proceedings' or further action.
      
    Serious Case Review No:  2020/C8262  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.         Serious Case Review   Conducted Under  Working Together 2015  Children’s Case W    Overview Report        Lead Reviewer Amy Weir MA MBA CQSW      2 | P a g e  Final 12.09.2018  SCR CASE W      LIST OF CONTENTS   1. INTRODUCTION AND BACKGROUND TO THE REVIEW  3 2. REVIEW PROCESS  3 3. NARRATIVE OF KEY EVENTS  7 4. The EXPERIENCE of the CASE W children 15 5. THEMATIC ANALYSIS & EVALUATION OF PRACTICE and THE WAY AGENCIES WORKED 19 6. Summary Thematic ANALYSIS 26 7. FINDINGS 28 8. CONCLUSIONS 30 9. RECOMMENDATIONS  31   Appendices  Appendix A - List of References           3 | P a g e  Final 12.09.2018 1. INTRODUCTION AND BACKGROUND TO THE REVIEW  1.1 This Serious Case Review (SCR) was commissioned following concern about the neglect and abuse experienced by the children of Family W over a period of many years. It considers the circumstances in which services were provided to the children and their family and seeks to identify learning about how practice could be improved. 1.2 All the names in this review have been anonymised and the children are known as W within this review report.  The case review considers the experience of the children but also of the older children of the family who are now adults.   1.3 There were care proceedings in relation to some of the children. These were concluded in 2017 and the children are no longer in the care of their parents.   1.4 The circumstances of the neglect and abuse experienced by the children of this family led to the decision in September 2016 by the Chair of the Local Safeguarding Children Board to undertake a serious case review.  The criteria for commissioning a SCR, as set out in Working Together 2015, were met.   2. THE REVIEW PROCESS 2.1 This review has been conducted with due regard to the principles of fairness, impartiality, thoroughness, accountability, transparency and above all with a focus on the children. The consideration of their interests and experience has been the central focus of the review. The significance of the circumstances in which they were abused and neglected has affected all those involved in the review.  2.3  Amy Weir, who is an experienced independent safeguarding expert, was appointed as the independent reviewer. A panel of senior managers 4 | P a g e  Final 12.09.2018 was formed to support the process.  Amy Weir wrote this report with the support and advice of the SCR Panel.   2.4 Critical points in the case were considered in the SCR. Possible reasons for actions taken at the time and learning and improvements that are now still needed have been identified – including the significance of these insights for current practice. Where there was evidence of good practice in the case, this has also been noted. These findings will inform the LSCB’s Learning and Improvement Plan and they have already led to progress in improving local practice.   2.5 This investigation has examined key documents and involved experienced senior managers who have had no direct involvement in this case. The root cause analysis “fishbone” approach to identifying key contributory factors has been used. The aim of this has been to gain an understanding of how the interaction between the various factors influenced the way practitioners responded to the children and their family.  2.6 There have been several other serious case reviews conducted by the LSCB in the last 2 years which have found that there were issues for all agencies about the effectiveness  of the identification of, and addressing of, the severe and chronic neglect of children. This review also looked across these other reviews to ensure that the learning from each of the others is considered within the findings of the Case W review.  2.7 A key focus for this review has been to ensure that the voice of the children, their wishes and feelings have been taken fully into account. This is a very large sibling group and the children’s experiences of being parented have varied considerably but it is clear that there has been significant harm and suffering for the children as a result of the compromised and inconsistent parenting they received from their parents.   5 | P a g e  Final 12.09.2018 2.8 The family have not been contacted about this SCR. It is not the intention to advise them that this case has gone through the review process because of the complexity of the relationships and the conflicting and differing views of family members. The parents are confrontational and have never demonstrated an understanding of their children’s needs and have not cooperated fully or honestly with the support provided to them.   There are also outstanding criminal investigations which are unlikely to be resolved for a considerable period.   2.9 There have been other proceedings in this case. The children have been subject to care proceedings. The Police are still investigating the neglect of the children by mother and father and prosecution may follow.  2.10 The main time period covered within this Serious Case Review is from 2012 to 2017.  Any additional historical information relevant to the review going back beyond these dates (e.g. within the family history) has been fully considered in the review as important contextual history.  2.11 The Judge in the care proceedings was consulted about the review. It has been agreed that the information should be anonymised, and that there should be consideration given to not publishing this SCR, given the concerns about the sensitive nature of this case and the high likelihood that the children would be identifiable.  This review is an anonymised thematic review, which does not provide the full details of the family or the issues faced by individual children.   The critical points considered are:  2.12 Following scoping of the case and the issues arising from it in January 2017, the SCR Panel was asked to summarise the key practice episodes within their agencies. The Panel met on 27th July 2017 to review the findings to date.    6 | P a g e  Final 12.09.2018 2.13 There are three key periods of involvement in 2009, 2012 and 2016 when there was significant involvement with the family and an increased concern about the care of the children and the poor quality of parenting.    2.14 The report considers the Terms of Reference and is structured to describe and discuss the major themes arising from these.    • The effectiveness of the child protection system and case management processes in identifying the needs of the children, in addressing poor parenting and in improving the circumstances of each child. This is particularly of interest for the two younger children who have additional medical needs.  • The impact of the size of the sibling group on identifying and addressing the needs and maintaining focus on each child whilst working with this family.  • Appreciation and understanding of the differential parenting provided and the expectations attributed to different children which characterised how different children were cared for.  • The impact of, and the management of the parents’ oppositional behaviour and non-engagement with services and professionals. The response of professionals and their mindsets and how this was affected by parental behaviours.  • Effectiveness of the professional engagement with the children to ensure their voice is heard and acted upon. This is a particular issue in relation to understanding the experience of each child and in protecting them within a context of domineering, uncooperative parents, who exert coercive control and influence on the children’s behaviours and opportunities to communicate.    2.15 The possible reasons for actions taken or not taken at the time were considered:  • What factors contributed to practice decisions at the time? • What could have been improved? • What worked well?  2.16 The significance of these insights for current practice.  7 | P a g e  Final 12.09.2018 • If the same event occurred now – what factors would influence the response?  • What learning, and improvements have already been implemented? • What is working well now and what still needs to be improved?  3. NARRATIVE OF KEY EVENTS  The scope of the review includes historical information with a focus on events from November 2012 when the first child with an additional medical condition was born.  Any significant relevant events outside of this period have also been considered.   3.1 Family History  3.1.1 This is a very large sibling group with a wide age range. Six of these are now adults; three of them had been in care as children, did not return home and are living independently.   3.1.2  In July 2016, the remaining children under 18 years, who were still living at home, were taken into care because of further and significant concerns about physical and emotional abuse of the children as well as both long term and immediate neglect. This was precipitated by a crisis point which was reached when it became clear that the parents were unable to meet the continuing and substantial medical needs of two younger children who both suffer a significant congenital condition. Essential medical follow-up appointments were arranged for the children but the children were frequently not taken to these. The youngest child became acutely ill at which point her condition required immediate medical intervention.   3.1.3 Legal proceedings were started, and these were completed in 2017 with none of the children returning to the care of their parents.   3.2 Agency involvement with the family 3.2.1 Universal services – health services and schools - have known the family for more than twenty years.  8 | P a g e  Final 12.09.2018  3.2.2 The incidents set out below are illustrative samples of significant events during the years 2007 to 2017.   3.2.3 Throughout the whole period there is evidence of the children suffering significant harm caused by the parents:  • Oppositional, uncooperative and aggressive responses to professionals with some misleading disguised compliance • Manipulation of professionals – favouring some over others. • Children cared for in overcrowded, chaotic, dirty and unsafe conditions • Evidence of physical abuse and undue domination and coercion of the children.   • Lack of parental care and supervision • Inappropriate expectation that older children would look after the younger children to the detriment of the needs of those older children • Encouraging rivalry between the children and failing to prevent physical and sexual abuse between some of the children • Children displaying inappropriate sexualised behaviour • Inconsistent and differential parenting of the children with some children being favoured and others being scapegoated • Neglect of the children’s needs with children dirty, smelly, hungry and inappropriately clothed • Lack of parental warmth and empathy towards the children • Not promoting children’s developmental needs resulting in developmental delay particularly in relation to speech and language.  • Failure to ensure children attended nursery and school regularly or to encourage and promote their educational progress • Failure to ensure children received prompt, acute treatment or regular appointments for medical care  9 | P a g e  Final 12.09.2018 3.2.4  Events in 2007 and 2008 The first recorded indication of significant difficulties occurred in 2007 when one of the girls – then aged 14 years – became the subject of a child protection plan as a result of concerns about likelihood of sexual harm from an 18 year old male and her allegation that she was being physically chastised by her father; her parents refused to become involved or to discuss the issues but father did agree for her to be accommodated into care in October 2007. She remained in care thereafter.  From November 2007 to June 2008, as a result of further concerns about neglect of the children and the poor quality of parenting, several of the children still at home with the birth parents were made subject to child protection plans under the category of neglect. The assessing social worker recorded that when she visited “all the children presented with frozen watchfulness” in the presence of their parents. The parents were said to show no emotion or empathy towards the children when they spoke to them.   3.2.5  Events in 2008 and 2009 After June 2008, the children were subject to child in need plans. The social work report to the child protection conference stated that there was no evidence that the children were at any identified risk of harm from their parents and it described this as “a fairly private family”. As a result the Child Protections Plans were ended and the intervention reduced to the level of Child in Need plans which given the family’s non-cooperative behaviours meant a very limited intervention and engagement. The high level of difficulty in working with this family does not appear to have been fully considered so for this reason reducing the level of required engaged from the parents was questionable. This social work report is likely to have led to an over-accepting mindset for the parental behaviours as it provided a family style / right to privacy explanation for those behaviours.  10 | P a g e  Final 12.09.2018 A few months later in September 2008, another daughter aged 11 years came into care. During 2008 and 2009, she disclosed several abusive and neglectful incidents about her parents’ care of her and other children. She alleged that she had also been hit – as had her siblings – by mother as well as father. She alleged that her brother, when a baby of nine months, had been hit for moving whilst he was having his nappy changed. She stated that she and her siblings were subject to neglect and having to care for the younger children and not having enough to eat. Further in April 2009, this 11-year-old stated that prior to coming into care in 2008, she had been sexually abused by her eldest brother and that she had also seen him having sex with another sibling before that sibling was 12 years old.  These allegations were formally investigated with ABE interviews and a physical examination, but the findings were inconclusive. This child remained in care and continued to raise concerns about the welfare and safety of her siblings at home.   There is evidence that the parents were increasingly uncooperative, and father was aggressive and refusing to allow social workers to see the children. The seven-year-old was seen with injuries consistent with her having been hit and it appears that an application for child assessment orders was made to the court in April 2009. A seven-day child assessment of the children was ordered by the court; the children were seen and assessed but the outcomes were inconclusive, and it seems that father was present when the children were being seen. In July 2009, six of the children were again made subject to child protection plans under the category of neglect; the youngest child then was not made subject to a plan. The analysis in the social work assessment completed in July 2009 states that there have (previously) been significant concerns around the welfare of the older children and around incidents and injuries to the younger children. The parents were recorded as having a history of non-engagement with children’s services therefore, despite children previously being on child protection plans, there are no assessments of parenting capacity or children’s well-being on record” There was an insufficiently 11 | P a g e  Final 12.09.2018 planned, objective and systematic approach to examining what the  experience of each child was and a comprehensive overview of the parenting capacity would have provided this. Decision-making as hampered by the lack of clear and specific evidence of the concerns and incidents.  In October 2009, the children at home were no longer subject to child protection plans and moved onto child in need plans which lasted until September 2010 though the parents were not cooperating with these plans. The challenging behaviour of father and the parental non-cooperation concerned professionals but they could not see how to overcome it and rather they adapted their ways of working to accommodate it. The risks to, and impacts on, the children of this aggression were identified by professionals but they appeared to be unable to articulate sufficiently and on an interagency basis to act more decisively and to maintain the child protection focus.     3.2.6  Events in 2010 During this year, the health visitor was the main professional involved in visiting the home and the parents allowed her to come in. Her focus was on the younger children. Mother had a miscarriage and was quite depressed; at one point, she gave the health visitor a letter saying she wanted to leave father, but this did not happen, and she was soon pregnant again. There was a pattern already established of the parents not ensuring that the children attended health appointments including remedial speech and language therapy. The health visitor worked hard to continue to engage the parents, but it was also clear that she was worried about the cumulative impact of the home situation and that she had had concerns about the children.   3.2.7  Events in 2011 The case was closed in children’s services.  12 | P a g e  Final 12.09.2018 The then 5-year-old boy fractured his clavicle, but no medical intervention was sought for five weeks from the day of the injury. His 13-year-old sister took him to the GP which was further evidence of the older children caring for the young ones. Father blamed one of the older children for this injury, but it was not reported to children’s services or investigated by the GP. This was an important missed opportunity for the real experience of the children to be exposed. The fact that the child was brought a long time after the injury and, not by a parent, should have raised the alarm. This matter should have been referred to Children’s Services as per the local policy and procedures. Then, a thorough child protection investigation could have been carried out providing an opportunity, in particular, for the children to be seen alone.   Another child was born, and all the focus of the parents was on the new baby. Father was not challenged about the injury to the 5-year-old.   3.2.8  Events in 2012 There were eight separate events of concern from February to June 2012. Two of the children were talking to school staff about the problems at home; they were not being given breakfast; one of the older boys then 14 years was hitting these two younger children aged 9 and 7 years. In June 2012, the 7-year-old broke his wrist and had to be taken to A and E by a neighbour and one of his sisters three hours after the accident because his father had refused to take him to hospital because he said, “he shouldn’t have climbed up there in the first place”. The nurse, who saw the boy, told the EDT social worker that the boy’s physical state was very poor; he was described as “filthy, smelly and shaven-headed”.  The next day a social worker visited the home. Initial assessments were completed after a referral from the primary school about the welfare of the children at home. The mother told the social worker that she cancelled appointments for the children because of having panic attacks about leaving the home and she said she had had agoraphobia for more 13 | P a g e  Final 12.09.2018 than 20 years. Chronic and widespread neglect of all the children living at home was the social worker’s assessment.   In August 2012 after the initial assessment of the children, the case was closed by children’s services as “there is no role for children’s services at this time” and “other agencies continue to work with the family”.  This represents a completely disjointed and an incoherent view given the evidence there was. There were several different social workers involved with the family and a stop-go approach therefore impaired the capacity of the service to understanding the needs of the children and the poor, abusive parenting being provided to them.   In September 2012, further concerns were raised by the primary school about one of the children coming to school with odd shoes, wearing dirty clothes and with black fingernails and saying he was hungry and thirsty.   In October 2012, a strategy meeting was held with the Police and it was recorded that the family have a long history with children’s services, long-term recurring concerns of neglect, concerns about lack of supervision and physical abuse allegations against father and sometimes against other siblings since 2006.   Concerns continued about the older children being carers for by the younger ones. The house, which only had 3 large bedrooms and one very small one was now even more overcrowded, and the health visitor was very concerned. She and a social worker contacted the housing association to see what could be done. The parents told the heath visitor that they had been told they could not get help to move and this was not true.   In November 2012, another child was born. She was born with substantial congenital condition - additional medical needs requiring care and attention. Mother had not used antenatal services so there was no 14 | P a g e  Final 12.09.2018 evidence of any preparation for this new child. The hospital staff were concerned about whether she would be appropriately cared for at home; the health visitor is said not to have been concerned.  There were subsequently many missed follow up appointments for her; the health visitor had then become concerned about the parents’ ability to understand the seriousness of this child’s condition.  The last social work assessment of 2013 states that the family circumstances are “not child protection”, even though it is recorded that the parenting is neglectful. There was clearly a lack of understanding or appreciation of neglect as causing children significant harm.  3.2.9  Events in 2013 There were several referrals to children’s services including an anonymous one. Social work assessments were undertaken in August and again in October 2013. The home was described as in a poor state with fire hazards and rubbish outside. The second recorded assessment was started because of concerns that the children were being physically abused.  3.2.10 Events in 2014 Initial assessments were completed in January 2014 for all the children. Although some of the children were seen alone at school, they disclosed nothing. When two of the children had started at primary school they appeared to be electively mute and did not communicate for some time. Despite concerns about poor school attendance, the case was closed in children’s services. There was no chronology in place and there was a lack of tracking of events including the high numbers of referrals so that the accumulating and continuing risks were not identified. Events and behaviours were somehow seen as “typical” of this family and “normalised”.  3.2.11 Events in 2015 15 | P a g e  Final 12.09.2018 In 2015, there were further referrals to children’s services including an anonymous one – later found to be from a family member. In one referral it was alleged that a photograph of one child with her head in a plastic bag had been posted on social media. In March and April, further assessments of the children were planned but instead the case was closed. In July, father agreed that the children at home should be made subject to child in need plans. In September, father told the health visitor to stop visiting which raised further concerns and led to another social work assessment; no concern was raised, and the case was closed.  There was a three-month period during which the health visitor was denied access, but this does not appear to have been escalated.   In November 2015, the hospital made referral to children’s services after father did not respond to calls about his daughter. Father had tried to consent by telephone for two operations on 13-year-old daughter who had broken both her legs in a road traffic accident. She had been run down by a car crossing the main road on the way to school. A referral to MASH by one of the adult children in December about the children being neglected was recorded for information only.  3.2.12 Events in 2016  A further child was born by emergency caesarean in January suffering from substantial congenital condition which required continual monitoring. Mother had not attended for antenatal care and she went into labour at home before being transferred to hospital.  Although GP and health service were aware of the increased risk of congenital problems for a further child, mother’s pattern of not reporting she was pregnant and not using antenatal services limited the capacity of those professionals to raise the alarm earlier.   Children’s services decided through the MASH not to assess the hospital’s concerns because it was said that the family would not engage. In March 2016, health professionals raised concerns at the child’s discharge meeting that they felt the parents could not meet the 16 | P a g e  Final 12.09.2018 child’s needs given the history of failed appointments for her older sister who also had the same significant congenital condition.   In early June, the then 13-year-old daughter, who had previously been involved in the car accident and broken her legs, stated at school that she had been held by the neck against a wall by her father. She also said she was hit regularly by him and she said her parents are “not very nice”. She appeared thin and unkempt and there were scratch marks on her. This child came into care with parents’ agreement and remained in care.  By June it was clear that the youngest child was not being cared for appropriately and her head circumference was increasing. The family were not listening to the health visitor. By the end of June, the child had to be admitted to hospital and she was made subject to a child protection plan.   In June 2016, all of the children, who were living at home, were made subject to child protection plans under the category of neglect. It was also decided that there should be emergency protection for the youngest child and interim care orders sought for the other nine siblings. The parents did not attend this child protection conference. In July 2016 Police protection was taken on all the children under 18 living with the parents and interim care orders were granted.   None of the children have returned to the care of the parents and plans for new families for them have been implemented.   4. The experience of the children  4.1 The children of the family have endured considerable suffering and harm at the hands of their parents. There is considerable evidence of this from the accounts given to professionals by the children over time. The harm caused, and their experience included:  17 | P a g e  Final 12.09.2018 • Lack of basic care – dirty, ill kempt, crowded chaotic living • Lack of food – hungry • Not taken to access acute health care by parents and not being brought to important medical appointments • Fear and frozen awareness from parental violence and threats • Dirty, overcrowded living conditions • Lack of parental supervision and exposure to risks outside the home and resultant injuries • Lack of warmth, empathy and emotional care • Developmental delay including speech not stimulated or promoted • Differential relationships with children with some being favourites, others being scapegoated • Acrimony and bitterness and recriminations between the siblings which continues • Physical violence and sexualised behaviour not prevented between the siblings • Being required to care for younger children  4.2 Professionals appear to have been unable to focus sufficiently on what the children were saying or to piece together all the various strands of information which provided tangible evidence of what was happening in this household. On many occasions, the overwhelming control and aggressive behaviour exercised by the parents seems to have prevented professionals from challenging what they were doing.   4.3 Some of the older children came into care when they were able to escalate the issues for themselves. Once out of the home they did not return and continued to tell professionals directly, and through anonymous referrals, how terrible was the existence of their siblings still at home.   It is remarkable how many of the older children once out of the home tried to alert the agencies to the suffering of their siblings who were still living at home. There is some evidence in the records that the 18 | P a g e  Final 12.09.2018 allegations from the children in care were sometimes seen by professionals as attention seeking behaviour and not valid.   4.4 Even when children suffered significant harm through direct physical abuse from father or as a result of the lack of supervision provided, decisive action was not taken to protect the children. When one of the children broke his wrist and the parents did not take him immediately for treatment, this was not even referred or investigated. When one of the daughters was involved in a car accident resulting in breaking both legs, this was not fully investigated nor followed up in relation to the known and recorded problem of the parents not ensuring the children were supervised to get to school safely. There are many examples of the children not attending important medical appointments and of children being taken by siblings to hospital or the GP even when they had suffered fractures.   4.5 There was little consideration of the extra pressure and impact on each child as each new child was born. As children grew older they were expected to provide care to the younger children to their own detriment. In each child protection or child in need meeting – most of which the parents did not attend, there was insufficient consideration of each child’s needs. When child protection plans were put in place they did not always relate to every child in the household even though each of those children was experiencing the same environment of harsh and inappropriate parenting.   4.6 Numerous reports about, and direct evidence of, neglect were not followed up robustly. For at least ten years the high level of neglect and the non-compliance and disengagement of the parents was known and recorded. Although earlier in the history in April 2009, children’s services had sought child assessment orders which were granted; this attempt ‘to get a grip on the situation’ did not succeed and the children remained at 19 | P a g e  Final 12.09.2018 home in the care of their parents. It does not appear that further legal advice was sought after this.  4.7 During assessments of need and during the child protection and child in need processes, it is difficult to see in the records that the views, wishes and feelings of each child were fully elicited and considered. There is no evidence of direct social work with the children individually. The children were assessed through child assessment orders in 2009 and later some of the children were seen alone at school but this was not the normal practice in this case. One of the children who came into care was interviewed by a police officer and social worker through ABE interviews but the outcomes from these interviews were not robustly pursued. Within the health visiting records, the individual health needs of the children were often not identified with each child’s needs tending to be lost within the context of the wider family.   4.8 It is of significant concern that it was recorded by a social worker in October 2013 that the repeated referrals by older siblings should be regarded as ‘bordering on abusive’ when they had resulted in the younger children at home being repeatedly subject to social care intervention. This is a really worrying perspective and was a great disservice to the children and showed no insight into the dreadful circumstances in which we know the children were living.  There is no evidence that there was effective supervision in place to challenge the view taken by the social worker.   4.9 Their childhoods were significantly impaired by the lack of care and abuse the children suffered. During the ten-year period to 2016, the primary school recorded multiple incidents and concerns. There are twenty-nine records relating to observed physical injuries ranging from facial bruising to cuts, scratches and at least one cigarette burn. Often the children had no explanation for their injuries or they blamed older siblings for them. The children were often dirty and hungry, and they came to school with the wrong and worn shoes and sometimes without underwear. 20 | P a g e  Final 12.09.2018 On four occasions, members of the public contacted the school because they were worried about road safety and the children running out on front of cars and crossing at red lights.     4.10 The children’s school attendance was poor – there was sporadic attendance with some periods of good attendance though this was not sustained. There is limited evidence that the children were spoken to about why they were not at school. In July 2016, there was successful court action to prosecute the parents for the children’s irregular school attendance.   4.11 Some of the children have experienced and continue to have poor outcomes into adulthood.  For example, in 2015, two of the children then teenagers were taken to hospital with suspected overdoses of painkillers and having self-harmed. Some of the children have been involved in criminal activity including assaulting others. However, some of the children have flourished in care and are progressing well in their new families.   5. Thematic Evaluation of agency responses and practice  5.1 Some good and determined practice to make a difference with the family did take place at times – though this was in isolation.   5.1.1 The recorded assessments early on, and indeed, later in children’s services do identify and name the long term serious problems in this family.  For the most part, the seriousness of the children’s situation and the recalcitrant behaviour of the parents was identified and known. In 2009 legal advice was taken and court proceedings were initiated. The children were made subject to Assessment Orders.  However, no further follow-up action occurred to pursue further court involvement; therefore, the seriousness of the harm being caused to the children did not result in further court proceedings. As far as the assessments which were 21 | P a g e  Final 12.09.2018 completed in 2009 are concerned, it is very likely that the children were constrained by threats from father to keep quiet about what was happening and therefore they did not disclose the harm they were suffering.   5.1.2 The health visitors tried very hard to stay in touch with the children – certainly the under five-year olds – and to ensure that the parents let them have access to see the children especially when other agencies – particularly the social worker – were prevented by the parents from engaging with the family. Understandably they did their best to appease the parents in the children’s best interests though this was clearly stressful to them and a pragmatic compromise.   5.1.3 The schools tried hard to make improvements for the children at school and through working with the other agencies. The parents would not work with them at all and even refused to walk the children to school even when, for safety reasons, they should have done. Teachers listened to the children when they would speak and followed up with making referrals about what they had been told. This was important support for the children who were very isolated and fearful of the consequences of sharing their lived experience at home in the care of their parents.   5.1.4 After the birth of the youngest child and the continuing worries about the parents’ inability to take her additional medical needs seriously, a new approach was taken, and the then-allocated social worker led a concerted effort to focus on the harm not only to this child but also to the other children who were still living at home. This marked a considerable step change in the practice which had occurred previously. The fact that the youngest child had a life-threatening event because her medical needs were not being met by the parents, who did not give her the care and attention she required, meant that a vital and crucial tipping point for action was finally achieved. The social worker was challenging of previous assessments of the family and was child-centred in practice. A chronology 22 | P a g e  Final 12.09.2018 of events and the time-line of the decades of abuse and neglect enabled that practitioner to see the pattern of events. Legal advice followed and a clear plan was made for future plans for the children. This resulted in 2017 in an effective, successful removal of the children through legal proceedings.   5.2 Overwhelming nature of the complexity and scale of the problems and of the oppositional, hostile behaviour of the parents  5.2.1 Even from 2007 this was already a very large family with many children each with different needs and concerns about their safety and welfare. For individual professionals – social workers, health visitors and teachers – it was hard to keep focus on every single child and their needs as individuals. Within this large family of children, the parents’ practice of differential and inconsistent parenting towards different children was a challenge to track. The parents made efforts to concentrate on their care of, and behaviours towards, the babies with mother breastfeeding them, for example; they were apparently more able to provide a show of warmth and care to this younger group. This was however, in stark contrast to the harsh and punitive regime they employed with the older children who were expected to look after their younger siblings and were expected to fend for themselves. The medical needs of the last baby were too much for the parents to cope with and they neglected her care to the extent that it resulted in a life-threatening event.    5.2.2 There was a lack of effective challenge to the parents and of pursuing and setting consequences for the parents in relation to their defiance in not following the advice of professionals and their overall non-compliance. They would “try” harder for a while to feign compliance in order to seek to persuade professionals that they were listening. This was difficult because the parents usually absented themselves from meetings such as child protection conferences. When they were seen – father in particular - could be aggressive and attacking of professionals with 23 | P a g e  Final 12.09.2018 threats though he stopped short of actually assaulting any staff even was extremely intimidating. Not only did they refuse or ignore invitations to meetings but they at times refused all access to the home and the children for extended periods; they refused access to some social workers and some health visitors even when the children were subject to child protection plans.   5.2.3 There was a lack of professional curiosity and determination to see the children’s needs. There was so much activity, coercive control of the children, rivalrous activity between the children and so much distraction and anger and unpleasantness from father that these incapacitated the professionals’ ability to do their best.   5.2.4 There is an impression in the records of professionals “buckling” under the parents’ aggressiveness and resistance to all advice which was given to them. It was not easy to manage and to feel validated in your practice when father banned you from visiting and made threats and nasty comments about you. This could be very isolating for professionals and could lead to their views being marginalised.  5.2.5 For most of the period under review, professionals appeared to be “stuck” and this resulted in them avoiding and skirting around the difficulties presented by the family. For example, when in 2015 father refused access by the health visitor and there was already considerable evidence of neglect and poor care, the agencies did not work either singly or together to escalate matters. 5.2.6 The Bridge Childcare Development Service in their report (1997) into the death of Rikki Neave in 1994 recommended that:   “recognition be given by managers to the impact on social workers and other staff of parental aggression and any fear that is aroused in them and the consequences for decision making and practice. Adequate professional supervision and support must be given in these situations”. 24 | P a g e  Final 12.09.2018 5.3 Responses from all agencies to concerns and interventions were generally short-lived, episodic and occurred as a reaction to particular issues and concerns as they arose.    5.3.1 Even though it was clear as early as 2008 that there were long term, chronic and serious problems with the parenting of the children being identified and recorded, the activity tended to be about single events – lack of an overarching focus and identification of patterns of neglect and harm being caused to the children.   5.3.2 There were multiple assessments of need for some children, sometimes for most of the children and several had plans for periods – child protection and child in need plans. These did not lead to effective action even when there was no resultant improvement in the parenting or the circumstances of the children. These safeguarding processes did not result in any improvements for the children and, even when this was apparent to everyone involved, the consequences of this were not followed through even with consideration of further legal proceedings until 2016.   5.3.3 Even when, at different points three of the children came into care, the links to, and the fate and treatment of, the other children was not made strongly enough and the children in care’s views were ultimately not taken seriously enough. Father blamed the children who had left and scapegoated them to make them the problem to confuse matters further and to sow seeds of doubt about the veracity of what the older children were saying.  5.3.4 A great deal of information was collected about the children from referrals, assessments made, meetings held and in contacts from and within other agencies.  However, this information was not organised and analysed to provide a framework of understanding 25 | P a g e  Final 12.09.2018 what was happening in the family over time. Keeping the full history of a family is essential to avoid slipping into over optimistic views when they are not justified by the full evidence. There were frequent changes of social worker / supervisor and  a lack of continuity of practice. Chronologies and timelines of events for analysis were not created to assist with the analysis and planning. In addition, legal advice was not sought even at times when it was justified. Throughout much of the history of the case, Children’s Services were regarded by Ofsted as inadequate and in need of improvement.  There were frequent changes of social worker / supervisor and  a lack of continuity of practice. Chronologies and timelines of events for analysis were not created to assist with the analysis and planning. In addition, legal advice was not sought even at times when it was justified.  The assessments which were competed were superficial for the most part being immediate and brief responses to events and incidents which occurred within the family without appropriate investigation and resolution.  Throughout much of the history of the case, Children’s Services were regarded by Ofsted as inadequate and in need of improvement.      5.3.5 There was a high, perhaps, over-reliance on schools and Health Visitors to support the children accompanied by opening and closing of the case in children ‘s service. For example, in August 2012 after the primary school had referred further concerns in June about the care of the children, assessments were carried out but then the case was closed with the justification – “no role for children’s services at this time” and “other agencies continue to work with the family”.    5.3.6. At some points practitioners tried to be more optimistic and focused too much on small improvements made by the family and they lost sight of the full history and the extent of chronic neglect. Some of the health visitor efforts to engage the family were very impressive but for 26 | P a g e  Final 12.09.2018 the most part as soon as she had left behaviours and parenting did not improve. Schools monitored the care of the children and recorded concerns and passed these to children’s services and tied hard to reassure the children they were being heard when they said anything. However, for the most part this involvement did not result in he required escalation with other partners. Often too the children would not or did not disclose anything, even when it was clear they were worried.   5.4 The enormity of the tasks and the level of conflict and obstruction of the parents resulted in a mindset of passivity, hopelessness and helplessness and sometimes complacency for professionals. Some professionals became “acclimatised” to the poor circumstances of the children which hindered their ability to escalate matters. 5.4.1 Despite direct acknowledgement as early as 2009 of the inadequacy of the parenting and of the harm being suffered by the children, and no evidence of any significant acceptance of this by the parents or improvements made, both decision-making and practice were ineffective in protecting the children from further harm.   5.4.2 The lack of engagement by the parents and the hostility expressed affected the practitioners’ decision-making capacities and ability to follow through with assessments and plans. It was difficult for practitioners to see the children alone; even at school the children were reluctant to talk about what happening at home.  As mentioned above, in October 2013, the reports made by the older children in care were being disregarded and seen as a “nuisance” and perhaps even as malicious and causing harm of themselves. The circumstances of the younger children were apparently seen as acceptable despite all the indications to the contrary and despite the significant numbers of referrals from other agencies and neighbours.    27 | P a g e  Final 12.09.2018 5.4.3 In May 2015, at a supervision session in children’s services, it was decided to close the case even though it was formally recorded that “this family will always be of some concern”.  This was after a member of the family anonymously reported concerns about the children not being taken to school and the risk of road traffic accidents from this. In fact, in November 2015, one of the children had a road traffic accident and was hit by a car which broke both her legs.   5.4.4 Neighbours’ referrals were not always taken seriously enough or followed through. For example, when a neighbour had to take the child with a broken wrist to hospital because the father refused to do so no effective challenge was made, or action taken. Legal advice was obtained but no specific action followed.  5.4.5 There are many examples in this case of either no action being taken by agencies and / or of inadequate responses being made to referrals received by children’s social care. Not all child protection issues received an appropriate response or were even referred to children’s services. For example, father nailed up the windows of the house so that the children could not get out; he said that he did this in response to complaints about anti-social behaviour from neighbours when they complained about the lack of parental supervision. It does not appear that any action was taken to questions this or to ask further questions about the impact of this on the children. On several occasions, the children came into school wearing the wrong shoes and ill-kempt, but these referrals were not followed up effectively.     5.4.6 There was very often an acceptance of lower parenting standards and unacceptable care for the children because this was seen as typical of and acceptable for this family. The individual needs of each child were lost sight of and the parents’ intimidation and lack of cooperation with professionals meant that the focus on the children was impaired. The GP did not refer to children’s services the child who was taken to the surgery by his sister, with no parent present, several days after the injury.   28 | P a g e  Final 12.09.2018  5.5 There was a lack of a full appreciation of the children’s lived experience; professionals do not appear to have put themselves “in the children’s shoes” or to visualise what their lives were like.  5.5.1 Although the children were occasionally seen alone, there was generally a lack of creative direct work with the children individually to establish wishes and feelings. Even when the Court Assessments were carried out, father was present when most of the children were seen by the paediatrician with one child sitting on his lap during it.   5.5.2 It is likely that the parents would have opposed this work, but it should have been tried. The parents’ refusal would have been a further test of the ability to put their children’s needs first and to reflect on their own parenting.   5.5.3 The Bridge Childcare Development Service in their report (1997) into the death of Rikki Neave in 1994 recommended: -  “when a parent is considered to be threatening or hostile any presumption that they are different with their children should be rigorously tested”.   5.6 There is no evidence of any formal assessment of parenting capacity in the family.  5.6.1 This is a further example of lack of focus and challenge to the parents. Clear standards were not being considered in relation to what was happening and even when no progress was being made with the children on child protection plans, there was insufficient professional challenge and no escalation.   5.6.2 In July 2009, the summary analysis of assessments of the children in that year records that there had previously been significant concerns around the welfare and safety of the children. It is also stated that the 29 | P a g e  Final 12.09.2018 parents had a long history of not engaging with children’s services but “despite the children being previously on child protection plans, there are no assessments of parenting capacity on record.”   6. SUMMARY THEMATIC ANALYSIS 6.1 The effectiveness of the child protection system and case management processes in identifying the needs of the children, in addressing poor parenting and in improving the circumstances of each child. This is particularly of interest for the younger children who have additional medical needs. The child protection system was not effective in improving the outcomes for the children over many years. When the younger children, who were born with additional medical needs, arrived this increased the stress on the family and further tested the parents’ parenting capacity. They were not able to prioritise the needs of the most vulnerable child and, as a result, the child’s condition worsened providing immediate evidence of the parenting shortfalls. When this was identified in 2016 the system was effective, and the children were removed.   6.2 The impact of the size of the sibling group on identifying and addressing the needs and maintaining focus on each child whilst working with this family. As described above the size of the family and the number of children made it very difficult to focus on each child individually. The allocation of a single practitioner – health visitor or social worker – was unlikely to deliver positive intervention.  6.3 Appreciation and understanding of the differential parenting provided and the expectations attributed to different children which characterised how different children were cared for. This links to the sheer complexity of the family circumstances and the large number of children and distractions in place including the hostile and uncooperative behaviour of the parents.  6.4 The impact of, and the management of the parents’ oppositional, manipulative behaviour and non-engagement with services and professionals. The response of professionals and their mindsets and how this was affected by parental behaviours. 30 | P a g e  Final 12.09.2018 This was very stressful for practitioners. The turnover and shortfalls in professional staffing and high levels of demand on services during this period also hampered effective practice particularly in children’s services.   6.5 Effectiveness of the professional engagement with the children to ensure their voice is heard and acted upon. This is a particular issue in relation to understanding the experience of each child and in protecting them within a context of domineering, uncooperative parents, who exert coercive control and influence on the children’s behaviours and opportunities to communicate.   There were significant shortcomings in the professional engagement with the children even when the children in care were trying to persuade children’s services to intervene to protect their younger siblings.  In summary, the practice was characterised by: • There were multiple, repeated assessments which lacked depth and analysis.  They were stop/go responses to the issues. Multiple assessments without coherent outcomes and levels of risk and impacts on the children not fully considered • Confused and incoherent practice – even when no progress or worsening conditions for the children, there were no clear consequences  • The history, patterns of events were not fully analysed and acted upon with focus • Minimisation of serious concerns occurred • Even when the children were subject to child protection plans, there was drift even when progress and improvement was not happening • Child protection processes were not attended by parents and they were not directly challenged or given targets and consequences to meet; their parenting was not assessed formally.  • Agencies did not always refer or escalate serious concerns to children’s services • The children were not the focus of the intervention and they were not heard; there was a lack of child centeredness. • There is little evidence of senior management oversight or of effective, challenging supervision which may have led to a more focused approach and earlier escalation of concerns.  31 | P a g e  Final 12.09.2018 7. FINDINGS 7.1 There was some positive effort and conscientious practice in this case to support and safeguard the children. The amount of involvement by professionals was enormous but it was generally ineffective in achieving improvement for the children. The primary school recorded multiple incidents and concerns and made referrals to children’s social care but most of these did not receive the level of response required. The health visitors tried to engage with the parents and at times they were the main point of access to seeing the younger children.  7.2 The parents of the children were deceptive, uncooperative and aggressive in their relationship with the professionals. They played professionals off against each other – health visitors, school staff, GPs and social workers refusing to engage with anyone who raised concerns. For a time, they would cooperate with a particular professional such as the health visitor but then they would refuse access to the children by the same person. Father was verbally abusive to one social worker who visited, and the police had to be called.  7.3 This was a family where interventions provided by professionals did not result in timely, improved outcomes for children whilst the children remained in their parents’ care. A variety of different forms of support were offered to the family including the involvement of the children’s centre and even grants to help them to get the children to school but the parents did not engage with these offers of help. The parents attended a few child protection conferences but generally refused to do so which meant there was at time a delay; for example, one child protection conference was adjourned because they had refused to attend.  7.4 All the children experienced abuse and neglect which has affected their development and outcomes for life. There is much evidence to show how the children were intimidated by the parents but also manipulated by them. When the children disclosed physical assaults by father, they usually withdrew these allegations and told professionals how afraid they 32 | P a g e  Final 12.09.2018 were of recriminations. Father used Facebook to name call some of the children. Boundaries within the household were not clear and often inappropriate and there were incidents of violence and inappropriate sexualised behaviour between the children.  7.5 The professionals and the agency network were overwhelmed by the enormity and complexity of the issues in this case – the number of children, the open aggression and recalcitrance of the parents. For the school there were considerable dilemmas about how best to resolve the major concerns they had about the children’s care and safety; the parents were hostile and threatening and this was hard to manage.  7.6 Professionals dealt with problems reactively and worked in isolation and did not work together to coordinate their views and to agree what action was required. The Housing provider had several opportunities to share information about the care and safety of the children, but the significance of the information was not appreciated and so it was not always shared. For example, it became too difficult to carry out the repairs to the house because of its dilapidated state but this was not considered in relation to the children’s safety. 7.7 The lived experience and suffering of the children was not appreciated and the attempts by the older children to intervene and to protect their younger siblings were not fully acted upon in a timely way.   7.8 There is no evidence of any senior management challenge or awareness of the serious and significant harm the children were suffering over a very long period within each agency or between agencies.   8.  CONCLUSIONS 8.1. This was a very challenging and overwhelming case for the agencies and practitioners to manage. 8.2 It was an extremely “stuck” situation and research evidence is that positive outcomes are difficult to achieve in the circumstances of such 33 | P a g e  Final 12.09.2018 compromised parenting. Bentovim (Bentovim et al 1987; Bentovim 2004) argues that parents’ failure to take responsibility for their children’s maltreatment, their dismissal of the need for treatment, their failure to recognise their children’s needs and the maintenance of insecure or ambivalent parent–child attachments are all key indicators of a poor prognosis following maltreatment. 8.3 Practitioners need very strong support and highly focused supervision to overcome the obstacles to practice in such situations. They may even need to seek specialist consultancy. Signs of Safety, for example, may have provided a workable framework for managing this case and for challenging the parents. 8.4 Professionals and each agency became compromised by the deflections engineered by the parents which were intended to and succeeded in preventing agencies from tackling the sheer enormity and scale of the abuse of so many children over such a long period.  9. Recommendations for the LSCB to consider and action: The following recommendations are made to the LSCB as an overview and summary of all the recommendations which have arisen from this review.  They reflect the key learning from this review. The Local Safeguarding Children Board should:   9.1 Establish a senior group of multiagency professionals to identify and scrutinise cases where children have been subject to multiple child protection plans and continuing concerns without significant improvement spanning over more than three years.  9.2 Update and improve the existing LSCB policy to provide specific advice and learning from this case for practitioners in working with parents who use hostile and threatening behaviour, are non-compliant/uncooperative behaviour as well as exhibiting disguised compliance (Apparent Co-operation).  34 | P a g e  Final 12.09.2018 9.3 Conduct an interagency review of current frontline practice with children who are subject to significant harm through neglect, where parental behaviour is hostile or uncooperative, to identify good practice to share but also cases which require improvement for action.  This should include a specific focus on large sibling groups. 9.4 Develop a model for interagency practitioner supervision for complex cases where working together closely and consistently is of paramount importance.  9.5 The LSCB to seek assurance, from an audit of current PLO cases, that the use of the Public Law Outline is being used effectively to give the local authority and social workers sufficient leverage with families which are deliberately and unreasonably obstructive by clarifying their concerns in a ‘Letter before Proceedings’ or further action. 9.6 Develop an interagency protocol through the LSCB for managing future interagency actions and interventions when care proceedings do not result in legal protection for children, against whom it is believed that significant harm continues to be happening.   35 | P a g e  Final 12.09.2018 Appendix A - List of References Action for Children – The state of child neglect in the UK, Action for Children and University of Stirling, 2013; www.actionforchildren.org.uk/media/5120220/2013_neglect_fullreport    Bentovim (Bentovim et al 1987; Bentovim 2004) Journal of Family Psychotherapy  Volume 15, 2004 - Issue 1-2 Working with Abusing Families General Issues and a Systemic Perspective Brandon M, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth and Jane Black - Analysing Child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005 The Bridge Childcare Development Service in their report (1997) into the death of Rikki Neave in 1994 C4EO Safeguarding Knowledge Review - Effective practice to protect children living in ‘highly resistant’ families NCB 2010 Child Abuse Review (2015) – Vol 24: 155-158. May-June 2015. Various articles on neglect and the importance of listening to children. Peter Dale, Murray Davies, Tony Morrison Dangerous Families Assessment and Treatment of Child Abuse Paperback – 1 Dec 1990 Department for Education – Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of Children – 2015 Horwath, J & Tarr, S; Child Visibility in Cases of Chronic Neglect: Implications for Social Work Practice British Journal of Social Work (2015) 45, 1379–1394  Ofsted - Learning lessons from serious case reviews, 2009–2010 (100087), Ofsted, 2010; www.ofsted.gov.uk/resources/learning-lessons-serious-case-reviews-2009-2010.   36 | P a g e  Final 12.09.2018 Ofsted - In the child’s time: professional responses to neglect – March 2014 Reder, Dr Peter, Duncan, Sylvia, Gray, Moira - Beyond Blame: Child Abuse Tragedies Revisited (1993)  