Developmental delay and obesity of a 4-year-old girl due to neglect over a number of years. Learning: managing long-term neglect can be complex and difficult; medicalisation of weight gain can distract professionals from safeguarding concerns; where a medical diagnosis is offered as an explanation for neglect, all aspects of the child's health and well-being should continue to be considered to avoid diagnostic overshadowing; managers should ensure their staff are able to use agreed multi agency escalation procedures; professionals who attend initial child protection conferences should be confident and able to professionally challenge one another, to avoid over-optimistic thinking or disguised compliance; ensure that information given to parents whose first language is not English is fully understood and that they can meaningfully engage in professional meetings and discussions; translation services should be used when appropriate; when children are not brought to medical appointments follow the family engagement process; the need to assess parental capacity to sustain change; ensure that the voice of the child is heard consider he lived experience of children within the family; ensure the vital role of early years settings in the safeguarding system is understood by all involved. Makes no recommendations but highlights the importance of understanding and assessing the capacity of a parent to sustain change and following the escalation policy where this does not happen.
      
 Title:  Learning review report: Grace. LSCB: Hampshire Safeguarding Children Partnership Author: Hampshire Safeguarding Children Partnership Date of publication: 2022  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1       Learning Review Report  Grace  A summary of the case:  Grace came to the attention of Hampshire Children’s Services at the age of two, initially due to concerns regarding the family’s housing situation. That year, a referral was made by the health visitor to the Disabled Children’s Team relating to Grace and her sibling. It was noted at this stage that Grace was obese and showing signs of global development delay. Assessments were undertaken and it was agreed that Grace did not meet the criteria for services.  The following year further referrals were made by the occupational therapist. Following further review by the Disabled Children’s Team, it was felt that considerable services were being provided to the family by universal services and the case did not progress.   It was reported by Grace’s nursery that Grace was not attending the setting as planned, despite funded transport being requested and provided.  When Grace was three, she was seen by a consultant paediatrician. It was reported that at age three Grace was 2.5 times the weight of an average three-year-old. She was unable to stand or walk and there was evidence of her airways being obstructed at night-time.  Grace was referred to a specialist medical team for further assessments, and a significant number of tests were undertaken to ascertain if there was a medical reason for the weight gain.  Later that year Grace was attending a pre-school, where concerns were raised regarding the impact Grace’s weight was having on her. A Child and Family Assessment was completed by Hampshire Children’s Services, and the case was progressed to Child in Need (CIN) planning. During the Child in Need planning, there were concerns raised that numerous appointments with specialist health services had been missed. However, it was being reported that the family were making good progress and sticking to diet plans. Grace’s parents were informed that she needed to lose weight quickly due to the risks associated with being morbidly obese.  Grace’s weight continued to increase, and she was admitted to hospital for one month. During this time Grace lost a significant amount of weight and made excellent progress developmentally. Concerns were raised that mother was refusing the use of potentially lifesaving equipment and taking Grace off the ward early. This was shared with the Health Visiting Service.  Four months after Grace’s admittance to hospital it was recorded that Grace continued to lose weight. Three months after this point her weight had started to increase again. Grace was observed in this period eating chocolate provided by her mother and had missed numerous health appointments.  At this point Grace was on a Child in Need plan.  A further referral was made to Children’s Services and an Initial Child Protection Conference was held.  At the Child Protection Conference, the consultant paediatrician advised that genetic testing identified that Grace had an underlying obesity disorder and that her weight was due to this  2  metabolic abnormality and her weight gain was not environmental. This was accepted, despite medical tests being inconclusive and evidence being gained whilst she was an in-patient regarding her significant weight reduction whilst on a controlled dietary regime. At the conference, Grace’s parents reported that they were struggling to follow diet plans as their first language was not English.  The outcome was unanimous that Grace should not be the subject of a Child Protection Plan.   At the age of four, Grace was seen urgently in hospital due to a significant weight gain in a short period of time. Her parents stated they had no idea she had gained this much weight. Parents had not been taking Grace to regular weigh-ins in-between clinic appointments.  The parents cited a lack of transport as the reason for missing appointments, despite the health visitor providing clear instructions regarding transport for hospital appointments. Grace’s parents were unable to provide an explanation for the weight gain.  At this point it became known that potentially lifesaving equipment that had been provided to Grace’s parents was not being used. A referral was therefore made to Children’s Services and an Interim Care Order was granted.  Learning points for managers:  • The complexity of managing long-term neglect and the difficulties which professionals can encounter when children and families appear to be compliant.  • The medicalisation of Grace’s weight appeared to allow practitioners to become distracted from the safeguarding concerns which were evident during her admission to hospital.   • Where there is a medical diagnosis offered as an explanation for the presenting features of neglect, all aspects of the child’s health and well-being should continue to be considered to avoid the potential for diagnostic overshadowing.  • Point for managers to ensure their staff are well versed and empowered to use agreed multi agency escalation procedures.  Learning points for practitioners:  • Professionals who attend Initial Child Protection Conferences should ensure that they are confident and able to professionally challenge one another, to ensure they are not being optimistic in their thinking and have explored the possibility of diagnostic overshadowing and disguised compliance. • When a parent’s first language is not English every effort should be made to ensure that information given to parents is fully understood and that they can meaningfully engage in professional meetings and discussions. Translation services should be used as appropriate. • When children are not brought to medical appointments the Family Engagement process should be followed.  Learning points for HSCP:  • Working effectively with neglect and in particular assessing parental capacity to sustain change. • Ensuring that the voice of the child is heard and there is careful consideration of the lived experience of children within the family. • Ensuring the vital role of early years settings in the safeguarding system is understood by all involved.   3   Themes in common with other reviews in Hampshire:  • The need for ensuring parents whose first language is not English have access to translation services as appropriate. • Parental capacity to sustain change. • Recognising disguised compliance. • Professional challenge and escalation.   If you do one thing, take the time to….  Understand and assess the capacity of a parent to sustain change. Where this continues to be an issue and progress is not sustained the Escalation Policy should be followed.  How was learning achieved:  A multi-agency review was commissioned by the Learning and Inquiry Group of Hampshire Safeguarding Children Partnership. Hampshire agencies provided written reports. These were reviewed by two senior managers, independent of the case and where required, additional information sought from professionals involved in the case.  HSCP response:  The Learning from this Learning Review Report has been incorporated into HSCP workstreams. This has included multi-agency training, planned audits, scrutiny work, professional guides, and featured newsletter items.   Training and resources:  • HSCP Training - HSCP offers training on a variety of safeguarding themes. • HSCP Training 2020/21 • HIPS Procedures  • HSCP and IOWSCP Neglect Strategy and Toolkit • Neglect training • Child and Family Engagement Guidance for Primary Care • Child and Family Engagement Guidance for Secondary and Tertiary Care • Escalation Policy for the Resolution of Professional Disagreement • Spotlight on Disguised Compliance • Published SCR/LCSPR reports and learning summaries can be found in the Learning and Reviews section of the HSCP website - Published Reviews.  Publication Date: 1 February 2022 