Death of a 4-month-old girl in September 2013 whilst sleeping in her parents' bed. The Inquest concluded there was no evidence that drugs caused or contributed to the death and the medical cause was recorded as unascertained. Parents were convicted of Child Cruelty and received a six month custodial sentence suspended for two years. Family had been referred to children's services by health professionals and the police due to concerns around parental substance misuse and the behaviour of the two eldest siblings. Initial assessments were undertaken, but did not result in any child protection intervention. Mother had a history of: non-engagement with professionals, substance misuse and a violent relationship with the father of her first three children. The role the mother's new partner, the father of Baby E, played in her children's lives had not been assessed by professionals. Identifies findings, including: failure to engage effectively with fathers or significant males; concerns not given high enough priority; professionals were too parent-focused and wishes of older children were not considered; lack of multi-agency collaboration and risk assessment tools; and conflicting professional views about the impact of illegal substances on parenting capacity. Sets out key findings using a systems model based typology. Sets out issues for the Local Safeguarding Board to consider in light of these findings.
      
 Title:  Serious case review: Baby E: overview. LSCB: Sunderland Safeguarding Children Board Author: Linda Richardson and Jan Grey Date of publication: 2016  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                             - 1 -       Serious Case Review    Baby E (The SSCB has used a pseudonym to protect the identity of the child and family)           Publication Date: 6 September 2016      - 2 - Contents           Page No  1.  Decision to hold a Serious Case Review  (SCR)       3  2. The approach we used          3  3. Scope and Terms of Reference         4  4. The Family’s Perspective          4  5. The Family as known to Agencies          4  6. Areas of Significant Practice (ASP)          6  ASP 1:  Children’s Services: Response to Referrals from other Agencies    7 ASP 2:  School’s response to concerns about the children      9 ASP 3:  The use of the Common Assessment Framework (CAF)    10 ASP 4:  Multi-Agency Partnership and Collaborative Practice   11 ASP 5:  Failure to challenge and escalate concerns     13 ASP 6:  Managerial Oversight and Supervision     15  7. Agency Learning          16  8. The Findings          17  9. Summary          25    Appendix 1   The SCR Review Team          26 Appendix 2 Roles and Responsibilities in the SCR Process     28 Appendix 3 Methodological Limitations        30 Appendix 4  Agency Learning Reports       32 Appendix 5 How has the learning from this SCR improved practice?    36       - 3 - 1 Decision to hold a Serious Case Review (SCR)  1.1 Baby E was born in May 2013 at 37 weeks plus 1 day and died in September, aged 4 months. The family had been known to agencies for several years. Professional concerns included parental substance misuse, poor school attendance and the behaviour of the two eldest children, but these concerns had never culminated in the children being subject to Child Protection or Child in Need Plans, although ‘child in need’ services had been offered to the family.  1.2 A Case Review Sub-Committee of Sunderland Safeguarding Children Board (SSCB) held a scoping meeting on 26 September 2013 and agreed that the circumstances surrounding the death of Baby E met the criteria for holding a SCR.1   The Independent Chair of SSCB endorsed the recommendation on 2 October 2013.  The reason for the delay in the completion of this SCR is an issue, which should be addressed by SSCB, but it appears that the volume of work in respect of other SCRs being undertaken was a contributory factor.   Publication of the SCR has been delayed due to criminal proceedings in respect of the parents of Baby E and the inquest into Baby E’s death. 1.3 The decision to hold this SCR was also influenced by the similarities between this case and other reviews relating to the death and injuries of babies under the age of one year in Sunderland.  The SSCB Chair therefore directed that this review should not only consider the learning and recommendation from previous SCRs but also should pay special attention to the findings and recommendations from Baby A and Child C, the most recent SCRs, and consider any similarities between the reviews. 2 The approach we used 2.1 It was agreed that the review be undertaken using a different approach to that which the Board had used previously and which was prescribed in statutory guidance 2010. Whilst the review was to consider individual practice, the SSCB Chair wanted to adopt a  ’systems methodology’, an approach that recognised that the actions and decisions of practitioners occur through a chain of events and the interaction of a number of factors, many of which are beyond the control of the individuals involved. This review therefore was undertaken using an approach that provides a theory and method for better understanding why good and poor practice occurs, so effective supports and solutions can be more easily identified. 2.2 Senior managers from key agencies who had worked with the family or were working with the family at the time of Baby E’s death were asked to join a Review Team which met on four occasions during the SCR process.   Membership of the Review Team is attached in Appendix 1.                                                    1Regulation 5 of the Local Safeguarding Children Boards (SSCB) Regulations 2006 requires SSCBs to undertake reviews of serious cases in specified circumstances and to ‘advise the Authority and their Board partners on lessons to be learned’.   A SCR is one where: ‘a) abuse or neglect of a Child is known or suspected: and b) either – (i) the child has died; or (ii) 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.’    - 4 -  3 Scope and Terms of Reference 3.1 Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference. This uses the evidence to lead into exploration of the key issues.  Key lines of inquiry for this review quickly emerged in relation to assessments and thresholds, early intervention, the role of the Common Assessment Framework (CAF)2, child protection referrals and hospital discharges for vulnerable babies when it was known parents misused substances.   3.2 This review looks at events that took place between March 2012, shortly before the birth of Sibling 3 and Baby E’s death in September 2013.  4 The Family’s Perspective 4.1 It would appear that LC and JR separated sometime in 2013. A number of attempts were made to contact both parents inviting them to contribute to this review but neither parent responded to these requests or to the correspondence sent to their individual addresses.  The absence of their views in this report sadly limits the scope of this review.   4.2 The Maternal Grandmother (MGM) did however contribute to this review. She met with two representatives from SSCB and offered a very helpful perspective.  During the discussion the grandparent’s commitment to their grandchildren and to their daughter was clearly evident. MGM described the children as ‘lively’ and those they were a ‘happy loving family’ with lots of hugging and lots of fighting”.    4.3 MGM offered regular support to her daughter and grandchildren but was not aware that there were concerns about the family and she was not aware of the involvement of Children’s Services until after their involvement ended.   Maternal Grandparents have found the agencies involved to be very helpful although she reported that the children had been allocated 5 different social workers since moving to live with them. 5 The Family as known to Agencies 5.1 The Family3   Mother LC    32 years         Sibling 1      8 years   Sibling 2      7 years Sibling 3  13 months     Father GB to above children  34 years                                                   2 The Common Assessment Framework (CAF) is a process for gathering and recording information about a child for whom a practitioner has concerns in a standard format, identifying the needs of the child and how the needs can be met. 3Names, dates of birth and some family details have been changed to preserve anonymity. The ages given are the ages at the time of Baby E’s death.    - 5 - Baby E     b. May 2013 d. September 2013 Father JR to Baby E   24 years   Maternal Grandmother (MGM)  Maternal Grandfather (MGF)  5.2 GB has a history of ongoing medical issues including mental ill health and alcohol and drug dependency. He has also a series of convictions for violent offences.  Children’s Services records indicate the couple separated in 2007 as a result of physical assaults on LC, but GB appears to have remained in contact with LC and has had some contact with his children.   5.3 Between 2007 and 2012, the children received variable care from their parents; their lives were affected by exposure to their father’s depressive episodes and severe mental health problems and they heard and witnessed violent outbursts. Throughout this period, Police, Probation and the Community Midwife all contacted, or made referrals to Children’s Services to highlight their concerns about the children in the family. In response to these, two Initial Assessments were undertaken by Children’s Services between 2008 and 2011 but these did not lead to any support or intervention. 5.4 During 2012, there were three significant missed opportunities where purposeful interventions could have positively impacted upon the lives of these children. In March 2012, a Midwife made a referral to Children’s Services expressing concerns about LC’s drug use during her 3rd pregnancy and referring to GB’s recent discharge from hospital. The response to this referral by Children’s Services however gave insufficient weight to the risk factors and explored the possibility of a CAF, missing an opportunity to undertake an Initial Assessment.  At the end of the Summer Term 2012, despite the children attending school with bruises and conflicting stories about how they were sustained and with previous evidence of neglectful care (hungry and poorly clad in cold weather), no discussions were held with partner agencies and no referral was made to Children’s Services by school staff.  This was also a missed opportunity to initiate more assertive interventions with the parents. In August 2012, the two older children were involved in the deliberate death of a kitten. Police sent a notification to Children’s Services who undertook an Initial Assessment and gathered information from agencies who knew the family. Whilst there were different views about the way the family was functioning, the assessment concluded in October 2012, with a plan to offer a family support package. A referral was  subsequently  made to the  Common Assessment Framework (CAF) Panel but no work with the family took place.  After several weeks delay,  the CAF Panel referred it back  to Children’s Services as they determined  that  the family’s needs met the threshold  for a higher level of intervention.  The children were subsequently made subject to child in need status.  5.5 Between October 2012 and May 2013, work with the family was uncoordinated and piecemeal. Communication between agencies was contradictory and confusing and without any child in need plan or multi-agency meetings,  the children continued to experience poor quality care within their family and concerns continued to be raised by individual frontline staff from different agencies.  Attempts by professionals to engage with LC were largely unsuccessful. LC did not often respond to requests to meet with school or health colleagues but when this did happen, records indicate she was vocal, co-operative and willing to talk about how best she could meet the needs of her children. Subsequent attempts however to follow up on plans or appointments were usually thwarted by LC   - 6 - failing to follow these through or offering various explanations/justifications for her non-engagement.   5.6 However, no professionals escalated their concerns to their safeguarding leads or questioned why no multi-agency meetings were taking place.  Towards the end of this period, school staff, the Health Visitor and Social Worker, having liaised by telephone, concluded that the children no longer met the thresholds for ‘Child in Need’ and were best supported using the CAF framework. 5.7 Baby E was born three weeks premature in May 2013.  Concerns were again raised by the hospital Midwife in another referral to Children’s Services in relation to LC falling asleep when feeding the baby and needing to be prompted to initiate these feeds. Despite the continuing concerns around the use of drugs, LC and Baby E were discharged without a pre-discharge meeting but an Initial Assessment was undertaken two weeks later. No further action was taken by Children’s Services following this visit as home conditions were considered to be satisfactory and  LC said she was not taking drugs and she and her [new] partner only drank alcohol on special occasions. LC said she was well supported by family members.  5.8 Baby E died in September 2013. The Inquest concluded that there was no evidence that drugs caused or contributed to the death of Baby E, but the baby was co-sleeping.  The Coroner’s view was that, more likely than not, that the primary cause of death was the child sleeping in the parents bed.  He recorded the medical cause of death as unascertained.    Her parents were convicted of Child Cruelty and received a six month custodial sentence suspended for two years. 6 Areas of Significant Practice (ASP) 6.1 The narrative above provides a clear indication of an absence of assertive interventions with LC and her children to ensure the children’s welfare was properly considered.  Whilst none of the concerns directly led to Baby E’s death the absence of proactive, co-ordinated, system wide action contributed to Baby E and her siblings continued  neglect. This section looks back at the actions and decisions of professionals working with Baby E’s family and explores ‘why’ these professionals acted as they did.  The ‘why’ questions are important as they helped the Review Team understand what systems were in place at that time to support good practice or make poor practice more likely.  6.2 From studying key documents and listening to the views and experiences of front line practitioners involved in this SCR process, the Review Team identified six areas of significance for Sunderland agencies. These are listed below and are explained in more detail in later sections • ASP 1: Children’s Services: Response to referrals from other Agencies  • ASP 2: School’s response to concerns about the children • ASP 3: The use of CAF  • ASP 4: Multi-Agency Partnerships and Collaborative Practice • ASP 5: Failure to question or challenge decisions taken by Children’s Services • ASP 6: Managerial Oversight and Supervision    - 7 - 6.3 ASP 1: Children’s Services: Response to Referrals and Initial Assessments  According to agency records, five referrals were made to Children’s Services between March 2012 and September 2013, one from Police, and four by Health professionals. The Police sent a Child Concern Notification (September 2012) to Children’s Services after Sibling 1 and Sibling 2 were found to have been directly involved in the death of a kitten. Referrals made by Health Professionals, (March, November 2012 and April, May 2013) were as a result of knowing the history of the family, LC not keeping medical appointments and continuing to take drugs through the pregnancies of Sibling 3 and Baby E. In response to these referrals, two Initial Assessments were undertaken, neither of which assessed the children as being at risk of significant harm or as meeting the Child in Need threshold.  6.3.1 How Children’s Services responded to referrals is significant.  The  pattern of referrals indicates the family were perceived by Children’s Services as having ‘low level’ needs and consequently the wider issues around risks in relation to substance misuse, domestic violence and mental health were never fully explored, or the Sunderland threshold model applied to inform decision making.  6.3.2 Concerns had been raised several times over a five-year period about domestic violence in the home, drug and alcohol abuse and the significant mental illness of GB, the father of the eldest siblings. Domestic violence, parental drug misuse and mental health problems are factors  which are well known to adversely impact on children’s outcomes. Despite the past history of domestic violence and LC’s known drug use, when it was known she was pregnant in 2011 and 2012, there were no Pre-Birth Assessments undertaken despite concerns being raised by Midwives who were aware of LC’s history.  6.3.3 In response to the five referrals made by the Police and Midwives during March 2012 and September 2013, the period under review, only two led to Initial Assessments but neither of these involved discussions or consultation with the referring agencies, or with the Substance Misuse Midwife who had known LC throughout her three previous pregnancies.  Nor were the GPs for LC or JR contacted for additional information.  6.3.4 The four referrals from the Midwives were made following single agency assessments, which took into account past history and what was currently known about the family. The Early Warning Tool was used by the Health Visiting Service to analyse current risk and the ‘high’ scores led to the referrals to Children’s Services. It is not however a requirement that these single agency assessment tools are forwarded with referrals and this possibly restricts opportunities for Social Workers to understand  the importance of concerns from a health perspective.   6.3.5 The first Initial Assessment in September 2012 sought information from the School Nurse, the Health Visitor and the Head Teacher, none of who had expressed any concerns prior to the killing of the kitten.  The Social Worker considered that the family were in need of support services, but as LC refused to engage with the ‘Child in Need’ process, it was decided the needs of the children could best be met by the CAF process. There is however little to suggest that LC was willing or motivated to engage in this process but nevertheless the notion of a CAF partnership was presented by Children’s Services as a viable means of support to the family. The Initial Assessment clearly highlights concern about attachment issues and confirmed that Mother uses cannabis ‘when the   - 8 - children are in bed’. In conversation with Social Worker 1 she advised that many families in the area are known to use cannabis and that in itself was not a significant concern.  6.3.6 The Initial Assessment was updated a few weeks later. LC informed the Social Worker that she was 10 weeks pregnant but she would not disclose the name of the father. This information did not change the Social Worker’s assessment.  They  concluded that Children’s Services intervention was not necessary. In the practitioner’s meeting held as part of the SCR process, the view was expressed by Social Worker 1 that ‘compared to some of the other referrals, these children did not particularly stand out’. CAF was seen as an appropriate way to meet their needs.  6.3.7 The referral to the CAF Panel went ahead but without any reference to LC’s pregnancy.  Even without this additional information, the CAF Panel returned the referral indicating the needs of the family were considered too high for CAF work. Although this prompted the children to be reassessed as ‘Children in Need’, in effect no additional services were offered and the family were ‘closed’ several weeks later.   The reasons given in conversations and in the practitioner meetings were that, according to the school, the children’s behaviour had ‘settled down’ and the phrase ‘low level’ concerns was again used to explain why the involvement of Children’s Services was no longer needed.  The children’s involvement in the killing of an animal was described as ‘no longer of any concern’ although there are no records which offer a rationale for this statement.  6.3.8 There was no action taken by Children’s Services in relation to the referrals made by the Community Midwife in November 2012, and April 2013, but the Team Manager in Children’s Services did agree to an Initial Assessment in May 2013 following a referral from the Midwife on the Labour Ward when LC had given birth to Baby E. This referral did not however prompt a pre-discharge meeting as might have been expected.  An Initial Assessment took place two weeks after LC had returned home with Baby E. The assessment concluded that home conditions were satisfactory; LC said she was not using drugs and neither she nor JR drank alcohol except on special occasions.  There was no consultation with the referring Midwife on the Labour Ward or with the Substance Misuse Midwife. The assessment relies heavily on self-reporting by LC in respect of her drug misuse and that of her current partner.  The impact of this is that other known professionals who would have pertinent information about the family were not contacted and therefore the decision was made based on limited and missing information.  It is possible that in viewing this family, as one with ‘low level’ needs, only information, which confirmed that view, was sought. Research suggests that professionals do have a tendency to maintain intuitive beliefs even in the light of contradictory evidence.   However, the existence of multi-agency processes, the Threshold Model and other tools are designed to minimise the possibility of this happening. 6.3.9 School staff were asked to contribute to the Initial Assessment in September 2012 but not to the later assessment in May 2013.  Given that Sibling 1 and 2 both attended school, this was poor practice.   6.3.10 The role JR played in the lives of the children was not assessed despite Children’s Services records, which note that the Health Visitor, in discussions with Team Manager, in April 2013 was advised that it ‘had been agreed that JR would oversee the care of Baby E due to Mum’s cannabis use’.  The Health Visitor however has no recollection of this discussion and it is not documented in Health records.     - 9 - 6.3.11 There were clear frustrations expressed by health colleagues during the review process that the risks posed to unborn and newly born babies (i.e. Sibling 3 and Baby E) were not adequately assessed or well understood by their colleagues in Children’s Services.  The Vulnerable Babies Protocol was not followed despite it being known that LC was pregnant with Sibling 3 and again with Baby E despite the concerns highlighted by the Midwives. 6.3.12 Approximately half of all SCRs are in relation to babies less than one year of age, underlining the importance of effective universal services provision for young children e.g. Health Visitors and early-years services. As in previous studies domestic violence, substance misuse, mental health problems and neglect were frequent factors in the families’ backgrounds, and it is the combination of these factors which is particularly ‘toxic ‘. 6.3.13 It is worthy of note that in single agency records, there are references being made to ‘referrals’ to Children’s Services, whilst in Children’s Services records, those same ‘referrals’ are recorded as ‘contacts’ by Children’s Services. There was no common language and understanding between professionals as to what constitutes a referral, what is determined as a contact and how professionals should challenge any of these applications if they are not in agreement.  The Review Team were informed that  this has subsequently been addressed in Sunderland. 6.4 ASP 2: School’s response to concerns about the children  School staff reported concerns about the children’s behaviour and describe an incident where Sibling 1 had claimed to have teeth knocked out by Sibling 2. This was backed up by bruises to body and eyes. School had concerns about the children being hungry, poor school attendance and lack of engagement with LC, yet there were no safeguarding records held in School. The children were described as ‘not standing out’. 6.4.1 The Review Team considered that this was an area of significant practice as school staff were well placed to observe at first-hand how these children presented and would have been able to monitor any changes in behaviours. There were no safeguarding records in respect of Sibling 1 or Sibling 2, yet notes held by a Teacher documented several concerns; the dead kitten; bruising to eyes and thighs of Sibling 2; 4 month old baby with nose bleed after falling from bed after being placed there by Sibling 1; the children often arriving late to school and being hungry. None of these individual concerns were referred to Children’s Services and neither do they appear to have been discussed with LC. Significantly, the concerns were not brought to the attention of the Designated Person in school4 nor brought to the School Nurse’s attention. It is clear that staff were not aware of their safeguarding responsibilities and procedures and in this respect, there was a concerning lack of  safeguarding leadership in the school.  6.4.2 It is equally concerning that school had no records which related to historical information, the mental health of the older children’s Father and the domestic violence the children must have witnessed. Nor were there any records on school files about the Initial Assessments that had been undertaken in respect of the children. The Review Team gained the impression that school was not well informed about this family, yet the school health records contained a wealth of historical information, which highlighted intermittent involvement from Children’s Services throughout the                                                  4 This person has responsibility for dealing with and responding to safeguarding concerns in school.   - 10 - older children’s pre-school years.  This information was not discussed, shared or accessed despite the concerns highlighted in the teacher records.  6.4.3 It is perhaps significant that the School Attendance Officer could not remember these children and neither could he recall a conversation with the Social Worker as part of an Initial Assessment in September 2012 or access any records in relation to that conversation. Given his name was on the documentation, he agreed that such a conversation must have taken place, but he could not remember the children or what information he may have shared with the Social Worker. According to school records, education professionals could not engage LC apart from one attendance at a ‘Barrier Meeting’ in October 2012, set up to try and help improve the children’s school attendance. The minutes from that meeting could not be located.  6.4.4 School had evidence of poor school attendance, children being hungry and inappropriately dressed but none of these, together with the reported injuries were seen in the context of neglect.  Due to the absence of any records it is impossible to state how, when and if these children were being supported and how Teachers and other school staff would have been able to identify and recognise the impact of cumulative concerns.  6.4.5 The School Nurse provided information to the Social Worker in the Initial Assessment undertaken in September 2012. Information was shared about A&E admissions for minor injuries, health appointments and Mother’s drug misuse. However, the school health records do not include any references to injuries or bruising to Sibling 2 or being seen for nursing/medical assessments or make any reference to discussion with school staff in relation to these.  6.5 ASP 3: The use of CAF   Children’s Services continued to persevere with CAF as a means of engagement despite historical and current evidence that LC was neither willing nor motivated to engage in this process.  This left the children vulnerable as they continued to live in an environment in which quality of care remained largely unassessed.  6.5.1 The Common Assessment is intended to provide a framework to help practitioners who work with children and families and/or young people to assess children and young people’s needs for earlier and more effective services, develop a common understanding of those needs and how to work together to meet them. This practice was deemed significant because the Review Team considered that the Initial Assessment undertaken in September 2012 was not sufficiently robust and yet CAF continued to be considered as a viable alternative to intervention by Children’s Services despite evidence that LC was unlikely to engage with that process.  6.5.2 It is unclear to what extent the issue of CAF was actually discussed with LC. The Review Team gained the impression that this was not discussed by the Social Worker in any depth and was seen as almost a conciliatory action on the part of both the worker and the parent. According to records made available to the Review Team, the Initial Assessment, which began in September, was updated in October when it became apparent that LC was 10 weeks pregnant and a referral was made, on the advice of the Team Manager to the CAF Panel in November 2012. This referral was not however accepted as the needs of the family were considered by the CAF Panel to be ‘too high’ for the CAF process.    - 11 - 6.5.3 CAF is a holistic assessment of a child’s needs for services. It is a process for recognising signs that a child may have unmet needs that universal services cannot meet. It is also a process for identifying and involving other agencies that may be able to support the child and/or undertake specialist assessment. Central to its development is the principle that it is child/young person centred, holistic and can be shared across professionals as appropriate. There is no evidence that any work was undertaken at any time with the older children, or any work even considered, despite significant concerns about their behaviour and, given the older siblings involvement in the death of a kitten, any possible risks to the baby within the family.   6.5.4 The view of the CAF Panel in November 2012, that the needs of the children met the threshold for Children’s Services intervention was accepted by Children’s Services without challenge and the three siblings, according to records held by Children’s Services, were ‘progressed to a Child in Need Plan’. The Review Team have however been unable to locate a Child in Need Plan for any of these children and it is doubtful that any such Plans were established. No multi-agency meetings took place and the family were ‘closed’ to Children’s Services three months later despite the knowledge that LC was again pregnant.  Social Work records indicate that the family would best be served through the CAF process – a decision which is difficult to comprehend given the views of the CAF Panel in November 2012 and the lack of any evidence to suggest that LC and JR would contribute to that process.  6.6 ASP 4: Multi Agency Partnerships and Collaborative Practice Despite the concerns highlighted by Police, school staff and several health professionals no multi-agency meetings ever took place in respect of these children and whilst information may have been gathered, it was not shared in a purposeful way. There were no attempts by any agency to set up multi–agency meetings with LC or to establish a professional’s meeting to share concerns and pool information.   6.6.1 Whilst the lead agency for undertaking Initial Assessments is Children’s Services, that agency does need to rely on partner agencies to provide much of the information, which underpins assessments. In this case there was a pattern of minimal contact between agencies from the outset, and that which did occur tended to be telephone contacts seeking information rather than creating opportunities for multi-agency working. Concerns were seen in isolation and were too readily seen as ‘low level’ but had information been pooled from other agencies, patterns of disengagement with services and the impact of parental resistance to professional intervention may have been more readily  identified.  6.6.2 Listening to the professionals who knew this family, the absence of any multi-agency work became clear and this potentially weakened the identification of needs and risks in this family. Each professional involved in, or with the family, appeared to be working from a single agency perspective and concerns or incidents were channelled through referrals or contacts with Children’s Services.  None of the agencies involved sought to initiate a CAF themselves but each looked to Children’s Services to take action.  6.6.3 Talking to frontline practitioners, it is clear that that Children’s Services continues to be viewed as the key agency for co-ordinating work around safeguarding children. Consequently, a sense of frustration was evident when the response of Children’s Services to concerns was slow or non-existent or when there was difficulty in understanding why certain decisions had been taken.   The   - 12 - responsibility of all professionals from every service to act assertively was neither well understood or well demonstrated. 6.6.4 Thresholds to access services from Children’s Services appeared to the Review Team to be high, even where there was evidence of domestic violence, [albeit historical] mental ill health and drug and alcohol addiction.  The response by Children’s Services was low key. However, what became very evident from feedback from professionals and from records is that where the children in this family were concerned, each referral or contact was viewed in isolation, with each agency having its’ own information and own perspective about the risks to the children.   6.6.5 Decisions were taken by Children’s Services that thresholds for services or intervention were not met. This was a matter of professional judgement which given the information gathered from LC, the school and the Health Visitor could be seen to be a reasonable judgement. However, the documents seen by the Review Team and information gathered from the conversations with practitioners suggest a lack of professional curiosity on the part of the Social Workers about what was happening in this family.  The local ‘Threshold Model’ for decision making was not applied and too much reliance placed on LC’s self-reporting that all was fine. The information about the house conditions contained in Children’s Services records contrasts sharply with what the Police found when they were called to the home after Baby E’s death.  The unwillingness to explore in any detail the extent of drug taking in the home and the impact this had on parental capacity also left all the children vulnerable.  6.6.6 Successive analyses of SCRs warn that the presence of significant males in families is often overlooked by professionals.  Although JR was not believed  to be living in the family, he was nevertheless a significant adult in the lives of these children and although he appears to have been regarded as a supportive, and compared to LC’s previous partner, a caring partner, he remained an unassessed risk.  6.6.7 There is a sense in this case that when the Initial Assessments were undertaken, the Social Workers looked for reassurance that all was well for these children and this is what they found. It is important that professionals are mindful of the dangers of making assumptions and using intuition as the only basis on which to make judgements.  Research5 advises that it is a human tendency to seek only the information that we ‘wish to find’, and confirms the dangers of a tendency to ‘stick to what we think we know’ and carry on with the plans without question or challenge.  Opportunities to reflect on and  explore thinking and conclusions were not discussed with colleagues from other agencies or it transpires, in supervision.  6.6.8 Brandon et al6 consider the importance of analysing rather than simply identifying what is known about a family’s history and warns without such an analysis there is a risk of falling into the trap of what is referred to as the ‘start again syndrome’. There is evidence that each report/referral to Children’s Services was seen in isolation from past concerns and this was clearly present.  6.6.9 It is clear from records that the hospital Midwife had concerns about LC’s ability to offer appropriate care to her newly born Baby E and she shared these concerns with the Team Manager in Children’s                                                  5 Fish, Sheila, Munro, Eileen and Bairstow, Sue (2008) Learning together to safeguard children: developing a multi-agency systems approach for case reviews.  6  Understanding Serious Case Reviews and their Impact – A biennial Analysis of Serious Case Reviews 2005-2007.   - 13 - Services.  These concerns did not lead to a decision to hold a pre-discharge meeting but resulted in mother and baby going home and an Initial Assessment being undertaken two weeks later, which led to no further action. The experience and expertise of health partners, especially in relation to Midwifery Services was simply not recognised by Children’s Services. The tension between the two agencies was evident at times in the practitioner meetings as was a clear and distinct difference of professional views about taking drugs, specifically cannabis and the impact this could have on unborn babies and a parent’s ability to offer good enough care for children in the family.   Regrettably concerns were not then escalated to senior managers. 6.6.10 Whilst agencies may demonstrate a theoretical commitment to multi-agency working this was not borne out in this case by a practical approach to safeguarding. The Housing Provider Manager was completely unaware that there were concerns about this family and considered that had they been so notified, they may have been able to offer support. In effect, records indicate that his staff had seen Baby E on a number occasions and the baby appeared clean and well dressed. There were no concerns about this family’s tenancy.  6.6.11 The safeguarding sector is emerging from a very procedurally driven era marked by a requirement to ‘follow the rules’ and there was a view clearly expressed in this and other SCRs in Sunderland that professionals cannot meet [as a group] unless they have parental consent. Professional meetings that do not involve family members did not feature in Working Together to Safeguard Children (2010) and it was, common to assume that they are not allowed.  6.6.12 However, such a course of action is perfectly legitimate and would have been useful to professionals in this case.  Had a meeting taken place with the School Nurse, the Health Visitor and the Midwives for example, it is possible that through the sharing of information, and joint decision-making, a more effective multi-agency and co-ordinated approach to work with this family would have occurred. Working in conditions of uncertainty and risk without legitimate forums for professionals across agencies to come together to share, reflect and make sense of what is going on in the lives of families they are trying to help leaves professionals isolated and highlights a vulnerability in multi-agency systems trying to safeguard and protect children. 6.7 ASP 5: Failure to challenge and escalate concerns The view that this was a family who did not meet the threshold for Children’s Services intervention was accepted too readily by some frontline practitioners who did not challenge decisions taken by Social Workers/Team Managers or escalate their concerns through their own line managers or safeguarding teams. 6.8 There is a sense in this SCR that only professionals in the Midwifery Service were concerned about the risks to children born into this family. It was these concerns that prompted the four referrals made to Children’s Services in 2012 and 2013 in relation to LC’s pregnancies. 6.8.1 The Unborn Baby Procedures clearly state that a multi-disciplinary pre-birth assessment must always be undertaken where7  • The mother is failing to take up ante-natal care ……                                                  7 Extracts from Sunderland Unborn Baby Procedures.   - 14 - • Where alcohol or substance abuse is thought to be affecting the health of the expected baby….. 6.8.2 Clearly these procedures were not followed when LC was pregnant with Sibling 3 and with Baby E although the above criteria were clearly met. There were however no challenges or queries by health professionals as to why these procedures had not been followed.  The view was expressed by some health professionals that decisions made about children by Children’s Services often seemed to be more influenced by the views held by Social Workers and Team Managers than by research, specialist knowledge and shared multi-agency concerns.  Nevertheless, the decisions taken in respect of the children in this family and the rationale for those decisions were not challenged and/or escalated to senior managers in the respective agencies. It is significant that concerns about procedures not being followed or the perceived failure of Social Work professionals to grasp the significance of parents who continue with drug misuse, were not discussed or shared with the Named Midwife for Safeguarding.  6.8.3 In conversations with the Social Worker who undertook the Initial Assessment in September 2012, she advised the Review Team that she believed that there should have been a further assessment, but her views were overruled by her Team Manager who directed her to make a referral to the CAF Panel.  The Social Worker advised she felt unable to challenge this decision; she was newly qualified and had joined the team only recently.  She considered her Team Manager had more experience to make these judgments and she was not confident enough to challenge this decision.  6.8.4 In the practitioners’ meetings the discussions highlighted a divergence of views between Social Workers and health professionals about the use of cannabis and the impact on families. In a previous SCR in Sunderland, Social Workers were acutely concerned about a mother’s use of heroin and the impact on children in the family. These concerns however, were not replicated with LC who self-reported regular use of cannabis. The issue of professional understanding and recognition of the impact of different substances on parenting capacity is an issue, which requires further exploration by SSCB. 6.8.5 The Midwives did not robustly challenge the decisions taken by Children’s Services, although there were many opportunities to do so:  following the decisions taken after the Initial Assessments; failing to liaise with key professionals; failure to follow pre-birth assessments and discharge of vulnerable babies procedures; the de-escalation from ‘Child in Need’ after only several weeks and without any consultation with key professionals.  In the meetings with Practitioners, it became evident that the health professionals had not discussed their concerns with their Safeguarding Leads and whilst they would not be expected to highlight each and every case, there were significant risk factors in this family to trigger further discussions.  6.8.6 It was acknowledged when Midwives have any Child Protection concerns, regardless of whether these are shared by Children’s Services, they should be brought to the attention of the Named Midwife for Safeguarding so support and advice can be offered.  It was also suggested that it was not uncommon for some professionals to hold the view that Social Workers ‘must know best’ so they could rest assured that their concerns had been appropriately shared and properly addressed. This made challenges far less likely.       - 15 -  6.9 ASP 6 Managerial Oversight and Supervision Besides supporting frontline staff, managers have a duty to monitor the functioning of the organisation and to check that responsibilities are being met. There is evidence in this case review that supervisory processes were not robust and the practice of frontline workers was not fully supported or challenged. Management oversight of practice and systems was weak possibly as a result of the family being assessed as incurring only ‘low level’ concerns.   6.9.1 High quality reflective supervision is central to providing good support for professionals working with families with complex needs. There is a wealth of research and literature to assist managers to develop high quality supervision across agencies8; the best supervision offers both managerial oversight and constructive challenge to practitioners, using evidence based research to help the practitioner decide what sort of support is required for individual families.    6.9.2 Supervision and managerial oversight for all key practitioners should identify poor practice and examples where short cuts are taken to manage organisational demands. This case review revealed that there were several instances where safeguarding procedures were not followed and where the very systems intended to highlight vulnerable families were ineffective. For the health professionals, supervisory practices were not robust either in terms of supporting the practitioners or challenging practitioners when they were not persistent in following up concerns. It was however pointed out that if issues/family concerns were not raised in supervision, managers would be unaware of these. This highlights the importance of clear guidance about risk indicators in families which if present, should always be discussed in supervision or with safeguarding leads.  6.9.3 Some aspects of frontline practice should have been addressed through supervision in Children’s Services; especially given Social Worker 1 was new to the team and was recently qualified.  In the conversations held with the Team Manager, it was pointed out that pressure of work meant that it was not always possible to audit every assessment, or check that historical and concerns had been addressed.  The Team Manager could not recall if she knew that LC was pregnant when the ‘case’ was closed in February 2013 but added that the volume of work restricted the amount of time she could spend on monitoring assessments and closure of cases. In addition there were several new members of staff joining the team and it was not possible to give the level of supervision that many of the workers needed.  This was also the reason given as to why there were no supervision notes for Social Worker 1 or 2, although the Team Manager was clear that supervision had taken place.   6.9.4 The Team Manager advised that she was aware of the Unborn Baby Procedures and that these procedures would have been discussed at every supervision with staff.  6.9.5 Two other factors were considered significant; one was the frequent change of managers through restructuring and sickness levels and another factor related to the way in cases were ‘block’9 transferred between teams allowing important details about vulnerable children to be easily overlooked.                                                   8Staff Supervision in Social care,” Tony Morrison, 3rd edition and  “The Impact of Supervision on Child protection practice –a study of Process and Outcome” 2003.Jane Wonnacot; Effective supervision in social work and social care, Professor John Carpenter and Caroline Webb SCIE Briefing 2012. 9 ‘Block’ transferring of cases was a shortcut process in which cases were transferred between teams by a list of cases on an email.   - 16 - 6.9.6 What became clear to the Review Team was that whilst the practice of supervision varies across agencies, there was an absence of managerial oversight in all key agencies, which made it easier for frontline practitioners to work in isolation and from a single agency perspective. This contributed to a start again syndrome whereby assessments of each individual incident always started from the beginning and the potential cumulative harm to the children was never assessed.  The ongoing concerns held by Midwives about the impact of drug misuse on unborn and newly born babies, a finding identified in other reviews - was not escalated to senior managers in partner agencies or robustly raised with SSCB.   6.10 Context in which professionals were working  Practitioners were clearly working under a great deal of pressure, both in respect of competing demands for time, and the fact that thresholds for intervention were high. The practitioners in the review process spoke about the impact of both, commenting that high caseloads could easily encourage professionals to focus more on their own individual responsibilities because multi-agency working can appear to take more time and maintenance.  6.10.1 Information from the Practitioners Group and the Review Team suggests that in this Local Authority like others, there are diminishing budgets and competing priorities. Research by Brandon et al (2008)10 suggests that these factors along with pressures of work result in a tendency to raise thresholds for access to services as a way of rationing responses.  Moreover, the acceptance of referrals for further intervention can be affected by the ‘speed practices’ and short cuts to manage and deflect referrals that develop when referral levels are high, especially when Local Authorities have tight timescales.  This was clearly evident when, in response to referrals in June 2011, March 2012 and September 2012, LC was asked to come into the office to discuss the concerns before a decision was taken about the next course of action.  6.10.2 This view of ‘rationing responses’ was endorsed by many of the practitioners who contributed to this review and especially from colleagues in health settings. There continue to be misunderstandings around roles, responsibilities and thresholds and these challenges are compounded by the growing number of families referred for services in this Local Authority.    7 Agency learning and actions taken11 7.1 All the agencies involved in this SCR completed Agency Learning Reports (see Appendix 4). The information contained in these reports highlight that the individuals who contributed to the process either as a member of the Review Team or the Practitioners Group were able to identify personal learning.                                                  10 Brandon, M et al:(2008)Analysing Child Deaths and Serious Injury through Abuse and Neglect: What Can We Learn? A biennial analysis of serious case reviews 2003-2005. Research Report DCSF-RR023. University of East Anglia.  11All agencies in the SCR completed a Learning and Reflection report, which are to be found in Appendix 4.  This section encompasses information from these reports and from comments in the Practitioner’s meetings.    - 17 - 7.2 Not all of the reports identified in detail, how this learning would be transferred to wider practice within individual agencies. Where necessary, the Lead Reviewers have identified or clarified additional actions that should be undertaken and which should be monitored by SSCB.   7.3 The pathway for interventions in relation to services for the family of Baby E was determined by a range of key points and decisions. The significant issues are identified below and are linked to previous case reviews in Sunderland. 8 The Findings 8.1 The Review Team identified seven findings or underlying patterns, which helped the team to understand why some practices happened in the way they did. Each of the findings is explained with a rationale, an indication of its impact on the wider systems in Sunderland and a series of questions designed to enable the Board to strengthen safeguarding by addressing the root causes underpinning the finding. 8.2 The findings fall into different typologies of systems issues, with a clear link between each of the findings and each of the typologies.  This is not unusual, as it would be expected to find links between findings when adopting a whole systems approach. There are 7 findings for the Board to consider, these are:  Patterns of Management of Systems 1. Managerial oversight is central to supporting critical thinking, challenge and good assessments in multi-agency work and this was not evident in this review.  2. Concerns, which appeared low-key and were not incident or crisis-driven, were not given high enough priority and this left the children, and especially Baby E vulnerable.    Patterns of Professional-Family interaction 3. Professionals were too parent - focused. The lack of engagement with the older children meant their experiences, wishes and feelings were not fully considered.  4. Understanding the presence and role of males in families is critical to understanding family functioning and assessing risk.  Patterns of Professional Bias 5. There are conflicting views between professionals about the impact of illegal substances on parenting capacity and the extent to which the use of cannabis increases the level of risk to children and unborn babies.    Patterns in Multi-Agency work 6. There was a lack of robust multi-agency collaboration and challenge across agencies regarding decisions, plans and threshold.  Patterns in the Use of Tools   7. Single agency risk assessment tools, where they exist, are neither recognised nor valued by other agencies and the absence of a multi-agency risk assessment tool made sharing information and assessing risk more difficult. This increased the risk of professional tensions.      - 18 -  Finding 1 _________           Managerial oversight is central to supporting critical thinking, challenge and good assessments in multi-agency work and this was not evident in this review.   How was this manifest in this review?  There is evidence that key frontline practitioners were not well supported by good quality reflective supervision. This case review revealed that there were two occasions when safeguarding procedures in respect of unborn babies were not followed and at least 4 occasions where assessments of children in this family failed to take place and/or did not meet expected standards in respect of robust analysis and multi-agency involvement. These issues were not discussed in supervision yet significant risk indicators were present. There was no managerial overview in respect of safeguarding practices in school and the absence of any robust recording systems left these, and possibly other, children vulnerable. What became clear to the Review Team was that whilst the practice of supervision varies, there was in this case, an absence of strong managerial oversight and challenge in key agencies and this made it easier for frontline practitioners to work in isolation and from a single agency perspective. This also made it less likely that concerns about decisions taken by Children’s Services practitioners would be challenged or escalated.   Clearly, the impact of competing priorities and limited resources impact on services delivery but it must also be recognised that times of transition are periods which increase risk and require strong contingency plans from managers to ensure that vulnerable children do not slip through the gap.  Is this an underlying issue in Sunderland or unique to this particular review?  • This finding was recognised by the Practitioners and the Review Team as being an underlying issue in Sunderland and not unique to this particular review.   • This finding replicates Finding 7, 8 and 11 in SCR Baby A and Child C, 2014 and Learning Lessons Review in 2012.  Issues for the Board to consider  1. How is the Board assured that partner agencies support the provision of good quality and regular supervision even and especially through times of organisation change?  2. Is the Board aware of what systems are in place in partner agencies to monitor safeguarding practice and performance of frontline practitioners? 3. Can the Board be assured that systems are in place in each agency to ensure that families with vulnerable children and seemingly ‘low level’ concerns do not slip through the net?    - 19 -   Finding 2    ________        Concerns, which appeared ‘low-key’ and were not incident or crisis-driven, were not given high enough priority and this left the children, and especially Baby E vulnerable.   How was this manifest in this review?  There was a lack of clarity across agencies about thresholds, and limited understanding about the boundaries of family support and child protection.  There was evidence that the children in this family had witnessed domestic violence, the parents misused drugs and the birth parents had at various times suffered with significant mental health problems. These factors, known as the toxic trio are well researched in terms of risk and poor outcomes for children and especially so for babies under the age of 1 year old.  School did not make any referrals despite evidence of injuries and the worrying behaviours of the older children.  Until (and even after) the incident with the killing of the kitten, concerns about children in this family were described as  ‘low level’ and each of the five referrals made in the period under review were seen in isolation from each other. Consequently cumulative risks to the children remained unassessed. There was clear disagreement between professionals about the risk posed to these children and different views as to the extent to which LC was compliant in working with professionals to address their concerns.  Is this an underlying issue in Sunderland or unique to this particular review?  • This finding was recognised by the Practitioners and the Review Team as being an underlying issue in Sunderland and not unique to this particular review.   • This finding replicates Finding 1 in SCR Baby A and Child C, 2014 and Learning Lessons Review in 2012. Issues for the Board to consider  1. Is the Board confident that frontline practitioners understand the risks to children associated with the ‘toxic trio’ and does the Board’s Multi-Agency Threshold document require amendments in the light of this finding? 2. Are there practice improvements that could be made to reduce risk for unborn babies where substance misuse or domestic violence in their families is known?  3. Are the procedures for instigating pre-discharge meetings for babies about whom there are concerns sufficiently robust and well understood by key practitioners?  4. Is the Board confident that professionals in all agencies fully understand the significance of missed medical appointments for pregnant women and children and are there processes in place to monitor when these occur, how often and what action to take when concerns about these arise? 5. Is there clarity about when parenting risk assessments should be undertaken and is it clear that these should include an assessment of parent’s capacity/willingness/motivation to change      - 20 - Finding 3             Professionals were too parent - focused. The lack of engagement with the older children meant their experiences, wishes and feelings were not fully considered.   How was this manifest in this review?  There is little to suggest that any professional had spent time with the older children to find out more about their life at home despite past concerns about domestic violence and aggressive behaviour whilst in school.  The lack of engagement with the children when it became known that they had killed a kitten is of some concern as is the view expressed by Social Worker 2 that the incident was ‘no longer of concern to Children’s Services’.  Social Worker 1 had recorded concerns about the behaviour of Sibling 2 and had queried the extent of drug misuse by the parent but there was no follow up work proposed or undertaken. When the parent did not engage with the CAF process, the needs of these children appear to have been forgotten despite previous and very valid concerns. Children mistreating animals is not a new phenomenon, but the killing of a kitten by such young children should have led to further enquiries. There are few records, which pertain to Sibling 3 or to Baby E, and most references are taken from Health Visitor records.    Is this an underlying issue in Sunderland or unique to this particular review?  • This finding, of the children’s views and experiences not being fully considered, was recognised by the Practitioners and the Review Team, although were also aware of pockets of excellent practice.  Issues for the Board to consider  1. How does the Board assure itself that where there are concerns about parenting the voices and experiences of children are actively sought? 2. Does the Board have a mechanism for quality assuring the extent to which the views and experiences of children are sought and recorded? 3. Is the Board confident that frontline practitioners understand what is meant by professional judgement and how to apply it?  4. How does the Board ensure frontline practitioners develop skills in engaging with non-compliant or resistant families?    - 21 -  Finding 4    _______        Understanding the presence and role of males in families is critical to understanding family functioning and assessing risk  How was this manifest in this review? Serious case reviews have repeatedly highlighted failures by Social Workers to effectively engage Fathers or significant males in the family and this was clearly evident in this review.  JR was clearly seen as a resource in this family, whilst the Father of the eldest children was considered a risk. However, neither male was considered or assessed in terms of their role and relationships with the children and this was poor practice.  Is this an underlying issue in Sunderland or unique to this particular review?  • This finding was recognised by the Practitioners and the Review Team as being an underlying issue in Sunderland and not unique to this particular review.   Issues for the Board to consider  1. This is a significant issue, well evidenced and researched. How can the Board ensure that assessments and work with families and children fully engage significant males in the family in those processes?  2. Gender biases are pervasive in child welfare research and practice.  Although these biases are to some extent well known, there continues to be a lack of information on Fathers and an overrepresentation of information on Mothers in case files and assessments, and thus the biases continue. How can the Board begin to tackle this issue?     - 22 -  Finding 5   _______         There are conflicting views between professionals about the impact of illegal substances on parenting capacity and the extent to which the use of cannabis increases level of risk to children and unborn babies.    How was this manifest in this review?  Community Midwives were concerned to learn from toxicology reports that LC was still taking cannabis and amphetamines during pregnancy despite her assertions to the contrary. Social Worker 1 noted that LC’s self-reported drug use was very probably understated but these facts alone did not lead to further enquiries as to how substance abuse by parents were impacting on LC’s parenting role and that of JR.  In the Practitioners meetings there was considerable debate and disagreement between professionals about the use of cannabis and the extent to which it should be seen as a risk factor significant enough for Children’s Services intervention.    Is this an underlying issue in Sunderland or unique to this particular review?  • This finding was recognised by the Practitioners and the Review Team as being an underlying issue in Sunderland and not unique to this particular review.   Issues for the Board to consider  1. Does the Board need to clarify its position and guidance in relation to Substance Misuse and the impact of different substances on parenting capacity?   2. Is there value in health and social care professionals exploring this issue in greater depth?  3. If the use of cannabis is as widespread in some areas as professionals indicate, how will the Board address this?    - 23 -  Finding 6     _______       There was a lack of robust multi-agency collaboration and challenge across agencies especially in relation to early help, decision-making and thresholds.   How was this manifest in this Review?  The absence of any multi-agency work with this family is striking, as too are the absences of any challenge about the decisions that were made.  All agencies seemed to look to Children’s Services to take action and when they chose not to intervene, this decision appears to have been accepted without challenge. The emphasis of partnership working with parents seems to leave professionals believing that without parental consent, and/or Children’s Services involvement they cannot meet to share concerns unless the child protection thresholds are met.   Is this an underlying issue in Sunderland or unique to this particular review?  • This finding was recognised by the Practitioners and the Review Team as being an underlying issue in Sunderland and not unique to this particular review.   • This finding replicates Finding 3 and 4 in SCR Baby A and Child C, 2014 and Learning Lessons Review in 2012.  Issues for the Board to consider  1. Do all professionals in the safeguarding system fully understand their responsibilities in relation to CAF/Early Help 2. Are professionals able to articulate the benefits of Early Help to parents who may be resistant to engage?  3. How can management systems encourage recourse to multi-agency processes and purposeful professionals-only meetings in situations where the practitioners are ‘stuck’ in finding a way forward 4. There are benefits of providing multi-agency first line management workshops which reinforce the systems to support multi-agency working  5. That further work is undertaken with practitioners to gain a greater insight into the operational barriers/resistances to multi-agency working as a first step to addressing changing cultures  6. To what extent are professional challenges welcomed between professionals and between agencies?  7. Is escalation encouraged and are staff in all agencies supported as a means of resolving professional differences?   - 24 - Finding 7      ________      Single agency risk assessment tools, where they exist, are neither recognised nor valued by other agencies and the absence of a multi-agency risk assessment tool made sharing information and assessing risk more difficult. This increased the risk of professional tensions.   How was this manifest in this review? Whilst health colleagues use the Early Warning tool to inform their judgement about risk and vulnerability, this tool did not appear to be generally recognised by colleagues in Children’s Services. The Early Warning tool was used by Midwives when LC was pregnant with Sibling 3 and Baby E and this contributed to a decision to make a child protection referral. The absence of any multi-agency risk assessment at the time meant that the different elements of risk experienced by these children were not considered holistically and the cumulative impact was not recognised. The issue of how risk is defined, assessed and by whom is an issue, which was widely recognised by the practitioners and review team members. Is this an underlying issue in Sunderland or unique to this particular review?  • This finding was recognised by the Practitioners and the Review Team as being an underlying issue in Sunderland and not unique to this particular review.   • This finding replicates Finding 5 identified in SCR Baby A and Child C, 2014 and Learning Lessons Review in 2012. Issues for the Board to consider  1. Is the Board confident that across all agencies the Multi-Agency Threshold Guidance ensures there is a coordinated and unified approach to identifying concerns, assessing needs and measuring risks? 2. Are current assessment and referral procedures effective in taking a holistic approach to both current and historic safeguarding issues?   3. If single agency assessments are undertaken such as the Early Warning tool, can these be used more effectively to aid assessment and decision-making?     - 25 - 9 Summary It is impossible to state whether the sad death of Baby E, aged 4 months was preventable. The family were advised by the Health Visitor about the risks of co-sleeping but the parents elected, as many do, to place the baby in their bed to sleep.  The cause of death was unascertained meaning it was not possible to find an explanation as to why the baby died.  However, the circumstances in which the baby was found after her death gave cause for concern and some difficult questions had to be asked of the professionals who knew the family.  The views of the parents would have undoubtedly enriched this report.  Just as it was not possible to predict the death of Baby E, neither is it possible to attribute the cause of death to any failings on the part of professionals who knew the family. The review has however highlighted the need for professionals to be persistent, curious and above all child-centred when pursuing concerns about the welfare of children. There are lessons to be learnt for all the agencies involved with this family. Arguably, had the concerns been more robustly assessed and the challenges to parents and professionals more dogged, with strong assertive interventions made to ensure the children’s welfare was promoted, several of the factors highlighted in this report may have emerged and the sharing of multi-agency information may have exposed the true vulnerability of the family’s circumstances.      - 26 -  Appendix 1  The Serious Case Review (SCR) Review Team  Function To conduct, on behalf of the SSCB, the Serious Case Review, ensuring timely progression and taking responsibility for the production of the final SCR report presented to the Board at an agreed date.   One or two lead reviewers, one of whom must be independent of any agency represented on the Review Team, will lead the work of the SCR Management Review Team.   Membership of the SCR Review Team Membership will usually be senior representatives from the various agencies working with or known to the family. They must not have had any direct contact with the family or children or have held decision-making or supervisory role in relation to the frontline practitioners working with the family.  Members of this Team will be expected to have the authority to hold their own agency to account to ensure that required reports/documents are made available and key staff supported to take an active role in the SCR process.  Agencies represented on the Review Team were as follows: Linda Richardson    Lead Reviewer Jan Grey      Second Reviewer  Lynne Thomas     SSCB Business Manager Head of Safeguarding    Sunderland CCG Lead Nurse Safeguarding   ST NHS Foundation Trust Education Safeguarding Team Manager Sunderland City Council Lay Member      SSCB  Legal Representative    Sunderland City Council Acting Detective Inspector   Northumbria Police Lead Midwife     City Hospitals Sunderland Head of Safeguarding    Sunderland People Directorate   Each member of that team was asked to identify the frontline practitioners from their agency who were known to, or had worked with, the family of Baby E.  These practitioners formed the Practitioners Group and this group met on three occasions.   The Practitioner’s Group consisted of: Operational Manager    Children’s Services Operational Manager    Children’s Services Social Worker     Children’s Services Social Worker     Children’s Services Deputy Head Teacher    School Class Teacher x 2     Schools   - 27 - Neighbourhood Managers x 2   Housing Providers Operations Manager    Housing Provider Detective Constable    Northumbria Police School Nurse     STNHS Foundation Trust Midwife x 3     Maternity Services  Health Visitor     ST NHS Foundation Trust  Responsibilities of members of the Review Team • Represent their agency  • Understand the broad details of the case under review  • Ensure that a very broad outline chronology is undertaken • Identify key frontline practitioners who were known to the family • Undertake tasks related to data collection and analysis • Take ownership of the contents of the final report in presenting findings to the SSCB   Rationale: This SCR Review Team may well involve many of the same managers involved in the SSCB Learning and Improvement in Practice sub-committee, it’s function and purpose however, are different in that its’ work is solely to lead and work on a specific SCR.  Members need to be clear about their responsibilities, as this model requires far greater involvement from senior managers than the previous prescriptive IMR type methodology.    - 28 - Appendix 2 Roles and Responsibilities   SSCB Chair • Confirms the decision to hold a SCR • Commissions  on behalf of the Board, the Independent Reviewers • Agrees to the model used  and holds agencies to account for their active involvement in the process • Ensures that there  are sufficient resources  in the SSCB Business Unit to support the SCR process • Ensure Board partners are kept well briefed about the SCR and its progress • Intervene where difficulties or barriers emerge from agencies  SSCB Business Manager • Is familiar with the model used and acts as a source of information for all who are involved in the SCR process. This can be a stressful and anxiety-provoking experience for those unfamiliar with this type of approach • Ensures that all key parties are kept informed and there is formal sign up from all agencies involved in the SCR • Convenes all meetings and ensures that these are well documented and minuted • Works with and to the lead reviewers in terms of access to resources, data collection and contact with key individuals • Ensures that steady progress of the SCR is maintained  • Keeps the SSCB Chair and the Board briefed about emerging issues and progress • Manages issues about any parallel processes • Acts as the key link between the SCR Review Team and the SSCB  SCR Review Team Members will be expected to • Attend all meetings where possible – deputies are not encouraged • Collect documentation from own agency as and where required  • Read and analyse relevant data • Undertake  discussions with frontline staff from their own and other agencies if agreed and write up these ‘conversations’  • Support their own staff who are involved with SCR ensuring they receive full and appropriate support  throughout the SCR process • Identify and facilitate changes within their organisation in response to any emerging practice or policy issues • Meet/communicate with the staff at the end of the SCR process to discuss agency and professional learning • Ensure that the required Learning and Reflection report is submitted for inclusion in the SCR final report • Ensure that information about SCR process is communicated throughout their agency to managers and frontline practitioners  • Ensure required reports are submitted on time • Read and contribute to draft and final reports • Take responsibility for addressing any issues, which arise in their organisation in relation to the SCR, including any findings and recommendations  Practitioners Group members will be expected to • Attend Practitioner  Group meetings   and/or    - 29 - • Meet with two members of the Review team to discuss their views about working with the family and what factors helped and hindered your practice • Reflect on their own practice and that of their agency • Offer support  and respectful challenge to other colleagues through  their reflective  and shared journey • Read and comment on any draft report circulated by the Review Team   Lead Reviewers will • Offer leadership to the  Review Team, chairing meetings and ensuring key tasks are identified and  followed through • Work in partnership with Review team to ensure work is co-ordinated and progressed • Offer guidance and support to all individuals involved in the SCR process  • Maintain a reflective log to ensure that lessons can be learnt for future use of this model • Produce draft reports for the Review Team, offering insights, analysis and challenge  and take responsibility for the production of the final report on behalf of the team • Ensure they  have supervisory and mentoring  opportunities to provide scrutiny and challenge to their role as lead reviewers   Rationale: The role of Business Manager is a vital one and it is essential that this individual understands the key part they play in supporting the SCR. Equally, others who are involved need to be clear about what is expected of them in this way of working.  SSCBs may elect to appoint one lead reviewer to lead on the SCR and agree that the second lead reviewer can be an internal appointment from any of the agencies involved.  It is important however to note that if this decision is taken, appropriate resources should be made available including external supervision for both reviewers.     - 30 - Appendix 3 Methodological Comments and Limitations  1. The Review Team’s understanding of using the model initially created anxiety due to this being a new experience.  Even with the benefit of the Review Team being provided a presentation of the model by the Lead Reviewers, concerns regarding elements of the process were expressed by some Review Team members.   2. There was clearly a good working knowledge of undertaking serious case reviews in the previous models prior to Working Together 2013.  This, coupled with a Review Team that had worked together for a considerable period of time, led to nervousness about the changed process but also created opportunities for challenging some accepted practices.   3. The terminology used within the Model was different and this also impacted on the understanding of individual Review Team members and led to additional explanations of the process and guidance from the Business Manager.  In future the Board will produce a SCR Information Pack for all those involved in the review process. This has already been developed as the Review Panel learnt lessons throughout the process.  4. Concerns about roles within the process became evident within Review Team meetings and a level of constant reassurance was required.  The less prescriptive approach of this model allowed some flexibility within the Review but timescales weren’t sufficiently robust and this is an issue the Board will address in future reviews when using this approach.  5. The number of SCRs being undertaken in this Authority at the same time clearly impacted not only on timescales but also on the workload and availabilities of the Review Team. On occasions it also made it more difficult for the Review Team to separate one review from another due to the similar nature of the case.  However, the lessons emerging from this Review corroborated those already identified and strengthened the messages for the Board.  6. The Model was amended part way through the process to include agencies producing a Learning and Reflection Report.  This enhanced the process of learning from the case as the staff themselves were directly involved in identifying the learning from the case.  However this had not been part of the original Model and was introduced when it became evident that the Board needed evidence that agencies had learnt lessons from their participation in the Review. Taking on board the Review Team’s feedback in future this needs to be explained much earlier especially regarding the sign off of these reports.   7. The Review Team have a better understanding of other agency’s learning through this very interactive practitioner/Review Team relationship.  Some of the learning enabled individual agencies to better understand the role, function, and practice of their multi-agency partners in this case.  It also challenged agency’s assumptions of one another roles and statutory responsibilities.   The experience of undertaking conversations with frontline practitioners although time consuming was thought to be beneficial to the SCR process.  8. Feedback from frontline practitioners indicated that they thought the Practitioners Meetings, although not always comfortable, did help them better understand the role of their colleagues and made a   - 31 - difference to their practice.  They valued being involved as key practitioners in the SCR process and thought this approach was more inclusive and offered greater learning than previous models.   9. Overall, the experience was thought to be a positive one, but one which was not necessarily any less time consuming than previous approaches.    - 32 - Appendix 4  Agency Learning Reports  1. City Hospitals Sunderland (CHS) Learning Points and Actions taken  • Importance of recognising risk where parents have history of non-engagement with services and substance misuse • Need to challenge and escalate concerns when procedures are not followed or referrals are not acknowledged • When communication channels are not robust, children are vulnerable • Any agency can instigate multi-agency meetings if there are concerns (Reviewer’s comments) • MASH processes have improved communication • Being involved in a Serious Case Review is stressful • CHS guidelines have been updated to aid practice • Postnatal documentation now includes a section relating to discussions with parents around safe sleeping practices. The HV and MW pathway will be audited to ensure this process is followed • Midwives will now escalate cases to the Named Midwife for Safeguarding children regarding any complex issues or delayed feedback from Children’s Services. The HV and MW pathway will be audited to ensure this process is followed • Pre-discharge planning meetings are now required for all cases where there are Child Protection concerns • Safeguarding arrangements have been reviewed and are now more robust regarding babies in hospital who are transferred to the neonatal unit  2. South Tyneside NHS Foundation Trust (STNHSFT) Learning Points and Action taken: • Where vulnerabilities in pregnant women are identified, this should lead to early allocation and early intervention by Health Visitors. The HV and MW pathway will be regularly audited to ensure this process is followed • All pregnancies where vulnerabilities are identified will be discussed with the safeguarding advisors to provide support for professionals and to ensure adherence to SSCB Unborn Baby Procedures • The Early Warning Tool will be reviewed and it's use clarified for all front line professionals, including social workers. An audit of its use across Sunderland will be completed within 6 months of this review • The learning from this review will be shared and discussed with the School Nurse Operational Lead to support the development and use of the Early Warning Tool for School Nurses • The learning from this review will be shared with operational leads and frontline professionals to ensure the impact upon parenting capability is both recognised and considered when there are concerns regarding any substance misuse. This should be clearly documented following each health contact • Better communication between the community health team allows for increased flow of information. The GP Safeguarding team meeting provides the ideal conduit for this   - 33 - information to be shared. Health Visitors and School Nurses will be encouraged to attend these meetings so information about vulnerable families can be shared • The Health Visiting service and the School Nursing Service are employed by STNHSFT. The learning from this case and the recommendations identified will be monitored by both STNHSFT Safeguarding Strategic Operational Group and the CCG Strategic Safeguarding Group  3. Learning for General Practitioners  Learning Point and Action taken • Record Keeping: There were issues within both practices12 about “flagging” safeguarding concerns on the electronic records.  “Flagging,” alerts every practitioner using the system to any concerns about, for example, Child Protection Plans, Toxic Trio and/or risks to staff visiting the home.  In busy General Practice where there may be a number of GPs this is of paramount importance as individual GPs may not have met the patient previously Clear guidance on how to “flag” safeguarding concerns will be incorporated into the Safeguarding Children Primary Care Resource Pack which will be circulated to all GPs and Practice Managers in June 2014.  Whilst this information was contained in a previous resource pack this has been reviewed and strengthened in the 2014 version • Analysis of Information:  There was good evidence that the antenatal vulnerability assessments were received into the GP practice from the midwife and being scanned into LC’s record, but these were not analysed in the context of her already having children and consideration was not given to ‘flagging’ the records accordingly The importance of utilising historical information and assessments undertaken by other health professionals features in all Level 3 GP safeguarding children training. This training will be reviewed and the learning from this case highlighted.  A briefing paper on the learning will also be produced and shared with all Practices • Communication with Midwives and Health Visitors:  JR’s GP practice was not contacted by the midwife involved in LC’s care despite his name and date of birth being included on midwifery records.  This information was also included in the child protection referral submitted by the midwife. The GP practice was not contacted by Children’s Services undertaking the Initial Assessments and the GP indicated that they would have shared the information known about his substance misuse • There has been an agreement that midwives will copy the antenatal vulnerability assessment to a father’s GP practice (if different to mother’s). Practices must ensure that this is scanned onto the father’s GP records and the system flagged accordingly.  This needs to be incorporated into the Safeguarding Children Primary Care Resource Pack, which will be circulated to all GPs and Practice Managers in June 2014 and will be included in the briefing note to all Practices. City Hospital’s internal safeguarding policies and procedures will need to be reviewed to ensure this change to practice is incorporated here is no evidence of midwifery verbally sharing or updating LC’s GP Practice regarding the vulnerabilities identified during her antenatal and postnatal period.  An audit of attendance at “vulnerable family “multi-disciplinary meetings within Primary Care must be undertaken across Midwifery, Health Visiting and Primary Care by the agency leads.                                                   12 LC and JR were registered with different GPs.   - 34 - Midwifery policies and procedures must be reviewed to ensure GPs are copied into any safeguarding children referrals and that attendance at such meetings should be seen as core business • Evidence Based Care:  It is imperative that GPs undertake regular training in safeguarding children and can recognise the “Toxic Trio” and other factors that may impact on parenting capacity.  The continued emergence of children not being brought to medical appointments in reviews emphasises the importance of GPs attending training on neglect and how it may present Both practices were not aware of the increased vulnerability of babies to Sudden Infant Death Syndrome when parents/carers adopt unsafe sleep practice. The training programme for GPs must be reviewed to ensure all of the learning from Baby E is highlighted and that all health professionals promote safe sleep practice to all parents/carers The Child Death Overview Panel is currently undertaking a review of the “Give Me Room To Breathe” campaign and any change to advice and new resources will be shared with all GPs in Sunderland • Systems and Processes: Both GP practices for JR and LC have been offered support from the CCG Safeguarding Children Team in reviewing their systems and processes in light of the learning identified from this review. The learning from this case review has already been shared with the 2 practices involved and will be shared across the city as the SCR progresses in a variety of training and awareness sessions.  A briefing paper on the learning will also be provided to the GPs and Practice Managers in Sunderland • GPs are commissioned by NHS England, the learning from this case and ensuring the recommendations are implemented will be monitored by both the CCG and NHS England, via the CCG Strategic Safeguarding Group and the NHS England Safeguarding Forum • The Head of Safeguarding will share the recommendations and the Named GP for Safeguarding Children within the CCG in timescales as agreed by the Serious Case Review Panel  4. Children’s Services Learning Points and Action taken • Lack of shared understanding by staff in Children’s Services of thresholds across Early Intervention and Social Care • Importance of following Vulnerable Babies Protocol • Importance of assessments seeking and incorporating views of other professionals • Practice of transferring cases between social care teams needs review • Supervision and support to staff need to be consistent • Need to improve Induction programmes • Business processes need to support the Safeguarding system • A review of the Step Up/Step Down procedure to be carried out to ensure that this protocol is fit for purpose, widely understood and followed  • Joint workshops on thresholds, preferably in localities, to be put in place • Refresher sessions re the Vulnerable Babies protocol to take place in team meetings across the 5 Child Protection Locality Teams and in the MASH • Follow up sessions after the Assessment Training being delivered in June 2014 to ensure that the learning from this training is embedded in practice • Implementation of the new Single Assessment to emphasise the importance of social workers routinely speaking to all other professionals involved when conducting assessments in order to inform their analysis • Transfer protocols to be reviewed and updated to be more specific re need for Transfer summary to be in place when cases are transferring between teams   - 35 - • Each CP team should have 2 Senior Social workers (rather than 1 as at present), to assist with supervision. The Senior Social Workers need to have significantly reduced caseloads so that they have time to supervise staff • Review of induction for new staff joining the service, including those who are not newly qualified, and agency social work staff. Process for in-service induction/familiarisation for staff moving to new team/taking on new roles within Children’s safeguarding to be put in place • Multi-agency development sessions, where possible on a locality basis so that staff from different agencies working with children can get to know each other and forge more effective professional relationships • Audits of Contacts to ensure an email or “action job” is sent to the social worker and manager to inform them when new contacts are received on open cases  5. Gentoo – Housing Provider Learning Points and Action taken • There were potential opportunities for the staff to have explored vulnerability and support needs of the tenant and wider household.  As there were no obvious presenting issues and as the family lived in general needs accommodation, this did not happen.  Therefore consideration of a more general approach to assess vulnerability needs to be given • Vulnerability is currently referenced throughout various separate processes at Gentoo.  We have dedicated Domestic Abuse and Safeguarding Policies as well as a Community Safety Strategy.  However, we do not have a more generic vulnerability policy, therefore, as stated above, consideration needs to be given to developing a more generic policy and approach • It is frustrating for Gentoo staff to have learned that Children’s Services had historic involvement with the family, yet no one at Gentoo had been notified of this. We need to agree information sharing process and protocol with Children’s services so Gentoo are notified of cases such as this and can contribute to any family support plan • Any tenancy breach matter should alert housing staff to the possibility that there may be vulnerability issues or tenancy support needs. This is obviously more difficult when there are no obvious presenting vulnerability issues.  Therefore, the matter of treating tenancy breaches as a vulnerability trigger needs to tie into the development of a more general vulnerability policy and approach • Develop generic vulnerability policy   • Develop specific information sharing protocols with Children’s Services  • Raise awareness of the learning points from the case with all front line housing staff • Train front line staff on the new vulnerability policy and approach which will include considering tenancy breach as a trigger • Carry out safeguarding refresher training to all front line staff   6. Children’s Services: Education  • Safeguarding procedures have been revised and implemented • Roles and responsibilities in school have been clarified • The importance of recording concerns and sharing these with the Designated Person in school has been stressed. Importance of seeking feedback has also been highlighted • Staff will receive Safeguarding training as a matter of some urgency so they are clear about roles and responsibilities in relation to safeguarding children in their care • Children’s Services will ensure these lessons are disseminated across all schools      - 36 - Appendix 5  How has the learning from this SCR improved practice?  City Hospitals Sunderland (CHSFT) • To improve midwifery documentation, to include evidence of information giving regarding safe sleep IMPACT: Post-natal documentation has been updated and this provides a section to evidence discussion relating to safe sleep for midwives to complete. An audit was undertaken in July 2015 and June 2016 and this provided assurance around compliance to discussion around safe sleeping practices and pre-discharge planning meetings • To ensure child protection cases are managed well, Midwives to escalate any complex cases or delayed feedback from Children’s Services to named midwife IMPACT: Communication via emails, supervision and staff briefings to all midwives regarding this requirement which has led to an increase in discussion with midwives around complex cases with the named midwife for safeguarding. Vulnerable babies Interface meetings were established with CHSFT and Children’s Services in February 2015 to ensure effective communication and oversight of cases • Pre discharge planning meetings are to be held in all cases where there is an unborn child protection plan in place IMPACT: Communication via emails, supervision and staff briefings to all midwives regarding this requirement. Documentation was improved to support these meetings and an audit was undertaken which evidenced that processes were being followed. This audit was repeated in April 2016 and again this provided assurance that pre-discharge planning meetings were embedded in practice and that babies were being discharged safely from hospitals • Where parents require supervision, the birth arrangements are clear on the agreed provision including if babies require to be cared for in the Neonatal Intensive Care Unit (NICU) IMPACT: New birth arrangements were formulated which have clear plans for supervision. All of the recommendations from this review will be included within CHSFT safeguarding children training and supervision IMPACT: The training and supervision is having a positive effect upon staff awareness and understanding of safeguarding and serious case reviews, with the training evaluation demonstrating feedback. Assurance via the quarterly safeguarding dashboard  South Tyneside NHS Foundation Trust (STNHSFT) • Improve communication between HV and MW services o All Health Visiting teams now have an ante-natal database to record patient information following receipt of ante-natal vulnerability (AVA) form from midwifery colleagues. Identification and Notification of vulnerable families via the AVA has led to early allocation and involvement of Named Health Visitor during earlier stages of pregnancy o On receipt of the AVA this is analysed by the Health Visitor in the context of what is already known about the family, enhancing sharing of information and multi-agency communication o Where vulnerability has been identified on the AVA, Health Visitors will undertake early contact and intervention with the family, contributing earlier to multi agency working o The Safeguarding team are notified on a monthly basis of AVA notifications received and the identified named health visitor. Improved communication between the safeguarding team and the health visiting service supports the provision of safeguarding advice during the pregnancy • Appropriate  use of the HV and SNS Early Warning Tool EWT across STNHSFT o Health Visiting Child Health records now include both an Early Warning Tool, and a Workload intervention tool. Early identification of risk ensures families and children receive   - 37 - specific support and intervention from the most appropriate health professional in a timely manner • All vulnerable UBB cases will be discussed by health professionals with the safeguarding advisors o Safeguarding Children Advisors now provide safeguarding supervision to all health visitors specifically with regard to Unborn Babies following identification of vulnerability on the AVA. Safeguarding supervision ensures SSCB and STNHSFT Safeguarding Unborn Baby Procedures are adhered o STNHSFT Safeguarding Team link with CHS midwifery lead to raise and discuss any concerns with the HV/MW Pathway both verbally and at a dedicated interface meeting. Enhanced communication across HV/MW ensures LSCB and STNHSFT Safeguarding Procedures regarding the Unborn Baby are adhered with • The impact upon parenting capabilities following the identification of the use of any substance should be considered at each health contact. This should be clearly documented within the child health records o A safeguarding training package Level 3 has been developed ‘Substance Misuse and the impact upon Children’. This training equips health professionals with the knowledge and skills regarding illegal substances, and the impact a parent’s reliance on illegal substances may have upon the child or children within the household. This supports health professionals with completion of health and risk assessments o New Health Visiting Child Health Records have been introduced 1st June 2016.Health Visitors are required with all families to discuss substance misuse at all contacts with the family as part of the overall health assessment.  Early identification of reliance on substances leads to early support and specialist intervention for the family and earlier identification of potential risks posed to children • The GP Safeguarding practice meeting should be attended or information shared with regard to  vulnerable families from community professionals o Each GP practice has a named Health Visitor to attend GP Safeguarding Practice Meetings. Vulnerable families are discussed at this meeting promoting effective communication and enabling primary care practitioners to share and analyse information to progress the most appropriate support and intervention for children and families  Learning for General Practitioners (GPs) • All practices will clearly ‘flag’ children and families where there are safeguarding concerns o Both clinicians and administrative staff will be able to easily identify children and families at risk, which may influence provision of appointments, and indicate who is the best person to see that child or family o Such children and families will be easily identifiable in order to piece together information shared from other agencies, which will help identify further needs o This will enable practices and staff to take a “whole family” approach to safeguarding and ensure that the right service is offered at the right time • GPs to recognise the importance of analysing information received and shared by agencies in the context of what is already known about the family o GPs are in a strong position for collating information from multiple sources about patients. Through recording information received and applying this to what is already known GPs can piece together a much fuller picture of a family o GPs all hold regular multi-disciplinary meetings which are an ideal environment to discuss families and any information received about a family. This enables practices to consider the relevance of the information and apply that to supporting a child or family in a timely manner, by the most appropriate practitioner    - 38 - • Midwives to send copies of antenatal vulnerability assessments to GP practice of the birth father of the unborn child, where the father is registered at a different practice, when safeguarding concerns are noted.  GPs to recognise the importance of the father’s history as well as the mothers and to aim to avoid the possibility of the ‘invisible’ father o Where safeguarding concerns are raised by the midwife, a safeguarding referral will be made, and standard procedures for safeguarding referrals will be used to gather information on relevant family members in order to process the referral. o Where male patients disclose information of concern to the GP, and the GP is aware that they are, or are soon to be a father, this information will be taken into account and discussed with the patient, and safeguarding referrals made where appropriate o Where safeguarding concerns are raised by the midwife and the father is present at that appointment, the fathers GP will be informed of the concerns • Practices to regularly hold multi-disciplinary meetings including midwives to discuss cases of concern and more complex cases o All practices in Sunderland hold regular multi-disciplinary meetings, at varying frequency depending on the size of the practice. Midwives are invited to these meetings o This should improve communication between a range of practitioners and result in a shared understanding of the needs of families, agencies involved and result in more timely involvement of appropriate services to improve outcomes for children and young people. o Most practices have systems in place to collate information from midwives, should they be unable to attend meetings, thus sharing their information and enabling informed discussions at MDT meetings o An audit is conducted on an annual basis to identify any problems in meeting with relevant professionals and holding MDT meetings. This is then fed-back to appropriate lead professionals and processes are reviewed to resolve any problems and improve communication between agencies  Children’s Services • Improve the understanding of thresholds across early Intervention and Social Care o The ‘Step Up and Step Down’ procedures were revised in 2014 and shared internally within Children Social Care & Early Help Services and with partner agencies  o Threshold Workshops were delivered across the city to multi agency groups in November 2015 o Early Help activity is being closely monitored by the Improvement Board • Need to follow Vulnerable Babies Protocol o The Unborn Baby Protocol was revised in February 2016 and is awaiting a further review in the light of the introduction of the Single Assessment  o Vulnerable Baby workshops have been delivered jointly by Health and Children’s Social Care  • Importance of assessment incorporating views of other professionals o The Single Assessment was fully implemented in February 2016 which emphasises the importance for social workers to routinely speak to all other professionals when undertaking assessments, in order to inform their analysis o Risk tools were introduced in August 2015 – Bruce Thornton, supported by training events to all Children’s Social Care and Early Help staff • Transfer of cases between social care teams o The Transfer Protocol  is currently under review in the light of the changes made to the structure of Children’s Social Care i.e. MASH moving to be an Integrated Contact and Referral team; Child’s Permanence Reports to be undertaken in the Locality Safeguarding Teams  o Transfer summaries are required and this is built into the Practice Standards for Social Workers and monitored through the audit process   - 39 -  • Supervision and support to staff including induction o Supervision Policy revised and re launched – May 2015 o New recording pro-forma has been developed and under continuous review to reflect the new guidance o All supervisions are recorded on CCM and there is monthly reporting to the Improvement Board  o Themed audit of supervision was carried out in January 2016 to assess quality with a further audit in August 16 • Continually work towards improving the working relationships with other professionals o This is an on-going endeavour and is best seen in some of the structural multi agency developments in Children’s Social Care ie the MASH and the Multi Agency Looked After Panel  • Improve the business processes supporting the safeguarding system o The introduction of the Business Manager in each of the locality teams has significantly improved the business processes o Quality of information and data has improved  o CCM version 29 has been implemented in the early part of 2016 and the introduction of Liquid logic is planned for June 2017  Gentoo – Housing Provider • There were potential opportunities for the staff to have further explored vulnerability and support needs of the tenant and wider household o Gentoo are in the process of developing a generic vulnerability policy o Training sessions have been held to ensure all relevant staff are clear about expectations around exploring vulnerability.  Sessions took place in November and December 2014, January 2015 and May 2016 Impact The impact of this new approach will mean that any tenancy breach matter, regardless of how minor, will alert housing staff to the possibility that there may be vulnerability issues or tenancy support needs. • Gentoo were unaware that Children’s Services were involved with Baby E and her family.  Information sharing protocols with Children’s Services to be developed Impact If Gentoo were made aware of all cases involving their tenants, we could be part of any improvement/support plan for the child/family.  Our involvement with the family would be completely different to those where we are simply managing a general tenancy   Children’s Services: Education  • Safeguarding procedures have been revised and implemented: o Children’s Social Care Services have revised procedures for contact/referral to MASH; escalation routes where schools are not satisfied with how referrals are dealt with have been clarified; all referrals should now receive acknowledgement response • Roles and responsibilities in schools have been clarified: o Termly training for designated persons in schools refreshes and reinforces the approach to safeguarding in schools which is also covered in schools/academies Ofsted Inspection Framework o The importance of recording concerns and sharing these with the designated person in school has been stressed. Importance of seeking feedback has also been highlighted o Schools are now encouraged to seek acknowledgement/outcomes of referrals if these are not forthcoming   - 40 - o Staff will receive safeguarding training as a matter of urgency so they are clear about roles and responsibilities in relation to safeguarding of children in their care o Designated person training, SSCB training, including social care/ health delivered training in relation to vulnerable babies o Children's Services will ensure these lessons are disseminated a cross all schools o Representative schools involvement in SSCB executive arrangements has led to improvements in dissemination of lessons in addition to termly training for designated safeguarding leads  Sunderland Safeguarding Children Board • SSCB have developed and implemented a procedure and a prompt sheet identifying how staff can work effectively with parents who are resistant, hostile or unco-operative.  This should have the impact of challenging the member of staff around whether parents are actually working with agencies to improve outcomes for their children.   Consultation with frontline staff confirmed that these prompt sheets did have the required impact on staff • The SSCB used the Section 11 audit process for agencies to self-assess their internal learning and improvement processes.  This included assessment around if the agency used learning from all reviews/audits to develop service deliver.  The SSCB is planning to undertake a staff survey in Autumn 2016 to triangulate the findings with the Section 11 audit findings in 2016-2017.  This will give the Board a more accurate overview of the impact of the extensive improvement work across the safeguarding system as a whole • The SSCB Unborn Baby procedures have been strengthened and a multi-agency audit of the instigation of pre-discharge meetings for babies (where appropriate) is to be undertaken in 2016-2017.  This will measure the impact of the procedural changes focusing on both compliance and the quality of work undertaken • The SSCB Threshold Guidance has been strengthened as part of the development of the SSCB Early Help Strategy.  Analysis of performance information has identified that these two frameworks have not significantly impacted to improve outcomes for children.  The SSCB is therefore undertaking a further review of both documents, establishing a joint framework for dissemination of information as a mechanism to fully embed the changes in practice required.  The impact this has will be measured through the planned multi-agency audits for 2016-2017 on referrals to Children’s Social Care, the robustness of the Step Up/Step Down procedures and the quality of early help where domestic violence is a risk to children • Whilst not a specific recommendation from this SCR, learning has highlighted the need to strengthen the SSCB so the SSCB has strengthened its approach to obtaining assurance about the safeguarding system in Sunderland and it’s partner agencies through: o Undertaking a Section 11 audit in 2015-2016 which evidenced compliance by partner agencies in respect of their staff supervision arrangements13 o The SSCB Chair is undertaking assurance work through requesting Board partners to provide assurance of their current safeguarding arrangements and their agency annual safeguarding report for 2015-2016.  This will be one element contributing to strengthening the SSCB’s understanding of how effective the safeguarding system in Sunderland is o Refocusing on the behaviours, values etc, that the SSCB wants to be embedded into safeguarding practice in Sunderland                                                  13 Section 11 of the Children Act 2004 places duties on a range of organisations and individuals to ensure their functions, and any services that they contract out to others, are discharged having regard to the need to safeguard and promote the welfare of children.  This includes ensuring they have safe recruitment practices for individuals whom the organisation will permit to work regularly with children, including policies on when to obtain a criminal record check; appropriate supervision and support for staff, including undertaking safeguarding training.      - 41 - • Implemented a learning and improvement monitor which is providing robust scrutiny and high challenge on the implementation of all recommendations from all SCRs the Board is undertaking 