Serious head injury of a primary-school-aged child in October 2014. Parents reported that Child A had fallen from a height in the early hours of the morning whilst trying to reach a cupboard. A subsequent visit by the police to the family home raised concerns about the safety of the conditions. The children were removed to foster care. At the time of the incident Child A and siblings were subject to child protection plans under the category of neglect. Family had significant contact with a wide range of agencies and were receiving support from a Team Around the Family (TAF) due to concerns about home conditions and the childrens failure to thrive. Mother had previously had two children removed from her care and adopted. Mother had a history of childhood sexual abuse, a lack of emotional warmth towards her children and suspicion of services and professional involvement with her family. Father had a history of alcohol misuse, domestic violence and controlling behaviour. Findings for learning include: parents were able to dominate and manipulate TAF meetings by disputing points, creating diversions and feigned compliance with recommendations; no formal parenting assessment was made of parenting capability or motivation to change; professionals struggled to distinguish between parental neglect and emotional abuse; assessment tools were not always used effectively; and the escalation policy was not used by professionals to challenge decision making following referrals. Uses a systems based approach to analyse information and present the findings. Poses questions for the Local Safeguarding Children Board to address.
      
 Title:  Serious case review:  Child A: overview report LSCB: Cheshire West and Chester Local Safeguarding Children Board  Author:  Date of publication: 2016  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            CHESHIRE WEST AND CHESTER LOCAL SAFEGUARDING CHILDREN BOARD   SERIOUS CASE REVIEW CHILD A   OVERVIEW REPORT           Date endorsed by LSCB 19th November 2015 Date of Publication  24th March 2016    2    Index           Page No   1. Introduction and Background to the Serious Case Review  3-11   2. Brief Summary of Agency Contacts and Key Practice Events 12-20   3. Professional Involvement and Analysis of Practice   21-25   4. Findings and Questions for the Board    26-31    5. Wider Learning       30   Addendum  AM’s comments on the report      33                          3      1. Introduction to the Serious Case Review  1.1 Family Names, Pseudonyms and Confidentiality  To protect the identity of the family in this case all family members and professionals re-ferred to in this report are anonymised.  The report does not refer to individual children within the family; the subject child will be referred to as Child A throughout the report.  Child A’s gender is not referred to in this report and any gender references will be neutral (i.e. through the use of ‘they’, ‘their’ or ‘them’).  Child A’s parents will be referred to as AM (mother) and AF (father).   1.2 Decision to Conduct a Serious Case Review   In December 2014 the Cheshire West and Chester Local Safeguarding Children Board Seri-ous Case Review Panel considered information regarding an incident involving Child A dur-ing which Child A sustained an injury that later required hospitalisation and surgical inter-ventions.  After considerable discussion and debate the Panel concluded that the case met the criteria for the conduct of a Serious Case Review (SCR) as set out in Working Together to Safeguard Children (revised 2015).    The incident leading to this SCR occurred in October 2014.  At this time the family were sub-ject to Child Protection planning with the children being registered under the category of neglect. Child A is the second oldest sibling amongst a large sibling group.   1.3 Rationale for conducting the review  The Local Safeguarding Children Board Serious Case Review (LSCBSCR) panel felt that, due to current concerns, historical contacts and the number of agencies involved with the family, significant learning could be gained by conducting a SCR.   It was noted that this is a com-plex case involving a large number of partnership agencies that are both local and regional.   1.4  Family History  There had been significant historical contact with a range of agencies.  AM had previously had two children removed and subsequently adopted prior to her being in a relationship with Child A’s father.  The oldest child in the family had been subject to Child Protection planning in 2004 under the category of neglect.  All the children were referred to Children’s Social Care in 2010 when the Health Visitor made a referral in relation to a man who was thought to have been involved in sexual abuse (it has been established that there were no convictions against this individual) visiting the family home.   4  It was agreed by the LSCBSCR panel that contextual information regarding the parents’ ex-perience in their own childhoods and the circumstances surrounding removal of AM’s first two children would be of benefit to the review.   1.5 The Incident  On the morning of the incident that led to this SCR, Child A had attended school as usual without any report from their parents of Child A having sustained an injury at home.  Whilst away from the school premises, Child A became unwell and required hospitalisation and emergency treatment.  This treatment was the evacuation of a left sided sub-dural haema-toma (bleed on the brain), which was the result of a head injury sustained in a fall earlier that day.    The hospital reported that a subsequent conversation with the parents described the mech-anism of the injury as being that Child A had a habit of coming downstairs at night to watch TV.  In the early hours of the morning in question Child A’s father (AF) was asleep on the  sofa and was woken by Child A saying that they had hurt their head, and that they would not let father look at their head.  AF also reported that Child A had told him, whilst on the intensive care ward, that they had got up to watch a TV programme and that they had climbed onto a kitchen work-surface, then on to the refrigerator to reach a high cupboard to get sweets.  They had fallen from the refrigerator onto the hard surface kitchen floor, hitting their head on the floor.  Child A’s parents were contacted and attended hospital where they were informed that fur-ther enquiries would be made by police and Children’s Social Care (CSC) who were con-cerned about the safety of the family home and of Child A and their siblings.  Police were asked by CSC to attend the family home and photograph the home conditions, to assess the suitability and safety of the conditions.  Based on photographic information it was deemed that the conditions were unsuitable, and that a police protection order (PPO) should be sought to enable the children to be taken to a place of safety pending further in-vestigations.  That same day Child A’s siblings were removed to foster carers, whilst Child A remained in hospital.  Child A was discharged six days later to foster carers.  At the time of writing, Child A and their siblings are currently residing with foster carers un-der an Interim Care Order.  1.6 Background - Child A and their Family  Child A is the second oldest child amongst a large sibling group.  Child A was described by professionals as being a lively and active child.  Child A appeared to have difficult relation-ships with their siblings; one relationship being of particular concern to professionals with high levels of aggression and anger being present between the two siblings.    5  During the period under review Child A and their siblings were subject to Team Around the Family (TAF) assessment (and later to Child In Need (CIN) and Child Protection (CP) plan-ning).  Child A was referred to specialist services in relation to concerns about faltering weight and growth, and behavioural difficulties - recorded as anger and hostility towards their siblings, inability to control their temper, and other behaviours of concern.    The siblings in the family were all subject to concerns by professionals in relation to their failure to maintain weight gain; there were also issues in relation to speech and communica-tion with some of the siblings.    Child A’s parents were reported by professionals involved in the TAF to have chaotic rela-tionships with the children.  They appeared unable to establish routines and boundaries. All professionals involved with the family noted that AM lacked emotional warmth and was un-able to maintain an emotional bond with the children, particularly as they grew older.  AM acknowledged this and attributed it to her childhood experiences.  AM disclosed to professionals that she had been the victim of sexual abuse in her childhood, she recounted that she had been abused from a young age and had been abused by her fa-ther and other males who were part of a ‘paedophile ring’.  She reported that she was made to perform sexual acts with these males from the age of two years.  She said that she had told people at her school about this and that she was taken to a police station in the area but no charges were brought.  The review tried to find further information about these events via police sources but could find no records.  The removal and subsequent adoption of her two children had led AM to be suspicious of services and professional involvement; this was noted by all professionals involved in the review, and was most apparent in relation to the involvement of CSC.  AF was perceived to be the primary carer by some professionals.  He appeared to have the main responsibility for taking the children to school and collecting them.  AF worked which meant that the family were not entitled to benefits, resulting in some financial hardship.  AF was reported to drink excessively on occasion.  His behaviours when intoxicated were of concern to professionals.    There had been two recorded incidents of domestic abuse between AM and AF going back several years.  There had also been a suspected incident of physical violence during the pe-riod under review, however, AM denied that there was any abuse when she was asked by professionals.  There was no formal assessment conducted (such as a CAADA DASH risk as-sessment, as the first two incidents pre-dated the introduction of this tool and AM denied the more recent incident).    Some professionals observed controlling behaviour from AF to AM in the way they interact-ed with each other; AF was reported to keep control of the finances.  AM had spoken to health professionals about feeling under pressure in their sexual relationship.   6  In 2012 the family were placed on Team Around the Family (TAF) following concerns raised by the Health Visitor about the home conditions and the children’s failure to thrive.  This review begins at that point.  1.7 Methodology  A Serious Case Review team was convened of senior agency representatives from Cheshire West and Chester agencies. The review was co-ordinated and managed by the LSCB Busi-ness Manager and a Lead Reviewer who was appointed following a commissioning process.  The review used a systems based approach to analyse information and present the findings.  A multi-agency chronology was compiled in March 2015 from which the Review Team drew the key lines of enquiry and terms of reference (research questions) see 1.9.  The Review Team identified the services and individual practitioners that would provide in-formation and participate in the review. A briefing session for practitioners was held in April 2015 which was followed by individual conversations with practitioners from a range of agencies. These conversations were conducted by members of the Review Team and the Lead Reviewer.   The Review Team used the information from the conversations and other evidence to iden-tify key and significant episodes of practice in the case from which the findings are drawn.  The review gathered written and electronic information and documentation for analysis; this included all relevant documents and reports from services working with the family in regard to assessments, agreements and plans, minutes of meetings and other relevant re-ports.  The review also received written reports from two hospitals that had contact with Child A on the day the incident took place.  The findings in the final chapter of this report use an adaptation of the framework devel-oped by SCIE to present the key learning within the context of the local arrangements.   The work of the review is exempt from the Freedom of Information requirements that apply to public bodies. There is case law in regard to the information that can and should be dis-closed to coronial and police criminal proceedings.   The review was conducted on the basis that the overview report would be published in full.   1.8 Scope of the Review  The period to be reviewed was agreed as 31st March 2012 to 31st October 2014.  Relevant information prior to 31st March 2012 was considered by the Review Team where this added to understanding of the case.   7  This report does not focus on events subsequent to 31st October 2014 in relation to any civil or criminal proceedings.  1.9 Issues identified for further exploration (research questions)  The LSCBSCR panel identified a number of areas for further exploration during the SCR, as follows:   Is the approach to dealing with neglect sufficiently outcome focused?   Is there evidence of any issues identified within local learning guidance that is rele-vant in this case?   Is there a sufficiently clear contemporary definition of neglect being used within all partner agencies that needs to underpin collaborative work?  How did practitioners working with the family consider and hear the voice of the child?   To what degree was this case appropriately stepped up and down through the con-tinuum of need?  Were relevant assessment tools appropriately applied and of good quality? Did safe-guarding processes, including recording systems support information sharing and decision making in this case?  Does the existing suite of training to partner organisations sufficiently cover the knowledge, skills and guidance staff require to identify and manage cases of neglect and is there evidence of learning being applied to practice?  Is there evidence of managerial oversight and supervision of practitioners within the case?  These questions will be reflected in the findings of the SCR detailed in Section 4 of this re-port.  1.10 The Review Team and Case Group  The Review Team was made up of members of the Serious Case Review Panel, all of whom were selected on the basis of their seniority within relevant organisations.  One of the Re-view Team members had direct contact with the family in a previous role.  This was declared at the outset and did not present any conflict of interest.  The Review Team met on three occasions to oversee the review and contribute to and ap-prove the final SCR overview report presented to the LSCB.  1.10.1 Membership of the Review Team  Position Organisation SCR Chair Designated Nurse Safeguarding Children (Chair) NHS West Cheshire Clinical Commissioning Group and Vale Royal Clinical Commissioning Group Business Manager Cheshire West and Chester Local Safeguarding Children Board Team Manager, Access to Re-sources Team Cheshire West and Chester Children’s Services  8  Senior Manager, Integrated Early Support Cheshire West and Chester Children’s and Young People’s Ser-vices Detective Constable, Major Crime Review Team Cheshire Police Head of Safeguarding Safeguarding Unit, Cheshire West and Chester Children’s Ser-vice Operations Manager Cheshire West, Halton and Warrington Youth Offending Ser-vice Designated Doctor Safeguarding Children NHS West Cheshire Clinical Commissioning Group and Vale Royal Clinical Commissioning Group Safeguarding Children in Educa-tion Service Manager Cheshire West and Chester Education Service  In Attendance Independent Lead Reviewer    1.10.2. Services and Practitioners Involved in the Review  Practitioners were identified at the ‘scoping’ stage of the review.  Each agency submitted a detailed chronology to the Serious Case Review Panel, from which practitioners were se-lected to participate in face to face or telephone conversations with the Lead Reviewer and members of the Review Team.  The following practitioners participated in the Review.  A brief description of services is given below.  ESAT (Early Support Access Team)  IES Integrated Early Support Case Management Teams based within localities – ESAT and IES are elements of the Early Support Offer in Cheshire West and Chester CART – Contact and Referral Team is the front door to level 4 services (CP and CIN).  Quarriers is a commissioned service offering support to children affected by Domestic Abuse at level 3 on the Continuum of Need.  Core Assets works with families across Levels 2, 3 & 4 of the continuum of need.  Role Pseudonym GP GP1 Community Midwife CM1 Health Visitor HV1 Head-teacher, Primary School 1 HT1 Head-teacher, Primary School 2 HT2 Family Support Worker 1 FSW1 Family Support Worker 2 FSW2 Integrated Early Support (IES) Manager IESM1 Integrated Early Support IESM2  9  (IES) Manager Team Leader School Health Service SHC1 Speciality Doctor SD1 Dietician D1 Quarriers Manager QM1 Family Support Worker Core Assets FWS3 Core Assets Manager CAM1   Early Support Assessment Team (ESAT) Manager EM1 Playgroup Manager PG1 Playgroup Manager PG2 Early  Years Worker ESW1 Social Worker   SW1 Social Worker  SW2 Social Work Manager SWM1 Independent Reviewing Of-ficer Service IRO1 Police Officer PO1 Police Officer PO2  NB: The Health Visitor who worked with the family for the first part of the period under review has now left her post and was not interviewed as part of this review.  She is re-ferred to in this report as ‘the Health Visitor’.  1.11 Other Sources of Information  All relevant agencies were asked to provide a chronology of their involvement within the period under review.  A comprehensive multi-agency chronology was compiled.  In addition to information provided during the course of professional conversations, written reports were received from two hospitals that treated Child A for the head injury.  The Review Team accessed a range of written and electronic records including minutes of meetings, assessments, records of referrals and responses.  1.12. Family Involvement  Child A’s parents were informed of the SCR at the beginning of the review process and were invited to participate.  However shortly after this a criminal investigation commenced and consequently this precluded them from making a contribution as the review progressed. The Review Team agreed to keep parental involvement under consideration until the final report was signed off by the LSCB and submitted to the National Panel.   10  In late 2015 the criminal proceedings concluded and the Review Team re-visited the oppor-tunity for the parents to contribute albeit the review had been completed. In early February 2016 parents were provided with a copy of the report.  The LSCB Business Manager on be-half of the review team visited AM to discuss the content.  AF could not be present but had made notes on the report for the LSCB Business Manager.    AM and AFs responses are set out in the addendum of this report at Page 33. Where rele-vant, AM’s comments are also noted in the main body of the report.  At the outset, the Review Team discussed offering Child A and their siblings an opportunity to participate in the Review; however due to the circumstances outlined above, a decision was taken to revisit this proposal once police had finished their enquiries. By this time, the report was finalised, but discussions are taking place between the LSCB and professionals working with Child A and siblings to share the report and provide an opportunity to respond should they wish.     1.13.      Parallel Processes  At the time of writing there is an ongoing criminal investigation which may lead to a crim-inal case being submitted to Crown Prosecution Service for prosecution.   1.14. Timescale for completion  The Review Team agreed a completion date of 30th May 2015 with the final overview review being presented to the LSCB on 8th June 2015, followed by submission to the National Panel.  1.15. Diversity Factors  The adults and children in the family are ‘White British’.  No specific diversity factors were identified.   1.16. Background to the Family  AM had been previously known to CSC, having had two children removed and subsequently adopted some years previously.  At this time AM was in a different relationship and none of the siblings involved during the scope of this review had been born, there are references to this throughout the narrative as it was referred to with frequency by professionals and was seen to be a key factor in the relationship between AM and professionals.  AM disclosed to professionals that she had been the victim of sexual abuse in her childhood, she recounted that she had been abused by her father from a young age and had been abused by other males who were part of a ‘paedophile ring’.  She reported that she ‘had to’ perform sexual acts from the age of two years.  She said that she had told people at her school about this but that nothing had ever been done.  There were no formal allegations made and there is no police record of these events.  11   The oldest child of AM and AF was subject to a Child Protection plan in 2004 under the cate-gory of neglect.    In 2007 it is recorded on police CAVA that AF had allegedly had a knife and ‘nicked’ AM to the neck.  AM was not prepared to follow up a complaint about this incident and it was not pursued. AM had also been victim of assault in 2002 by a different partner.  In 2010 the Health Visitor made a referral to CSC reporting that a male was present in the family home who had allegedly been involved in sexual behaviour with a child.  The parents were advised that this was inappropriate and the referral did not progress beyond checking.  1.17 Child A  Child A was known to the majority of professionals involved in the review.  Child A was the second oldest child in the family and was noted to be a lively child who interacted with their siblings in a chaotic way.  Child A was reported to have a particularly difficult relationship with one sibling with whom they often fought and argued.  This behaviour was observed at school and at home.    Professionals commented that Child A seemed to get most of the attention from their par-ents (although this was largely negative attention).  Chid A was referred to services in rela-tion to behavioural problems, undiagnosed ADHD and failure to gain weight. Some profes-sionals observed that Child A appeared to be constantly hungry.  When they were referred to the dietician in August 2014 Child A attended with their father; HT2 noted that Child A seemed to be accompanied by their father on most occasions which she found to be unusu-al.  It was noted that Child A appeared to have few boundaries when they were with their sib-lings; the siblings appeared as a chaotic group who seemed to ‘egg each other on’ to bad behaviour.  Child A was described by HT2 as coming across as quite dominant when seen with their parents and the rest of the siblings and that this felt like an unusual dynamic.    There were concerns about sexualised behaviours and a lack of parental control over what Child A viewed on television early in the morning when they were unsupervised.  HV1 had raised with the parents that Child A may be accessing TV programmes containing ‘adult’ ma-terial.            12     2 Brief Summary of Agency Contacts and Key Practice Events  During the period under review there were numerous contacts between the family and pro-fessionals involved in the case.  The integrated chronology details around 350 recorded con-tacts; the Review Team consider it is likely that there were other contacts and communica-tions with the family during this period.  FSW1 reported that AM made frequent (daily) visits to the local Children’s Centre and spoke to professionals and other staff there on many oc-casions.  An overview of professional contacts is provided below; fifteen of these contacts have been identified as key practice events (i.e. pivotal points in the progression of the case).  2.1 Contacts Between March and December 2012  During this period the main contacts with professionals and the family were with the Health Visitor, the Community Midwife and the Community Paediatrician in relation to routine and non-routine health appointments for the children.    No specific safeguarding concerns were noted by professionals until, in October 2012 AM disclosed to the Health Visitor that AF comes home ‘drunk’ and urinates in inappropriate places.  NB AM disputes that she said this. It was noted by the Health Visitor that the chil-dren appeared to be experiencing inconsistent care and that there were no routines or boundaries in the home.  It was recorded that AM said she did not want family support.  The Health Visitor recorded her concerns and spoke to a Family Support Worker FSW1 about trying to engage with the family.  During October 2012 Child A had two appointments with the GP, one in relation to an acci-dent where they had fallen downstairs; the second regarding a referral to the Community Paediatrician for undiagnosed ADHD.  In November 2012 the Health Visitor noted that she had been told by AM that Child A and another sibling were copying their father and not using the bathroom and toilet appropri-ately and that bedrooms were sometimes soiled.  In December 2012 it was again noted that the family did not want TAF support and that par-ents were reluctant to engage.  FSW1 had conducted a joint home visit with the Health Visi-tor to try to get the family to engage.  FSW1’s first impression was that the family was cha-otic and that the issues they presented were ‘huge’.  FSW1’s first priority was to establish a relationship with the parents to begin to address the needs of the children.  2.2 Contacts from January 2013 Onwards  Key practice event 1: In January 2013 a professional’s meeting was held to discuss concerns about the family which included long standing issues in relation to parenting, AM’s disclo- 13  sure of historic sexual abuse as a child.  The removal of two older children and concerns about negative parenting.  The result of the professional’s meeting was to initiate a TAF and allocate FSW1 as support worker to the family.    Later that month a TAF meeting was held where it was noted that Child A could be frustrat-ed and angry and that they showed some sexualised behaviours.  Health issues in relation to other siblings were also discussed at the meeting.  Between late January and September 2013 TAF meetings took place on a regular basis, the family appeared to be engaging with FSW1 and the TAF plan was being followed.  The par-ents attended a Webster Stratton parenting course and conditions in the home appeared to be improving.   On one occasion in April 2013 AM asked to see the Health Visitor and told them that she had no money to buy food as AF was unable to go to work after falling of his bike whilst ‘drunk’.   In August 2013, whilst AM was in hospital, the children were being looked after by AM’s mother who reported that AF had not returned home.  Police looked into the report, how-ever AF returned home later that same day and no child welfare concerns were noted by police.  Key practice event 2: Towards the end of September 2013 a TAF meeting was held at which all professionals agreed that the family had been provided with sufficient ongoing support and advice to manage routines and boundaries, and that a period of time was required to assess whether parents were able to manage independently.  A decision was taken to close the TAF as there were no current significant concerns – there had been no incidences over the summer holidays and parents reported they had had positive experiences with the chil-dren.  The School Nurse was to continue to monitor the height and weight of the children.  Key Practice Event 3: In November 2013 a new baby was born.  Whilst AM was in hospital police received a 999 call from one of the children. An older child and an adult could be heard in the background. There were no requests made and no disturbance heard. Police attended family home and found no concerns. The Hospital would not release AM until they knew she was safe as they had a record of historic domestic abuse by AF.   The hospital team noted previous safeguarding concerns and took robust action to ensure that recent and historic concerns were addressed prior to discharge, this included consulta-tion with ESAT.  Following AM’s discharge from hospital with the new baby HT1 noted concerns regarding the children’s appearance and behaviour.  It was noted that the children appeared hungry, that Child A was thin and pale and that one of the siblings appeared to be ‘sad and quiet’ in the classroom.  HT1 raised these concerns with the parents and arranged a meeting to dis-cuss the issues with them; the parents queried whether this was a TAF meeting, although at that time the TAF had not been re-opened.   14  HT1 telephoned ESAT to share her concerns and it was suggested that the FSW conduct a home conditions assessment and complete a graded care profile and that consideration be given to re-opening the TAF.  A post-natal visit conducted by CM1 noted the room to be dirty and cold, dogs were barking loudly, the children were disruptive and the parents were shouting.  Key practice event 4: In late November 2013 a professional’s meeting was held at which concerns were discussed regarding the children’s emotional wellbeing, lack of food and eat-ing patterns, tiredness, clothing and behaviour.  The children had been asked about why they were urinating in their room, they said they were afraid of the two dogs so would not go to the toilet.  It was agreed that a TAF assessment would be completed by FSW1 and FSW2.  It was also agreed that 1:1 work would take place with children to discuss their wishes and feelings.  The TAF was re-opened.  One week after the TAF was re-opened FSW1 and FSW2 visited the family at home.  The vis-it was said to be a very difficult one.  AF was shouting at the children and Child A was seen to be very angry; they said that one of their siblings did not use the toilet properly.  The FSWs were struck by the way the parents engaged with Child A as if they themselves were children – arguing with Child A rather than setting boundaries.  The situation became worse and the parents did not appear to grasp that they were responsible for Child A’s behaviour.  Following this visit a Home Conditions Assessment was completed with a score of 23 from a possible score of 90.  Key practice event 5:  A few days after the home visit a TAF assessment was completed.  This included a ‘My Views’ assessment with the children.  Two of the older siblings, including Child A said that they fight and don’t use the toilet properly as they are scared to go down-stairs because of the dogs.  Child A said that they hated their siblings and wanted to be the only child.  The parents disputed what Child A had said.  The children’s weights were record-ed and Child A was recorded as not having gained weight, and was referred to the Communi-ty Paediatrician.  A further TAF meeting took place in mid January 2014 where concerns regarding the behav-iour of Child A and a sibling was discussed.  It was noted that the children were receiving the same meals cooked by parents and that they should be weighed again in March.   It was also noted that sessions with Child A and their siblings were ongoing, with the aim of improving their relationships, and that Child A preferred to have sessions on their own.  A referral to the Quarriers service was agreed to undertake further work with the children re-garding their wishes and feelings and relationships.  It was noted that the children appeared unkempt and not always clean.  Key practice event 6:  One week after the TAF meeting Child A was seen by the Community Paediatrician, having been referred by the School Nurse for faltering growth and behavioural difficulties.  Both parents attended the appointment with Child A and reported that they were concerned about Child A’s anger, violence towards one of the siblings and that Child A was using other rooms instead of the toilet.  The Community Paediatrician noted Child A’s  15  weight and made a referral to the Consultant Paediatrician to establish whether there may be a medical reason for Child A’s faltering weight and growth.    The Community Paediatrician also made a referral to Child and Adolescent Mental Health Services (CAMHS) regarding Child A’s behavioural difficulties.  (CAMHS saw Child A with their parents in March 2014.  They did not receive a full assessment as they were not found to have any mental health needs, and was discharged without any further appointments).  Key Practice event 7: In early February 2014 FSW1 and FSW2 visited the family at home.  The home conditions were observed to be cold, dirty and cluttered. A referral to CSC was dis-cussed with the parents.  FSW1 later observed AM with Child A at the Children’s Centre, they were being roughly handled with AM saying that it was because of Child A’s behaviour that the children would be removed by Social Care.  Key Practice event 8: The following day FSW1 and FSW2 made a referral to CART (Contact and Referral Team), they had consulted with senior managers who felt the case should be escalated to Level 4.  The referral set out the TAF’s ongoing concerns about the home condi-tions, presentation of the children, behavioural issues and faltering weight.  The referral also set out concerns about parenting capacity and capability, capacity to change and disguised compliance.  The referral stated that there were ongoing issues of neglect and emotional harm to the children.  The referral made specific reference to Child A’s behaviour towards their siblings, their anger and aggression towards them and their lack of remorse when they had hurt them.  The refer-ral stated that Child A only received attention for negative behaviour which perpetuated these behaviours.  The referral also made reference to AM’s disclosure that she had been a victim of sexual abuse as a child and that she had an inability to form emotional bonds with the children.  There was also reference to historic domestic abuse within her relationship with AF.  In summary the referral stated that despite a TAF being in place for 18 months there had been minimal change or improvement and that the TAF group felt that a Level 4 assessment was required.  Key practice event 9:  CART’s response to the referral was to seek a further rationale from the TAF.  A senior manager from the Integrated Early Support (IES) service expressed her concerns by email that the referral had not been accepted, and received a written response.  The written response stated that the case was not considered by CART to be at Level 4 (it was acknowledged that the case was at ‘complex Level 3’) as parents were engaging with the TAF process and some improvements had been made.  The response suggested that the TAF should continue, that unannounced visits should be put in place and that a graded care profile should be completed.  The response included an offer to reconsider the referral if cir-cumstances changed.  Over the next month professionals involved in the TAF continued to engage with the par-ents and some improvements were seen in safety and in engaging with the children’s health  16  appointments.  It was noted that areas that needed to improve were physical care, hygiene, clothing, approval and responsiveness.  In early March 2014 Child A was seen by the Consultant Paediatrician who could find no un-derlying cause for faltering growth and discharged Child A from the general paediatric clinic with a requirement for height and weight to be monitored on a 6 monthly basis.  Child A was also seen by CAMHS and it was felt that they did not have any mental health needs, Child A was therefore discharged by the CAMHS service.  Over the next few weeks unannounced visits took place to the family home, where some improvements to the home conditions were noted, however, Child A and a sibling were not  using the toilet appropriately and fighting between them was noted (AM reported that Child A had ‘strangled’ the sibling the day before).  An appointment was made for Child A to meet the Quarriers worker to begin work around wishes and feelings, to which both parents agreed.  Over the next four weeks Child A and both parents met with the worker and appeared to engage well.  A TAF meeting was held in late May 2014 at which the parents discussed the behaviour of Child A and their sibling, saying that things had deteriorated and that they were taking food out of cupboards.  Parents refused to take responsibility for the behaviour of the children, saying that it was the children’s ‘fault’.  The parents asked if the TAF would be closed as they were feeling pressurised by having services involved.  Key Practice event 10: In early June 2014 a professionals meeting was held at which FSW1 reported to the Quarriers worker that a man who had allegedly been involved in sexual be-haviours with children had been in the family home. This information had been gained from CSC who had raised the issue of the man having visited the family home in the past.  They had advised parents that the man should not be in the family home with the children. Two days earlier FSW1 had reported to the Quarriers worker that there had been domestic abuse in the family and that AF had been arrested in 2008 for threatening AM with a knife.  Key practice event 11: Three weeks later the children were weighed by the School Nurse and all had lost weight.  This was discussed with FSW2 and a referral was made to CART the fol-lowing day.  Later that week Child A attended a further appointment with the Community Paediatrician where it was confirmed that they had lost weight, the advice was to keep a food diary and a referral was made to the Dietician.  A letter was sent to parents and school with regard to the need to complete and return a ‘Connors 3’ questionnaire with regard to behavioural is-sues.  The day after the referral was received by CSC police received notification from them that a strategy meeting was to be held a week later.  The meeting took place and it was agreed that CSC would begin a single assessment.   17  FSW3 from Core Assets was allocated to the family.  FSW3 visited the family one week later with SW1.  The parents were advised that the FSW3 would be providing regular support to the family particularly in relation to home conditions and mealtimes.  The parents were asked what support they thought they required and said that Child A was really naughty so support with that would be useful.  Over the next four weeks the family continued to receive intensive family support from FSW3, contact with SW1 and SW2 and with Quarriers, who were now also working with Child A’s siblings.  The family moved house to a larger property in early August 2014, condi-tions in the new property were initially poor with no cooker or carpets.  AM was engaged with the local church who were providing assistance.  Key Practice Event 12: Nine days after the family had moved house, FSW3 visited the family at home.  On entering the home FSW3 found that one of the younger siblings was choking and appeared to have something stuck in their throat; parents were not responding to this and FSW3 had to take control of the situation.  Whilst FSW3 was there SW2 arrived and was informed of the choking incident.    SW2 went to speak to one of the older siblings upstairs and found writing on a bedroom wall about AM hurting one of the children, this read ‘I hate my mum because she hurts me every day – and that’s true’.  Key practice event 13: The following day SW2 visited the family home and found the young-est sibling face down on the floor of the lounge fast asleep, SW2 said he feared that they might be dead.  AF’s reaction was one of unconcern saying about the child that ‘they would sleep anywhere’.    Key Practice event 14: SW2 raised his concerns with his manager and initiated a strategy meeting with police that took place the following day.  Concerns were discussed and were felt to have escalated in the last week. The decision of the strategy meeting was that the threshold for referral to child protection was met. Only police and CSC were involved in this strategy meeting.  The following day during a home visit FSW3 noted that the parents said that the children had been stealing from the fridge.  It was also noted that some of the children had minor in-juries, cuts and scratches.  This was discussed with the parents who could not account for these injuries, but gave an unconvincing account of bruising to one of the older siblings.  FSW3 informed AM that she would be reporting these injuries to CSC.  In early September the older siblings, including Child A, started at Primary School 2.  HT2 felt that the parents had been open and honest about their involvement with services.  The school identified that, although parents had expressed concerns about Child A’s behaviour, they had more significant concerns about one of Chid A’s siblings who appeared to be a sad and isolated child.  Key Practice Event 15: In mid September an Initial Child Protection Conference was held at which the family were present.  The Conference Chair requested that Core Assets provide vis- 18  its on seven days per week; this was felt to be excessive as it is unusual to have more than two visits per week in most cases.  It was agreed that five visits per week be provided.  The meeting discussed TAF having been in place for 18 months with minimal change.  Parents disputed all the points made by professionals.  The risks identified were poor supervision leading to fighting amongst some of the children, lack of routines and boundaries, basic needs not consistently met, weight loss, the size of the family, emotional impact on the chil-dren of being told they will be taken into care by parents, parents displaying no motivation to change and being defensive and uncooperative.  There was a unanimous decision to continue Child Protection planning under the category of neglect and a core group meeting was set for late September.  Over the next three weeks the family continued to receive intensive support and an-nounced/unannounced home visits.  Primary School 2 reported to CSC that one of the chil-dren had sent a letter to a fellow pupil saying that they wanted to ‘have sex with them’ – it appears that the older siblings had colluded in sending the letter.  The same sibling was also excluded from school for two days for hitting another pupil.  Key practice event 16:  On the day that the incident leading to this review took place, Child A reported for school as usual, accompanied by AF.  There were no signs that Child A was un-well and no report from AF that an incident had occurred at home in which Child A had hurt their head.  Whilst away from the school, Child A became unwell and was taken to a local hospital, from where they were transferred to a specialist Children’s hospital where they underwent emer-gency surgery to evacuate a left sided sub-dural haematoma (bleed on the brain).    That same day CSC and police held a strategy discussion regarding the safety of the siblings and discussed invocation of a Police Protection Order (PPO).  Police visited the family home and reported poor conditions; a further discussion was held with CSC and it was decided to invoke a PPO.  The children were removed from the family home and placed with foster car-ers. Child A was discharged from hospital six days later to foster carers.  2.3 Summary of Key Practice Events  Date/Event Significance January 2013 – Professionals Meeting fol-lowing concerned raised by Health Visitor This brought the family to the attention of a wider group of professionals and was the catalyst for the TAF September 2013 – TAF was closed Professionals agreed that the family had been offered all relevant support and that time was needed to see how they could cope without professional support (this was a missed opportunity to explore why there was minimal change) November 2013 Police received a 999 call from the children whilst AM was in hospital This alerted concerns amongst health staff however police noted no safeguarding con- 19  cerns (this was an indication that AF was not addressing the needs of the children) November 2013 Professionals agreed that the TAF should be reopened Concerns were discussed which led to the TAF being re-opened, this was an opportuni-ty to evaluate whether a higher level of in-tervention was required November 2013 A TAF assessment was completed The assessment contained both positive and negative factors and reinforced the view to continue with TAF December 2013 Child A was seen by the community paediatrician Faltering weight and behavioural issues were discussed.  Referrals were made to Hospital Paediatrician and CAMHS February 2014 A home visit by the FSWs raised their concerns The home conditions were observed to be poor, both FSWs felt that a referral to CART was necessary and informed AM of this February 2014 A referral was made to CART requesting Level 4  A detailed referral was submitted on behalf of the TAF expressing concerns about the wide range of issues and lack of progress in achieving change February 2014 CART assessed the referral and rejected it CART asked for a further rationale for the referral, ultimately rejecting the referral and proposing that the TAF continue and put in place additional checks and assessments, including the graded care profile June 2014 New information is shared about a man accused of sexual behaviours with a child having visited the home in the past. This information was shared by FSW1 with Quarriers (however it does not appear to have been shared with the TAF group?).  This was historic information, not related to any recent events, however, it was deemed to be of enough significance for some profession-als to share June 2014 The School Nurse makes a refer-ral based on concerns about Child A and other siblings weights The school nurse discussed her concerns with the TAF lead and it was agreed that a referral should be made to CART asking for a single assessment to be put in place.  The referral was accepted and a single assess-ment commenced. July 2014 FSW3 visited the family home and found one of the younger siblings choking with little response from the parents  SW2 visited the family home whilst FSW3 was present and found writing on the bed-room wall of one of the children This raised FSW3’s concerns about safety in the home, it was noted and communicated to CSC   SW2 went to speak to one of the older chil-dren in an upstairs room and found writing on the wall about mother hurting the child.  SW2 spoke to the children and parents about this, the children denied having writ- 20  ten it and tried to blame each other July 2014 SW2 visited the family home and saw one of the babies lying face down in the middle of the room SW2’s immediate reaction was that the child appeared lifeless.  They were in fact asleep but the unconcern showed by AF was of concern to SW2.  SW2 returned to the office and initiated a strategy meeting that took place the following day July 2014 SW2 initiated a Strategy Meeting A strategy meeting took place between CSC and Police where it was decided that the case met the threshold for child protection. No other professionals were involved in this strategy meeting. September 2014 An Initial Child Protection Conference was held that was attended by the parents.  Core Assets were brought in to provide additional support sessions for the family.  The meeting was observed to be ‘long and very difficult’. October 2014 Child A presented to school as usual with no report that they had hurt their head earlier that day.  Whilst away from school Child A became unwell and was hospitalised for emergency treatment.    21  3 Professional Involvement in the Case and Analysis of Practice  3.1 Synopsis of Professional Observations  Professionals had been involved with Child A and their family over many years.  CSC were briefly involved in 2004 when the oldest child in the family was subject to Child Protection Planning under the category of neglect.   Professionals saw the family as having multiple issues and as being ‘very complex’.  Despite their engagement with the TAF it was felt that AM and AF were largely resistant to profes-sional involvement.  AF was said to be opposed to any form of support at the outset, but appeared to accept this once the TAF had begun.    Professional observations were that AM presented differently to different agencies, some found her to be co-operative in terms of engagement  with services, whilst others found her to be constantly on edge and never at ease.  AM was highly suspicious of professionals, which was attributed to her previous experience of two children having been removed and subsequently adopted.    AM’s GP noted that AM was a feisty individual who was not afraid to challenge professional views.  Her main contact with the GP was when the children were young, bringing them in for the treatment of childhood illnesses.    AM mostly saw the GP with pregnancy related issues, GP1 and the other professionals in the practice tried to get AM to think about preventing pregnancies as her own physical health was beginning to suffer as a result of numerous pregnancies.  She was prescribed a range of contraceptives, none of which seemed to be effective at preventing pregnancy.  AM does not appear to have ever discussed any issues relating to the disclosure of sexual abuse in her childhood with GP1, nor did she seek any advice or support in relation to emo-tional or mental health issues.  GP1 recalled that she could appear stressed and sometimes angry but he associated this with having to cope with a large family.   CM1 had known AM for some time but had not been required to visit her at home until 2012.  CM1 considered her relationship with AM to be open and honest; AM attended ante-natal appointments and CM1 had no difficulty in engaging her.   Prior the period under review, in an historic pregnancy, CM1 saw a footmark on AM’s stom-ach and enquired about domestic abuse.  AM denied that there was any domestic abuse in her relationship with AM at that time.  CM1 acted appropriately in recording that she had raised the matter with AM and discussed it with her supervisor, which resulted in a contact to CSC. When the TAF began in 2012 the aims were to improve home conditions, the presentation of the children and their behaviours and to strengthen emotional bonding in the family.  Professionals were aware of other issues emerging within the family, including sexualised behaviours that were observed at school and in the home.  These issues were raised at TAF meetings although there is no evidence of actions to investigate or address the causes.  22   The majority of professionals found AM to lack emotional warmth with the children which AM herself attributed to the childhood experiences she had disclosed.  Although she had received ‘low level counselling’ AM did not seek any additional psychological support for these issues, reporting that she found it too difficult to cope with.  FSW1 felt that AM had benefitted from counselling, AM attended twenty sessions following which AM did appear to show some empathy with Child A when they were unwell, which had never been wit-nessed before.    Some professionals observed that AM appeared to be ‘controlled’ by AF - asking his permis-sion to do things.  However professionals also observed her asserting herself with AF in the home environment.  At meetings they appeared as a couple but displayed distraction behav-iours, being argumentative and walking in and out of meetings.  AM often displayed physical symptoms of being unwell during meetings.  Professionals noted that AF appeared to be the parent who took responsibility for the chil-dren.  He took the older children to school and to health appointments.  It was noted by professionals from the nursery that he had a very strong bond with the child attending nursery and this was apparent when he was taking and collecting them from nursery.  How-ever, it was noted by some professionals that AF did not bond with the children when they were babies, that he did not make eye contact with the babies and that he only began to interact with them when they were around six months old. NB This is professional opinion and is disputed by AM.  Following the re-opening of the TAF in November 2013 professionals observed a decline in home conditions and parenting.  When the decision was taken to refer to CART in February 2014 the two FSWs and the TAF group felt that it was no longer appropriate to continue with TAF and that a higher level of intervention was required.  When CART proposed that the case continue to be managed at TAF professionals in the TAF felt demoralised and un-sure as to what they could do next.    It is of note that all professionals observed distracting and diversionary behaviours by the parents at meetings; AM appeared to respond to suggestions to make improvements in the home conditions and in relation to managing the children, however, these were not sus-tained.    TAF meetings were often disrupted by the parents who refused to accept the responsibility they had for managing the children.  The parents blamed the children for their behaviours and argued about the best way to improve things at home.    All professionals felt that the family stood out and that they were unusual.  This was be-cause of the size of the family and also because of the interactions observed between them.  The majority of professionals observed a lack of warmth and emotional bonding between AM and the children.  This was particularly apparent when AM was observed with the older children, although some professionals also noted that AM was negative towards the unborn during later pregnancies.   23  PS1 had been very involved with the family for a number of years having had the children with them since nursery.  When the family engaged with TAF PS1 continued to have signifi-cant involvement in the process, with FSW2 leading the TAF.  FSW2 had known the family for some time. FSW2 began leading the TAF and found that the family engaged very well with agencies.  There were several professionals involved with the family, the aim of the TAF was to achieve an improvement in home conditions, to ensure that the children were doing well and that school attendance was good.  Both parents seemed to find it difficult to praise the children; this was particularly marked with AM.  It was noted that AF appeared to have a stronger bond with some of the children than others.  FSW1 noted that AF did not bond with the children when they were first born and did not show much interest in them, he didn’t make eye contact with them and attend to their needs.  It was only when the children reached the age of around 6 months that AF began to bond with them.  Both parents seemed to withdraw emotionally from the children when they were around age 5 or 6, this was particularly apparent with Child A and one of their older siblings.  When Core Assets received the referral neither alcohol abuse or domestic abuse was men-tioned.  FSW3 recalled calling to the house on a Sunday and hearing there was a commotion inside, AM handed the baby to FSW3 and said, just take them I can’t handle it any more.  FSW3 went into the kitchen with AM after sorting the children out; AM said AF ‘comes in drunk; he is useless most of the time’.  Two professionals separately made reference to a specific event where they felt that one of the children had been intimidated by AF in a particular way; when asked about this event the parents had said that this was a prank and should not be taken seriously. However, pro-fessionals described the child as visibly distressed and affected by the incident. This had giv-en rise to concern by these professionals and was felt to be indicative of a neglectful ap-proach to the emotional wellbeing of the child.  NB. At the point of discussion with the LSCB Business Manager the parents continued to dispute the circumstances of this inci-dent.   When observed together by professionals, both in the home and in other settings, the older children were often said to be out of control, wild, chaotic and ‘almost feral’.    When the children changed school in September 2014 parents had said to HT2 that they were most concerned about Child A’s behaviour, however HT2 felt  more concerned about one of the other siblings who was described as being ‘a very sad child who had no self-esteem or sense of self-worth’.  The relationship between Chid A and this sibling appeared to be hostile; they fought and argued a great deal.    HT2 observed the relationship between AM and AF to be tense at times.  AF appeared to be controlling of AM with AM ‘checking out’ decisions with him all the time.    When SW1 and SW2 had become involved with the incident that led to this review, both parents had become hostile towards professionals, they were constantly complaining about professionals and reporting them to other agencies, saying that professionals were not turn- 24  ing up to appointments to support them in the home.  The children appeared to be afraid to speak in front of professionals, having been told by their parents that they would be taken away if they said anything.  This created a tense and difficult situation between parents and professionals which continued until the children were taken into foster care.  3.2 Analysis of Professional Practice in the Case  There is clear evidence that professionals involved in the case worked hard to support the family.  There were no issues of professional misconduct or malpractice.  Professionals worked well together although the large number of professionals involved with the family may have enabled AM and AF to cause distractions and feign compliance. The nature of parental engagement and disguised compliance was recognised by the majori-ty of professionals working with the family and was discussed at professional meetings and cited in the referral made to CSC in February 2014.    Because the parents appeared to make occasional improvements (although these were not sustained) this led to an over-optimism in relation to parenting capability and motivation to change.  There was no formal assessment of parenting capacity or capability conducted which would have enabled professionals to measure motivation and change over time.  There was a strong focus from professionals on the home conditions, the presentation of the children and their physical health. Professionals also shared concerns about the lack of emotional warmth, specifically from AM towards the children.  This may have had the per-verse effect of professionals not exploring the underlying causes of neglect, emotional abuse and the behavioural problems of the children.  The majority of professionals were aware of AM’s disclosure of sexual abuse and her inabil-ity to show emotional warmth to the children.  AM was offered ‘low level’ counselling to explore the impact of her childhood experiences.  Professionals did not know what else could be offered to AM, particularly as she told them that she did not want to think about what had happened to her as a child.  It was recognised by professionals that AM attributed her lack of emotional warmth to her earlier experiences, and that this had an impact on her relationship with the children, however, there seemed to be nothing more that profession-als could do to address these issues.  Interactions and information sharing between professionals was of an expected standard. In general meetings were well attended and actions were followed up and completed.  The interaction between TAF group and CART was described by members of the TAF group as being hierarchical.  The escalation policy was not used by the TAF group to challenge the decision not to accept the referral in February 2014, although professionals in the TAF were aware of the policy and procedure. IESM1 did challenge the decision made by CART in Feb-ruary 2014 but this was not taken any further.    Professionals referred on more than one occasion to the recent transformation programme and noted that the structure of services had changed significantly over the past 18 months.  Whilst there were some benefits to this restructure, which was becoming apparent to pro- 25  fessionals now, there had been some early difficulties in communication between services.  This was particularly the case where Level 3 services had been decommissioned from Chil-dren’s Social Care and a new provider, Core Assets brought in.  It was not clear to the Review Team how assessment tools such as the Edinburgh Depres-sion Inventory, Domestic Abuse Risk Assessment tools and other risk/harm assessment tools were used by professionals to build a complete picture of risk/harm and protective factors within the family.  All professionals received management and supervision within their own agencies, and managers were appropriately consulted in relation to safeguarding and referral decisions.  However oversight of the TAF group was lacking.    Professionals were focused on the needs of the children and ensured that their wishes and feelings were considered at all meetings, and through referrals to commissioned services.                               26  4 What does the case tell us about the local system for safeguarding children    4.1 Analysis of key themes from the case and description of findings for learning and improvement  Meaningful analysis of the complex human interactions and decision making processes that are involved in multiagency work with vulnerable children needs to understand why things happen and the extent to which the local systems (people, work processes, organisational arrangements) help or hinder effective work locally within ‘the tunnel’1.   This section sets out the key findings designed to offer challenge and reflection for the Cheshire West and Chester LSCB and partners.   a) The key findings are framed using a systems based typology devel-oped by SCIE to identify some of the underlying patterns that appear to be significant for local practice in Cheshire West and Chester, these typologies are: b) Cognitive influence and human bias in processing information and ob-servation; c) Family and professional contact and interaction; d) Responses to significant incidents and information; e) Tools and frameworks to support professional judgment and practice; f) Management and agency to agency systems. The remainder of this report uses this case to reflect on what this reveals about gaps or are-as for further development in the local safeguarding system.   In providing the reflections and challenges to the Cheshire West and Chester LSCB there is an expectation that there will be a response to the key findings in regard to the following:  a) An indication as to whether the CWACLSCB accepts the findings; b) Information as to how the CWACLSCB will take any particular findings forward; c) Information about who is best placed to lead on any particular activity; d) An indication of the timescales for responding to the findings; e) Information about how and when it will be reported.  The CWACLSCB will determine how this information is managed and communicated to rele-vant stakeholders.  The formal response should form part of the publication of the SCR.   p 1 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the per-spective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight.   27  4.2 Finding 1 TAF Meetings and Process (typologies Family and Professional Contact and Interaction; Responses to Information and Incidents; Tools to Support Professional Judgment and decision making; management and agency to agency systems)  TAF provided a useful process by which to engage the family and establish professional relationships with them.  However, the TAF lost impact over time, primarily because the family’s needs and complexities required a higher level response.  Professionals involved in the TAF attempted to escalate the case on two occasions, on the first occasion without success.  4.2.1. TAF was in place for 18 months (other than a break of two months between Sep-tember and November 2013).  It is the view of the Review Panel that a quality assur-ance process needs to be in place to ensure that TAF is running effectively and that the case is still appropriate to be managed at TAF level. 4.2.2. The parents engaged in TAF meetings however they appeared to dominate the agenda and manipulate the meetings by disputing points raised by professionals, us-ing diversionary behaviours and feigning compliance with recommendations made by the TAF.    Questions for the Board to address:   What can be done to improve quality assurance of TAF?  How can professionals be supported in discussing concerns at TAF level where par-ents are disruptive and distracting in meetings, thereby stifling debate and divert-ing focus?  What can the Board do to enshrine review of TAF referrals to CART to quality as-sure decision making?                      28   4.3   Finding 2: Parenting Capacity, Capability and Motivation to Change (typologies Family and Professional Contact and Interaction; Tools to Support Professional Judgment and de-cision making)  All professionals judged parenting capacity and capability to be poor; however no formal parenting assessment was ever undertaken, there was no assessment of motivation or capability to change, nor any formal assessment of causal factors such as disclosures of historic sexual abuse.  Parenting capability and motivation to change was a key factor in this case, professionals appeared disarmed by factors such as historic sexual abuse, potentially abusive relation-ship between parents and sexualised behaviours  4.3.1.  It was apparent throughout involvement with the family that parents lacked capacity and capability and that motivation to change was low.   4.3.2.  Factors influencing parenting capacity such as disclosure of historic sexual abuse, domestic abuse and alcohol misuse were known but not explored fully. 4.3.3.  There is no evidence that a formal parenting assessment took place, although parents were referred to, and completed a ‘parenting course’.    Questions for the Board to address:   Are professionals working at TAF level equipped to address issues of parenting ca-pability and causal factors?  What professional support exists for discussion of causal factors where these re-quire specialist consideration (e.g. historic sexual abuse)?  Are the tools for parenting assessment easily available and understood?  What quality assurance measures are in place to ensure that parenting assess-ments take place and are acted upon?                  29      4.4 Finding 3:   Neglect and emotional abuse are one and the same in the mindsets of some professionals.  This resulted in the clear issues of emotional abuse being obscured by responses to neglect that were focused on seeking visible improvements.  4.4.1  Despite all professionals identifying emotional abuse having a profound impact up-on the children the causal factors and impact of emotional abuse was not fully ex-plored. 4.4.2 Categorising the presenting issues under the banner of ‘neglect’ created a tendency to become focused on evidence and events 4.4.3. Professionals found it difficult to separate neglect and emotional abuse, it may be helpful to revisit these categorisations to support the hypothesis that emotional abuse can stand alone from neglect and has a significant and ongoing impact on out-comes for children 4.4.4. It appears that CAMHS focus on identifying a recognised mental health condition re-sulted in the causal factors for Child A’s behavioural issues remaining unexplored 4.4.5. The causal factors for the sexualised behaviours of the children were not fully ex-plored  Questions for the Board to Address   What can be done to strengthen focus and responses to emotional abuse?  Is the current ‘neglect strategy’ sufficiently clear in guiding professional decision making?  What can be done to strengthen assessment of behavioural problems in non-specialist services to ensure that causal factors and behaviours are fully assessed?  Do professionals have the knowledge, skills and support to assess sexual abuse (as opposed to Child Sexual Exploitation)?                  30   4.5  Finding 4:    The use of tools to assess and refer lacks rationality; some tools are per-ceived to be intrusive and lacking in usefulness whilst other are useful but require integra-tion  4.5.1. The Graded Care Profile was not implemented when first recommended by CART.  This is because it was seen as being intrusive and too detailed.  This may be profes-sional bias or choice but is an important indicator of the interpretation of this tool and its application 4.5.2. The Home Conditions Assessment was used on several occasions and appears to be a useful tool but needs to be seen in context with other assessments to make it mean-ingful 4.5.3. Some agencies using different assessment tools (e.g. Core Assets – Signs of Safety), this may add to depth of understanding and guide responses, however these tools should be integrated into the wider system to ensure that they have legitimacy and authority 4.5.4. The quality of the initial referral via MARF has a significant bearing on whether refer-ral to Level 4 is accepted.  Further training on the completion of MARF may be re-quired to enable professionals to best represent their concerns in this format.  There was a  feeling from professionals of this being a process of ‘trying to get something over the threshold’ 4.5.5. Domestic Abuse Risk assessments do not appear to be formally used or integrated alongside other risk/need assessment tools.  Questions for the Board to Address   What steps can be taken by the Board to ensure that the current suite of assess-ment and referral tools being used are fit for purpose, clearly understood by pro-fessionals, quality assured and integrated?                    31    4.6  Finding 5: The escalation policy was not used to challenge decision making in this case; this is reflected in other Practice Learning Reviews conducted by the Board, suggest-ing that there is a systemic issue in relation to escalation.  4.6.1.   Although a challenge was made in relation to the decision not to accept the case at Level 4 following referral to CART in February 2014 this did not follow the policy in relation to escalation.  When the challenge was rejected there was no further action to escalate the decision despite professional dissatisfaction and concern.  Questions for the Board to Address   What action can the Board take to ensure that escalation is seen as a positive ac-tion to protect children?  What support do professionals require to enable them to use escalation appropri-ately?                                32     5 Wider Learning   5.1       Sharing of Information across all agencies  Although information sharing in this case was generally of a good standard, there were two areas in which professionals suggested that information sharing could be improved.  These were   (i)   Sharing of safeguarding concerns and other relevant information with the Nursery. The Nursery in this case had been operational for around 18 months and was run by a not for profit provider, which was relatively new to the local community.  It was felt that it had tak-en some time for the Nursery staff to become known and ‘embedded’ in the local communi-ty and professional network, which may have contributed  to them being outside of the in-formation sharing network.  However, the importance of involving Nurseries in safeguarding practice and systems has been highlighted in this case.  (ii)   Sharing of intelligence and relevant police information with schools.  HT2 felt that shar-ing of this type of information did not take place routinely.  This may be because PS2 is lo-cated outside of the host Local Authority area.     5.2  Involvement of All Agencies in Strategy Meetings and Discussions  The strategy meeting called by CSC in August 2014 included only police and CSC.  Whilst this may not be a systematic issue, it is important to reinforce the need to include all agencies in such meetings and discussions to ensure that all aspects of the case are considered.   5.3  Responding to Domestic Abuse  Responses to domestic abuse are often ‘incident’ led.  Domestic abuse was recognised by professionals in this case (both as a historic and current issue) however it does not appear to have featured as a significant factor in discussions at professional, TAF or other meetings.    5.4  Impact of Service Redesign  Joint working and reintegration following major service redesigns is becoming stronger, however further work is required to integrate new services following restructure and rede-sign.        33  6.1 Addendum – AM’s Comments on the Report   6.1.1 On behalf of the review group, the LSCB Business Manager delivered a copy of the re-port to AM and AF. A follow-up visit was scheduled to give parents an opportunity to discuss the content of the report and provide their perspective. AM was present and provided a re-sponse of behalf of both parents. AF although unable to be present, provided a written re-sponse to aspects of the report that were discussed more fully with AM.   6.1.2 Specific feedback was received in relation to the following:  6.1.3 AM said the report suggested that the family had received a lot of support and that this was not the case.  AM specifically challenged the statement that the family sup-port service was provided on a frequent basis and that the family did not receive seven or even five visits per week.  This does not correspond with information re-ceived from the agencies who report high levels of contact and support.   6.1.4 AM has been provided with information to enable her to complain about the service in question as this is not within the remit of the review.  6.1.5 AM disputed that the parents had been told about poor home conditions when they received notification of Child A’s accident.  This does not correspond with profes-sional accounts of the information provided.  6.1.6 AM highlighted that the move to another property took place at only one day’s no-tice and that this impacted the home conditions.  6.1.7 AM felt that the wording of the report implied disbelief of her disclosures in relation to historic sexual abuse.  It was agreed that this would be reviewed as there was no intention to suggest that AM had not been telling the truth about these events. The author has reworded sections of the report as appropriate to ensure that no bias is implied.  6.1.8 AM said that references made to an incident of a child ‘choking’ were untrue and that the child was not in distress.  Two professionals were present when this event took place, their recollection of events is different to AM’s.  6.1.9 With regard to writing on the wall of the bedroom about ‘mummy hurting me’ AM said that this was already present in the house when they moved in and that it was inside a wardrobe. The professional recollection of this is different to that of AM and is documented in professional records.  6.1.10 AM disputed the account of the incident when SW2 said he saw one of the siblings asleep on the floor and thought he was dead. This differs from the professional’s recollection of this event.  6.1.11 AM disputed the accuracy of events described on Page 23 of the report as follows:   34  6.1.12 AM disputed that AF did not bond with the babies.  The text has been changed to illustrate that this is professional opinion.  6.1.13 AM disputed that she told a professional that AF came home drunk.  This is not the recollection of the professional.  6.1.14 AM disputed the professionals account of the incident referred to in Section 3.1, page 23 or that AF had intimidated the child.  A note has been made in the body of the report that AM disputes this.          