Death of a 10 year old girl in October 2011 by hanging. Amy had been in contact with Specialist Children's Services (SCS) at various points regarding allegations of sexual abuse: in 2006, following suspicion that Amy had witnessed another child being abused and in 2008, following an allegation of abuse reported to the police by her father and later confirmed by Amy. Neighbours contacted both SCS and Amy's school with allegations of physical abuse and neglect and school staff had concerns regarding Amy's unkempt appearance and insufficient lunches. Amy's behaviour was characterised as suggestive of ADHD by her mother and GP as early as 2006, with a diagnosis being made in February 2010. Following the initiation of the Common Assessment Framework in late 2010, Amy was described as borderline Child in Need and it was agreed that a Team Around the Child (TAC) be set up. Amy's parents did not respond to a number of attempts to set up an initial TAC meeting; however a plan of intervention including referral to an educational psychologist and to an early intervention service were agreed in February 2011. Review considers issues of focus on the child; disability needs; working with hostile or resistant families and makes various interagency and single agency recommendations covering education services, children's social care and health services. Key recommendations include: the use of CAF and referral to children's social care are well understood and consistently implemented; schools have the necessary safeguarding systems in place and to a good standard; development of guidance for commissioners of health services so that, if Health Overview Reports are required in future serious case reviews, authors will have clear expectations as to their purpose and expected contents.
      
Title: Amy: a serious case review LSCB: Kent Safeguarding Children Board Author: Kevin Harrington Date of publication: September 2012 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. This report is the property of the Kent Safeguarding Children Board. Page 1 of 41 Kevin Harrington Associates Limited           AMY  A SERIOUS CASE REVIEW  Kevin Harrington JP, BA, MSc, CQSW   On behalf of the Kent Safeguarding Children Board  Chair Maggie Blyth  Serious Case Review Panel Chair Keith Ibbetson  September 2012             This report is the property of the Kent Safeguarding Children Board. Page 2 of 41 TABLE OF CONTENTS  TABLE OF CONTENTS ................................................................................................. 2 1. INTRODUCTION ..................................................................................................... 4 2. DECISION TO CONDUCT THIS SERIOUS CASE REVIEW ......................................... 4 3. SERIOUS CASE REVIEW PROCESS .......................................................................... 4 4. METHODOLOGY USED TO DRAW UP THIS REPORT ............................................. 8 5. CHRONOLOGY ........................................................................................................ 8 5.1 Introduction ............................................................................................................. 8 5.2 Key events ............................................................................................................... 8 6. THE FAMILY .......................................................................................................... 11 7. THE AGENCIES ...................................................................................................... 12 7.1 Introduction ........................................................................................................... 12 7.2 Kent County Council, Specialist Children’s Services ............................................ 12 7.3 Kent County Council, Education, Learning and Skills ........................................... 13 7.5 Kent Community Health NHS Trust ...................................................................... 15 7.6 The General Practitioners ..................................................................................... 17 7.7 Maidstone and Tunbridge Wells NHS Trust ......................................................... 19 7.8 Kent and Medway NHS and Social Care Partnership Trust ................................. 19 7.9 Kent Youth Offending Service ............................................................................... 19 7.10 Kent Probation .................................................................................................... 20 7.11 Housing Provider ................................................................................................. 20 7.12 South East Coast Ambulance Service NHS Foundation Trust ............................ 21 7.13 KCA Drug and Alcohol Services ........................................................................... 21 7.14 Health Overview Report ..................................................................................... 21 8. ISSUES IDENTIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW ............... 21 8.1 What were the facts in this case? ......................................................................... 21 8.2 Did agencies listen to the “voice of the child”?  Did agencies know what life was like for Amy? ................................................................................................................ 21 8.3 Were Amy’s needs appropriately assessed, with particular reference to the consequences of sexual abuse and neglect? .............................................................. 24 8.4 How were the outcomes of assessments used to inform practice and decision making in relation to Amy? Were Amy and her family appropriately engaged and involved by agencies? ................................................................................................. 26 8.5 How far was Amy helped to cope with the adverse circumstances in her life, particularly her sexual abuse? .................................................................................... 27 8.6 Did assessments and services take sufficient account of the family’s race, culture, language, and religious needs, and any disability needs? ........................... 27 8.7 Were Kent Safeguarding Children Board and individual agency procedures followed? ..................................................................................................................... 28 9. ISSUES ARISING FROM AN OVERVIEW OF THE CASE ......................................... 28 9.1 Good practice and service improvements ........................................................... 28 9.2 The circumstances of Amy’s death ....................................................................... 29 10. REVIEW PROCESS .............................................................................................. 30 11. CONCLUSIONS: KEY LEARNING POINTS AND MISSED OPPORTUNITIES .......... 31 12. RECOMMENDATIONS MADE IN THE MANAGEMENT REVIEWS OF THE PARTICIPATING AGENCIES ...................................................................................... 33 This report is the property of the Kent Safeguarding Children Board. Page 3 of 41 12.1 Introduction ......................................................................................................... 33 12.2 Kent County Council, Specialist Children’s Services .......................................... 33 12.3 Kent County Council, Education, Learning and Skills ......................................... 33 12.4 Kent Police ........................................................................................................... 33 12.5 Kent Community Health NHS Trust .................................................................... 34 12.6 Kent and Medway NHS and Social Care Partnership Trust ............................... 34 12.7 Maidstone and Tunbridge Wells NHS Trust ....................................................... 35 12.8 General Practitioners .......................................................................................... 35 12.9 Health Overview Report ..................................................................................... 35 12.10 Kent Youth Offending Service ........................................................................... 35 12.11 Kent Probation .................................................................................................. 35 12.13 South East Coast Ambulance Service NHS Foundation Trust .......................... 36 13. RECOMMENDATIONS FROM THIS OVERVIEW REPORT ................................... 37 13.1 Introduction ......................................................................................................... 37 13.2 Recommendations to the Kent Safeguarding Children Board .......................... 37 APPENDIX A: Biographical details of Independent Chair and Overview Report Author ...................................................................................................................... 39 APPENDIX B: References ......................................................................................... 40   This report is the property of the Kent Safeguarding Children Board. Page 4 of 41 1. INTRODUCTION  1.1 Amy Singleton1 died in 2011. She was ten years old and was found hanging by a belt from a window in her bedroom. The circumstances of Amy’s death, in a context of substantial current and historical involvement of various agencies with her family, led the Kent Safeguarding Children Board (KSCB) to conduct a Serious Case Review (SCR). This is the Overview Report from that review.  1.2 The death of a child is distressing for staff who have known that child and their family. This review has been greatly assisted by the co-operation and commitment of staff from all contributing agencies.  2. DECISION TO CONDUCT THIS SERIOUS CASE REVIEW  2.1 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Boards to undertake reviews of serious cases. The Regulation defines a serious case as 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.  2.2 In this instance it was alleged that Amy had been sexually abused by a member, or members, of her extended family. Allegations of neglect had also been made. It was therefore agreed that the criteria for conducting a SCR were met. The review was initiated in February 2012.  2.3 In line with statutory guidance, Ofsted2  should be immediately notified of the decision to conduct the SCR. As a result of an oversight that formal notification was not sent until 30/7/12, although this did not lead to any delay in the process of the Review.  Guidance indicates that the target timescale for completion of SCRs is 6 months. It became clear that further time was needed to determine the scope of the Review and complete it. An extension to the timescale was agreed by the LSCB Chair and the review was duly completed in September 2012. 3. SERIOUS CASE REVIEW PROCESS  3.1 The purposes of SCRs are set out in “Working Together to Safeguard Children3                                            1 This is not the real name of the child who is the subject of this review. The names of all family members have been changed to protect their anonymity. ” (Para 8.5). They are to 2 The independent body, reporting directly to Parliament, responsible for inspecting and regulating services to children and young people. 3 Working Together to Safeguard Children (2010) – referred to in this report as “Working Together” – is a government publication containing statutory guidance on how organisations This report is the property of the Kent Safeguarding Children Board. Page 5 of 41 • establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; • identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and • improve intra- and inter-agency working and better safeguard and promote the welfare of children.  3.2 During February 2012 arrangements were made to appoint the independent people who are required to contribute to the conduct of SCRs. Mr Keith Ibbetson was appointed to lead the review and Mr Kevin Harrington was appointed to produce this Overview Report, with an accompanying Executive Summary. Further details can be found at Appendix A.  3.3 The LSCB constituted a SCR Panel (the Panel) to manage and oversee the conduct of the review. The membership of the Panel is set out below.  Name / Designation Organisation Role Mr Keith Ibbetson Independent Independent Chair Head of Safeguarding Kent and Medway NHS and Social Care Partnership Trust (KMPT) Panel Member Named GP for Safeguarding Children NHS Kent & Medway Panel Member Acting Head of Safeguarding (or deputy) Kent County Council, Specialist Children’s Services (SCS) Panel Member Designated Dr. for Safeguarding Children East Kent Hospitals University NHS Foundation Trust (EKHUFT) Panel Member Designated Nurse for Safeguarding Children NHS Kent & Medway Panel Member Team Manager, Safeguarding Children Kent County Council, Family & Children Services (Education) Panel Member Assistant Head of Integrated Youth Services Kent County Council Panel Member District Manager – Dover Kent County Council, Family & Children Services (Children’s Social Care) Panel Member                                                                                                                              and individuals should work together to safeguard and promote the welfare of children and young people in accordance with the Children Act 1989 and the Children Act 2004.  This report is the property of the Kent Safeguarding Children Board. Page 6 of 41 Detective Superintendent, Public Protection Unit Kent Police Panel Member Senior Probation Officer Kent Probation Panel Member Manager Kent Safeguarding Children Board In attendance Mr Kevin Harrington Independent Overview Report author In attendance Administration Assistants Kent Safeguarding Children Board In attendance  3.4 It was determined that the following agencies should contribute to the Review. Those agencies with substantial and / or recent contact would be required to submit full Individual Management Reviews, in line with statutory guidance, whereas agencies with less or less recent involvement should provide reports for background information.   AGENCY NATURE OF CONTRIBUTION Kent County Council  Specialist Children’s Services Individual Management Review (IMR) Maidstone & Tunbridge Wells NHS Trust IMR NHS Kent & Medway IMR / Health Overview Report 4Kent Probation  IMR NHS Kent & Medway General Practitioners IMR Kent Police IMR South East Coast Ambulance Service NHS Foundation Trust IMR Kent Community Health NHS Trust IMR Kent County Council Youth Offending Service IMR Kent County Council Education Services IMR Housing Provider IMR KCA Drug and Alcohol Services IMR Kent & Medway NHS & Social Care Partnership Trust IMR Medway NHS Foundation Trust Information Report  3.5 Amy’s death has also been considered by the Coroner – to establish cause of death, and by police / Crown Prosecution Service – to consider whether a crime may have been committed. It was decided in October 2011 that there would be no criminal proceedings. The inquest was concluded in June 2012, with the recording of                                             4 Working Together (Paragraph 8.30) requires that in every SCR the appropriate Primary Care Trust should draw up a health overview report focusing on how health organisations have interacted together, which will also constitute the IMR for the PCTs as commissioners.  This report is the property of the Kent Safeguarding Children Board. Page 7 of 41 an open verdict. The Kent Police representative on the SCR Panel acted as the link between this Review and coronial and criminal investigations. The final report from this Review will also be considered by the Kent Child Death Overview Panel.5   3.6 The key issues for consideration in the review are summarised below. Agencies were asked to:  • provide detailed accounts and analysis of their contact with the family from 2006 to 2012 and summarise any earlier contact with the family • consider the “voice of the child” and what life was like for Amy • evaluate whether Amy’s needs were appropriately assessed and met • assess whether Amy and her family were appropriately engaged and involved by agencies • consider how far Amy was helped to cope with the adverse circumstances in her life, particularly her sexual abuse. • establish if assessments and services took sufficient account of the family’s race, culture, language, and religious needs, and any disability needs.  • review whether Kent Safeguarding Children Board and individual agency procedures were followed.  3.7 In the early stages of gathering information it became clear that the extended family composition was complex and that there was a great deal of information across a number of agencies about members of that extended family. This raised the immediate issue of needing to ensure that children in the extended family were safe. This was referred back to operational services and was immediately followed up by them.   3.8 There were indications that agencies might have lessons to learn from their involvement with extended family members. However it was judged that it would be unhelpful to incorporate an examination of involvement with the extended family into the review arising from Amy’s death. It would take a great deal of additional time and would complicate the task of ensuring that this report was appropriate for publication. Consequently it was decided to limit the scope of this review to considering Amy and her immediate family. Reference to extended family members is made only where it is relevant to an understanding of Amy’s circumstances.  The LSCB has accepted a recommendation that they should conduct a separate exercise to identify any lessons to be learned from agencies’ involvement with members of the extended family.  3.9 In conducting this review agencies were asked to give particular attention to practice since August 2010 when an inspection by Ofsted led to a formal Improvement Notice because “the overall effectiveness of Kent’s safeguarding and services for looked after children (was judged) to be ‘inadequate’.                                              5 The establishment of Child Death Overview Panels, reviewing the deaths of all children under 18 and reporting to the LSCB Chair, became a mandatory requirement in April 2008 This report is the property of the Kent Safeguarding Children Board. Page 8 of 41 Service improvements relevant to issues arising from this review are considered throughout this report.  4. METHODOLOGY USED TO DRAW UP THIS REPORT  4.1 This Overview Report is based principally on the agency IMRs, background information submitted and subsequent Panel discussions and dialogue with IMR authors. Family involvement is discussed at section 6 below.  4.2 The report consists of • A factual context and chronology. • Commentary on the family situation and their input to the SCR. • Analysis of the part played by each agency, and of their IMR. • Closer analysis of the specific issues identified in the Terms of Reference, detailed above. • An account of issues arising from an overview of the case. • Conclusions and recommendations  4.3 The government has introduced arrangements for the publication61)  take reasonable precautions to prevent the identification of the child concerned or other family members  in full of Overview Reports from Serious Case Reviews, unless there are particular reasons why this would be inappropriate. This has implications for the extent to which certain matters can be detailed. This report is written in the anticipation that it will be published. Consequently the information it contains is limited in order to 2) protect the right to an appropriate degree of privacy of family members  3) avoid the possibility of heightening any risk of harm to other children.  5. CHRONOLOGY  5.1 Introduction  5.1.1 Each of the agencies involved in this review submitted a detailed chronology, in tabular form, of their involvement with the family in the period under review. Those submissions have been co-ordinated into an integrated tabular chronology. This document is some 230 pages in length. This section of this report aims to summarise that chronology in an accessible way. It does not include every contact, or failed contact, and does not provide a detailed account of all the work carried out.   5.2 Key events  5.2.1 Amy started school in September 2005. Her health visiting records cannot be traced so no background information is available before this date. There was early                                             6 See letter from the Parliamentary Under Secretary for State for Children & families dated 10th June 2010  This report is the property of the Kent Safeguarding Children Board. Page 9 of 41 recognition that she needed additional help and an Individualised Education Program (IEP) was set up.  5.2.2 In 2006 police and children’s services investigated a report that a member of Amy’s extended family had sexually assaulted a child.  Mr Singleton expressed consequent concerns for Amy and she was taken to the family GP. The GP discussed this with the Named Nurse for Child Protection, but no action was taken as a result. In August the GP made enquiries with child mental health services (CAMHS) about treatment for Amy for ADHD. At that time it was felt that she was too young for this to be reliably diagnosed and treated.  5.2.3 Later that year SCS received an anonymous referral alleging neglect of Amy. There was a delay of several weeks before SCS followed this up by writing to the family. Mr Singleton responded, denying any cause for concern. Amy’s school reported that they had no serious concerns. No home visit was made, Amy was not seen by SCS and no further action was taken.  5.2.4 Mrs Singleton met with staff at Amy’s school regularly during 2007, and saw the GP once, because of concerns that Amy’s behaviour was difficult and, in her mother’s view, suggestive of ADHD. In school, although some academic targets were being met or exceeded, her behaviour remained difficult to manage. There was continuing concern about her coming to school unkempt and poorly clothed but these were not raised directly with her parents.  5.2.5 In 2008 Mr Singleton reported to police that Amy had been sexually abused by a member of her extended family, who denied this. The allegation of abuse was confirmed by Amy. After an investigation by police, with limited input by SCS, it was decided that there was insufficient evidence to support any further action. There is no indication of consideration being given at that time to measures to protect Amy, or other children with whom the alleged perpetrator might have contact.   5.2.6 A neighbour made allegations in June 2009 that Amy was physically abused and neglected.  Neighbours also reported that they had seen Amy displaying sexualised behaviour in public. No action was taken by SCS for several weeks. A social worker then visited the home but it does not appear that the allegations of child abuse and neglect were investigated, or that the children were seen alone. The follow-up to the interview was focussed on financial problems the family were said to be experiencing. The case was closed by SCS in September. There had been no assessment under child protection arrangements despite the nature of the original referral.   5.2.7 Towards the end of the year Amy was assessed in school because of her special educational needs. That assessment found that although Amy’s reading ability was above average, her self-esteem and “emotional literacy” were very low. Various strategies were suggested to assist the school in addressing these issues and the school started a programme of specialist therapeutic play work with her.   This report is the property of the Kent Safeguarding Children Board. Page 10 of 41 5.2.8 In February 2010 Amy was diagnosed as having ADHD and was started on medication for this. Around this time her school had also tried to initiate a Common Assessment Framework (CAF)7  assessment. Although initially in agreement with this, her father said that he would not co-operate if there were any involvement from SCS. This led to considerable delay and the CAF was not initiated until September, when agencies agreed that there would be no SCS involvement.  5.2.9 In March a member of Amy’s extended family pleaded guilty to a charge of “engaging in sexual activity with a child” and received a custodial sentence. He had previously been the subject of allegations of sexual abuse in respect of Amy.   5.2.10 A neighbour contacted the Head Teacher of Amy’s school later that month to express concerns about her. The school decided not to pass these reports on to SCS, on the basis that SCS were already aware of general concerns about the family. The school subsequently received three letters, all apparently from concerned neighbours, expressing concerns about Amy. These letters did not lead to any action being taken. School staff had concerns that Amy’s packed lunch was insufficient and offered to fund free meals but report that her parents declined this offer.   5.2.11 The CAF was initiated towards the end of 2010. It was decided that the approach should be consistent with Tier 2 of the CAF arrangements – there is a fuller discussion below but Tier 2 involvement indicates that the level of need was not judged to require referral to SCS. Amy was described as “borderline Child in Need 8 ” – Children in Need should be seen as requiring intervention under Tier 3 of the CAF arrangements. The Special Educational Needs Co-ordinator (SENCO) at the school was identified as the Lead Professional. It was agreed that a Team Around the Child (TAC) be set up including Amy’s parents, a local parenting support service, school staff, the School Nurse and an ADHD nurse. It was suggested the TAC might consider referral to an early intervention service, Support Services for Kids and Young People (SSKY).  5.2.12 There were a number of attempts to set up the initial TAC meeting but Amy’s parents did not respond. In mid-December Amy made comments to a member of school staff which suggested that she was concerned about being sexually abused by members of her extended family. This was discussed with her father who said that                                             7 The CAF was established by the former Department for Children, Schools and Families. It is described on the Every Child Matters website as “a standardised approach to conducting assessments of children's additional needs and deciding how these should be met…The CAF promotes more effective, earlier identification of additional needs, particularly in universal services. It aims to provide a simple process for a holistic assessment of children's needs and strengths; taking account of the roles of parents, carers and environmental factors on their development” 8 Children in need are defined in law as children who:- • need local authority services to achieve or maintain a reasonable standard of health or development • need local authority services to prevent significant or further harm to health or development • are disabled. This report is the property of the Kent Safeguarding Children Board. Page 11 of 41 these people were no longer considered part of the family and would not be visiting the home. There was no referral to SCS.  5.2.13 The first TAC meeting was held in February, attended by Amy’s mother, the SENCO, the headteacher, class teacher and school nurse. A plan of interventions was agreed including referral to the educational psychologist for assessment and referral to SSKY. The ADHD liaison nurse was to be asked to review Amy’s weight.  That plan was pursued throughout the year, during which there were continuing concerns about Amy’s health, presentation and general wellbeing. A review in September judged that a “Tier 2” approach remained appropriate and the situation did not meet the criteria for a referral to SCS.  5.2.14 In October Amy was found hanging from the window of her room. Her parents called an ambulance which arrived within minutes. Amy had been put to bed at 21:30 after taking medication. She came downstairs once more and then returned to her room, apparently untroubled. Her father checked on her at 23:30 and found her hanging by a fabric belt attached to the window. Advanced life support was commenced by the attending ambulance crews but her condition did not improve during this time. She was taken to hospital without delay and a Consultant Paediatrician attended from home but her life could not be saved.   5.2.15 Police had been routinely notified of the incident by ambulance staff and attended the hospital. There was no evidence of injuries or signs of sexual assault. Police spoke with Mr Singleton who told them about an incident of attempted sexual assault on Amy by a member of her extended family some months previously. This had not been reported to any agency at the time. Police then went to the home address, noting a range of concerns about the home conditions.  5.2.16 There was no evidence to suggest Amy was depressed or intended to take her own life. No suicide note was found.  The police investigation considered the hypothesis that Amy could have been experimenting with a practice where an individual gets a “high” by self asphyxiating but there was no evidence to substantiate this. Computers were recovered from the house but none were found to contain material which raised any concerns. Police concluded that there was nothing to indicate the involvement of any other person in Amy’s death.   5.2.17 A decision was made to conduct a child protection investigation as there might be concerns for other members of the family. A joint investigation by police and SCS subsequently found no evidence to indicate that any further action was necessary.  6. THE FAMILY  6.1 Amy’s parents were contacted twice during the process of the Review to see if they wished to contribute in any way. They declined invitations to meet the chair of the Review and the author of this report. Mrs Singleton replied to the second invitation, advising that she and her husband were still trying to come to terms with This report is the property of the Kent Safeguarding Children Board. Page 12 of 41 what had happened. She said that they had been optimistic that good progress was being made in relation to Amy’s ADHD, although they remained disappointed that this could not have been diagnosed earlier.  6.2 In that correspondence Mrs Singleton spoke warmly of the assistance the family had received from Amy’s school, which she felt was evidenced in her school reports. She said that police had also been helpful, both at the time that the abuse of Amy was reported and around the circumstances of her death. However, Mrs Singleton said that they were disappointed that SCS had not been involved more fully in supporting the family.  7. THE AGENCIES  7.1 Introduction  7.1.1 Each of the agencies contributing to this review has carried out an internal review (IMR), detailing and analysing their involvement with the family. This section of this report confirms the nature of that involvement and comments on the analysis contained in the IMR.  7.2 Kent County Council, Specialist Children’s Services  7.2.1 This report confirms that SCS had contact with Amy’s family on a number of occasions before her death, as a result of allegations or concerns about physical or sexual abuse or neglect. The report notes evidence of unnecessary delay and failure to carry out appropriate checks with other agencies. There was only one Initial Assessment when there were at least three occasions when a more comprehensive assessment should have been carried out.   7.2.2 The report highlights the significance of the weak response to the allegation made by Amy’s father in 2008 that Amy had been sexually abused. Although a Strategy Meeting took place, SCS were not otherwise involved in the investigation, which was carried out solely by police. This incident seems to mark the onset of Mr Singleton’s animosity to SCS. It was a missed opportunity for SCS to intervene with the family at a point where “it was accepted by both professionals and her family (my emphasis) that (Amy) had experienced sexual abuse”. The Panel was provided with evidence of considerable efforts to improve collaborative working between police and SCS and was satisfied that this was not now a systemic problem which required a recommendation from this Review.   7.2.3 The report goes on to detail the delay and subsequent failure to follow child protection procedures by SCS in response to allegations of neglect in 2009. The children were not seen, the circumstances in which they lived and slept were not thoroughly investigated and routine checks with other agencies were not carried out comprehensively.   This report is the property of the Kent Safeguarding Children Board. Page 13 of 41 7.2.4 One other service within SCS had been involved. SSKY is a local authority early intervention service. The worker who made initial contact with the family shared similar concerns to other agencies about Mr Singleton’s hostility to SCS and about differential treatment of Amy within the family.  7.2.5 A number of issues are detailed as having led to these weaknesses in the service provided to Amy and her family. Many of the aspects which give cause for concern were identified more widely across the county in the Ofsted inspection in 2010. Of key importance is the lack of management oversight and direction to underpin any of the agency’s responses to matters of serious concern. There were a number of instances of delay and lack of purpose which may have been linked to major problems of high vacancy levels across the organisation. It is clear that there were very serious difficulties arising from the introduction of a new computer system in 2008 which led to problems in tracking incoming work. Mr Singleton’s overt hostility to social workers is correctly highlighted as probably having contributed to some of the weak responses. The reaction to the family’s presentation, across all agencies, indicates a disturbing lack of knowledge and skill in recognising and responding to concerns about sexual abuse.   7.3 Kent County Council, Education, Learning and Skills  7.3.1 This report considers the involvement of Amy’s school and the local authority’s Special Educational Needs services. The report summarises the general perceptions held by education staff: “Amy … presented as needy in terms of seeking adult attention and experiencing difficulty with peer relationships. .. sometimes untidy, occasional issues regarding adequacy of diet. .. cleanliness and hygiene”  7.3.2 The school was not adequately involved in the investigation, in 2008, into the alleged sexual abuse of Amy. The headteacher is said to recall discussing this with police at the time but kept no written records. There were inappropriate responses by the school in 2010 to a number of expressions of concern. Information from a neighbour that there were concerns locally about the treatment of children of the family was not passed on by the school to SCS. Some weeks later the headteacher discussed the issue with the Area Children’s Officer for Child Protection9  (ACOCP).  This officer advised that the information should still be reported to SCS but it does not appear that this was done. After the summer break the school received three written expressions of concern about the children but did not make a referral to SCS. 7.3.3 The implementation of the CAF was stalled for 6 months as a result of Mr Singleton’s overt hostility to any SCS involvement. This seems to have been accepted at face value by the school, rather than prompting concerns as to why he should allow this to impede the arrangements to help his daughter. This again suggests a lack of confidence in the relationship between the two agencies, and / or a lack of familiarity with CAF arrangements.                                             9 An officer with an advisory role on safeguarding for education staff. This report is the property of the Kent Safeguarding Children Board. Page 14 of 41  7.3.4 A further concern arises from the school’s response to comments by Amy suggesting that she feared sexual abuse by members of her extended family. The school did not share this information with SCS. Instead the headteacher spoke to Mr Singleton – an action which in some circumstances might have placed Amy at greater risk – and accepted reassurances from him that no further action was necessary. Even if, as the IMR points out, this had been a reference to historical abuse, it was both an error in judgment and a missed opportunity for agencies “to have a discussion and come to some joint understanding about Amy’s wider needs in respect of her previous experiences of alleged sexual abuse”.   7.3.5 The final report of concern about Amy was made to the school by neighbours in March 2011. This led the headteacher again to talk to the ACOCP.  There is no recording of this discussion but the IMR reports that  “ In the absence of further new evidence and given father’s hostility to SCS it was on balance thought to be more effective to concentrate on developing an effective working relationship with the school and seek assistance elsewhere for the difficulties with neighbours. The school therefore contacted the housing association and local police community support officer”. Effectively the concerns of neighbours about the welfare of the children were not shared with the appropriate agency but were redefined as a housing problem / neighbour dispute.  7.3.6 There is a more encouraging account of the school’s direct work with Amy and, eventually, of the beneficial consequences of the CAF: “At the time that the school last saw Amy it appeared that after a long period of concerns about her home life there was evidence that she was benefitting from their input and that the family were at last co-operating with plans for the children”.  7.3.7 Overall, there is a positive picture of the school’s commitment to Amy, both through the input of individual members of staff and more widely. Equally however analysis of their involvement indicates that the school did not understand or follow safeguarding requirements. The principal contributory factors appear to be a failure to keep abreast of those requirements and an ineffective working relationship with SCS.   7.4 Kent Police  7.4.1 Police involvement consisted of their part in the 2008 allegation of the sexual abuse of Amy. The IMR is satisfied that, although this should have been a joint investigation, it was appropriate that police went ahead when SCS were unable to provide any input. The police investigation is judged to be satisfactory and the report notes that “interviews were conducted with professionalism and took into account the needs, views and wellbeing of Amy”.  This report is the property of the Kent Safeguarding Children Board. Page 15 of 41 7.4.2 Police had no other contact with Amy before her death. However there is cumulative evidence of a range of inappropriate and illegal sexual conduct, by various members of this extended family, over a period of years. This evidence was not seen in its totality, and did not lead to assessments co-ordinated with other agencies. For example, when a member of the extended family was imprisoned for sexual abuse  “there was no consideration given to his potential threat to child members of his own family; including Amy.  In view of the family history, some form of risk assessment would have been appropriate”.  7.4.3 This IMR also recognises the threat arising from the ingrained nature of inappropriate sexual conduct across this family. When the person mentioned in the previous paragraph was released from prison, in a very short space of time he was living with a woman with young children, in total disregard of his Sexual Offences Prevention Order (SOPO): “This again shows how (he) had little regard for the consequences of his actions”.  7.4.4 The decision about how widely to “cast the net” is a difficult one for police. It may lead to the accumulation and requirement to analyse very large amounts of material, much of which may not be directly relevant to the principal focus of an investigation. The extensive information gathered in this review about criminal activities of members of the extended family is a case in point. However the IMR notes that  “one of the people interviewed remarked, “We can’t go looking for victims”.  and the IMR author responds that “In some cases this is exactly what we should be endeavouring to do”. Police do hold and have access to very extensive information about people and a key learning point from this review turns on the need to put that information together and make best use of it.  7.4.5 The IMR identifies some lapses in routine record-keeping and notes the possible consequences of referrals being received “out of hours”, when agencies may have more limited resources. This was the case when the abuse of Amy was reported, and police proceeded on a single agency basis. The report also raises the issue of how agencies might improve their response to situations where a young person is alleged to be the perpetrator of a sexual offence, which may be indicative of that young person also being the victim of abuse.   7.5 Kent Community Health NHS Trust  7.5.1 The author of this IMR attempted to research the agency’s early involvement with Amy and her family, which would have been held in Health Visiting notes, but these could no longer be traced. There has consequently been very little information available about Amy’s early life. This is a matter of concern for this review and more widely. Health records should be stored and kept appropriately until the person to whom they refer reaches the age of twenty-five. As the IMR notes, the consequence This report is the property of the Kent Safeguarding Children Board. Page 16 of 41 is that information about Amy’s early years and the family’s relationship with health visitors is lost.  “The missing health visiting record may indeed have had a significant impact on the understanding of Amy's pre school life… (particularly because)…within two months of entering school, Amy needed an individual education plan”.   7.5.2 The Panel accepted that all appropriate steps had been taken both to investigate this issue, and to confirm that current arrangements were satisfactory. Consequently this Overview Report, in line with the IMR, does not make a recommendation about this matter. In the light of the records being missing the report principally addresses the involvement of health services in the management of Amy’s ADHD and their collaboration with the other agencies involved in the TAC.  7.5.3 Amy was originally referred by her GP for investigation of possible ADHD when she was under six years of age. It is explained that in normal circumstances this is too young for ADHD to be diagnosed and treated with medication. She was re-referred by her school when she was a little over eight years old and  “her behaviour had deteriorated to the extent she had difficulty with friendships, her sleep was an issue, she would compromise her safety by walking out in front of traffic and would talk to strangers”.  7.5.4 She attended for paediatric assessment with her father who told the paediatrician about the sexual abuse of Amy. There was subsequently a specialist assessment leading to the diagnosis of ADHD and treatment which continued throughout Amy’s life. Overall there seemed to be a positive reaction and an improvement in Amy’s behaviour. Specialist ADHD staff joined and contributed to the TAC from February 2011 onwards.  7.5.5 The report identifies that the information about the sexual abuse of Amy, which was disclosed to the paediatrician initially assessing her, did not prompt any further enquiries and was not included in the referral to the ADHD Clinic. One ADHD nurse has confirmed having no knowledge of this until after Amy’s death. The overall report from that service is that the history was taken into account in her assessment and treatment but there is no explanation of how they became aware of it. If they did take it into account – and there is no evidence that they did – it is clearly unsatisfactory that an agency should be allowing such a potentially significant issue to be considered without making any reference to it in records.   7.5.6 The IMR comments on any possible association between Amy’s ADHD and her state of mind at the time of her death: “The … medication for ADHD which Amy was on at the time of her death lasts approximately 10 - 12 hours. After this time there would be no residual drug left in the system leaving the person essentially non-medicated, from approximately 8 pm until the following morning…. During interview ( the …paediatrician) stated that at the time of her death Amy may not have had any medication in her system so the ability to moderate her risk taking behaviours was reduced”.   This report is the property of the Kent Safeguarding Children Board. Page 17 of 41 7.5.7 The clear conclusion of the IMR is that Amy’s ADHD was diagnosed appropriately and managed well. It is similarly clear in questioning how the knowledge that she was said to have been sexually abused by a family member could not have prompted any further enquiry.  “Possible sexual abuse did not appear to be considered in a holistic assessment. No one appeared to consider was the perpetrator still in contact with Amy, how long had the abuse being going on and how was it discovered”. The doctor to whom the comment was originally made reported that “As Mr Singleton stated the police had been involved (she) did not believe at the time that she should make any further enquiries as she considered the case had been investigated and closed”.  7.5.8 This leads to a fundamental concern which is to some extent captured in this IMR – the sub-optimal response to the issue of sexual abuse and, to a lesser extent here, neglect. This comes in a context, otherwise, of the professionals working well together to tackle Amy’s diagnosed condition of ADHD. There are reports of improved supervision arrangements and reassurances that this would not happen now, but there must be a key learning point about improving professionals’ understanding of their responsibility for sharing information.   7.5.9 The issue of Amy’s weight was explored by the Panel.  “Amy’s weight was on the 75th centile at 5 years 3 months, was between 75th and 50th centile by 8 years 6 months dipped to just below the 50th centile at 9 years 1 month and remained steady until a small reduction by 9 years 7 months with another slight reduction by 10 years 1 month to between 50th centile and 25th centile”. This pattern in itself was judged by the Medical Advisor to the Panel to be not unusual. However, in the context of other evidence, including concerns about general neglect, the IMR notes that this pattern of slower growth than might be anticipated could give cause for concern.   7.5.10 Finally this agency has provided information about reported associations between suicide and the ADHD medication taken by Amy. It notes that “There are theoretical risks of increased suicide with …However nothing has been proven, and research has not shown an increased incidence of suicide over the normal rates in those on medication. The Medicines and Healthcare Products Regulatory Agency (MHRA) information  …states ‘1 report of suicidal ideation and /or suicide attempt has been received in patients treated with (this medication)… The incidence of suicidal ideation is uncommon, and incidence of suicide attempts not known” The report concludes that there was no reason not to use this medication because of possible risk of suicide.  7.6 The General Practitioners  7.6.1 The IMR considers information held by the GPs for Amy and her extended family.  For the purposes of this SCR, this Overview Report focuses on Amy and her immediate family. This report is the property of the Kent Safeguarding Children Board. Page 18 of 41  7.6.2 Mr and Mrs Singleton have experienced a range of illnesses and conditions. Mr Singleton has been seriously unwell, requiring treatment that will have significantly affected his daily living. The report is satisfied that, medically, these matters were generally dealt with thoroughly. Their emotional / psychological consequences might have been further explored but Mr Singleton does not appear to have welcomed this. There is no indication of any consideration of the consequences of the parents’ health issues for their parenting responsibilities. The report notes that Mrs Singleton had been in hospital very recently before Amy’s death and makes a general observation that “the time prior to and following the procedure (may) affect the ability to care for dependants and this is something we should consider supporting as a health service during pre-operative assessments”  7.6.3 In 2006 Mr Singleton sought the GP’s advice because Amy was reported to have been present while another child was sexually abused. The GP appropriately discussed this with the Named Nurse for Child Protection, but this did not lead to any cross-checking to ensure that SCS were fully aware. Similarly, when more conclusive evidence of Amy’s sexual abuse emerged, this was not shared by SCS with the GP. This Review has also identified a difficulty in the information sharing arrangements more generally in relation to sexual abuse between children. Even when information was shared in respect of the abused child, that information sharing did not extend to the child perpetrating the abuse and other siblings.  7.6.4 The GP appropriately followed up concerns about Amy’s ADHD, enabling early diagnosis and treatment (if it is agreed that such a diagnosis could not reliably have been made at age six, when the concerns were first raised). There are no concerns about the GP’s continuing involvement in the management of her ADHD.  7.6.5 The report contains further information from the GPs about Amy which may be significant: “ In 2003 Amy was ‘pointing at herself when weeing’ -  there is no clear documentation regarding the duration of these events or how this was investigated at all, just that the examination was normal” Amy also has recurrent presentations with head lice, continuing until shortly before her death.  “(These) were perhaps a missed opportunity as this is often an indicator of possible neglect”.   7.6.6 There were practical difficulties: “Unfortunately there was no informed global family assessment and this would have been very helpful. As the whole extended family (was)… also registered across Kent this fragmentation does not allow any full cohesive analysis of this vulnerable family” This “fragmented” approach, and consequent flawed assessments, are key factors in understanding the failure of agencies to grasp the substantial, cumulative evidence of indications of child sexual abuse.   This report is the property of the Kent Safeguarding Children Board. Page 19 of 41 7.7 Maidstone and Tunbridge Wells NHS Trust  7.7.1 This report deals with hospital services provided to Amy and her family. Amy had one direct contact with Maidstone Hospital following a minor accident when she was four. Other members of her immediate family had treatment throughout the period under review for a range of conditions, including serious illness. Amy died at Maidstone Hospital and the report describes the circumstances of her death.   7.7.2 The IMR raises the issue of the effects on front-line staff of child deaths or serious injury. In this case those effects will have been aggravated by comments made by Mrs Singleton, who spoke to a nurse about the sexual abuse of Amy. The report appropriately makes a recommendation about the need for staff in such critical situations to have time and support which enable them to reflect on the events with which they have had to deal. There are no other matters arising for this agency to be considered in this Overview Report.  7.8 Kent and Medway NHS and Social Care Partnership Trust  7.8.1 This agency (KMPT) was involved only after Amy died. The family GP referred a sibling for assistance in coping with Amy’s death. The referral was made in late October and prompted a series of attempts to elicit more information and gain written confirmation that the GP’s referral had been made with parental consent. There was no response from the family and, in January, the GP, concerned that the situation had deteriorated, made a further referral.  7.8.2 Amy’s sibling was eventually seen once in February, as a result of which it was decided that there was no need for secondary mental health support but a referral was made for bereavement counselling. The report comments that “Feelings of significant loss are a natural response following sudden unexpected death. It does not necessarily mean that there is a need for secondary mental health involvement”  7.9 Kent Youth Offending Service  7.9.1 Kent YOS contributed to this review as a result of their involvement with members of Amy’s extended family. The review appropriately focuses on the detail and outcomes of their work in relation to one young person’s criminality and finds “much to commend the work for in terms of the focus on both meeting needs and on reducing the risk of reoffending”  7.9.2 However, the most striking issue for the purposes of this review is that the YOS was apparently entirely unaware of allegations that he had sexually abused Amy in 2008. They remained ignorant of this until their involvement in this Review. Although the events preceded their involvement it is of concern that routine checks with partner agencies did not bring this to light.   This report is the property of the Kent Safeguarding Children Board. Page 20 of 41 7.9.3 This concern is aggravated by the fact the YOS did understand from March 2009, as a result of routine checks in December 2008, that there had been other allegations of sexual abuse within his family by this young person. This was not taken into account in any of the work undertaken by the YOS. Even when there was liaison, agencies did not share this important information: “There was no discussion of this risk when there was liaison between YOS and Children’s Social Services which occurred in September 2009 at the point when he became homeless”.   7.9.4 The consequences of this for the YOS’ work will be considered as part of a separate management review but, for the purposes of this review, it raises again a persistent concern about the quality and reliability of information – sharing between agencies. This is aggravated by the account of the agency’s understanding that their relationship was effective: “In addition to the Case Manager contact there was regular informal contact between YOS and CSS which was described as positive by the Practice Supervisor and Team Manager. They felt that the relationship between YOS and CSS allowed the teams to discuss young people and their families, and through doing so to identify solutions to issues or to share information that might assist in service delivery. Both YOS and CSS are based in the same building and would frequently have discussions about young people”.  7.9.5 The agencies need to review their arrangements for liaising with each other and sharing information, as the allegations should certainly have been the subject of further discussion between them. A number of recommendations from the IMR seek to address this.  7.10 Kent Probation  7.10.1 This report relates solely to a member of Amy’s extended family who was convicted of “engaging in sexual activity with a child”. He minimised the seriousness of this and sought to blame the child involved. The report then provides evidence of his disregard for the requirements of his release on License and his status as a convicted sexual offender.  Within a short time of his release from custody he was known to have been living at addresses where children were also resident. He also failed to notify this Offender Manager of various changes in his circumstances. The report does not include any information about Amy but it adds to the cumulative concerns about sexual abuse running through this family.  7.11 Housing Provider  7.11.1 This agency is not named in order to protect the anonymity of the family. It was the landlord for the Singleton family. It dealt with neighbour disputes involving the family and staff were aware of neighbours’ concerns that Amy was being mistreated. These allegations were apparently passed to them by Amy’s school (who did not pass them to the appropriate agency, SCS). The Housing Provider accepts This report is the property of the Kent Safeguarding Children Board. Page 21 of 41 that they should also have approached SCS about this. There are no other matters arising from the information supplied by this organisation.  7.12 South East Coast Ambulance Service NHS Foundation Trust  7.12.1 For the purposes of this Review this Trust was significantly involved only on the occasion of Amy’s death. The Trust gave appropriate advice and attended without delay. There are no matters arising for this agency which concludes that “At the time of Amy’s death, SECAmb provided a very rapid response to the 999 call and all possible advanced life support interventions were undertaken, sadly without success”  7.13 KCA Drug and Alcohol Services  8.13.1 This agency was involved with a member of Amy’s extended family. No matters relevant to this review arise from that contact.  7.14 Health Overview Report  7.14.1 The Health Overview report considers the submissions made by all the NHS agencies involved in this review. It largely echoes the findings of those reviews and those contained within this report. However the report does not identify any issues relevant to the commissioning of health services. This is its principal purpose.   7.14.2 This does reflect a wider, national issue about how Health Overview reports might best contribute to the SCR process. New (draft) guidance does not clarify this. It may be that in future the LSCB and health commissioners will decide whether there should be a specific report of this nature. In this case there is a recommendation that the LSCB and health commissioners produce a brief guidance note so that if such reports are commissioned in future authors will have clear expectations as to their purpose and expected contents.  8. ISSUES IDENTIFIED IN THE TERMS OF REFERENCE FOR THIS REVIEW  8.1 What were the facts in this case?  8.1.1 The factual content of the IMRs and chronologies has been drawn together and summarised in Section 5 of this report. This has been accepted by all the agencies as, for the purposes of this review, an accurate description of the events leading to the death of Amy Singleton and the involvement of the participating agencies with Amy and her family.   8.2 Did agencies listen to the “voice of the child”?  Did agencies know what life was like for Amy?  8.2.1 There is substantial evidence, across the agencies, that Amy herself was not given an adequate priority in their responses to the various issues which raised This report is the property of the Kent Safeguarding Children Board. Page 22 of 41 concern. Professionals did feel for her and tried to support her. Overall though, the requirement to understand her individual circumstances, and respond appropriately was not given sufficient weight.  8.2.2 The agency with the greatest direct involvement with Amy, as would be expected, was her school. The IMR recognises that “Schools have day to involvement with children and through this are probably best placed amongst all professionals to identify and act upon any concerns about children”  8.2.3 In Amy’s case the school identified her particular educational needs quickly and responded appropriately. They “had prepared an individual education plan (IEP) within two months of her commencing school”. This was followed by continuing support through a School Action10“Amy’s needs as a sad isolated and vulnerable child, who sometimes sought adult attention inappropriately”.  programme. The school also recognised, to some extent, her broader social and emotional needs: they were aware of Consequently arrangements were made for her to be involved in therapeutic play at school. This confirmed a  “need to be nurtured and a wish to do more “girly” things”.  8.2.4 The IMR concludes that “Amy felt sufficiently trusting to express her worries and concerns to a range of adults in school”. However, the concerns for Amy were not seen by the school as particularly unusual: “The school responded to what they were seeing - a sad child, with a difficult home life – in this way not unlike other children in the school”. This Review has demonstrated that Amy’s experience was probably very different to the home lives of other children in the school.  8.2.5 The report from SCS is more straightforward in accepting that “assessments…did not fully consider the context of her life or attempt to understand her family fully.  The children’s voices were not heard, or sought and therefore their view and understanding of their life was unheard”. This report also highlights the way in which agencies redefined the issues that they were considering. After the 2009 assessment the family’s financial situation became a leading concern, although their poverty and its consequences were accepted at face value – there was no recorded attempt to explore how the family spent its money. Amy’s school had offered financial assistance to enable Amy to participate in extra-curricular activities and to arrange for her to have free school meals, all of which was refused by Mr Singleton.   8.2.6 Police visiting the home on the night of her death also found that                                             10 This is the initial stage of the statutory arrangements for supporting children with Special Educational Needs. This report is the property of the Kent Safeguarding Children Board. Page 23 of 41 “the living conditions were far below the standard (one) would expect for a family with young children…the house was very untidy and very dirty and had clearly not been cleaned for quite some time. The children’s beds had sufficient bedding on them but again, the bedding was very dirty and had obviously not been washed for a number of weeks”.   8.2.7 The possible significance of Amy’s behaviour with adults was not recognised. The GP IMR notes that “Once under the Community Paediatric team it was clear that Amy was showing recurrent “stranger danger (and) lack of awareness and cuddling people she hardly knew inappropriately”. This could be an indicator of familiarity with adult sexualised behaviour, or the craving for attention of a neglected child or both.  8.2.8 Little is known about Amy’s relationship with her mother and, equally, there is little information about Mrs Singleton herself. There is evidence that she was struggling with illness, her husband had had major surgery and the family’s financial circumstances were difficult. She was unemployed for some time during the period under review. Before that her work would have required her to be away from home for long spells during the day and evening. Mrs Singleton largely co-operated with the school’s attempts to assist Amy but did miss a number of TAC meetings. She was aware of at least some of the evidence suggestive of child sexual abuse within her family. In May 2011 she indicated to the TAC meeting a knowledge of some sort of inappropriate behaviour involving Amy. This failed to arouse any professional curiosity or prompt any further investigation, but equally there is no indication of her taking action to protect her daughter.  8.2.9 Mr Singleton seems to have been the dominant figure in the household and there is evidence that his aggression towards agencies may have intimidated them. The school preferred to communicate with Mrs Singleton. He was consistently hostile to SCS, threatening violence to any social worker who visited him after Amy’s death. We know little about his relationship with Amy.   8.2.10 There are strong indications of both neglect and sexual abuse of Amy and a number of allegations of child sexual abuse across her extended family, which might explain her presentation. Her presentation may have been “normalised” by her school, where she was said to be not significantly different from other needy children. It was not identified by SCS in their contacts with her. There appears to have been a reluctance to recognise that abuse, and particularly sexual abuse, might provide an explanation for Amy’s presentation. A range of organisational pressures and individual weaknesses contributed to that and also affected the one joint investigation with police. All the agencies involved with this family could have done more to protect her.     This report is the property of the Kent Safeguarding Children Board. Page 24 of 41 8.3 Were Amy’s needs appropriately assessed, with particular reference to the consequences of sexual abuse and neglect?   8.3.1 Amy’s ADHD was identified, assessed and treated appropriately. The Designated Doctor for Child Protection, who was a member of the Review panel, confirmed that national (NICE) guidelines were followed and appropriate medication was given. There was, of course, a perverse consequence of this diagnosis – all her difficulties could be attributed to this condition, both by family members who might wish to avoid investigation of other causes, and by professionals who might also, perhaps unintentionally, be seeking to avoid the possibility of other factors. It is clear that, whether through failure to keep adequate records, read records fully or because professionals genuinely did not have access to the information, the alleged sexual abuse of Amy was not fully taken into account in assessing and responding to her needs. Moreover, as the Education IMR notes, “the diagnosis of ADHD may have contributed to some professionals identifying concerns for Amy rather than considering fully the wider family and environmental issues”.  8.3.2 Amy’s needs as a child who had probably suffered sexual abuse and neglect were never adequately assessed. The only formal agency response to concerns of sexual abuse was the action taken following Mr Singleton’s allegations, in 2008. This led to a police investigation but SCS were not involved in that investigation and took no subsequent action to assess what Amy’s and her family’s support needs might be. At this time there was already knowledge “in the system” of allegations of historical abuse involving various members of the extended family. A comprehensive assessment should have pulled together this accumulating evidence to identify all the indications of sexual abuse and inappropriate sexual activity across this extended family.  8.3.3 Agencies received four allegations of neglect and inappropriate treatment of Amy from neighbours. There was never a formal assessment by SCS. The most substantial response to any of these allegations was the action taken in 2009 in response to a neighbour reporting a range of concerns - neglect, physical, and emotional abuse and the use of sexualised language and access to inappropriate magazines by Amy.  This was recorded as a child protection referral but was not then followed up as such – there should have been a strategy discussion and a timely multi-agency response. Instead there was a single agency response from SCS, three weeks later, consisting of one visit by appointment, following which the only issue followed up was the family’s assertion that they were living in poverty. The child protection aspects of the referral were either neglected or avoided. As the SCS IMR suggests this suggests a “neglect case mindset”11  - where acceptance that there may be neglect serves to move any analysis away from considering that a child might also be physically and / or sexually harmed.                                             11 Brandon M, et al, (2009) Understanding Serious Case Reviews and their Impact, DCSF This report is the property of the Kent Safeguarding Children Board. Page 25 of 41 8.3.4 Amy and her family were engaged, at the time of her death, in a CAF process. As described above, these are national arrangements for helping children who have needs additional to those being met through universal services. The CAF is not an appropriate way of tackling the issues of neglect and sexual abuse which feature prominently in this case. An informed appraisal of Amy’s circumstances at this time against the authority’s guidance12“They also had considered the revised Threshold and Eligibility criteria …and did not feel that the criteria for a Tier 4 child protection referral were met whilst acknowledging that Tier 3 services would require parental consent – which would not be given”.  would have indicated that Amy’s experience required the need for the direct involvement of SCS, through child protection, or, at least initially, child in need arrangements. Given Mr Singleton’s hostility to SCS, it is unlikely that he would have co-operated with child in need provision, so that the case would probably then have been escalated to Tier 4, the threshold for implementation of child protection arrangements. There is an indication in the IMR that the school took this into account in deciding that Tier 2 represented the appropriate level of concern: Anticipating parental opposition should be an aggravating feature, leading to escalation of intervention rather than to the school stepping down their approach.  8.3.5 The use of CAF does indicate the recognition, principally at school, that Amy did have additional needs, building on the early action to support her educational special needs. The initiation of the CAF was delayed by six months as a consequence of Mr Singleton’s professed hostility to SCS and the school’s lack of challenge to that. That lack of challenge raises questions about the school’s own relationship with SCS – collusion with Mr Singleton’s judgment effectively endorsed it and suggested that the school did not view it as entirely unreasonable.  8.3.6 In any event the CAF process became the main opportunity for the professionals involved to work together and develop interventions to support Amy. The agencies formed a Team Around the Child (TAC). That TAC had met three times before Amy died. Collaboration from Amy’s parents had been patchy. Mr Singleton had not attended any meetings. Mrs Singleton attended the first two. A number of meetings were cancelled because the parents sent apologies. The range and combination of services which the agencies sought to put in place to help Amy build resilience and self-esteem was impressive. KCHT judge that “The CAF process in itself was thorough and highlighted many issues”.  8.3.7 The difficulty is that these services were all predicated on the assumption that a CAF intervention was appropriate. This was reviewed by the Head Teacher and the SENCO after the third TAC meeting and they concluded that this was still the correct method and level of intervention. To some extent this is understandable – the threshold guidance is in some respects equivocal about levels of intervention and about which factors lead to which conclusions. But there was enough knowledge in the system, if it had been properly researched, to reveal that there had been                                             12 Threshold criteria.pdf This report is the property of the Kent Safeguarding Children Board. Page 26 of 41 multiple concerns about sexual abuse in the family. Police had discussed this with the Head Teacher during their investigation in 2008. There was also knowledge of anxiety in the community about Amy’s general welfare.  8.3.8 It is disappointing that the Head consulted twice with the education service’s child protection adviser for the school but this did not lead to action to escalate the agencies’ approach. These were general discussions, not supported by a search of what was known to the various agencies. Yet the fact that there were two such consultations reflects the underlying unease about Amy.   8.3.9 The Education IMR reminds us of the increasingly difficult position of Head Teachers: The issue of supervision and support of Head Teachers  in dealing with pastoral care and welfare issues…may become more of an issue as schools and Head Teachers become increasingly autonomous (and possibly isolated). Senior staff in schools often perceive themselves as having increased responsibility for welfare issues and managing risk but feel that their support systems in this field are variable across the county. In this case the support and advice from the ACOCP was found to be very helpful but the ACOCP role is an advisory function with no line-management responsibility”. The support and advice from the ACOCP was effectively a false reassurance.  8.3.10 This combination of factors – a lack of shared knowledge about the background of concern, the (false) reassurance afforded by applying the CAF process, the lack of challenge to Mr Singleton’s resistance and the lack of confidence the school felt in SCS – contributed to a failure in inter-agency working which meant that the levels of risk and harm to Amy were under-estimated.  8.4 How were the outcomes of assessments used to inform practice and decision making in relation to Amy? Were Amy and her family appropriately engaged and involved by agencies?  8.4.1 As indicated above there was no appropriate assessment, perhaps the most fundamental failing arising from this review. Even the ADHD assessment, which has been judged to be medically sound, may not have been fully informed by knowledge of previous alleged sexual abuse. The CAF assessment was certainly not adequately informed by all the evidence which would cause concern for Amy.  8.4.2 Had there been a thorough assessment one would have expected that a lack of engagement by the family would have featured prominently as a cause for concern. That should have been considered in the light of Mr Singleton’s hostility to SCS and the apparently perverse refusal to accept the school’s offers of funding extra-curricular activities and free school meals.   8.4.3 Amy herself appeared to participate enthusiastically in any activity in which her parents allowed her to take part. In terms of therapeutic and supportive measures the most significant input was through the play therapist but she was also said to This report is the property of the Kent Safeguarding Children Board. Page 27 of 41 enjoy Brownies and other “normal” activities. Despite the problems in her family, and her overall presentation,  the agencies’ descriptions of her do not suggest that they were seeing a child who was consistently unhappy – which may go some way towards explaining the weaknesses in the overall response.  8.5 How far was Amy helped to cope with the adverse circumstances in her life, particularly her sexual abuse?  8.5.1 The evidence submitted to this SCR suggests that the adverse circumstances in Amy’s life were her special educational needs, her ADHD, emotional abuse and neglect within her family and sexual abuse within her extended family.  8.5.2 There was an impressively swift and sustained effort to help Amy to meet the challenges arising from her educational needs. Her ADHD was diagnosed early and accurately, the prescribed treatment for the condition was appropriate and compliance with that treatment was good. The agencies and professionals involved in the CAF process tried hard to use those arrangements to support her – the matters which may have served to weaken all these initiatives have been set out above.  8.5.3 Emotional abuse and neglect were not sufficiently clearly identified. Her school recognised that she was needy and did a great deal to support her, in the face of a lack of consistent co-operation from her family. Those efforts were undermined by a failure across the agencies to recognise the nature and extent of emotional abuse and neglect, evidenced in her presentation, the referrals by neighbours and the ways in which her parents responded to attempts to assist her.  8.5.4 There is compelling evidence to suggest that Amy was sexually abused by one or more members of her extended family, and there is further evidence of sexual offences against children and inappropriate sexual activity across that extended family. The most clearly evidenced sexual abuse of Amy was when she was six or seven years old. There was a disjointed approach to the assessment of that concern, with no adequate input from SCS. Amy was offered no specialist help targeted at the consequences of that experience. Her GP was not made aware of it. Her school were not adequately informed about what had happened and consequently were not in a position to offer targeted support. There is no evidence that her family provided continuing support. From the evidence we have seen she was very much alone.  8.6 Did assessments and services take sufficient account of the family’s race, culture, language, and religious needs, and any disability needs?    8.6.1 Amy’s ethnicity was white British and there does not appear to be any racial diversity in the family. This would not be unusual in the area in which the family lived. When she died her mother declined any religious support and there is no indication of any family member having religious beliefs.   This report is the property of the Kent Safeguarding Children Board. Page 28 of 41 8.6.2 The potential significance of ill health and disability in the family is widely recognised by the agencies. There is evidence that Mr Singleton had an active lifestyle before suffering a life-altering condition. One of the IMRs suggests that this may have led some professionals to be over-tolerant of difficult and aggressive behaviour from him. His wife had a number of medical conditions and had undergone a surgical procedure the day before Amy’s death. An exclusive focus on Amy’s ADHD may have contributed to the failure of agencies to conduct a more comprehensive assessment.   8.7 Were Kent Safeguarding Children Board and individual agency procedures followed?  8.7.1 There is evidence of non-compliance with child protection procedures across the agencies. The extent of this non-compliance ranged from the failure by SCS to ensure that they were appropriately involved in the 2008 investigation of sexual abuse of Amy, to failures by the police and the school fully to record all that they had done during that investigation.   8.7.2 Non-compliance with procedures is a “dry” judgment. The important issue for a review like this is to identify the factors behind that failure. They range from individual lack of thoroughness to a number of systemic weaknesses. There are clear indications of an unsatisfactory working relationship between school and SCS, which is likely to have contributed to the poor communications evidenced here. The police were over-tolerant of the failure by SCS to become fully involved in the investigation of sexual abuse of Amy – possibly indicating that they had low expectations of SCS input into investigations. If the ADHD team were aware of the issues relating to sexual abuse they did not make a record of them. The YOS was unaware, throughout their extended contact with a young person, that he had been the subject of an investigation into alleged sexual abuse of Amy.  The paediatrician who saw Amy in 2009 and referred her to the ADHD service did not pass on the information that she had been sexually abused and, in interview, suggested that the responsibility to do so was still not fully understood.  9. ISSUES ARISING FROM AN OVERVIEW OF THE CASE  9.1 Good practice and service improvements  9.1.1 SCS have detailed a number of fundamental changes to service arrangements. These largely arise from the wider task of improving services in response to Ofsted’s judgment in 2010 that the overall effectiveness of Kent’s safeguarding services was inadequate. They are significant to the issues arising from this case review. The supervision of staff has been overhauled to become more reflective, supporting staff in considering “what life is like” for the children with whom they are working. More work is being done to ensure that children are directly involved in assessments. The management and oversight of assessments has been improved and supported by more helpful, analytical performance data. The co-ordination of CAFs has been specifically targeted for improvement with new staffing resources within SCS. Overall This report is the property of the Kent Safeguarding Children Board. Page 29 of 41 the authority is committed to changing organisational culture, so that learning and service improvements are prioritised and supported.   9.1.2 The school mentioned in this review demonstrated a clear commitment to Amy and worked hard to lead the establishment of arrangements to support her and promote her development and learning. The individual commitment of key staff is clear and the plans made under the CAF arrangements provided a broad range of initiatives designed to support Amy and promote her education and development.   9.1.3 The clinical assessment, diagnosis and treatment of Amy’s ADHD were thorough. This was in part a consequence of very early intervention from the GPs.  9.2 The circumstances of Amy’s death  9.2.1 It is not the purpose of SCRs to identify the cause of death. That task falls to the Coroner who has returned an open verdict and commented that  "I am satisfied there is no suggestion it was (Amy’s) intention to take her own life”.  9.2.2 We do know that suicide and suicidal ideation are common among children who have been mistreated and are at risk of continuing mistreatment. These children often have many different problems and are unable to form good relationships with peers or others to help them build resilience. Being suicidal is essentially about the intent to cause self-injury or death, regardless of the cognitive ability to understand finality, lethality, or outcomes more generally.   9.2.3 A number of aspects of the circumstances of Amy’s death are not suggestive of suicide. Suicide is often preceded by self destructive behaviour and repeated self-harming, of which there is no evidence here. Similarly there is no evidence of Amy having researched suicide on the internet, again a factor often associated with suicide. There have been media reports of incidents of children who have allegedly committed suicide as a result of persistent bullying at school and, although she was said not to make friends easily, there is no evidence of Amy being bullied.  9.2.4 The Panel heard that there had been some discussion about whether Amy had been experimenting with something called the “choking game” where people get a “high” by holding their breath or using a ligature around the neck. The Education IMR confirms that there was an incident of this nature in Kent during 2011. Information about this was subsequently sent to all Kent schools. We do not know whether Amy was aware of the “choking game”. There is no evidence to link this with her death.  9.2.5 We cannot tell what was in Amy’s mind when she died. The evidence from this Review suggests that agencies did not give adequate weight to the impact of abuse, and may have underestimated how unhappy she was. However there is no evidence that she ever had suicidal ideas or plans. Nor is there evidence of extreme distress or recklessness.  Agencies could not have been expected to take the eventuality of her tragic death into consideration in their work with Amy. This report is the property of the Kent Safeguarding Children Board. Page 30 of 41  10. REVIEW PROCESS  10.1 The Panel needed to spend some time determining the scope of this review, so that it adopted the most efficient way of considering the issues leading to Amy’s death, while also ensuring that wider concerns were addressed. Once that had been resolved the process of this Review has been satisfactory. There has been full co-operation from all agencies and all timescale targets have been met. As described above, there has been no family input but that was perhaps understandable, in all the circumstances. The Panel was satisfied that nothing further could have been done about this. This report is the property of the Kent Safeguarding Children Board. Page 31 of 41 11. CONCLUSIONS: KEY LEARNING POINTS AND MISSED OPPORTUNITIES  11.1 There was a lack of awareness across the agencies of the nature and prevalence of sexual abuse. When Amy was known to have been abused, the alleged perpetrator suggested that the allegations against him could be attributed to Amy having access to pornography. In the unlikely event that this was true, it would in itself have been the cause of harm. In the context of this family it was highly suggestive of more extensive and damaging abuse. There was an equally improbable acceptance that this was an isolated event, when a thorough consideration of agency records would have identified the numerous concerns about inappropriate and illegal sexual conduct across the extended family.  11.2 Where there was knowledge of abuse, there was a limited understanding of its potential consequences for those involved. An over emphasis on disclosure or physical / forensic evidence, and a lack of confidence in challenging the denial of abuse, left Amy at continuing risk.   11.3 There was a failure not only to draw together a composite picture of the concerns felt about the family but also to appreciate the cumulative consequences of neglect and abuse. Where broader safeguarding concerns were raised – four times by neighbours directly, as well as three written expressions of concern and the issue of alleged sexual abuse of Amy – there is no evidence that staff looked back, to understand the history of the family’s contact with child protection services. This has been recognised by a number of the agencies which have made recommendations about systematic use of chronologies when assessing and working with families.  11.4 None of the agencies involved with her identified and responded appropriately to the isolated position of Amy within her family. The school were unable to build an effective working relationship with the father so worked almost exclusively with Amy’s mother.  They did not challenge parental behaviour such as delaying the implementation of the CAF, and refusing free school meals for Amy, while complaining of the family’s poverty. Her father’s antipathy to social workers was accepted at face value and went unchallenged.  11.5 There is almost no evidence of agencies working together to assess and deal with child protection concerns. SCS were not involved in the most clearly evidenced allegation of sexual abuse. Neither they nor police should have allowed the investigation to proceed on that basis. For most of the investigations which were carried out, the evidence of agency checks and subsequent feedback is minimal.   11.6 There were a number of organisational and resource issues.  The SCS IMR notes that “There appeared a general lack of management oversight or supervision in any of the interventions prior to Amy’s death”. That report also identifies management practice which is even more concerning than a failure to supervise, referring to a manager who This report is the property of the Kent Safeguarding Children Board. Page 32 of 41 “appeared to attribute much of the responsibility (for unacceptable delay) to other team members”.  11.7 There was a great deal of information about this extended family in agency records. None of the agencies’ investigations and assessments were fully informed by the information they held. Even during the course of this Review it has become clear that agencies had been working with family members without being aware of important information. The introduction of a new computer system had been extremely problematic for SCS, although it is not clear that there were specific consequences for the management of this case. It is acknowledged that there are real challenges in drawing together relevant information from health records held, in this case, by five GP practices and numerous other healthcare providers. However, while acknowledging that some records may not have been kept or accessed, the more significant problem was the failure to take account of what was known about the family. This was a practice issue, not a technological challenge.  11.8 The prioritisation of referrals by SCS, and the thresholds applied, were based on immediate risk. There is little evidence of arrangements which promote the capacity of staff to deal with abuse which is not directly evidenced. Police similarly could have taken a broader view and researched historical information more thoroughly to inform their decision-making.  11.9 A number of agencies have expressed their optimism about the improved management of future cases as a result of the establishment of the multi-agency Central Referral Unit (CRU). They may well be right but this is a service for receiving new referrals. Its introduction will not necessarily address issues arising in cases where there is already continuing involvement. The Panel pointed out that this provision will also not be dealing with children with disabilities or unaccompanied asylum seekers, both widely evidenced as particularly vulnerable groups.   11.10 In some ways the CAF process served to redefine and contain the problem of Amy’s continuing unhappiness rather than bring its causes to light. The agencies have not yet developed arrangements for evaluating the quality of CAF interventions and this review demonstrated a looseness in the interpretation of guidance on thresholds. This report is the property of the Kent Safeguarding Children Board. Page 33 of 41 12. RECOMMENDATIONS MADE IN THE MANAGEMENT REVIEWS OF THE PARTICIPATING AGENCIES  12.1 Introduction  13.1.1 This section of the report details the recommendations made by agencies, in so far as they relate to the issues considered in this Review. Some agencies have made recommendations which relate to wider concerns and members of the extended family. As explained above, those matters are being followed up in separate processes.  12.2 Kent County Council, Specialist Children’s Services  12.2.1 Specialist Children’s Services should ensure that there is consistent use of chronologies in accordance with procedures.  12.2.2 Specialist Children’s Services should ensure that there is a continued improvement in the quality of analysis contained in social work assessments.  12.2.3 Specialist Children’s Services should raise awareness of the recognition, assessment and complexities of sexual abuse.  12.2.4 Specialist Children’s Services should raise awareness of the challenges and approaches when working with hostile and resistant families.  12.2.5 Specialist Children’s Services should ensure that social work staff have a greater understanding of the complexities of working with neglect.  12.3 Kent County Council, Education, Learning and Skills  12.3.1 Amy’s Primary School should be reminded of the importance of maintaining accurate written records of any contact with statutory agencies such as the Police and Children’s Social Services.  12.3.2 A more pro-active stance in following up concerns with other agencies should also be addressed as part of the learning for the schools involved in this case.  12.3.3 Where there is parental refusal to consent to a CAF or significant delay then schools and those advising them need to be reminded of the advice contained in the Thresholds and Eligibility Criteria March 2011 to consider the impact of this on the child and whether a consultation with or referral to CSS is required.  12.4 Kent Police  12.4.1 When an allegation of familial sexual abuse has been made against a child, consideration should always be given to establishing whether there has been similar This report is the property of the Kent Safeguarding Children Board. Page 34 of 41 abuse committed toward siblings or other children within the extended family.  Where appropriate, an assessment of risk should be conducted in relation to those children.  12.4.2 The introduction of the Central Referral Unit (CRU) should improve the joint response of both the Police and Social Services Department to incidents reported during ‘out of hours periods’. Once the CRU has been properly established, it should be the subject of a post implementation review, and this anticipated improvement in ‘out of hours’ activity should be tested.  12.4.3 Officers working within Child Protection should be reminded that decisions made following the report of alleged child abuse or neglect must not only be recorded, but the reason for making those decisions should be made clear.  12.4.4 When a child is alleged to be the perpetrator of a sexual offence, this may be indicative of that child also being the victim of abuse. In such cases, information should be shared with Children’s Services and decisions then made as to whether any additional safeguarding activity is required.  12.5 Kent Community Health NHS Trust  12.5.1 Where a history of possible sexual (or any) abuse is shared there must be a written record of how this is considered, managed and informs the assessments of the child.  12.5.2 In situations where the family details are complicated or when understanding the family make up is necessary a genogram should be completed and kept in a prominent position in the records.  12.5.3 All staff should be reminded of their responsibility to keep accurate records which reflect communication and decisions in the assessment processes.  12.5.4 A genogram is beneficial and should support an assessment of the likely impact of bereavement, or any loss of a significant person, on a child or young person.  12.5.5 The child should be at the centre of all assessments and the ‘voice of the child’ heard and not be lost in the chaos of family dysfunction and issues.  12.5.6 Non engagement and low levels of compliance should be assessed in relation to the impact of those behaviours on the child.  12.6 Kent and Medway NHS and Social Care Partnership Trust  12.6.1 Review Screening process of all referrals to Child and Adolescent Mental Health services (CAMHS) Tier 3.  This report is the property of the Kent Safeguarding Children Board. Page 35 of 41 12.7 Maidstone and Tunbridge Wells NHS Trust  12.7.1 The Trust should ensure with immediate effect that safeguarding supervision is offered to staff in Accident and Emergency Departments.  12.8 General Practitioners  12.8.1 Safeguarding training of the primary care teams involved to take place so as to be fully compliant with forthcoming CQC requirements.  12.8.2 Safeguarding training to address the need to communicate with all agencies and with other GP practices where the family is fragmented and registered with multiple practices.  12.9 Health Overview Report  12.9.1 This report details the recommendations from the health agencies involved in the review but makes no further recommendations.  12.10 Kent Youth Offending Service  12.10.1 Kent YOS should review the present practice guidance (August 2011) for both YOS and SCS staff to ensure that it supports effective joint work with children / young people and their families where there is a shared case responsibility.  12.10.2 Kent YOS and SCS should evaluate the costs and benefits of seconding SCS Social Workers into YOS teams.  12.10.3 Ensure that staff within both SCS and YOS can, as appropriate to role and responsibilities, access the electronic case records used by both services.  12.10.4 Kent YOS should ensure that all assessments and plans produced by YOS are quality assured and counter-signed by Practice Supervisors and Team Managers in line with YOS procedures.  12.10.5 Kent YOS should ensure Team Managers and Practice Supervisors include within supervision the opportunity for reflective practice as required by the YOS Staff Supervision Policy.  12.11 Kent Probation  12.11.1 When supervising offenders and, on receipt of information regarding convicted sexual offenders residing in accommodation with children, consideration must be given by Offender Managers to making a referral to Children’s Social Services in order to safeguard the welfare of children.  This report is the property of the Kent Safeguarding Children Board. Page 36 of 41 12.11.2 Offender Managers must identify full family composition when working with offenders, ensuring a holistic assessment of the individual in order to identify at an early stage whether there are any potential safeguarding issues.  12.12 Housing provider  12.12.1 The housing provider should ensure that any information received relating to potential safeguarding concerns is passed to appropriate agencies, i.e. Police or SCS, even when it is believed that the agency is already aware.  12.12.2 The housing provider’s safeguarding procedures should ensure that staff in the agency participate fully in all aspects of local interagency arrangements for safeguarding.  12.12.3 The housing provider should take steps to improve the accessibility and accuracy of available information that is relevant to safeguarding.  12.13 South East Coast Ambulance Service NHS Foundation Trust  12.13.1 No recommendationsThis report is the property of the Kent Safeguarding Children Board. Page 37 of 41  13. RECOMMENDATIONS FROM THIS OVERVIEW REPORT  13.1 Introduction  13.1.1 These recommendations arise from this Overview Report which reflects the views of the SCR Panel and the independent Overview Report author. They have been endorsed by the KSCB. Where they are particularly significant they may overlap with the recommendations, set out above, made by individual agencies. They are in line with the Government’s guidance13 “focus on a small number of key areas with specific and achievable proposals for change”.   that Serious Case Reviews should  13.1.2 In this case those “key areas” relate largely to fundamental safeguarding practice. This was not a review where the principal lessons to be learned are new, complex or intricate. Some of the recommendations necessarily arise from the review and are detailed here even though the agencies have already taken action to address those issues. There is one recommendation that relates to the process of any future Serious Case Reviews.  13.2 Recommendations to the Kent Safeguarding Children Board  13.2.1 The Board should, with reference to the findings of this review, ensure that there are satisfactory, multi-agency arrangements for a)  recognising and responding to cases of sexual abuse within families b)  recognising and responding to cases of chronic neglect and that agencies’ compliance with those arrangements is routinely monitored and evaluated. This recommendation is not restricted to new referrals: agencies should also address its implementation in their continuing work with families.  13.2.2 The Board should promote an emphasis on ensuring that the “voice of the child” is heard across all partner agencies, that practice in this regard is evidenced and monitored and that agencies are able to show how their policies and practices are influenced by the children and families with whom they work.   13.2.3 The Board should, by dissemination of the lessons learned from this review, emphasise to staff in all agencies the importance of ensuring that assessments are informed by thorough research into any previous contacts between agencies and families and that chronologies and reference to previous contact are routinely used to inform assessments of risk.   13.2.4 The Board should ensure that there are clear arrangements for working with hostile or resistant families, that front line staff are appropriately supported in this work. The Board should regularly review arrangements in this area across all partner agencies.                                             13 “Working Together” (2006) Paragraph 8.34 This report is the property of the Kent Safeguarding Children Board. Page 38 of 41  13.2.5 The Board should review and strengthen as necessary a) arrangements for sharing information within and between agencies about children and young people who may be perpetrators of sexual abuse b) arrangements for working directly with children and young people who may be perpetrators of sexual abuse  13.2.6 The Board should satisfy itself that the implementation of the CAF is helpful in leading to more purposeful interventions with children and their families and that thresholds between non-intervention, the use of the CAF and referral to children’s social care are well understood and consistently implemented.   13.2.7 The Board should seek to ensure that all schools have the necessary safeguarding systems in place and to a good standard, and that the relationship between schools and the local authority allows for the proper level of support and challenge. The local authority should satisfy itself and the Board that the level of input to schools is proportionate and appropriate.    13.2.8 The Board should liaise with commissioners of health services to produce a brief guidance note so that, if Health Overview Reports are required in any future SCR, authors will have clear expectations as to their purpose and expected contents. This report is the property of the Kent Safeguarding Children Board. Page 39 of 41  APPENDIX A: Biographical details of Independent Chair and Overview Report Author  Independent Chair: Mr Keith Ibbetson  Keith Ibbetson began his career as a residential social worker in 1981 in Lambeth. For the next 16 years he worked as a social worker and manager in children’s services in Hertfordshire and London. Since 1997 he has worked as an independent consultant in children’s services, specialising in child protection, quality improvement initiatives and the development of preventative services.  He has been involved in more than thirty Serious Case Reviews and independent management reviews, as panel chair, overview report writer and in implementing the findings of reviews.  Independent Author of Overview Report; Mr Kevin Harrington  Kevin Harrington trained in social work and social administration at the London School of Economics. He worked in local government for 25 years in a range of social care and general management positions. Since 2003 he has worked as an independent consultant to health and social care agencies in the public, private and voluntary sectors. He has a particular interest in Serious Case Reviews, in respect of children and vulnerable adults, and has worked on more than 35 such reviews. Mr Harrington is involved in professional regulatory work for the General Medical Council and for the Nursing and Midwifery Council. He has served as a magistrate in the criminal courts in East London for 15 years.    This report is the property of the Kent Safeguarding Children Board. Page 40 of 41  APPENDIX B: References  Footnotes have been used to indicate specific quotations from or references to research, practice guidance and other documentation. This Overview Report has been generally informed by the following publications  • Working Together  to Safeguard Children,(HM Government  2010) • The Victoria Climbie Inquiry (Lord Laming 2003) • The Protection of Children in England: A Progress Report  ( Lord Laming 2009) • The Annual Report of Her Majesty’s Chief Inspector of Education, Children’s Services and Skills 2007/08 • Safeguarding London’s Children: Review of London Serious Case Reviews First Annual Report (London SCB 2007) • Joint Area Review, Haringey Children’s Services Authority Area Review of services for children and young people, with particular reference to safeguarding (2008) • Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008  • Analysing child deaths and serious injury through abuse and neglect: what can we learn – A biennial analysis of serious case reviews 2003-2005 • Understanding Serious Case Reviews and their Impact - a Biennial Analysis of Serious Case Reviews 2005-07 DCSF 2009 • Developing an effective response to neglect & emotional harm, Gardner 2008 • Child maltreatment in the United Kingdom: A study of the prevalence of child abuse and neglect ( Cawson, Wattam, Brooker, Kelly November 2000) • Review of the involvement and action taken by Health Bodies in relation to the case of Baby P ( Care Quality Commission (2009).   • Learning together to safeguard children: developing a multiagency systems approach for case reviews. ( SCIE 2009) • The Munro Review of Child Protection: Final Report (HMSO May 2011) • The Munro Review of Child Protection: Interim Report (HMSO February 2011) • Publication of Serious Case Review Overview Reports: Letter from Parliamentary Under Secretary of State for Children and Families 10th June 2010 • ADHD - Quick Reference Guide (NICE 2008) • ADHD as a cultural construct (Timimi & Taylor, British Journal of Psychiatry 2004)      This report is the property of the Kent Safeguarding Children Board. Page 41 of 41                   