Three siblings aged between 6-15-years-old who experienced a significant domestic abuse incident in August 2021. The abuse was perpetrated by their father against their mother and lasted over 11 hours in the family home. Learning includes: agencies should be cognisant of the assessment, chronology, and history of families, before making judgements about risk based upon the decisions of others; children's case closure should highlight ongoing support offered to the family and identify risk factors which would result in the case being escalated and re-assessed; agencies need to follow up and follow through when parents are tasked with self-referring for agency support or services; significant low attendance at school should at least prompt an early help assessment; supervision should consider gender bias and ensure that discussions focus on the risks presented by both parents; agencies working with children and young people would benefit from hearing from domestic abuse survivors and their experiences of statutory interventions. Recommendations include: agencies should alert the multi-agency safeguarding hub (MASH) if it is known or becomes apparent that children have been the subject of care proceedings or child protection planning in another local authority; safeguarding partners should consider how learning from the Covid-19 pandemic is embedded into organisational forward plans; raise practitioner awareness of young carers and their routes for support, and the link between the young carer role and neglect; child protection plans, child in need plans and early help plans need to reflect the actions that safeguarding agencies take if parental relationships and contact is resumed without formal agreement.
      
    Serious Case Review No: 2022/C9901  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.     1       Local Child Safeguarding Practice Review (LCSPR) Children O, P & Q                     Completed December 2022 Agreed by the Local Authority Safeguarding Board 19th January 2023  Independent Review Author – Ian Vinall        2        Contents   Introduction        3  Methodology and Process      3  Key Practice Episodes       4  Emerging Practice Themes      9  Good practice         24  Conclusion         25                        3  Introduction  1.1 The subjects of this review are three children, Child O (aged 15), P (aged 8) and Q (aged 6). They are a sibling group.  The children are currently living with family members and are subject to public family law decisions regarding their future care. Up until August 2021, all three children lived with their birth parents. For the purposes of this review and to maintain confidentiality, the parents are referred to as Jill (mother) and Michael (father)1.  1.2 In August 2021, the three children were present in the family home and experienced and witnessed a significant domestic abuse incident perpetrated by their father against their mother. This experience lasted over 11 hours, during which time their father seriously assaulted their mother several times, leaving her with life threatening injuries. He removed all forms of communication during this period, preventing the children calling for help from family or the emergency services. Eventually, when he fell asleep the eldest Child O contacted family members and the emergency services.  Their mother sustained significant injuries requiring urgent and specialist hospital treatment and she was placed into a coma. 1.3 At the time of the incident, the three children were subject to child protection plans under the category of neglect.  1.4 The children were referred to the local authority Safeguarding Board and a Rapid Review2 was undertaken in September 2021 to consider whether the criteria were met for a Local Child Safeguarding Practice Review (LCSPR). The National Panel3 confirmed the request for an LCSPR following receipt of the Rapid Review report.  1.5 Consideration was given as to whether the children’s mother had ‘care and support’ needs at the time of the attack and whether the criteria were met for a Safeguarding Adult Review (SAR). The Rapid Review Panel confirmed the need to commission case reviews that met the requirements of Working Together 2018 and Section 44 of the Care Act 20144.  1.6 The independent author was appointed in April 2022 and the initial LCSPR Panel met on the 27 April 2022.   Methodology and Process  2.1 The LCSPR panel confirmed that relevant agencies would provide a chronology of involvement and the independent author would engage in 1:1 conversations with the parents, grandparents and practitioners involved with the family.  Practitioner events were held in June and October 2022. The LCSPR Panel met on four occasions.  2.2 The independent author met with both birth parents separately and the maternal grandparents. The independent author did not meet with the children directly. As the children are receiving ongoing trauma therapy, it did not seem appropriate to engage with them to discuss their experiences. Their voice was represented through family  1 Not their real names 2 Working Together 2018 Chapter 4  3 National Child Safeguarding Practice Review Panel 4 Section 44 of The Care Act 2014 requires Safeguarding Adult Boards (SABs) to arrange Safeguarding Adult Reviews (SARs) when the criteria are met, and when they are not met but the SAB believes there is value in doing so.    4 members, the Social Worker, and their schools. The report author is grateful for the engagement of family members to assist the understanding of the family story.  2.3 A separate SAR Panel was agreed to ensure the focus remained on the children’s mother and her care and support needs. This LCSPR report should be read alongside the SAR report.  2.4 The independent author also reviewed many documents, assessments, plans and reports.   2.5 The LCSPR Panel agreed that the timeframe for the review should cover from 2019 up until the incident in August 2021. The independent author also agreed to summarise agency involvement prior to this as there was significant and relevant information regarding the children dating back to the birth of Child O.  Key Practice Episodes   3.1 2007- 2018 3.2 The family first came to the notice of Children’s Social Care in a London Borough in January 2008. Child O, at that time aged 9 weeks old, was admitted to hospital with a broken leg and fractured rib. Child O was subject to a Section 47 investigation5. Child O was placed into foster care under Section 206. This period of voluntary foster care for Child O, aged 9 weeks, continued until September 2009. Child O’s father was arrested and was convicted of causing the injuries and was sentenced to 6 months imprisonment. In October 2009, Child O returned to the care of Jill and became the subject of a child protection plan and the local authority applied for a Supervision Order. This order was granted in February 2010 and the order concluded in November 2010. It was recorded that the family worked well with Children’s Social Care and their case was closed on the conclusion of the Supervision Order. Child O’s father had moved out of the family home and was living with his mother.  3.3 In March 2011, a referral to Children’s Social Care was made via the Police following Police attendance at the family home because of a serious incident of domestic abuse perpetrated by Michael. It was reported that he seriously assaulted Jill, her parents, and her brother. Michael was arrested, charged, convicted, and given a suspended sentence.  He was ordered to attend the IDAP7 and Caring Dad’s8 programme. Child O was again made the subject of a child protection plan. Michael and Jill remained in a relationship and Michael returned to the family home after several months. There was positive feedback about the couple’s work with Children’s Social Care and the case was closed in 2012.  3.4 In March 2013, Child O disclosed at school a further significant domestic abuse incident perpetrated by Michael and they sustained an injury. Both parents denied the incident. Child O and Jill went to live with the maternal grandparents and Child O became the subject of the third child protection plan. It was reported that the family made ‘good progress’ and Child O returned to the care of their mother. Michael once  5 Section 47 Children Act 1989 6 Section 20 Children Act 1989. Section 20 of the Children Act 1989 provides the local authority with the power to provide accommodation for children without a court order.  It is widely known as voluntary accommodation because the parents must agree to the Child being accommodated.  7 Integrated Domestic Abuse Programme - IDAP was a cognitive-behavioural programme which challenged convicted offenders’ attitudes and beliefs in order to change their behaviour.  8 The Caring Dad’s Programme is a group intervention programme for men who have abused, neglected or exposed their children to domestic abuse.      5 again remained out of the family home. A child in need plan was ended in May 2014 and the case was closed.  3.5 The family moved to another local authority in 2014 and there is very little information available as the family did not come to the notice of safeguarding agencies despite the significant history of involvement and the children’s father returning home and resuming his relationship with the family. Closing summary documents highlight Jill’s responsibility for ensuring safe ‘contact’ for Child O with their father.  3.6 Child O was referred to Children’s Social Care by the school in July 2017. Child O joined the school in April 2016 and they reported poor school attendance and had previously been the subject of a child protection plan. Children’s Social Care did not accept the referral stating this was a ‘School attendance issue’. No additional checks were undertaken regarding the history of the family referred to in the initial contact from the school. 3.7 Child O has a concerning medical history including a urinary tract infection in 2015, a fractured toe and injuries to the foot in 2016, injury to the shoulder and arm in 2017, a fractured finger in 2018 and a further fractured foot in 2019.  3.8 The reports during this period highlight the concerns about the children’s father’s mental ill health, significant drug, and alcohol use.  3.9 2018 - 2021 3.10 The family moved to the local authority area in 2018.  3.11 A review of health records identified that no documentation relating to the children’s transfer to the local authority had been uploaded to their electronic health records. There were no records indicating that a verbal handover was received from the previous Health Visiting Service, particularly given they had been in receipt of enhanced services previously.  Learning point: The lack of information sharing regarding historic risks previously identified may have impacted the family needs assessment being completed by the Health Visitor during her initial contact with family.  Recommendation 1:  Practitioners in Health, Police, Schools, and other agencies should alert the Multi- Agency Safeguarding Hub (MASH) if it is known or becomes apparent that children have previously been the subject of care proceedings or child protection planning in another local authority. Multi-agency safeguarding procedures should be updated to ensure that supports this practice.   3.12 A transfer in home visit was completed by the Health Visitor in late December 2018. The student Health Visitor discussed alcohol and substance use with Jill and she responded ‘no’ to both questions. Domestic abuse was explored and no disclosures of domestic abuse were made. At this contact she reported Michael to be supportive. When asked about existing or historic child protection within the family, Jill reported the family had no history of child protection. Sleep issues were discussed in relation to Child Q also causing Child P to have disturbed sleep and reportedly leading to their school attendance dropping. Sleep advice was given and a referral was made to the Health Visiting Skill Mix Sleep Programme. No health or safeguarding concerns were identified.    6 3.13 The family initially lived with Jill’s parents at their home address before seeking suitable housing locally. 3.14 In January 2019, Jill was referred to ‘Talking Therapies’ by her GP following reporting low mood and self-reported that the marriage to Michael was ‘ending soon’. In May 2019, she was prescribed anti-depressant medication.  3.15 In December 2019, a 14-year-old girl disclosed that Michael had sexually abused her. The subsequent investigation led to all three children being made the subject of a child protection plan in January 2020.  3.16 At the Initial Child Protection Case Conference, concerns were raised about the children’s history, together with concerns regarding all three children’s school attendance, the children reporting that their dad presents as angry, the historic domestic abuse incidents and the sexual abuse allegations against Michael. Children’s Social Care reported that the parents were accepting of their involvement however, the allegations against Michael were not evidenced and the Police investigation concluded with no further action. 3.17 In February 2020, Child P disclosed in a direct work session with the Social Worker that ‘daddy was smacking him’.  3.18 Jill was charged with drink driving in March 2020 and was subsequently banned from driving for 16 months. She sustained a broken ankle and facial injuries. She told Police that she had been drinking alcohol the previous evening. Jill’s parents reported that this incident occurred as Michael had ‘chased’ her out of the family home and she was escaping violence; however, this is not confirmed by other agency information.  3.19 The children were stepped down to a Child in Need Plan just three months later at the ‘virtual9’ Review Child Protection Conference in April 2020 following the Police decision not to pursue the allegations against Michael. This decision was ratified by a Head of Service in Children’s Social Care. The drink driving incident was not disclosed at the review conference by the Police.  Learning point: Agencies need to be cognisant of the assessment, chronology, and history of families, before making judgements about risk based upon the decisions of others. This is particularly the case in situations where the Police or Crown Prosecution Service decide not to pursue a prosecution of an offender.   3.20 The initial virtual Child in Need meeting was held in June 2020, some seven weeks after the review Child Protection Case Conference. It was reported by Children’s Social Care that the family were ‘not engaging’ in the Child in Need plan.  Recommendation 2: The safeguarding partners should consider how learning from the Covid-19 pandemic and the adaptations to children’s safeguarding practice as a result, is embedded into organisational forward plans.    3.21 The case was then closed at the beginning of September 2020. Michael did not engage with any elements of the plan. It is of note that these interventions were at the time of the national lockdowns owing to the Covid-19 pandemic.   9 The local authority had instigated virtual meetings owing to the Covid-19 pandemic. These are ‘real time’ meetings held over the internet using integrated audio, video and chat tools.    7 Learning point: Families unable to engagement with assessments, interventions and care planning should be the subject of more scrutiny and not less.   Learning Point: Children’s case closure by Children’s Social Care should highlight ongoing support being offered to the family and identify risk factors which would result in the children’s case being escalated and re-assessed.   3.22 In September 2020 Michael suffered a bereavement in his family and he feels this impacted his mental health and drug use significantly.  3.23 Further reports of domestic abuse were received by Children’s Social Care via the Police in November 2020. A medium domestic abuse risk flag was placed on the Police records management system (Niche). There are no documented attempts to undertake enhanced safety planning with Jill and the children. Michael received a caution for ‘extreme pornography’ in 2020 but this did not feature in multi-agency risk assessments until after the incident in August 2021.  3.24 A further Section 47 investigation was instigated and as part of the child and family assessment, Child Q disclosed that their mummy hates them and hits them and their daddy hits mummy and their sister and this makes them feel sad. In December, Child Q stated to School staff “My dad always shouts at me, I didn’t do nothing wrong. My dad always hurts my sister and my mum and it always make me cry”. This information was shared with the children’s Social Worker and there was contact with mother. Jill reported to School that she ‘cannot stop the children from lying’.  3.25 The children’s father moved out of the family home and went to live with his mother. He was expected to complete interventions to address his mental ill health, drug, and alcohol use to enable him to return to the family home. The decision following the conclusion of this assessment was a Child in Need Plan. Recommendation 3: Where children are subject to Section 47 enquiries and/or child protection processes and where risk assessment determines the need for adults to leave family homes, there should be a multi-agency agreement regarding visiting families at evenings and weekends to reinforce decision making and safety. This should be referenced in the safety plan.  3.26 A Child in Need Meeting was held in March 2021 where it was reported that the father had not engaged with the interventions proposed.  3.27 In April 2021, a further Section 47 investigation was instigated following Child O’s sexual exploitation online. This led to a Child Sexual Exploitation Risk Assessment and a further Initial Child Protection Conference. The focus of this conference was Child O’s risk of exploitation and the three children were placed on a child protection plan under the category of neglect. There were several actions including to check whether the children’s father undertook any of the interventions, as this was not clear. The child protection plan was largely a repeat of previous plans and interventions which had been unsuccessful in the previous period of child protection planning, and with which the parents did not fully engage. There were challenges in engaging the family in the plan because of regular Covid-19 presentations of the family members.   8 Learning point: Current risks need to be placed into the context of history of risks and concerns.   Learning point: Agencies need to follow up and follow through when parents are tasked with self-referring for agency support or services.   3.28 In May 2021, Jill arrived at school to collect the youngest children intoxicated which led to a further Section 47 investigation and the children were moved to their maternal grandparents.  3.29 In June 2021, there was an audit undertaken by the Conference and Review Team in the local authority. They highlighted Michael had not engaged historically with work on the plan to address his behaviours and reduce risk. The team recommended to the Team Manager that they consider the outcomes for the children given the history and lack of sustained change. Recommendation 4: Safeguarding audits undertaken by any agency that raise practice concerns or where risks to the children are heightened should be appropriately escalated if not initially responded to with appropriate assurance.   3.30 Michael was referred to Substance Misuse Services and was assessed on 30 June 2021. He was offered other services, including a referral to mental health services, which he declined. He refused to cooperate following the Review Child Protection Case Conference but requested a referral to New Hope (New Hope provides a range of substance misuse services to anyone aged 18 and over who lives in the local authority). This was not actioned as Michael failed to respond to contact. 3.31 Both parents were referred to Adult Substance Misuse Services and it was difficult for the parents to engage with the service. This was referred in the Children’s Social Care chronology as ‘disguised compliance’. Drug testing was instigated as part of the child protection plan and they both tested positive for cocaine on two occasions between July and August 2021.  3.32 At the Review Child Protection Case Conference in July 2021, the Child Protection Conference Chair emailed the Team Manager in Children’s Social Care highlighting concerns around the parents engagement and recommended they seek legal advice and undertake a risk assessment for Michael. The Chair's summary stated, “Given the long-standing issues and the lack of meaningful engagement I suggest that a discussion with the manager needs to take place to consider if legal advice is sought – the drugs and alcohol test, parenting assessment and domestic abuse work, as well as family members viability may be more timely done within PLO10 (the children have had involvement for a long time). The positive drug test yesterday could be the trigger event to consider legal advice and discuss the threshold for PLO. This is with the view of avoiding delays and if it turns out there are serious addictions and domestic abuse, then the children’s long-term safety can be addressed more  10 The Public Law Outline (PLO) process takes place when the Local Authority is  concerned about a child’s wellbeing and unless positive steps are taken to address and alleviate those concerns, the Local Authority may consider making an application to the Court. The PLO process is therefore the  last opportunity  for parents to make improvements to their parenting before  care proceedings are issued.     9 promptly”. There was no evidence that this was responded to by the Team Manager but the Team Manager recalls discussing this with the social worker at the time.  Learning Point: The responsibility for escalation rests with the individual raising the concern. Professionals needs to own the responsibility for escalation and follow up and follow through those concerns.   3.33 On the 8 August 2021, the children witnessed a serious incident involving a significant and sustained physical assault on their mother by their father in which she received life threatening injuries. The incident lasted approximately eleven hours during which time all forms of communication were removed by the father and the children were unable to seek help. Their mother sustained several significant injuries requiring urgent and specialist hospital treatment.  Emerging practice themes  4.1 The children’s experiences 4.2 The children have not been spoken to for this review following the advice of the review panel. This does leave a gap in understanding and information is based on adult reporting.  4.3 Child O attends secondary school and has an aspiration to be a solicitor. They enjoy sports and have played rugby for a club in the county. Prior to the incident in August Child O was very supportive and protective of their parents, yet they regularly stated that they would do whatever was necessary to ‘keep the kids safe’. Child O took on caring role in the family and regularly, if not daily, ensured that their siblings were up, dressed and in school. The younger children report feeling very close to Child O and spoke about them regularly in school. There is no evidence that Child O was considered a ‘young carer’ and no assessment took place of their role in caring for the siblings. The children have presented as very close to each other.  Recommendation 5: All agencies working with children and young people should raise practitioner awareness of young carers and their routes for support. The Children and Young People’s Partnership Board should assure themselves that all practitioners understand the link between the young carer role and neglect.    4.4 Child O has spoken about what life was like at home and they recall ‘things starting to go bad’ when they were aged nine. Child O recalled their father drinking and smoking ‘weed’ in the garden with young men and how they assumed that their father was selling drugs. They described how Michael would ‘do cocaine on the kitchen table’ and there would be remnants left behind and their mum would clear it up afterwards. Child O believes this is why Jill was testing positive for cocaine. Child O described seeing loads of little bags of cocaine in the house and how Michael’s bedroom drawer was full of them. They recall their mother calling Michael a ‘coke head’ and that he needed to stop. The information from Child O confirmed Michael’s late arrival at home as they were tasked with ensuring the front door was locked behind him. They reported that they would get the siblings ready for school and make them breakfast. They would make breakfast for their parents who remained in bed and cleared up after them. Child O reported that if they did not ‘get it right’ then they would get a slap or punch. Child O reported that in December 2020, Michael   10 threatened them with a kitchen knife and stated that ‘if they tell anyone what is going on, he would find them and kill them, would cut their throat, put them in a body bag and drown or burn them alive’. Child O has described the fear of speaking out and how Michael would look at them with ‘cold eyes and then laugh or smile’.  4.5 As a coping mechanism, Child O describes coping by ‘crying, getting angry or blacking out’.  4.6 Child O has a concerning health history of unusual fractures during their childhood. This has not been the subject of professional scrutiny and yet the Social Worker did highlight this in their assessment.  4.7 There is a view held by the maternal grandparents that Child O exaggerates their experiences of the family home. However, the detailed descriptions of what life was like for Child O and their siblings is reinforced by information from the professional network, by Jill herself and by the statements and observations of the other children. This detail is triangulated and is therefore highly likely to be the children’s experience.  4.8 There have been ongoing concerns about Child O’s vulnerability to exploitation and this led to assessments and plans to support them. There was significant concern that they were vulnerable to easily being pressured to do things that are at the cost of their own safety. They were referred for ‘keep safe’ work yet struggled to talk about their experiences. 4.9 Child P is the middle sibling and described as loving with a wicked sense of humour. They are described as charismatic and would do anything for anyone. Child P loves school and has a good peer group of friends. They never talked about home life and there is evidence that they were coerced into defending the parents, stating for example that ‘Child Q is always fibbing’.  4.10 Child P was very wary of discussing the situation at home and consistently stated that they had no worries and were happy. They described daddy ‘not shouting at me’. It was Child P that had reported to school in March 2021, how Child O’s arm had been ‘snapped’ by Michael. There is no medical information available as to the veracity of this report.  4.11 Child P gave a graphic description of the incident in August 2021. They recalled ‘daddy jumping on mummy’ and how this made them cry. They said that blood was ‘everywhere’.   4.12 Child Q is the youngest sibling and is described as ‘full of fun, with a big grin and loves rough and tumble’. School report that they are confident yet not particularly academic. They have settled well in school and have made friends. Child Q was anxious not to get Jill into trouble but did disclose regularly what life was like at home. Child Q has told school staff that ‘daddy always shouts at me’. Child Q ‘adored’ the family and spoke positively about Child O. Child Q has disclosed being ‘hit by mummy’ and observing ‘daddy hit mummy’.  Learning Point: Listening to children, hearing their voices and responding to their statements needs to be reinforced with all agencies who have contact with children and young people.    4.13 Attendance at school has been a significant issue for all three children, at times below 50%. Some of these absences are believed to be Covid-19 related. However, the evidence available would also indicate the parents’ own struggles in getting up   11 and ready for the morning routine and the heavy reliance on Child O to support with the care of the children. There is a history in previous local authorities regarding Child O’s attendance at school.  Learning Point: Children’s significantly low attendance at school should prompt, at the very least, an Early Help Assessment to ascertain the reasons behind the absences and what the agency network should do to support the children to access education.   4.14 Assessments undertaken by Children’s Social Care indicate that the family home was always ‘clean and tidy’ and the children’s physical presentation was good.  4.15 The children have been present, witnessed and experienced the domestic abuse perpetrated by Michael over several years and most likely all of Child O’s childhood. They have witnessed both parents’ drug and alcohol use in the family home and have experienced physical abuse and emotional harm from both parents. Child O has been significantly injured by their father in the past and has been a young carer for some significant time.  4.16 These descriptions of life in the family home have left long standing emotional, mental, and physical impacts on all three children and some of their current behaviour and presentation reflects the significant trauma that they have experienced. All three children will need ongoing therapeutic support to help make sense of their experiences.  4.17 It was evident that the children were told not to tell adults what was happening at home and they were taught, particularly Child O, how to cover up information about the situation at home.  4.18 There does appear to be periods of stability for the children and when the family moved in 2014 to another local authority area there are no significant incidents that were reported or referrals to safeguarding agencies. This is not to say that harm did not continue yet both parents separately reported that there were times in their relationship and in their family life that was positive.  4.19 Since living in the local authority, the children have been the subject of three Section 47 investigations, five child and family assessments, two child protection plans, a child in need plan and Child O’s child sexual exploitation risk assessment between late 2019 and August 2021. They have spent twelve months on either a child protection or child in need plan in this time. They have been the subject of multi-agency meetings and regular contact with safeguarding professionals from a range of agencies. It is difficult to quantify what impact these interventions have had on the children. Their experiences of harm and neglect did not significantly change during this time. The multi-agency plans developed following these assessments identify interventions and activity aimed at reducing the risks to the children and are overtly focused on interventions with the parents. Those plans rightly identify what impact is expected for the children if the parents complete those interventions.  Recommendation 6: Children’s Social Care should undertake a sampling of children’s cases where there has been more than three child and family assessments in a 12-month period to assure themselves that assessments are focused on the historic risks for children and young people as well as the presenting incident.    12  4.20 Drug and alcohol misuse  4.21 Initially, the extent and impact of the parents’ alcohol and drug misuse was not fully evaluated, particularly the drug use of Michael.  4.22 Both parents confirmed their use of drugs and alcohol and were open about the impact this had on them individually and as a couple. There was a level of acceptance of the impact their behaviour had on the children, particularly for Child O who would have to look after their younger siblings when they were ‘coming down’.  Michael reported low level cocaine use up to the death of a close family member which then significantly increased into a daily use at the cost of over £50 per day. He reported that he was in significant drug debt but was not at risk of harm from dealers as a result. The amounts of cocaine described by Michael are believed to be excessive for someone’s daily use and there were discussions about whether Michael was allegedly also dealing drugs.  4.23 Jill reported that the family did not have any money and she would take out money from accounts so the family could buy food. Practitioners working with the family gave no indication that the family were deprived of money or goods. 4.24 Following the child and family assessment completed by Children’s Social Care in December 2020, the Social Worker reported that Michael was planning to seek support for his drug use from the Addiction Recovery Community near to his birth mother’s address. This was not evidenced in the subsequent plan and no practitioner followed up Michael’s attendance. The expectation that Michael would proactively take action to address his drug use and self-refer for support was not challenged within the professional network and Michael did not attend any treatment programme. Michael stated that he had no time to attend treatment as he was working full time. Michael was frustrated that no services were available at weekends and felt this to be a gap for those who work full time during the week. He is now engaging with drug and alcohol services in the prison.  Learning Point: When there are recommendations for parents to self-refer to services, there needs to be a plan in place to evaluate attendance and efficacy.   4.25 Jill reported that there were periods when she and Michael had a loving and caring relationship. She reported Michael was drinking and using cocaine throughout their time together but this increased when he was arrested for the alleged sexual assault in December 2019. Jill reported that Michael would come home each evening after work after 10pm and would drink and take cocaine before bed avoiding the meals Jill had prepared. She stated that she developed a routine where all the children were in bed by 9/10pm to avoid any confrontation that they could witness. She stated that Michael would line up several lines of cocaine on the mantlepiece and snort those throughout the late evening. Jill reported that the following morning she would be up at 5am to bleach and clean the house so that the children had no visual signs of Michael’s drug and alcohol use. This was confirmed via webcam footage located by the Police of Jill clearing up after Michael.  4.26 Jill told the report author that she used cocaine rarely and could only recall taking cocaine twice. Jill explained that she took cocaine to ‘try to be supportive to Michael’, yet it is not clear why this was the case. Substance misuse workers believe Jill’s cocaine use to be far higher than she reported. Jill did use alcohol and would drink   13 with Michael in the evenings and she reported that the children would always be in bed when the couple used drink or drugs. Jill’s parents believe that Michael was adding cocaine to Jill’s food but there is no evidence of this. Jill described having concerns about the marriage and how it could continue in this way. Jill described her increased use of alcohol as a ‘coping strategy’. This was confirmed by the substance misuse worker. Michael reports that Jill’s alcohol use was significant and that she would excessively drink at all times of the day. 4.27 Jill’s own alcohol use increased from May 2021 and has been a consistent feature in assessments up to the incident in August. Her increasing alcohol use and drug use was the subject of regular testing. The evidence available indicated that Jill tested positive for cocaine on three occasions between May and July 2021. The last test before the incident in August took place in mid-July. This was negative. There was a failed visit recorded on the same day as the incident in August but there is no record as to the reasons for this. More significantly and with possibly less focus, was Jill’s use of alcohol. This was far more significant than her cocaine use but was not prioritised over her cocaine use.  4.28 As part of the Family Safeguarding Model in the local authority, Children’s Social Care worked alongside colleagues from Adult Services who provided drug testing and support for Jill from May 2021after the incident where Jill arrived at school under the influence of drugs and alcohol. The substance misuse worker began an assessment of Jill and this concluded in July 2021 with a proposed support and reduction plan. This support was only put in place following the school incident and it is not clear why substance misuse workers were not involved previously with the family given the history.  4.29 The school described Jill as ‘incredibly embarrassed’ about her presentation at the school and regularly apologised to school staff for her behaviour.  4.30 There was regular liaison between the adult and children’s practitioners and joint supervision was in place. There were joint visits made to the family home by the Social Worker and the Adult Substance Misuse Worker. The Adult Substance Misuse Worker was of the view that Jill was using cocaine much more than she admitted and whilst she was amenable to drug testing initially, Jill became more ‘oppositional’ over time. Substance Misuse Workers attempted to engage Jill in alcohol safety planning and a reduction plan. It was felt that Jill was not being honest with professionals and they did question whether she was not able to talk ‘freely’. This did not result in any more investigative questions about her relationship and her experiences of domestic abuse.  Michael did not engage with any ongoing drug testing despite requests for doing so.  4.31 Alongside this, Jill was referred, through the Family Safeguarding Model, to qualified mental health practitioners who are seconded from health into the multi-agency teams. All the contact with Jill was virtual and she was not able to engage with this support and her case was closed.  4.32 This presents a challenge to joint working between Adults and Children’s Services as threshold, policy and practice remains different for adults and children. Jill was closed to the Substance Misuse Service on the 18 August 2021 due to her hospital admission. The legal and procedural arrangements differ in Adult’s and Children’s Services and non-engagement can be a precursor to case closure which might contradict the approach and risks highlighted by Children’s Social Care.    14 4.33 Children’s Social Care requested drug tests or breathalysers as a way of monitoring adult behaviour. It is not normal practice in the Substance Misuse Service and these are normally more ‘random’. These tests often mean adults can be reluctant to engage as they do feel ‘judged’ about their drug or alcohol use.  4.34 There was an overt focus on testing Jill for cocaine and alcohol and despite agencies knowing of Michael’s own drug use, it is not clear why the safeguarding partners did not feel it necessary to understand more about Michael’s substance misuse, which was by far more serious at the time. As Jill was the main carer, she became the focus of the drug and alcohol testing. Michael’s role, influence and behaviour did not seem to be considered as a risk factor and potentially a pre-cursor to Jill’s increased use of alcohol.    Learning point: Supervision should consider gender bias and ensure that discussions focus on the risks presented by both parents.   4.35 Domestic abuse 4.36 There is information that Jill experienced domestic abuse from a previous relationship in her teenage years.  4.37 Records indicate that there were serious incidents of domestic abuse perpetrated by Michael dating back to 2008. He was convicted in 2008 and in 2009 for assaults on a female and in 2011 was convicted of 4 counts of battery and criminal damage on Jill’s parents and brother. Michael caused injuries to Child O on at least 2 occasions. Jill herself reported that Michael physically assaulted her soon after the birth of Child O. There were third party disclosures of domestic abuse but not an extensive history of reported incidents by Jill. Jill never supported Police action against Michael.  4.38 Both parents do report periods of stability and limited physical violence at times in their relationship and there is a period between 2015 and 2018 where there are no reported incidents of violence. This is surprising given the history and experiences of the family.  4.39 There was a pattern of Michael leaving the family home following domestic abuse incidents, sometimes at the request of safeguarding agencies and the court and returning to his birth parents’ address. This was considered an effective safety plan but there was ongoing evidence that Michael returned to the family address and this was with agency knowledge. The relationship between Jill and Michael continued and despite this significant history, Jill’s vulnerability to domestic abuse was not risk assessed. There is indicative evidence that agencies knew tacitly that Michael was living in the family home, yet there were no subsequent risk assessments evidenced and no sense of professional concern that he had returned to the family home. The level of acceptance of this arrangement without risk assessment raises concerns about the weight given to the domestic abuse perpetrated by Michael and the impact this had on the children.  Recommendation 7: Child Protection Plans, Child in Need Plans and Early Help Plans need to reflect the actions that safeguarding agencies will take if parental relationships and contact is resumed without formal agreement. This is particularly the case, where there is evidence of significantly highlighted risks to the other parent and/or children.     15 4.40 It was reported by Jill’s parents that Jill was fleeing domestic abuse perpetrated by Michael on the 6 March 2020, when she had driven her car under the influence of alcohol. The Police report states that Jill had been ‘celebrating’ the night before with Michael following his ‘release from the investigation for which he was falsely accused’.  The two domestic abuse incidents in November 2020 did prompt the completion of a DASH risk assessment11 and Jill was ‘graded at standard risk for domestic abuse’ in the first and medium risk in the second. Michael was arrested but, due to there being insufficient evidence, no further action was taken. The three children were present at this incident and the children were referred to Children’s Social Care. The information recorded on the Police systems, Niche, had little detail about the children including no detail of their previous Child protection status.  4.41 A ‘Risk Management Occurrence’ (RMO) was generated automatically via the self-populating computer systems in the MASH indicating the need for ongoing risk management and victim safety planning. This information was shared with Children’s Social Care yet there is no documented evidence that safety planning was undertaken with Jill.  4.42 The commissioned service providing enhanced safety planning with domestic abuse survivors were struggling to provide the service at the time. They have since been decommissioned.  4.43 Thames Valley Police (TVP) have since identified that medium risk domestic abuse RMO’s are not owned by individual officers and therefore no on-going risk management takes place. The work regarding all RMOs (not just domestic abuse) is being undertaken by the TVP Policing Strategy Unit (PSU). The PSU are proposing that the current RMO system for Medium Risk Domestic Abuse will be replaced with a standardised use of each Local Police Area’s (LPA) Multi-Agency Tasking and Coordination (MATAC) function. A coordinator in each county will review and manage cases with more problematic risk according to a Recency, Frequency, Gravity and Serial matrix. This change would represent a more focused, risk-based approach to Medium Risk Domestic Abuse cases.  4.44 TVP are proposing that the DOM5/DASH model for assessing risk in domestic abuse cases, be replaced with a new model, the Domestic Abuse Risk Assessment (DARA) which is seen to be more effective than the existing models in identifying coercive control. The DARA is recommended by The College of Policing and the National Police Chief’s Council.  4.45 TVP are to move towards the use of the ‘Victim’s First Hub’ to provide information and support for Medium Risk Domestic Abuse victims. It is proposed that by March 2024 Victim’s First will be contacting all victims of domestic abuse regardless of consent, effectively making the service an ‘opt out’ service rather than one requiring consent.  4.46 In late November 2020 following the two recorded incidents of domestic abuse, Jill asked Michael to leave the family home and Michael had self-reported the regret he had felt after the assaults on Jill. Both Michael and Jill self-reported that they would both comply with the plan for Michael to live with his mother and would abide by contact arrangements with the children. The child and family assessment undertaken by Children’s Social Care following these incidents concludes that ‘without Michael in  11 The Domestic Abuse, Stalking and Honour Based Violence (DASH 2009) Risk Identification, Assessment and Management Model was implemented across all Police services in the UK from March 2009.    16 the house, the children are safe and appear to feel secure, their basic needs are met and their well-being is maintained’. A child in need plan was recommended following this. Jill presented at school with facial injuries and was open about who caused them, however, Jill reiterated that Michael needed help. The school offered support to Jill which was appreciative.  4.47 There are no assurance methods put in place to monitor Michael’s attendance in the family home and, as was the case in 2012, he slowly returned to the family home with the knowledge of professionals.  4.48 The subsequent child and family assessments completed make references to the need for ‘clarity’ as to whether Michael has returned to the family home when there is clear evidence from elsewhere (school and the children’s reporting) that he has done so.  4.49 For many women and children, violence continues or intensifies after separation12 and it is recognised that children living with post-separation violence maybe the most distressed in the population13. Social Workers need guidance, support, and effective supervision to ensure that enforced separation does not exacerbate the risks to women and their children.   Learning Point: There is evidence to suggest that the domestic abuse perpetrator leaving the relationship and/or the family home heightens to the risks to the survivor and their children. All agencies working with children and young people would benefit from hearing from the voices of survivors who have experienced domestic abuse and their experiences of statutory interventions.  4.50 Jill explained to the report author that Michael would call her names daily but would become more physically aggressive after a ‘come down’ from cocaine use. She described having to ‘walk on eggshells’ when he returned home after work and would make a point of ensuring all the children were in bed to avoid confrontation. She reported wanting to protect the children from his violence. Jill clearly outlined, which was supported by other information, how she effectively ‘self-safety planned’ when Michael returned home each evening. 4.51 Jill indicated that she had intended to leave Michael and this, in her view, prompted his violence on the evening in August 2021 that led to this review. Michael believes Jill was having another relationship which prompted his violence.  4.52 Regardless of the reasons, Jill suffered significant injuries that evening in a prolonged and sustained assault. Michael’s behaviour that evening cannot be explained by a ‘come down’ from cocaine. He was lucid enough to remove all communication methods to enable no contact with emergency services and at times reportedly tended to her injuries. His level of violence that evening and overnight suggests his intention to seriously harm or kill Jill. The fact that Child O was able to call for help the following morning may have prevented her mother’s death.  4.53 There was a chronology available to professionals highlighting the domestic abuse in the family home and this appeared to carry less weight in terms of risk than the drug  12 Routes to Safety: Protection Issues Facing Abused Women and Children and the Role of Outreach Services, Bristol, Women’s Aid. Humphreys & Thiara (2002) 13 Buchanan, A., Hunt, J., Bretherton, H. and Bream, V. (2001) Families in Conflict: Perspectives of Children and Parents in the Family Court Welfare Service, Bristol, Policy Press    17 and alcohol use and the sexual abuse concerns raised. The fact that Michael had not completed any work to address his behaviour was ‘skirted over’ in assessments and whilst not commented upon in the analysis of chronologies, some elements of ‘victim blaming’ was evident regarding the expectations placed upon Jill. Whilst Jill continued to have significant issues herself regarding alcohol and some drug misuse, it is difficult to evidence how her situation was understood in the context of a violent and abusive relationship and what methods she chose to manage her situation. With no expectations placed upon Michael to address his behaviour, Jill has had to consistently ‘prove’ herself to safeguarding agencies. This has impacted on her emotionally and mentally.  4.54 This does not deny how much of Jill’s own parenting behaviour has impacted on the children but it goes some way to explain how challenging she found everyday life and there was not a great deal of professional empathy evidenced for this. There was evidence that Jill was complicit in telling untruths to professional agencies and she hid the fact that Michael had returned to the family home yet this had to be seen in context.  4.55 Child O had remained consistently protective of Michael despite the experiences of them as a family. This has changed since the incident in August. There is evidence to suggest that Child O has been manipulated into the belief that midwives caused the significant injuries to them as a baby. There is a high likelihood that Michael manipulated Child O with either threats of violence or inducements that reflects his relationship with them. Child O has developed victim blaming behaviours towards their mother. However, they are likely to have felt very let down by both parents and this behaviour may be a normal and natural response given their experiences.  4.56 Michael did not engage in any interventions proposed. Jill did cooperate with some of the interventions yet the family found it hard to engage with support services. Covid-19 did impact on the services and interventions proposed and the virtual nature of visiting and support arrangements presented their own challenges. Jill would maintain that she was the parent that had to ‘prove herself’ to agencies and Michael was given no responsibility.  4.57 Coercive control is an underlying feature of domestic abuse yet this has not been considered in the assessments of the children or in Jill’s circumstances. Whilst she did not disclose this information at the time, all professionals should be cognisant of the high likelihood of this if physical abuse allegations are present. Professionals should ask questions about this issue. The climate of fear in the family home that emerged following the incident in August suggests that questions were not asked or professional hypotheses made about what life could have been like for the children in the household.   4.58 Children’s Social Care 4.59 Children’s Social Care have implemented the Family Safeguarding Model14 of social work practice. The design of the teams is highlighted in the appendix. Services supporting the family as part of this model were a substance misuse worker, a mental  14 Developed in Hertfordshire, Family Safeguarding is a model of system change where specialist adult practitioners are embedded within Family Safeguarding teams of Social Workers. The intervention supports a whole system change to a local authority’s child protection approach for children up to adolescence, focusing on supporting the needs of children and adults in order that children can safely remain within their families.     18 health practitioner and a worker supporting drug testing. Whilst domestic abuse ‘Victim Practitioners’ were available, as the domestic abuse allegations were either withdrawn or denied by Jill, a referral was never made. Perpetrator work was proposed for Michael but this became a self-referral process rather than an active intervention. This enabled Michael to absolve himself from taking responsibility for seeking support and his actions. It is understood there were discussions held with Michael about his involvement in services at the time, but these were never followed up with clarification of attendance and engagement.  4.60 There was evidence of regular group supervision with the practitioners involved with the family and a real positive sense of working together. All practitioners attended core group meetings, Child protection planning meetings and child in need meetings. Practitioners highly valued this joint working approach.   4.61 The children’s Social Worker was allocated the children in early 2021 and has been a consistent professional in the children’s lives. They often would see the children in school. The Social Worker reported that the domestic abuse in the family was minimised by both parents and the focus was initially the sexual abuse allegations against Michael, the sexual exploitation of Child O and then the drug and alcohol misuse of Jill. These separate yet inter-linked concerns for the children and adults were never truly seen in a historic context of ongoing abuse and harm. It was believed there was never enough evidence of harm to progress to legal intervention with the family and the only ‘trigger’ was evidence of Jill’s cocaine use.  4.62 It was reported that the local authority moved away from the ‘pure Family Safeguarding Model’ as caseloads in the teams became very high and, reportedly, the individuals working in the teams remained working in their professional silos. Children’s Social Care were losing staff and this exacerbated the situation. The children should have been visited weekly but this never materialised. At the time the children were open to Children’s Social Care, the head of service was not in work and managers were expected to seek direction from other senior leaders in the organisation. This did lead to fractured decision making particularly when different directions were given by different senior leaders.  There was a pressure on front line managers to close children’s cases. Managers were instructed to close children’s case files without interventions being concluded and work with families completed. Updating assessments would evidence the need for case closure. Jill had ‘attended’ an online parenting course, the children were presenting as ‘clean and tidy’ and were reporting no worries.  It may have been evident to senior leaders that this was one such case.  Learning Point: Attendance at groups or individual support and advice sessions by parents should be evaluated in terms of effective impact and change on parental behaviour rather than attendance being evidence of parental change.   4.63 On occasions when Children’s Social Care became involved with the family, there was evidence that the parents had been proactive and were taking steps to safeguard the children by Michael moving out of the property and living with his mother. This was viewed as effective safety planning. At no stage was there consideration given to visiting the family unannounced and at evenings or weekends. This would have found Michael more likely than not at the family home. It was clear from the point of Children’s Social Care involvement dating back to 2007, that the   19 couple misled agencies into believing they were living separately. As Michael gradually moved back into the family home, Children’s Social Care and other safeguarding agencies chose not to reassess the risks and accepted this arrangement without question. This had been a pattern of behaviour adopted by the couple throughout Children’s Social Care involvement.  4.64 The proactive non-engagement of Michael in any visits, meetings and interventions with the Social Worker was never challenged and his reasons for not engaging not questioned. There was equally limited flexibility to accommodate his engagement in any meaningful work. This resulted in Jill being the focus of intervention.    4.65 Agencies would confirm that they only knew what life was like for the children in the household at a ‘surface level’, partly because of the ability of professionals to engage the family and the ‘acceptance’ of active non-compliance. Whilst the joint working approach is highly valued by practitioners, it is less clear in this case how that joint working impacted on the outcomes for the children.  4.66 There was a subsequent delay in progressing court action for the children following the incident in August 2021 despite a court statement being available the following day. The legal status of the children was not secured for some weeks despite no adult acting with parental responsibility and the Team Manager recalls receiving conflicting legal advice on the matter.  Whilst this post-dates the review, Children’s Social Care would benefit from reviewing the process of decision making and the delays in taking effective action to safeguard the children following the incident in August 2021.   4.67 Multi-agency Child Protection Arrangements 4.68 The first Child Protection Conference was in person but soon after the first pandemic lockdown, the subsequent conferences were virtual. The Child Protection Conference Chair was new to the role and was appointed during the lockdown and had to adapt quickly to a virtual style of working. This presented all practitioners with unknown and new challenges. It was and has been very demanding to undertake these complex meetings via video and telephone and particularly for the family proactively to engage fully in the process. Child O did give their views to the virtual review conference (which was via telephone only) and was defending Michael throughout. What was not known, was whether he was in the room at the time.   4.69 The decision by the virtual Review Child Protection Conference in April 2020, to end the child protection plan after just three months was ratified by the head of service in Children’s Social Care and was a unanimous decision. This judgment, based on the decision by Thames Valley Police to not progress a prosecution of Michael for sexual activity with a child, was not challenged by any agency, despite the significant history and a disclosure from Child P that they were physically hit by Michael and was an over reliance on the Police taking no further action. A repeat child protection plan audit was undertaken on this case and the audit did highlight how this may have influenced decision making.  Significantly, the Police also did not provide information to the conference that Jill had been arrested for drink driving. This contrasts with the information that school attendance had improved and the children presented as ‘happy’.   4.70 The second period of child protection planning occurred following concerns about Child O’s sexual exploitation in May 2021. There was difficulty in categorising the main risks to the children and this was the subject of debate in the conference. The   20 history and accumulative concerns are considered at this conference.  The danger statement is far more comprehensive and captures the risks from the chronology of concerns, the domestic abuse, the lack of meaningful engagement with the family, Michael breaching his bail conditions, proactive non-engagement of Michael, his potential return to the family home and the unassessed risks, Child O’s vulnerability to child sexual exploitation, the children’s poor school attendance and Jill’s mental health. This conference requested clarification of whether Michael had indeed engaged with Addiction Recovery Community. Jill’s drug and alcohol use only prompted changes to the plan when she presented at school under the influence. There was evidence of regular core group meetings and information sharing arrangements were said to work well. There was praise for the Social Worker from partner agencies who they felt communicated well and shared information appropriately.  4.71 There is an unhelpful focus on the ‘incidents’ that led to the initial child protection plans and not necessarily a wider consideration of the other risk factors or evidenced in the history. The Child Protection Conference Service did raise this with Team Managers that the assessments were overly focused on an incident-based assessment and analysis. A holistic picture of the children’s experiences was less considered than the incident that led to the child protection conference. Equally, the Child Protection Conference Chair (who was the Service Lead for the Child Protection Conference Service standing in for the original chair) did express their concerns to the Social Worker and Team Manager in July 2021 following discussions in the Child Protection Conference about the parents ‘engagement’. They felt that the risks had increased and this was not possibly reflected in the social work report to the conference. They acknowledge that there is a need to tighten the transition point when Child Protection Case Conference Chairs cover for each other. 4.72 They recommended that legal advice was sought and consideration of the Public Law Outline (PLO)15 as Jill had also had a recent positive drug test for cocaine and followed this up with a written email following the conference. There is no evidence to indicate that this was responded to by the team manager and clearly no decision was made to escalate the children’s case to the PLO.  4.73 There is an effective escalation process in place for Child Protection Conference Chairs to raise concerns about children’s planning and reportedly this works effectively. There is a need for child protection chairs to follow up and follow through with their concerns raised to Social Workers and their Managers.  4.74 It is worthy of note that some agencies, particularly the school, were not aware of the significant history of the children and this highlights the need to ensure all agencies in the safeguarding system are aware of the chronology in relation to children and young people. 4.75 Michael was not registered at the same GP surgery as the rest of the family therefore his GP was not receiving the same requests for information or being informed of the safeguarding concerns and the plans for the children. A GP Practice is unable to check or add information to records for patients not registered with them. Vital details  15 The Public Law Outline (PLO) process takes place when the Local Authority is concerned about a child’s wellbeing and unless positive steps are taken to address and alleviate those concerns, the Local Authority may consider making an application to the Court. The PLO process is therefore the last opportunity for parents to make improvements to their parenting before care proceedings are issued.     21 to manage the risks and needs of the children was not requested or shared with Michael’s GP. Learning Point: Not all family members may be registered at the same GP practice. When requesting or sharing information with GPs, safeguarding agencies need to ensure that they have the correct details for each family member and that all the individual GP Practices are contacted and information shared.    4.76 Focusing on the parenting of mothers 4.77 Jill was referred to in discussions and reports as occasionally very hostile and challenging to professionals. Agencies who struggled to engage her would refer to her ‘disguised compliance’. This unhelpful terminology gives no consideration to Jill’s context. Her ongoing defence of Michael was misunderstood and the more agencies focused on her parenting, the more she felt under pressure and potentially became hostile.  4.78 There was evidence that Jill struggled in her parenting role and behaved in ways that would have placed the children at risk of harm. This was balanced against evidence that she was actively protecting the children from harm. Jill was parenting from a place of trauma herself and had developed ways of safeguarding herself and the children. Jill had often presented to practitioners as angry and aggressive but she did cooperate occasionally with the interventions and support offered. Studies repeatedly show that child protection work tends to focus on mothers, (Strega et al, 2008)16. Michael himself felt that agencies failed to engage him to get the help he needed. He knew that placing the responsibility on himself to seek help was a ‘non-starter’.  There was no meaningful work undertaken with Michael by professionals and no professional appeared to hold him to account for his lack of engagement or his behaviour in the family home. The focus clearly shifted to the behaviour and parenting of Jill and this was reinforced following the incident at school in May 2021.  4.79 The child protection practice in this case reflected the invisibility of Michael and the accountability of Jill. There was a sense that Jill oversaw the safety of the children and when she ‘failed’ to do so, there was proactive intervention to place the children elsewhere. It is likely that child protection practice was focused on the parent who could engage and was more accessible. One professional noted that ‘Michael was out of sight and out of mind’. Despite this, Michael maintained his relationship with Jill and was visiting and staying at the family home with the knowledge of professionals. This approach had worked before for Michael and was effective again. Slowly he began returning to the family without question or risk assessment. No doubt Jill colluded with Michael to ensure agencies were not aware of their circumstances, yet this behaviour must be placed into the context of living in an abusive and coercively controlling relationship for many years. Information shared by Child O reveals the climate of fear in the household. Whilst interventions were focused on effective drug treatments and support, increasing knowledge, enhancing parenting skills and supporting Jill overcome personal challenges, these were attempted in the context of ongoing harm and abuse. Her ability to engage in such work was not considered in that context.   16 Strega, S; Fleet, C; Brown, L; Dominelli, L; Callahan, M and Walmsley, C (2008) Connecting father absence and mother blame in child welfare policies and practice, Children and Youth Services Review, Volume 30, pp705-716    22 4.80 The level of self-reporting from the parents, particularly Jill, was not triangulated with other evidence and was accepted by the professional network. The crucial aspect of following up and following through on actions was lost.  4.81 Farmer and Owen’s study17 into child protection clearly showed that in two parent families the focus of the intervention tended to switch from the abusing father to the mother.  The process is also evidenced in the Dartington Social Research Unit (1995) ‘Messages from Research’. As Michael was also not allegedly in the family home at times, Jill became the focus of care, protection, and support.  4.82 The maternal grandparents have played a significant role in the care of the children and they may have been able to provide a greater role in the ongoing safety of the children. It highlights the need to involve appropriately the wider family and friends network in the safety planning for the children.    4.83 Impact of the Covid-19 pandemic 4.84 The COVID-19 pandemic heightened concerns for people who, during lockdowns, were trapped at home with abusive partners with limited access to their support network and specialist services. The children became subject to child protection plans just prior to the pandemic and the subsequent lockdowns. The pandemic lockdowns prevented regular visiting and observation of the family home. It was suggested that the parents ‘utilised’ the pandemic controls as a way of avoiding scrutiny of the children and the family circumstances. The process of ‘digital’ scrutiny emerged over time but was beset with challenges about how risk could be assessed and risk judgements made in the absence of direct physical contact with the children and adults. It was suggested that Jill found the process of telephone and video calling far easier to divert agencies away from the ongoing risks and needs of the children and to avoid contact.  4.85 The child protection conference service has led on reinstating face to face child protection conferences since the pandemic and are clear that those arrangements support better risk assessment and planning.  4.86 Post Covid-19 there has been a significant increase in the numbers of children subject to child protection planning and this has added pressure in the safeguarding system.  4.87 Families who live in ‘digital poverty’ and the associated costs of electricity and phone charges are discriminated against by agencies’ insistence that complex and challenging meetings are held virtually. In addition, the ability to risk assess is diminished by practitioners being unable to see the presentation of adults and children. These virtual meetings may prove productive for safeguarding agencies as they are easier to attend and partake yet there needs to be a better understanding on the impact of families by continuing this approach to practice.  4.88 The children did not attend school during the lockdowns yet were flagged as vulnerable learners and being subject to child protection interventions did mean that they were expected to attend. This exacerbated an already challenging issue for the children in terms of school attendance. Their regular absences have affected their educational development over time.   17 Farmer, E., & Owen, M. (1995). Child protection practice: Private risk and public remedies—Decision making, intervention and outcomes. London: Protection Work HMSO.   23 4.89 In the second lockdown in January 2021, the Designated Safeguarding Lead at Child O’s school submitted a ‘vulnerable attendance action plan’ to the local authority and the Social Worker due to Child O not attending school and initially declining a place at school. This was a requirement of all school in the local authority at the time. Online lessons and tutor registrations were provided. This was monitored daily and Child O did not attend any lesson or tutor registration. 4.90 Child O’s school, alongside Child P and Q’s primary school, worked together to mitigate absences, including the provision of Covid-19 tests.   4.91 Working with families who struggle to engage 4.92 This has been a consistent theme in this case and there has been overt non-compliance at times from both parents. This compliance has not been disguised and agencies were fully aware of it. It has been quoted many times in discussions and reports. The challenge for practitioners was whether this non-compliance was ‘significant enough’ to use legal powers to address the risks. There was a level of ‘acceptance’ at this level of engagement, particularly with Michael. Likewise, it is it is crucial to shift the language relating to a lack of engagement. The focus needs to be on how agencies proactively reached out to the children and adults to ensure that their approaches are accessible and that any potential barriers to support are well understood. This certainly reflects the view of Michael who described feeling a lack of understanding and support.  4.93 Eileen Munro’s 2011 review18 into child protection emphasises the importance on the building of relationships with parents and the benefit for those parents in feeling better understood. The parents have experienced safeguarding professionals in their lives since 2007. They would have experienced the power and authority of those professionals for many years and developed ways of avoiding professional scrutiny. Relationships are a crucial part of effecting change and relationship‐based practice recognises that people want to be understood and be treated as an individual in their own right rather than parents simply being seen as “a means to the end of protecting their children from harm” (Turney 2012)19.  4.94 Motivational interviewing is a method used as part of the Family Safeguarding Model and is described as a collaborative conversation style for strengthening a person’s own motivation and commitment to change. There is limited evidence that this approach was used in supporting Jill and Michael in making changes to safeguard the children. It is again based on the relationship approach to practice and seeks to engage the parent first rather than action to address risk and need.  4.95 The maternal grandparents have raised the issue of the engagement of the wider family in safeguarding both Jill and the children. They are of the view that they should have been involved at an earlier stage when concerns first came to light in December 2019. They report they have only become aware of the history, risks and needs of the children and Jill because of being party to the family law care proceedings. They firmly believe that if they had been engaged at an earlier stage in discussions, they could have been part of safety planning for Jill and the children. They have been frustrated by the statements regarding the restrictions of confidentiality and cannot understand how this can be a barrier to effective wider family support. The  18 Munro, E (2011) Munro review of Child Protection: Final report, a child-centred system. England: The Stationary Office 19 Turney D (2012) ‘A relationship-based approach to engaging involuntary clients: The contribution of recognition theory‘. Child & Family Social Work, 17(2), 149-159   24 Government has produced guidance for practitioners on information sharing and it may well be worth re-visiting this in the local authority20. 4.96 The Independent Review of Children’s Social Care published in May 2022, clearly lays out the role of wider family members in the care and support of children, “When considering the best option for a child the system too often overlooks the most immediate and closest solution by not spending enough time and effort finding family members that could provide a safe, stable and loving home. Despite statutory guidance recommending the use of Family Group Conferencing (Department for Education, 2014), too often this does not happen at all before a child is taken into care or happens too late in the process when care is rapidly becoming the only option21”.  Recommendation 8: The Safeguarding Board should review the current policy and procedures regarding information sharing. This is to assure themselves that it is clear to practitioners that as risks escalate for children and young people, there is proportionate and legally appropriate information sharing in place with wider family members.   Learning Point: Children’s Social Care should remind practitioners of the need for Family Group Conferences at an early stage of family involvement to ensure that wider family members are engaged appropriately and with the necessary information sharing arrangements agreed between family members.   Recommendation 9: The Safeguarding Partners are recommended to include the concepts of “overt non-compliance” as well as disguised compliance into future training for professionals. Disguised compliance should be explained in the family context rather than a ‘cover all’ for those families who struggle to engage.   Good practice  5.1 The children’s schools have provided comprehensive and detailed chronologies regarding the children and it emphasises the need to ensure that schools are proactively involved in the support and planning for children at risk of harm. Both secondary and primary schools have liaised well together and with Children’s Social Care to ensure appropriate information was shared and risks understood. They have continued to provide the children with the consistency they have needed given their significantly disrupted care experience.  5.2 There have been positive views of the Social Worker and how they engaged with the safeguarding network, sharing appropriate information and being a consistent person in the children’s lives. 5.3 The Family Safeguarding Model has been praised by those who are directly involved with the children and their parents. The cross agency working and different agency understanding of the family has been valued. There has been consistent group supervision to consider the interventions and risks to the family.   20 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1062969/Information_sharing_advice_practitioners_safeguarding_services.pdf 21 https://childrenssocialcare.independent-review.uk/wp-content/uploads/2022/05/The-independent-review-of-childrens-social-care-Final-report.pdf   25 5.4 The conference chair and service lead recognised the risks and escalated their concerns following the child protection review conference.  Conclusion 6.1 The children have experienced significant and prolonged harm and are now safe in the care of family members. The experiences of August 2021 and what they witnessed will no doubt impact them as children as they grow and as adults and there needs reassurance that they will receive the therapeutic interventions needed in the long term. 6.2 No one professional could have predicted that Michael would carry out such a sustained and violent attack on Jill that evening and the following morning or that he would prevent the children from accessing medical support for their mother. The level of persistent violence perpetrated against Jill, together with the perverse care taken by Michael to address her injuries that night, was sickening. To place the children through that experience indicated Michael’s complete lack of empathy, understanding and care for the children.  6.3 The history of these children is significant. The details of Michael’s previous behaviour towards Child O and on at least two occasions significantly injuring them, was a predictor to the level of violence and aggression of which he was capable. Coupled with the ongoing domestic violence and coercive control perpetrated towards Jill there were significant risk factors. Agencies knew that he had undertaken no interventions to address that behaviour and allowed this to happen without challenge. His slow return to the family home on several occasions went without risk assessment.  The focus of ‘incidents’ in the children’s lives leading to interventions from safeguarding agencies detracted from the overall understanding of what life had been like for these children.  6.4 There were periods in this family where the situation was settled and the children received adequate care.  6.5 The overt focus on Jill’s drug and alcohol use detracted from the more significant risk factors that were evident in this case. At no stage did agencies view Jill as a victim in her own right.  6.6 The children’s lived experience was not well considered and whilst there was evidence of harm and there were opportunities to engage with the children, there was little evidence that professionals had a good understanding of their experiences at home. They gave clear hints to professionals about their experiences yet they were not considered in the light of the history. There is no sense that professionals really got alongside the children and Jill to enable trusting and safe relationships. The more Jill was considered a risk, the more she withdrew from agency support.  6.7 The pandemic was prevalent during this period of the review and there was very limited contact with the children and the parents. This influenced assessment and judgements of risk. Agencies need to return to face-to-face meetings and contacts with children and families.  6.8 The parents overt non-compliance with safeguarding professionals went unchallenged and as risks escalated there were protracted conversations about threshold for interventions, particularly legal intervention. This hierarchal approach to intervening in family life needs challenging. Michael had successfully ensured that he   26 had returned to the family home way before considerations were given to legal action.  6.9 Focusing on and potentially blaming women for failing to safeguard their children without full consideration of their lived experience needs to be challenged. Group supervision sessions would have benefitted from looking at the situation through the eyes of Jill as well as the children.  6.10 Michael’s significant drug use was not sufficiently considered. His drug use was not the focus of testing, primarily as he was considered not to be living in the family home even though he clearly was.   6.11 The Family Safeguarding Model is well evidenced as being successful in addressing needs and risks for children. Information sharing was not as robust outside of the practitioners involved in this practice model and there was evidence of some information from the Police not reaching the safeguarding network. Alongside this, more efforts should have been made to develop a relationship with Jill which may have been more effective in safeguarding the children.  6.12 The children’s lived experiences will significantly impact on their emotional development and they are likely to display behaviours that reflect their trauma. The three children deserve and will need ongoing therapeutic support into adulthood and this needs to be provided to them and those caring for them.       27 Appendix  Family Safeguarding Teams are made up of: • Social Workers, family workers and parenting assessors - working directly with parents and children • Domestic abuse victim practitioners - working with victims of domestic abuse, helping them to recognise abuse and support them to make changes to protect their children and themselves • Domestic abuse perpetrator practitioners - working with perpetrators of domestic abuse, helping them to recognise the impact of their actions and find ways to stabilise their relationships and keep their children safe • Recovery workers - working with adults who are experiencing difficulties with drugs or alcohol, supporting them to make positive lifestyle changes and help them to care for their children • Mental health practitioners - working with parents who are experiencing mental health difficulties • Clinical psychologists - working with parents using cognitive behavioural techniques (CBT) and dialectical behaviour therapy (DBT), as well as looking at different aspects of parenting  