Death of a 4-week-old boy in July 2020 attributed to non-accidental head injuries. Learning includes: the family should have continued to receive the right level of support when they were transferred to another local authority; disagreements between local authorities over the transfer and status of the family caused delays in the family receiving the appropriate level of service; housing services not being aware of the neurodiversity and safeguarding needs of the family; lack of communication between mental health services and children's services; bruises or marks observed on a non-mobile baby should have triggered a robust multi agency response. Recommendations include: current approaches to risk assessment through child protection enquiries or child in need processes obtain and take sufficient account of family background and previous experiences such as trauma, neurodiversity, and parental mental health difficulties; strengthening education and training on the think family approach, as well as neurodevelopment disorders and what such difficulties mean for parents' understanding and interpretation of information and advice; raise the role of housing services in statutory child protection processes as an issue of concern with the Child Safeguarding Practice Review Panel, including how housing services share information with partners and how they assess vulnerable families who need accommodation; ensure practitioners understand the significance of bruising in infants and the need to act.
      
 Title:  Baby ‘R’ – local safeguarding practice review. LSCB: Bexley S.H.I.E.L.D. Author: Jane Doherty 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.                           1          Baby ‘R’ - Local Child Safeguarding Practice Review  (Bexley S.H.I.E.L.D.) Reviewer – Jane Doherty – Independent Social Work Consultant               2   1 Introduction  1.1 This Child Safeguarding Practice Review was conducted in response to the death of a 4-week-old baby in 2020 who at the time of his death was subject to a Child Protection Plan in the London Borough of Bexley. Baby R’s parents presented him to hospital with non-accidental head injuries and he died a few days later.  1.2 The family had been known to multi agency child protection services since the birth of Baby R’s older sibling (known in the report as Child S), amid concerns around neglect.  1.3 Baby R’s death was notified to Bexley SHIELD and at a Rapid Review meeting which took place shortly after the baby’s death, members recommended a Local Child Safeguarding Practice Review should take place. They notified the National Panel who agreed with their recommendation.  1.4 The incident led to Child S being placed in foster care and a police investigation commenced.  2 Terms of Reference  2.1 The time period for the review is from July 2019 (a year before the incident to August 2020). This included an expectation that relevant information prior to that would be summarised to add context to the information. Agencies also provided brief information for the period May to July of 2019 as that is when the family first moved out of Bexley to Kent.  2.2 The full Terms of Reference are attached at appendix 1 but the Panel members requested specific information about the following areas.   • The identification and response to risk (individually and on a multi-agency basis) for the parents and the children including the following areas: parenting capacity, mental health, the parents young age and troubled childhoods, learning disability and neurodiversity, drug use, domestic abuse, and resistance to engagement  • Issues arising from diversity    • What was known about father’s other child and how curious were practitioners about this situation, including how agencies ensured that father was engaged in assessments • How did agencies understand the transient nature of this family and how was this dealt with?   • How agencies understood and implemented escalation processes between the local authorities  3  • What impact did COVID 19 have on the circumstances of the child / family and/or on the capacity of services to respond to their needs. • Practitioners’ understanding of policies and procedures and how they support their work – e.g., bruising policy, transfers, escalations, access to previous records and information etc  • Areas of good practice 3 Summary of professional contact  Background history 3.1 Mother experienced early childhood neglect and was in care as a child. She was subsequently adopted into a family where she spent most of her childhood. The adoption broke down when she was in her late teens, and she became Looked After by Croydon Children’s Social Care. She has suffered with poor mental health since she was a teenager and at times expressed suicide ideation. She was diagnosed with a reactive attachment disorder, a moderate social disability and (latterly) autism.  At the time of the incident, she was supported by Croydon’s Leaving Care Service.  3.2 Father is also reported to have experienced disruption in his childhood and was known to Lewisham Children’s Social Care. His parents died when he was a child, and he went to live with an aunt in Bexley.  He was diagnosed with a speech and language disorder, dyslexia, and autism traits in his early teens.  3.3 Mother became pregnant in 2018 with Baby R’s older sibling. He was on a Child Protection Plan (pre-birth) in another London borough and the plan was subsequently transferred to Bexley. The concerns at that time were Mother’s unstable mental health, lack of engagement with ante-natal appointments and poor financial management.  There were worries about how the couple would manage a new-born baby given their own difficulties.   Key Period of Involvement May 2019 – November 2019  Family moved from Bexley to Kent. 3.4 At the start of the period under review the family were living in Kent, having moved from Bexley in May 2019.  Child S had been subject to a Child Protection Plan in Bexley for seven months and remained on the plan until September 2019.  3.5 When the Child Protection Plan in Bexley ended, a referral was made to Kent Children’s Social Care as a Child in Need. The family were offered Early Help services in Kent but despite efforts, after a very short period of intervention the family did not engage.     4  PRACTICE LEARNING POINT  When the Child Protection Plan ended in September 2019, Child S was effectively stepped down to an Early Help Service in Kent which, when the parents declined this, meant that they were without support. The circumstances surrounding the Child Protection Plan being stepped down is elaborated on in paras 4.7 – 4.9.  Good practice would have been to ensure that the family continued to receive the right level of support in transferring of the family from one Local Authority to the other.   Key Period of Intervention 2; December 2019 – March 2020 Kent CSC undertake an assessment/Family move back to Bexley   3.6 In December 2019, Mother’s Leaving Care worker in Croydon made a referral to Kent Children’s Social Care and a family assessment was undertaken under s17. The worker was worried about an arrangement for the older child to go abroad with a family friend had not been well thought through.  She further noted that Mother was pregnant with Baby R and was concerned about how the parents would cope with two very young children.      3.7 Kent’s assessment recommended a Child in Need plan but before this could be implemented, the family moved back to Bexley in March 2020. NB this coincided with the COVID-19 pandemic and the subsequent lockdown which made visiting and supporting the family much more difficult.  3.8 There were disagreements between Bexley and Kent about the status of the family, e.g., Practitioners in Bexley felt that the Child Protection framework was more appropriate than Child in Need. There was subsequently a short delay with the transfer. To avoid further  delay Bexley accepted them as a Child in Need transfer at the end of March 2020.   PRACTICE LEARNING POINTS  The disagreements between Kent and Bexley over the transfer and status of the family caused delays in receiving the appropriate level of service. Good practice was however seen in the second transfer when these were escalated further in line with Kent and Bexley’s escalation protocol. This is discussed in paras 4.1 – 4.4 Housing moves were very difficult for this family, given their needs around neurodiversity and their challenges in making relationships. Good practice would dictate that Housing departments be cognisant of these needs. This family’s needs in terms of neurodiversity and safeguarding were not understood by housing. In addition, their difficulties were exacerbated in March 2020 by the Covid-19 global pandemic. This is discussed in paras 4.13-4.16     5  Key Period of Intervention; April 2020 – June 2020   Family become subject to a second Period of Child Protection Plan 3.9 Amid growing concern about the parents’ capacity to care for Child S and a newborn baby, the Social Work team discussed with the Child Abuse Investigation Team with a view to undertaking s47 enquiries. The police were not in agreement and thought this decision was premature. The assessment continued and support was offered to the family, albeit with limited face to face contact during this early period of lockdown for the United Kingdom.  3.10 In May the couple separated briefly and this caused stress to them both – Mother had contemplated suicide and Father had reportedly ‘hurt himself’. The couple reunited the following day, but a strategy meeting was held and single s47 enquiries were agreed between police and Bexley Children’s Social Care. An Initial Child Protection Conference was booked for early June. This was cancelled due to an administrative problem and took place later that month. Both children were made subject to a Child Protection Plan under the category of emotional abuse.  3.11 In relation to Mother’s suicide ideation, there was some confusion about which service to refer Mother to. This caused a delay to her having an immediate assessment. There was some liaison between Children’s Services and Mental Health Services, but mental health professionals were not involved in the multi-agency meetings about the care of the children. A Family Network Meeting took place Just prior to Baby R’s birth. This was attended by Father’s family and a family friend and good support was offered, especially around the time of the baby’s birth.  3.12 Child R was born in mid June 2020.   PRACTICE LEARNING POINTS  Mental Health services were key for this family given the parents troubled backgrounds and previous difficulties. A holistic service to the family was hampered by the lack of communication between mental health services and children’s services. A more collaborative approach would have meant that services were appraised of each other’s involvement and concerns and joint planning would have been a priority. Mental Health professionals were not part of the core group for this family. This is discussed in paras 4.23– 4.26  The delay to the Child Protection Conference caused by an administrative error, falls short of acceptable standards of practice. This has been addressed with the relevant service as part of the review process and a recommendation is made to ensure that there is appropriate oversight of decisions such as these.     Key Period of Intervention 4: July 2020 - Observation of bruises  3.13 In early July, the health visitor visited the family at home. Whilst there, she observed bruising on Baby R’s left cheek and ear. The parents were unsure how this had happened 6  but thought Child S may have thrown a toy into Baby R’s cot. There was a delay in the health visitor telling the social worker about the injuries but a core group meeting which took place about a week later discussed the bruising. The explanation changed but this was not questioned further.  3.14 In July 2020 – the incident which led to this review unfolded and Child R sadly died.   PRACTICE LEARNING POINT  Best practice for bruises or marks observed on a non-mobile baby is the triggering of a robust multi agency response including s47 enquiries and a Child Protection Medical examination. This did not happen in this instance and the review noted that there was a lack of knowledge among the professional network about the high risks associated with bruises in non-mobile infants. This is discussed in paras 4.17 – 4.22 4 Findings   Transfer of Case responsibility across local authorities for children subject to child protection and child in need plans                     Initial transfer from Bexley to Kent – May 2019 4.1 The panel identified key issues arising from the family’s moves in terms of how services were able to work with them and these are examined in turn in the paragraphs below.   4.2 At the start of the review period (May 2019), Child S was subject to a Child Protection Plan in Bexley under the category of neglect, but the family had moved to Kent.  The Bexley social worker and Bexley health visitor continued to work with the family whilst they were in Kent until September 2019 when the Review Child Protection Conference in Bexley decided to end the Child Protection Plan. Expected practice in this area would be that the family would transfer to the Local Authority in which they were living. Bexley CSC did not inform Kent that a child on a Child Protection Plan was residing in their area so that they could place the child on their temporary register. This would have been an avenue to start the negotiations of transfer at a much earlier stage. It also meant that Child S was not flagged as a child with a Child Protection Plan, had an emergency occurred in Kent.   4.3 According to the case records in both Bexley CSC and Bromley Healthcare, the reason for not transferring in this case was due to Bexley Housing assessing the family’s housing needs, prior to accepting them to be permanently housed. This was delayed and the social work and health visiting teams were cautious in case housing transferred them back to Bexley which was their preferred borough. Part of the reason for the delay was due to the parents not being proactive in submitting the correct paperwork for the housing assessment. Significantly, housing was not party to the safeguarding process.   4.4 At the Review Child Protection Conference, the plan was to transfer to Kent Children’s Services on a Child in Need Plan but the need for this was disputed by Kent Children’s 7  Social Care.  Their view was that Bexley should continue with the Child in Need plan and continue to work with the family across the border.  Bexley however closed the case as the family were no longer living in their borough and Kent declined to accept them as a Child in need.  4.5 This is a complex situation made more complex by the lack of formal procedures about transferring Child in Need cases from one local authority to another especially (as in this case) where the two local authorities do not share a set of child protection procedures. A more child centred approach (and procedurally correct in both local authorities) would have been for Bexley to make a request to Kent for a Transfer in Child Protection Conference soon after the family moved there in May of 2019 regardless of their housing status. There is a clear process to follow in this circumstance and this would have alerted Kent to the family and allowed for some joint planning between the local authorities.  Although the family were placed in temporary accommodation (which is sometimes an argument for not transferring a case), often, this is for lengthy periods of time - ten months in this instance. This family were using local resources in Kent during this period so it would make sense for a transfer to occur.  4.6 Consideration of timing of the transfer and a thought out transition plan was needed for this family. Unfortunately, between the two local authorities, the family were left without support when they declined the offer of Early Help in Kent. Despite many attempts, Kent workers were unable to establish contact and had declined to accept the family on a Child in Need basis.   In this circumstance, it would have been prudent for Bexley along with services in Kent to review their positions and if necessary, use their internal escalation processes to ensure that the family received the right level of support.  4.7 On reviewing the minutes of the Child Protection Conference of September 2019, it is difficult to see the rationale for the decision to ‘step down’. Of the four professionals who attended the meeting, three of them thought that the child protection plan should continue but they were overruled by the Chair. The child protection plan had not been progressed and although there had been some improvements, there was much that was outstanding. Mother did not have mental health support in place and there had been a police call out due to an argument between the parents. Those who knew and worked with the family felt that the parents were very dependent on professionals to organise themselves and that without structured support in place they would struggle to maintain the progress they had made.  The decision was based on the ‘here and now’ rather than considering the history and additional needs of this family.  4.8 It is extremely unusual practice to end a child protection plan without having a clear transition plan of support and this fell short of expectations of good practice.  It is difficult to conclude anything other than the decision being overtly influenced by the fact that the family were no longer living in Bexley, rather than considering who and what service could best support this vulnerable family. Child S’s voice and his lived experience do not come through strongly in this feature of the practice.  4.9 Bexley Children’s Social Care missed another opportunity to revise their plan, when shortly after the Review Child Protection Conference a concern was raised by a member of the network about the ending of the Child Protection Plan. This was good practice on their part.  The decision was reviewed by a manager who upheld the original decision. It 8  is not clear who else was consulted at that time to review the decision, but this was hampered by the premature case closure. The manager did recommend that a handover meeting take place between Bexley and Kent, but this did not happen as there was no practitioner in Kent to handover to.   Second period of transfer from Kent to Bexley March 2020 4.10 The family were offered accommodation back in Bexley (their preferred location) in February 2020. As described in the narrative, Kent Children’s Social Care had conducted a Children and Family Assessment just prior to the move and this necessitated a further transfer from Kent to Bexley Children’s Social Care.  4.11 There was disagreement between the two boroughs about the appropriate framework in which to work with the family. This caused delay to Bexley Children’s Social Care accepting the family as Child in Need. Kent’s practitioners escalated the difficulties, and this was resolved between the two relevant service managers. This is an example of this process being used to good effect, but this was more protracted than it needed to be due to the disagreement.  Added pressures at that time would have been evident in both Kent and Bexley as this happened as the UK went into the first lockdown because of the global C-19 pandemic in March 2020. Local authorities had to adjust very quickly to new circumstances, and this caused anxiety and stress within the workforce.    Good practice was noted by Kent who continued to visit the family whilst the dispute was negotiated despite the national lockdown.  4.12 There was also good recognition of the impact of the moves in the work done by Bexley and the parents preferred method of communication it is noted at the Initial Child Protection Conference in June 2020.  Housing Participation in the safeguarding process  4.13 Within the many assessments conducted during the period under review, the family’s housing situation was always recognised as an added pressure for them. In the timeframe, the family moved out of Bexley to Kent and then back again but prior to that they also moved around. Many moves are inevitably destabilising for families, and this is case is no exception.  4.14 Mother was entitled to be housed as a care leaver but the only option for her would have been to be housed as a single person in Croydon and she did not want to reside there. The family were therefore allocated temporary accommodation which was (as is often the case), in another borough.   4.15 The nature of families living in temporary accommodation means that they have little or no say in the moves that are required of them. In this instance it was detrimental to the family, not least because of the parents’ needs around neurodiversity and finding it difficult to make new relationships. In this situation, there is a complex dynamic to negotiate as the responsible housing department is different from the one providing local services.  This was then further exacerbated by the move to virtual visits and consultations used by many agencies when the C-19 pandemic made face to face visiting more difficult.  9  4.16 There was some liaison with housing departments between agencies but there was a disconnect in the safeguarding process as housing providers were not engaged in multi-agency assessments and plans. Housing was therefore not aware of how agencies were seeking to reduce the risks in this family and the impact that moves would have on them. There is no evidence that housing departments sought to understand the family’s safeguarding needs or the needs of the adults in relation to their neurodiversity.  They were therefore unable to contribute to the plan.  4.17 A positive move forward because of this review has been an agreement by Housing that families with children subject to a Child Protection Plan will not be moved out of the borough in which they are residing . This is a welcome move and will reduce the stress and impact of many moves for vulnerable families.  Agencies understanding and response to bruises or injuries in non-mobile babies 4.18  The observation of bruises to Baby R’s face and ear (aged 3 weeks) in early July were not dealt with in a robust manner. The parents were unable to offer a definitive explanation which should have aroused suspicion, given the very young age of the baby and the need to always supervise a toddler. The health visitor told the social worker two days later as an adjunct to a separate matter. Core group members discussed the bruise, and the parents’ explanation had changed. Members of the core group did not challenge the family about their change of explanation or seek to investigate further. 4.19  It has emerged that the practitioners involved with this family lacked an understanding of the high risk indicators associated with bruises or marks in non-mobile infants.  The significance of them is a well-rehearsed theme from other multi agency case reviews. The National Institute for Clinical Excellence (NICE)1 provide very strong guidance based on extensive research on this subject.   The current health policies in existence stress the high risks associated with bruising in babies but the evidence from this case indicates that the everyday application of this in practice needs to be developed. Regardless of the circumstances and the explanation (however plausible) there should be a standard response. The absence of consultations (through the process of s47 enquiries) with colleagues to check out the explanation given and treat the incidents with a degree of uncertainty was poor practice. Bromley Healthcare have strengthened their safeguarding training and supervision in a response to this.  4.20 It is necessary to consider the possible impact of the C-19 global pandemic on the response to the bruising. As a result of the pandemic, offices were generally closed and although in this case face to face visits occurred workers became much more isolated in their work. Working from home and conducting meetings via the internet became the norm and the team working of a busy office environment was lost to many. Child protection work is very complex and those on the front line rely on being able to reflect and check things out with their colleagues and managers. The absence of this supportive environment may have contributed to a lack of reflection. This also meant some management oversight was lost and created space for more errors of judgement made by frontline practitioners which went unchallenged. Usual checks and balances were not  1 National Institute for Health and Clinical Excellence. (July 2009 Last Modified October 2017) When to suspect child maltreatment. NICE clinical guideline 89.   10  present to take time to step back from a situation and agree a way forward. An additional stress was caused by many health workers having been redeployed which at one stage was nearing 50%. Their workload therefore fell to practitioners who were still in their main role.  4.21  In the period March – October 2020, OFSTED reported a 20% increase in non accidental injuries to infants2. This was attributed to the added pressure that parents were under, coupled with the complexities of trying to offer support to during the pandemic. This is an alarming figure, given that a significant proportion of non-accidental deaths of children is already high in that age group.  4.22 To support early implementation of the learning from this review, the panel were made aware that Bromley Healthcare have taken several actions to ensure staff have relevant knowledge and training. This includes updating their general safeguarding policies to be more explicit about non-accidental injuries in non-mobile babies, additional training covering this specific subject and an emphasis on the policy and the need to treat this as a high-risk event. Bromley Healthcare have since completed an audit on under 1’s. Children social care have also completed an audit on work with under 1’s to provide assurance of how well the needs of under 1’s are being responded to.  4.23 At the time of the incident, Bexley SHIELD did not have a policy that covered the expectations of a multi-agency response, but this is now in train. The policy will be officially launched with a multi-agency training offer to embed the practice fully.  This is due to begin in September 2021.  Practice will be strengthened by a requirement of an immediate referral to the relevant social worker or to Bexley’s front door services. Usual practice for such incidents would then be to ensure that the baby is subject to a multi-agency strategy discussion, s47 enquiries and an assessment by a specialist paediatrician.   Requirements for which agencies must attend the strategy meeting will be made explicit within the new policy and this includes the presence of a community paediatrician to advise and assist with decision making. Updated information will also be available to parents in line with the new protocol.  Liaison between Mental Health Services and Children’s Services 4.24  The parents’ mental health was a key issue for this family.  As previously noted, they both had troubled histories and had received support from services in the past. They both had diagnoses in relation to their neurodiversity which added to their complex presentations.  Both parents would have benefitted from a ‘trauma informed’3 approach.  4.25  Mother received support from mental health services during both of her pregnancies.   She had a pattern of engaging well during a crisis but disengaging once she felt better. She was aware that she needed support but was not always forthcoming with attendance at appointments and this became more of an issue once the C-19 pandemic prevented face to face visits.  4.26 The information provided by Oxleas about their services makes some important points in  2 https://www.gov.uk/government/speeches/amanda-spielman-at-ncasc-2020  3 An approach which considers a person’s adverse experiences such as severe domestic abuse, unformed or broken attachments to carers, parental substance and/or alcohol misuse and chaotic or unpredictable routines in childhood.  11  relation to how they supported Mother and some comprehensive recommendations for improvements. To summarise there was some delay to services in Mother’s second pregnancy and poor internal communication between the Perinatal Mental Health Service and the Primary Care Plus services.  4.27  From a multi-agency perspective, Mother’s mental health workers were not embedded within the network of professionals supporting the family and this was problematic. They were not therefore party to the discussions that happened at the Child Protection Conference and did not contribute to the children and family assessments conducted by Bexley in 2020. They therefore did not form part of the core group which is designed to implement the child protection plan. This is particularly pertinent given Mother’s suicide attempt in the month prior to the meeting being held as that was the trigger to initiate child protection enquiries.  There was a need for practitioners to ‘Think family’ and to work with them in a more holistic way.  4.28 Positive changes have been made in the Perinatal team since this incident. Practitioners are now required to complete a Safeguarding children assessment for every new service user (and their unborn/baby), this is in addition to a comprehensive mental state assessment. This is an encouraging step and compliance, and quality of the information will be monitored by senior managers.  4.29 As result of learning from this review members of the panel recognised that there needs to be an improved response to parents with mental health problems and their families. To address this, SHIELD and the Adult Safeguarding Partnership have started work on a joint ‘Think Family’ Protocol to strengthen this approach in the borough. There is ongoing development of restorative practice and an emphasis on adopting a collaborative approach with families. The priority will be joint learning events for children’s and adults’ workers together with the launch of the protocol. Senior leadership from across both partnerships will champion this practice to ensure it is embedded across agencies. The impact of the learning identified will be reviewed and evaluated through the Bexley multi-agency learning forum. This will be further supported by a focus on the Department for Education’s ‘Think family’ evaluation project which includes multi agency processes outside of statutory meetings. This will ensure an ongoing review of the impact and outcomes from the learning in this review.   Impact of the parents’ identity and presentation on their day to day lives and capacity to parent 4.30 The parents of Baby R were vulnerable. They had both suffered trauma in their childhoods and struggled to communicate effectively with each other. Mother spoke of their arguments and their somewhat tempestuous relationship. Whilst they agreed a safety plan with professionals to address this, it was becoming a more frequent occurrence. They had little in the way of family support to help them care for two very small children and at times managed this by the older child being cared for, for lengthy periods of time by friends. More is said about this in the following section.  4.31 In the first period of child protection planning the review has highlighted that their vulnerability was not sufficiently assessed. Other multi agency reviews have highlighted 12  the issue of young parents with additional needs and the lessons are repeated here in terms of the depth of knowledge about Mother and Father’s mental health problems, how they were assisted to address them and how this affected their parenting. Mental health services were not sufficiently engaged with the safeguarding process throughout the review period. Greater recognition and account of their difficulties was made in the second period of child protection planning with some proposed targeted work about their histories and support with parenting.  Sadly, this was curtailed due to the events on this review.  4.32 The parents were very open about their additional needs and recognised themselves as finding certain things hard such - making and maintaining relationships, being proactive in completing tasks and contacting professionals by telephone. During the C-19 lockdowns this difficulty was exacerbated by several services being provided over the telephone or via the internet.  Good practice was exercised by Bexley CSC and Bromley Healthcare who continued to visit the family face to face.  4.33 Father’s child from a previous relationship with whom he had no contact was not explored with him as part of the assessments. Given his childhood experiences and concerns raised, it would have been helpful to be more curious about this and have had more specific details, not only in terms of him being a safe carer but also the impact for him of not being in contact with this child.  4.34 The information provided by agencies is mostly silent on the issue of how their conditions impacted on their parenting. This indicates that the records also do not reflect detailed consideration of it and the ‘think family’ approach has yet to be embedded. Issues of neurodevelopment (neurodiversity) and an understanding of these on the impact on parenting need to be developed and although worked has started (see following paragraph), a recommendation is made to this effect to keep this on track.  4.35 To address these issues, SHIELD jointly with children’s social care have commenced a training programme and the first round of ‘trauma informed’ practice training has been delivered. This will be followed up by complementary training which will equip practitioners to better understand neurodiversity and its possible impact on parenting capacity. The overall aim is to improve multi agency risk assessment that considers the whole family and this is now a main priority in Bexley.  This training package and its impact will be monitored through single agency and multi-agency audits as part of the council and SHIELD’s quality assurance frameworks.   Assessing the children’s lived experience and the capturing the voice of the child.  4.36 Following on from the above in terms of assessing the complex needs of the parents, the two very young children (more so Child S) in this family had many contacts with professionals over the review period. Their voice does not however stand out strongly in the information provided. In the first period of intervention, the interruption of services when the family moved out of the borough meant that agencies did not assess the risk of neglect over time.  Therefore, the accumulative effects of long-term neglect and Child S’s lived experience were missing and as stated elsewhere the Child Protection Plan ended. Professional curiosity was not exercised when it was noted that Child S spent considerable amounts of time being cared for out of the family home.  13  4.37  In the second period of intervention, the subsequent Child Protection Plan (although short lived due to the circumstances of the review), was much more child oriented and the focus of the plan was to achieve security and stability for the children. Good practice was seen when the family were assessed as high risk and therefore despite COVID restrictions practitioners continued to visit face to face as much as they could.  There were stronger descriptions and discussions of the likely impact of the parents’ behaviour on the children and these were clearly set out.  The conference made good use of previous information about the parents’ struggles to care for one child and related this to the arrival of a new baby and how challenging this would be for them.    The multi-agency network recognised the parents’ own difficulties and were beginning to put plans in place to address some of these. Sadly, these plans were curtailed as a result of Baby R’s death.  5 Parental Contribution  5.1 The parents were notified that a Child Safeguarding Practice Review was taking place at the start of the process and to invite them to contribute. Despite several attempts they have not contributed to date, and this represents a key gap in the information and analysis. It is however an understandable decision by them, given the stressful situation they have found themselves with the loss of their child in and pending police investigation. Both parents have been made aware that this option remains open to them if they wish to take this up in the future.  6 Recommendations  6.1 Bexley SHIELD should seek assurance through audit that current approaches to risk assessment (through Child Protection enquiries or Child In need processes) obtain and take sufficient account of family background and previous experiences such as trauma, neurodiversity, and parental mental health difficulties. Trauma informed training has taken place to support further learning. Bromley Health care and Children’s Social Care have both conducted separate audits on children under 1 to inform ongoing work measuring impact of learning from this review. Education on neurodiversity and awareness raising on Think Family approach should remain as part of ongoing areas of practice for review within Children Social Care and beyond. 6.2 To support the above Bexley SHIELD should continue to seek to strengthen education and training across the partnership on Think Family, neurodevelopment disorders and what such difficulties mean for parents’ understanding and interpretation of information and advice. This should be made available for all agencies in contact with parents and children.  6.3 Assurance should also be sought that those relevant adult services such as mental health and housing are consulted as an integral part of the assessment and planning process. The Director of Children’s Social Services has held discussions with housing department and shared the learning from this review. A multi-agency protocol on completing assessments has been refreshed to reflect the recommendations and learning from this review. 6.4 Bexley Housing Services should ensure that they respond to invitations to multi agency 14  meetings and that their policies and procedures reflect their responsibilities to attend these. The agreement made by Bexley Housing Services that families with children subject to Child Protection Plans will not be moved out of the borough of residence, needs to be embedded in local practice.  6.5 As a result of learning from this review and similar multi agency reviews where a family’s housing situation has been noted to be challenging, Bexley Safeguarding Children Partnership should raise this as an issue of concern with the National Panel. This is regarding Housing’s role in statutory child protection processes, how they share information with partners and how they assess vulnerable families who need accommodation.  6.6 The initial findings from this review have been shared with Bexley Safeguarding Adult Board with a view to working jointly on the ‘Think Family’ protocols and training.  The newly developed protocol addresses the importance of a collaborative approach to assessments and the need to establish a link with housing providers to ensure that they are sufficiently versed in a family’s circumstances.  6.7 SHIELD should review and adapt, if necessary, the process undertaken when the decision of a Child Protection Conference is challenged by another professional. The multi-agency practice guidance currently being reviewed should provide clarity about the process and minimum expectations to be laid down about who should be consulted. Bexley guidance will now include in all cases, the requirement for there to be senior management oversight of the decision, and for evidence of this to be visible on the records. as part of this process.  Clarity should be provided to agencies attending Child Protection Conferences about what pathway to follow in cases where they wish to register a formal dissent. SHIELD in conjunction with the Independent Chair Manager is reviewing Practice guidance to include the above changes.  6.8 In addition, Children’s Social Care should provide assurances to SHIELD that the process of postponing Child Protection Conferences that occur due to administrative or technical errors is robust and has children’s safeguarding at its core.  6.9 Work began immediately by SHIELD to ensure that practitioners understand the significance of bruising in infants and the need to act. Going forward this should include clarity about the referral pathway to MASH, increased awareness raising of existing policies (frontline practitioner events, audits of practise, visual aids etc) and that it remains a focus for all safeguarding partners as the learning is embedded. As part of this work SHIELD should update information available to parents to ensure it is in line with their new protocol.  6.10 In addition, through regular audits of practice in this area, SHIELD should be assured of its continued high profile and partner agencies’ consistent compliance with its application. Any decision not to adhere to the Bruising Policy should be escalated to a senior manager to review.  6.11 SHIELD and Kent Safeguarding Children’s Partnership to undertake some joint work in reviewing the lessons of this CSPR and agree a protocol for case responsibility for families who are placed between the two boroughs   15   Jane Doherty Independent Social Work Consultant  September 2021       