Neglect of a 10-year-old child over a number of years. Child B was born with a disability and needed significant support from health specialists. They lived with mother, father and older siblings. In May 2015, Child B was admitted to hospital to have a toe amputated. Concerns were raised that the infection that led to the amputation was preventable. Child B was not brought to a significant number of health appointments. Further concerns were raised and formally escalated in 2018. In February 2019, Child B was made subject of a child protection plan. Nationality or ethnicity not stated. Learning includes: children not being brought to appointments is an indicator of potential neglect; effective and child focused safeguarding practice with disabled children ensures they are seen, heard and helped; the focus on engaging parents and carers to support disabled children is key, but this should not dilute professional challenge; multi-agency working, information sharing and understanding the responsibilities of others can be complex; the need for professionals to think family and think fathers. Recommendations include: ensure that all services have access to and use a 'Was Not Brought policy across the local health system; the Disabled Children's Service should ensure that meetings that they convene include an analysis of a child's attendance at appointments; ensure that recording systems are sufficient to identify repeating patterns of children not being brought to appointments; ensure that guidance for safeguarding children with disabilities is sufficient in terms of setting out the importance of communication and hearing the voice of the child.
      
 Title:  Serious case review: Child B. LSCB: City and Hackney Safeguarding Children Partnership Author: City and Hackney Safeguarding Children Partnership Date of publication: 2021  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.                           Serious Case ReviewChild BApril 2021Contents1.Executive Summary22.Introduction43.Key Circumstances, Background & Context5Child B:  Five to Seven Years Old6Child B:  Seven to Eight Years Old12Child B:  Eight to Nine Years Old14Child B:  Nine to Ten Years Old174.Views of the Family195.Findings & Recommendations2011.Executive Summary1.1The publication of this Serious Case Review (SCR) was significantly delayed as aresult of a number of unforeseen circumstances.A first draft of the reportcompleted by the independent reviewer was subsequently finalised and approvedby the SCR review panel overseeing this process.1.2TheSCRmakessixfindingsandninerecommendationsforimprovingmulti-agency safeguarding practice.These have particular relevance for thoseworking with children who have complex needs and disabilities.Finding 1:Children not being brought to appointments is an indicator ofpotential neglect.This is a clear finding of the review and one that has beenseen in other SCRs. Child B, whilst being offered many appointments by differentservices, was not brought to a significant number of these. The hypothesis thatthese were as a result of neglect was not robustly pursued and there was littlepractical support offered to help the family manage these.Finding 2:Effective and child focused safeguarding practice with disabledchildren ensures they are seen, heard and helped. Whilst Child B was seen onmany occasions, there was limited evidence that his voice was consistently heardor that he was directly engaged by involved professionals.However, someprofessionals, particularly school staff were able to effectively engage andcommunicate with Child B.Finding 3:The focus on engaging parents and carers to support disabledchildren is key, but this should not dilute professional challenge whenneeded.Parentalinvolvementfordisabledchildrenwithcommunicationdifficulties is especially important.However, practitioners had no real clarity orguidance within the system about when non-engagement should be a ‘red flag’.This lack of clarity is likely to have been a reason why the identification of potentialneglect to Child B took so long to action.2Finding 4: Multi-agency working, information sharing and understanding theresponsibilities of others can be complex.Clear systems and processescan support effective child focussed safeguarding practice. It is clear that noagency involved with Child B had a clear overview of the family history, itsdynamics or a complete picture of Child B’s needs. Even professionals who knewChild B well were learning new information as part of a practitioner workshopconvened for this SCR.A strong view expressed was that the lack of thiscomplete picture can often arise in the system supporting children with complexhealth needs and disabilities when so many different agencies are involved. This isa known feature and a challenge for both professionals and parents alike.Finding 5:The need for professionals to think family and think fathers. Itwas accepted that there was no clear picture of the dynamics of Child B’s family.Professionals should have been thinking (and acting) beyond the individual theywere working with.There was a need to Think Family.1 There should also havebeen a greater focus on Child B’s father. The SCR recognised an over-reliance oncontact with mother and not enough questioning of the dynamics of therelationship with Child B’s father and what his role was in supporting his child’scare.1 Think child, think parent, think family: a guide to parental mental health and child welfare; Social Care Institute for Excellence, 201132.Introduction2.1Child B was born with a disability that led to urological problems and mobilitydifficulties. Child B has reduced sensitivity in the lower limbs (which means pain isnot felt in the same way as other children), speech and language delay andlearning difficulties. Child B has required surgical intervention to address a rangeof health complications.2.2Despite daily challenges, Child B is an active, friendly and happy child who canmake good relationships with adults. Child B is able to express themself well andsay what they like and want.2Throughout childhood, Child B has requiredsignificant support from a range of health specialists3. This has included routinecare from a specialist children’s hospital (Hospital 1), a local hospital (Hospital 2)and occasionally the services of the local emergency department or outpatients(Hospital 3). Child B is also known to different community-based health services.Child B attended a children’s centre and later a mainstream school. Child B hasalso received social work support as a disabled child and due to concerns abouttheir welfare.2.3For the period under review, Child B lived with mother, father and older siblings.One of the siblings was also in receipt of services as a disabled child andsubsequently as a disabled adult.2.4In May 2015, Child B was admitted to hospital to have a toe amputated.Theopinion of health practitioners at the time was that the infection that led to theamputation was preventable.Child B had not been brought to a significantnumber of health appointments. Had they been, then it is likely that the infectionwould have been treated and managed.On a number of occasions, concernsabout Child B’s welfare were raised internally by health practitioners. Whilst theseconcerns focused on possible neglect, there was no action until the case was3 Neurosurgeons, Orthopaedic Surgeons, Plastic Surgeons and Urologists at different hospitals and from community paediatrics, therapists andnursing, as well as Emergency Department care and GP primary care.2 As described by Child B’s mother and school to the Independent Reviewer.4formally escalated to senior managers in late 2018. Child B was then aged 10years.  In February 2019, Child B was made subject of a child protection plan.3.Key Circumstances, Background & Context3.1In 2002, Children’s Social Care (CSC) became involved with the family due toconcerns about domestic abuse and the capacity of the parents to meet the needsof their children.Assessments undertaken by CSC at the time resulted in eitherno further action or the provision of support from early help services, charities andeducation.3.2In 2007 another incident of domestic abuse was reported and in 2008 (the year ofChild B’s birth), there were reported concerns about physical chastisementinvolving one of Child B’s siblings. Assessments were once again undertaken byCSC, with no further action being considered necessary.There were notedpressures in the family as a result of financial difficulties and caring responsibilitiesfor the children.3.3In 2010, all the children were made the subjects of child in need plans as a resultof one of them sustaining a burn injury and ongoing concerns about their collectivewelfare.In the same year, Child B was seen by the GP and referred to the localEmergency Department for a serious abrasion and ulceration to a toe3.4Throughout 2011 and 2012, several health practitioners identified that Child B was‘missing’, had ‘failed’ or ‘did not attend’ appointments.Routine letters wereordinarily sent to the GP and the parents were regularly advised of the need totake Child B to scheduled appointments.3.5Child B started to attend education at the age of three. The assessment processfor a statement of special educational needs commenced.4Child B’s needs atschool were monitored through termly and annual reviews. The school remainedconcerned about Child B and agreed to provide one to one support.4 Later an Education, Health & Care Plan53.6In early 2013, a meeting was convened by the Disabled Children’s Service (DCS)to review the care package for Child B’s older sibling.Professionals reportedfinding it difficult to engage and communicate with the parents. The DCS advisedthe professional network that it was ‘closing the case’ for Child B as there were noconcerns and appropriate services were being provided by health and education.3.7Over the subsequent years covered by the review’s terms of reference, there weretwo main strands of professional involvement with Child B which highlight arepeating pattern of concern.3.8The first was that Child B sustained a number of toe injuries and on occasions,was brought late to the local emergency department of Hospital 3. Child B’sdisability, lack of sensation in the lower limbs and general footcare complicated thewound which did not heal well. This subsequently affected Child B’s ability to wearspecial aids such splints and shoes.3.9The second strand was that both acute and community-based health serviceswere seeing a growing number of incidents of Child B not being brought toappointments.The nature of Child B’s disability meant that ongoing support wasessential for specialist aids and therapeutic services. At times, practical aids weremissing or broken, putting Child B’s limbs under additional strain and potentially atrisk.3.10The following narrative provides an overview of the significant events involvingChild B. Whilst comprehensive, it remains a summary and does not set out everyoccurrence recorded in agency files.This should be taken into account whenconsidering the overall context of Child B’s lived experience and the complexityarising from the number of professionals involved over this time.Child B:  Five to Seven Years Old3.11In late 2013, Hospital 2 noted that Child B’s toe required treatment. This led toChild B having successful operations, but they were not brought to a number offollow up appointments, including those arranged for physiotherapy.Child B’smother was reporting that she was finding it hard to manage all the appointments6for Child B and her other children. At the time, none of the missed appointmentswere considered as potential safeguarding concerns.The condition of Child B’stoe subsequently deteriorated.3.12The community nurse contacted the DCS5 recommending that Child B’s motherneeded additional support managing appointments and that a special needskeyworker6 may have a role to play.This was subsequently considered at amulti-agency meeting, although it was agreed that the DCS social worker wouldprovide this support (given their ongoing involvement with Child B’s older sibling).At this meeting, the question was raised as to whether Child B was beingneglected.Critique of PracticeThis appears to have been the first time that the concerns relating to Child Bwere expressed using the term neglect.The DCS was tasked to undertake a‘child in need’ assessment in respect of these concerns.The meeting held to discuss the keyworker did not have access to informationabout the different hospitals’ services to Child B or those from the GP Practice.This would have indicated an even greater pattern of ‘was not brought’.3.13Shortly after this meeting, Child B was not brought to a clinic at Hospital 2 to dresstheir toe. This was not escalated. At a multi-agency school review meeting held inApril 2014, the parents mentioned that Child B’s siblings were helping withphysiotherapy.Critique of PracticeChild B’s siblings should have been considered as possible Young Carers.They weren’t.3.14The following month, Child B was brought to the Emergency Department atHospital 2 following a deterioration in their toe. Child B was scheduled to havesurgery the next day (unrelated to the toe) and it was agreed the toe would be6 from the Centre for Integrated Services for Disabled Children5 A social worker from the Disabled Children’s Service was involved with the family, although there was noted confusion in the networkabout whether the social worker was for Child B or the older sibling.7reviewed then. However, as a result of confusion over appointment times, this didnot take place.3.15The planned surgery was rescheduled and Child B’s toe eventually examined. Adecision was made that it needed to be partially amputated. The wound was to bere-dressed by mother prior to the operation the following week.Critique of PracticeThe Hospital team dealing with Child B’s amputation were unaware of theconcerns in the community network of missed appointments and possibleneglect.Erroneously, it was assumed that mother was a nurse and could appropriatelydress the wound (and so may not attend the planned dressing clinic). Child Bwas not brought to the clinic.3.16On meeting with the physiotherapist, mother expressed her concerns that she wasunclear of the hospital’s plan for the partial amputation of Child B’s toe. She alsomentioned that Child B’s wheelchair strap was broken. Mother was advised tocontact the wheelchair service. The physiotherapist contacted the hospital onbehalf of mother to check arrangements about the planned operation. They wereadvised by the Doctor’s secretary that Child B was not booked for surgery. Thesecretary advised that mother needed to contact the appointments section.Critique of PracticeThis above narrative shows some of the complexity of what Child B’s motherwas having to negotiate across services.3.17Following surgery,a review was scheduled at Hospital 2 .Child B was notbrought to this appointment. Separately over this period, Child B was not broughtto a routine orthopaedics appointment at Hospital 1 and the physiotherapistcontinued to have difficulty contacting mother.3.18As part of a plan to support the parents, the DCS social worker was monitoringmissed appointments and requested other services provide information about8future scheduled appointments as necessary.However no contact was maderequesting this information from the three hospitals or the GP.3.19The child in need assessment was completed by the DCS social worker, althoughthis was several months overdue. Despite identifying the frequently missed healthappointments,theassessmentdid not conclude these were safeguardingconcerns or make any recommendations for ongoing support. Whilst Child B wasplaced on a child in need plan, this did require regular visits to be undertaken tosee Child B.3.20In November 2014, Child B was not brought to appointments at Hospital 1 or to acommunity paediatrics appointment. Child B was also not brought to a re-arrangedappointment by Hospital 1 to complete an orthopaedics review.Hospital 1 wasalso unaware of a recent operation undertaken at Hospital 2.3.21The school, social worker and physiotherapist exchanged emails about Child Bmissing appointments.The school’s Designated Safeguarding Lead noted thatthere was a risk of this becoming a safeguarding issue. In late January 2015, ChildB was not brought to Hospital 2. The physiotherapist sought to escalate this to theDCS, but was told that the case was now ‘review only’ and that there was noactive social work role.Critique of PracticeNot all partner agencies were advised that Child B’s case was now for ‘reviewonly’. Practically, this meant that the only function of the DCS was to coordinatereviews of Child B’s care package. The agreed role of the DCS social workeras a coordinator of appointments had lapsed, but no contingency arrangementswere put in place, such as considering whether a special needs keyworkershould now take up this role.3.22In February 2015, the school was concerned as there was poor communicationwith the parents. The school believed that Child B’s physical and health needswere not being met and asked for a DCS social worker to follow this up.Critique of Practice9The DCS engaged with the family and noted that there was a risk of Child B’smissed appointments becoming a ‘safeguarding matter’. A DCS social workerdiscussed this with Child B’s mother over the phone after she had missed aplanned appointment to meet them. No practical help or solution was offered tosupport this problem. Child B continued not to be brought to a range ofappointments and mother was not responding to several services’ attempts todiscuss this.3.23In March 2015, Child B was not brought to a routine developmental review at theCommunity Paediatric Service. As this was the second missed appointment, ChildB was discharged to the care of the GP. This meant that Child B was longerreceiving general paediatric oversight for their specialist health needs.Child Bwas not brought to a follow up fitting for new splints and also missed anappointment at Hospital 3.3.24At the end of April 2015, Child B was taken to the emergency department ofHospital 2 after injuring their toe. This was a late presentation. The wound wasweeping and discoloured and Child B had difficulty walking without support. Thedelay in seeking treatment for Child B was not immediately recognised as asafeguarding concern or referred to CSC.However, after discussion in thehospital’s psychosocial meeting and escalation to the hospital’s safeguardingnurse, the Disabled Children’s Service was notified of this concern.3.25Child B was later found to be suffering from an infection in the bone and wasadmitted to hospital. Child B was given intravenous antibiotics and it was decidedthat further amputation was required.Child B was an in-patient for ten days.Following discharge, Child B was brought back to the emergency department bymother as the wound was not healing.It was recorded that Child B was notcompliant with advice about weight bearing.Critique of PracticeChild B was six years old and had learning and communication difficulties.Recoding ‘non-compliance’ with weight bearing advice does not appear to haveconsidered Child B’s age and specific needs.Specialist communication may10have been required to assist Child B understand what was being asked. Thereis no evidence this was offered.3.26In May 2015, a review at Hospital 2 established that Child B had not been takingthe prescribed antibiotics.  Child B was not brought to the next appointment.3.27In June 2015, Child B was back at school, using a wheelchair. The school advisedthe community physiotherapy service that there were difficulties contacting motherand she was not responding to written communication.3.28The physiotherapist was concerned about the healing of Child B’s toe and whowas changing the dressings. They contacted Hospital 2 and left messages on twooccasions to seek clarification, with no response.In conversation with the DSCsocial worker, mother said that Child B’s wound was being dressed once a week atthe hospital.This does not appear to have been the case. By the end of June2015, Child B’s wheelchair was broken and they were using a walking frame andhopping.3.29Child B subsequently missed an appointment with the community physiotherapist,the third missed appointment in six months. A ‘Did not Attend’ letter was sent tothe parents, but it was agreed that despite the policy (which suggested closure),the service would be continued.3.30Child B was also not brought to Hospital 1 for a neurosurgery appointment.Hospital 1 closed this service to Child B and informed the GP that a re-referralcould be made if necessary.Later in the month, Child B was not brought to anappointment at Hospital 2.Child B was also not brought to a communityphysiotherapy appointment and it was decided that if any more appointments weremissed, Child B would be discharged.In late October 2015, after not beingbrought to three appointments, the wheelchair service closed Child B’s case.3.31The DCS social worker visited Child B’s parents and raised the issue of Child B’smissed appointments.The parents reportedly became angry saying that theyfound taking Child B to so many appointments difficult and that they couldn’t leaveChild B’s disabled sibling at home alone. Both parents were working.Despite the11obvious challenges this presented to the parents, no solution was agreed or plandeveloped to support the parents in this respect.Critique of PracticeDespite the significant number of missed appointments, this was not yet seenas meeting the threshold for neglect.The seriousness was again stressed tothe parents (referring to the possibility of using child protection processes), butthe failure to take any subsequent action lacked any authority or decisivenessto resolve this issue in Child B’s interests. Previous ‘warnings’ to the family hadyielded no results. Neither had the assistance of the DCS social worker to helpthe family manage Child B’s appointments. The next day B was not brought tothe GP for a planned flu vaccination.Child B:  Seven to Eight Years Old3.32From the ages of seven to eight, the pattern of concerns about Child B missingappointments continued.  Key events included the following:●In April 2016, after attending the emergency department of Hospital 3 withan injured toe, Child B was not brought to a follow up appointment. Motherwas still being seen as competent to dress Child B’s toe at home.●At the same time, community health services noted that Child B had brokensplints and that they were too small. Mother had been previously remindedof the need to inform services when this happened.●The condition of the wound to Child B’s toe was a continuing concern forcommunity health and school staff and mother was advised to take Child Bto the GP.●At school, Child B disclosed that father was hitting mother. A DCS socialworker visited, and denied there was any domestic abuse. During thisengagement, mother explained that Child B’s wound was being followed upat the clinic and by the GP, although this was not happening.Critique of PracticeThere was regular communication between the school, community nursing,community physiotherapy and the social worker about Child B. Professionals12believed that they were regularly raising concerns about possible neglect viathe social worker.However, the DCS had no remit to pursue these concernsunder child protection procedures.In the absence of the DCS recognising achild protection response was required, other agencies were likely to have beenfalsely reassured they had reported their concerns via the correct pathway.3.33In June 2016, Child B was seen at the GP for foot pain.The GP took theopportunity to raise the issue of the number of missed appointments. Mother saidthat it was hard to take Child B to so many appointments as she had other childrenand Child B’s sibling also had special needs. The GP suggested that the familymay wish to find a surgery closer to their home.3.34The following month, Child B was admitted to Hospital 3, having been brought inby ambulance due to breathing difficulties. Child B had viral induced wheezing fortwo days, was unkempt and their eczema was being poorly managed.Critique of PracticeA referral was appropriately made by Hospital 3 to the paediatrician to considerChild B’s social situation. Mother was reported as being uncooperative as shefelt that she had already told the emergency doctor about Child B’s needs onadmission. Hospital 3 noted that Child B was an ‘open case’ to the DCS andthat the social work team had no safeguarding concerns. Child B wasdischarged home the same day, after several hours monitoring.3.35The next professional contact was again at Hospital 3 due to a worsening in thecondition of Child B’s toe. The hospital discussed this deterioration as a possiblesafeguarding issue.3.36An X-ray of Child B’s toe (referred by the GP) was undertaken at Hospital 2. Thisconfirmed the toe was in a poor state. Hospital 2 also noted potential safeguardingconcerns, although no referral was made to CSC in respect of these.3.37The concerns of Hospital 3 were shared with the DCS social worker. They wereinformed that the DCS social worker was seeking to support the parents inmeeting Child B’s needs. The plan was for the DCS social worker to again meet13with the parents to raise the issue of missed appointments. This was the fourthsuch meeting.3.38During an appointment at the foot clinic in Hospital 3, a new and open wound toChild B’s foot was observed. Child B was referred immediately to the emergencydepartment at Hospital 3. Mother reported she had been abroad and was not fullyaware of the circumstances of the injury. She had not sought medical help as shefelt that she was looking after Child B’s foot appropriately. Hospital 3 discussedthis possible safeguarding issue at a paediatric psychosocial meeting. It noted theconcerns and also that the community physiotherapist had already made a referralto CSC7 in the light of these new (but repeated) developments.3.39Other significant event around this time included the following:●Mother was seen by the GP and alleged that father had slapped her and thatthe police were involved.  There is no evidence that they were.●On meeting with the CSC social worker (following the referral by thecommunity physiotherapist), mother told them that she had not been givenany advice about the care of Child B’s toe. The social worker was not awareof the allegation of domestic abuse made to the GP. No further action wasdeemed necessary by CSC.●At the end of 2016, Hospital 2 reviewed Child B’s toe and found multipleingrowing toenails. This was not seen as an issue relating to parentingcapacity and a plan was made to review Child B in six months.●It was agreed at a Care Package Review Panel to extend Child B’s support(direct payment for seven hours of care) until 2017. There was no discussionabout potential safeguarding risks and no advice on how support could bearranged to help the parents manage Child B’s appointments.Child B:  Eight to Nine Years Old3.40In March 2017, the school was concerned that Child B needed glasses andcontacted the DCS social worker. The DCS social worker visited Child B at home.7 As a child protection concern, the referral would have been made to the First Access & Screening Team, not to Disabled Children’s Services.14Child B’s care package had now ceased based on the rationale that Child B hadtwo parents and needed no additional support.3.41Later that month, mother contacted the police following an argument with fatherover money. This information was passed to the CSC immediately by the police,although it was not followed up for two months. At this point, mother was engagedand declined any further assessment.3.42Other relevant events over this period included:●InMay2017,thecommunityphysiotherapistconsideredcallingaprofessionals’ meeting as she felt that Child B’s needs were not being met.The meeting was not convened for a further four months.●Child B was brought to the emergency department of Hospital 3 withtoothache and was given antibiotics. The toothache was not seen as a furtherpotential symptom of neglect.●Child B was recorded as a ‘did not attend’ to the follow up meeting at Hospital2 for the review of their toe.  Child B was discharged from the service.●In June 2017, the community physiotherapist saw Child B at school.Shecontacted the DCS social worker as Child B had missed all the physiotherapysessions since January 2017.Mother was reported to have regularlycancelled the planned sessions.●A planned meeting with mother, the community physiotherapist and the schoolwas cancelled by mother as she was going away for a month. She also askedfor all appointments for Child B to be postponed, even though Child B was notgoing away with her.●The community nurse reviewed Child B’s toe at school at the end of June2017. Child B had pain, possibly as a result of their shoes which were toolarge and rubbing the feet.●At the beginning of July 2017, the physiotherapist wrote again to the DCSsocial worker to say that Child B still had no glasses and that their footwearwas inappropriate, asking for these to be taken up with the family as they weresignificant health needs.Critique of Practice15The community physiotherapist had formally referred similar concerns as asafeguarding issue only a few months prior, but these had not been acceptedas concerns indicating neglect. It is, perhaps, not surprising, therefore, that shedid not make a further safeguarding referral.3.43The community physiotherapist was also concerned about Child B possiblyexperiencing back pain and the risk to their hip, questioning whether this was as aresult of Child B’s disability and gait, and perhaps not using the required aids. Shereferred to Hospital 2 asking for Child B’s hip to be reviewed.3.44At the end of July 2017, the community physiotherapist rang the home to remindthe family of an appointment the following day. The phone was answered by ayoung child and there appeared to be no adult at home, in the school holidays.The community physiotherapist rang the DCS social worker and was advised torefer the concern to CSC. On doing this, CSC advised her to ring the police.Critique of PracticeThe police established by phone ( but did not check) that a 15-year-old hadanswered the phone and that father was reported to be present but asleep. Thepolice told the community physiotherapist that this was not a matter for them tofollow up and she agreed to discuss it with CSC.The importance of a home visit was not recognised in this instance. Someonein the professional network should have taken the initiative to visit the familyhome to assess what was happening and who was looking after Child B. Thiswas particularly relevant in the context of Child B’s complex needs and the carethey required.3.45The next day, the community nursing team decided to discharge Child B from theircare as they could not see Child B (as the school had closed for holidays) and theparents were not responding. The GP was informed.The day after, Child B didnot attend an appointment at the Foot Clinic.3.46In September 2017, there was a Team Around the Child (TAC) meeting at theschool.Some improvement was noted in attendance at some appointments, but16mother was reminded of the continuing need for Child B’s foot and leg care. ChildB was missing a splint and specialist shoes. She re-stated the difficulty that shehad with the large number of appointments. Support plans, including appropriatephysical activities for Child B were to be put in place. However, no contingencyplan was agreed should the situation deteriorate and no review date for a furtherTAC Meeting was set.3.47Other events over this period included:●Child B had to have some teeth removed. Child B was almost nine years old.The possibility of neglect was not considered.●Child B had not been brought to several appointments at the Foot Clinic.●In November 2017, mother was admitted to hospital for several weeks with aserious health problem. Professionals supporting Child B were unaware ofthis. At the time, there were signs that Child B was not being looked afterproperly and that they were hungry. When it came to the attention of the DSCsocial worker (just as mother was being discharged), seven hours additionalsupport in the home were arranged for a month.Child B:  Nine to Ten Years Old3.48In January 2018, Child B was not brought to a GP appointment and one of theirsiblings was discharged from another service for not attending appointments.3.49Child B’s mother called CSC asking for Child B’s father to be removed from thehome. She described an acrimonious relationship, but said there was no domesticabuse. She said that he was not supporting her. Mother was advised to call thepolice if necessary. CSC took no further action.Critique of PracticeThis is one of the few times that father featured in the records in any context.He was largely absent from the records and from the professional engagementwith the family.Research is well established in this respect, with the need forprofessionals to actively include a focus on fathers as part of multi-agencysafeguarding practice. It is clear that father’s role was never really explored in17any depth, or what his role was in respect of supporting mother manage thecare of Child B and the other siblings.3.50Other events of note over this period include:●Small improvements in Child B’s attendances at appointments were observed.●Some of Child B’s equipment was noted as being ‘lost’. Child B was notwearing the correct shoes and could not attend school as a splint was broken.●Ongoing tensions in the parental relationship were noted.●Child B was not brought to the gait clinic on three occasions despite remindersand also missed a GP appointment.●At the school annual review, Child B said that they did not want to be seen asdisabled. It was noted that Child B had experienced a deep pressure sore onthe ankle.  Child B said they had injured it on the stairs.●The annual review noted this was evidence that the family was still not copingwith Child B’s needs. Appointments were being missed, even though they hadbeen reduced in number. It was recorded that ‘crucial health needs were notbeing met’ and that there was a ‘serious risk to Child B’s wellbeing’.3.51In June 2018, Child B’s mother again called CSC asking for father to be removedfrom the home and alleging physical and verbal abuse. She was again advised tocall the police.She later denied the alleged physical abuse and there was nofurther exploration of the reported domestic abuse. The parents did not attend ameeting with a social worker from CSC to discuss this further.3.52In September 2018, Child B was not brought on two occasions to ophthalmologyand was discharged from this service. A new DCS social worker was appointed toassess concerns about non-attendance at appointments and Child B’s needs notbeing met.The same month, the school reported that Child B’s shoes werebroken, and their feet were exposed. The parents were not responding to theschool’s request to deal with this or contact them. Mother was thought to be awayat the time. A few days later, Child B was noted to be unkempt and dirty and theirbehaviour had changed.It was questioned whether Child B was being fed athome. A request was made to the DCS for an urgent TAC meeting, but there wasno response.18Critique of PracticeThis would have been a further opportunity to consider a child protectionreferral.3.53In late October 2018, Child B was seen at Hospital 2. It was agreed thathip-reconstructive surgery was required.This was scheduled for the Spring of2019.Child B was subsequently not brought to two orthotics appointments inNovember 2018. As a result, the case was escalated by Hospital 3 to the NamedSafeguarding Lead for the Health Trust.The case was subsequently referred toCSC as a safeguarding issue of neglect.3.54In parallel, Child B also disclosed to the school that they were being physicalharmed at home. The school made a referral to CSC. A child protection enquiryunder section 47 of the Children Act 1089 was subsequently initiated.Thisresulted in Child B being made subject of a child protection plan in January 2019.4.Views of the Family4.1Both parents were invited to participate in the SCR.Only Child B’s motherengaged. She met with the Independent Reviewer and the Head Teacher of ChildB’s school.4.2Mother’s expressed her concern about the injury to her child’s toe and thesubsequent treatment this required, including amputation. She said she was toldby health professionals that the toe should heal and she did not understand why ithad not. She was shown how to manage the dressings by health staff, but saysthat she was not confident with this and may not have done it correctly. Inretrospect, she thought that it would have been helpful if a nurse had visited tohelp.4.3She also found the need to take Child B to the many appointments hard tomanage.This was compounded by her own health needs (which had at timesinvolved hospital admission) and her caring responsibilities for her other children.19One of Child B’s siblings also required significant support due to disabilities andanother had health problems, which meant that mother sometimes had care of hergrandchild. Child B’s mother felt that professionals were not listening to her whenshe told them how hard it was to take her child to all the appointments. She saidthey just told her ‘you have to take Child B’.4.4Helping Child B manage their physical difficulties had been a challenge as theyliked to be active and do things such as play and swimming. Child B found walkingto be painful. The direct payments for respite care helped as mother was able toengage a relative to help take Child B to leisure activities and to pay for cabs.4.5Mother questioned whether more could have been done by professionals atHospital 2 to prevent the infection and avoid the amputation of Child B’s toe.However, she believed that overall, the hospital had provided care. Mother notedHospital 1 as being very supportive in helping Child B with walking when younger.4.6Child B’s mother also felt well supported by the Children’s Centre and school. Shenamed a senior teacher who had been very helpful to the family. Child B was andremains very happy at the school and likes the teachers.4.7Community Health staff, particularly the Physiotherapy Service and the Speechand Language Service were also noted by mother as being very helpful in theirsupport of Child B. She also appreciated the provision of transport to school eventhough they did not live far away. Child B’s mother confirmed that she was not anurse but had worked as a healthcare assistant. She juggled her work hoursaround the needs of the children.5.Findings & Recommendations5.1At the time this SCR was initiated, similar concerns about safeguarding practicehad been identified in other cases held by the DCS, albeit not the same extent asthose seen with Child B. This resulted in the management arrangements for DCSmoving to CSC in 2018, as part of a plan to strengthen social work practice andthe identification of safeguarding concerns for children known to this service area.205.2This plan was considered as part of Ofsted’s inspection of Hackney in 2019, withits impact being noted as ‘beginning to have some positive impact in improvedsafeguarding practice and more robust management oversight of the progress ofchildren’s cases’.5.3Whilst recognising the historical context of this SCR (and acknowledging a numberof improvements made since the period under review), there are nonethelessimportant messages for contemporary safeguarding practice. These derive fromthe main question that the SCR has sought to answer, namely why it took severalyears of multi-agency involvement with a disabled child to recognise that theywere experiencing neglect?5.4The messages of this SCR mirror those of a number of other reviews undertakenin respect of children with disabilities and referenced in the NSPCC briefing: Deafand disabled children: learning from case reviews - Summary of risk factors andlearning for improved practice when working with deaf and disabled children;20168.5.5Finding 1:Children not being brought to appointments is an indicator ofpotential neglect.5.6This is a clear finding of the review and one that has been seen in other SCRs.Child B, whilst being offered many appointments by different services, was notbrought to a significant number of these.5.7Some of these were routine for a disabled child, such as regular developmentalmonitoring or therapeutic support. Some could, at times be made as much as sixmonths in advance, and reminder systems were not always in place. Some wereinresponsetonewcrisesorproblems.Onoccasions,long-standingappointments were also changed due to the needs of the particular service. Attimes, appointments for Child B were made by different services in the same weekor on the same day.8 https://learning.nspcc.org.uk/research-resources/learning-from-case-reviews/deaf-disabled-children215.8The SCR found two issues of relevance in this respect.Firstly, there was noeffective multi-agency co-ordination or oversight of these appointments. Secondly,the missed appointments failed to be seen in the context of potential neglect andas an indicator that the parents’ were unable to meet the needs of their child.5.9In respect of the coordination of health appointments, there was no evidence ofany systematic planning of these or effective information sharing across the threehospitals and the range of community health services. For example, practitionersdid not always know what treatment and support was being offered by others. Asan example, Hospital 3 referred Child B to community nursing for follow up care tothe toe. When it later became infected, Child B was referred to Hospital 2.Hospital 2 assessed the toe to be healing and, unaware of the community nursinginvolvement, decided to monitor Child B directly and to train Child B’s mother todress the toe. They understood that Child B’s mother was a nurse, which was notthe case.5.10Furthermore, despite Child B’s mother stating on several occasions that shesimply could not cope, the practical response to help her was insufficient. Indeed,Child B’s parents were also frequently missing appointments for their own ongoinghealth problems and the challenges they were facing should have prompted amuch earlier and more supportive response.5.11Whilst the DCS tried to support by requesting professionals share the details ofscheduled appointments with them, there was little rigour in this approach. Keyagencies weren’t approached and as such, this response was always going to belimited.5.12During the period under review, services were also not using the phrase ‘Was NotBrought’ when children missed appointments. The policies and practice in place atthe time were mainly in the health services and followed ‘Did Not Attend’procedures. These failed to point to neglect as a potential cause or recognise theresponsibility of parents and carers to bring their child to these.The primarycontingency plan in procedures at the time for continuing missed appointmentswas a referral back to the GP Practice for follow up.Services were ordinarilyterminated at this point.225.13A key lesson for the practitioners is that they need to be more curious about thereasons why a child is not being brought and to look for patterns of incidence.They should thoroughly explore potential options for support and have clearmechanisms for recording events in order to identify themes, patterns and trends.This requirement should be reflected in related policy.5.14Practitioners at the workshop were clear in their view that ‘Was not Brought’should also be embedded in the terminology of agency recording systems, neglectguidance and in the local threshold document.This will ensure that the child’sperspective is central.Recommendation 1:The City & Hackney CCG should provide assurance tothe CHSCP that all services have access to and use a ‘Was Not Brought” policyacross the local health system.Recommendation 2:The Disabled Children’s Service should ensure thatterms of reference and agenda structures for meetings that they convene(involving a review of disabled children and those with complex health needs)include an analysis of a child’s attendance at appointments.Recommendation 3: The CHSCP should seek reassurance from safeguardingpartners and relevant agencies that their recording systems are sufficient toidentify repeating patterns of children not being brought to appointments.Recommendation 4:The CHSCP should review and update its guidance onneglect and the local threshold tool to ensure this sufficiently describes the risksassociated with children not being brought to appointments.5.15Finding 2:Effective and child focused safeguarding practice with disabledchildren ensures they are seen, heard and helped.5.16The participation of children in decision making about their own welfare and in theservices that they receive is a legal requirement. All children can communicatepreferences if they are asked in the right way by people who understand their23needs and have the skills to listen to them. It is never acceptable to say or writethat a disabled child is ‘unable to communicate their views’.A disabled child’spreferred communication method for understanding and expressing themselvesneeds to be given the utmost priority. Where a child has speech, language andcommunication needs, adequate arrangements must be made to ensure that theirviews and feelings can be obtained.5.17Whilst Child B was seen on many occasions, there was limited evidence that hisvoice was consistently heard or that he was directly engaged by involvedprofessionals. Some professionals, particularly school staff, were however, able toeffectively engage and communicate with Child B.5.18They understood Child B’s limited communication and actively sought to help ChildB understand issues in ways that they could – such as why it was important towear the splints and shoes (which Child B did not want to do).The SCR foundthat the school proactively accessed the advice of Speech and LanguageTherapists to support communication with Child B and to suggest ways to talkabout complex ideas. Other services did not. Indeed, across services as a whole,there was little evidence of a similar focus. Child B’s voice in the clinical notes wasnotably sparse.5.19Barriers to communicating with disabled children were identified by the NSPCC intheir 2016 report on learning from case reviews involving deaf and disabledchildren9.  These included:●Disability was sometimes linked to impaired speech or comprehension,making it hard for children to express themselves.●Parents were sometimes relied on to interpret what their children weresaying, preventing children from confidentially disclosing concerns.●Sometimes children's disruptive or distressed behaviour was interpreted asa result of their disability without consideration of potential safeguardingconcerns.9 https://learning.nspcc.org.uk/research-resources/learning-from-case-reviews/deaf-disabled-children24●In some cases letters or written agreements were used with young peopleto arrange access to services or manage their risky behaviour despite themhaving limited or no ability to read.5.20Potential solutions were also suggested by the NSPCC:●Professionals should make sure the child's voice is heard. Where there aresafeguarding concerns children should be spoken to alone and parentsshould not be used as interpreters.●In cases where a child's disability precludes or limits verbal communicationefforts should be made to facilitate communication by other means.●Practitioners should also consider how a child may communicate throughtheir actions. Distressed or disruptive behaviour should not automatically beattributed to the disability.●Educational personal safety resources should be tailored to the child'sneeds. Advice should not be considered to have successfully been givenunless there is evidence that the child or young person has understoodwhat they have been told and is able to apply this.Recommendation 5:The CHSCP should ensure its guidance (and anyrelevant single agency guidance) for safeguarding children with disabilities issufficient in terms of setting out the importance of communication and hearingthe voice of the child and how this can be effectively achieved.5.21Finding 3:The focus on engaging parents and carers to support disabledchildren is key, but this should not dilute professional challenge whenneeded.5.22In the practitioner workshop, there was agreement that parental involvement wasessential in all services and that for disabled children (with communicationdifficulties) it is especially important. However, practitioners also stated that therewas no real clarity or guidance within the system about when ‘non-engagementbecomes a red flag’.255.23This lack of clarity could have been a reason why the identification of potentialneglect to Child B took so long to action. It is also likely to have been influencedby how professionals have historically approached working with disabled children.Indeed, lessons from previous SCRs10 have shown that parents can often be seento be ‘doing the best they can’. Because of this, the threshold for a ‘red flag’becomes higher.Professionals are unwilling to challenge or appear critical ofparents who are looking after children in what are undoubtedly challengingcircumstances.5.24One practitioner at the workshop asked, “are our expectations too low?”.Manyhad tried hard to work with Child B’s mother, but were clearly frustrated by thedifficulties in communicating with her. The attempts at ‘authoritative practice’ onlyappear to have involved repeated warnings about the seriousness of Child Bmissinghisappointmentsandthepossibilityofinitiatingchild protectionprocedures.There was no impact from this approach, no ‘difficult conversations’with the parents, challenge wasn’t sustained and the same pattern of Child Bmissing appointments was allowed to continue without robust action.Recommendation 6:The CHSCP to review related guidance and its trainingto ensure the issues on non-engagement, professional challenge and difficultconversations are sufficiently focused on working with disabled children.5.25Finding 4: Multi-agency working, information sharing and understanding theresponsibilities of others can be complex.Clear systems and processescan support effective child focussed safeguarding practice5.26It is clear that no agency involved with Child B had a clear overview of the familyhistory, its dynamics or a complete picture of Child B’s needs. Even professionalswho knew Child B well were learning new information as part of a practitionerworkshop convened for this SCR. A strong view expressed by them was that thelack of this complete picture can often arise in the system supporting children withcomplex health needs and disabilities when so many different agencies areinvolved. This is a known feature and a challenge for both professionals andparents alike.10 https://learning.nspcc.org.uk/research-resources/learning-from-case-reviews/deaf-disabled-children265.27Indeed, not only can families be overwhelmed by the number of professionalsworking with them, but professionals can be confused too.In Child B’s case,different information was being shared with different professionals at differenttimes.There was no system to properly coordinate this and engagement wasad-hoc and un-structured.5.28A core systems issue identified by professionals was seen as there being nodefined, ‘central place’ for all the involved professionals to share relevantinformation about Child B, especially as the family was accessing services acrosslocalities (and from different hospitals). There was also a lack of clarity about whomight be a ‘lead professional’. Due to these issues, there was too much reliancebeing placed on the family to be the main source of sharing important information.This hindered the oversight on what was actually happening in the family.Forexample, it was only through the collation of the multi-agency chronology for thisSCR that professionals came to learn just how many occasions Child B ‘was notbrought’ to appointments.The inability of the network to see the bigger picturemasked the growing neglect for Child B.5.29Despite the view that the system lacked a ‘central place’ to collate information,therewereseveral meetings where Child B was being considered in amulti-disciplinary way.There were opportunities at these forums to gain a betterunderstanding of Child B’s lived experience, but based on the respective focus ofthese meetings, none did so in any systematic way.●The termly All About Me meetings at the school reviewed progress and notedChild B’s needs and concerns, agreed actions and followed these up with theparents.●The EHC Plan Annual Review was also held at the school. Relevantprofessionals were not always invited to these meetings (or did not attend)which impacted on information sharing and gaining a complete picture of ChildB and the extent of the building concerns.●The Multi-Agency Referral Meeting (MARS) brought services together forchildren with disabilities and could be used for advice and multi-disciplinarythinking about a child and their needs.27●The Care Package Panel reviewed the provision of support.5.30In respect of a lead professional role, whilst this would ordinarily be a communityor local hospital-based paediatrician, practitioners at the workshop reported thatthere was no clarity about who could or would be a lead professional toco-ordinate the network.5.31There was also an assumption by health agencies that if a DCS social worker wasinvolved, that the lead responsibility lay with them for any safeguarding concernsand agreed actions from meetings. However, there was a lack of understanding ofthe different social work role in the DCS at the time.The team did not holdsafeguarding responsibility or for families receiving respite services or directpayments, they was not always an allocated social worker.5.32Since this time, a number of changes have been implemented in the DCS.Following an expansion of the scope of the work undertaken in the team, socialworkers are now undertaking more Child and Family Assessments whensafeguarding issues arise where children are known to them. This minimisestransitions for disabled children and their families and provides a more consistentapproach. However, the challenge of consistently identifying a lead professional isunderstood to remain. A key systems issue identified by the SCR is that agenciesoften did not allow staff the time for their staff to be lead professionals and take onthe additional tasks this role involves, especially co-ordinating information sharing.A manager at the workshop noted there was no formal local sign-up acrossservices to the lead professional roles in Early Help Services5.33Two recommendations arose from the SCR workshop about this issue.Thesehave been included for consideration as part of a review into Early Help servicesthat is ongoing.Recommendation 7: The review of early help services in Hackney shouldconsider how the identification of lead professionals for cases being ‘steppeddown’ from social work intervention can be improved.28Recommendation 8:The review of early help services should consider theuse and involvement of professionals in developing EHC plans and the EHCPlan Annual Review.This should include addressing aspects such as thenaming of a lead professional, the sufficiency of information sharing in respectof social care needs and the oversight of whether children are being taken toappointments.5.34Finding 5:  The need for professionals to think family and think fathers.5.35It was accepted that there was no clear picture of the dynamics of Child B’s family.Many in the network were not aware when one of the parents was away, unwell orin hospital; nor when another young child was temporarily in the house. This was afamily with two disabled children and their siblings. In retrospect there wasrecognition of the need to Think Family11 and professionals should have beenthinking (and acting) beyond the individual they were working with. For example,this was seen in the failure to consider Child B’s siblings for a young carersassessment when they were reported as helping with Child B’s physiotherapy andthe known concerns about the parents’ health needs.5.36It was also seen in the lack of focus on Child B’s father. The SCR recognised anover-reliance on contact with mother and not enough questioning of the dynamicsof the relationship with Child B’s father and what his role was in supporting hischild’s care.Recommendation 9:The CHSCP should promote guidance on ThinkingFamily and Focusing on Fathers as part of multi-agency practice.11 Think child, think parent, think family: a guide to parental mental health and child welfare; Social Care Institute for Excellence, 201129