Death of a 3½-year-old African boy in November 2015. There were indications that there might have been some degree of force feeding, causing ingestion of food into the lungs. The father was found guilty of manslaughter and child cruelty. Family was known to children's services and children had previously been subject to child protection plans for neglect, physical and emotional abuse and children in need plans. Family history of: missed health, optician and speech therapy appointments and repeated attendance at accident and emergency departments due to children's injuries. Maternal history of: low level neglect; domestic violence; disguised compliance; health problems due to AIDS and missed medication. Paternal history of: physical abuse; domestic violence; refusal to attend parenting education; irregular attendance at the home as he rented another property where he stayed four nights a week. Child G's teenage step-sister had joined the family from Africa and was providing care for her step-mother and step-siblings. Identifies findings including: lack of recognition of the impact of the mother's ill health on her parenting capacity; insufficient awareness of father's lifestyle and the reliance placed on Child G's step-sister to provide family care; parental inhibition of their children's voices; problems in information sharing following the family relocation; and professionals overlooking the needs of the children. Sets out key findings and opportunities for learning. Recommendations include: amending the Neglect Toolkit to include feeding issues and dental health; practice tool to be used by the Health Visiting Service to ensure systematic and robust information capture for new families.
      
    Serious Case Review No: 2016/C6264   Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.                                                                                                                                                                  ‘BOROUGH 2’ SAFEGUARDING CHILDREN BOARD  SERIOUS CASE REVIEW     CHILD G  FERGUS SMITH  29.11.16        Contents   1 INTRODUCTION 1 1.1 Background & event triggering a serious case review 1 1.2 Purpose & conduct of the serious case review 2 2 FAMILY HISTORY & CHILD G’S EXPERIENCES 5 2.1 Introduction 5 2.2 Family’s move to current borough 7 2.3 Assumption of responsibility by borough 2’s Children’s Social Care 12 2.4 First review child protection conference (RCPC) in borough 2: protection plans retained 16 2.5 Second review child protection conference in borough 2: step down to ‘child in need’ status20 2.6 Case closure by Children’s Social Care 23 2.7 Renewal of child in need plan in response to domestic abuse 24 2.8 Initial child protection conference: protection plans formulated 26 2.9 Further review child protection conference: step down to ‘child in need’ status 36 2.10 Case closure by Children’s Social Care 39 3 RESPONSES TO TERMS OF REFERENCE 41 3.1 Introduction 41 3.2 Quality of assessments 41 3.3 Thresholds 44 3.4 Culture, religion & language 45 3.5 Voice of the child 46 3.6 Information sharing 48 3.7 Supervision & management 50 3.8 Resourcing & organisational change 51 4 FINDINGS & CONCLUSIONS 52 4.1 Findings 52 4.2 Opportunities for learning 53   5 RECOMMENDATIONS 55 5.1 Introduction 55 6 BIBLIOGRAPHY 57 7 FINAL TERMS OF REFERENCE 58                                                                          CAE                                                            1 1 INTRODUCTION  1.1 BACKGROUND & EVENT TRIGGERING A SERIOUS CASE REVIEW 1.1.1 On 27.11.15 at 17:20 child G’s father made a 999 call and asked for an ambulance to be dispatched to one of his children (a 3.5 year old male of African ethnicity referred to in this report as ‘child G’). Father explained to Ambulance Control that he had just fed child G, gone upstairs to obtain a nappy and returned to find his son limp and unresponsive. Father was advised to initiate cardio-pulmonary resuscitation while awaiting an ambulance though there remains doubt about whether he did so. 1.1.2 In spite of the ambulance crew arriving only six minutes later, efforts to resuscitate child G were unsuccessful. He was transported to the local ‘hospital 1’ arriving at 18.05. At 18:32 life was pronounced extinct. Mother who had not, it is understood, been present at the time of her husband calling an ambulance, returned home in time to accompany her son to hospital. 1.1.3 Following provision of inconsistent explanations of the lead-up to the 999 call, both parents were arrested. There were indications that child G might have suffered some degree of force feeding, causing ingestion of food into the lungs. A criminal investigation was initiated, and child G’s three other siblings were placed with a foster carer.  1.1.4 Prior to child G’s death, his family had been in receipt of a significant level of services from Children’s Social Care in a neighbouring ‘borough 1’ and when the family moved there in December 2012, from Children’s Social Care in ‘borough 2’ where he died. RAPID RESPONSE & CONSIDERATION OF A SERIOUS CASE REVIEW 1.1.5 In accordance with the Local Safeguarding Children Board Regulations 2006 and local agreed procedures, child G’s death was reviewed at ‘rapid response meetings’ on 01.12.15, 07.12.15 and 17.12.15. It was concluded that the primary criterion for initiating a ‘serious case review’ (SCR) which are reproduced in paragraph 1.2.1 below, was satisfied and a recommendation made to the independent chairperson of the borough’s Safeguarding Children Board that a serious case review be commissioned. The chairperson ratified that recommendation and the Department for Education’s regulatory body Ofsted and the ‘National Panel of Independent Experts’ (NPIE) were immediately informed. 1.1.6 This serious case review was undertaken between January and July 2016. Parallel criminal inquiries led to a decision by the Crown Prosecution Service that father would be charged with manslaughter and child cruelty (he was subsequently found guilty and has been imprisoned). Mother faced no criminal charges. A Coroner’s Inquest has been initiated and is currently adjourned awaiting further evidence.                                                                                  CAE                                                       2                                       1.2 PURPOSE & CONDUCT OF THE SERIOUS CASE REVIEW 1.2.1 Regulation 5 Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Children Boards (LSCBs) to undertake reviews of ‘serious cases’ in accordance with Working Together to Safeguard Children HM Government 2015. A ‘serious case’ is one in which abuse or neglect is known or suspected and the child has died [this case satisfied that criterion] or been seriously harmed and there is cause for concern as to the way in which the local authority, LSCB partners or other relevant persons have worked together to safeguard the child. 1.2.2 Its purpose is to identify required improvements in service design, policy or practice amongst local or if relevant, national services. A serious case review is not concerned with attribution of culpability (a matter for a criminal court) or cause of death (the role of the Coroner). The period for review was from the date of the family’s move to the area in December 2012 to the day of child G’s death. An independent report was commissioned from www.caeuk.org and it was agreed that upon receipt of relevant material the lead reviewer Fergus Smith would:   Collate and evaluate it   Conduct any required supplementary enquiries   Develop for consideration by the review group a narrative of agencies’ involvement, an evaluation of its quality, conclusions and recommendations for action by the local Safeguarding Children Board and member agencies  1.2.3 The review group consisted of the:  Independent Chairperson of the LSCB   A Lay Member / Deputy Chairperson of the LSCB  Independent Lead Reviewer   Locum Designated Doctor   Associate director of Quality, Safeguarding & Safety (NHS Foundation Trust)  Head of Service (Quality Assurance & Service Improvement Children’s Social Care)  Designated Nurse (Borough 2 Clinical Commissioning Group)  Review Officer (Police)  Interim Head of Safeguarding & Quality Assurance (Children’s Social Care)  Divisional Director Education Services  Principal Lawyer for  Borough 2   The LSCB Business Manager & a Support Officer  1.2.4 A copy of this report is being sent to the government-appointed national panel of independent experts (NPIE) and to the Department for Education (DfE).                                                                                  CAE                                                       3                                       INVOLVEMENT OF FAMILY MEMBERS 1.2.5 To avoid the risk of contaminating trial evidence, father’s involvement was deferred. A translated invitation to contribute was sent by the LSCB to child G’s mother and a further invitation issued later by the lead reviewer. Mother has not responded. The advice of the allocated social worker and Children and Family Courts Advisory and Support Service (Cafcass) officer was that sib.3, though old enough, is too emotionally disturbed to contribute without risking further distress and damage (in consequence of some of her observed conduct, a psychiatric opinion has been sought). The younger children were regarded as having insufficient understanding to evaluate services delivered.   1.2.6 The report has been anonymised to minimise the risk of identifying family members or involved professionals and is being published on the national repository of completed serious case review reports.             TIMETABLE FOR COMPLETION OF SERIOUS CASE REVIEW Event Date Decision to initiate serious case review & formal notifications 18.12.15. Completion of merged chronology 18.03.16 Panel meeting 1  03.03.16 Consultation / briefing of professionals 09.03.16 Panel meeting 2: analysis of submitted agency reports 14.04.16 Panel meeting 3: analysis of revised and delayed reports 12.05.16 Panel meeting 4: panel debate about all remaining incoming material 27.05.16 Panel meeting 6: debate about revised and delayed reports 08.06.16 Panel meeting 7: discussion of preliminary overview of 15.06.16 20.06.16 Revised draft submitted  29.06.16 Practitioners’ event November 2016 Involvement of family members Father - deferred during criminal proceedings; mother: 2 offers made; sib. 3 too vulnerable Presentation of final draft to Safeguarding Children Board 08.12.16 Submission of report to national panel of independent experts (NPIE), Department for Education (DfE) & NSPCC repository December 2016                                                                                       CAE                                                       4                                       STRUCTURE OF CHILD G’S FAMILY Father   Age 31   Mother  Age 34      Unknown Step-sister Sib.3  Age 17 Sib.2  Age 8  Sib.1  Age 9   Child G Age 3.5                                                                               CAE                                                       5                                       2      FAMILY HISTORY & CHILD G’S EXPERIENCES 2.1 INTRODUCTION 2.1.1 The period for review was December 2012 when the family moved from adjoining ‘borough 1’ to the current ‘borough 2’ through to November 2015 when child G died. The following summary of the family’s history prior to its move, helps to evaluate better the events that occurred after it. Italicised comment on professional practice is provided at relevant places and issues arising from such observations are further analysed in section 3.  PARENTAL ORIGINS, RELATIONSHIP & INITIAL CONCERNS 2.1.2 Information provided by borough 1 indicates that both parents were born in the same central African country, came to the UK over a decade ago, met in their local church and were married in 2004. 2.1.3 Records confirm that Children’s Social Care in borough 1 was aware of mother’s chronic blood-borne infection1. Borough 1’s Children’s Social Care first became aware of the family when medical staff at ‘hospital 1’ initiated a referral rooted in a concern that mother was not taking her own prescribed medicine nor administering necessary anti-viral medication to her then new-born child sib. 1. FIRST SUSPICIOUS INJURY: SIBLING 1 2.1.4 In November 2006 sib.1 (aged 9 months) was taken to hospital 1 by both parents with what was diagnosed as a broken left clavicle. Examination also revealed three old rib fractures. Parental explanations were inconsistent with the medical observations and after an initial child protection conference, the child was made subject of a child protection plan. Care Proceedings were initiated and in a fact-finding hearing in February 2007 the Judge concluded the rib fractures were non-accidental and could have been caused by either parent.  2.1.5 Whilst legal proceedings were continuing, mother gave birth to sib. 2 in July 2007 and the new baby, mother and father, moved to a residential assessment centre where they were later joined by sib.1. The outcome of the residential assessment was positive and the family was discharged in December 2007. Both children were made subject of a child protection plan later in December (in consequence of physical abuse) and an extensive support package put in place. 2.1.6 A final hearing in May 2008 resulted in a 1 year Supervision Order and a joint Residence Order (the latter intended to assist father’s immigration application). By August 2008 the children ceased to be subject of protection plans.                                                    1 Mother had been HIV+ for some years and her condition deteriorated to the extent that during the period under review, she was living with AIDS.                                                                                CAE                                                       6                                       FURTHER SUSPICIOUS INJURY SIBLING 1 & BROADER INDICATIONS OF NEGLECT 2.1.7 An injury to sib.1’s face observed by a health visitor in October 2008 was investigated under s.47 Children Act 1989 and the explanation provided by his father found to be credible. A month later the health visitor re-referred with concerns about a parental failure to protect their children e.g. not seeking medical advice in the event of illness / accident, insufficient stimulation of both children (sib.1 spent long periods of time in a high chair and had few toys) and developmental delay. The health visitor also relayed a parental claim that both children (aged 3 and 2 respectively) slept from 4pm until 8am or 9am next day.  2.1.8 The 1 year Supervision Order with respect to sib.1 expired in May 2009   and marked a further decline in parental co-operation. 2.1.9 On a date in late August 2009 both parents brought their then 3.5 year old son sib.1 by bus to hospital 2 where he was treated for a fractured left femur. A number of suspicious features were recognised and further medical examinations arranged. The parents denied any involvement of Children’s Social Care. Legal proceedings were commenced though the children remained in the care of their parents during that time. 2.1.10 The expert opinions of an orthopaedic paediatric and a paediatric radiology consultant were that the parental explanation was plausible. The injuries were concluded to have been accidental and in October 2009, proceedings were by agreement, terminated. The case remained open with minimal involvement until it was closed in August 2010. INITIAL & REVIEW CHILD PROTECTION CONFERENCES 2.1.11 Both parents were involved in crimes of dishonesty in 2010. Of greater relevance was a growing concern during 2011/12 about ‘low level neglect’ and in May 2012 sib.1 reported at his school, physical abuse by his father. This prompted an initial child protection conference in July 2012, the result of which was that all three children were once again made subject of child protection plans under category of ‘physical abuse’. 2.1.12 Sib.1 revealed at this time that he had been told by his parents to deny being hit by his parents and there were occasions on which the children had been left alone emerged. The school was aware that the children were wary of their parents to the point where staff had become reluctant to raise any concerns with them about the children’s conduct (aggression and violence toward peers) lest it result in them being physically chastised.                                                                                 CAE                                                       7                                       2.1.13 At a review child protection conference in October 2012 concerns remained about the impact on child G of witnessing parental use of physical punishment of his siblings, as well as mother’s ability to function as a result of her chronic medical condition. Plans were re-formulated under the category of ‘emotional abuse’. The level of parental co-operation increased during this period, in particular with the last of several social workers allocated to the case. 2.2 FAMILY’S MOVE TO CURRENT BOROUGH TRANSFER OF INFORMATION 2.2.1 It is understood that the family moved into its ‘address 1’ in early December 2012. An electronic transfer of school health records was completed two days in advance of that move and a phone briefing provided by an unidentified health professional to borough 2’s HV1. HV1 in turn sought to contact the then allocated social worker in borough 1 (SW3) by phone and was told she was on annual leave until January 2013.  Comment: although a few days after the actual move, the briefing of the family’s health visitor about this vulnerable family was good practice; the social worker’s leave was unusually extended and it is unclear whether the arrangements for covering her caseload were made known to callers. 2.2.2 Paper records were received only on the day of the home visit described below and arrived in Community Health via a third borough’s Safeguarding Children Office implying that borough 1 might have transferred the relevant material to the wrong borough. Comment: though transfer of records is now completed electronically, the risk of human error in defining the intended destination will always remain.  INITIAL CONTACTS WITH FAMILY 2.2.3 HV1 managed after further efforts to make contact with borough 1’s SW4 whom it appears had by then replaced SW3. He was told of HV1’s planned home visit three days later. At HV1’s home visit she met mother and all three children. Child G was observed to be developing normally and to be up-to-date with his immunisations. Dental care, diet and nutrition were discussed and HV1 recorded no concerns. A follow-up visit in two weeks (it later transpired this was to become a phone contact) was planned and no specific needs or risks were noted. Comment: the records do not refer to the mother-child or child-child interactions nor to the observed affect of each family member, which, given the existence of child protection plans, were relevant.                                                                                  CAE                                                       8                                       PLANNING FOR A TRANSFER-IN CONFERENCE 2.2.4 On 09.01.13 and 16.01.13 borough 1’s SW4 asked for a ‘transfer-in conference’ to be arranged and supplied minutes of the review conference of October 2012. Borough 2’s records of the calls suggests that no chronology of involvement was supplied at this time nor before the conference when finally held some five months later. Evidence was found during the course of this review confirming the provision of a partially legible though nonetheless usable ‘system-generated’ chronology. The papers supplied to borough 2 indicated that there had been no recent repetition of inappropriate physical punishments. Comment: ‘transfer-in’ conferences should, in accordance with the Child Protection Procedures be convened within 15 working days of a family’s arrival; earlier if the move is known in advance. All available material should be supplied. Support & monitoring from health professionals in borough 2 2.2.5 Having spoken with mother by phone on 31.12.12 and the day before to confirm availability, HV1 called on 22.01.13 and again met mother and all three children. Her records indicate child G was alert and well and had been registered with a GP. There was a routine discussion and a reminder about immunisation. Mother reported (accurately) that borough 1’s social worker had visited twice since HV1’s last visit. Comment: HV1’s actions suggest a careful attention to detail. Authorisation of ‘transfer-in conference’ 2.2.6 Borough 2’s Children’s Social Care records confirm that by 17.01.13 the deputy in that agency’s Multi-agency Safeguarding Hub (MASH) had authorised a transfer-in conference and that by 02.02.13 the existing child protection plan, conference report and core group minutes, though not what was perceived to be a missing chronology had been received. Comment: the absence of an anticipated chronology (unjustifiably) delayed the convening of the required transfer-in conference. At his supervision on 23.01.13 SW4 had assured his supervisor that all relevant documents had been sent to borough 2. A recommendation is included in section 5. 2.2.7 HV1 sought from borough 1’s SW4 the date of the next ‘core group’ and commented upon the absence to date of liaison. Records transferred in December had referred to a core group having already been scheduled for 10.01.13, though there is no evidence to confirm that it was held. Records do not confirm that SW4 returned HV1’s call. On 29.01.13 borough 1’s School Nursing Service made phone contact with its equivalent in borough 2 and provided a briefing. School nurse SN1 initiated liaison with school 1, a clinic and Children’s Social Care. The latter agency informed her that the case had yet to be allocated and was awaiting a ‘transfer-in conference’. Comment: the actions of the school nurse represented good practice.                                                                                 CAE                                                       9                                       2.2.8 Child G’s mother had some contact as an out-patient and (briefly) as an in-patient at hospital 2 at this time. Some doubts about her compliance with medication were noted. There was no indication of involvement of any social worker and it is uncertain whether a ‘flag’ in mother’s GP medical notes was an accurate or historical reference to her children being subject of child protection plans. There was anyway no code in the children’s records at this time.   Comment: the potential value of a ‘flag’ to alert a GP to safeguarding issues is lost if the record does not appear in child/ren’s record and/or is incorrect. 2.2.9 An unremarkable new patient screening for sib.1 was completed on 14.02.13. On the same day School Health received paper records from borough 1 and arranged for their collection. Comment: the physical collection by SN1 minimised the risk of loss and was an example of standard good practice. Formal initiation by borough 2 of transfer-in conference 2.2.10 On 18.02.13 the Child in Need (CIN) deputy team manager recognised that what had been merely noted in mid-January as a ‘contact’ requiring no significant response, needed to be re-designated to trigger action. She initiated a request for a transfer-in conference by 11.03.13. The delay was ascribed to a failure to provide borough 1 with records. Borough 2’s SW5 became the allocated social worker and made efforts via email to acquire the documents required from the previous borough.  Comment: the arrangements for a transfer-in conference should have been more robust than it was in this instance. In accordance with child protection procedures, case accountability remained with borough 1 pending re-allocation at a formal conference. 2.2.11 HV1 made a planned visit on 20.02.13 to find curtains drawn and no response to phone calls. Later that day borough 1’s SW4 indicated that the overdue conference was scheduled for 06.03.13 (Police records indicate instead an intended date of 13.03.13, later postponed to 27.03.13). Borough 1’s SW4 reassured HV1 that he had been visiting regularly and had no concerns. HV1 expressed concern about the absence of core groups and lack of communication from SW4. Comment: The report supplied by borough 1 confirmed visits by SW4 on four occasions to the end of February; no conference was held on 06.03.13 and no explanation has been found for the reported statement that it would be (though borough 1’s SW4 did meet mother and children on that date). 2.2.12 HV1 made a further two unsuccessful attempts in February to complete planned home visits as well as a third unplanned visit in March when she was denied entry. She was unable to get confirmation from Children’s Social Care of the conference she thought was scheduled for 27.03.13 and it remains unclear whether a report she prepared was actually submitted. Comment: HV1 would have been justified in escalating her concerns.                                                                                CAE                                                       10                                     Support & monitoring from education & health professionals in borough 2 2.2.13 Borough 2’s SW5 helpfully tried to agree a joint visit with his counterpart SW4 but the latter reported that he was unable to do so in advance of what was still anticipated to be a transfer-in child protection conference. An initial visit by SW5 alone on 07.03.13 indicated that he found that ‘the home circumstances seemed on the surface good’. A second visit a fortnight later also revealed nothing of concern and his record included an observation of a smiling child G. Comment: the date of the potential conference remained uncertain; further confusion arose when SW4 and SW5 discussed a potential step-down to child in need status and in consequence convening the meeting in borough 1. 2.2.14 On 18.03.13 child G’s elder brother ‘sib.1’ (aged 7) transferred from school 1 to school 2 and entered Year 3. A week later its head teacher HT1 received a call from borough 1’s SW4 who had been alerted to a report of mother hitting her daughter sib.2. SW4 was at this point still anticipating a conference two days later. There was no confirmation of these contacts in the report provided to this review by borough 1 and it appears likely that this incident was not shared with SW5. 2.2.15 HV1 tried again on 22.03.13 to obtain confirmation about the conference she understood to be scheduled for 27.03.13 (three and a half months after the family had moved into the area).Nobody in the office was able to help. A borough 2 Children’s Services supervision record dated 22.03.13 referred to a borough 1 decision to convene the conference there because it now planned to step-down to child in need status. Comment: the response to the health visitor was unacceptable and she should have escalated her concern about this muddle; appropriate multi-agency debate and decision-making that a conference offers should not be pre-empted. Postponement of the scheduled transfer-in conference 2.2.16 The actual decision to postpone or indeed cancel the anticipated conference was a result of a disagreement between respective independent chairperson 1 (borough 1) and 2 (borough 2). The exchange occurred only after borough 2’s SW5 had actually travelled to borough 1 on 27.03.13 in anticipation of the meeting. Borough 1’s SW4 completed his sixth home visit to the borough 2 address on this date. Comment: the needs of the children were overlooked in this relatively academic exchange. A debate focused on the needs of the children should have taken place at the by now long overdue transfer-in conference. 2.2.17 The organisational tension implied by the exchanges between independent chairpersons risked exacerbation when borough 2’s manager decided on 12.04.13 to close the case and re-open it when a conference was convened. A senior manager in borough 2 then appropriately directed the conference to be held in his area within 15 working days.                                                                               CAE                                                       11                                      2.2.18 In response to an enquiry from Police at this time, borough 1’s SW4 reported that the planned conference (he is quoted as saying “on 20.03.13”) had been postponed and that ‘senior managers’ in both boroughs were ‘having meetings about next steps’. 2.2.19 HV1 made a further unsuccessful attempt to access the family on 17.04.13 when she visited unannounced. Next day the lunch-time supervisor at school 2 reported child G’s older brother sib.1 (then aged 7) was wearing a nappy / pull-up. When staff from the medical room spoke to him, he indicated that mother had told him not to tell anyone.  2.2.20 When contacted, mother denied that her son was wearing a nappy.  Next day, sib.1 clarified that he wore a ‘pull-up’ to bed and had forgotten to take it off in the morning. Comment: whatever the reason for or frequency of sib.1’s use of nappies, the episode suggests a lack of transparency on the part of mother. 2.2.21 What would have been an advisable joint visit by HV1 and borough 1’s SW4 was cancelled by the latter and not re-arranged. An opportunity to gain an insight into domestic childcare arrangements was also lost when at a pre-operation assessment of mother at the local hospital 1 on 02.05.13, relevant sections of the form were left blank.  2.2.22 There was further confusion in early May when the borough 1’s independent chairperson confirmed that all required material had been provided to borough 2 but the newly allocated SW6 from the latter area indicated that no chronology has arrived (a conference report, protection plan and core group meeting notes had done so). Comment: in the view of those who have seen the systems-generated chronology, it was poorly presented but nonetheless of use. 2.2.23 HV1 succeeded in gaining entry when she made a further unannounced home visit on 09.05.13. Her records indicate that she addressed mother’s lack of compliance and was given an apology as well as a current mobile number. HV1’s observations of child G (then 14 months old) indicated that he was alert, well, active and developmentally within normal limits (though not yet walking unaided). 2.2.24 Nutrition and food was discussed and mother reported that her son had a good appetite, enjoyed home cooked meals and that his diet was being supplemented with multi-vitamins. HV1 noted that child G’s lower lip was slightly swollen with a ‘little pale old white mark line’. Presumably because mother could not explain the cause of the mark, HV1 assumed that child G had hit his lip against something. She then discussed home safety and accident prevention. Comment: the minor injury noted by HV1 could have been connected to the manner in which the child was fed;  she should have been more curious though in the absence of other indicators it is unsurprising that such a rare cause was not considered; the contribution of child G’s father to his children’s care is not apparent from records.                                                                               CAE                                                       12                                     Ongoing monitoring by borough 1’s Children’s Social Care & allocation of borough 2’s social workers  2.2.25 There were it seems, no core groups arranged by borough 1 and limited contact by its allocated social worker during the six months in which the transfer-in conference was awaited. Although borough 2’s SW5 had been allocated on 18.02.13 involvement had been limited to two home visits. On 02.05.13 borough 2’s SW6 became case-accountable and a record indicates that she reminded borough 1’s SW4 to bring the still-awaited chronology to the conference on 21.05.13.  Comment: case management of a family living in another area is intrinsically more demanding and is why the agreed regional procedures require a prompt 15 working day transfer of responsibility. 2.3 ASSUMPTION OF RESPONSIBILITY BY BOROUGH 2’S CHILDREN’S SOCIAL CARE TRANSFER-IN CONFERENCE 2.3.1 The transfer-in conference was finally held on 21.05.13. Borough 1’s SW4 and his senior were the only representatives from that area. In spite of the lengthy delay in it being convened, the head teacher of school 2 HT1 was apparently given insufficient notice to enable her attendance (a recurring problem). Police were represented though it remains unclear which agencies were subsequently sent minutes. 2.3.2 The report from HV1 was generally positive with respect to mother’s level of co-operation, receptivity to advice and observations of how she related to her children. HV1 reported no examples of risk since her first involvement some six months earlier. The conference noted but did not explore a reference to sib.1 (aged 7) having a lock on his bedroom door and it is uncertain whether allegations of hitting and/or the nappy incident were debated. The outputs of the conference included the following:  Borough 1 to provide a chronology of contacts (this had been sought for over six months, though as indicated elsewhere borough 2 did actually possess sufficient to use or challenge)  A family group conference (FGC) was to be arranged (a task first identified whilst the family was in borough 1)  A core assessment which would include the impact of mother’s chronic illness, father’s role in the family and the support from extended family Comment: HV1’s report is at odds with her four ‘no access’ visits of which three were planned; recent apparent engagement may have been unduly influential.  2.3.3 The decision was made that all three children would remain subject of a child protection plan for ‘physical abuse’ (a reflection of the previous physical punishment of sib.1 and sib.2).                                                                                  CAE                                                       13                                     2.3.4 HV1’s child protection supervision immediately preceding her conference attendance had been essentially task-focused and had not included discussion of the risk of physical punishment of child G. Although an identified ‘strength’ was mother’s reported seeking-out of services that would offer her toddler more stimulation, which services she had actually considered was unrecorded.  2.3.5 HV1 had covered for SN1 who was unable to attend the conference. She later prompted SN1 to write to the parents urging them to ask their GP for a referral to the enuresis clinic for sib.1. Though un-represented at the conference, specialist hospital 2 was sent a copy of the protection plan of 21.05.13. It received no further reports. Comment: it is uncertain why neither HV1 or SN1 initiated direct contact with the GP Practice. IMPLEMENTATION OF INITIAL CHILD PROTECTION PLANS 2.3.6 Borough 2’s SW6 made her first home visit on 29.05.13. Her records indicate that child G was again sleeping strapped in his buggy and this was ‘to be discussed at her next visit’. Father refused to contemplate attending a parenting course though this had been agreed previously in the course of borough 1’s involvement.  2.3.7 On 04.06.13 mother consulted a locum GP1, not about sib.1’s enuresis but about stammering which she reported began at the age of 5. A referral for speech and language therapy was initiated two days later. Sib.1 was not present. Medical presentation 1: child G / respiratory condition 2.3.8 About a fortnight after the conference decision that all three children still required protection plans, child G was brought (by which parent was un-recorded) to hospital 2’s Urgent Care Clinic and was reported to have experienced diarrhoea and vomiting for some days. A ‘respiratory infection’ was diagnosed and the allocated social worker was informed by the unit’s liaison health visitor on the same day. Medical advice to the serious case review has indicated that unless such infections become frequent, further exploration should not be expected. Comment: the clinic IT system had helpfully enabled the doctor to be aware of child G being subject of a protection plan. Upon notification, the event was also promptly up-loaded onto borough 2’s health visiting database.    Core group 1 2.3.9 HT1 was (for the second time) given insufficient notice of a multi-agency event and was unable to attend the first core group in borough 2 on 07.06.13. Present were borough 2’s SW6, HV1 and a school 2 special educational needs co-ordinator (SENCO). Neither parent attended and in spite of an unannounced home visit later that morning by HV1, it did not prove possible to make contact with either parent.  Comment: it was to be over two months before the record was inputted of that core group, leaving it invisible to colleagues until then.                                                                               CAE                                                       14                                     2.3.10 On 13.06.13 mother consulted GP2 about sib.1’s nocturnal enuresis. An analysis of a urine sample (a routine step in formulating a referral to an Enuresis Clinic) showed no infection.  Comment: sib.1 (aged over 7) was reported never to have been dry at night – an unusual phenomenon justifying exploration e.g. there is evidence bedwetting children are more likely to have behaviour problems (Joinson 2007) and that consequential stress within families can be considerable with an increased risk of child punishment including abuse (Sapi 2009): http://www.eric.org.uk/Professionals/info_bedwetting_wetting_professionals#sthash.1Dqn3prS.dpuf. 2.3.11 On 14.06.13 (possibly prompted by a concern about mother’s non-compliance with medication) a specialist nurse from hospital 2 initiated contact with borough 2’s SW6 who undertook to send a child protection report to the nurse.  2.3.12 At a further home visit on 26.06.13 SW6 was told about father’s other daughter and his plans to bring her to the UK. SW6 was also given addresses for mother’s own mother, brother and sister.  The former lived in the same region. In SW6’s supervision several days later, it was agreed borough 1 should again be chased for a chronology of its involvement. Comment: the potential value of case history was clearly recognised; what was overlooked is the utility of what was already possessed by borough 2’s staff. Further contact by health professionals & referral to Children’s Social Care 2.3.13 Sib.1 (aged 7.5) was seen at his school by school nurse 1 on 01.07.13. Her observations (shared at the second core group later that month) were that the child looked well-presented though had a hole in one of his shoes. Sib.1 said he liked school and his friends and reported he had been to an optician but not to a dentist. Relative weight and height were comparable at the 97th centile i.e. sib.1 was much taller and heavier than most of his peers. An examination of sib 2 by SN1 on the next day identified no concerns.   Comment: an absence of dental care was a recurring concern.  2.3.14 Just three days after his consultation with the school nurse, school 2 made a referral to Children’s Social Care because sib.1 (aged 7) had soiled his trousers prior to attending school and while changing had exposed himself to another child. His stammer and a perceived need for speech and language support were was also included in the referral. 2.3.15 Borough 2’s SW6 liaised with a SW10 from her Adult Social Care department on 08.07.13 and was told she would be contacted upon completion of an assessment of mother’s social needs.                                                                                   CAE                                                       15                                     2.3.16 HV1 was again unable to make contact because of ‘inactive’ mobile numbers. She made an opportunistic home visit on 11.07.13 and for the first time met the children’s father whom she noted was receptive and accepting of the visit. Child G (16 months old) was in his buggy and at HV1’s suggestion taken out. He demonstrated that he could crawl and pull to stand against his mother and furniture, though was not yet able to walk unaided (most achieve this at 14-18 months). HV1 was satisfied with his diet, nutrition and development and reminded the parents of the core group. Comment: the note of child G sitting in a buggy mid-afternoon raises the question of how often and for how long his movements were constrained in that manner. Linguistic development was not captured on this occasion. 2.3.17 Borough 2’s SW6 met father with child G at a home visit on 15.07.13 and became aware that he also had an alternative address thus (possibly) enabling an unjustified Benefits claim. Nothing of significance was noted in terms of conditions or care of child G. Comment: other members of the network were also aware of and did not challenge or report to housing colleagues the suspicious arrangement. A recommendation is included in section 5.  Core group 2 2.3.18 Both parents (and SN1, SW6 and unknown others) attended the core group on 17.07.13 held at school 1 at which sib.2 remained a pupil. It was confirmed that sib.1 was due to see an optician and had been taken for an enuresis appointment. His soiling at school was discussed and the school raised concern about his aggression toward peers. The group recorded that child G was typically in his buggy on each occasion that a professional called which was likely to constrain his walking skills. Comment: next day, mother told GP2 that she no longer wanted further investigation of sib.1’s bed wetting – arguably one of a number examples of apparent or disguised compliance.2 2.3.19 The parents were encouraged to minimise child G’s time in his buggy so as to offer him more opportunity for development of ‘large motor’ skills. SW6 who said that she had been making announced and unannounced visits, agreed to explore the possibility of some nursery time for child G. HV1’s report identified no other concerns and reported she thought there had been an improvement in family functioning in the months she had known it. SW6 agreed to explore the use of a ‘systemic practitioner’ or a referral to some form of parenting programme. Comment: it is unclear what precise parental needs had been identified nor why it was thought they might be motivated or able to use such services.                                                    2 Disguised compliance’ involves a parent or carer giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention - the term is attributed to Peter Reder, Sylvia Duncan and Moira Gray who outlined this type of behaviour in their book ‘Beyond Blame: Child Abuse Tragedies Revisited’.                                                                               CAE                                                       16                                     2.3.20 The notes of the core group were received in Community Health after a two month delay and then took a further month to be uploaded to electronic records (thus significantly reducing their potential value). The fact sib.1 was subject of a child protection plan was uploaded for the first time at GP Practice A only on the day of the core group and an invitation to the review conference received five days in advance  of it.  Comment: All of these apparently straightforward administrative tasks when completed efficiently can assist in briefing professionals such as GPs of relevant facts in a timely manner and thus reduce the risk of un-informed responses. Second referral from school to Children’s Social Care & a disclosure by sib.1 2.3.21 On the same day as the core group met, sib.2 (rising 6) was referred to Children’s Social Care. She had been ‘unkind’ to another pupil, then kissed her/him and exposed her bottom. She reported that this was how her older brother behaved and that she had kissed his bottom. Enquiries confirmed with sib.1 the accuracy of his sister’s account. 2.3.22 Borough 2’s SW6 appears to have taken no further action in response to sib.1 telling her on 18.07.13 that his parents had instructed the children not to report that they were physically punished because they might be taken away (the children were at this time subject of a protection plan under the category of ‘physical abuse’). Comment: sib. 1 had made similar claims whilst in the previous area (see para. 2.1.12) and the lack of response implies an insufficiency of interest in the children’s daily experiences; the instruction attributed to the children’s parents also challenges the idea of their engagement with the efforts of local agencies. 2.4 FIRST REVIEW CHILD PROTECTION CONFERENCE (RCPC) IN BOROUGH 2: PROTECTION PLANS RETAINED 2.4.1 The notice given of the review conference on 23.07.13 was very limited e.g. the invitation to HT1 was received only 5 days before the conference, itself convened on the last day of term. In consequence, HT1 was unable to attend though she did submit a report. Comment: given the inadequate notice, the inability of the GP Practice to be represented is unsurprising as is, to a lesser extent the fact that it did not provide a report (the serious case review group was informed that this is not unusual).  2.4.2 Father was present at the conference and the professionals in attendance were borough 2’s independent chairperson and SW6, HV1, SN1, senior practitioner SP1 and the SENCO.                                                                                 CAE                                                       17                                     2.4.3 Father expressed resentment at the ongoing social work involvement. He reported that he took on the bulk of the household chores. The possibility of a nursery place for child G was blocked because father was unwilling to present wage slips. The following tasks for professionals reportedly remained unachieved:  Receipt of a chronology from borough 1 (senior practitioner SP1 undertook to follow this up with the conference chairperson willing, if necessary, to escalate the issue)  A family group conference (though father indicated that, amongst the extended family, only his mother-in-law was aware of Children’s Social Care involvement – this option was anyway later rejected by the parents) 2.4.4 Borough 2’s SW6 confirmed the lock on sib.1’s door had been removed. The aetiology of the observed aggression of sib.1 and sib.2 was not explored. Mother’s assertion that she had resolved sib.1’s enuresis by waking him at night and would arrange dental examinations was accepted. Father admitted renting a second property. Records lack detail so that it is unclear whether the lawfulness of the arrangement was addressed nor its consequences for his family (subsequent comments by him suggest staying up to four nights a week at his second home). Father’s plan to bring his eldest daughter to the UK was noted. Comment: the lawfulness and time spent at the other property were relevant to the issue of honesty, openness as well as his availability to care for the children.  2.4.5 The decision was made by the chairperson that child protection plans were still required. The category used to justify the child protection plan was ‘physical abuse’ though there were also significant indicators of neglect of the children’s basic needs as well. ‘ALERT’ TO THE IMPACT OF MOTHER’S HEALTH ON PARENTING 2.4.6 The day after the conference, CNS1 wrote to borough 2’s Housing Department (Children’s Social Care also possessed a copy) and provided a very clear and detailed account of the impact of mother’s serious and chronic illness on her ability to adequately parent her children e.g. she referred to the need for child G to remain in his buggy if his mother needed to go up to the first floor. Comment: the proportion of the week that father actually spent in the home had been and remained of critical importance in terms of support or risk. Father was entitled to a ‘carer’s assessment’ and the extent of mother’s reduced ability had not been reflected to the extent here described at the review conference. It does not appear that an earlier proposed core assessment adequately captured the extent of mother’s disability and its consequences for her children.  2.4.7 On 06.08.13 a helpful three monthly summary was completed by SW6 in order to inform her successor SW7. Aside from the recurring concern about how much mobility child G was experiencing, the question of whether father was actually cohabiting with the family and a failure to sort out Benefits were (relatively recent) concerns that were spelled out.                                                                                CAE                                                       18                                      2.4.8 The GP surgery received confirmation from speech and language therapist SLT1 of an initial consultation. Sib.1 reported that English and a (named) central African language were spoken at home, though he preferred English. The child did not stammer during his appointment. His school had reported that he was above average in terms of literacy but that he hit and pushed others when angry or frustrated. Observed concerns at home visits by Children’s Social Care 2.4.9 At a home visit by borough 2’s SW6 on 09.08.13 an account was provided of how an argument between sib.1 and sib.2 had resulted in the former being stabbed with a pencil. SW6 was not wholly convinced by the children’s description of events. She also remained concerned that child G was still not getting enough stimulation or opportunity to practice walking. 2.4.10 SP1 undertook a visit on 28.08.13 and noted that father was not pleased to see him. Child G was asleep in his high chair. No further detail of that visit has been provided, so presumably does not exist. Comment: if the frequent observations that child G was spending unhelpful periods of time in a buggy or highchair had been more effectively aggregated and addressed, the consequences for his development and for mother’s need for more support would have been better understood. Core group 3 & ongoing support 2.4.11 A third core group was convened at school 2 on 04.09.13. Both schools, SW6 and mother were present. The group heard that sib.2 (aged 7) had stabbed her elder brother with a pencil and it was agreed that behavioural support would continue to be offered by her school. No notes of the meeting or of what the ‘behavioural support’ actually entailed have been located. Mother reported the imminent arrival (from Africa) of her partner’s daughter (sib.3 aged 16) from a previous relationship and said she had made arrangements for her to enrol at a local college.  2.4.12 Borough 2’s SW6 made her final home visit on 06.09.13 and reported no concerns. She informed mother and the children (father was not present) that the case was to be taken over by a SW7.  2.4.13 Mother underwent a routine operation on 13.09.13 rendered more complex because of her chronic medical difficulties. A number of administrative issues have been identified by those evaluating the records of this health-related episode e.g. ambiguity of personal and professionals’ contact details, next of kin, and who was caring for the children etc.  2.4.14 HV1 completed a further planned home visit on 16.09.13 and met child G together with his mother. Her notes indicate he was alert, happy and playful, beginning to use some clear expressive language appropriate to his age. Diet and nutrition were again discussed. Child G was almost walking. HV1 noted ‘nil apparent concern’.                                                                                CAE                                                       19                                     Child protection supervision of HV1 2.4.15 At her supervision next day HV1 raised the issue of mother disengaging from professionals and ceasing to take reliably her prescribed medicine, thus reducing her ability to care adequately for the children. Both parents were noted to be actively stimulating their children. As in the previous supervision session, family support and church members were described as strengths and protective factors. Comment: without the FGC that had been planned, it is unclear what level of support was actually being afforded the family from friends, relatives or fellow church-goers; the query about the frequency of father’s presence as in SW6’s summary was not addressed, nor was the school’s continuing concern about the behaviours of sib.1 and sib.2, which could have placed child G at risk and anyway suggested a level of family-related stress. 2.4.16 Though the immediate outputs of the conference were uploaded within a week, minutes of the July core group meeting were received by Community Health only on 10.09.13 (a 2 month delay) and their uploading was further delayed and completed on 11.10.13. Minutes of the conference of 23.07.13 were not received until October. Thus the supervision of HV1 on 17.09.13 depended upon her individual perspective. Comment: the fact of substantive delays in circulation and inputting of minutes on both occasions, coupled with the absence of complaint or challenge suggests that this is a systemic weakness. 2.4.17 On 17.09.13 SW7 took on the case from SW6. An apparent attempt at arranging a nursery place for child G was thwarted by father’s reluctance to supply details of income. It seems as though the issue of child G spending excessive in his buggy was not discussed. Comment: father’s suspicious reluctance to divulge details of income that would allow an assessment denied his son required additional stimulation but does not seem to have been articulated in that manner within records of professional involvement. 2.4.18 When SLT2 contact sib.1’s school on 03.10.13 she was unaware of the child being subject of a protection plan and referred to mother’s lack of interest in the speech therapy, describing it as ‘boring’ – though she had agreed to attend an intensive course at half-term. 2.4.19 An exchange between CNS1 and the clinic treating mother indicated that the former had discussed with SW7 mother’s mental capacity / function (which presumably might have been impacted upon by her medical condition). Comment: the issue of the mother’s mental as opposed to physical condition is not apparent from records provided.                                                                                 CAE                                                       20                                     2.4.20 HV1 completed a further planned home visit on 15.10.13 and met mother and child G. Father was said to be at work and the other children at school. Child G was well, alert and happy. A reference to him ‘feeding himself with family food’ is ambiguous and might refer to an observation or an assertion by his mother.  HV1 left health promotional information on dental care, home safety, accident prevention and immunisations.  2.4.21 Later that day, SN1 met with sib.1 whom she noted was well-presented though with worn out shoes, torn trousers and a holey sock. His history of bed wetting was not raised.  2.5 SECOND REVIEW CHILD PROTECTION CONFERENCE IN BOROUGH 2: STEP DOWN TO ‘CHILD IN NEED’ STATUS 2.5.1 The second review conference was convened on 16.10.13. Father but not mother was present. Professionals present included the independent chairperson, SW7, SP1, HV1, HT1, and SN1. The GP service was unrepresented and no report was submitted from it. A check of GP records has confirmed that a flag indicating child protection status existed in child G’s but not in his sibling’s medical records. Comment: the absence of GP contribution represents a significant systemic weakness though it is unclear in this instance whether the Practice was sent an invitation; it is also unclear whether mother’s earlier reluctance to make use of speech and language therapy was addressed. 2.5.2 Sib.1 was reported to be scheduled to attend speech and language treatment for his stammering. His mother had reported that bed-wetting has ceased and in-school support for aggressive conduct was ongoing. Professionals no longer felt concerned about parental physical abuse. 2.5.3 With respect to the ongoing perceived absence of a chronology from borough 1, the chairperson suggested that a worker might have to organise to go and read that borough’s records. Comment: it had been agreed on many previous occasions that the chronology was required and would be chased. The chairperson should have escalated the issue of the (apparent) failure to provide it. 2.5.4 The decision made by the chairperson of the review conference (and supported unanimously by those present) was that the children no longer required protection plans (recorded as having been for ‘neglect’) and would instead be supported by means of ‘child in need’ plans.   2.5.5 In October 2013 GP Practice A’s records erroneously noted child G as having ‘CP status’ (he had by then been stepped down to child in need status). Comment: this apparent misinformation raises doubts about the efficiency / effectiveness of the system by which GPs are notified of the attribution or amendment of such a status.                                                                                 CAE                                                       21                                     2.5.6 The minutes of the review conference were received in Community Health some four weeks later but the ‘child in need’ plan was not received until 15.01.14 and its inputting delayed a further month until 19.02.14. Pending receipt of those documents, health professionals were obliged to depend upon the chairperson’s ‘action plan’.  2.5.7 At a further health review completed by SN1 on 02.12.13 sib.1 (aged 8) was noted to be above 97th centile for weight and height i.e. very tall and heavy in relation to peers. SN1 noted the child’s worn trousers and shoes but considered him ‘well-presented’ and did not initiate any liaison with Children’s Social Care.  Attempts by HT1 a week later to return a call from newly allocated SW8 failed in spite of 4 recorded attempts, suggesting an absence of ‘voicemail’ facility. Comment: colleagues should always have the means and be aware of how to leave a message or alert a manager. 2.5.8 Though the information was shared by sib.2 rather than a parent (father was noted to be ‘disappointed’ that the news had been shared), SW7 became aware at her visit on 17.12.13 of the arrival four days earlier of father’s eldest daughter (sib.3 then aged 14 from a Central African country).  2.5.9 Sib. 3 engaged with the local health services during December 2013, initially by means of GP registration and later for specialist hospital treatment where her need for a French-speaking interpreter was recognised (no interpreter was used for an appointment early the next year possibly because her step-mother interpreted for her). Sib.3 initially complied but later proved unreliable in take-up of prescribed hospital treatment and was supported by community paediatric nurses. No record of such contact exists in GP medical records suggesting that the Practice was denied the advantage of having a complete picture of medical needs. 2.5.10 Child G was again seen at home by HV1, for a planned appointment this time in the care of his mother (father was at work). No concerns were noted and development was recorded on his ‘red book’ (the standard parent-held document) as being within normal parameters. It was agreed a nursery would be sought for a February 2014 start. Nearly two months elapsed before the record of this visit was uploaded. FIRST CHILD IN NEED REVIEW MEETING 2.5.11 At the first of the multi-agency reviews of the child in need plan held on 16.01.14 at school 2, no new incidents were reported. The arrival in the UK of sib.3 before Xmas was noted. It was understood that her mother had died (though when appeared unclear). Sib.1’s need for speech therapy had still not been taken up by the parents. The additional possibility of learning mentor input was noted to depend upon a parent meeting the class teacher to discuss this. Comment: to this date, there was limited evidence of actual, as distinct from promised, parental co-operation with services offered.                                                                                 CAE                                                       22                                     2.5.12 HV1 planned a further home visit in February. Material shared with the serious case review group has not clarified what actions were agreed by other professionals in attendance. A further CIN meeting was planned for late April. The completion of tests in this period prompted the prescription of routine medication for all family members. 2.5.13 During February the family moved to ‘address 2’ (local authority accommodation awarded on the basis of mother’s medical needs). Further monitoring by health professionals  2.5.14 On two occasions during a week in March 2014 mother presented herself at a hospital A&E department and her chronic medical condition was noted. On the second occasion she did not wait to be seen. Sib. 1 was again seen by school nurse SN1 on 18.03.14. Observations were essentially unchanged as was sib.1’s relative height and weight. SN1 did not share her findings with other professionals. 2.5.15 On 27.03.14 HV1 completed her planned visit and saw child G (by then 2 years old). Records indicate he was appropriately dressed and toddling happily around the house. He was noted to be heavy and tall for his age but had anyway ‘always been a big baby’. Mother was encouraged to use a cup not a bottle to provide water and in the presence of HV1 was able to get child G to accept this overdue step.  2.5.16 Mother referred to child G’s unclear speech and a family history of such difficulties. It would appear that measures to encourage speech and language development were not discussed at this visit, though management of temper tantrums was. The arrangement agreed with mother was that she would contact HV1 if required and that HV1 would otherwise review child G’s speech development in 2 months. Comment: HV1’s reasonable hope was that interactions at nursery would serve to improve receptive and expressive language. It is unclear whether HV1 ever saw child G feed himself or was noting mother’s description of him doing so. SECOND CHILD IN NEED REVIEW MEETING 2.5.17 At the planned review of the child in need plans held on 29.04.14 and attended by mother, sib.1’s stutter was noted to have worsened and it was agreed that SW7 would re-refer to the Speech and Language Service. No other concerns were shared and a unanimous view was formed that after three more months of monitoring, the case should be closed to Children’s Social Care. Mother claimed all the children would be seen by a dentist on 07.05.14 (sib.2 had reported to SN1 perhaps inaccurately, that she had been taken to a dentist in March).  Comment: a reliance on mother’s account and perspectives risked mis-calculating the impact on the family of her chronic medical conditions; with respect to the narrow issue of the children’s dental treatment, no confirmation that they received any has been located.                                                                                 CAE                                                       23                                     Presentation of child G at hospital 2.5.18 As a result of respiratory difficulties child G was brought to hospital 2’s Urgent Care Centre and referred on to its A&E Department on 18.05.14. A ‘viral wheeze’ was diagnosed. Medical notes indicate that the parents denied current involvement of a social worker. Comment: if current involvement of Children’s Social Care had been acknowledged or known, the hospital’s safeguarding team would routinely have been alerted; this presentation was not captured in the child’s GP records. 2.5.19 Mother was hospitalised for three days in late May and required follow-up having failed to comply with the use of some of her medication.  2.6 CASE CLOSURE BY CHILDREN’S SOCIAL CARE 2.6.1 A decision was made by a manager on 28.05.14 that the case would be closed. There remained the following uncompleted actions:  The required chronology had not (apparently) been provided by borough 1 nor developed by borough 2’s staff  The intended FGC had not been organised  No assessment of the impact of mother’s physical (and mental) health had been completed 2.6.2 The ability or willingness of the newly arrived sib.3 to provide safe and sufficient care of younger step-siblings remained untested; nor had sib.3’s own emotional, educational or practical needs been addressed.  PRESENTATIONS: SIB.3 AT A&E & CHILD G AT URGENT CARE CENTRE & GP PRACTICE 2.6.3 About a month later sib.3 (approaching 16) was presented by father and step-mother to hospital 2’s Urgent Care Centre and referred on to its A&E Department. Gynaecological symptoms were explored and relevant follow-up arranged to complete investigations the young woman found too intrusive at the time. Records confirm she was spoken to alone by a consultant and that a follow-up by phone was completed with sib.3’s GP. 2.6.4 It would appear that child G’s parents again denied that there was any social work involvement (it is currently unclear whether the family had by then been told of the case closure decision). It seems probable that information available to them was insufficient for the hospital staff to make the link with the other children in child G’s family.  2.6.5 An unnamed paediatric liaison health visitor emailed sib.3’s school nurse about the above presentations. Other medical information was provided and no safeguarding concerns passed on.                                                                                 CAE                                                       24                                     2.6.6 On 25.06.14, the parents though they did not present child G, sought medication from the same hospital’s Urgent Care Centre. The symptoms about which they were concerns are not clear. A nurse provided a letter for them to present to the GP and notification was sent by the duty health visitor and received by the Health Visiting Service on 03.07.14.  2.6.7 About a week later mother attended the Practice again without child G, and sought from the GP an inhaler for his use. Child G was subsequently seen at the Practice on 07.07.14 by a GP when antibiotics and an inhaler were prescribed. Comment: the parents had twice sought medication for child G without presenting him to a medical practitioner; the extent to which their child’s symptoms were related to the consequences of aspirating food remains unknown. 2.7 RENEWAL OF CHILD IN NEED PLAN IN RESPONSE TO DOMESTIC ABUSE  2.7.1 Police attended the family home on 18.07.14 in response to an argument between child G’s mother and sib.3 (by then aged 15). Whilst officers were present, mother and sib.3 began to fight. Mother was arrested for actual bodily harm (having allegedly bitten sib.3) and sib.3 arrested for affray. Both mother and sib.3 were brought to the local hospital 3 A&E where their medical needs were assessed and liaison with the paediatric team initiated. SN1 was notified on 22.07.14 of the incident but records do not offer any confirmation that the child protection history of sib.3’s step-sibling was acknowledged. 2.7.2 There were no prosecutions following the altercation during which it appears that father sought to contain the mutual aggression. In spite of the notification from Police of the domestic abuse incident, no strategy discussion / meeting was convened (which in all the circumstances would have been justified). Children’s Social Care did re-open the case and a re-assessment was completed by SW7. The agency response was signed off by her manager. Material supplied refers to effective case supervision by a ‘Pod manager’. 2.7.3 SW7 informed HT1 of the incident of 18.07.14 and was offered reassurance that there were no concerns about sib.1 and sib.2 who were being collected from school by the 15 year old sib.3. 2.7.4 At a home visit on 22.07.14 SW7 and manager TM1 saw an injury to the side of child G’s mouth said by his siblings to have occurred whilst they played outside. Records do not indicate whether the explanation offered was questioned or medical assessment recommended. 2.7.5 At SW7’s supervision on 13.08.14 the impact of sib.3’s arrival was discussed. It was agreed SW7 would seek advice about the justification for a further initial child protection conference (the independent chairperson later advised such a response was not justified), establish the school’s capacity to provide mentoring, explore the value of some therapeutic input and/or a referral to a parenting course.                                                                                 CAE                                                       25                                     2.7.6 On 21.08.14 HV1 was late arriving for a pre-arranged home visit and was unable to gain access. Mother had left for another appointment and sib.3 who was caring for the three younger step-siblings explained she was not allowed to open the front door. A record of this was only made a month later. It does not seem as though a further attempt to complete a visit was made nor that the experience was shared with SW7. 2.7.7 SW7 made direct contact with sib.1 and sib. 2 on 08.09.14 and in the course of her re-assessment of the family’s needs father’s insufficiency of insight as well as resistance to agency involvement became clear. Mother was hospitalised overnight on 15.09.14 for treatment associated with her chronic medical condition. CHILD G LEFT ALONE  2.7.8 At 17.17 on Thursday 25.09.14 police officers (dealing with another issue) spotted child G (aged 2.5 years) at a window with ‘a white substance around his mouth’. They correctly discerned that he had been left alone at home and forced entry. Mother returned during the course of the actions taken by Police and claimed that her sister should have been looking after her son.  2.7.9 Child G was taken by ambulance to hospital 3 A&E for a precautionary check-up. No injuries were recorded but a diagnosis of ‘? lower respiratory tract infection’ was made. A reference to a ‘foreign body’ remains unexplained. Standard notifications were initiated electronically for community health visitors, school nurse and GPs. 2.7.10 Sib.3 remained at home with her father and step-mother and Police Powers of Protection under s.46 Children Act 1989 were exercised on the 3 younger children all of whom were then fostered with parental consent under s.20 Children Act 1989.  2.7.11 A strategy discussion was completed on 29.09.14 between Police and TM1 and a joint investigation under s.47 Children Act 1989 initiated. HV1 contacted the family and visited on 29.09.14 when she noted that mother was tearful and appeared remorseful (mother later admitted to Police that she had left child G alone and accepted a caution for the offence of neglect). Later still, it emerged that mother had been shopping and that child G had been unsupervised for over an hour. 2.7.12 HV1 later liaised with the children’s carer though a planned visit to the foster home was overtaken by their return home. The school had become aware of the incident only when sib.1 and sib.2 failed to attend.  Comment: the school should have been informed by Children’s Social Care. 2.7.13 The children were returned to their parents’ care on 03.10.14 and the agreed conclusion of the s.47 investigation was that an initial child protection conference was required. Information provided by Police included the fact (not seen in previous records and possibly unknown to the local network) that there has been violence between father and a previous partner in a local authority in rural England.                                                                                 CAE                                                       26                                     2.7.14 HV1 completed a planned home visit two days after the children’s return home. Her notes refer to the home being ‘a bit cluttered’ which the parents attributed to a planned transfer to a three bedroom house. Child G was noted to be appropriately dressed and calmer than on previous occasions but still not communicating verbally. Mother said that child G had a good appetite and disliked ‘mashy foods’ (an observation that was consistent with the comments made to HV1 by the foster carer). 2.7.15 Mother reported child G’s nursery had made a referral and HV1 liaised with the Speech & Language Therapy Service to be told that a referral had been received on 02.10.14 and an appointment was pending. It seems no attempt was made to expedite an initial appointment. 2.8 INITIAL CHILD PROTECTION CONFERENCE: PROTECTION PLANS FORMULATED  2.8.1 Mother attended the conference on 13.10.14 but her partner sent his apologies. Professionals present were the same independent chairperson as for previous conferences, SW7, HT1, the pastoral manager from school 4 at which sib.3 was a pupil, SN2, HV1, CNS1, Police and a representative of the nursery child G had begun to attend 2.8.2 Concerns that were discussed included sib.2’s ‘scruffy and a little smelly’ appearance at school, as well as about her aggression toward other children. Mother’s difficulty in relating to her step-daughter and (for health-related reasons) managing the demands of toddler child G were acknowledged. The parents had refused a suggestion that they undertake some form of parenting programme that could offer them an enhanced ability to deal with the newly arrived teenager. Comment: previous reports from teachers and school nurse had been more positive about the children’s presentation. 2.8.3 A GP was reportedly invited (though no record of that was found in medical records) but did not attend or provide a report. It does not seem as though paediatric input was sought. None of the participants were aware that Care Proceedings had been initiated whilst the family had lived in borough 1. The result of the discussion at the conference was that all four children were made subject of protection plans for neglect. The chairperson’s conference report was uploaded within a week and the minutes after two and a half months (it is unclear with whom responsibility for that lay. As well as child G continuing at nursery, the plan involved:  HV1 escalating child G’s referral for speech therapy and seeing him monthly, alternating between home and clinic  A school nurse completing termly health assessments  Sib. 1 being provided with a block of concentrated speech and language therapy during half-term  SW7 requesting a neuro-psychological report on mother and (again seeking advice from a systemic practitioner with respect to more effective ways of working with the family                                                                                 CAE                                                       27                                     Comment: this conference (like its predecessors) was weakened by the absence of GP input - though it remains unclear whether an invitation to contribute was issued; Practice A had also failed to capture the change of status of the records for child G’s siblings; the conference focused on the narrow recent issue of child G being left alone as opposed to the overall family dysfunction. 2.8.4 SN2 initiated her first school-based assessments of the children within a week. She noted sib.1 to be very tired and wearing a dirty ill-fitting school uniform; his face was unwashed and nose dirty. Sib.1 reported the children were given biscuits or crisps with tea instead of an evening meal. He contrasted this with the proper cooked dinners (meat and pasta) whilst fostered. He was unable to recall ever attending a dentist. Records indicate an intention to discuss the findings with mother.  2.8.5 Sib.2 (at her school) reported that she shared a bedroom with her step-sister who provided comfort when she had bad dreams; sib.3 also told sib.1 off ‘when he hit child G’. Sib.2 described an inadequate diet at home. 2.8.6 SN2’s assessment of sib. 3 (aged 15) was of a sullen reluctant child with poor eyesight and evidence of tooth decay. Sib.3 claimed that nobody would take her to an optician or dentist. The child’s account of her diet at home also implied that she was inadequately fed. Though of average height, her weight was below the 3rd centile i.e. extremely few children of her height would weigh as little. Comment: lack of dental care had been identified from an early stage and the clear allegations of inadequate feeding were of real significance. Sib.1 who was known to be aggressive could have seriously hurt child G thus representing an acute risk. SN2 should have immediately shared her findings of neglect with the allocated social worker SW7. FIRST CORE GROUP MEETING 2.8.7 The first core group meeting following the October conference was held on 21.10.14. Child G was then aged 2 years and 7 months old. Present were HT1, SN2, SW7, CNS1, HV1, and the pastoral manager for the High School at which sib.3 was then a pupil. Sib.1’s increasing lack of focus at school was noted. The account provided by both children of their evening food intake differed from that of their mother. SW7 was tasked with monitoring the children’s evening meals and SN2 was to ‘possibly start food diaries’. Mother claimed that the children had optician appointments during the imminent half-term. Comment: how SW7 was to achieve her task is unclear and no evidence has been provided to confirm that she did so. The word ‘possibly’ with respect to SN2’s food diaries was too vague to be of value. Compliance with dental and optician appointments remained unchecked.                                                                                 CAE                                                       28                                     2.8.8 There is no record of SN2 sharing with others the account of sib.1 hitting child G. There was a recognition of the possibility of sexual exploitation of sib.3 though the risk was agreed as ‘low’.  2.8.9 Later that week the GP Practice at which all the children were registered received a record of the initial conference. A flag was added to the records of child G but not his siblings and no further updates were made following the review conference in 2015. Comment: as well as a recurring absence of contribution to the multi-agency planning, this Practice had no flag within children’s records to confirm the previous and once again, current status of being subject to a child protection. 2.8.10 An intention by SW7 to spend time with the children on 27.10.14 (a trip to McDonalds) was prevented by mother who said they were all too busy preparing for their house move. A second home visit on 05.11.15 (presumably to the new address) found nobody at home. SW7 was able to meet the children on 12.11.14 but enquiries about what meals the children had recently been given were blocked by sib.2 citing father’s instruction not to share anyone outside the home any ‘family business’. Comment: sib.2’s attribution of the comments to her father seem credible; father should have been confronted and it made clear that a failure to comply with the defined child protection plan would lead to a legal planning meeting. TRANSFER TO GP PRACTICE B & FURTHER OBSERVATIONS OF CHILDREN BY HEALTH PROFESSIONALS 2.8.11 On 19.11.14 all members of the family transferred to an alternative ‘Practice B’ presumably in consequence of their move to larger accommodation in a new area.  Comment: any erroneous or misleading information in records is automatically transferred to a new Practice via the ‘GP2GP’ system. 2.8.12 SW7 received supervision on 19.11.14 from TM1 and it was agreed that mother though not her husband, was engaging with the professional network. SW7 and the independent chairperson held an apparently unrecorded meeting with a systemic practitioner in an attempt to develop a more effective way of gaining acceptance by both parents of the need for professional involvement. 2.8.13 Two days later sib. 2 was brought by her mother to the Urgent Care Centre at hospital 2 and diagnosed as having an upper respiratory tract infection. Mother also presented child G at the same time and he was diagnosed as having diarrhoea and vomiting. Though the involvement of a social worker was identified, it does not appear that Children’s Social Care was informed of the presentations.                                                                                 CAE                                                       29                                     2.8.14 HV1 completed a home visit on 24.11.14 (whether planned or not is recorded). Mother was in hospital and HV1 saw child G with his father for the first time. HV1 noted him to be alert and well and the home to be clean. Child G was having a snack of juice and a biscuit before attending nursery. Father reported his son had already eaten lunch which HV1 though was early in relation to a nursery start-time of 1pm.  2.8.15 Child G responded positively to HV1 and she thought he had a good and reciprocal relationship with his father. Records do not refer to HV1 offering advice about child G’s delayed use of speech and language, though she had noted father’s assertion that child G spoke more when siblings were home. HV1 did discuss diet and dental care. 2.8.16 HV1’s action plan was to continue her monitoring pending a transfer to a new HV2 (a consequence of the family’s move). By 28.11.14 HV1 had received confirmation from the Speech & Language Service of child G’s expressive speech delay and the advice offered his parents. No further involvement of that agency has been seen. A further visit by SW7 on 27.11.14 found nobody at home. SECOND CORE GROUP MEETING 2.8.17 A second core group meeting was convened on 03.12.14. Mother was in hospital at the time and father attended. The same professionals as had made up the first core group were present. Sib. 1 was still coming to school in dirty clothes and the issue of insufficient food was again debated. HV1 recommended that father reduce the children’s intake of juice and offer them healthy snacks.  2.8.18 The aggressive behaviour of sibs.1 and 2 continued and they were reported not to be progressing at school. Child G was doing well at his nursery. No concerns were shared about sib.3 who was immaculately presented though performing below average at college. Comment: the source of sib1 and sib 2’s aggression needed exploration as did the perhaps connected issue of food; sib.3 was old enough to self-care and her under-performance as a recently arrived non-English speaker, unsurprising.  2.8.19 Dates for the review conference and further core groups were agreed. Following a home visit  about which no notes were made, SW7 and her supervisor TM1 discussed the case again on 10.12.14 and apparently retained the hope that father could be persuaded to access therapeutic service in his own right or involving the family. 2.8.20 In mid-December HV1 discussed the case in her child protection supervision. A reported level of ‘support from maternal grandmother and the church community’ was not described or evaluated. Comment: HV1 had shown a high level of commitment to the family but her view of parental engagement and parental progress was at odds with the evidence.                                                                                 CAE                                                       30                                     INITIAL OBSERVATIONS OF NEW HEALTH VISITOR 2.8.21 On 05.01.15 an initial home visit was made by HV2. She met child G in the care of his mother. His recorded self-help skills extended to consuming juice and yogurt without help. HV2 noted also that child G’s expressive language had improved. Comment: it is unclear why HV2 thought any more input from speech & Language Therapy Service was scheduled. REVIEW CHILD PROTECTION CONFERENCE  2.8.22 On 07.01.15 the first review child protection conference was convened and was chaired by independent chairperson 2 covering for his colleague who had chaired previous conferences. A (confirmed) hospital appointment prevented attendance by mother but father was present. 2.8.23 SW7, SN2, HV2, HT1, CNS1 and representatives from schools and nursery were present. Police were unrepresented though sent a report confirming no new contacts. No GP or GP report was available and it is uncertain whether any requests had been made. 2.8.24 HV2’s account of the family was comparable to that of her predecessor i.e. the family was engaging and receptive to advice and strategies and no sources of risk had been observed. HV2 was asked to expedite what was apparently considered to be an active referral for more speech and language input. There seems to have been no debate about father’s historical record of violence toward a previous partner. Comment: though HT1 reported sib.2’s further comments about insufficiency of food at home, no written confirmation of the results of SW7’s monitoring of the children’s evening food intake has been traced. 2.8.25 The thought that there might be value in a neuro-psychological report on mother disappeared at this conference with a comment from CNS1 that neither she nor her consultant had observed changes in mother’s functioning. 2.8.26 The needs noted within the analysis section of documentation remained essentially unchanged and a manager’s comment of ‘minimal progress’ was justified and perhaps a little more positive than the facts suggest. 2.8.27 The independent chairperson decided that all four children would remain subject of a protection plan under the unchanged category of neglect. Concerns included mother having left child G alone (the trigger for action in October 2014), mother’s ability to manage teenager sib.3 and toddler child G, the emotional condition of sib.1 and sib 2 (both still bedwetting) and their appearance as well as the parental relationship.                                                                                  CAE                                                       31                                     2.8.28 With respect to child G in particular, the chairperson’s plan may be summed up as ‘more of the same’ and the contingency position also remained as the possibility of legal planning meeting if the plan was blocked or the younger children again left without supervision. Comment: This conference focused less on the issue of sufficiency of food for the school-aged children; the extent to which child G’s mobility was being limited so as to reduce the pressure on mother was not addressed. CORE GROUP MEETINGS & ONGOING MONITORING 2.8.29 An unannounced visit to the family’s new address on 16.01.15 found nobody at home. The day before the core group meeting on 20.01.15 SN2 met with sib.1 in school. His uniform was clean and well-fitted though his face dirty. Sib.1 reported cooking a pizza for himself after school and then his mother or older step-sister cooking a meal in the evening. He described twice-weekly baths and admitted that he did not brush his teeth every day.  2.8.30 Sib.1 also described a fight with sib.2 in which she had cut her back sufficiently seriously to prompt his father to return home. His mother was said to have been ill and asleep in bed at the time of the incident. Sib.1 reported that he had still not been seen by an optician. The issue of a dental appointment was apparently not raised. SN2 also met with sib.2 who offered positive news with respect to provision of a hot meal in the evening but reported getting herself ready in the mornings. Comment: there is no record to confirm that the school shared this information with the allocated social worker (SN2’s failure to share information with relevant others has emerged on previous occasions). 2.8.31 The parents arrived late for the meeting and most of the discussion centred on the older children. It appears that the altercation between sib.1 and sib.2 was not raised by SN2. In response to the parents’ claim that sib.2 had been taken to but refused to co-operate with a local dentist, SN2 followed up with the specialist dental service and received confirmation of the offer of an appointment. Comment: it seems that no core group meeting notes from this or previous meetings were kept or if they existed, were not circulated to participants; it seems unlikely that the dental appointment was kept. 2.8.32 The day after the core group sib.3 was seen by SN2 who had no concerns about the young woman’s dress or physical appearance. On 27.01.15 SW7 completed an unannounced home visit. Neither parent was present though all four children were and sib.3 appeared distressed. She reported that mother had packed her belongings and told her that she could no longer stay there. SW7 remained with the children for over two hours before father returned. He refused to accept that sib.3 was not old enough to be left with that amount of responsibility.                                                                                 CAE                                                       32                                     Comment: SW7’s notes suggest that this episode amounted to emotional abuse of sib.3 and that she planned to discuss with managers and the independent chairperson, it is not clear that anything more decisive emerged, perhaps because SW7 left her role in the borough soon afterwards. 2.8.33 SN2 brought this case to her safeguarding children supervision on 10.02.15 where it appears that based upon her positive account of parental co-operation, the existing approach was ratified. FURTHER CORE GROUP MEETING 2.8.34 Though SP1 remained in post, SW7 was replaced on 10.02.15 by borough 2’s SW8. It would appear that no handover visit had been achieved. At the next core group meeting on 14.02.15 SW8 who had not yet met the children heard about the aggressive behaviours of sib.1 and sib.2 as well as some reduction in school attendance rates. 2.8.35 HV2 completed a home visit on 17.02.15 (whether planned or unannounced is uncertain). She met mother, sib.1 and child G (rising 3) who was noted to look well and able to user his inhaler to good effect. SW8 made his first home visit a few days later on 24.02.15 though beyond his encouragement that parents might engage with a clinician in the recently developed ‘Pod’ 3, no other observations of the children’s quality of life was recorded. Father asked for additional alternative care for child G though whether this reflected his wife’s difficulties in coping with her chronic ill-health and all the children was not noted. Comment: with respect to the idea of deploying a therapist, this family had no capacity and little motivation to engage with any additional professionals. The priorities remained ensuring that they did not abuse their children and did meet the most basic needs for food and clean clothes. 2.8.36 SW8 made his contact with the family on 24.02.15 and noted nothing of concern. Mother was seeking subsidy for more nursery care of child G. FURTHER CORE GROUP MEETING 2.8.37 A further core group meeting was held on 04.03.15 at school 4. HT1 had sent her apologies and provided a report. SW8 and CNS1 as well as both parents attended. The latter reported that glasses for either sib.1 or sib.2 had been fixed and that an appointment had been received for sib.2 to be brought to the specialist dentist. Comment: the review group has been unable to confirm the accuracy of the claim about the specialist dentist. 2.8.38 SW8 completed a home visit on 10.03.15 and met and spoke with all the children. He was informed of an argument between the adolescent and her step-mother but concluded that it was of no significance and that ‘the family was functioning well’.                                                    3 Along with a proportion of other Children’s Social Care Departments, borough 2 has established a number of  Pods (units consisting of a team of social workers and  therapist led by a manager of that team / unit)                                                                               CAE                                                       33                                     2.8.39 Any attempt in late March by HV2 to establish the date of the next core group meeting was thwarted when she was unable to contact parents or leave a message for SW8.  Comment: liaison levels between health visitors, nurses and social workers seems to have declined during 2015. ‘POD SUPERVISION 1’ IN CHILDREN’S SOCIAL CARE 2.8.40 A process labelled ‘Pod Supervision’ took place in Children’s Social Care on 19.03.15. The case supervisor was named as someone other than TM1 and the supervisee as SW7 who had actually left her employment on 06.03.15. Comment: the purpose and recording of this event as well as those that followed it, in particular their link to other sources of case supervision, should have been clearer. 2.8.41 SW8 made a further home visit on 24.03.15 and spent time playing with child G who appeared to be well, appropriately dressed and lively. Feedback from the older children indicated some form of bedtime routines though their reports could not be verified.  2.8.42 Sib.3 attended the Urgent Care Centre on 04.04.15 complaining of abdominal pain. No treatment was required and the electronic system which flagged up the involvement of Children’s Social Care enabled SW8 to be informed of the incident.  2.8.43 SW8 was not informed of the presentation at the same Centre of sib. 2 at midnight on 08.04.15, though records confirm an awareness of his involvement. The child (7.5 years old) is thought to have had a urinary tract infection but mother did not wait for her to be seen. Comment: the significance of such a late night presentation and potential consequence of mother’s refusal to wait deserved exploration.  2.8.44 SW8 was able to complete an unannounced visit on 09.04.15 when father willingly let him in. Child G was present but no specific observations about him were recorded. SW8’s record shows that he believed that father had good insight into the needs of his children and was engaging well with the child protection process and the therapeutic worker. His view at that time was that he would recommend ‘stepping down’ to child in need status at the next review conference. Comment: whilst the parents’ love for the children was not in doubt, there was limited evidence of sustained co-operation with the child protection plan, no demonstrable improvements in the children’s lived experience and long-resisted therapeutic work had only just started.                                                                                 CAE                                                       34                                     2.8.45 A further core group meeting was held on 15.04.15 and both parents were present. HT1 who had been very involved in all planning to this point was apparently not invited (though a conversation with SN2 a week or so later indicated that there were no new concerns about sib.1) The consensus remained that the parents were being co-operative (seemingly based upon attending two sessions with a systemic practitioner) and that the risks to the children were thought to have decreased. It seems probable that no minutes were kept. Comment: without an agreed record of the output of this or any other meeting, the obvious risk is that individuals will have differing view of allocated tasks.  SCHOOL NURSE HEALTH REVIEWS & AN IN-SCHOOL INCIDENT 2.8.46 On 21.04.15 sib.1 hit 2 other class-mates and in addition to an in-school response from the learning mentor, a note was sent home to the parents. 2.8.47 Later that week at an unannounced home visit mother spoke of the incident in September 2014 when she had left child G strapped in his high chair and gone to the GP Practice (shopping at Argos was another possible explanation according to observations of attending police officers). Mother said this would not happen again. SW8’s observations of all three younger children (which have not been provided) prompted no concerns. POD SUPERVISION 2 IN CHILDREN’S SOCIAL CARE 2.8.48 There was a further ‘Pod supervision’ session on 24.04.15 which referred still to the recently departed SW7. Its record suggested that the focus of the systemic therapist’s work was the marital relationship and management of the teenage sib.3 – not the concerns about care of the younger children. Nonetheless based upon the debate at that forum, the named case supervisor proposed to consult the independent chairperson about bringing forward the date of the scheduled review conference. Comment: if such forums are able to exercise a level of influence seemingly greater than traditional individual case supervision, it is critical that this is understood and accepted by all agencies. 2.8.49 At the core group earlier in the month it had been agreed that a further health review would be completed by the school nurse prior to the scheduled review conference. SN2 completed those health reviews on sib.1 and sib.2 on 08.05.15. Sib.1 (whose presentation was ‘improved’ though the hem of his trousers were falling down) spoke of being friendless because he hurts people. He reported that home was okay and that he expected to be moving school. His relative height and weight remained above the 98th centile. At his sister’s review no health concerns were identified. Her weight and height were not recorded. Comment: it would have been best practice to capture weight and height.                                                                                 CAE                                                       35                                     2.8.50 At a further unannounced home visit by SW8 on 08.05.15 child G was seen and briefly spoken to. Mother reported that aside from a respiratory infection, she was fine. No other detail has been provided. Four days later HV2 also visited and obtained from mother the date of the next core group meeting and, apparently a name for the new social worker. Child G (3 years and 2 months old), was on the 96th centile for weight and height. Immunisations were up to date and mother reported that use of his inhaler was limited to those times he had a cold. 2.8.51 A core group meeting was convened on 20.05.15 at school 2. In addition to both parents, the professional attending included assistant head of school 2, school 4’s ‘pastoral manager’, SW8, SN2 (and her student), CNS1 and HV2.  2.8.52 SW8 offered reassurance about the provision of food within the family (he had seen ‘plenty’). The initiation of contact with the therapeutic worker was noted though no feedback about its effectiveness was received. SW8 thought that mother’s relationship with her step-daughter had somewhat improved. Sib.3 was collecting her younger siblings from their nearby school every day. 2.8.53 Sib.1’s stutter had worsened though he had been discharged from the Speech & Language Therapy Service. The ongoing issue of a lack of dental or optical care was not debated and, because not all had been notified, the high and erratic use of the urgent care, A&E and GP services remained largely unknown. 2.8.54 A consensus was developed that the children could safely be stepped down to ‘child in need’ status at the next review conference. A home visit was completed later that day by SW8 who spent time with the three young children. No concerns were recorded. 2.8.55 On 22.05.15 SN2 undertook a further assessment of sib.2 who presented and engaged well in conversation. The chid said she had friends at school and was happy. She indicated though that she had still not been to a dentist. Sib.2 referred to her favourite food at home which was prepared by her step-sister not a parent. POD SUPERVISION 3 IN CHILDREN’S SOCIAL CARE 2.8.56 A third ‘Pod Supervision’ was completed on 22.05.16 and (aside from the recurring errors with respect to the allocated social worker and dates of proposed further sessions) merely repeated what had been rehearsed at the last core group. 2.8.57 The contents of a child protection supervision session for SN2 on 28.05.15 in which the family was discussed do not appear in her records. A home visit by SW8 on 04.06.15 noted nothing of concern in appearance or behaviours of the children.                                                                                 CAE                                                       36                                     2.8.58 A report from the speech and language therapist SALT 1 dated 05.06.15 (though it may have been sent earlier) offers a very different account of the extent to which mother was in touch with child G’s needs and her ability or interest in engaging and improving his delayed receptive and expressive language e.g. mother presented her son significantly late on four of five sessions and prioritised examining her mobile when she should have been focusing on child G. 2.9 FURTHER REVIEW CHILD PROTECTION CONFERENCE: STEP DOWN TO ‘CHILD IN NEED’ STATUS 2.9.1 The second review conference on 10.06.15 was attended by both parents. Police who had had no new contacts with the family did not attend. Aside from the independent chairperson other professionals present were SW8, HV2 (and a student) HT1, SN2, CNS1, the speech and language therapists and the school’s pastoral manager. Child G’s nursery was not represented and SW8 was tasked with obtaining a report from staff there. 2.9.2 The parents reported that they had found the therapist very helpful and now related to one another differently. The speech therapist reported that mother had not fully engaged with the block of therapy offered to child G. In spite of mother’s ongoing reluctance to accept speech therapy for child G, a consensus was reached that the children no longer required to be subject of protection plans. HV2 would henceforth visit every other month.  POD SUPERVISION 4 IN CHILDREN’S SOCIAL CARE 2.9.3 A fourth ‘Pod Supervision’ on 23.06.15 merely noted and welcomed the fact that the case had been stepped down to child in need status. It contained the same inaccuracies about allocated social worker and next scheduled session as its predecessors. 2.9.4 During June and July mother was provided with a high level of specialist treatment for her chronic medical difficulties. On 02.07.15 an offer by SW8 of a parenting programme was turned down by the parents who reminded him that the child protection plans had now ceased. Comment: the incentive implicit in a child being subject of a child protection plan had been removed and the parents’ apparent engagement diminished. 2.9.5 In mid-July a visit by HV2 was completed. She observed child G (3 years 4 months old) with mother and older sister though father returned during the course of her visit. Child G was thought to be ready to start nursery in September. He was heard to use some expressive language. A holiday play scheme was discussed but the extent to which there existed any extended family or community support was not explored.                                                                                 CAE                                                       37                                     CHILD IN NEED (CIN) MEETINGS CIN review 1 2.9.6 On 15.07.15 the first ‘child in need’ meeting was held. Father and sib.2 were present as were SW8, HT1, the school’s pastoral manager and HV2. Apologies had been received from SN2 and the specialist nurse neither of whom passed on any current concerns. The school reported that sib.1 had responded well to anger management sessions. Sib.2’s class teacher remained concerned about that child’s ability to process information and the child was still receiving weekly counselling. 2.9.7 HV2 reported no concerns about child G who was awaiting a further block of speech therapy. She raised the possibility of funding from Children’s Social Care for holiday activities citing mother’s recent poor health. In the parents’ view they no longer required support and the professional view also appeared to anticipate stepping down within a short period from CIN status. Comment: the fact of mother’s continuing and probably permanent poor health and her acknowledged need for support over the summer was at odds with the parents’ wish to be free of the CIN plan. 2.9.8 Mother’s ill-health required further high levels of specialist intervention over the summer and into the autumn of 2015.  Comment: the time mother was obliged to spend seeking and receiving treatment and its various side effects must have rendered it very difficult to be sufficiently available both physically and psychologically to her children.  2.9.9 A home visit by SW8 on 04.08.15 raised no concerns. SW8 spent time with child G and noted the family’s plans for schooling after the summer break (sib.1 and sib.2 were to transfer to an alternative school nearer to the family’s new home). Child G was about to re-start speech and language therapy. POD SUPERVISION 5 IN CHILDREN’S SOCIAL CARE 2.9.10 Senior practitioner SP1 was noted as the supervisee at a further example of ‘Pod supervision’ on 25.08.15. SW8 was not involved thus reducing the opportunity for individual reflection on facts and fears.  Comment: contents of a sixth session in October cast no more light on the family’s needs; there is a need to review the purpose and conduct of these events. CIN review 2 2.9.11 Sib. 1 and sib. 2 began to attend a new school 3 in September and soon after child G began attending the nursery. On 15.09.15 staff suggested mother present child G to the GP to examine a ‘sore lip’ which mother indicated she had inflicted (how she had done so was not captured and, in the light of the circumstances of his death may have some relevance).                                                                               CAE                                                       38                                      2.9.12 On 16.09.15 a second review of the CIN plan (CIN review 2) was completed. Both parents attended. Professionals were SW8, HV2 and the deputy head of school 3. SN2 and mother’s specialist nurse sent apologies. Child G was reported to have settled into nursery well, and to arrive well dressed with spare clothes as requested. HV2 had last seen child G at a visit in July.  2.9.13 Mother reported 80% attendance for child G’s speech and language therapy sessions. One record seen indicates that the family would be monitored for a further two months with a view to ending the CIN status at the next review.  2.9.14 In fact, rather than that approach or a ‘step-down’ with a view to involvement with the ‘Early Intervention Service’ a unanimous decision seems to have been that Children’s Social Care would close the case. One consequence of that decision was the immediate discontinuation of visits by HV2.  Comment: cessation of visits by the health visitor was not inevitable, was regrettable and presumably reflected a need to prioritise apparently needier families.  PRESENTATION OF CHILD G AT GP PRACTICE 2.9.15 A phone consultation about child G (reported by mother / father to have a high temperature aggravating his asthma) was initiated with a nurse practitioner on 29.09.15. Child G was later seen by GP7 who was told child G had ‘been unwell for three days, to have a blocked nose with some wheezing and to have been off his food’. His inhaler had been exhausted. Examination indicated a viral infection with asthma exacerbation.  2.9.16 Soon after the cessation of child in need status, the parents failed to present child G to several speech and language therapy sessions and were warned that he would be discharged unless they made contact. This information was shared with HV2 but it appears to have triggered no further action by her. Comment: given how recently these children had been considered at risk or in need, the news should have triggered at the very least, contact with the parents. 2.9.17 The Practice nurse saw child G on 07.10.15 and noted that he looked better. Child G was still coughing, using Clenil and Ventolin4 and was noted to be due for his flu immunisation.                                                    4 Clenil and Ventolin are standard medicines used to alleviate the symptoms of asthma                                                                               CAE                                                       39                                     ONGOING CONTACT / OVERSIGHT FROM CHILDREN’S SOCIAL CARE & SCHOOL EXPERIENCES 2.9.18 The last recorded visits by SW8 was on 14.10.15 when all the children and were seen and an explanation provided about him ceasing visits. SW8 recorded that child G had engaged with his speech and language though that is at odds with the view of the therapist herself. A parents’ evening on 20.10.15 revealed some continuing concerns about sib.2’s aggression toward some other children.  2.10 CASE CLOSURE BY CHILDREN’S SOCIAL CARE 2.10.1 SP1 formally closed the case on 02.11.15 (a decision ratified next day by his manager). The closure record offered a positive picture of progress with a brief mention of mother’s illness. The rationale for closure was that child G was in nursery three days per week and sib.3 (who had recently begun a course at a local Further Education college) now provided additional assistance to the family.  2.10.2 Tasks originally specified when the family arrived in the borough (ensuring the provision of a case chronology, and convening a FGC) remained undone. School 2 (teaching staff and SN2) were formally notified by email later that week and there was no further discussion. Next day mother agreed that sib.2 could see a play therapist at school. INJURY TO CHILD G 2.10.3 On 04.11.15 father presented child G to GP6. He reported an incident on the morning of the day before. He had not himself witnessed the event but understood that his 10 year old i.e. sib.1 had accidentally hit child G with his head. Child G had not lost consciousness and had not bled. When asked by the doctor child G said that it was his sister sib.2 who had struck him but did not divulge any other detail. He said he didn’t hurt anywhere else. 2.10.4 The medical record indicates an abrasion to the right cheek; evidence of bilateral erosion to the mouth (father reported a dentist as having attributed that to the child biting those areas); no break in the lip border, no puncture wounds and no other injuries on the boy’s trunk. 2.10.5 The doctor thought the child’s behaviour was unremarkable and that the account was consistent with the observed injury. He was fully aware of the history of child protection plans but understood there to have been no history of violence to child G. The doctor surmised that father was presenting his son because of his partner’s view that he should do so. The advice given was to monitor in case an infection developed. Comment: in the light of what later happened to child G, injuries to and around the mouths of these children may have had a significance beyond what would normally be considered but the GP’s responses were justifiable given the information available to him.                                                                                  CAE                                                       40                                     RENEWED CONCERNS ABOUT APPEARANCE & BEHAVIOUR & DEATH OF CHILD G Renewed signs of neglect 2.10.6 On 20.11.15 HT2 at sib.1’s new school was obliged to ask mother to attend to discuss her son’s conduct toward other children, personal hygiene and his torn and dirty shirt. Sib.1 had explained to HT2 that his step-sister got him and his sister up in the mornings.  2.10.7 Mother appeared to take the concerns shared by HT2 seriously and there was a marked improvement in the boy’s appearance and cleanliness the following week. Fatal incident 2.10.8 Immediate and subsequent responses on 27.11.15 by Ambulance and Police services respectively, when father made a 999 call for an ambulance have been described in section 1 of this report. 2.10.9 The implications of risk to child G’s siblings were recognised by medical staff at Accident & Emergency and liaison with Children’s Social Care appropriately initiated. Records relating to the safeguarding work associated with sib.3 had not been passed over to the college when she began attending it and were transferred only as a consequence of the liaison that followed child G’s death. A recommendation has been included in section 5.                                                                               CAE                                                       41                                     3 RESPONSES TO TERMS OF REFERENCE 3.1 INTRODUCTION   3.1.1 The inclusion of a number of paragraphs of italicised comment in section 2 justifies the provision below of relatively succinct responses to the elements of the appended terms of reference. Section 4 provides some overarching findings and opportunities for learning and section 5 some resulting recommendations. 3.2 QUALITY OF ASSESSMENTS INFORMATION PROVIDED BY BOROUGH 1 & EMERGING FROM FAMILY’S INITIAL PERIOD IN BOROUGH 2 3.2.1 The electronic transfer of school health records, a phone briefing and (belatedly) the arrival of paper records offered HV1 relevant information that informed her initial visit. 3.2.2 For the period of nearly six months prior to borough 2 assuming responsibility, no core groups were convened and the un-coordinated monitoring of the family depended upon the 7 contacts by borough 1’s SW4, as well as the persistent efforts of HV1 described in section 2 of this report. 3.2.3 Records indicate that HV1 worked hard to engage the family and an initially unresponsive Children’s Social Care. There was scope within her accounts of the family to better capture the parent / children relationships and dynamics and the role of father. The more substantive areas for learning though, centre around:  An acceptance (rather than a challenge via the escalation procedure) of the ‘transfer-in’ muddle   The distinction between her real-time records of the substantive challenges presented by child G’s family (disguised compliance was evident) and her more optimistic reports at core groups and to conferences  3.2.4 Consultation events with staff suggested that there may be (possibly because the need for its use is infrequent) insufficient appreciation across the network of the existence or appropriate use of ‘escalation processes’. The recommendation in section 5 that this case is used to inform LSCB training addresses that implied need.  RECOGNITION OF THE IMPACT OF MOTHER’S ILL-HEALTH 3.2.5 There was very limited liaison between hospital 2 from which mother’s specialist treatment was organised and her GP. This fact coupled with the absence of GP advice at any multi-agency forum meant that the network was almost entirely dependent upon information and advice from the very committed clinical nurse specialist CNS1.                                                                                  CAE                                                       42                                     3.2.6 The letter sent by CNS1 to the Housing Department in July 2013 was very clear and made explicit the name and nature of mother’s health condition. Discussions amongst the professional network were more circumspect and seemed (in the view of the serious case review panel members) to have been unnecessarily coy about a condition that no longer evokes the same level of fear and prejudice it did a generation ago. Meetings with staff served to confirm that professionals felt constrained by an uncertainty about who knew what about mother’s medical condition.  There existed insufficient clarity about the extent of mother’s consent to share (amongst involved professionals) the fact and impact of her medical condition (though mother’s involvement with the ‘specialist nurse’ offered an indication).   3.2.7 In the view of CNS1 the network did not appear to sufficiently appreciate mother’s ongoing and varying physical vulnerability and its consequences for capacity to parent i.e. that the excessive proportion of child G’s waking and sleeping time spent unstimulated in his buggy may have been primarily a result of mother’s health-related lethargy.  3.2.8 On a more practical note, CNS1 was not invited to all relevant meetings and the absence of her expertise and ability to advise on mother’s current health and functioning would have represented a loss to those co-ordinating protective or supportive plans.   FATHER’S PRESENCE & SIGNIFICANCE, & WIDER SUPPORT NETWORK 3.2.9 In general terms regarded as a positive and supportive presence, the significance of father’s attitude and behaviours and indeed the proportion of time spent with his family should have been challenged and more fully explored. 3.2.10 In this instance, in addition to the often-observed marginalisation of fathers (without sufficient evidence of positive or negative potential) a further factor was at play. The network knew and chose to set aside the knowledge that father was maintaining a second tenancy (about which little was or is known). 3.2.11 The well-intended but unacceptable consequence was that what was probably an unlawful arrangement served to confuse understanding of, and diminish the level and nature of support to meet the needs of his wife and growing family. 3.2.12 A failure amongst professionals to challenge parental reluctance and check the actual quantity and nature of support from the extended family and church may also have been linked to a fear of identifying mother’s health condition.                                                                                   CAE                                                       43                                     NEED / RISK ASSESSED AT INITIAL & REVIEW CONFERENCES 3.2.13 After borough 2 had assumed responsibility, core groups and conferences were held in a timely manner. There was though room for improvement in terms of the information and/or assessments provided for use by the network:  There was a complete absence of input from GPs even when advice or reports had been sought  The issue of dental health, though often raised, was never pursued to a definite conclusion  At times when the children’s food intake was in doubt, it appears as though an opportunity to set one of the parents a simple challenge i.e. to list each evening meal for a week was missed  Consistent weight and height checks by the School Nursing Service were desirable 3.2.14 It would appear that the professional network at its review conference of July 2013 had recognised the possibility of father being a registered carer and of the value of a nursery place for child G which would have reduced the levels of physical and emotional demands on his mother. 3.2.15 The brief report provided by Adult Services SW10 added little additional understanding beyond confirming that mother did not want any additional help. SW10 did though usefully add the family to a waiting list for a more suitable property. 3.2.16 The fact of mother declining further help from Adult Services together with a refusal by child G’s father to provide requested wage slips appears to have diverted attention from the originating rationale for their consideration i.e. that mother’s medical condition at times reduced her capacity to provide her young child with constant care and stimulation. A more child or parent-centred approach might usefully have challenged father’s reluctance and/or argued for the use of s.17 funding to cover the costs. DISGUISED COMPLIANCE 3.2.17 A retrospective analysis of records reinforces the possibility of disguised compliance (see footnote 3 on page 14) e.g.:  After several unconvincing excuses offered, HV1 finally gaining entry at her at unplanned visit on 09.05.13 - a few days before the transfer-in conference  The parents, having agreed to it effectively undermined attempts to provide speech and language therapy for sib.1  Mother declined initially accepted treatment, of sib.1’s nocturnal enuresis, offering an unconvincing explanation later about how she had resolved the problem                                                                                 CAE                                                       44                                     3.3 THRESHOLDS 3.3.1 The muddle that ensued at the point of case responsibility transferring between the boroughs has been described elsewhere. It and the resultant delay before completion of transfer would have justified a challenge via the escalation policy by either Health or Education colleagues, but the threshold for taking such action was not recognised.  3.3.2 Debate between borough 1’s SW4 and borough 2’s SW5 risked adding to the confusion when they anticipated an immediate step-down from the child protection plans that had been introduced in borough 1. 3.3.3 The decision made at the first review conference in borough 2 (July 2013) that the children should remain subject of child protection plans was wholly justified. The decision at the second review conference (October 2013) to step-down to child in need status was, on the basis of the known facts and then current experiences, not unreasonable. Had the full history been better appreciated, the confidence felt by all those who contributed to that decision might have differed. 3.3.4 As well as threshold decisions with respect to child in need / in need of protection, there were other examples of insufficient recognition that the threshold for taking individual action had been reached:  SN2’s observations of the children in October 2014 reached the threshold for immediate reporting to SW7  CNS1 could usefully have alerted the school nurse to the anticipated arrival in the UK in late 2013 of sib.3   HV2 when told in October 2015 of the parents’ failure to present child G to his speech and language therapy did not make contact with the family or any other professional 3.3.5 The justification for the conclusions of core groups of April and May 2015 that a step-down to ‘child in need’ status was justified is not obvious. The parents attended both meetings and their assertions may have unduly influenced the debate.  3.3.6 The view of the parents’ co-operation appears to have been based upon attending two sessions with a therapist (they were not continued). The focus of concern had by then shifted toward the adults’ relationship and the tension between mother and her step-daughter sib.3.  3.3.7 Underlying anxieties about parental performance remained and there existed unfulfilled objectives e.g. dental care for sib.2 and perhaps his brothers and sisters and a worsening of sib.1’s stammering had been observed. Nonetheless the conference chairperson at the review in June 2015 supported the widespread view that the children no longer required protection plans.  Unsurprisingly without the incentive those plans had represented, the parents declined an offer by SW8 of places at a parenting programme and reminded him that engagement was now wholly voluntary. The parents also failed to make use of the speech and language therapy planned for child G (though later denied that).                                                                                 CAE                                                       45                                     3.3.8 At the second CIN review in mid-September 2015, what was to have been a planned further step-down at the next review (leaving the possibility of ongoing involvement with the Early Intervention Service) became instead, an agreement that Children’s Social Care should close the case. The formal decision to do so followed soon thereafter and (with a contemporaneous cessation of health visitor contact) left the family with no targeted service intervention. Renewed concerns from his school about sib.1’s appearance and behaviours weeks later suggests that the case closure was premature.  3.4 CULTURE, RELIGION & LANGUAGE 3.4.1 Although the fact that both parents had originated in a central African country was known and captured by most agencies, the implications of that for parental knowledge about or commitment to operate within, the parameters of acceptable / good enough parenting in the UK remained un-explored. For example, the country in question has suffered prolonged wars, massacres of civilians and widespread abuses of human rights. The extent to which mother, father or sib.3 had been directly or indirectly impacted upon by such experiences remained unknown. 3.4.2 It may be that in the course of challenging the parents’ use of physical chastisement (assumed to be a euphemism for beating) that borough 1’s staff debated the differences between what may have been accepted practice in the parents’ country of origin and what is lawful in the UK. If so, such detail was not forwarded and/or accessed by professionals in borough 2. 3.4.3 For practical day to day purposes, whilst it was known that mother’s first language was linked to her country of origin and that she could also speak French, her command of English was considered quite sufficient for everyday and health / social care-related purposes. In the course of this serious case review no new evidence has emerged to contradict that presumption.   3.4.4 The parents’ reluctance to facilitate contact with extended family was rationalised in terms of most of them being unaware of mother’s diagnosis and accepted by professionals for that reason. It may be that any thought of approaching their church for additional support (no record of that has been seen) was met with a similar response. 3.4.5 Whilst it is a fact that an HIV diagnosis can have pejorative associations and that these may be more prevalent in some African countries than in contemporary Britain, mother was quite open about her diagnosis when she had bitten her step-daughter in the presence of police officer and when her specialist nurse composed (with her agreement) a letter to the Housing Service seeking more suitable accommodation.                                                                                 CAE                                                       46                                     3.4.6 With respect to the issue of feeding traditions, the academic with expertise about various African cultures (who had assisted in the other published case of death by force-feeding) confirms the importance attached by parents in a number of cultures across the continent of Africa (and indeed in Asia) of taking steps to avoid their child being ‘too thin’. What might be considered fat or obese by current Western standards may instead reflect and indicate family wealth or a child who will be regarded as attractive to the opposite sex as they grow up. 3.4.7 The charity AFRUCA set up following a number of high profile deaths of African children in the early years of this century offers some useful guidance on the cultural differences that are of relevance to child protection professionals working with African families who may still follow traditional practices that are unlawful in the UK5. 3.4.8 A more accessible example of a potential clash of cultures was that of sib.3 joining child G’s family. Very little indeed was known about this young woman’s childhood experiences in her war-torn country of origin and whether traumatic experiences (including the reported death of her birth mother) had or would impact on her adjustment to life in the UK. 3.4.9 There was a passing recognition of a risk of sexual exploitation but little exploration of the more mundane possibility of being used or at worst exploited, as a young carer for her step-mother and step-siblings.  3.5 VOICE OF THE CHILD  PARENTAL INHIBITION OF THEIR CHILDREN’S VOICES 3.5.1 For the reasons explained elsewhere, the professional network in borough 2 was aware of only a proportion of the family history in the UK. As far back as the summer of 2012, sib. 1 had revealed that he had been instructed by his parents not to tell professionals that he was being hit at home. School staff had also been sufficiently worried about the parental reactions as to withhold from them, concerns about the child’s behaviour at school.  3.5.2 Moving ahead to the period under review, if there existed any awareness that the children might have been coached by parents to offer false reassurances about their well-being, few records confirm it. Where they do, as described below, they led to no decisive action.                                                     5 Africans Unite Against Child Abuse - Promoting the Rights and Welfare of African Children -WHAT IS PHYSICAL ABUSE? -Safeguarding African Children in the UK Series 6                                                                               CAE                                                       47                                     OPPORTUNITIES MISSED 3.5.3 Apparently accepted as merely examples of low level neglect, at times, one or other child had been sufficiently confident to refer to, or present an appearance that implied sub-standard parenting:  There is no documentary evidence about how parental use of the lock on sib.1’s bedroom (noted at the transfer-in conference in summer 2013) was explored or challenged  Sib. 1 in July 2013 (aged 7.5) revealed to a school nurse that he had never been to a dentist and it remains probable that this important example of responsible parenting was not followed through properly for him or his siblings    In Autumn 2014 sib.1 and sib.2 told the then school nurse of their inadequate diet at home, the former contrasting it with the ‘proper cooked dinners’ they had received whilst being fostered  Later in 2014 sib.2 told her social worker who had enquired about food, that her father had prohibited her from speaking to anyone outside the family about ‘family business’ 3.5.4 From the children’s perspectives, little changed regardless of what they reported. Though less directly available than their various statements, the needs of the children could also have been usefully explored if the reasons underpinning the aggressive attitudes of both sib.1 and sib. 2 observed at school had been explored in their own right. 3.5.5 Very few records capture the lived or day-to-day experiences of any of the children and only a report by a Contact Centre supervisor (provided at the time of the children’s temporary removal and of no direct relevance to this serious case review) provided a comprehensive account of the children’s appearance, behaviours and affect. WISHES & FEELINGS OF SIB.3 3.5.6 Whilst the impact of sib.3’s presence on the parental relationship was recognised and addressed, the needs of a then 14 year-old, non-English-speaking female entering the UK and joining a mainstream school were insufficiently considered. It is unclear from records to what extent this young woman was provided with any opportunities to discuss her childhood experiences, hopes and fears and whether she was content with the domestic and educational life that had been planned for her by father and step-mother. 3.5.7 Staff events revealed that there had been more effort made to engage with and seek to better understand the needs of sib.3 than was apparent from formal records of meetings i.e. the records of such exchanges was limited to ‘case records’.                                                                                  CAE                                                       48                                     3.6 INFORMATION SHARING 3.6.1 Given the complexity of an increasingly fragmented network of commissioners and service providers, it is and will remain a substantial challenge to ensure that all relevant information (and no more) is shared in a timely and efficient manner with professional colleagues. MAJOR CONSTRAINTS 3.6.2 In this case, there seems to have been two major factors and several less strategic ones limiting the extent to which all those in the professional network knew what they might usefully have known. 3.6.3 The main and more tangible constraint amongst local professionals was the muddle associated with the family’s move to the borough which denied them an appreciation of the family’s full and worrying history whilst in borough 1  (injuries, proportion of time sib.1 had spent restrained in a buggy/ highchair, parental dishonesty etc). 3.6.4 A less tangible but nonetheless significant constraint appears to have been insufficient appreciation amongst those (other than the specialist nurse CNS1) of just how debilitating mother’s chronic condition was. Clearly, a balance has to be struck between maximising patient confidentiality and the legitimate needs of dependent children.  3.6.5 The reluctance of CNS1 to identify mother’s condition was more than an individual professional judgement. The reticence is also reflected in her employing Trust’s current insistence that such details are not available in the database employed elsewhere in its organisation. The unintended impact in this case was that school staff and to a less certain extent, social work staff underestimated the level of mother’s disability and hence the increased dependence on her partner and/or consequential pressure on her children.  3.6.6 The wider systemic risk is that until the Trust resolve how to capture such information and include it (suitably ‘masked’) in more general patient records the unacceptable practice of an individual nurse having to carry around highly sensitive paper records which cannot be linked to other community service records will continue. Other Trusts have developed suitable electronic systems and the Healthcare Trust must also do so.                                                                                 CAE                                                       49                                     OTHER CONSTRAINTS TO EFFECTIVE INFORMATION SHARING 3.6.7 Other examples of systemic or individual weaknesses with respect to information sharing may be summarised as follows:  The fact that the children had been subject of protection plans whilst in borough 1 was not apparent in the medical records transferred to GP Practice A  Though in February 2013 there was a so called ‘Read code’ in mother’s notes at GP Practice A referring to protection plans for the children, there were no such ‘Read code’ in the children’s records  When all the children were again made subject of a protection plan in October 2014, a ‘Read code’ was added to child G’s medical record but not to those of his siblings  There were unhelpfully long delays in the circulation of notes of core groups and conferences by borough 2’s Children’s Social Care with the consequent risks compounded by delayed inputting of records by Community Health  There was very limited liaison with other agencies initiated by staff at hospital 2 e.g. CNS1 was not copied in to correspondence sent to mother’s GP 3.6.8 Further examples of weakness in information management or sharing that appear to be more individual than systemic are offered by the following examples:  HT1’s determined yet unsuccessful attempts to contact SW8 in late 2013 suggests a lack of responsivity in that individual’s team  The results of the school nurse’s assessment of sib.3 in Autumn 2014 and her contact with sib.1 in January should have been shared promptly with the allocated social worker  In September 2014 the school was not informed that the children had been removed and temporarily fostered  No evidence has been found of GP – health visitor liaison with respect to child G  In GP Practice B, minutes of child protection conferences are kept in paper format and not scanned into the database   Following the allocation of SW8, the very significant professional CNS1 received no further invitations to multi-agency meetings                                                                                 CAE                                                       50                                     3.6.9 In spite of the organisational and individual weaknesses identified above, there were many examples of basic or commendable best practice e.g. a clinician from hospital 2 in March 2011 phoning Practice A and a very prompt provision by that same Practice of medical information when in September 2014 the children were temporarily accommodated. 3.6.10 In those cases where an identified failure implies a need for systemic action, a recommendation is included in section 5. 3.7 SUPERVISION & MANAGEMENT 3.7.1 Records offer clear and welcome evidence of the individual supervision of involved social workers and health visitors and of the appropriate involvement of managers at relevant stages in the case planning processes. However, the Trust providing health visiting services and Children’s Social Care respectively should address the issues below. TASK-FOCUSED / SELF-REPORTING IN SUPERVISION 3.7.2 HV1 had sought and been provided with safeguarding supervision immediately prior to the ‘transfer-in’ conference of May 2013. It was essentially a task-focused event and did not for example enable a reflective discussion about what other and associated risks there might be to the youngest child. 3.7.3 In spite of the insufficient level of co-operation that followed HV1 managed to form a working relationship with mother and later father of child G. Her perception and hence her reporting (late 2014) of the case at her supervision appeared at times to be unduly positive.  3.7.4 If supervision is based wholly on what is self-reported and/or causing the supervisee concern, there is a significant possibility that sources of risk may be overlooked or understated. There is therefore potential value is some cases being selected by a supervisor.   ACCOUNTABILITY IN SUPERVISION 3.7.5 Within Children’s Social Care there appears to be at least from a consideration of records, some overlap and therefore risk of confusion between traditional individual case supervision, that provided by senior staff in ‘Pods’ and the formal decision-making for which responsibility rests with independent chairpersons of child protection conferences.  3.7.6 Aside from the mis-attribution of names for the supervisees (referred to in the narrative of section 2), the authority of the so-called ‘Pod Supervision’ (the first of which was provided in March 2015) is unclear. A second such supervision was provided a month later when the supervisor was minded to consult the independent chairperson about bringing forward the date of the scheduled review conference. A third such session a month later added no new information.                                                                                 CAE                                                       51                                     3.7.7 It is unclear to the author whether the social worker was also in receipt of one to one supervision at this time, nor how the independent chairperson might balance a proposal to bring forward a conference against the value of a multi-agency perspective expected to be developed at this forum. The fourth Pod supervision merely noted the decision made at the review conference in June 2015 and the fifth such session in August the allocated social worker was not present with the case represented by SP1 (thus preventing reflective challenge).  3.8 RESOURCING & ORGANISATIONAL CHANGE  3.8.1 It is not possible without further research to conclude whether the following systemic weaknesses are a function of inadequate funding and/or sub-optimal organisation. 3.8.2 In each case the relevant agency needs to consider how it can best tackle the problem implied by this case of current policy, procedure or practice. GP PRACTICES 3.8.3 GPs are of critical importance in safeguarding children and their contributions must be facilitated. In GP Practice A, it was acknowledged that invitations to attend or offer a report to child protection conferences do not always elicit a response. In Practice B, such written invitations are kept in the paper format in which they arrive and so do not become integral to the otherwise electronic patient record. 3.8.4 The capture and re-presentation of child protection status on patient information systems needs to be ensured in a more timely and accurate fashion than appears to have been achieved in this case at Practice A.  CHILDREN’S SOCIAL CARE 3.8.5 An apparently common insufficiency of notice provided by Children’s Social Care of child protection conferences has been referred to elsewhere. 3.8.6 A further difficulty that may reflect staffing levels and/or efficiency is the delayed circulation of records of completed core groups and conferences. In the absence of such agreed records there is a substantial risk of mis-informed actions by involved agencies. 3.8.7 At a more general level there was during the period of review significant structural change e.g. group supervision and the use of the ‘Strengthening Families’ model. It is possible that, pending development of sufficient familiarity, these may have had a significant impact on clarity and consistency of case planning. HEALTHCARE TRUST 3.8.8 The need referred to elsewhere for the Trust to develop a database which is compliant with data protection principles and communicates across all its functions is sufficiently significant and urgent so justify a recommendation in section 5.                                                                               CAE                                                       52                                     4 FINDINGS & CONCLUSIONS  4.1 FINDINGS  4.1.1 No evidence has been located to suggest that child G’s death could have been predicted and very little that it might have been prevented. There were examples of effective systems and good professional practice as well as scope for learning about the issues outlined below.  4.1.2 The transfer of responsibility between the boroughs was very poorly managed & borough 2’s service delivery consequently insufficiently informed by available case history, serving to reinforce the risk of the well-known ‘Start Again Syndrome6. 4.1.3 There were numerous indications of varying and ongoing low-level (dirty clothing, lack of personal hygiene) and intermittingly more explicit (failure to ensure sufficient food or medical treatment) neglect. There was clear evidence of disguised compliance in terms of parental use of speech and language therapy or parenting courses offered. 4.1.4 There was insufficient appreciation or analysis of the impact of mother’s medical condition on her ability / motivation to cope and child G’s time spent restrained in his buggy or highchair / time attending medical appointments – possibly compounded by a misplaced sense of sympathy / hyper-sensitivity to the need for confidentiality because of mother’s specific medical condition (living with AIDS). 4.1.5 The reportedly supportive role played by the extended family and or church should not have been accepted at face value. The quite proper reason these sources had first been identified as relevant was that the parents had demonstrated an inability to sustain ‘good enough’ parenting without external input. Their rejection of such help (mobilised via the planned Family Group Conference) needed to be challenged. 4.1.6 There was also insufficient awareness and exploration of father’s lifestyle / overall impact on the family leaving no certainty that a ‘safe parent’ existed. His second address should not have been tacitly accepted and left unchallenged. 4.1.7 The children’s voices were not sufficiently sought / evaluated / explored when they actually revealed being silenced by their parents; their lived experiences were not apparent in the records maintained and there was scope for more challenge of apparent co-operation and compliance with agreed service delivery e.g. SALT, enuresis clinic etc.                                                     6 Brandon et al 2008 pointed out that family histories tended to be complex, confusing and overwhelming for professionals who often found it difficult to decide when ‘enough is enough’ in cases of neglect ; worker can feel helpless and at times fearful of families, which leads to avoidance and drift in decision-making; the authors identified the ‘start-again syndrome’ as one way practitioners managed these dynamics i.e. little consideration is given to the parents’ past histories and the focus is on present circumstances, leading to a lack of systematic analysis of parental capacity and the children’s experience of harm                                                                               CAE                                                       53                                     4.1.8 Some evidence of professional optimism exists in terms of direct contacts by professionals and decision of managers based upon those contacts. Given the rarity of the phenomenon though, it is understandable that neither medical nor other professionals considered the possibility of prolonged force-feeding. 4.2 OPPORTUNITIES FOR LEARNING   FORCE FEEDING 4.2.1 Amongst the many involved doctors, teachers, social workers, police officers and others, none had knowledge or experience of the phenomenon of force-feeding which is thought to be rare in the UK7 but more widespread in some African countries and elsewhere. MIND-SETS / ATTITUDINAL OBSTACLES TO BEST PRACTICE  4.2.2 Amongst the professional network the quality of assessment of need / risk and subsequent information sharing was constrained by:  Well-intentioned but nonetheless misplaced sensitivity about mother’s medical diagnosis which served to mask the extent of her loss of functionality as a parent  Equally well-intentioned but unjustified collusion about father’s maintenance of two properties which it was tacitly accepted may have  served to increase income via Benefits and reduce the proportion of time committed to care of his children or partner RELEVANCE OF PAST TO FUTURE BEHAVIOURS 4.2.3 The ability to discern behaviour patterns and predict risk can be constrained by:  Incomplete information transfer between local authorities or between agencies  Extent to which personal history is incorporated into assessments ACCURACY & RIGOUR OF ASSESSMENT / REPORTS 4.2.4 There were occasions when the recorded experience of professionals e.g. compliance / co-operation of the parents did not match the rather more optimistic reports shared at multi-agency forums. 4.2.5 In the complexity of multi-agency service provision compounded by turnover of social workers, some important indicators of neglect were overlooked e.g. dental care. The extent to which the children’s (limited) accounts of their daily experiences was factored into evaluations of need and risk was insufficient.                                                    7 The author co-authored a serious case review in 2011 for Waltham Forest LSCB which is thought to be the first (and until this one only) known example in the UK of manslaughter of a child by means of force-feeding.                                                                                CAE                                                       54                                     ORGANISATIONAL NEED FOR MORE EFFICIENT SYSTEMS 4.2.6 Though there was ample evidence of a willingness to share information and plan family support / child protection, the review has highlighted a number of systemic weakness that require urgent strategic management action:  Any insufficiency of notice provided by Children’s Social Care of initial and review child protection conferences limits the extent to which other willing professionals from school, or health agencies are able to participate and/or offer reports  An apparently common failure to ensure that GPs are invited in a timely manner and do contribute (presence and/or submission of  a report) to child protection conferences denies the network key information and perspectives  Toward the end of the period under review, there was a repeated failure by Children’s Social Care to invite relevant key professionals (CNS1, HT1) to multi-agency forums   The wholly unintended result of the current patient information systems in the Healthcare Trust whereby records in the Acute and Community Specialist Services are electronic and paper-based respectively and an individual such as CNS1 is obliged to carry around highly sensitive material [in the panel’s view a problem of sufficient magnitude to attract the interest of the Information Commissioner’s Office]  Delays in circulation and inputting of records (seen in both Children’s Social Care and Health Visiting Service) inevitably diminish their potential value to colleagues   There needs to be clearer clinical pathways between the specialist services of the hospital 2 and relevant GPs and specialist nurses such as CNS1                                                                               CAE                                                       55                                     5 RECOMMENDATIONS 5.1 INTRODUCTION 5.1.1 Several contributors have identified ways in which individual practice within respective agencies may be improved. So as to facilitate local learning and the Board’s monitoring of improvements introduced, the most strategic required changes are provided below. BOROUGH 2’S SAFEGUARDING CHILDREN BOARD 5.1.2 In the context of increasingly diverse communities, training introduced or evaluated by the Board should include the existence and significance of cultural practices that pose a risk to children e.g. force-feeding. 5.1.3 The Board should establish the extent to which the insufficiency of GP involvement in children’s safeguarding seen in this case is typical, and if justified by its findings, liaise with relevant member agencies or (to the extent that the issue is about performance or contractual requirements of GPs the local NHS England) so as to initiate appropriate responses. 5.1.4 The Board should seek confirmation from member agencies that potentially unlawful / improper arrangements relating to housing relevant to a child’s welfare which may be discerned by one agency will be shared with relevant other agencies (and if feedback suggests it to be necessary, develop guidance for local application). 5.1.5 The learning from this case should be used to inform local training and staff development opportunities (where possible making use of some individual professionals who have some direct experience of force-feeding practices in some cultures).  CHILDREN’S SOCIAL CARE 5.1.6 A date for a ‘transfer-in’ conference should be agreed as soon as it becomes known that a child is becoming resident in the borough and any delays or difficulties in obtaining all relevant records, escalated. 5.1.7 ‘Transfer-in’ records should be quality-assured as compliant with Child Protection Procedures  and if necessary, challenged by receiving manager / independent chairperson. 5.1.8 All case recording should include a chronology of significant events / professional responses. 5.1.9 The purpose and relationship with other established processes such as individual supervision of ‘Pod Supervision’ should be reviewed.  5.1.10 The extent to which the insufficiency of notice of conferences (schools and GPs) or omission of relevant professionals (specialist nurse) seen in this case is typical, should be audited and any required corrective actions taken.                                                                                 CAE                                                       56                                     5.1.11 The current ‘Neglect Toolkit’ should be amended to include specific references to:   Feeding issues  Dental health e.g. s.17 or s.47 Children Act 1989 assessments should consider any feedback on dental health and any child in need or child protection plan subsequently agreed should note and take remedial action if appropriate dental development is of concern BOROUGH 2’S SCHOOLS / COLLEGES 5.1.12 The Education Service should confirm that arrangements exist and work effectively to ensure that any child protection records are transferred from an early years setting to the school and if relevant, college to which the child / young person may transfer. HEALTHCARE TRUST 5.1.13 The Trust should enable effective electronic linkages so as to offer practitioners in Acute and Community Services access to all relevant information and an alternative to the current unacceptable arrangements which clearly breach data protection requirements. 5.1.14 A practice tool such as the ‘SBAR’ (situation, background, assessment, risk) tool should be rolled out across the Heath Visiting Service in an attempt to ensure systematic and robust information capture when responsibility is allocated to a health visitor for a new family. 5.1.15 A qualitative audit programme should be completed of a sample of health visitor reports compiled for child protection conferences. 5.1.16 All professionals who work with families must receive safeguarding supervision and training at a level appropriate to their role.                                                                                 CAE                                                       57                                     6 BIBLIOGRAPHY  Improving safeguarding practice, Study of Serious Case Reviews, 2001-2003 Wendy Rose & Julia Barnes DCSF 2008   Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial study of serious case reviews 2003-2005 Marian Brandon, Pippa Belderson, Catherine Warren. David Howe, Ruth Gardner, Jane Dodsworth, Jane Black, DCSF 2008  Learning Lessons, Taking Action: Ofsted’s evaluations of serious case reviews 1 April 2007 to 31 March 2008 Published December 2008  The Child’s World Jan Horwarth Jessica Kingsley 2008  What can we learn from a decade of reviews of child fatality and serious harm from maltreatment from the 4 UK nations? Marian Brandon, Peter Sidebotham, Sue Bailey, Pippa Belderson   Learning Together to Safeguard Children: A ‘Systems’ Model for Case Reviews March 2009 SCIE  Healthy Child Programme DH 2009    A Study of Recommendations Arising from Serious Case Reviews 2009-2010 M Brandon, P Sidebotham, S Bailey, P Belderson University of East Anglia & University of Warwick   Understanding Serious Case Reviews and their Impact a Biennial Analysis of Serious Case Reviews 2005-07 Brandon, Bailey, Belderson, Gardner, Sidebotham, Dodsworth, Warren & Black DCSF 2009   Building on the learning from serious case reviews: A two-year analysis of child protection database notifications DFE – RR040 ISBN 978-1-84775-802-6 2007-2009  Getting it right for children and young people – Overcoming the cultural barriers in the NHS so as to meet their needs -Sir Ian Kennedy September 2010  Personal Communication: Dr Kwadwo Osei-Nyame, Jnr (D.Phil/PhD Oxford) Lecturer in African Literature, Cultural and Diaspora Studies Africa Department School of Oriental and African Studies (SOAS) University of London 2011 [related to previous case of proven force feeding in Waltham Forest]  Working Together to Safeguard Children, HM Government 2010, 2013 & 2015  Ages of Concern: learning lessons from serious case reviews: a thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011  Munro Review of Child Protection: A Child-Centred System TSO www.tsoshop.co.uk Professor Munro 2011  Learning together to safeguard children: a systems model for case reviews SCIE January 2012  New learning from serious case reviews: Marian Brandon et al RR226 DfE 2012   Improving the Quality of Children’s Serious Case Reviews Through Support & Training@ NSPCC, Sequili, Action for Children; DfE 2013 (revised Feb. 2014)   AFRUCA: Africans Unite Against Child Abuse - Promoting the Rights and Welfare of African Children -WHAT IS PHYSICAL ABUSE? -Safeguarding African Children in the UK Series 6                                                                                 CAE                                                       58                                     7 FINAL TERMS OF REFERENCE  1. SCOPE OF THE REVIEW The Review will focus on the period from when the family moved from borough 1 to borough 2 in December 2012 to the day that Child G died in November 2015. 2. KEY LINES OF ENQUIRY a) FAMILY HISTORY AND CASE TRANSFER (i) Borough 1 LSCB will be asked to provide the family history prior to moving to borough 2 and an outline of agency involvement.  Borough 1 will be asked for a more detailed account and an analysis of the case transfer arrangements when the family moved  (ii) Agencies in borough 2 will be asked to provide details of their involvement in or following the family’s transfer into the borough and analysis of how this was managed. b) QUALITY OF ASSESSMENTS (i) To include an analysis of how well agencies took into account the family history and the impact of current health or cognitive issues – at the point of transfer and in on-going assessments: (ii) To consider the influence of any optimism on assessments (iii) To identify any development of hypotheses and whether these were revised over time c) THRESHOLDS (i) To include an analysis of the response to changing levels of risk and need (Step up – Step down responses) d) CULTURE, RELIGION & LANGUAGE (I) To examine the actual or potential impact of the family’s culture on parenting style and ability to work cooperatively with agencies in this country – alongside practitioners curiosity in seeking this information to inform assessments and interventions (II) To examine whether sufficient consideration and response was given to any communication needs of the family e) VOICE OF THE CHILD (i) To examine how well the views and experiences of the child and siblings were sought and how these informed intervention, including whether the children were seen / interviewed on their own (ii) To examine how well observations of the child and sibling’s appearance and interactions were obtained and how these informed intervention f) INFORMATION SHARING (i) To examine the effectiveness of information within and between agencies (ii) To examine how well child protection alert systems, including electronic systems worked                                                                                 CAE                                                       59                                     g) SUPERVISION AND MANAGEMENT OVERSIGHT (i) To examine the formal arrangements in place for management oversight and supervision – and the effectiveness of their application in this case (ii) To examine the ad hoc arrangements for supervision when required – and the effectiveness of their application in this case h) RESOURCING AND ORGANISATIONAL CHANGE (I) To examine the impact of any resourcing, capacity or organisational change on the practice and management of this case 3. REVIEW MODEL (i) The Review will be overseen by a Panel of senior managers representing the agencies involved as well as professionals providing particular expertise (ii) The Review Panel will be chaired by the Independent Chair of the LSCB (iii) The Panel will be supported by an Independent Overview Author who will produce the final SCR Report (iv) Involved agencies will provide chronologies and single agency reports which analyse their agency’s involvement with regard to the identified lines of enquiry.  The reports will be based on evidence from agency records and interviews with relevant staff. (v) Two practitioner events will be held for staff involved in the case.  The first will explain why the review is taking place, its process and will also provide an opportunity for the initial Terms of Reference to be tested against the views and experiences of front-line staff. The second practitioner event will be held following the production of the Overview Author’s initial findings, in order to test these findings against the views and experiences of front-line staff. (vi) Subject to criminal proceedings and the advice of the Police and CPS, the views of the family will be sought to inform this review where possible. (vii) Agencies to be involved include local authority Children’s Social Care; Police, relevant schools and college, GP Practices, community health Trust, relevant hospitals, and borough 2’s Children’s Social Care. 4. TIMELINE The Chair of the LSCB notified the DfE, Ofsted and the National Panel of Independent Experts that a Serious Case Review would be undertaken on the 18th of December 2015.  The objective of the SCR Panel is to complete the review within a six month time scale, subject to any on-going dual processes e.g. criminal proceedings. 5. PUBLICATION The final Overview Report will, following endorsement by the LSCB, be available from the NSPCC repository. The report will be anonymised with respect to family members and the professionals involved  .   