Death of a 5-year-old child in July 2016. Child E's step-father pleaded guilty to manslaughter and no inquest was carried out. Family had contact with children's services over 14-month period prior to Child E's death, with fluctuating concerns by professionals about care being provided by Step-father and home environment. Step-father was judged as medium risk to the children concerning domestic abuse, alcohol use, driving without a license, and sexual offending. Concerns over contact with unknown men who posed risks to the children. Mother had some level of learning difficulty. Significant incident in May 2015 when children were pulled from the family car by Step-father and left on the pavement. Learning includes: focus on the physical care of the children and home conditions diverted attention from other serious issues, including risk of being in contact with people who presented risks to the children; professional challenge and escalation is important in effective intra and inter-agency work; agencies that saw signs of concern dealt with them appropriately most of the time but some intra and inter-agency communication and information sharing could have been better. Ethnicity and nationality not stated. Recommendations include: more training on neglect and its impact on children, more understanding of legal processes and what local authorities must evidence to secure statutory orders; raise awareness of the Escalation Procedure and the importance of robust, respectful professional challenge between and within agencies; consider the introduction of a panel, chaired by a different professional to take a fresh look at cases that are making insufficient progress.
      
 Title:  Serious case review overview report in respect of: Child E 2016. LSCB: Staffordshire Local Safeguarding Children Board Author: Glenys Johnston Date of publication: 2019  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.                                 Local Safeguarding Children Board  Serious Case Review Overview Report  in respect of: Child E 2016           Glenys Johnston OBE Director Octavia Associates Ltd           2  Contents   Title Page 1. Introduction 3 2. Summary 6 3. Case management 6 4. Information sharing 10 5. Assessments 11 6. Neglect 12 7. The views of the family 14 8. The views of practitioners and managers 14 9. What was life like for the children? 15 10. Conclusion 16 11. Recommendations 17                    3  1.0 Introduction  The Serious Case Review Process 1.1 On 27th July 2016 a notification for consideration of a Serious Case Review was made to the Local Safeguarding Children Board by Children’s Social Care and the  Independent Chair of the Board agreed that a Serious Case Review should be undertaken, in accordance with Chapter 4 of the statutory guidance ‘Working Together to Safeguard Children’ (HM Government 2015) and the Local Safeguarding Children Board’s Learning and Improvement Framework; Ofsted were notified in accordance with procedures on 16th March 2017.  1.2 A multi-agency Review Panel was established by the Local Safeguarding Children Board to conduct the Serious Case Review and report progress to the Board through the Serious Case Review Subgroup Chair. Membership included an Independent Lead Reviewer and Overview Report Author, together with representatives from key agencies who were involved with the child and/or their family. The Panel met regularly, was well attended; Panel members provided important information and were constructively challenging, minutes were distributed promptly, and all follow up actions were completed. The Local Safeguarding Children Board’s Interim Manager and administrators provided excellent support.  1.3 The following agencies were members of the review panel and provided an Individual Management Review:    Agency Acute Hospital NHS Foundation Trust     Birmingham Community Healthcare NHS Foundation Trust District Borough Council Heart of England NHS Foundation trust National Probation Service (NPS) Pre-school Primary School Staffordshire Clinical Commissioning Groups Staffordshire County Council Families First Staffordshire Police Staffordshire and West Midlands Community Rehabilitation Company (CRC)   1.4 I, Glenys Johnston OBE was appointed as the Independent Overview Author, I have extensive experience of undertaking SCRs, chairing Local Safeguarding Children Boards, service reviews and government inspections of child protection. I  4  have previously undertaken consultancy work for the local authority, but I have not had any involvement in this case.  Links with parallel processes  1.5 Consideration was given to parallel processes, it was identified that 2 police forces were investigating Child E’s death, and this meant that the Serious Case Review was paused to allow time for this to be completed, before meeting managers, practitioners, or the family to seek their views. Once the prosecutions were completed, the review continued without further delay.  1.6 As SF pleaded guilty to Child E’s death by manslaughter there was no inquest.  1.7 Following the completion of the Serious Case Review, the report has been presented to the neighbouring Local Safeguarding Children Board and their Child Death Overview Panel for consideration.   Period covered by the Review  1.8 The review covers the period from 1st December 2014 to the time of Child E’s death on the 23rd July 2016. Any significant incident relevant to the case but prior to the start of the period was included in a contextual summary completed by each agency as part of their Individual Management Review report.  Subject(s) of the Review  Mother M Step-Father SF Child subject of the review Child E Child E’s eldest sibling Sibling 1 Child E’s youngest sibling Sibling 2  Purpose of the Review 1.9 The purpose of Serious Case Reviews is to identify learning that will improve the practice of agencies, locally and potentially nationally, it is not to apportion blame. 1.10 The full terms of reference for this review are attached at Appendix 2, the key areas to be addressed were: • Determine whether decisions and actions in the case complied with the policy and procedures of named services and the SSCB. • The knowledge of professionals about neglect.   5  • The effectiveness of supervision and the quality of management decisions.  • Examine inter-agency working and service provision, including quality of assessments including risk, for the child and management oversight.    • The quality effectiveness and monitoring/revision of plans and the contribution of agencies.  • Where necessary were concerns, for example about drift and delay or decisions made, escalated?  • Determine the extent to which decisions and actions were child focussed and the extent to which the child’s voice was listened to and contributed to plans.  In relation to the above key questions:  • Identify any organisational issues that affected practice.  • Identify the reasons for any practice that fell below expected standards or in relation to good practice.  Methodology 1.11 The Review Panel considered the most appropriate methodology for the review and agreed that this would be in accordance with ‘Working Together 2015’ but include events for practitioners and managers to gather their views, as included in ‘Protecting Children in Wales: Guidance for Arrangements for Multi-Agency Child Practice Reviews’ 2013. Opportunities for the family to make their views known to the Independent Overview Author were also seen as particularly important. 1.12 Each agency that had been involved with the family produced an Individual Management Review report, written by a manager with no previous involvement in the case. The Individual Management Reviews used the Local Safeguarding Children Board’s template and guidance; they were of a good standard, completed on time, approved by a senior manager and where necessary, were updated with some minor revisions, following the second Review Panel meeting. The authors set out clearly their experience, qualifications, and independence from the case; the methodology they used and their sources of evidence, together with recommendations for improvements. 1.13 This is an overview report based on the Individual Management Reviews and meetings with managers, practitioners, and M and SF, it does not repeat all the information or single agency learning contained in the Individual Management  6  Reviews but draws these together with additional comments, analysis, and recommendations. 1.14 The names of family members and professionals have been anonymised to protect their identities.  2.0 Summary 2.1 The above key events indicate the persistent and periodically growing concerns about the family over the 14 months before Child E’s death.  It is evident that there was a significant amount of contact with the family by professionals (the Social Worker hereafter referred to as SW, family support worker, health visitor and school staff) and the conditions at home changed rapidly from acceptable to unacceptable and acceptable again. There were intermittent concerns about the inappropriate (personal) care being provided by SF and a clear under-lying frustration about the time taken to complete risk and parenting capacity assessments of M and SF expressed by partner agencies, together with concerns about the lack of effectiveness of the core group. The situation appeared to deteriorate following the birth of sibling 2 in October 2015. 2.2 Over the 19-month period between the 5th December 2014 and the 20th July 2016 the children were very young; sibling 1 was between 6 years and 10 months and 8 years and three months old; Child E was between 4 years and three months and 5 years and 9 months old; and sibling 2 was between 0 and 9 months old. In reviewing the chronology, it is evident that the number of occasions when the situation was not acceptable far outweighed the number of occasions when they were.  • There were 67 occasions when the home conditions were seen to be extremely poor or school were expressing concerns about the care of the children (dirty bodies, dirty clothes, Child E not wearing spectacles, insufficient clothes for weather conditions, lack of food, being hungry and head lice) which lasted over an extensive period and caused sibling 1 great distress. • There were also 29 occasions when concern was expressed about the children’s contact with inappropriate adults or about the adults driving uninsured, children being pulled from a car (one occasion) and being out late at night with their parents, who were delivering take away food. • 18 occasions when the home conditions and the care of the children had improved and were adequate, although on several of these occasions, there were still some concerns.                                  3.0 Case Management 3.1 From April 2012 this case was managed through several different processes; early help, child in need and child protection.  3.2 Children’s Social Care’s Individual Management Review highlights that the period before that covered by this review was not effective with poor quality assessments,  7  drift and delay, weak management oversight and an over optimistic view by some professionals about M’s ability to change and a lack of a clear understanding of her over reliance on her new partner. 3.3 The second period of involvement (covered by this review) showed some improved practice though the previous problems remained within the family. 3.4 A Family Dysfunction Referral was received on 28th July 2014, reporting several male visitors to the family home.  M was by this time in a new relationship with SF who was known to be a person presenting a risk to children.  Concerns continued in relation to the home conditions and parenting capacity, it was also reported that the couple were using alcohol excessively; empty bottles of alcohol were regularly seen in the house and sibling 1 told the SW about their concerns.  3.5 CSC made an initial visit to the family home within the correct time-frame on the 30th July 2014 and found conditions to be inadequate and indicative of chronic neglect. The record of the visit focusses on the narrow issue of poor home conditions, demonstrates an over reliance on M’s view of things and an over optimistic view that the situation would improve.  The issue of SF’s risk status is dealt with by the SW stating that he must not stay overnight at the family home and he should not have unsupervised access to the children without the SW assessing M’s capacity to support this.  3.6 CSC took the decision to undertake a Child Social Work Assessment to be completed in twenty days and to implement a Child in Need Plan.  The decision making did not adequately consider the known history of concerns, intervention and family functioning.  It makes no reference to SF’s history of domestic violence with a previous partner and does not report or risk assess his risk status or use of alcohol.   A Child in Need Plan was however, an opportunity to assess his role within the family, the risk he presented, his previous behaviours with particular reference to his risk status and to seek the views of the children.  3.7 It is considered good practice to allocate a re-referral to the SW that has previously worked with the family, it can be beneficial to the family who already know the SW and enables the worker to build on the knowledge they already have in relation to the children’s needs and family functioning.  This was the decision made in this case however the additional context and consideration of the previous level of concern for Child E, the performance/practice of the SW during the previous period of involvement and the lack of sustained improvement should have led to a decision to allocate the family to a different worker.     3.8 The Child Social Work Assessment was not concluded until 11th February 2015, some seven months after it commenced and outside the forty-day target, this drift within the process was not addressed by the Team Manager.   8  3.9 The first risk assessment of SF was undertaken by the National Probation Service at court, it described him as being of “medium risk”, and this was later confirmed by the Staffordshire and West Midlands Community Rehabilitation Company, on the 30th of January 2015. The risk assessment was comprehensive and complemented by specific assessments in relation to risk of sexual offending and domestic abuse and judged that SF presented “medium risks to children and others”. 3.10 The recommendation from the Child Social Work Assessment was to refer the family for an Early Help Assessment, to help and support the family, as at that point progress had been made in the home conditions.  The SW again formulated their view without the benefit of appropriate assessment tools and does not discuss the impact of continued neglect on the children, nor take account of the risk presented by SF and it is therefore an inadequate report.   3.11 A Child in Need Plan was not however, put in place until 29th April 2015 some eleven weeks later.  Within the plan there were tasks for SF and M to improve the home conditions and the children’s presentation and development.  It is evident from the plan that SF was part of the family unit, had responsibilities within the home and M was pregnant with his child.  3.12 From case records, escalating concerns included associates of SF who also presented risk to the children staying at or visiting the family home.  It is also reported that the children were visiting the home of the same risky adults.  Child E’s appearance continued to be poor, with holes in their shoes, recurring head lice, and lack of food.  The children are at this stage also being included in delivering take away food with M and SF, returning late at night. Conditions at the family home continued to be unsafe, unsanitary, and malodorous. SF was reported to be driving M’s car, despite the fact he did not have a driving licence and therefore was also not insured.   3.13 The incident on the 8th May 2015 in which the children were pulled from a car resulted in SF being asked to stay away from the family home for the weekend. The Emergency Duty Service passed this information to the area team appropriately and promptly.  3.14 A strategy meeting was convened on 19th May 2015 which was too long after the incident, the police contributed to the discussion and agreed it met the Sec 47 threshold and that an Initial Child Protection Conference should be convened.             The central issue remained the neglectful care of the children and the outcome was to return to an Initial Child Protection Conference with Child E being at risk of significant harm.  This was the appropriate action.  3.15 On the 22nd May 2015 a written agreement was put in place and signed by the SW, Team Manager and M, the intention being to ensure that M was aware of the expectation to keep Child E safe until the Child Protection plan was in place. The SW  9  was aware that M had some level of learning difficulty and it was unlikely that she understood the agreement or what was expected of her, so it was of little value. In addition, SF was not asked to sign the agreement, which was a missed opportunity to engage his commitment. Serious Case Reviews frequently raise the issue of professionals not engaging men in care planning.  3.16 Despite the Community Rehabilitation Service attending and informing the Initial Child Protection Conference of the assessed risks presented by SF, there remained no risk analysis in relation to the domestic abuse, alcohol use, driving without a licence or his and others’ risk status, by the conference. The minutes of the meeting record that a cognitive assessment had previously been carried out with M. There is nothing in Child E’s records to suggest that this was the case. The Conference does, however, give clear direction in relation to the assessment of SF.  3.17 The SW report to the Conference used the Signs of Safety model to analyse risk appropriately, it had a good focus on the children’s quality of life and the inadequacy of their care although the home environment was still a significant focus. The author of the Children’s Social Care Individual Management Review is of the view that a greater level of respectful caution/challenge should have been applied to M’s account that SF was not living with her as the report also stipulates that she and the SF ‘are untruthful’ and I concur with this.  3.18 At that Review Child Protection Conference in September 2015, the risk assessment of SF remained outstanding, as does the recommended cognitive assessment of M.  This is some three months from the Initial Child Protection Conference and leaves the children in a situation of unassessed risk or the risks being addressed in the Child Protection plan.  The Team Manager does comment that the County Manager had agreed to fund a cognitive assessment of M.  3.19 In December 2015, concerns were such that the SW sought advice from a Legal Gateway Meeting. When concerns are escalating or not reducing for children, this is the correct meeting for SWs to seek advice from the County Manager and Legal Services.  Decisions are made at these meetings that might include making an application to the Family Court for approval and direction for complex ‘expert’ assessment and reporting to be made.  3.20 The following Review Child Protection Conference took place on 18th May 2016, cognitive testing of M (agreed in September 2015) had still not taken place and the risk assessment in relation to SF remained outstanding. The Team Manager recommended that the Public Law Outline process should be considered due to the children’s continued exposure to neglectful care.  It follows therefore that the SW would attend a Legal Gateway Meeting to seek the advice of the County Manager. This was the last Review Child Protection Conference before Child E’s death.   10  4.0 Information sharing 4.1 The effective and appropriate sharing of safeguarding information about children and adults involved with them has been an ever-present issue identified in Serious Case Reviews. 4.2 As the Triennial Review- Pathways to Harm and Pathways to Protection DfE 2016 states; “The persistence of findings relating to communication and information sharing suggests a deep, systemic issue. That information sharing is highlighted repeatedly in reports and training suggests neither a lack of professional awareness nor a failure to appreciate the importance of information sharing that is at fault. Nor can the issues be blamed on lack of guidance or systems for sharing information. All national guidance and legislation on confidentiality and data protection supports sharing information to safeguard children and vulnerable people.  Our reviews of Serious Case Reviews spanning more than ten years suggest that, despite national guidance and legislation, there are deep cultural barriers to effective information sharing among professionals.  Data protection legislation is viewed as a set of constraints limiting information sharing rather than a facilitative too” 4.3 In this case there were some good examples of agencies making referrals, raising concerns with Children’s Social Care and sharing information within and between agencies. Some of which are included as follows. 4.4 The pre-school reported concerns about the incident of the 8th May 2015 to which Children’s Social Care responded appropriately by convening a strategy meeting and ultimately a Child Protection plan. The primary school regularly shared information with the SW and at core groups, strategy meetings and child protection conferences and were alert to the indicators of abuse and acted appropriately when they had safeguarding concerns. Through this Serious Case Review the pre-school has identified that they did not share a full written safeguarding chronology with the primary school when Child E transferred there, although information was shared verbally. 4.5 The police appropriately informed Children’s Social Care in December 2014 when they had reason to check SF’s offending history. 4.6 Invitations for the GP to attend the Child Protection Conferences appear inconsistently in Child E’s and sibling 1 records. It is evident in Child E’s record that the GP was not invited to the Review Child Protection Conference on 1st December 2015 and for sibling 1 the invitation to conference was received on the 23rd May 2016 when the conference was held on the 18th May 2016. There is evidence of some invitations to conferences and minutes from conferences are available to view in all three children’s records. Notification of death is provided on the same day Child E died. There is no evidence of GP attendance at any of the Child Protection Conferences or contribution towards the health information required in the form of a report or telephone conversation. However, GPs are currently using a new report  11  template designed to enable them to share their information and professional views appropriately, if they cannot attend a Child Protection Conference. 4.7 Although the GP did not attend any Child Protection conferences due to capacity and availability, information was shared with the GP by the health visitor and the GP was fully aware that there were safeguarding concerns about the children from conference minutes. The sharing of information within health was one-way i.e. to, rather than from the GP, however, in relation to the older children as the GP rarely saw them the family did not ‘stand out’ as being of significant concern. Contact with M and the baby sibling 2 was more frequent and there could have been more liaison with the community midwife as the GP was involved in M’s asthma care and could have explored with her, the child protection concerns. 4.8 However, at the Practitioners’ Event in February 2018 professionals commented on the poor performance of the core groups with information not always being shared by the SW, (who did not always attend) for example the midwife did not know that SF was a PPRC before sibling 2 was born which had implications for the management of the birth. Minutes of core groups were not always produced so attendees had to rely on their own notes and there was insufficient consideration or monitoring of the Child Protection Plan at each core group meeting. 4.9 The SSCB Multi-Agency Neglect Strategy Nov 2016 states:  Effective information-sharing within and between agencies. Each area should have a cross sector information-sharing protocol. All relevant agencies and services should be signatories and it should clearly state what information should be shared, by whom and the process for doing this. This information should inform assessments and decisions about risk. It is also paramount when reviewing information that all agencies consider historical information and the potential impact of this on a child’s presenting circumstances; this will help to identify families at risk of inter-generational neglect. In addition, all frontline practitioners should have significant regard to be the overlap between neglect and other forms of child maltreatment, such as parental domestic abuse, substance misuse and mental ill-health. 5.0 Assessments of M and SF 5.1 The Individual Management Reviews and chronology provided for the review identifies a running thread of frustration, delays and drift in the completion of a cognitive assessment of M and a risk assessment of SF; this was an action agreed in the Child Protection Plan of September 2015 and raised by the health visitor, the school and the Child Protection Conference chair on several occasions but by the time Child E died these had not been completed. 5.2 Although professionals have the skills to assess observed behaviour, they are not clinical experts. Identifying parents with cognitive limitations is an essential first step for SWs and other partners and there was a shared view that M may indeed have a learning difficulty or impairment.  Without formal psychological, expert assessments it  12  was difficult to ‘un-pick’ whether M was able (had the capacity) to understand the concerns of professionals and whether she agreed with them, comply with plans, and whether she had the willingness to do so and if not whether she was affected by SF’s manner and dominance and if so why she accepted this. The Children’s Social Care Individual Management Review mentions a written agreement but does not evaluate its accessibility. M was not referred to Adult Services for assessment and should have been although the referral may not have been accepted if the service determined that the threshold was not met. 5.5 SF’s angry outbursts, mentioned above together with his dominant personality was known but never specifically assessed in relation to these children. 5.6 Without the assessments it is difficult to see that measures to safeguard and protect the children could be informed by clinical expertise, nor could the concerns about SF be clearly explained to M. 6.0 Neglect 6.1 Throughout the period the children were known to Children’s Social Care and at times, other agencies, there were concerns, identified above, about neglect, the physical care of the children, the chaotic state of the home, physical chastisement, alcohol use by adults, domestic abuse, sexual offenders having contact with the children and risky adults visiting the home. At times, these concerns reduced but overall, the care of the children continued to be of concern to professionals. 6.2 Neglect is the most common form of child maltreatment. For example, Brandon et al 2014 1 notes, “During 2013 in England almost half of child protection plans occurred as a response to it and it also featured in 60% of serious case reviews. However, a number of high profile child deaths in the UK have shown that it is extremely difficult for professionals with safeguarding responsibilities to identify indicators of neglect, to assess whether what they have seen is serious enough to take action and to decide on the most appropriate course of action.”  ‘Working Together 2015’ defines neglect as: The persistent failure to meet a child’s physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: • provide adequate food, clothing, and shelter (including exclusion from home or abandonment); • protect a child from physical and emotional harm or danger; • ensure adequate supervision (including the use of inadequate care givers); or • ensure access to appropriate medical care or treatment.  6.3 Further to this, the glossary to ‘Working Together 2015’ defines emotional abuse as:  13  • The persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child's emotional development. • It may involve conveying to a child that they are worthless or unloved, inadequate, or valued only as far as they meet the needs of another person. It may include not giving the child opportunities to express their views, deliberately silencing them or 'making fun' of what they say or how they communicate. • It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child's developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction • It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying (including cyber bullying), causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. • Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone. 6.4 Some of the characteristics and challenges of neglect contained in the Department for Education Research report of 2014, ‘Missed opportunities; indicators of neglect, what is ignored, why and what can be done’ are paraphrased below as they are relevant to this case: - neglect can in some cases be challenging to identify because of the need to look beyond individual parenting episodes and consider the persistence, frequency, enormity and pervasiveness of parenting behaviour which may make them harmful and abusive;   - there is a reluctance to pass judgement on patterns of parental behaviour when associated with social disadvantages such as poverty.   6.5 Services in this case were not unresponsive to the family, many neglectful families like this one are extremely demanding of professional time with frequent crises and requests for assistance as happened in this family, but the focus can be, and was, on the presenting problem-the home conditions and physical care of the children rather than their being exposed to sexual harm and domestic abuse. As a result, plans were largely ineffective as was their monitoring, nor was there reflective pauses as to whether the care of the children was ‘good enough’ and what the cumulative impact of their neglect was.     14  7.0 The Views of the Family 7.1 The Local Safeguarding Children Business Manager spoke to Child E’s birth father on 20th July 2017, he shared that he had raised concerns about M’s care of the children in 2012 but had not seen his child for five years and had little to contribute. 7.2 In February 2018 I met M with the local authority’s Head of Partnership and Development. M explained that she had been born with physical difficulties and learning difficulties and had had difficult relationships with her first two partners which included domestic abuse. She described her contact with professionals as “feeling bullied all the time” which made her feel very anxious that her children would be removed from her care. To avoid contact with professionals she often spent the whole day driving around while the children were at school. She said she understood why professionals were concerned about the state of her house but not why they were concerned about the care of the children. 7.3 She did not receive copies of assessments or reports which were submitted to Child Protection Conferences, she did receive minutes and Child Protection Plans but struggled to understand them and despite pictures being included to help her understand she did not find the written agreement helpful either. She said that when she attended Child Protection Conferences she had to join professionals who were already in the room, which was intimidating. 7.4 She recognised the efforts made by the Family Support Worker in that she played with the children and talked to them. She said she would have found some instruction and assistance with how to run the house helpful. 7.5 In March 2017 I also met SF with the local authority’s Head of Partnership and Development. He recognised that M had difficulties in maintaining their home properly but felt he had played a significant part in improving it. He resented the involvement of the SWs but found most other agencies were helpful, he acknowledged that at times he became irate and professionals probably found him challenging. He was adamant he had not been responsible for CE’s death and had only pleaded guilty to charges to avoid M going to prison as she had no previous offences. 8.0 The Views of Practitioners and Managers 8.1 As part of the review, it was decided that two events, one for practitioners and one for managers involved in this case, would be held, facilitated by me. These took place in February 2018. 8.2 Practitioners found M’s lack of appreciation and criticism very difficult to accept as they felt they had all worked very hard to support the family. They did welcome the opportunity to meet to discuss the case although this was almost two years after CE died, a long time to contain their concerns about the outcome of the review. In summary the views of those who attended the events, which are not necessarily endorsed by me, were:  15  • Overall, there was good information sharing by agencies. • Core groups were poorly managed; there was no regular monitoring of the plan, poor attendance by some agencies, cancellations not always being notified to attendees and inadequate minutes which did not reflect changes or decisions. • Practitioners are aware of the need to professionally challenge and escalate concerns and are increasingly confident in doing so. However, in this case they felt the outcome was not positive, e.g. delays in assessments etc still did not reduce. There was information in the multi-agency chronology produced for this review that not all agencies were aware of, had they known it they may have escalated more frequently.  • There were real problems to do with no timely assessment being completed of M’s cognitive abilities, which was regularly raised by professionals and the Child Protection Conference Chair. Children’s Social Care seem to have conveyed that parenting assessments by clinicians can only be funded when families are in proceedings. Some confusion about what single or multi-agency are parenting assessments and which are specialist assessments involving clinicians  • What risk was posed by SF given his offending history? Why wasn’t this assessed especially given the risk.  • Agencies lack a clear understanding of the legal processes which are open to CSC and the thresholds and evidence requirements at each stage. • Agencies would find it helpful to have sight of CSC’s assessment timetables for parenting assessments and the content as it progresses.   • Overall, agencies were unfamiliar with the LSCB neglect assessment tool (The Graded Care Profile) and therefore had not used it, the benefit of using the same tools across agencies is that information and assessments can be easily shared, using the same language.  9.0 What was life like for the children? 9.1 From reading Children’s Social Care Individual Management Review and the chronology it can be gathered that life for these children was far from ‘good enough’ or that we would wish for our own children. As they had been the subject of two Child Protection Plans before the period covered by this review there had clearly been concerns since sibling 1 was four and Child E was two years of age. 9.2 There is evidence that professionals worked hard to seek the children’s views and envisage what their life was like and this is captured in the Children’s Social Care Individual Management Review and the last Child Social Work Assessment. 9.3 Child E was described in pre-school as a quiet, happy child who enjoyed staff attention, never appeared reluctant or scared to go home at the end of the school day and had a good emotional bond with M. However, concerns noted by the pre-school and school clearly evidence that all was not well; they constantly had to remind M about making sure they wore their spectacles, was clean i.e. not smelling of cat urine,  16  had a proper packed-lunch in a clean lunch-box. On the day of the car incident in May 2015, Child E said that they had ‘skin on their toes’ and on checking them, the staff saw that the toenails were so long they were bending over the edge of the child’s toes. 9.4  Sibling 1 suffered from head lice for most of the period covered by the review which made her embarrassed and led to her being bullied, she is described in the Children’s Social Care Individual Management Review as being proud to show the SW when her bedroom was tidy but was very conscious of the appalling state of the house and commented that M “did not help her tidy up”. The chronology clearly indicates that sibling 1 was visiting a property where there were several men who posed risks to children including SF. 9.5 The incident when the children were pulled from the family car by SF and left on the pavement while he and M drove away, was considered to be abusive by pre-school staff, they describe witnessing how the children ran after the car along a busy road and that they (especially sibling 1) were visibly frightened. SWs, the police and education professionals were united in their view that this situation was of serious concern and supported the convening of the Initial Child protection Conference. 9.6 The pre-school Individual Management Reviews also makes an important reflection, that SF could appear intimidating, that his large physique and at times, angry face, angry and overpowering behaviour and kicking doors and shouting must have made an impression on the children. The Children’s Social Care Individual Management Review also highlights that SF was a controlling individual who managed all elements of the family home and that M appeared content to accept this by following his wishes, rather than accepting responsibility. 10.0 Conclusion 10.1 From this Serious Case Review there is evidence that the three children who are considered in the review, suffered from neglectful abuse for at least the last four years and it is reasonable to assume that the neglect occurred before then. 10.2 The review has enabled us to gather a clear sense of the children and their experience of being cared for and it presents a worrying and unsatisfactory picture. 10.3 Most concerns were identified and largely shared through emails, verbally, referrals and at meetings although information was not always shared by children’s social care between and at core group meetings. Agencies that saw signs of concern, dealt with them appropriately on an individual basis most of the time. However, some intra and inter-agency communication, sharing information, could have been better, a finding of many Serious Case Reviews and the Department for Education Triennial Review of Serious Case Reviews. 10.4 Core groups are an important part of the child protection process, their role is set out in statutory procedures and is to develop and monitor the child protection plan, amending it as new information comes to light. They are an invaluable arrangement  17  to share information between professionals and the family. In this case they did not work well until the latter stages. 10.5 Services were not unresponsive, many neglectful families like this one are extremely demanding of professional time with frequent crises and requests for assistance but the focus can and was on the presenting problem-the home conditions and physical care of the children and there was the lack of a reflective pause on whether the care of the children was ‘good enough’ and what the cumulative impact of their neglect was. 10.6 The focus on the physical care of the children and the home conditions, diverted attention from other serious issues such as the risk of being in contact with people who presented risks to the children, despite relevant information being communicated by professionals from Staffordshire and West Midlands Community Rehabilitation Company. 10.7 Children’s Social Care openly accept that the social work support given to the family was not of the standard to which they aspire, this led to unusually poor communication and drift and delay in the case work and planning. This was highlighted by the Head Teacher of the primary school who has worked with the service for many years and described the practice in this case as not of the quality previously delivered. The problem was compounded by poor management at both levels above the SW, this practice was regrettable but has been robustly addressed by the service. 10.8 Professional challenge and escalation is of significant importance in effective intra and inter-agency work. There were occasions when concerns about delays and decisions were escalated but where they were not or not escalated further this would appear to be because professionals outside Children’s Social Care believed what they were told by the SW. They also felt that their concerns, when raised to the SW’s manager were unhelpful and they had little confidence that action would be taken, or decisions re-considered. Some also lacked confidence in and a full understanding of the escalation process, comments from the practitioners’ event indicated that they now have a better understanding and more confidence in doing so. 10.9 The agencies that contributed to the review undertook their work well and have identified and have or are implementing the recommendations for improvements in their own agencies. 11.0 Recommendations Local Safeguarding Children Board should: i. Reflect on the comments from the practitioners’ and managers’ events. These included: • the need for more training on neglect and its impact on children,  • more understanding of legal processes and what the local authority must evidence to secure statutory orders;  18  • the changing role and landscape of children’s social work departments, given the impact of rising demands and reducing resources. ii. Assure itself that core groups are functioning effectively and in accordance with procedures. iii. Raise awareness of the Escalation Procedure and the importance of robust, respectful professional challenge between and within agencies iv. Highlight to agencies the value of using chronologies in supervision, core groups and case conferences to monitor progress in cases where neglect is of concern and consider the practicality of establishing combined (inter-agency) chronologies for child protection planning purposes. v. Consider the introduction of a panel, chaired by a different professional to take a “fresh look” at cases that are making insufficient progress.    