Injuries and hospitalisation of a 2-and-a-half-year-old boy in 2020. Child G was found to have a depressed skull fracture, resulting in a section 47 enquiry. Learning is embedded in the recommendations. Recommendations include: decisions stated in MASH outcomes as 'necessary' need to be actioned; MASH decisions which are not the outcome of strategy discussions and require adjustment to reflect local considerations and knowledge of the family must have a clear rationale recorded; workers and agencies who are key to the understanding and progress of a case should always be kept updated; the possibility of non-accidental injury should always be considered in the case of multiple injuries and bruises and when parents' explanations for these are inconsistent; professionals should always check the history, past referrals and the social worker/social work team to ensure all relevant and significant information is gathered; social care should routinely update all agencies involved in a case; all professionals involved in a case should ask questions and get clarity about the key adults in a child's life, and these questions should be standard practice for supervisors and managers to ask at supervision; all professionals should be guided to read the Child Safeguarding Practice Review Panel's report 'The myth of invisible men' (2021); supervision in social care must always allow for reflection by the social worker.
      
 Title:  Local children’s safeguarding practice review Child G: overview report. LSCB: Suffolk Safeguarding Partnership Author: Tracy Murphy Date of publication: 2022  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 Children’s Safeguarding Practice Review Child G  Overview Report November 2021 Author: Tracy Murphy, Professional Adviser, Suffolk Safeguarding Partnership      Page 3 of 16 Contents 1. Introduction and Background to the Child and Family ................................................................ 4 2. Scope of Review ........................................................................................................................ 4 National Themes ........................................................................................................................ 4 Methodology .............................................................................................................................. 5 3. Organisational Context .............................................................................................................. 5 4. Analysis of Agencies’ Actions .................................................................................................... 6 Key Findings .............................................................................................................................. 6 Discussions with the MASH ....................................................................................................... 7 Discussions with the Nursery ..................................................................................................... 8 Discussions with Health Practitioners ......................................................................................... 8 Discussions with the Social Worker ........................................................................................... 9 Discussions with the Social Care Managers ............................................................................. 10 5. Recommendations Emerging from this Review ........................................................................ 12 Addressing the National Themes ............................................................................................. 13 6. Glossary .................................................................................................................................. 14     Page 4 of 16 1. Introduction and Background to the Child and Family 1.1 At the time of this review period, Child G was reported by his mother to be living at home with her and her partner. It is important to note that no professional got to see him at his home during the period of this review. The review is addressing the period of time when Child G was two and a half years old. Child G had limited contact with his birth father due to the father shielding during lockdown. He attended nursery for 18 hours a week from September 2020 and was receiving support from the Health Visiting service. Child G was open to Social Care from November 2020. Following a strategy discussion in the MASH on the 10th of November 2020 it was determined that the threshold for Section 47 was reached. Prior to this, the case had been open in Social Care for reasons of neglect. A social work assessment was completed with recommendation for support from Early Help. Early Help had undertaken a Graded Care Profile 2 and held Family Network Meetings. The case closed to Early Help in February 2020. No support or intervention from Early Help or Social Care took place from February 2020 to November 2020 because the family weren’t raising any concerns. 1.2 Child G is now living with Foster Carers. He has weekly contact with his mother and father and sees his grandparents within these contact sessions. He has been able to progress and achieve developmental milestones and responds well to positive praise and rewards. He is also making good progress with his health, and he can see and hear. He is attending nursery. He is described as a playful and happy child. 2. Scope of Review 2.1. The review covers the period from the 9th of November 2020 to the 24th of December 2020 and focuses on the multi-agency involvement during that period. The review will identify and consider the key findings from agency and practitioner discussions, address the learning from the case and will make recommendations as part of the learning. Chronologies and case records from Liquid Logic and SystmOne were explored and have informed the review alongside the learning discussions with the practitioners and managers involved in the case 2.2. The key themes identified for this review are:  • To establish whether there are lessons to be learned from the circumstances of the case about the way in which local professionals and agencies work together to safeguard adults • To review the effectiveness of procedures (both multi agency and those of individual organisations) • To inform and improve local interagency practice • To improve practice by acting on learning (developing best practice) • To prepare or commission a summary report which brings together and analyses the findings of the various reports from agencies in order to make recommendations for future action. National Themes 2.3. The review will also explore how the six key practice themes that were identified in the Child Safeguarding Practice Review Annual Report 2020 can be addressed as part of the learning from this case. The national report states that ‘we expect these six themes to be a focus for shared learning with safeguarding partnerships, and nationally, to improve the safeguarding system’. These six themes are: • Understanding what the child’s daily life is like • Working with families where their engagement is reluctant and sporadic • Critical thinking and challenge • Responding to changing risk and need • Sharing information in a timely and appropriate way • Organisational leadership and culture for good outcomes  Page 5 of 16 Methodology 2.4. A series of in-depth discussions which asked key questions based on the review themes were undertaken with the key practitioners involved in the case from Health, Social Care, the MASH and the Nursery. The key findings and recommendations have been established through these discussions.  3. Organisational Context 3.1. The time period that this review is addressing (9th of November 2020 to the 24th of December 2020) concerns an exploration of the practice across all involved agencies who were working with Child G and his family. A summary of the events that happened during this time period is outlined below.  3.2. On the 9th of November 2020 Child G was brought to the GP practice for a head injury. The GP had been contacted by Paramedics due to Child G suffering a head injury. The Paramedics considered that the injury didn’t warrant their involvement but did need a GP to be involved. The GP tried to contact the paediatric consultant on call at the local acute hospital but after getting no response, felt it best for the child to go to the Emergency Department. The GP spoke to a nurse at the acute hospital. Child G was taken to the Emergency Department for an assessment and was then discharged. The GP completed a MASH referral stating his concerns about the head injury, two previous head injuries, bruising around the eye and with a question mark over possible neglect. 3.3. A strategy discussion was held between Police, Health and Social Care which concluded Single agency Section 47 enquiries, a Social Work assessment to be included. The MASH also concluded that a paediatric assessment should be undertaken. The strategy discussion took place on the day the referral was received from the GP.  3.4. Child G sustained a further injury to his eyebrow on the 12th of December 2020. Child G’s mother phoned the GP surgery on the 14th of December 2020 for advice stating that the injury had been sustained by Child G jumping on his bed and cutting his eyebrow on the corner of the bed. She reported that she had contacted 111 and they had advised her to steri strip it and call the GP on the Monday. The GP stated that she was to call and arrange to see a Practice Nurse if she had any concerns about how it was healing.  3.5. Child G’s last day at nursery was the 13th of December 2020. 3.6. Child G’s mother phoned the nursery on the 13th of December 2020 to say he had been sick in the night and wouldn’t be coming to nursery. 3.7. On the 24th of December 2020, a safeguarding referral was received following Child G being admitted to hospital on the 23rd of December 2020 with concerns for a suspected cardiac arrest. A CT scan was undertaken which showed a depressed skull fracture. A strategy meeting was convened with outcome of joint Section 47.  3.8. Although outside of the timescales for this review, it is important to note that there were seven previous referrals to the MASH between April and October 2019. These were largely anonymous referrals from non-professionals with concerns about the mother’s lack of care of Child G including drug taking, drugs being delivered to the house, mother spending most of her time out late in the pub with Child G, evidence of neglect in the home and mother asking people for money. A social work assessment was opened and completed in August 2019. The recommendation from the social work assessment was for Child G to be supported with a plan under Early Help. A Graded Care Profile1 was undertaken in Early Help and was graded at 2s2 and 3s3. Early Help closed the case in February 2020 following good progress being made.  1 Deliver NSPCC services in your area | NSPCC Learning 2 Definition of a Grade 2: “All essential needs are always met. The child is a priority”. 3 Definition of a Grade 3: “Most of the time the essential needs of the child are met. The child and the carer are on par”.  Page 6 of 16 4. Analysis of Agencies’ Actions Key Findings 4.1. The GP tried to contact the paediatric consultant at the hospital on numerous occasions at the time of the head injury on the 9th of November 2020 before Child G was sent to A and E. Because there was no reply from the paediatric consultant at the hospital, the GP contacted the Emergency Department instead. The GP referral from this injury needed to be clearer with explicit details about the concerns. 4.2. The MASH is comprised of specialist Safeguarding Officers from Police, specialist Safeguarding Nurses and Consultant Social Workers who are charged with the task of making decisions on contacts and referrals and they were clear in the recordings that the outcome from the referral on the 10th of November 2020 was a unanimous agreement that the threshold for a S47 had been met and that “a paediatric assessment is necessary to ensure that there are no further injuries to Child G”. The social care team should have held a further strategy discussion with a paediatrician as stated by MASH practitioners.  4.3. The nursery received very little feedback or updates from social care and the Health Visitor during the critical week before Christmas and were unsure as to who was leading on the case at this time. The duty social worker did return calls to the nursery but there is no evidence of advice to the nursery regarding what they could do. The Social Worker going off sick and the case remaining unallocated with no lead worker contributed to the lack of any updates and feedback on Child G. 4.4. All agencies and professionals involved directly with Child G and his family, noted the lack of warmth and empathy shows towards him by his mother along with the poor interaction, poor supervision, and lack of any concern for risk. 4.5. The GP surgery are not currently on SystmOne and this impacted on their ability to check key information about Child G and the family. They were unaware that the case was open to social care with an allocated worker. The GP surgery didn’t receive updates on Child G from the social work team. 4.6. The Social Worker was concerned about the accounts of the injuries the mother was giving and her presentation at nursery when she was due to see Child G on his own. 4.7. The Practice Manager and Consultant Social Worker both advised that the expectation would be for conversations to take place with the other agencies and for the Social Worker to see the mother’s partner. The Practice Manager advised that she was not aware that this hadn’t happened. The Social Worker spoke to the nursery but didn’t manage to speak to the Health Visitor as part of the Section 47. A further opportunity to gather this information as part of the assessment was missed because the Social Worker went off sick. The assessment wasn’t undertaken, and the case was left unallocated with the assumption that the sick leave was to be short term. The social work team considered that because the case was child in need, it wasn’t a priority for reallocation. 4.8. Two opportunities for a paediatric assessment were missed by agencies, the first occurred at the initial hospital attendance when the GP attempted to contact the Paediatric Consultant and then after the MASH decision and recommendation. If the paediatric assessment had taken place, the history of the injuries and inconsistencies in the accounts of the injuries from the mother would have been fully considered.  4.9. The social worker never met the partner who lived with Child G and his mother. 4.10. There was confusion in both Health and social care as to who were the parents of Child G. There was an assumption made at the hospital that the male who attended with Child G and his mother was his birth father. It was unclear on the referral as to who ‘dad’ was and as a consequence, MASH workers were also unclear as to was Child G’s father. MASH Health colleagues consider that the lack of an initial trawl on Liquid Logic, impacts on their ability to establish who are the key adults in a child’s life.  4.11. The Social Worker had worked hard to develop a trusting relationship with Child G’s mother.  Page 7 of 16 4.12. Supervision sessions were regular, and concerns were discussed as part of this, however there was little opportunity in these sessions for reflection and deeper discussion of the case.  4.13. The Social Worker said that she was always worried about this case and the escalation of injuries. 4.14. The Practice Manager said that the decision in the MASH for a paediatric assessment remains a consideration for them unless a Paediatrician has agreed it as part of the strategy discussion. Because a Paediatrician wasn’t included in the Strategy Discussion for Child G, they felt that they would then make the final judgement on the need for a paediatric assessment. 4.15. It is clear in discussions with MASH Health that a lot of time and research had been spent contacting key Health professionals and gathering the evidence from Health in order to reach their conclusions with regard to the paediatric assessment and the Section 47. 4.16. There is some confusion and lack of clarity in this case due to the fact that recordings in social care were put on Liquid Logic retrospectively. Discussions with the MASH 4.17. The initial referral from the GP on the 10th of November 2020 was limited in its content and came into the MASH the day after the head injury incident and the visit to the GP and the hospital. The MASH was initially unaware that Child G had been discharged from hospital. 4.18. The MASH practitioners reported that the information they received from the GP had been impacted on by the chaotic nature of the visit by the mother to the GP surgery and it was unclear if the GP was aware of the Emergency Duty Service (EDS). 4.19. The MASH noted that there was a disconnect regarding the communication between the GP and the hospital. This was because the GP couldn’t get hold of the paediatric consultant. As a consequence of not receiving any replies from the paediatrician, the GP contacted the paediatric nurse. 4.20. The referral that came in on the 10th of November 2020 was the seventh referral for Child G. The MASH was concerned about the number of referrals and the reasons for the referrals which was largely neglect and parenting of Child G found wanting.  4.21. The discussion the MASH had with the nursery gave a clear picture of the events and the alleged incidents.  4.22. There is an understanding in the MASH that all agencies and partners should be adhering to Working Together 2018 and an expectation that when the MASH has stated on the outcome that something needs to happen, that it will be acted upon in Social Care Teams as per the advice from the Assistant Director. The decision from the referral on the 10th of November 2020 is recorded as a unanimous agreement for a Section 47 and a paediatric assessment to be undertaken. For those strategy discussions which involve the paediatric service, the MASH will always seek to include the receiving Team in the discussion. MASH stated that it is their objective to include the Teams at the strategy discussion stage. MASH staff confirmed that there is an expectation that all decisions made in the MASH are to be acted upon and if they aren’t, then there needs to be a written rationale as to the reasons why not. 4.23. There is a MASH/fieldwork interface meeting which meets monthly to have conversations with Social Care Teams and discuss decisions. These conversations enhance learning and develop relationships between the MASH and the Teams. 4.24. The importance of clarity and information regarding blended families – the ‘Relationships’ section in Liquid Logic can sometimes cause confusion with regard to who is in a family and who the key people are. The MASH practitioners felt that they hadn’t explored the family dynamics of dad and mother’s partner as fully as they should have, but also agreed that it wasn’t clear on the referral. Their focus had largely been on the history of Child G and gathering the story. 4.25. Where a decision has been made for sec 47 enquiries, either joint or single agency, there will be an immediate handover to the Practice Manager/Consultant Social Worker of the CiN team to complete the strategy discussion to plan the sec 47 enquires with the relevant partner  Page 8 of 16 agencies. A statutory assessment is assigned to the team’s duty tray in Liquid logic and a telephone call is also made to the team’s Assessment Co-ordinator.” Discussions with the Nursery 4.26. Child G attended nursery from September to Christmas 2020. Up to the October half term, the nursery had no concerns for Child G. After the half term holiday, Child G started coming to the nursery with bruises and injuries. 4.27. The nursery noted that Child G’s mother showed little warmth or empathy towards him. 4.28. On each occasion that the nursery mentioned the bruising and injuries to Child G’s mother and asked for an explanation as to how he had received them, her answers were inconsistent, and the explanation and story changed. The explanations concerning the injuries ranged from hitting his head on a cupboard door or the corner of a table and that he had pinched himself on the cheek. She also said that the bruising and injuries had happened when she wasn’t with him. 4.29. In the week before Christmas, the nursery was becoming increasingly concerned about the injuries and bruising that Child G was sustaining. He received an injury to his eyebrow on the 12 of December 2020. Child G stopped coming to nursery on the 13 of December 2020. The explanation given by his mother for him not attending after the 13th was that he had been sick in the night and wouldn’t be coming to nursery for two days. The nursery closed for Christmas on the 17 of December 2020.  4.30. The nursery staff were very concerned for Child G and the escalating injuries during the week prior to Christmas knowing that they wouldn’t see him for three weeks. They persistently phoned the Duty Social Worker and the Health Visitor during this week to ensure that they were aware of their concerns and worries for him. They were assured that Child G would be seen over the Christmas period. The nursery said they were unsure at this time as to whether the allocated Social Worker was still leading on the case as they were directed to the Duty Social Worker on each occasion. On the occasions they had to leave a message, they did receive calls back on more than one occasion from the Duty Social Worker but were not made aware of the action undertaken following their calls. They feel that they weren’t listened to fully enough about their concerns for Child G.  4.31. The nursery staff didn’t know the process for a Section 47 Enquiry. Outside of the timeframe for the Section 47, they only saw the Social Worker and the Health Visitor once.  4.32. It would have benefitted the nursery to have an explanation of the social care processes and procedures, particularly for Section 47 and Section 17. Discussions with Health Practitioners 4.33. There had been nine attendances to the family by the ambulance service from October 2019 to December 2020. Following the first of these on the 18th of October 2019 for a febrile convulsion, the ambulance service made a call to the Paediatrics Unit at the hospital outlining their concerns about the relationship between the family and Child G and concerns that Child G’s mother didn’t show any concern for him and didn’t follow the care advice given. On this occasion the hospital was unconcerned about any risks. A total of three safeguarding referrals were submitted and two of these were in regard to the interaction between Child G and his mother and mother’s partner.  4.34. MASH Health noted that the referral from the GP came a day after the first head injury in November 2020 and was very brief in content and lacking in clarity. They noted that the GP hadn’t mentioned that he felt the need for a paediatric assessment to take place and there was an emphasis on the concerns being historic. The GP did struggle to get enough detail from Child G’s mother at the time of the consultation at the surgery because she was very upset and was crying.  4.35. It isn’t clear as to what prevented the GP and West Suffolk Hospital reporting their safeguarding concerns. It is unclear as to why the GP didn’t consider contacting EDS about his concerns. The GP has said that he knows he should have done another referral for the second injury in December 2020. A face to face in person appointment with the mother would have helped this.   Page 9 of 16 4.36. On the day of the first head injury in November 2020, the GP rang the hospital and tried to speak to the on-call consultant paediatrician but was unable to get a response. He wanted to make them aware of the situation and the history concerning previous injuries to Child G prior to him arriving at hospital. The GP didn’t use the words paediatric assessment in his information about the child or in his dialogue about what needed to happen.  4.37. MASH Health were very clear at the threshold discussion that a paediatric assessment was necessary.  4.38. MASH Health were concerned about the discrepancies in the explanations from Child G’s mother and that this was potentially NAI. However, they couldn’t reach a definitive conclusion about NAI without further investigation and assessment. The Social Care Team and to an extent, West Suffolk Hospital were focused on the mother’s poor supervision of Child G as the main concern in this case. It should be noted that just because concerns are not definitively viewed as NAI, it doesn’t mean that they aren’t, and an open mind should always be held. When there are recommendations/decisions made by MASH Health, and Social Care don’t agree with these, it’s important that there is a discussion and rationale given for the disagreement. It will be important to explore how a feedback loop from all agencies can be managed. It was also noted as part of the discussion that when referrals come in for allocated cases, because they don’t always go through the MASH, that things can sometimes be missed, and agencies are not always updated.  4.39. The health perspective and views need to be considered equally alongside Police and Social Care at Strategy Discussions. Health colleagues should feel confident that they can escalate if Social Care challenge their decisions.  4.40. The GP surgery are not on SystmOne and the safeguarding lead see this as a risk. The surgery is aware that they are missing key information on children and families. The health professionals involved with Child G didn’t know what information each other held and as a consequence weren’t able to see the inconsistencies that led the MASH professionals to have concerns for NAI. 4.41. Not enough questions were asked by Health services to clarify who the parents of Child G. were. There is often an assumption made that the people who attend appointments and A and E are the birth parents. Staff assumed that the male who was at the hospital with Child G and his mother, was his birth father. MASH Health noted that they should have explored the family dynamics more fully at the time of the referral on the 10th of November 2020. 4.42. Health professionals noted that holding meetings on Teams has greatly improved multi-agency working in terms of communication and collaboration for Health professionals. Discussions with the Social Worker 4.43. At the time of the first S47 on the 9th of November 2020, Child G had been seen by three different Health professionals and a decision had been made by the GP from him to go to A and E. The involvement of the Health Professionals at the hospital and their decisions not to raise any safeguarding concerns coupled with what the social work team considered to be consistent accounts of the injuries by Child G’s mother and partner led the social work team to conclude and decide that a Paediatric assessment wasn’t needed. The social work team’s main concern regarding Child G’s mother was her inexperience as a parent and the subsequent poor supervision from this lack of experience, although the lack of emotional warmth towards Child G by mother had been noted. The Social Worker stated she sought advice from both the Consultant Social Worker and the Practice Manager on this decision.  4.44. During the course of the S47 enquiry, there were a further two bruises to Child G. The social worker was concerned about the mother’s accounts of these two bruises to Child G. The accounts didn’t match up. The Social Worker was also concerned about the mother’s presentation at nursery and the initial difficulties in engaging and speaking with her and trying to develop a working relationship. On each occasion that the social worker went to the nursery to see Child G on his own, his mother also arrived at the nursery. The Social Worker was worried about the lack of emotional warmth shown by Child G’s mother towards him, she seemed only concerned about the practical side of parenting. The Social Worker also said that mother was  Page 10 of 16 difficult to get hold of and that she had been unable to see the partner despite attempting to do this as part of the assessment.  4.45. Child G was receiving support from a Health Visitor who was very much involved with him and the family. The Social Worker stated the Health Visitor was worried about possible neglect and the eating of non-foods; he was eating charcoal and chalk. For the Section 47, the advice given by the CSW to the Social Worker was to speak to the parents and complete the Section 474. The Social Worker said there wasn’t time to speak to either the Health Visitor or the nursery in detail about their concerns prior to the completion of the Section 47. There would have been a further opportunity to do this as part of the social work assessment by the allocated Social Worker, however, the allocated Social Worker went off sick in early to mid-December. The social work assessment was started retrospectively. It was opened on the 21st of January following the second Section 47 commencing and closed on the 22nd of January but the date on the assessment was back dated to the 9th of November 2020. It is important to note that this Section 47 was the first Section 47 the Social Worker had undertaken although she had been qualified for almost a year. Given this was the Social Worker’s first Section 47, some reflection time on this in supervision would have been beneficial. 4.46. The Social Worker noted there was some confusion as to who was Child G’s father. The man who lived with Child G and his mother was mother’s partner, but they called him dad. The social worker didn’t get to meet the mother’s partner. Each time she went round to meet him or spoke to the mother about him she was told that he was working or was somewhere else. In discussion with the Practice Manager and consultant social worker they advised they had not been made aware of this and that had they known, this would have added to their concern.  4.47. When the case was open to Early Help, the worker had the same concerns as the Social Worker and the nursery with regard to the lack of emotional warmth shown by the mother towards him.  4.48. The Social Worker said she worked hard at developing a trusting relationship with the mother and to convince her that she needed support. The mother was initially very reluctant to work with social care.  4.49. Regular updates were given by the social worker to the Consultant Social Worker as part of supervision and the Social Worker regularly checked concerns with the Consultant Social Worker. The Social Worker felt the focus for supervision sessions was on ensuring that an update on the case was given and actions for the social worker to undertake. The Social Worker said that opportunities for reflection were minimal. 4.50. The Social Worker stated that she worried about this case and the escalating injuries for Child G. Discussions with the Social Care Managers 4.51. Although the MASH outcome decision was for a paediatric assessment to be undertaken, the social care team felt that it wasn’t necessary for several reasons. Child G had been seen by a number of Health professionals (GP, paramedic, hospital) and all had commented that they didn’t have any significant safeguarding concerns. The social care team felt that there weren’t enough red flags/risk factors and that the main worries concerned mother’s immaturity, her lack of confidence in parenting and her need to be supported to develop parenting strategies in her supervision of Child G. The managers said that they would always consider a paediatric assessment within Section 47 investigations but felt that a paediatrician should have been included as part of the strategy discussion. They felt that unless it was agreed by a paediatrician,  4 Note: From MASH Operating Manual regarding the opening of S47 Enquiries and Social Work Assessments “Where a decision has been made for sec 47 enquiries, either joint or single agency, there will be an immediate handover to the Practice Manager/ Consultant Social Worker of the CiN team to complete the strategy discussion to plan the sec 47 enquires with the relevant partner agencies. A statutory assessment is assigned to the teams duty tray in Liquid logic and a telephone call is also made to the team’s Assessment Co-ordinator.”  Page 11 of 16 then it remains a consideration and that they would then make the judgement based on the injury and risk factors.  4.52. Following the first Section 47, the Practice Manager and Consultant Social Worker stated that it was agreed that the case would be worked at CiN and that a social work assessment would be completed. The risk factors and concerns that had been identified as part of the Section 47 were the head injury, two other recent head injuries, old bruising around the eye and neglect in the home conditions and in parenting and lack of supervision. These were to be addressed within the social work assessment; however, the Social Worker went off sick and therefore did not undertake the social work assessment. The social work assessment was opened retrospectively. It was opened on the 21st of January and closed on the 22nd of January but the date on the assessment was back dated to the 9th of November 2020. The social worker went off sick at the end of November 2020. The case wasn’t reallocated because it was thought that the period of sickness wouldn’t be long term. The Social Work Managers said that because it was a CiN case and the Social Worker had not indicated increased concerns prior to going off sick, it wasn’t seen a priority case for re allocation.  4.53. The fact that the case was open during Covid wasn’t seen as a contributory factor by the Practice Manager and the Consultant Social Worker. Debriefs after Section 47s always took place, supervision was regular, and management debriefs were regular. The Practice Manager and Consultant Social Worker felt the Social Worker was able to seek support from managers throughout this period of time. 4.54. With regard to the confusion about the male in the house, the managers believe that the social worker had a conversation with both him and Child G’s birth father. They would always advocate that significant adults are spoken to as part of a Section 47. However, it is difficult to tell in this case because the recordings were put on retrospectively.  4.55. A lot of the recording in this case has been added retrospectively so it is difficult to get a true picture of the events that occurred at the time.  4.56. The team have considered their decision with regard to the paediatric assessment and are consulting on injuries and marks with the paediatrician as a joint decision with Health in respect of a paediatric assessment. They have also invited the lead Paediatrician to a team meeting to discuss the process and are doing meet and great sessions with GPs to highlight the process around Section 47s and social work assessments.     Page 12 of 16 5. Recommendations Emerging from this Review 5.1. Recommendation 1: All GPs need to know a). what the Emergency Duty Service (EDS) is and understand how EDS works with regard to out of hours referrals and b) the escalation process and how to escalate concerns. Both should be incorporated into GP safeguarding training.  5.2. Recommendation 2: Whenever there are reoccurring head injuries to children, GPs should involve a paediatric consultant to inform their concerns. The MASH Standard Operating Procedures state that: “A paediatric medical assessment should always be considered when there is a suspicion of, or a disclosure that indicates a child is at risk of significant harm (Sec 47 Children Act 1989). This includes child abuse and/or neglect involving injury, suspected sexual abuse or serious neglect.”. A pathway for when to involve a paediatrician in a strategy discussion should be developed and shared with the Named Nurses, the MASH, and the Social Care Teams. 5.3. Recommendation 3: Decisions stated in MASH outcomes as ‘necessary’ need to be acted upon. A recent Comms from the Assistant Director Early Help, Children’s Social Care and Youth Justice to CYPS states that “all decisions reached in MASH strategy discussions, in accordance with statutory guidance, should be actioned, including those pertaining to health. There might be rare occasions where local knowledge indicates that a different approach should be undertaken where this is in the interests of the child. In such circumstances any deviation from the MASH outcome of a strategy discussion must be agreed between a Service Manager and MASH Head of Service or their deputy. MASH outcome decisions which are not the outcome of strategy discussions and require adjustment to reflect local considerations and knowledge of the family must have a clear rationale recorded in the child’s record to explain how the revised outcome better meets the needs of the child. This should be agreed by a Practice Manager”.  5.4. Recommendation 4: Workers and agencies who are key to the understanding and progress of a case should always be kept informed and updated on progress and outcomes of decisions made, including when there is an absence of a lead Social Worker. 5.5. Recommendation 5: Health visiting teams need to liaise regularly on cases with GP surgeries to discuss social care updates and any concerns and worries they may have about children. 5.6. Recommendation 6: The possibility of NAI and the resultant increased risk should always be considered when children receive multiple injuries and bruises and when parents’ explanations for these are inconsistent. Professionals should always check the history, past referrals and the social worker/social work team as the lead workers should ensure that they gather all relevant and significant information from all professions and agencies involved in the case. All professionals should feel supported to revisit decisions and risks and revise where necessary. For example, where other /new incidents occur or where new evidence emerges. Multiple injuries and bruises and inconsistent explanations should always serve as an alarm bell for risk to a child. 5.7. Recommendation 7: All professionals need to work more closely to ensure opportunities are not missed for assessment and intervention and that they fully consider the impact of any missed opportunities on children and families.  5.8. Recommendation 8: Any professional or agency who contributes to the assessment and is a key professional in the case must receive the outcome of the assessment. Social care should routinely update all agencies involved in a case regardless of whether an assessment is being undertaken and including when referrals come in on allocated cases.   Page 13 of 16 5.9. Recommendation 9: All professionals involved in a case should ask questions and get clarity about the key adults in a child’s life. Poor or no recording of these details was noted on agency databases. Agency record keeping procedures should be updated to reflect this if they don’t currently, and agency databases should have a section that enables practitioners to record the key adults in a child’s life. Questions about the key adults in a child’s life should be standard practice for supervisors and managers to ask at supervision. 5.10. Recommendation 10: An explanation of social care processes and procedures including Section 17 and Section 47 should be included in the safeguarding training for nursery workers. 5.11. Recommendation 11: All professionals should be guided to read the Child Safeguarding Practice Review Panel’s report on the Myth of Invisible Men5, September 2021 which focuses on the circumstances of babies under 1 year old who have been harmed or killed by their fathers or other males in a caring role. Workforce leads should include this in safeguarding training updates.  5.12. Recommendation 12: Supervision in social care must always be a two-way process that allows opportunities for reflection by the Social Worker and Managers should refresh themselves with the supervision guidance. 5.13. Recommendation 13: There needed to be a deeper understanding of what life was like at home for Child G. All agencies recognised the lack of emotional warmth, poor interaction, the lack of any concern for risk by his mother and the reluctance in allowing any worker to meet the man who lived with them. The Social Worker going off sick and the lack of an allocated social worker and any oversight of the case contributed to the lack of a complete picture of life at home. Social care must ensure they always continue to build this picture from observations, regular home visits and discussions with other agencies and professionals. 5.14. Recommendation 14: A decision made late in the afternoon for a single Section 47 should make no difference to whether a social care team starts the Section 47 on that day. Actions to be taken need to be determined by the level of risk and shouldn’t be influenced by the time of day the referral comes into the team. Addressing the National Themes 5.15. The six national key practice themes are on the whole addressed through the recommendations from this case. I have identified which recommendations capture each of the national themes. 5.16. Understanding what the child’s daily life is like Recommendation 12 5.17. Working with families where their engagement is reluctant and sporadic Recommendation 9 and 12 5.18. Critical thinking and challenge Recommendation 3 and 9 5.19. Responding to changing risk and need Recommendation 6 5.20. Sharing Information in a timely and appropriate way  5 The Myth of Invisible Men  Page 14 of 16 Recommendation 4 and 8 5.21. Organisational leadership and culture for good outcomes Recommendation 3 and 11 6. Glossary  CT Scan Computed Tomography Scan CYPS Children’s Young People Services within Suffolk County Council GP General Practitioner CiN Child in Need Liquid Logic CYPS client recording database MASH Multi-Agency Safeguarding Hub – central point through which all safeguarding referrals are made NAI Non-Accidental Injury SCC Suffolk County Council SSP Suffolk Safeguarding Partnership SystmOne NHS Clinical notes recording system used by GP practices      Endeavour House Ipswich Suffolk, IP1 2BX www.suffolksp.org.uk  