Death of a 14-week-old girl in March 2012. Post-mortem examination jointly conducted by two pathologists resulted in the recording of two different probable causes of death: Sudden Infant Death Syndrome and unascertainable. Child Y lived with mother, father and five older siblings in a three bedroom property at the time of the incident. Family had been known to children's services since 2003 and children were subject to Child in Need and Child Protection plans at different times before and after Child Y's death. Professionals' concerns primarily related to home conditions, children's personal hygiene and school attendance. Issues identified include: father's dominance, his occasional threatening behaviour towards professionals and his resistance to professional intervention; poor assessments, not carried out in a timely manner contributing to 'drift'; and lack of appreciation of the long-term impact of neglect and belief that better outcomes would be achieved by maintaining parents' cooperation. Makes various recommendations focusing on conflict resolution, multi-agency working and training. Undertaken using a systems model.
      
 Title:  Serious case review: concerning Child Y: overview report. LSCB: Leeds Safeguarding Children Board Author: Peter Ward Date of publication: 2015  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                          Leeds Safeguarding Children Board Serious Case Review Concerning Child Y Overview Report Published 27 January 2015 Child Y Overview Report  27 January 2015  2  Table of Contents    Page 1. Introduction  3 2. Circumstances leading to decision to carry out a Serious Case Review  3 3. Scope and Terms of Reference of the Review  4 4. Contributors to the Review and Methodology  5 5. Summary of Family Circumstances  7 6. Summary of Agency Involvement and Key Events  7 7. Analysis 23  8. Views of the Family  49 9. Conclusions  49 10. Recommendations  52  Appendices  Appendix 1 Abbreviations Appendix 2 References  Appendix 3 Integrated Action Plan   Child Y Overview Report  27 January 2015  3  1. Introduction  1.1    This Serious Case Review (SCR) was commissioned following the death of Child Y who died at 14 weeks of age.  1.2 The review was commissioned in compliance with regulation 5(1) (e) and 5(2) (a) & (b) (ii) of The Local Safeguarding Children Boards (LSCBs) Regulations 2006 which came into effect on 1 April 2006.  Regulation 5 sets out the functions of LSCBs including the requirement for them to undertake reviews of serious cases in specified circumstances.  1.3 Working Together to Safeguard Children 2013 states that an SCR must be undertaken when abuse or neglect of a child is known or suspected and either (i) the child has died or (ii) the child has been seriously injured.  In the case of (ii) an SCR has to be undertaken unless it is clear that there are no concerns about inter-agency working.   1.4 In accordance with Chapter 4 of Working Together to Safeguard Children 2013, the purpose of this SCR is:   To look at what happened in this case, why, and what action will be taken to learn from the SCR findings?  For such action to result in lasting improvements to the services which safeguard and promote the welfare of children and help protect them from harm.  To ensure that there is transparency about the issues arising from the SCR and the actions that LSCB partner agencies are taking in response to them, including sharing the final Report of the SCR with the public. Consequently this report is not intended to be a judicial opinion or to apportion blame but to consider, with the benefit of hindsight, the above three points.  2. Circumstances leading to decision to carry out a Serious Case Review  2.1 Child Y was born in November 2011 and died in March 2012 having lived with both parents and five older siblings.  Child Y’s mother woke one morning to find the child apparently dead; Child Y was taken to hospital by ambulance and formally pronounced ‘life extinct’.  According to the parents Child Y had appeared fit and well the previous night and had last been seen alive at 05:00 hours when the mother had fed the child.  2.2 The cause of Child Y’s death will be determined by an inquest, which has yet to take place.  A post mortem examination was carried out jointly by two pathologists the after the death and they wrote separate reports.  One pathologist considered the probable cause of death to be Sudden Infant Death Syndrome whilst the second considered the cause of death to be unascertained.  Both reports refer to there being several recognised risk factors for sudden infant death in this case.  These include co-sleeping, Child Y being small for their age, maternal smoking and alcohol misuse, poor social circumstances and the time of year (winter).   Child Y Overview Report  27 January 2015  4  2.3 Although no evidence has been found to indicate that abuse or neglect was a direct factor in the death of Child Y, several agencies had been involved with the family over a lengthy period of time and had, at times, raised concerns about the care of the children.  In addition, following death, Child Y was found to have been malnourished and to have had severe vitamin D deficiency.   As a result of these factors, the Chair of the Leeds Safeguarding Children Board decided, on 16 August 2013, to commission an SCR.  2.4 Following a detailed investigation by West Yorkshire Police a decision has been taken by the Crown Prosecution Service that FY and MY will not face any criminal charges relating to Child Y’s death or neglect of the children.    3. Scope and Terms of Reference of the Review  3.1 The timeframe of this SCR is from 1 January 2010 to 1 July 2013 although organisations were also asked to provide brief relevant background information which pre-dated this time period.  The SCR considers Child Y and all the siblings, including Sib6Y who was born after Child Y died.  3.2 In considering organisational involvement, organisations were asked to specifically consider the following key issues:  1. What evidence did agencies have that Child Y and the siblings were being neglected and how did they respond to this evidence, in ensuring the wellbeing of the children? Were the risks to the children properly identified, evaluated, and appropriately responded to? Were the right services provided to meet the needs identified?  2. How did professionals take this information into account in relation to Child Y before and after birth and what weight did they give to it?  3. To what degree did agencies engage directly with the children to hear their account of home life prior to and following Child Y’s birth?  4. Did the professionals involved with and in contact with the children and their family members exercise respectful disbelief, active curiosity and build constructive and assertive relationships with the family and if not, why not?  5. What opportunities were there for agencies to intervene more robustly and provide assertive family support with clear plans and clear reviews of those plans and which set out the nature of the concerns the plans were designed to address?  6. When was consideration given to the potential need for a pre-birth Initial Child Protection Conference and to the impact on the family of another child?  7. How did agencies deal with disagreements between one another and what was the impact of this on the service provided to the children?   8. How were issues of non-engagement, including the parents’ failure to Child Y Overview Report  27 January 2015  5  register Child Y with a GP, addressed and what was the impact of this on the service provided to the children?  9. How did agencies respond to father’s intimidatory behaviour and what was the impact of this on the service provided to the children?  10. How have agencies responded differently to the family since Child Y’s death and what has been the impact of this on the children?  11. How well supervised and supported were the frontline staff in contact with the family and were they given  the opportunity to reflect on what they were seeing and doing as regards the family?  12. Were there any barriers identified that impacted on how staff exercised their professional practice?  4. Contributors to the Review and Methodology  4.1 The Lead Reviewer for this SCR is Peter Ward who has a background in social care and has worked in management and front line social work.  Mr Ward is qualified to degree level in social work and has a post-graduate diploma in management studies.  He is now the Director of Arrow Social Care Consultancy Limited and, as such, undertakes investigations and other consultancy work on an independent basis.  Since 2005 he has been involved in 15 Serious Case Reviews as an Independent Overview Report Author, Individual Management Review Author or Panel Chair.    4.2 The Panel Chair for this SCR is Sheila Sutherland who has been a qualified social worker since 1972. Mrs Sutherland has over thirty years experience in working within or managing social care services for children; including a total of fourteen years as Head of Services for Children and Families in Cumbria and Blackpool. Since September 2009 she has worked as a self employed consultant to Children’s Social Care Services. In addition she worked throughout the last three years with the Centre of Educational Leadership, (CEL) Manchester University as Social Care Learning Development Consultant on the development and delivery of Children’s Social Care Leadership Programmes.  4.3 As a Consultant Mrs Sutherland has worked with Blackburn, Blackpool, Bury, Bradford, Cumbria, Leeds and Rochdale on both Serious Case Reviews and as investigating officer in case and staff conduct enquires.  She works as an Associate of CEL Leadership and Change, contributing to the design and leading on the coordination and delivery of Social Care Leadership Development programmes.   4.4 In accordance with the guidance issued in Chapter 4 of ‘Working Together to Safeguard Children’ (HM Government 2013), both the Lead Reviewer and the Panel Chair are independent of Leeds Safeguarding Children Board and the organisations involved in the review.  4.5 This SCR has been undertaken using a ‘systems’ model in order to reach a deeper understanding not only of what happened but why.  The initial terms of reference were agreed based on information which was provided to the SCR Child Y Overview Report  27 January 2015  6  standing sub-Committee of Leeds Safeguarding Children Board.  Organisations which had been involved with the family during the relevant time period were then asked to provide a detailed chronology of their involvement and an analytical report which considered their involvement alongside the key issues identified in the Terms of Reference.  The individual chronologies were subsequently integrated into one integrated chronology which has been used in writing this Overview Report.   4.6 Reports were provided by the following organisations:  Leeds City Council – Children’s Social Work Service (CSWS)  Leeds City Council – Education Service  Leeds City Council – Housing Leeds  NHS England – GP Services  Leeds Community Healthcare NHS Trust (LCH)  Leeds and York partnership NHS Foundation Trust (LYPFT)  Leeds Teaching Hospitals NHS Trust (LTHT)  West Yorkshire Police  4.7 Two facilitated learning events have been held using Root Cause Analysis, to analyse Key Practice Episodes (KPEs) identified from the chronology and reports.  In total 10 KPEs were identified and these are listed below.  Each was considered by a group of approximately five participants.  For each of the KPEs, participants were asked to consider: a. what happened,  b. what should have happened,  c. the reasons for any discrepancy between a & b d. what has been learnt as a result  4.8 The concept of using KPEs in SCRs was introduced by Fish et al in the Social Care Institute for Excellence document Learning together to safeguard children: developing a multi-agency systems approach for case reviews (SCIE guide 24).  Fish et al write that  “‘key practice episodes’ describe episodes from the case that require further analysis. These are episodes that are judged to be significant to understanding the way that the case developed and was handled. They are not restricted to specific actions or inactions but can extend over longer periods. The term ‘key’ emphasises that they do not form a complete history of the case but are a selection. It is intentionally neutral so can be used to incorporate good and problematic aspects.”  4.9 Every organisation that provided a report was represented at the Learning Events, which were attended by a mixture of management and front line staff in order to achieve a wider knowledge base and understanding of the working environment.  The events were led by the Panel Chair, the Lead Reviewer and the assistant manager, Leeds Safeguarding Children Board.  Administrative and Clerical Support was provided by Leeds Safeguarding Children Board.  4.10 Key Practice Episodes considered at the Learning Events 1. Timing of the decision by the Primary School to refer to the Children’s Social Work Service in April 2010 2. Response to a referral from the primary school to the Children’s Social Work Service in April 2010 alleging neglect   Child Y Overview Report  27 January 2015  7  3. Reported ‘drift’ in Summer and Autumn 2010 4. What were the opportunities for better joined up agency working in May 2011? 5. The decision by the Children’s Social Work Service to end their involvement with the family after the Child In Need meeting in July 2011 6. The response to concerns expressed by the Leeds Addiction Unit Midwife in October & November 2011 7. The response to concerns raised by the school in February 2012 8. Agencies’ response to the pregnancy of MY with Sib6Y compared to her pregnancy with Child Y 9. Why was there such a superficial response to the Neglect of the Children? 10. What were the barriers, between and within health agencies, to information sharing regarding the children?  4.11 Child Y’s parents and older siblings were all invited to contribute to this SCR and chose to do so.  The Lead Reviewer met with MY alone and Sibs 2Y & 3Y together whilst the Panel Chair met with FY alone and Sibs 4Y & 5Y together.  The Lead Reviewer and Panel Chair together met with Sib1Y.  A brief summary of those discussions is provided in section 9 of this report.  5. Summary of Family Circumstances  5.1 The whole of Child Y’s short life was lived with both parents, who are married to one another, and five older siblings.  The family lived in a rented three bedroom property.  5.2 Other significant family members were an aunt and uncle of Child Y’s father.  Child Y’s siblings lived with this great aunt and uncle for a few weeks following their sister’s death.  5.3 Since Child Y died, but during the period covered by this review, Child Y’s parents have had another child, referred to in this report as Sib6Y.  The family have also moved to a larger house.  5.4 The family are white, British and both parents grew up in West Yorkshire.  No specific needs have been identified in relation to the family’s race, language, ethnicity or religion.  There are no issues relating to disability.  5.5 A genogram was produced to assist in undertaking this review.  6. Summary of Agency Involvement and Key Events  6.1 Introduction  6.1.1 This section of the Overview Report provides factual information regarding agencies involvement with Child Y and the family during the period from 1 January 2010 to 1 July 2013.  It is divided into two parts, the first of these is a brief description of each of the agencies that has contributed to this SCR along with a brief outline of the services they provided to the family during the period covered by it.  The second part is a chronological summary of the key events that occurred during the period in question.  As part of the SCR, each agency produced a detailed chronology showing their contacts with and about Child Y Child Y Overview Report  27 January 2015  8  and the family over the period covered by this SCR.  These individual chronologies were integrated into one composite chronology which has been used throughout the SCR.  The chronological summary in this section of the report has been produced from the composite chronology.  The analysis of this factual information will follow in section 8 of this Overview Report.  6.2 Organisations Involved  Leeds City Council – Children’s Social Work Service (CSWS)  6.2.1 CSWS has been involved, from time to time, with the family since 2003.  During the period covered by this SCR, CSWS involvement has primarily been due to poor home conditions, the children’s personal hygiene, school attendance and punctuality.  6.2.2 During the period covered by this SCR CSWS had involvement with the family during the following time periods:  April 2010 – July 2011  October 2011 – January 2012   March 2012 – end of review (case closed briefly in November 2012)  6.2.3 From April 2010 to February 2011 a Family Resource Centre worker undertook some work with the family.  The children were subject to a Child in Need plan from September 2010 to July 2011, and July 2012 to October 2012 and a Child Protection Plan from February 2013 to the end of the period covered by the review.  Following the death of Child Y a ‘bridging plan’ was in place.    Leeds City Council – Education Service  6,2.4 The Education Service has been involved with the family since January 2002 when Sib1Y entered statutory school provision.  Records suggest that the Education Service had safeguarding concerns for the children, specifically in relation to neglect, from approximately 2005.  6.2.5 Although Child Y never reached school age the five older siblings were all of school age throughout the period covered by this review.  Between them they received education at one primary school and two high schools and one was home educated for part of the time.    6.2.6 Information from the Education Service shows that throughout the period covered by the review, school staff had concerns about the welfare of some of the children and shared these concerns with other relevant agencies.  6.2.7 On two occasions (one of which was prior to the period covered by this review) FY chose to home educate one of the children.  On both occasions, the elective home education officer determined that the standard of education being provided was ineffective and recommended a return to school.  During the periods when this child was on the roll of High School 2 attendance was poor; recorded at various times from March 2011 to July 2012 as being between 17.6% and 24.3%.     6.2.8 In November 2011 one child was referred to the Educational Psychology Team and eventually issued with a statutory statement for Special Educational Needs.  Child Y Overview Report  27 January 2015  9  Records show that the primary school had considered a referral to be appropriate as early as February 2010 but the parents had been unwilling to consent.  Leeds City Council – Housing Leeds  6.2.9 The family were tenants of Leeds City Council throughout the period covered by the review; living in a three bedroom property from December 2003 to July 2013 when they moved into a four bedroom property.  Local housing office staff visited the property to carry out annual tenancy visits and made additional visits as required in relation to reports of anti-social behaviour and when other organisations raised concerns about the condition of the property.  NHS England – GP Services  6.2.10 Child Y’s parents and older siblings were all registered with the same GP practice throughout the period of the review and they each visited the GP between two and five times during that time period.    6.2.11 Child Y herself was never registered with a GP.  Leeds Community Healthcare NHS Trust (LCH)  6.2.12 LCH is a Community Health Service Provider which provides many services to the residents of Leeds.  During the period covered by this review LCH provided health visiting and school nursing services to the Y family.  LCH also provided the Sudden Unexpected Death in Infants and Children (SUDIC) rapid response team that investigated the death of Child Y  Leeds and York Partnership NHS Foundation Trust (LYPFT)  6.2.13 LYPFT provides specialist mental health and learning disability services to people within Leeds, York, Selby, Tadcaster, Easingwold and parts of North Yorkshire.  Leeds Addiction Unit (LAU) sits within LYPFT and provides assessment, treatment and aftercare for people who misuse alcohol and other drugs and who have complex needs.  The pregnancy and parenting team of LAU were involved with the family from April to November 2011 when MY was pregnant with Child Y and again in 2013 when MY was pregnant with Sib6Y.  The involvement of LAU in 2011 ceased 16 days before the birth of Child Y, when FY said he was unwilling to allow the midwife to visit the family home again.    Leeds Teaching Hospitals NHS Trust (LTHT)  6.2.14 LTHT provides specialist and general hospital services across the city of Leeds and incorporates Leeds General Infirmary, St James’s Hospital, Chapel Allerton Hospital, Seacroft Hospital and Wharfedale Hospital.    6.2.15 Child Y was born in an LTHT hospital and Sib6Y was taken to hospital immediately after being born at home.  Although the majority of antenatal care to MY was provided by LYPFT (see above), a community midwife from LTHT was involved towards the end of the pregnancy with Child Y after FY refused to allow Child Y Overview Report  27 January 2015  10  the LYPFT midwife to visit the family home.  Community midwives also provided post natal care following the births of Child Y and Sib6Y.  6.2.16 Four of Child Y’s five older siblings visited the Emergency Department on at least one occasion during the period covered by this SCR.  In total the siblings attended the Emergency Department as a result of 10 separate incidents; it appears that two were sports related injuries, four were understood to be other accidental injuries, and three were self-inflicted as the result of deliberate acts.  The remaining attendance is described as a ‘left knee injury’ with no indication as to the cause.  Some of these attendances were at Leeds General Infirmary whilst others were at St James’s Hospital.  6.2.17 One sibling attended a clinic due to enuresis and was admitted overnight, from the Emergency Department, on one occasion due to blood being seen in the child’s stools.  6.2.18 MY attended the Emergency Department twice during the period covered by the review; once with a lacerated finger and once with chest pains.  6.2.19 FY did not receive any services from LTHT during the period covered by the review.  6.2.20 Child Y was taken to the Emergency Department at Leeds General Infirmary on the morning of her death and pronounced life extinct at the hospital.  West Yorkshire Police  6.2.21 West Yorkshire Police had their first contact with the family in 1999, in respect of a domestic incident.  Full details of this incident are no longer available.  Other contacts prior to the period covered by this review occurred in 2005, 2006 and twice in 2007.    6.2.22 In 2010 and 2011 West Yorkshire Police had brief contact with the family in relation to issues that have no bearing on this SCR.  None of these contacts resulted in any family member being charged with an offence.  In October 2011 a Police Officer attended a multi-agency meeting to discuss the family.   6.2.23 The Police were contacted by hospital staff when Child Y died and an investigation into the death was carried out.  Subsequently the Police have been involved with the family in respect of child welfare issues.    6.2.24 The Police have also carried out an investigation into the death of Child Y in order to establish whether there may be grounds to charge anyone in connection with her death.  As stated at paragraph 2.4 of this report, the Crown Prosecution Service have now decided that charges will not be brought.  6.3 Chronological Summary of Key Events  Start of period covered by SCR – Notification of MY being pregnant with Child Y (January 2010 – April 2011)  Child Y Overview Report  27 January 2015  11  6.3.1 In April 2010 the learning mentor from the Primary School made a referral to CSWS regarding concerns about neglect.  It was recorded that the children attended school in dirty clothing; one child had reported eating nuts from the hamster cage due to hunger and another was exhibiting self-harm type behaviour.  The learning mentor then phoned FY who was reportedly cross about this, said he would move the children from the school and denied being aware of the school’s ongoing concern regarding the children.   6.3.2 Prior to the referral being made, staff from the primary school had had concerns for at least four months and had discussed these concerns with Housing Services.  During this same period, school staff had offered to support the family through a Common Assessment Framework (CAF)1 on four occasions but FY had always declined these offers of support.  This included two occasions when a staff member from the school visited FY and MY at home to discuss concerns.  FY and MY had also refused to visit the GP regarding one child’s behaviour or to agree to a referral to the educational psychologist.  On 21 January 2010 one child received a ‘year 6 school health surveillance’ check from the school nurse and the outcome was recorded as satisfactory.  Five days later, in a telephone call, the special educational needs co-ordinator from the Primary School informed the school nurse that the school may commence a CAF in respect of the three youngest children.  The special educational needs co-ordinator agreed to keep the school nurse informed but subsequent records do not indicate that the school nurse was made aware of the parents’ refusal to engage with a CAF.  6.3.3 Following receipt of the referral CSWS liaised with the school nurse and a social worker and family resource worker visited the family at home, seeing both parents and all five children and carrying out an Initial Assessment.  Concerns were documented about hygiene, the children’s presentation and school attendance.  As a result of this assessment it was agreed that the family resource worker would offer support in the short term.  6.3.4 In May 2010 the social worker made a follow up visit to MY, FY and one child, who was not in school, to discuss the outcome of the assessment.  The social worker expressed concern to the school nurse that the children were thin and their hygiene poor and asked for treatment for enuresis which two of the children were experiencing.  It was agreed that the social worker would give the school nurse’s contact details to FY and MY so they could make an appointment. The parents did not contact the school nurse so the social worker contacted the school nurse again to ask that MY and FY be contacted regarding enuresis.  The school nurse made contact with the parents and both the children received appointments to attend the clinic in June 2010.  They did not attend the first appointments but by the end of the month they had attended appointments and been prescribed medication.  The concerns about hygiene and the children being thin were not picked up by the school nurse at this stage and there is no evidence of the school nurse sharing concerns about the family with the GP practice.   6.3.5 Also during May 2010, one child was taken to hospital with a tooth lodged in the bottom lip after reportedly falling over a barrier. The child was admitted to a ward                                             1 The Common Assessment Framework is a national assessment tool which can be used to assist agencies in supporting families where children have additional needs that are not being met by their current service provision. Child Y Overview Report  27 January 2015  12  for surgery.  Hospital staff were concerned that all the family were unkempt and contacted CSWS who informed that a plan was in place.  6.3.6 The same month, one child disclosed, at school, being hurt by an older sibling.  The learning mentor undertook to discuss this matter with MY although there is no evidence in the records that this was ever done.  Four days later the children were all late for school and when they arrived, MY reported that there had been trouble at home.  Following further discussion MY disclosed that she and her husband had had an altercation which had resulted in FY leaving the family home.  There are no subsequent records concerning this but the social worker made a record of a home visit to the whole family shortly after.  6.3.7 Around the same time, it was agreed in supervision between the social worker and CSWS team manager that the social worker, family link worker and school would continue to support the family.  6.3.8 In June 2010, the elective home education officer determined that the family home was not suitable for one child to be home educated.  Attempts to get the child back into High School continued throughout the period covered by review, with limited success.    6.3.9 6½ weeks after the initial assessment had been carried out, the social worker visited the whole family at home to check on progress and recorded that the family were positive about continuing to work with the Family Resource Centre.  A few days later it was recorded in the social worker’s supervision that there were no concerns regarding family dynamics and that school attendance had improved but that concerns remained regarding home conditions and presentation.  6.3.10 Concerns about the children’s hygiene continued in July 2010 with High School 1 reporting that in July 2010 that one child was extremely dirty, smelt unclean, had no socks on and had fallen asleep in class.  One week later another child was seen by the GP having carved their own initials into their forearm with a dart.  It is recorded that the child had scratched the arm but not drawn blood and did not need medical attention.  The child reported doing this “to be cool” and the GP accepted this.  The GP did not identify any behavioural problems and deemed this not to be in the category of a self-inflicted injury.   The GP confirmed this view to the social worker.   6.3.11 A CAF was recommended in June 2010 and again in August 2010 but these were not undertaken.  In August 2010 the family resource worker informed the social worker that the family as they had not been in when a visit had been attempted and therefore they had not been seen.  On the same day the social work team manager recorded a concern that the case had been low priority compared to some of the social worker’s other cases and had “drifted”.  It was recorded that the case would be transferred to a different social worker and was to close in the next six weeks.  The new social worker discussed the family with the family resource worker that same month and agreed that the best option would be to proceed to a CAF; the reason given being that the core assessment had not been completed because the family are wary of agencies.    6.3.12 Despite the request to transfer to a CAF, a Child In Need meeting was held eight days later with a review date set for three months later.  It was agreed that the Child Y Overview Report  27 January 2015  13  family would be transferred to a long term social work team but this transfer was delayed as the manager of the long-term team had left.  As a result of this delay it was agreed, in the social worker’s supervision in October 2010, that the current social worker would carry out the Core Assessment within a month.  However, records suggest that, in the event, the family were transferred to a social worker in the long term team before the end of October 2010 but this social worker did not manage to meet the family until December 2010 after two planned visits in October 2010 were cancelled by the social worker and a planned visit in November 2010 did not go ahead because the family were out.  6.3.13 There is no record as to when the Core Assessment was completed because the ‘assessment started’ and ‘assessment completed’ dates have not been recorded; however, it is clear from the content of the assessment that it was completed after the end of 2010.  In addition, the Core Assessment is not signed off by a team manager, as it should be.  It is signed, but not dated, by a social worker; but this is believed to be a different social worker to the one who undertook the assessment.  6.3.14 Also in October 2010 one child was taken to the GP by MY complaining of intermittent abdominal pain and not eating much.  The GP took a urine sample and noted that the child’s hygiene was poor.    6.3.15 In November 2010 FY reported that one child was still wet at night despite the treatment received for enuresis.  The child was referred to hospital regarding the enuresis and given an appointment in January 2011 which was not attended.  Also in November 2010, one child was offered a place at High School 2.  6.3.16 The Child in Need meeting scheduled for December 2010 actually took place in January 2011; there was no representation from the school nursing service.  Records indicate some disagreements between professionals about the level of support required but concerns remained and it was agreed that the Family Link Worker would give extra support.  6.3.17 On the day of the Child in Need meeting one child was observed at school to be tired and unclean with a strong odour.  The child reported going to bed around 1.00 a.m. and been woken by a sibling at 6.30 a.m. It was recorded that this was not the first time this child had appeared tired in lessons and these concerns were raised at the Child in Need meeting.  6.3.18 Also during January 2011, one child attended hospital having had a finger bitten by a hamster and, later in the month the same child attended with an injured knee.  A different child, meanwhile, fractured two fingers having reportedly caught them in the garden fence.  6.3.19 In February 2011 the Primary School asked the school nurse to carry out health checks on the three youngest children.  Parental consent was obtained and the checks were duly carried out.  The school nurse found that all three children were on track with regards to their growth and noted that they were wearing clean clothes but their hair was not brushed.  6.3.20 One day in February 2011 one child arrived at school late (approximately 10:30 hours) with MY and it is recorded that the child smelt of urine, was dirty and had Child Y Overview Report  27 January 2015  14  a smudge on their face.  The safeguarding support worker at the High School sent an email to the social worker listing the concerns that the school had about the child.  Two days later the social worker phoned the learning mentor at the Primary School to ask whether there were any concerns about the younger siblings.  The learning mentor outlined concerns about the children being poorly dressed and having poor hygiene and recorded that the social worker said the case was going to be “stepped up as the parents are not improving” and that there would probably be a Child Protection Plan due to long-term neglect.  CSWS do not have a record of this conversation.    6.3.21 Also in February 2011, the social worker informed High School 1 of a plan to have a meeting with the family that week.  Records indicate that the meeting did not take place until a month later; however it is also recorded that the social worker was on annual leave on the date that the meeting is recorded as having been held.  Therefore the Lead Reviewer wonders if the meeting with the family was actually in February 2011 but has been incorrectly dated.    6.3.22 In March 2011, a child did attend the enuresis clinic with the mother and medication was prescribed.  It was recorded that the child appeared unkempt and had a bruised left arm, but claimed not to know the cause.  It was also recorded that the family was receiving input from CSWS.  6.3.23 In April 2011, the same child was taken to hospital after MY saw blood in the child’s stools.  It was recorded that the child had a history of eating bolts and screws and had eaten sharp plastic and crayons the previous day.  The child was seen in the Emergency Department, referred to paediatric surgeons and admitted to a ward.  Investigations were undertaken and the bleeding resolved itself; LTHT records state that the child was discharged with follow up from the GP, GP records show that the only correspondence received regarding this was a discharge advice note from the hospital.  6.3.24 Also in April 2011, the social worker had supervision with the team manager and it was recorded that the social worker would refer to Family Support as the family resource worker had been taken off the case and that there would be a Family Support meeting in May “to pull it all together”.  Records show that the family resource worker’s involvement with the family had ceased in February 2011.  Notification of MY being pregnant with Child Y – Birth of Child Y (April 2011 – November 2011)  6.3.25 In April 2011, MY attended the first antenatal appointment of her pregnancy with Child Y, at approximately 12 – 14 weeks gestation.  It was decided that the antenatal care should be provided by LAU because MY disclosed that she was drinking four cans of lager each evening and the community midwife dully made this referral.  Two weeks later, MY failed to attend an antenatal clinic appointment at the GP practice.  6.3.26 In May 2011, the Primary School contacted the social worker to express concerns about the children’s poor attendance at school.  The social worker explained that the family resource worker was no longer working with the family and the social worker did not have time to provide the continuous support needed by the family.  The social worker agreed to discuss the case with the Child Y Overview Report  27 January 2015  15  manager and did so that same day.  The manager recorded that the children were fed and wore appropriate clothing and there was lots of emotional warmth but that school attendance was declining.  The manager also recorded that a Family Support Meeting was required and that the case would be transferred to a new social worker or social work assistant in early July 2011.  6.3.27 Also in May 2011 midwife 1 and an addiction nurse from LAU had their first meeting with MY, visiting her at home and carrying out a comprehensive assessment.  The LAU staff noted that the house was very dirty and unkempt due to there being multiple animals in the house.  It was also recorded that there was a social worker involved with the family. The author of the IMR from LYPFT has noted that the assessment was only partially completed and that there was neither information about FY nor a needs analysis of the other children.     6.3.28 Following the assessment, the midwife contacted the RSPCA to try to arrange for in excess of 15 hamsters to be re-housed; it is not recorded whether this was achieved.  The midwife also completed a communication form to alert the obstetric service to LAU involvement and the maternal alcohol issues but this form did not mention the concerns around hygiene.  The day after the home visit from LAU staff, MY missed another ante natal clinic appointment but the day after that, she attended a booking appointment.  6.3.29 That same month, a Child in Need Meeting was held in relation to the family.  This was the first such meeting since January 2011.  MY’s pregnancy was noted but LAU staff were not present at the meeting.  An overall improvement in the family was noted with future targets set for the children to improve their punctuality and attendance at school.  It was stated that CSWS may cease their involvement if these targets were reached.  6.3.30 Later in the month, MY attended an antenatal clinic at hospital with the midwife and addiction nurse from LAU, her alcohol consumption was reviewed, and the effects of alcohol on an unborn child was discussed.  An alcohol reduction regime was planned and a referral made to a cardiologist at LGI regarding MY’s Supra Ventricular Tachycardia (SVT).  6.3.31 MY continued to receive antenatal care through June 2011 and reported that she was still drinking four cans of lager each evening.  The LAU midwife expressed concern about the presence of birds and bird faeces in the house.  6.3.32 In July 2011 another Child In Need meeting was held and it was reported that there was to be a change of social worker.  The current social worker was unhappy with the lack of progress and suggested more intensive family support was required.  FY became angry about this and was reportedly abusive to the social worker.  After the meeting the CSWS team manager decided to close the case because FY did not want social work involvement.  The following month CSWS sent a letter to MY and FY to inform them that CSWS was to close its active involvement due to the parents’ “reluctance to engage with social care in last Children in Need meeting” but that CSWS would become involved again if there were any more referrals to CSWS.   This letter was copied to the other agencies involved.   Despite this letter and the social worker writing a closing summary, the case was not formally closed until January 2012; however CSWS had no more direct contact with the family until November 2011.  For three Child Y Overview Report  27 January 2015  16  months between July 2011 and October 2011, the service’s involvement appears to have been limited to phone contact with other professionals, including the elective home education officer, the addiction therapist and the head teacher at the Primary School.    6.3.33 In August 2011, the midwife and addiction nurse from LAU carried out another home visit, seeing MY, FY and some of the children.  The midwife recorded that MY appeared ‘vacant’ when her husband was talking and the midwife was unable to talk to MY on her own because some of the children were present.  The midwife also recorded that the house appeared unkempt and all the children appeared dirty and markedly dishevelled, however well nourished.  6.3.34 LYPFT records state that in September 2011, the addiction nurse discussed the case with the social worker who reported having only recently taken over the case and not knowing about MY’s alcohol intake.  Also that there had been a Child in Need plan but FY was not willing to engage with services so the case was to be closed the following week.  6.3.35 A few days later, the elective home education officer visited the family home regarding one child’s education and subsequently contacted CSWS to express concern about the condition of the home, especially with a baby due.  This included a report that the house contained a pigeon, hamsters, a rat and two dogs.  The following day the social worker passed these concerns on to the addiction nurse and subsequently the midwife and addiction nurse carried out a home visit.  At this visit the midwife told the parents that there had been liaison with CSWS; FY is reported to have become verbally abusive and aggressive and stated that the LAU staff were no longer welcome in his home.  This was the last time staff from LAU visited the family home in connection with MY’s pregnancy with Child Y.  6.3.36 Following on from this home visit the case was discussed within LYPFT at clinical supervision and a team meeting.  It was agreed to contact CSWS and also to contact Public Health if needed for further action and/or advice.  The addiction nurse phoned CSWS and was told that staff familiar with the case were on leave but information would be sent to them by email.  Public Health and Infection Control within NHS Leeds were also contacted.  In October 2011 the addiction nurse spoke to CSWS again and expressed concerns.  6.3.37 As a result of the concerns from LAU, CSWS requested assistance from Housing Services, who visited the property and reported that the condition was fair but that rubbish needed to be cleared in order for surveyors to undertake a full inspection.  Later in the month it was recorded that that FY and MY had been provided with a garage and the house condition had improved.  Surveyors had identified various repairs that were needed but FY and MY had declined any other support apart from assistance in applying for a larger property.  6.3.38 CSWS also arranged a meeting which took place in October 2011.  The meeting was attended by social worker 1, the LAU midwife and representatives from the Primary School, High School1, Housing Services and the Police.  It is recorded that the social worker and midwife were to carry out a joint visit to the family and the social worker was going to check whether there should be a pre-birth Initial Child Protection Conference regarding the unborn baby or an Initial Child Child Y Overview Report  27 January 2015  17  Protection Conference for all the children.  The following day, the social worker informed other professionals involved that there was not going to be a Child Protection Conference and the planned joint visit was not going ahead because the CSWS service delivery manager thought it might seem oppressive to the parents.  6.3.39 Also in October 2011, a ‘32 week’ meeting was held at LAU, which was attended by the midwife, addiction nurse and health visitor all of whom were from LAU.  The ’32 week’ meeting has routinely been held by LAU in the 32nd week of a service user’s pregnancy.  It constitutes a multi-agency review of the service users’ care and treatment and the level of risk to the unborn and existing children.    Housing Services and the schools were not invited whilst the social worker, community based health visitor and neonatal abstinence specialist nurse were invited but not in attendance.  In addition MY was invited to the meeting but did not attend and she also missed an ante natal appointment, leading to concerns that she was not engaging following her husband telling the midwife and addiction nurse to leave the house.  Concern was expressed about the lack of involvement from CSWS and it was agreed that the midwife would co-ordinate a referral to CSWS from the various agencies with concerns.  This action was taken and a referral was made on eight days later.  6.3.40 Three days after the midwife made the referral; the health visitor from Leeds Community Healthcare made their first visit to the home and was concerned about the state of property, including the number of animals. The health visitor considered it to be unsuitable for a new born baby and contacted the midwife and CSWS, who told responded that the family was not an open case to CSWS.  6.3.41 Also in October 2011 the social worker told the midwife that the social worker wanted them to carry out a joint visit to the family home a few days later.  However, the following day the social worker left a message for the midwife to cancel this visit and instead the CSWS team manager and a social work assistant visited; apparently because FY said that he would not allow the midwife to come to his house.  It was agreed with FY and MY that CSWS would keep the case open until the baby was born and for four weeks afterwards but the rationale for this decision is not recorded.  6.3.42 In November 2011, the social worker, health visitor and community midwife from LTHT all carried out visits to the home and found the property to be in a much better condition than had previously been the case.  The community midwife had taken over from the LAU midwife as a result of FY’s refusal to allow the community midwife to visit his home.  Also in November 2011 Child Y was born in hospital; mother and child were discharged home two days later.  Child Y’s lifetime (November 2011 – March 2012)  6.3.43 The social worker visited the family at home a few days after Child Y was born, seeing all the children including Child Y.  It was noted that the home was warm and the lounge acceptable.  A smell of urine was noted in one bedroom but the bedding was clean and the baby was recorded as eating and sleeping well.    6.3.44 The community midwife visited Child Y and MY at home on six days after Child Y was born and again five days later; before handing care over to the health visiting Child Y Overview Report  27 January 2015  18  service.  The health visitor tried to visit but got no reply but visited again six days later and did gain access.  The health visitor recorded that the house was a little cluttered but generally clean; although it is unclear how many rooms were seen.  6.3.45 The day before the health visitor’s visit, the social work assistant tried to visit the home. FY would not allow the social worker into the property but they spoke through a window.  The social work assistant informed FY that this might be the last visit as the concerns ‘had been addressed’. The case was closed by CSWS in January 2012; it appears that the social work assistant never saw Child Y and had not been in the house, or seen any family members except for FY since nearly seven weeks before.  6.3.46 Twice in January 2012, the Primary School noted that one child was very tired.  The child reported being kept awake by the baby.  Also in January 2012, another child was taken to the Emergency Department after punching a wall due to being angry with a teacher.  6.3.47 Also in January 2012, the health visitor visited to complete the 6 – 16 week contact.  The health visitor told MY that there would be a change of health visitor due to services being ‘realigned’.  The health visitor had no concerns about the house or Child Y.  MY told the health visitor that she had not had an appointment from the GP for the 6 – 8 week medical (Child Y was 7½ weeks old) or contact from the Children’s Centre.  After this visit the health visitor requested a visit from an Outreach Worker from the Children’s Centre and contacted the GP practice who said that Child Y was not registered with a GP.  The health visitor phoned MY to recommend that Child Y be registered with a GP as soon as possible.  This was the last occasion when anyone from an agency involved with this SCR saw inside the family home prior to Child Y’s death.  6.3.48 The day after the health visitor had visited the family home, the Primary School phoned CSWS to express concerns that one child had reported being kept awake because Child Y was persistently crying.  The member of staff from the school was informed that social worker 1 was not in work and that the case was closed to CSWS so, if school were concerned they needed to re-refer.  The member of staff from school spoke to the health visitor and explained that two of Child Y’s siblings had said Child Y cried a great deal. The health visitor reported having no further concerns, having seen Child Y the previous day, but said the service would be visiting more frequently than the ‘core offer’ requires, due to the recent involvement with CSWS.  The health visitor also said that if school continued to have concerns they should contact CSWS.  6.3.49 One week later two of the children informed school staff that their mother had been taken in an ambulance that morning. Records from LTHT show that MY attended ED at 06:06 hours with right sided chest pain when breathing in or moving. She declined pain relief; chest X-ray and blood tests showed no abnormalities. Child Y remained with MY due to being eight weeks of age and breast feeding; one of the other children was also in attendance. MY was discharged at 08:10 hours with no follow up required.   6.3.50 The following day, the learning mentor from the Primary School phoned social worker 1 again to explain that school staff still had concerns and were unhappy that CSWS had ended their involvement with the family.  The social worker Child Y Overview Report  27 January 2015  19  responded by saying that if any additional concerns came to light school staff could re-refer.  The social worker also recommended that the learning mentor should phone the health visitor regarding concerns that the other children were being kept awake by Child Y.   6.3.51 That same day, health visitor 1, phoned the GP surgery again and was informed that Child Y had still not been registered with the GP.  Health visitor 1 also contacted CSWS, having been informed that they had ceased their involvement.  Health visitor 1 expressed concerns about this due to Child Y not being registered with a GP and already being late for the first immunisations and medical check.  Finally, the health visitor tried to phone FY and MY about GP registration but did not receive an answer to the call and therefore left a message asking them to phone back.  The family did not phone back but a few days later the health visitor managed to speak to FY who said that he would register Child Y with the GP the following day.  However he did not do so.  6.3.52 In January 2012 the child who had reportedly eaten hard plastic met with the educational psychologist.  6.3.53 In February 2012 FY & MY attended a meeting at High School 1.  School staff were concerned that the parents and Child Y were very dirty.  The school teacher initially spoke to the social worker about this concern and was told that the case was closed to CSWS and that contact should be made with the health visitor.  The school did phone the health visitor whose response was that concerns must be referred to CSWS as they have a statutory duty to investigate concerns about neglect.  The health visitor then spoke to the manager about concerns that CSWS had asked the school to contact the health visiting service; the manager advised the health visitor to complete an incident form to highlight these concerns and this was done two days later.  Also that day the health visitor and social worker spoke to each other about the case.  Following the phone call, the social worker recorded that the health visitor would visit the family and the health visitor recorded that records would be transferred to the new health visiting team to facilitate an early visit to the family.  6.3.54 Child Y’s care was transferred to a new health visitor, as health visitor 1 had previously said would happen, and the new health visitor wrote to MY and FY on  to arrange a visit 18 days later.  six days before this visit, the learning mentor at the Primary School contacted the Health Visiting Service with concerns about two of the children and to report that a member of staff had seen Child Y and thought the child looked very underweight.  The learning mentor was informed of the planned visit.  When the health visitor visited the house there was no answer; the health visitor spoke to MY by phone and arranged to visit again with an outreach worker two days later but again there was no response and a further date was set to meet seven days later.  6.3.55 On the day of the attempted visit by the health visitor and outreach worker, the head teacher from the Primary School again expressed concerns to the health visitor about Child Y and was told that the health visitor intended to make a referral to the health visiting safeguarding team if Child Y was not seen the following week.  Child Y Overview Report  27 January 2015  20  Child Y’s death – Notification of MY’s pregnancy with Sib6Y (March 2012 –January 2013)  6.3.56 The following morning MY stated that she woke to find Child Y lifeless.  Despite attempts at resuscitation by FY and health staff Child Y was pronounced dead at hospital.  The Sudden Unexpected Death In Infants and Children (SUDIC) process commenced and consequently the Named Nurse, Consultant Paediatrician and police visited the family home.  Following the visit, the Named Nurse reported the home conditions as appalling, and one of the worst environments the Named Nurse had witnessed.  Records and verbal reports suggest that the improvements made before Child Y was born had not been maintained and that items that had been moved out of the house and into a garage had since been moved back in.  6.3.57 CSWS reopened the case, held a strategy meeting and initiated Section 47 enquiries to consider issues of possible neglect.  All five children and their parents went to stay with FY’s aunt and uncle.  An Initial Child Protection Conference was arranged for the following week but was adjourned, by the Conference Chair, in consideration of the family’s mourning of the loss of Child Y.  Instead the professionals held a meeting without FY and MY present and a Child Protection Bridging Plan was put in place.   6.3.58 The family remained with FY’s aunt and uncle through April 2012 but confirmed to the social worker in late April 2012 that they intended to move back to their home whilst they waited to be re-housed, this move happened in late May 2012.  In late April 2012 the social worker’s manager recorded in supervision that core assessments still needed to be completed in respect of all the children.  6.3.59 During May 2012 the school nurse completed health assessments of three of the children and it was reported that the hygiene of all the children was better whilst they were living with their great aunt.  The educational psychologist met with the same child as before, MY and FY’s aunt and allegations were made that this child was being bullied at school.  CSWS completed the core assessments and decided that the family should be supported under a Child in Need Plan as they believed that Child Protection could be seen as a punitive measure that could further alienate the family.  6.3.60 In June 2012 one child was excluded from High School 1 due to behaviour and FY was reported to be verbally abusive to the school about this.  There were further reports that the child who had seen the educational psychologist was being bullied at school and this was having an impact on attendance.    6.3.61 Plans were made for a Child In Need meeting and a Family Group Conference to be held.  The Child in Need meeting went ahead in July 2012 and it was agreed that the current plan would continue but the Family Group Conference did not go ahead as, having met the family, the Conference Co-ordinator considered that the time was not right as they were still grieving and distressed.    6.3.62 In August 2012, concern was expressed that whilst one child’s appearance had improved whilst living with the father’s aunt it had deteriorated again since the family had moved back into their own home.  Child Y Overview Report  27 January 2015  21  6.3.63 Also in August 2012 a child attended hospital having punched a wall when angry with a teacher; there had been a similar incident with the same child in January 2012.  It was recorded by school that counselling was being sought for this child and a referral was made by CSWS to the Specialist Therapeutic Team (STT) who questioned the relevance of the referral given the parents’ resistance to help.  Therapeutic services expect consent and co-operation from parents and it appears that this was not forthcoming.  Consequently, the Specialist Therapeutic Team did not become involved with the family.  At the end of September 2012 it was reported that this child’s behaviour in school had stabilised.  Another child’s school attendance was reported as being 33.3%.  6.3.64 In October 2012 High School 1 raised concerns about the children being late for school and their unkempt appearance whilst the Primary School expressed concern to CSWS about the appearance of one child.  Later in the month three of the children were suspected of causing criminal damage to vehicles.  The Police expressed concerns about their hygiene.  6.3.65 FY’s aunt and uncle were continuing to support the family and liaise with CSWS and at a Child in Need meeting in October 2012 CSWS decided to close the case.  They were asked by the Primary School to keep it open until after the inquest into the death of Child Y but the Primary School was told to re-refer if they had further concerns and the case was closed the following week.  It was, however, reopened shortly after when CSWS became aware that the SUDIC process had not yet been completed.   6.3.66 The final SUDIC meeting took place in November 2012 and, following this, reminders were placed on the GP records for both parents and all five children to refer to CSWS if they had any concerns.  6.3.67 Also during November 2012 High School 1 and the school nurse referred the family to CSWS due to concerns that their situation was deteriorating again and reports that FY’s aunt was no longer seeing the children.  The Named Nurse for Safeguarding Children from LCH spoke to the CSWS team leader regarding concerns and the team leader confirmed CSWS’s view that the case could be managed with a CAF but that there were concerns if FY’s aunt was not seeing the children.  6.3.68 Education Officers visited the family home on 12 occasions between October 2012 and November 2012 regarding one child’s non school attendance.  On the majority of occasions there was no response.  In 1 November 2012 the elective home education officer visited with a police officer.  FY opened a window but would not open the door or let the officers in.  He did however allow them to see the child through a window.  FY was angry with the enquiries made by the Police Officer to ascertain the location and welfare of the child and rang the Divisional Control Room, wanting to make a complaint. FY spoke to the Divisional Control Room Supervisor who advised him of the Police Powers of Entry under Section 17 of PACE. FY did not wish to pursue a complaint but requested that the attending Police Officer be spoken to.  FY also stopped sending the other children to school and told High School 1 that he intended to home educate all the children.  Child Y Overview Report  27 January 2015  22  6.3.69 In December 2012 concerns continued to grow and CSWS decided to re-open the case with a view to holding a Child Protection Conference and Family Group Conference.   FY visited the GP in December 2012 and said that he had been feeling down for months.  GP notes refer to him arguing with one child and striking out but it is unclear whether he struck the child, or which child he was referring to.  A follow up appointment was arranged for 28 December 2012 but FY did not attend.  Despite the alert in FY’s GP record, the GP did not refer to CSWS.  Notification of MY’s pregnancy with Sib6Y – Birth of Sib6Y (January 2013 –April 2013)  6.3.70 In January 2013, MY was seen by the GP and found to be 25 weeks pregnant; she was referred to the GP and the addiction unit.   Also in January 2013, a Special Educational Needs (SEN) support worker met the child who had seen the educational psychologist and completed an assessment.  6.3.71 In February 2013, an Initial Child Protection Conference was held and all the children were made subject to Child Protection Plans.  At the first Core Group meeting later in the month FY expressed a wish to transfer all the children to High School 2 but said the school did not want them because of attendance issues with one child.  6.3.72 Also in February 2013 the GP practice was asked to screen all the children for vitamin D deficiency.  This was because the post mortem of Child Y had shown vitamin D deficiency.  When the children were screened they were all found to have vitamin D deficiency and were prescribed supplements.  6.3.73 In March 2013 it was decided that when the baby was born, MY and the baby would go to a mother and baby unit together for three months.  Also in March 2013 the statutory educational assessment of one child began and a referral was made for a Family Group Conference.  6.3.74 In April 2013, the LAU midwife, social worker and health visitor carried out a joint home visit.  Both parents were present, along with three of the children; the condition of the house was deemed to be ‘acceptable’ and it was recorded that MY was on an alcohol reduction programme.  6.3.75 A core group meeting was held in April 2013 and three days later Sib6Y was born at home at 35 weeks gestation.    Birth of Sib6Y – End of Review Period (April 2013 –July 2013)  6.3.76 Following Sib6Y’s birth at home the baby and mother were taken to hospital.  10 days later an Interim Care Order was made for Sib6Y with Interim Supervision Orders for the other five children, who were in their father’s care. MY and Sib6Y remained in hospital for 12 days more and were then discharged together to a foster placement.  The following week a Review Child Protection Conference was held and it was decided that the children would remain subject to Child Protection Plans.  Six days later, a Family Group Conference was held and a Family Plan was agreed.  Child Y Overview Report  27 January 2015  23  6.3.77 In June 2013 the family were offered a tenancy of a four bedroom home near to FY’s aunt and uncle.  They accepted this and MY and Sib6Y were reunited with the other family members in July 2013 when they moved into this house.    7. Analysis   Introduction  Analysis is provided for each of the individual terms of reference (ToRs), based on information gathered from the individual agency reports, consideration of the Key Practice Episodes which were explored during the two Learning Events, discussions within the SCR Panel Meetings and wider reading undertaken by the Lead Reviewer.  There is considerable overlap between some of the ToRs so, in order to avoid unnecessary duplication of information the report cross references where appropriate.  7.1 Term of Reference (ToR) 1.  What evidence did agencies have that Child Y and the siblings were being neglected and how did they respond to this evidence, in ensuring the wellbeing of the children? Were the risks to the children properly identified, evaluated, and appropriately responded to? Were the right services provided to meet the needs identified?  7.1.1 Working Together to Safeguard Children 2013 provides the following definition of neglect: “The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:   provide adequate food, clothing and shelter (including exclusion from home or abandonment);   protect a child from physical and emotional harm or danger;   ensure adequate supervision (including the use of inadequate care-givers); or   ensure access to appropriate medical care or treatment.   “It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs” (page 86, appendix A)  7.1.2 Throughout the period covered by this review there was evidence of neglect within the family, which at various times included the following:  the children’s poor hygiene and presentation, including unpleasant smell, dirty clothes, unwashed and unbrushed hair and persistent head lice;   the children being hungry;   the children being late for, or absent from, school;   inconsistent attention to the treatment of enuresis in two of the children, including not collecting prescriptions and not attending appointments at the enuresis clinic Child Y Overview Report  27 January 2015  24   the condition of the home, including overcrowding, animal faeces, absence of food and cleaning materials, no bedding and urine soaked mattresses.    7.1.3 The children’s attendance at school in a tired, hungry, dirty, unkempt and smelly condition created problems for them with other pupils. One of the children was particularly affected by bullying; as a result spending playtimes and lunch breaks playing alone in the classroom on the computer, to avoid this.  This child ate sharp metal objects and at seven years of age reportedly expressed a wish to die when talking to school staff.  7.1.4 Historic records show that many of these issues had been present for several years.  LCH identified that basic indicators of neglect had been present for at least twelve years requiring intermittent episodes of statutory intervention.   Agency knowledge of neglect in this case  7.1.5 Throughout the period covered by this review the Primary School had concerns that the children were being neglected as a result of the way the children presented at school.  School staff monitored this and referred to CSWS on several occasions.  Concerns were also raised by staff from High School 1 and by the elective home education officer who attended the family home with regard to one of the children.    7.1.6 The school nurse, from LCH, was aware that the children displayed indications of being neglected; in addition to the school nurse’s own observations information was received from school, CSWS, Emergency Department attendance slips and hospital consultant letters.  The school nurse offered support to the family with the enuresis being experienced by two of the children and showed persistence when MY and FY did not collect prescriptions or take the children for appointments.  The school nurse also referred one of these children on to the enuresis clinic in hospital when the child’s enuresis persisted.    7.1.7 The health visitor, also from LCH, became involved with the family in October 2011 as a result of MY’s pregnancy.  LCH have identified that liaison between the school nurse and health visitor did not happen early enough in this case and that historical health records should have been accessed due to the presence of safeguarding concerns.  7.1.8 CSWS had had periods of involvement with the family prior to the period covered by this SCR.  During the period covered by the SCR they were aware of features of neglect within the family from April 2010 when the Primary School made a referral and were involved in providing support to the family during the majority of the period covered by the review.  It appears that at times this was proportionate and led to improvements in the overall care of the children but there was a lack of clear assessment and planning, and periods when the case was allowed to drift.  These issues are explored in detail elsewhere in this analysis  7.1.9 Child Y’s five older siblings each visited the GP surgery between two and five times during the 3½ year period covered by this SCR.  Therefore none of the children could be described as frequent visitors to the GP.  On one occasion a GP recorded that the hygiene of one of the children was poor but no action was Child Y Overview Report  27 January 2015  25  taken.  The author of the Primary Care IMR explains that the GP practice was aware that CSWS and addiction services were involved with the family and speculates that the GP may not have pursued the hygiene issue because the family were already receiving additional support.  Records suggest that whilst the school nurse was aware that the children were experiencing neglect, the nurse had little communication with the GP practice about the family and did not make them aware of the concerns.  Child Y was never registered with a GP.  7.1.10 LTHT’s contacts were with the children individually rather than as a family and were in respect of specific incidents and ailments.  There is no sense that staff from paediatrics in LTHT were aware that the children were from a family where neglect was a concern.  Of 20 contacts that paediatrics in LTHT had with the various children there were two occasions where concerns were noted about the appearance of the family.  Firstly, in May 2010 one of the children attended the Emergency Department following an accident at home; the family was noted to be unkempt and staff in the Emergency Department contacted CSWS via the emergency duty team (EDT).  It is written on a social care communication sheet within the child’s hospital record that CSWS staff contacted the ward to which the child had been transferred for surgery and provided information that the child was subject to a child protection plan which should continue.  In actual fact this information is incorrect; CSWS were involved with the family in May 2010 but they were receiving Family Support and were not subject to Child Protection Plans.  It is not known whether CSWS provided incorrect information or if it was incorrectly recorded by LTHT staff.  On another occasion one of the children was described as unkempt at the enuresis clinic appointment; CSWS were contacted and informed hospital staff that the family was known to them.  This was confirmed by the school nurse.    7.1.11 LYPFT first became involved with the family in April 2011 when MY was referred to LAU due to her pregnancy and known alcohol misuse.  Records show that the LAU midwife and addiction nurse had concerns about the condition of the property from the time of their first visit.  These concerns were in the context of MY expecting a baby, not concerns about the children who already lived in the property.  7.1.12 Housing Services were contacted by the Primary School in December 2009 and by CSWS in September 2011.  On both occasions contact was made because of concerns about the property and Housing Services’ involvement was correctly focussed on the condition of the property.  Practical solutions were put in place and Housing Services’ reported back to the school and CSWS as appropriate.  Although Housing Services’ focus was on the property, staff have received safeguarding training and, following the visit in December 2009 reported that the children appeared happy and did not present as unwell or dirty.    7.1.13 The Police were unaware about the concerns of possible neglect in the family until October 2011 when they were asked to attend the meeting called by CSWS.  Prior to Child Y’s death there is no indication that agencies ever considered whether the neglect reached the level where a criminal act may have been committed.  Since Child Y’s death the Police have collated and investigated all the child neglect concerns in order for a decision to be made as to whether there are grounds for a prosecution.  Child Y Overview Report  27 January 2015  26  Referral from Primary School to CSWS April 2010  7.1.14 Paragraphs 6.3.3 and 6.3.4 summarise the initial action taken as a result of the referral from the Primary School in April 2010.  Although CSWS undertook an Initial Assessment, the case was not progressed to a Core Assessment and a Child in Need plan was not put in place until five months later, in September 2010.  It is the view of the CSWS Head of Service (Social Work) involved in this SCR that the initial assessment and previous history downplayed the significance of neglect.   At the Learning Lessons Event, it was considered that continued CSWS involvement should have resulted in a Core Assessment being undertaken to identify the children’s needs.    7.1.15 CSWS appear not to have considered the referral in the context of the long history of concerns relating to neglect within this family but instead the referral was treated in isolation.  The statement that there were no concerns about family dynamics ignores the concerns about some of the behaviour and suggests that the possible significance of self harming, particularly in young children, was not considered or understood.  Equally there was no consideration of what the parents’ apparent unwillingness to recognise there was a problem and their refusal to agree to it being investigated further, indicated about their commitment to the welfare of the child.  Instead, because professionals observed what appeared to be positive relationships within the family, it was assumed that the family dynamics were fine and input focussed on school attendance and hygiene.  7.1.16 There is no evidence of the school nurse addressing the concerns about the children being thin or making the GP practice aware of the concerns about the family.  Family Support  7.1.17 The principal outcome, from the initial assessment, appears to have been the introduction of a family resource worker to support the family.  The family resource worker commenced work with the family in May 2010 and is believed to have worked with them until February 2011.  However this review has found significant problems with this provision of family support.  7.1.18 At the time the case was referred to the Family Resource Centre it was expected that a social worker would request support from the centre using a referral form which the centre manager would then process.  It appears that, in this case, the family resource worker bypassed this system and carried out the work without the manager’s knowledge.  This did not come to light until approximately nine months later in February 2011 at which point action was taken which meant the family resource worker could no longer work with the family.  7.1.19 Given this situation it is evident that the manager of the Family Resource Centre did not provide any supervision or management in respect of this case.  The family’s social worker was aware that the family resource worker was working with the family and it may be that the social worker did provide some oversight of the work that was carried out but no records of such work have been found.  Equally, there is no plan as to what work the family resource worker was asked to undertake.  Child Y Overview Report  27 January 2015  27  7.1.20 MY and FY have both contributed to this SCR by meeting with the Lead Reviewer and Panel Chair respectively.  MY told the Lead Reviewer that CSWS was “in and out of the house a few times and offered to help get the children ready for school in the morning”.  She added that she was not bothered about CSWS coming in and helping but her husband was set against having any help.    7.1.21 Given the above information, it is impossible to know how much support was provided to the family or whether this had any benefit for the children.  It seems to be the case that this problem was created by one member of staff acting independently but it is a matter of great concern that it took so long to come to light.  It is believed that the social worker did not know that the family resource worker was working without the manager’s knowledge.  Nevertheless the absence of a clear plan for the family resource worker or records of ongoing communication between the social worker and family resource worker are a further concern.     Summer 2010 to early 2011  7.1.22 Paragraphs 7.3.17 to 7.3.19 summarise the action taken in the summer and autumn of 2010.  7.1.23 Two weeks before the first Child in Need meeting, which was held in September 2010, a record had been made that the case would be closed in six weeks.  However, at the meeting it was agreed that a Core Assessment would be undertaken and the family transferred to a long term social work team.  The SCR Panel has not received any information as to why the plan changed in this way.  7.1.24 A core assessment should have been carried out much sooner.  This would have facilitated a decision as to whether the children should be supported through a Child in Need plan or if concerns were sufficiently serious to warrant an Initial Child Protection Conference.  Either way, a clear multi-agency plan was required, which clarified the roles of different agencies and stated what needed to be achieved.  Regular meetings, involving the key parties were required to monitor progress.   7.1.25 Despite the Child in Need meeting in September 2010 and the decision to carry out a core assessment the drift in the case was not arrested.  The core assessment was still not carried out in a timely manner and the introduction of the new social worker from the long term team was delayed significantly.    7.1.26 Over this period the family was given low priority by CSWS; the SCR Panel has been told that CSWS in Leeds had assessment teams with high caseloads and long term teams would not accept cases without the proper assessments having taken place. Therefore cases drifted due to being “stuck” between assessment and long term teams.  CAF was wrongly promoted or understood to be a gatekeeping process with the result that a family would not be taken on by CSWS unless a CAF had been tried first.  Consequently, agencies faced difficulties referring to CSWS in cases where the family would not agree to a CAF being undertaken.  It is reported that the team working with Child Y’s family were very stretched with low morale and agency staff filling several vacancies.  Social workers previously had up to 30 children on their case loads whereas the current target is 15 to 20.  At the present time average caseloads are about 22 with Child Y Overview Report  27 January 2015  28  some teams having achieved the target of 15 to 20 and all other teams heading in that direction.    7.1.27 Records from the Child in Need meeting held in January 2011, nine months after CSWS became involved, indicate some improvements for the children but also that significant concerns remained.  It was recorded that the family resource worker was to give extra support but, as is explained above, the following month the family resource worker actually stopped working with the family and the social worker reportedly told the Primary School that there was likely to be an Initial Child Protection Conference (see paragraph 6.3.20).   7.1.28 Contrary to the suggestion that an Initial Child Protection Conference would be held, the records provided to this SCR suggest that CSWS did not have any significant involvement with the family until the next Child in Need meeting which was in May 2011.  By this time MY was pregnant with Child Y and the analysis is contained within ToR2 below.  7.1.29 In summary, during the period from January 2010 to May 2011 agencies were involved with the family due to concerns about neglect.  The main intervention appears to have been the introduction of a family resource worker but this was not managed properly, there are no records to show what work was done and little if any indication of positive change.  7.2 ToR 2.   How did professionals take this information into account in relation to Child Y before and after the birth and what weight did they give to it?  7.2.1 In May 2011 LAU became involved with MY as a result of her pregnancy.  The midwife and addiction therapist from LAU had concerns about the condition of the family home when they carried out their first visit and the midwife took some action to try to improve matters.  However, despite taking some positive action to try to improve the home situation, the midwife did not liaise with other organisations involved with the family.  The midwife knew that CSWS were involved but did not discuss the concerns with CSWS until three months later.    7.2.2 No explanation has been provided as to why the midwife did not contact CSWS regarding these concerns in May 2011.  As a result of this, action has been taken to tighten up LAU’s process of seeking background checks from CSWS when referrals are first received.  7.2.3 At the Child in Need meeting in May 2011 MY and FY informed people of MY’s pregnancy.  The only agencies in attendance at this meeting were CSWS and the schools.  Records do not indicate what consideration these agencies gave to the arrival of another baby into the family, either in respect of the impact on the baby of coming into a family where neglect was a feature or the impact on the other children of the arrival of a sixth child.  In fact, CSWS suggested that they may end their involvement with the family.   7.2.4 Following the news that MY was pregnant it would have been appropriate for the social worker to contact the midwife to ensure that the midwife was aware of CSWS involvement, co-ordinate the work being undertaken with the family and invite the midwife to the next Child in Need meeting.  However, none of this was Child Y Overview Report  27 January 2015  29  done and by the time of the next Child in Need meeting in July 2011, there had still not been any contact between the LAU midwife and CSWS.  Therefore they were unaware of one another’s concerns.  7.2.5 The next Child in Need meeting was held in July 2011 and was attended by FY and MY as well as staff from the Primary School, High School 1, CSWS and Housing Services.  No health staff were present even though the school nurse was involved in respect of the children.  This was the fourth Child in Need meeting to be held over period of 10 months but the school nurse had not attended any of them.  The school nurse was an important resource who was actively involved in addressing the enuresis experienced by two of the children.  The school nurse’s presence at Child in Need meetings could have enhanced the care planning.  Barriers to the school nurses attendance are considered in ToR 12.  7.2.6 By the time of the July 2011 Child in Need meeting the midwife and addiction nurse from LAU had still not had contact with the other agencies working with the family and were still unaware of the CSWS involvement despite their involvement with MY due to her pregnancy and continued drinking.  Once again, there is no evidence that the potential impact of MY’s pregnancy and the arrival of a sixth child into an already overcrowded house was considered at all.  7.2.7 The decision of the CSWS team manager, after the Child in Need meeting, to close the case was contrary to the view expressed by the social worker that more intensive support was required.  Records suggest that this decision was made on the basis of what FY wanted rather than what was considered to be in the best interests of the children, which suggests that the work was not child focussed in the way that it should have been.  It appears that throughout the period covered by the review FY was the dominant person within the family.  Not only was there a lack of child focus but professionals did not take time to seek the views of MY.  It is also clear and that the family were still hard to engage.  Given FY’s unwillingness to work with CSWS at this time, the SCR panel are of the view that CSWS should have considered whether there were grounds for an Initial Child Protection Conference to put social work involvement onto a more formalised footing.  There is no evidence that this was considered (see paragraph 6.3.32).  7.2.8 The elective home education officer and addiction nurse acted appropriately in raising concerns about the condition of the property in September 2011, although, as has already been explained the addiction nurse and midwife from LAU should have made CSWS aware of these concerns several months earlier.  When the concerns were raised with CSWS they appropriately liaised with Housing Services who supported the family with improving the condition of the house.  This included carrying out repairs and providing a garage so that the family could move items out of the third bedroom.  (see paragraphs 6.3.34 – 6.3.37)  7.2.9 The meeting arranged by CSWS, which was held in October 2011 (see paragraph 6.3.38), resulted in a shared view that an Initial Child Protection Conference should be held due to the concerns that were in place.  However, this did not go ahead because the service delivery manager in CSWS was of the view that working with the family on a child in need basis was more likely to secure parental co-operation than child protection measures would.   Child Y Overview Report  27 January 2015  30   7.2.10 Whilst acknowledging that improvements were made to the condition of the home over the next few weeks, and recognising the danger of hindsight bias, the SCR panel are of the view that there were grounds for convening an Initial Child Protection Conference following the meeting in 5 October 2011. There were significant concerns about the suitability of the property which were long standing and the imminent arrival of a new born baby increased these concerns.  However, the condition of the home should not have been the only concern.  A primary focus of organisations should have been on the welfare of the children and the condition of the home should have been seen as an indicator that the parents were either uncommitted or unable to adequately care for their children.  Concerns remained about the children’s personal hygiene, their punctuality at school, the mental health of one child, lack of schooling of another and MY’s drinking.  Furthermore, there was no reason to believe that the improvements relating to the house would be maintained as no significant improvement had been achieved in the 18 months since the Primary School referred to CSWS in April 2010.  Agencies did not really question why FY and MY had allowed the property to deteriorate to such a state, what this said about their motivation to provide a suitable environment for their children or their motivation to sustain any improvements.  In addition, the imminent arrival of a baby would add a new dynamic to the family and this should have been considered.  7.2.11 It is, of course, impossible at this stage know how the family would have reacted if CSWS had gone down the route of an Initial Child Protection Conference or what the outcome would have been for the children.  32 week meeting  7.2.12 The ‘32 week’ meeting, held in October 2011, should have provided an opportunity to plan for Child Y’s birth.  In the event it was only attended by staff from LAU, none of whom had any further contact with MY, FY or any of the children because FY refused to allow them into the house after he had been verbally abusive to the LAU midwife in September and MY had not attended antenatal appointments.  The community midwife did not attend the ‘32 week’ meeting because at the time it was held, there was no plan to transfer antenatal care from LAU to LTHT.   Records do not show why the health visitor and social worker did not attend the ‘32 week’ meeting although it was held around the times described above when the Primary School and health visitor were told that the case was not open to CSWS.    7.2.13 LAU have now changed their procedure and brought this meeting forward to 26 weeks to ensure interventions are made in a more timely way.  Further work is underway in LAU to improve the involvement of key professionals in these meetings and to consider how risk and vulnerability are assessed.  Communication between LAU and maternity services at LTHT has also been improved to ensure that relevant information from this meeting is shared with staff on the delivery suite at hospital.    Discharge home for Child Y  7.2.14 Although there was no Initial Child Protection Conference, the concerns expressed by the midwife, and subsequently by the health visitor whilst MY was Child Y Overview Report  27 January 2015  31  pregnant with Child Y led to a multi-agency response that resulted in an improvement to the condition of the house.  This improvement was such that agencies felt comfortable with Child Y being discharged home after birth.    Closure of case by CSWS  7.2.15 As with some of the earlier interventions it appears that there was a lack of planning and joined up working in CSWS’s decision to end their involvement with the family in January 2012.  In November 2011, CSWS recorded that they would remain involved until four weeks after the baby was born.  Any CSWS involvement should be based on a process of assessment, planning, intervention and review and therefore it is not practical, at the outset, to determine the length of intervention as this will need to be dependent on the outcomes.  Instead of deciding in advance that the case would be kept open until four weeks after the baby was born, CSWS should have set a date to review their involvement.  7.2.16 The history of this case should have led to concern that the family were unlikely to sustain the improvements in their home conditions without continued intervention.  The fact that they had a new baby in an already overcrowded household should have made agencies even more wary that improvements would not be maintained. Working Together to Safeguard Children 2013 states that: “The plan should be reviewed regularly to analyse whether sufficient progress has been made to meet the child’s needs and on the level of risk faced by the child. This will be important for neglect cases where parents and carers can make small improvements. The test should be whether any improvements in adult behaviour are sufficient and sustained.” (pages 22-23, paragraph 52)  7.2.17 In the event CSWS closed the case in January 2012, but the last time anyone from CSWS had seen Child Y was seven weeks earlier and the last contact with the family had been on over three weeks earlier when the social work assistant spoke to FY through a window after he refused entry to the house (see paragraph 6.3.45). It is difficult to imagine a situation where it is appropriate to close a case when access to the house and the children has been refused at the last visit.  Instead the refusal to allow access should have been viewed as an additional concern.  The decision to close the case indicates that CSWS may have used the rule of optimism, believing that real change had been made despite the behaviour of FY, the family history and there being no evidence that the improvement would be sustained.  7.2.18 ‘Doing the Simple Things Better’ describes the ‘de-escalation’ process that should be followed when a case needs decrease in complexity or severity and a family requires a different level of response.  The following principles should be followed:  “There should always be an interim arrangement, with a mutually agreed handover date, whereby the current Lead Professional or key worker re-assigns lead responsibility to the new key worker but continues to be available to provide information, advice and guidance about the case  “Any relevant information gathered before the escalation or de-escalation of need should be made available to the services who will henceforth be providing support; practitioners should build on existing assessments where possible, rather than carrying out new assessments Child Y Overview Report  27 January 2015  32   “A written care plan should support the re-assignment of lead responsibility, to ensure that the agreements made are recorded” (Doing the Simple Things Better, p10)  7.2.19 When CSWS closed this case the health visitor became the Lead Professional involved with the family.  However there is no indication that any planning took place of the nature described above, although the de-escalation process has been in place since 2010.  The Health Visiting Service had determined that Child Y should receive a service in line with the Universal Plus category of the Healthy Child Programme.  This requires the health visitor to visit “as appropriate”.  In this case, health visitor 2’s first visit was planned to take place six weeks after health visitor 1’s last visit.  In the absence of a written care plan, there is no indication as to how an appropriate frequency of visits was determined.  School concerns January & February 2012  7.2.20 During the second half of January and early part of February 2012 both the Primary School and High School 1 expressed concerns about the welfare of Child Y to the social worker and health visitor both of whom appear to have been of the opinion that the other should address the concerns (see paragraphs 6.3.46 – 7.3.50 and 7.3.53).  The case was closed to CSWS at this time and the health visitor was the lead professional.    7.2.21 It is unclear from the Education Services record whether the Primary School’s concern in January 2012 was about the impact on one of the children of being kept awake or the welfare of Child Y but the LCH record suggests that the school’s concern was for the welfare of Child Y.  Given that the school’s concern was based on a report from a child that the baby cried a lot and the fact that the health visitor had visited the family and seen Child Y the previous day, the health visitor’s response, of having no concerns, appears reasonable.  However, the Lead Reviewer considers that it would have been appropriate for the health visitor to have suggested that the school phone again if they continued to have concerns, rather than suggesting that future contact should be with CSWS.    7.2.22 The concern raised by High School 1 in February 2012 amounted to a concern about neglect as Child Y and the parents were reported to be very dirty (see paragraph 7.3.53).  The records from that time show that the social worker considered that the High School’s concerns should be addressed by the Health Visiting Service whilst the health visitor considered that they should be addressed by CSWS.  That difference of opinion has been repeated in this SCR with CSWS considering that the social worker’s request that the school phone the health visitor was “proportionate and in line with policy” because the health visitor was lead professional and LCH explaining that the health visitor considered it to be CSWS’s duty to investigate the School’s concerns about possible neglect.  This difference of opinion illustrates the complicated nature of work with children and families and demonstrates the need for decisions to be made on a case by case basis following a conversation about the individual characteristics and history of the specific case.  7.2.23 In this case the social worker and health visitor did have a conversation about the case but their records suggest that there was a misunderstanding between them about what action was going to be taken following the conversation. The social Child Y Overview Report  27 January 2015  33  worker appears to have incorrectly believed that the health visitor intended to visit the family whilst the health visitor in fact went through with the earlier plan to transfer the family to a different health visiting team with a request for an early visit.  It is important for professionals to be clear with one another about exactly what action is going to be taken following such a conversation.  Furthermore if agreement cannot be reached, practitioners should escalate their concerns to their manager.  7.2.24 An additional factor was that the school contacted a specific social worker who had been involved with the family but had closed the case some weeks before.  A request for service in respect of a closed case would need to be made through the Duty and Advice Service rather than being made to an individual social worker.  7.2.25 The situation with the Health Visiting Service was also complicated as the case was being transferred from one team to another due to a service reconfiguration.  The health visitor who had been involved up to that point had carried out what was planned to be the final visit in January 2012.  Health visitor 1 then delayed transferring the case whilst trying to chase up Child Y’s registration with the GP.  When the school contacted health visitor 1 with their concerns in February 2012 the case was about to be transferred.  7.2.26 A number of different actions could have been taken at this stage; the school or health visitor could have contacted the Duty and Advice Service and made a referral regarding their concerns.  Alternatively the health visitor could have carried out an opportunistic visit to the family before transferring the case or the new health visitor could have done so as soon as it was allocated.  The school could also have sought advice from the education safeguarding advisors, something which they did do November 2012.  However, although these actions were available, it is not possible to know whether any of them would have resulted in a different outcome for Child Y.  Summary  7.2.27 Key messages from a recent study of Neglect and Serious Case Reviews included the following:  “neglect can be life threatening and needs to be treated with as much urgency as other categories of maltreatment  “neglect with the most serious outcomes is not confined to the youngest children, and occurs across all ages  “the possibility that in a very small minority of cases neglect will be fatal, or cause grave harm, should be part of a practitioner's mindset. Practitioners, managers, policy makers and decision makers should be discouraged from minimising or downgrading the harm that can come from neglect and discouraged from allowing neglect cases to drift  “the key aim for the practitioner working with neglect is to ensure a healthy living environment and healthy relationships for children.”  (Brandon et al, Neglect and Serious Case Reviews, University of East Anglia/NSPCC, March 2013)  7.2.28 The indication in this case is that the neglect was never considered to be particularly serious or potentially life threatening and it is important to note that, at Child Y Overview Report  27 January 2015  34  the time of writing, there has been no finding as to the cause of death of Child Y, as the inquest has not been held.  However, considering the whole period covered by this review, there is a picture of chronic, ongoing neglect.  Improvements were made in the short term when agencies made a concerted effort to work together with the family but these improvements were not sustained when agencies, particularly CSWS reduced their involvement.  This is not untypical of neglect cases, and is highlighted in Working Together to Safeguard Children 2013 (page 24, paragraph 59) where it is also stated that “professionals should be wary of being too optimistic”.  Also in common with many cases of neglect, until the death of Child Y, there was no single serious incident that warranted child protection enquiries.  Instead there were ongoing concerns at a lower level.    7.2.29 Child Y’s imminent arrival provided a catalyst for a more robust response which focused almost entirely on the condition of the property rather than the care of the children.  However within weeks of Child Y’s birth, work with the family had almost ended; CSWS ended their involvement and there was no clear plan as to what support and monitoring other agencies were going to provide.  The Health Visiting Service had determined that the family would receive the Universal Plus service but a minimum visiting frequency had not been determined.   At the time of Child Y’s death at three months of age, no one from any agency had been inside the house for six weeks and the property was found to be in a very poor state again; cluttered with no food, washing materials or bedding and Child Y’s Moses basket unusable.     7.2.30 In January 2012, Action For Children in partnership with the University of Stirling carried out a review of Child Neglect in the UK.  This found that teachers, health workers and nursery staff were increasingly aware of child neglect but unsure what to do.  They also found that 42% of social workers questioned felt that the point at which they could intervene in cases of child neglect was too high.  Many social workers also said that there was a lack of support services or resources to refer families to.  A follow up report in 2013 found that nine out of ten teachers, social workers and police officers were regularly coming into contact with children they suspect are suffering from neglect but as many as 40% feel powerless to intervene.  These findings reflect some of the features of this case with agencies being aware of the neglect but feeling unable to take action that would significantly improve the situation.  7.3 ToR 3.   To what degree did agencies engage directly with the children to hear their account of home life prior to and following Child Y’s birth?  7.3.1 Many of the concerns about the children were raised by the schools, which did have an opportunity to engage with them directly.  The Primary School report that one of the children did share information about home life and sometimes presented as quite unhappy to the extent that at seven years of age, the child had expressed a wish to die.  By contrast the schools found that the other siblings were reluctant to engage in talking about home life.  One child spent very little time in school so there were limited opportunities for schools to engage with the child.  Child Y Overview Report  27 January 2015  35  7.3.2 CSWS reports that the children’s views were gathered during regular home visits across the period covered by this report and records are full and thorough in this respect on most occasions.  These records include references to the children being seen alone at school but they were not recorded as being seen alone in the home which would be the usual expected practice.  7.3.3 CSWS staff considered the children to be contented and they are often described as “chatty”, “playing” and “settled” with good relationships between them and their parents, who are described as loving.  However CSWS acknowledged in the SCR that FY was a dominant and difficult personality and this may have impacted on what the children said.  The Lead Reviewer believes there to be evidence that relationships were not as good as CSWS believed but, even if they were good, this is insufficient if the quality of physical care is likely to lead to significant harm.  It is important that professionals do not allow apparent warm relationships to blind them to negative features of neglect.    7.3.4 The author of the CSWS IMR considers that it would have been pertinent for CSWS to give more weight to the information being shared by school. In reality there is no indication that CSWS ever explored the school’s concerns about how the child referred to in paragraph 7.3.1 presented.  7.3.5 There were a small number of occasions when health practitioners had an opportunity to engage with individual children.  Prominent among these was when a child was taken to hospital on 1 April 2010 with blood in their stools, having reportedly eaten hard plastic and crayons and it appears that the matter was dealt with purely as a physical health issue with no questioning as to why the child had done this.  There was no follow up from the GP and CSWS were not informed of the incident.  This SCR has not established why hospital staff appear not to have been curious or concerned about the child’s behaviour.  7.3.6 Similarly one of the other children was taken to hospital twice in 2012 having injured their own hand by punching a wall at school reportedly due to being angry with a teacher.  On both occasions the child was discharged with no follow up and no investigation as to the underlying causes of the behaviour.  The guideline for the management of repeated attendance at the Emergency Department by Children and Young People makes specific reference to the response required when a young person attends ED following an incident of self-harm.  Further enquiries suggest that the injuries sustained by the child were very minor; amounting to nothing more than grazing of the hands and it seems probable that the incidents were considered to be an immediate response by the child to a frustrating situation rather than a deliberate attempt at self harm.  The Lead Reviewer accepts that these were not clear incidents of self harm but is of the view that staff at ED should have explored the reasons for the behaviour with the child in order to consider whether referral to another agency would have been appropriate.  7.3.7 The GP review identified that the surgery had a chance to proactively engage with the family when the children had their vitamin D levels checked.  It concludes that the GPs and other staff should have exercised a respectful disbelief, activity curiosity and a more assertive approach in their engagement with the family.    Child Y Overview Report  27 January 2015  36  7.4 ToR 4.   Did the professionals involved with and in contact with the children and their family members exercise respectful disbelief, active curiosity and build constructive and assertive relationships with the family and if not, why not?  7.4.1 As explained in the analysis of ToR 3, CSWS staff appear to have disregarded the Primary School’s concerns about one of the children, instead concluding that the children were all happy at home.  Records show that CSWS staff mainly dealt with FY who was sometimes “eloquent, convincing and rational” and at other times was “abusive and obstructive”.  However, although staff found FY’s behaviour to be unpredictable and difficult there is little evidence of them considering the children’s experience of living with him  7.4.2 Statements contained within the Core Assessment suggest that CSWS’s focus was on working in co-operation with the parents and avoiding, at almost any cost, the risk of using child protection procedures or commencing legal proceedings.  The Lead Reviewer believes that this approach prevented staff from developing appropriate assertive relationships with FY and allowed him to dictate the agenda.  Based on the information within the core assessment, it appears that the reason for this approach was the aforementioned view that there was love and emotional warmth within the family.    7.4.3 Staff from most of the agencies involved in this SCR had concerns about the condition of the family home at some time during their involvement and much of the interventions focused on trying to improve this.  By contrast there appears to have been no assessment of parental motivation to maintain better standards or the apparent contradiction between the perceived emotional warmth and the inadequate living conditions.  7.4.4 The agency report provided by LYPFT considered that there was a possibility that the addictions work was too task focussed and the holistic picture not taken into account but found it difficult for good practice to be identified in some areas due to a lack of robust record keeping.  7.4.5 Also, as explained in the analysis of ToR3, on some occasions medical problems were considered as purely medical without consideration of the triggers or emotional impact of the issue.  Where medical problems are considered in this way practitioners are less likely to liaise with other agencies to gain a wider understanding of the child’s situation.  It is not known why hospital staff were not more curious as to why the children had behaved in these ways.  7.4.6 In many cases where neglect is a feature, there is no single incident that requires an immediate response from agencies but a series of smaller incidents which, on their own can seem innocuous but taken together cause concern.  In this case there was a perception at the Learning Events that the children had attended the Emergency Department at the hospital on a large number of occasions and it was questioned whether staff on the Emergency Department should have recognised this and been curious about it.  The Lead Reviewer has established that over the period of 3½ years that this review covers, Child Y’s five older siblings attended the Emergency Department (ED) in respect of a total of 10 Child Y Overview Report  27 January 2015  37  injuries, including two which were sports related.  One of the children sustained five of these, including both the sports related injuries.    7.4.7 On 1 November 2011, part way through the period covered by this review, LTHT introduced a guideline for the management of repeated attendance at the Emergency Department by Children and Young People.  This guideline defines regular attendance as “attending more than three times at the Emergency Department within a period of six months” although it points out that discretion needs to be exercised with regard to children attending for appropriate management of long term medical/psychological conditions.  Three attendances at the Emergency Department by the child who sustained five injuries were between January and June 2011.  Therefore, if this policy had been in place at that time the child would have just met the criteria of being a frequent attendee on this occasion.  7.4.8 Overall, the Lead Reviewer concludes that the children’s attendance was not sufficiently frequent that it should have been recognised by Emergency Department staff.  Nevertheless, in considering this issue it became clear that there are barriers to Emergency Department staff identifying families where there are repeated and frequent attendances and these will be addressed in the analysis of ToR12.   7.5 ToR 5.  What opportunities were there for agencies to intervene more robustly and provide assertive family support with clear plans and clear reviews of those plans and which set out the nature of the concerns the plans were designed to address?  7.5.1 The introduction of Family Support following the referral to CSWS in April 2010 was an appropriate response.  However, as has been explained in the analysis of ToR1, the introduction of Family Support was not handled appropriately and it is impossible to know what input the family resource worker had.  In addition, there were no clear plans and no Child in Need meeting until nearly five months later.  Therefore it is unknown what impact the Family Support had.  7.5.2 In the following months there were several opportunities for CSWS to intervene more robustly but instead the case was allowed to drift, with CSWS seeming to vacillate between planning more intensive support and considering closing the case. In October 2010 there was a decision to carry out a Core Assessment, which could have led to a more robust response with a clear plan but this was not carried out (see ToR1).   In July 2011 the social worker advocated more intensive support but a decision was then taken to close the case because FY withdrew his co-operation (see ToR 2).  In October 2011 professionals involved with the family considered that there should be an Initial Child Protection Conference but the Service Delivery Manager considered that this would be counterproductive and in January and February 2012 the schools expressed further concerns (see ToR2).  7.5.3 One child missed a considerable amount of schooling and, for two periods, was home educated by FY until assessments deemed that this was not of sufficient standard.  The Education IMR found substantial problems with the manner in which High School 2 dealt with this child’s non attendance and a recommendation has been made to address this.  The Education IMR also points Child Y Overview Report  27 January 2015  38  out that where vulnerable children and young people are being home educated, they do not benefit from the protective factors associated with school attendance.  The author of the Education report explains that from January 2014, the Integrated Safeguarding Unit has established a ‘risk management’ panel to consider complex cases in relation to electively home educated pupils and other vulnerable groups such as children identified as missing education.        7.5.4 During the period covered by this review, CSWS records report one attempt to engage with the Special Therapeutic Social Work Team.  This was in August 2012 and appears to be in relation to the behaviour of the child who had twice punched a wall. Therapeutic services expect consent and co-operation from parents and it appears that this was not forthcoming, consequently no service was provided.  Efforts to secure support should have been made much earlier in relation to the concerns about the behaviour of the child who ate hard plastic but this was not addressed.  A lack of co-operation from the parents should have been a consideration in the care planning and may have led to an Initial Child Protection Conference which would have the rigour of a child protection plan or action under public law outline.  This therefore is another occasion when the parents’ resistance to support resulted in services ‘backing off’ when a more robust response would have been appropriate.  7.5.5 ToR 8 of this report analyses how issues of non-engagement were addressed.  Many of these provided opportunities for agencies to intervene more robustly.    7.6 ToR 6.  When was consideration given to the potential need for a pre-birth Initial Child Protection Conference and to the impact on the family of another child?  7.6.1 There was one occasion when consideration was given to holding a pre-birth Initial Child Protection Conference whilst MY was pregnant with Child Y.  This was in October 2011 and is addressed in the analysis of ToR2.  The analysis of ToR2 also details the consideration given to the impact on the family of another child.   7.6.2 Within days of Child Y’s death an Initial Child Protection Conference was arranged in respect of the other children.  This is addressed in the analysis of ToR 10.  7.6.3 When FY was found to be pregnant with Sib6Y a pre birth Initial Child Protection Conference was held which resulted in all the children being made subject to Child Protection Plans.  This is also addressed in the analysis of ToR 10.  7.7 ToR 7.   How did agencies deal with disagreements between one another and what was the impact of this on the service provided to the children?   7.7.1 Agencies involved with the family were unhappy with the decision of CSWS to end their involvement in July 2011 but did not challenge the decision or voice their dissatisfaction formally.   In 2011 there was no protocol regarding disagreements between agencies and it is believed that the professionals involved were unaware how to challenge the decision to close the case.  Since Child Y Overview Report  27 January 2015  39  then a ‘conflict resolution process’ has been introduced regarding disagreements between agencies with provision for issues to be escalated where staff cannot agree.  This protocol is included within ‘Doing the Simple Things Better’ a handbook issued by Children Leeds in May 2012 to support joint working for people working with children.   Some participants at the learning Events suggested that this protocol is not well known about by staff.    7.7.2 Staff from LAU were unhappy about the response from CSWS in September 2011 and the addiction nurse escalated concerns within LYPFT.  This was an appropriate response which resulted in action from CSWS.  7.7.3 The decision taken by CSWS not to hold a pre birth Initial Child Protection Conference in October 2011 was counter to the views expressed by agencies present at the meeting on 5 October 2011.  However this review has not been provided with any information to suggest that agencies formally challenged the decision.  7.7.4 At the beginning of February 2012 the social worker and health visitor had a difference of opinion as to who should respond to the High School’s concerns regarding Child Y.  They had a phone conversation on 3 February 2012 to try to resolve the issue but records suggest that the call ended with them having a misunderstanding as to what was going to happen next.  This is addressed in the analysis of ToR2.  7.7.5 In October 2012, at a child in need meeting, CSWS stated that they were going to close the case.  The learning mentor from the Primary School  requested that the case be kept open until after the inquest as the school still had concerns regarding hygiene, dirty and unsuitable clothing and MY and FY not providing sufficient food for the children.  The learning mentor was advised to re-refer, if there were any further concerns and the learning mentor’s opinion was recorded in the minutes of the meeting at their request.  The author of the Education IMR considers that this decision should have been challenged more robustly by the learning mentor.  7.7.6 In November 2012 High School 1 and the School Nursing Service both raised concerns with CSWS that the family situation was deteriorating.  Initially CSWS were unwilling to become involved with the family again and the school and School Nursing Service both sought guidance within their own organisations which resulted in CSWS being formally challenged over the decision not to re-open the case.  Subsequently CSWS did re-open the case and a Child in Need meeting was held on 14 December 2012.  It is considered that both the school and the School Nursing Service acted appropriately in seeking advice and challenging CSWS at this time.  7.7.7 Whilst the SCR was being carried out a view was expressed by several Panel Members that the disagreements that arose in respect of this case were largely the result of CSWS applying a higher threshold to their intervention than is applied by other agencies. Particular incidents which reinforced this view were when CSWS decided to close the case after the July 2011 Child in Need meeting, the decision not to hold an Initial Child Protection Conference in October 2011 and the response to the concerns raised by the schools in January and February 2012. Child Y Overview Report  27 January 2015  40   7.7.8 SCR panel members considered there to be a need for clear thresholds to allow organisations to challenge one another with confidence.  Panel members noted that at present Leeds does not use an explicit threshold document to determine eligibility for service and it was explained that Leeds Safeguarding Children Board is committed to pursuing a non-thresholds model where decisions result from conversations between professionals based on assessments of the individual needs of the children concerned.  Concern was expressed that this non-thresholds model may make it more difficult for practitioners to identify and refer cases where children are at risk of significant harm, especially where the concerns are around neglect.  7.7.9 Despite the perception that CSWS applied a higher threshold to intervention in this case, there is no evidence of any agencies referring to thresholds whilst they were working with the family.  The Lead Reviewer is of the opinion that the disagreements between CSWS and other agencies were not principally the result of CSWS applying a higher threshold for intervention but were driven by a lack of appreciation of the long term impact of the neglect in this family and a belief that better outcomes would be achieved by maintaining the cooperation of the parents.  Nevertheless, the introduction of a non-thresholds approach is clearly a source of anxiety for some agencies and will be explored in the final section of this analysis.  7.8 ToR 8.   How were issues of non-engagement, including the parents’ failure to register Child Y with a GP, addressed and what was the impact of this on the service provided to the children?  7.8.1 During the early part of 2010 the Primary School suggested to FY and MY, on four occasions, that it would be beneficial to undertake a CAF.  However FY and MY would not agree to this and they also refused to consent to a referral to the educational psychologist in respect of one of the children.  They also refused to take this child to the GP.    7.8.2 Without parental consent school staff were unable to carry out a CAF or to refer to the educational psychologist and therefore they were limited in the action they could take to address their concerns.  Nevertheless any agency could have made a referral to CSWS before April 2010 if they had considered their concerns as to the welfare of the children to be sufficiently serious.  Education records show that the Primary School thought that Housing Services had made a referral to CSWS in January 2010 and that CSWS had declined to get involved.  Records from Housing Services do not support this version of events and it therefore appears that there was a misunderstanding between the Primary School and Housing Services.  However, the Primary School’s belief that a referral had been made to CSWS, may well have acted as a disincentive to make a referral themselves.    7.8.3 Schools cannot ask school nurses to see children without the parents’ consent.  However, the school could have consulted more with the school nurse about their concerns.  A finding in many SCRs is that professionals have not shared important information with colleagues from other agencies.  Caution is required when sharing sensitive, personal information, particularly if consent has not been given.  Nevertheless, where there are concerns about the welfare of children it is Child Y Overview Report  27 January 2015  41  reasonable for professionals to share concerns in a proportionate manner, in accordance with national guidance.  The aforementioned handbook, ‘Doing the Simple Things Better’ includes the seven golden rules for information sharing taken from Department for Education Guidance ‘Information Sharing: Guidance for Practitioners and Managers’.  The SCR was informed that the LSCB and Human Resources within Education Services now offer training on working with hard to engage parents and recognising and addressing disguised compliance.  7.8.4 The analysis of ToR 1 includes an explanation of why the family resource worker stopped working with the family in February 2011.  At the Child in Need meeting in May 2011 it was stated that the family resource worker initially visited the house seven days a week to support the family and help put some boundaries in place but was now on a leave of absence and both parents did not wish for another worker to take over.  Due to the lack of records it is impossible to know how CSWS responded to FY and MY’s refusal to accept a different family resource worker or what difference this made to the children.   7.8.5 It is also explained in the analysis of ToR 1 that the decision made by CSWS to end their involvement with the family was the result of FY withdrawing his co-operation to work under a Child in Need Plan during the Child in Need meeting in July 2013.  This decision ran counter to the expressed view of the social worker, at that meeting, that more intensive support was required.  It is difficult to understand why the CSWS team manager made the decision to act in line with FY’s wishes although it is reported that, at that time, there was a culture, within CSWS, of closing cases due to parental non-engagement.    7.8.6 In September 2011, FY reportedly became verbally abusive and said that staff from LAU were no longer welcome in his house (see paragraph 6.3.35).  As a result of this MY missed antenatal appointments and she also failed to attend the 32 week meeting at LAU, although it is not known whether she would have attended if the incident with FY had not occurred.  Ultimately the LAU midwife handed care over to the LTHT community midwife prior to Child Y being born as a direct result of FY and MY ceasing to engage.  This therefore is an occasion when FY determined what services another family member received.    7.8.7 In December 2011 FY refused to allow the social work assistant into the house (see paragraph 6.3.45).  CSWS’s response to this was to end their involvement with the family, so again there was no challenge to FY’s lack of engagement and no assessment of the welfare of the children.   7.8.8 Twice in the space of three days no-one answered the door when the health visitor tried to carry out planned visits to the family home (see paragraph 6.3.54).  The second of these dates was the day before Child Y died.  It is impossible to know what action would have been taken if either of these visits had gone ahead but, given the situation that faced the SUDIC team on the day of Child Y’s death, it seems almost certain that the health visitor would have found a house that was once again in a poor condition.  7.8.9 In 1993 Reder et al coined the term ‘disguised compliance’, which they used to refer to situations where a parent or carer appears to co-operate with agencies in order to reduce the professional concerns so that professional intervention is reduced or ended.  In this case the parents demonstrated disguised compliance Child Y Overview Report  27 January 2015  42  by working with agencies to tidy and clean the house prior to the birth of Child Y but allowing it to deteriorate again as soon as agencies withdrew their involvement.      7.8.10 Similarly, the parents stated on three occasions that they were going to register Child Y with a GP the following day when, in reality, they had not even registered Child Y’s birth and therefore Child Y could not be registered with a GP (see paragraphs 6.3.47 and 6.3.51).  The first health visitor showed persistence in chasing up this issue of non-registration but there is no indication that the new health visitor addressed the issue after taking over.  Despite showing persistence the health visitor did not speak directly to any of the GPs within the practice, instead checking with the receptionist whether registration had taken place.  The report provided to this review by NHS England states that the surgery does not assume responsibility for registering a new born baby, considering that it is the responsibility of the health visitor to encourage the parents to register their child.  Nevertheless, the lead Reviewer considers that where the health visitor is having difficulty acquiring the parents’ co-operation contact with the GP would be appropriate to consider what other action could be taken.    7.8.11 Parents have 42 days in which to register the birth and after this time the Registrar on occasion will contact the health visitor.  Child Y was 96 days old at the time of death but the registrar had not made contact with the health visitor.   7.8.12 On three occasions one of the children did not attend appointments at the enuresis clinic.  The child was eight years of age at the time of the first appointment and nine at the times of the others.  At this age the child could not be expected to go to the clinic alone and was dependent on being taken by MY or FY.  Indeed it is the view of the Lead Reviewer that the use of the phrase ‘did not attend’ for children is misleading; ‘was not brought’ would be more accurate.  7.8.13 After the first failure to attend, the clinic wrote to the school nurse, who re-referred.  After the later ones the child was discharged from the clinic and the GP was informed.  In such circumstances a failure to attend could, in itself, be viewed as a sign of neglect but there is no evidence that it was viewed in this way in this case.  In November 2013 LTHT approved a revised version of the ‘Elective Treatment Access Policy’.  This is the Trust’s policy for dealing with missed appointments.  Appendix 4 of this policy provides guidance for the follow up of vulnerable children and vulnerable adults.  This specifies that if a vulnerable child or adult does not attend a clinic appointment, notes must be reviewed, at the time, by the consultant or senior doctor who must consider certain specified factors in order to consider whether there is a safeguarding risk in the non-attendance and then act accordingly.  Appendix 4 further states that a letter detailing the DNA (did not attend) appointment should be sent to the referring GP or Health Professional with a copy to the health visitor or school nurse (if applicable) and that this letter should clearly state what action the GP is expected to take in response.  7.8.14 Brandon et al have identified the risk of ending a service because a child misses appointment writing that: “Missed appointments should be followed up and not considered a reason to withdraw a service. Children and young people who disappear from view may be at risk of severe or life-threatening harm from neglect. To be Child Y Overview Report  27 January 2015  43  safe, children need to be seen and importantly, to be known.” (Neglect and Serious Case Reviews, 2013, p15)  7.9 ToR 9.   How did agencies respond to father’s intimidatory behaviour and what was the impact of this on the service provided to the children?  7.9.1 With the exception of LTHT and Primary Care, all the agencies involved in this SCR had some experience of FY behaving in a way that was perceived as threatening and/or intimidatory.  In the case of Primary Care, although there is no record of him being threatening or intimidating, there is a record of him being difficult to engage and, on one occasion, verbally abusive.  On occasion, agencies asked staff to visit in pairs as a result of concerns about how FY might behave.  7.9.2 Education Services have provided the SCR with evidence of occasions when school staff persevered with action they believed to be in the best interest of the children, despite FY responding in a threatening manner.  One example given is an occasion when FY was “extremely upset and argumentative” in a telephone conversation with the director of safeguarding at High School 1 and said he was going to home educate his children due to alleged victimisation, lack of education and being assaulted. The director of safeguarding contacted FY’s aunt and explained his concerns about the impact that this course of action would have on the children. The outcome was that the children returned to school.  Another example was when the learning mentor at the Primary School phoned home to request a change of clothing for one of the children due to the fact that they smelled and FY reportedly became verbally abusive. Later that same day the learning mentor visited the house and found FY’s attitude to be much improved.  7.9.3 LYPFT consider that the addiction midwife was not intimidated by FY but that his constant presence and hostility did hinder conversation around domestic violence with MY and potentially also with the older children, particularly one who was present at many of the appointments.  7.9.4 LCH found that neither the health visitors nor the school nurses felt personally threatened by FY’s behaviour and, despite his behaviour health visitor 1 made a referral to CSWS and informed FY that this had been done.  7.9.5 CSWS report that their response to FY’s alleged intimidatory behaviour was to persist.  The example given is that the team manager urged FY to discontinue this behaviour for a period up to the impending birth of Child Y and for four weeks beyond.  In addition, CSWS also report that there does not appear to be a sense of intimidation towards social workers that was at an uncomfortable or unmanageable level on most occasions but also that there is little evidence recorded of direct confrontation with FY.  It is evident from parts of the Core Assessment that CSWS took great care to avoid direct confrontation with FY as it was considered that this would have an adverse affect on his willingness to engage which would ultimately be counterproductive.    7.9.6 Although agencies have generally found that staff did not allow FY’s behaviour to adversely affect their actions it is evident that he was the dominant family member who controlled agency interaction with the rest of the family.  Child Y Overview Report  27 January 2015  44  Furthermore, as described in the analysis of ToR 8; his failure to engage reduced agency contact with the family and on some occasions his behaviour directly prevented professionals from seeing the children. In addition, the Lead Reviewer believes it possible that FY’s threatening behaviour at the Child in Need meeting in July 2011 was a factor in the decision of CSWS to end their involvement with the family and as explained in the response to ToR4, the Lead Reviewer considers that CSWS should have been more challenging of FY’s behaviour at a much earlier stage.  7.10 ToR 10.   How have agencies responded differently to the family since Child Y’s death and what has been the impact of this on the children?  7.10.1 Paragraph 6.3.57 of this report describes the action taken by CSWS immediately after Child Y’s death. This was the first time that the family had been dealt with under Child Protection measures and was appropriate in the circumstances.    7.10.2 The decision to postpone the Initial Child Protection Conference was taken based on the Chair’s assessment of the situation at the time and as such it would be inappropriate to second guess whether this was the correct decision. The Lead Reviewer has seen the bridging plan that was agreed in place of holding a Conference.  This consists of 10 actions all with the desired outcome of supporting the children in relation to their emotional health.  The actions comprise a mixture of support to be provided to the family and information that is required for the reconvened conference.  None of the actions require the parents’ cooperation and although this review has been told that the family went to stay with FY’s aunt and uncle this is not mentioned in the ‘Bridging Plan’.  Therefore it appears to have been an informal arrangement with the family free to return home at any time.  7.10.3 Although there was an intention that the Conference should be reconvened this was not done as the children’s presentation improved whilst they were living with their great aunt and uncle and a decision was taken to manage the case via what was described as a robust child in need plan.  7.10.4 Through the second half of 2012, after the family had returned to their own home and were no longer living with FY’s aunt and uncle, a number of concerns were raised, particularly by the schools.  Notwithstanding these concerns, CSWS ended their involvement again. In December 2012, CSWS attended a meeting at High School 1 and, according to education records, it was agreed that an Initial Child Protection Conference would be held in the New Year.  In the event the Conference did not take place until February 2013, after it was found that MY was pregnant.  It is not known whether or not the Conference would have gone ahead if MY had not been found to be pregnant. (see paragraphs 6.3.58 – 6.3.69)   7.10.5 The above history suggests that despite a relatively robust response immediately after Child Y died, CSWS continued to view the family as needing short term support rather than long term intervention.  This is despite indications that nothing had really changed for the children.  However one positive change was the involvement of FY’s aunt and uncle in supporting the family.  FY had reportedly spent significant parts of his childhood living with this aunt and records Child Y Overview Report  27 January 2015  45  suggest that she was a positive influence on the family.  During the time they lived with her the children’s presentation improved during this time and the child whose behaviour and demeanour had caused the primary school most concern, in particular, appeared happier than had previously been the case.   Quality assessment should consider the support available within the extended family and, where appropriate, agencies should work with members of the extended family to support families.  There is no evidence to suggest that this was done prior to Child Y’s death but it was done afterwards.  7.10.6 In November 2012 High School 1 and the School Nursing Service challenged CSWS in a way they had not done when they had concerns prior to the death of Child Y.  7.10.7 Following the completion of the SUDIC process, in November 2012, the GP practice put an alert on the records of FY, MY and all the children, to the effect that CSWS should be informed if practitioners had any concerns regarding Child Neglect.  However, when FY visited the GP in December 2012 the GP missed the alert and did not make CSWS aware of concerns.  The author of the Primary Care IMR believes that this was the result of human error on the part of the GP as opposed to a problem with the system that is in place for alerts.  Consequently there is no recommendation that this system should be changed.  7.10.8 Agencies did not know about MY’s pregnancy with Sib6Y until January 2013 when she was approximately 25 weeks pregnant.  She was again referred to LAU for antenatal care due to her continued drinking and an alcohol reduction programme was commenced.  She was also offered, and accepted, the Care of the Next Infant (CONI) programme, which is a national programme led by health visitors for parents who have lost a child previously.   The GP referred MY’s pregnancy to CSWS which was appropriate in light of the previous history and was consistent with the alert that had been placed on the GP record for MY and the other family members.  An initial Child Protection Conference was held at which all the children were made subject to Child Protection Plans and subsequently arrangements were made for MY and Sib6Y to go to a foster placement for a limited time following Sib6Y’s birth.  The LAU midwife, social worker and health visitor carried out a joint visit to the family home where both parents and three of the older children were seen.  An Interim Care Order was made by the court in respect of Sib6Y following birth, along with Interim Supervision Orders for the other children.  MY and Sib6Y remained in the foster placement until the family were re-housed to a bigger house near to FY’s aunt, at which point they moved back together as a family.  The Family Group Conference held in May 2013 provided a more formalised opportunity to involve FY’s aunt and uncle in working with professional agencies to support the family.  7.10.9 MY’s pregnancy with Sib6Y received a much more robust and co-ordinated response than the pregnancy with Child Y which was, in part at least, a direct consequence of Child Y having died.  Records suggest that MY and FY largely cooperated with this more robust response.  However it is not known whether, having lost a child, they were more willing to co-operate with agencies than they had been previously or if a robust response earlier in CSWS’s involvement would have paid dividends.   Child Y Overview Report  27 January 2015  46  7.11 ToR 11.   How well supervised and supported were the frontline staff in contact with the family and were they given  the opportunity to reflect on what they were seeing and doing as regards the family?  7.11.1 The SCR Panel has been provided with little information about the level of supervision received by front line staff in contact with family although there are several records which refer to the social worker receiving supervision.  7.11.2 Staff from LAU, in September 2011 and the High School and School Nursing, in November 2012 sought safeguarding advice from within their agencies regarding concerns they had about the welfare of the children and the CSWS response to these concerns.    7.12 ToR 12.  Were there any barriers identified that impacted on how staff exercised their professional practice?  7.12.1 The school nurse did not attend any of the four Child in Need meetings that were held prior to Child Y’s birth, including the one in May 2011 when the school nurse, reportedly, did not receive an invitation.  The SCR panel questioned whether the School Nursing Service gave this case a lower priority than Child Protection Cases would be given and if this was the reason for non-attendance.  It was also questioned whether this was a resource issue and whether the agency’s commitment to attend such meetings needed to be reviewed.  It was noted that the School Nursing Service does have difficulty meeting the expectation that it will attend all Child Protection Conferences, Core Group meetings and Child In Need meetings involving school age children and, understandably prioritises Child Protection meetings ahead of Child in Need meetings.  It was also noted that since this time, a citywide, electronic diary has been introduced within the School Nursing Service which assists managers in prioritising the attendance of school nurses at meetings.    7.12.2 The analysis of ToR5 describes the impact on CSWS staff in late 2010 of large caseloads and staff absences.   7.12.3 During the period covered by this SCR the family had contact with four different health care providers; the GP practice, LCH, LTHT and LYPFT.  Within LCH they had involvement with Health Visiting and School Nursing Services and within LTHT with Maternity Services and Paediatric Services.  The level and range of involvement of these various health care providers is outlined in section 7 of this report and their awareness of neglect within the family is addressed in the analysis of ToR1.  7.12.4 The individual agency reports and the integrated chronology suggest that there were significant gaps in information sharing between and within health agencies.  For example, the GPs appeared unaware of the extent of neglect in the family despite the School Nursing Service being aware of this and staff in different parts of LTHT were not fully aware of each other’s involvement.    7.12.5 One practical barrier to information sharing is that different services, even within individual organisations, use different IT systems and these systems are not Child Y Overview Report  27 January 2015  47  compatible with one another.  Other information is still recorded in paper systems which are not always shared.  This appears to have been a particular problem at LTHT.  7.12.6 As stated in the analysis of ToR4, there are barriers to staff in the Emergency Department at LTHT identifying families where there are repeated and frequent attendances.  Historically two hospital sites within the Trust had Emergency Department provision for children and staff on one site would not have been immediately aware if the child had previously attended the other one.  This problem has now been overcome as provision for children is now concentrated onto one hospital site with one IT system.  A remaining issue is that children are treated as individuals and systems do not make links between different children from the same family attending the Emergency Department.  Whilst it is correct to treat children individually the Lead Reviewer is concerned that the Emergency Department may miss an important link if the children from one household had frequent attendances to the Emergency Department but these were spread out between several siblings.  7.13.  Recent Changes in Leeds  7.13.1 In carrying out this review, the SCR Panel have been made aware of the substantial and significant structural changes being introduced in Leeds to support families.  7.13.2 Services for children have been reorganised across 25 local clusters with a Targeted Services Leader in post in each cluster.  The aim behind cluster working is to “ensure that families are offered the right intervention at the right time, as early as possible in the life of a problem, to prevent issues escalating which may result in poor outcomes for the family.” (One minute Guide number 13).  If this arrangement had been in place in early 2010, staff from the Primary School could have discussed this case at a guidance and support meeting in order to help to find a way forward.  7.13.3 Working Together to Safeguard Children 2013, in line with a recommendation from the Munro Review of Child Protection, has removed the distinction between initial and core assessments, replacing this with a set of conditions that should be met by local assessment protocols (Working Together to Safeguard Children 2013, p24, paragraphs 62-63).  7.13.4 CSWS in Leeds have responded to this by introducing the Child and Family Assessment which has been in use since November 2013 for all children’s assessments.  This is an assessment tool also used by several other Local Authorities.  The assessment tool is being introduced alongside Frameworki, a new computerised information management system and CSWS state that this will have the following benefits compared with the initial and core assessments used previously:  A dynamic assessment   One single assessment  Less prescriptive format  Emphasis on direct work  Focus on analysis and action  (One Minute Guide 12)   Child Y Overview Report  27 January 2015  48  7.13.5 CSWS also report that the service is now more responsive, with social workers typically having smaller caseloads and the introduction of Clusters enabling agencies improve the way they work together. Whilst these changes are viewed positively, it is vital that the outcomes are monitored carefully to ensure that they result in improved outcomes for the most vulnerable children in Leeds.     7.13.6 A Duty and Advice team has been established to act as the front door for referrals into Children’s Social Care and to provide advice to professionals and practitioners.  This team is primarily comprised of qualified social workers and an advanced practitioner from CSWS and also has representation from the Police and Community Health.  Therefore, any practitioner who has a concern about a child has an opportunity to speak to a qualified social worker.  7.13.7 The ‘Early Help Approach’ is a framework that is being developed with the aim of helping to ensure that children are provided with the right support at the right time.  Instead of using specific ‘thresholds’ to help practitioners decide whether or not a child or family qualifies for a particular type of support this model encourages ‘conversations’ between practitioners to consider the individual circumstances of a particular family with the aim of reaching a decision as to what help or support is required.  The Deputy Director, safeguarding, Specialist and Targeted describes the advantages of this approach as follows:  “Founded on collaboration and conversation   “Promotes shared responsibility and flexibility  “Recognises complexity of unique needs of each individual child and family  “Reduces bias of individual professional and agency decisions through debate.”  (Beyond Thresholds: A framework for better decision making for vulnerable children in Leeds, p5)  7.13.8 The Deputy Director, safeguarding, Specialist and Targeted also acknowledges that work is required with “all local agencies and professionals” regarding this new approach and a programme of “consultation and engagement events” are planned throughout Spring 2014.   (Beyond Thresholds: A framework for better decision making for vulnerable children in Leeds, p6)  7.13.9 This is an ambitious set of changes and there is a danger that the absence of thresholds may be perceived by some as an attempt to ration scarce services at a time of significant budgetary constraints and that practitioners will feel disempowered when referring to CSWS.  However, it should be noted that, in this case, the availability of thresholds did not prevent a situation whereby agencies disagreed about the level of intervention required and who should provide such intervention.     The proposed consultation and engagement events are key to getting practitioners on board with the changes but the Lead Reviewer suggests that there will also be the need for clear guidance for all agencies and robust systems to enable decisions to be challenged and professionals’ disagreements to be resolved.   7.13.10 Considering these changes in the context of this case, some panel members expressed an anxiety that the potential serious harm, particularly emotional harm, caused by neglect was not always fully recognised or understood by some staff.  This deficit in understanding could undermine the success of the case ’conversations’ which are to be central to the ‘Beyond Thresholds’ framework.  In this SCR it has been established that there was a failure over some years to fully Child Y Overview Report  27 January 2015  49  appreciate the extent of the neglect by the parents, FY and MY, in not properly caring for their children.  The Panel were concerned that the long term emotional harm which could result to the children from such prolonged neglect was not fully understood by the staff involved with the parents.  Panel members spoke of the need for a conference or regular training which addresses not only the indicators of neglect but crucially the long term effects of parental neglect upon children.  8. Views of the Family  8.1 All family members, except for Sib6Y who is a baby, engaged with this process and shared their views of some agencies.  Their comments reinforced the picture of a close family who want to be left to get on with their life together.    8.2 From the information provided FY presented as the dominant adult; he believes that professionals became over involved with the family and exaggerated issues, such as the risk of his wife drinking whilst pregnant and the children arriving at school late.  He said that he previously held positive view of social workers has been destroyed by his family’s involvement with them.  FY appears reluctant to accept agencies becoming involved in his family’s life; even during a period when he acknowledged that the family had difficulty managing the house he is unsure if he would have accepted help if it had been offered.    8.3 MY presented as more amenable to help but said she has always been quiet and appears to have readily accepted her husband’s refusal of help.    8.4 MY and FY provide contrasting information about whether there were concerns about Child Y’s weight in the weeks leading up to the death.  MY stated that she asked the health visitor if she should take Child Y to the doctor because she (MY) was concerned that Child Y was underweight.  This is interesting as the health visitor was actively trying to persuade the family to register the baby with a GP.   8.5 A common theme from the discussions with the children was that they did not think their mother and Sib6Y should have had to go into foster care when they came out of hospital following Sib6Y’s birth.  Instead they believe that the whole family should have been able to live together.  8.6 Various family members acknowledged that their old house was over crowded and in poor condition and that the new property is much better but there was no acknowledgement that the children were being brought up in an unacceptable environment.  8.7 It was acknowledged that some professionals had worked well with the family but one child expressed the view that social workers do not take any notice of what is said unless it is what they want to hear and also that whenever relationships between the family and workers becomes good the workers are replaced.  9. Conclusions  9.1 This SCR was commissioned as a result of the tragic death of Child Y.  The cause of Child Y’s death is unascertained as the inquest has not yet taken place and it has not yet been established whether neglect was a factor.  It follows that this review is unable to conclude that different actions from any of the agencies Child Y Overview Report  27 January 2015  50  involved may have led to a different outcome for Child Y.  Nevertheless, this review has produced learning which will result in changes being made to improve practice for the future.  The key learning is summarised below.  9.2 Within the period covered by the review, Primary School staff showed great perseverance in trying to work with the family.  However, in early 2010 they were unsure what action to take in the face of FY’s reluctance to accept help and, with hindsight, should have referred to CSWS sooner than they did in.  The introduction of Cluster working should make it easier for schools, and other agencies in such situations to share concerns, thereby allowing a quicker response.  9.3 Following the referral from the school, CSWS became involved but there was an absence of an appropriate assessment or a clear plan with the result that the situation was allowed to drift.  Involvement focussed on the outward, physical signs of neglect without addressing the underlying causes, questioning the parents’ motivation and/or ability to care adequately for their children or considering the psychological well being of the children.  The referral was treated in isolation rather than in the context of there being a long history of concerns relating to neglect within the family.    9.4 Assessments were not carried out in a timely manner and there were no clear, consistent plans to support the family, with clear statements of what improvements needed to be achieved.  Until February 2011, the main input to address the neglect was family support via a family resource worker but this was not properly set up or managed and it is not possible to know what support was provided or what impact this had.  After this support ended, CSWS vacillated between wanting to provide additional support and planning to cease their involvement.    9.5 When MY became pregnant with Child Y there was insufficient consideration of the potential impact of another child on the family.  Antenatal services from LAU and CSWS should have engaged with one another much sooner once it was known that MY was pregnant with Child Y and there should have been better representation at Child in Need meetings.  Four Child in Need meetings were held between September 2010 and July 2011 but the school nurse did not attend any of these.  Midwifery staff should have been invited after it was known that MY was pregnant but this was not done.  9.6 For a period of almost two years immediately prior to Child Y’s death, work was attempted with this family to address the unsuitable home conditions and the neglect that the children were experiencing.  When agencies intervened the family made improvements to the home conditions but these were not sustained when intervention was stepped down.  Agencies should have been particularly alert to the risk that the family would not sustain the improvements in the condition of the property following the birth of Child Y.    9.7 FY is the dominant person within the family; he was often unwilling to accept help and support and at times was intimidating and threatening to professional staff providing services to the family.  As a result, insufficient attention was paid to the views of the children and MY, and services were withdrawn on FY’s request.  The Lead Reviewer and SCR panel are of the view that FY was not challenged Child Y Overview Report  27 January 2015  51  sufficiently robustly and that in July 2011, CSWS should have considered initiating an Initial Child Protection Conference when FY was not prepared to work with them.  In addition, the Lead Reviewer and SCR panel are of the view that there were grounds for an Initial Child Protection Conference in October 2012.  9.8 At times agencies disagreed with one another about the level of intervention required and there was a view amongst some agencies, most notably the schools, that CSWS had a higher threshold for intervention than they themselves had.  The Lead Reviewer is of the opinion that the disagreements between CSWS and other agencies were not principally the result of CSWS applying a higher threshold for intervention but were driven by a lack of appreciation of the long term impact of the neglect in this family and a belief that better outcomes would be achieved by maintaining the cooperation of the parents.  With neglect, unlike some other forms of abuse, there is usually no single incident that requires a response.  The findings of this review suggest that professionals in Leeds working with children need training which addresses not only the indicators of neglect but crucially the long term effects, particularly the emotional harm, of sustained parental neglect upon their children.  9.9 On some of the occasions when front line staff disagreed with one another about the level of intervention required by the family they escalated their concerns to their managers.  However, this was not consistently done and a view was expressed in the Learning Events that the ‘conflict resolution process’ was not well known about or understood by staff in some agencies.   9.10 There were occasions when GPs and practitioners at the hospital saw one of the children and should have questioned the underlying issues behind the presenting medical problem.   It is important that medical practitioners listen to the voice of children and share concerns with other agencies.  9.11 There were also occasions when the parents did not take children for hospital appointments.  LTHT have recently reviewed the ‘Elective Treatment Access Policy’ which details the actions that should be taken when a person does not attend a hospital appointment.  The Lead Reviewer and SCR Panel believe that there is a need to recognise that, generally, children do not decide not to attend appointments.  Instead they are not taken to appointments by their carers.  In some cases this is, in itself, neglect and should be viewed as such by health professionals.  9.12 The response when MY was pregnant with Sib6Y was considerably more robust than during the pregnancy with Child Y.  An Initial Child Protection Conference was held and legal proceedings were instigated.  Although the children were understandably upset at being separated from their mother for a few months it is the view of the Lead Reviewer and SCR Panel that agencies finally put the needs of the children first and acted appropriately.  It is vital that the agencies continue to provide a robust response to ensure that the needs of the children are met in the long term.  The Family Group Conference has provided a formal opportunity to involve FY’s aunt and uncle in supporting the family.  9.13 Throughout the period covered by this SCR, one child’s attendance at school was poor.  For part of the period covered by this SCR, the child was being home Child Y Overview Report  27 January 2015  52  educated.  The review has found concerns when vulnerable children and young people are home educated as they are unable to benefit from the protective factors associated with school attendance.  At other times, this child was on the role of High School 2 but attendance was very poor, often less than 20%.  This was not well managed by the school.  9.14 Substantial changes are being made to the delivery of services to children and families in Leeds.  This includes the development of locality cluster working, a multi-agency Children’s Services Duty and Advice Service, and an ‘Early Help Approach’ (the right service at the right time) which promotes multi-agency conversations to determine the best way to intervene in the lives of vulnerable children and young people rather than a reliance on a more traditional ‘thresholds for intervention’ framework.  These changes provide opportunities for professionals to provide a more responsive and timely service.  However, it is a new way of working and will need to be introduced carefully with a comprehensive package of training and guidance to ensure that staff in all affected agencies understand the changes.  10. Recommendations  10.1 Individual agency reports have identified changes that need to be made within their organisations and 27 separate recommendations have been made to address these.  The Panel endorsed these recommendations, which have been progressed by the relevant agencies..  The SCR Panel and Lead Reviewer make the additional recommendations below:  1. The Chair of the LSCB should ensure that the conflict resolution process (also known as ‘dispute resolution process’ and ‘concerns resolution process’) is updated, published on the LSCB website and widely disseminated to staff in agencies working with Children and Families in Leeds.  This process should be completed within six months of this Overview Report being approved by the LSCB. The Outcome sought is that children and young people receive early help to promote their wellbeing and safety  2. The Chair of the LSCB should ensure that a system is developed to monitor(i) the frequency with which the dispute resolution process is being used and (ii)the outcomes of the process.   This system should be developed within six months of this Overview Report being approved by the LSCB. The Outcome sought is that children and young people receive early help to promote their wellbeing and safety  3. The Chair of the LSCB should ensure that a dissemination programme and comprehensive package of training and guidance is provided to ensure that staff in all affected agencies understand the changes being made to the delivery of services to children and families in Leeds.  This should be consistent with the programme outlined on page 6 of ‘Beyond Thresholds’ (9 January 2014), a report from the Deputy Director, Specialist, Safeguarding and Targeted to Leeds Safeguarding Children Board.  This should be achieved within six months of this Overview Report being approved by the LSCB. The Outcome sought is that children and young people receive early help to promote their wellbeing and safety Child Y Overview Report  27 January 2015  53   4. The Chair of the LSCB should ensure that the Learning and Development  sub group develops and implements an initiative to address the training needs of staff in agencies working with Children and Families in Leeds in relation to working with families where chronic neglect is a feature.  This should include guidance as to when the Police should be involved.  This should be achieved within six months of this Overview Report being approved by the LSCB. The Outcome sought is that children and young people do not suffer neglect and receive early help to promote their wellbeing and safety.  5. The Deputy Director, Specialist, Safeguarding and Targeted should assure the Chair of the LSCB, through regular reporting to the LSCB, that the changes in practice reported by CSWS, as detailed in paragraphs 7.13.4 and 7.13.5 of this report are firmly embedded in practice and are leading to improved outcomes for children.  This should be achieved within six months of this Overview Report being approved by the LSCB. The outcome sought is that the needs of children and young people are effectively assessed and met through the provision of appropriate services that lead to the promotion of their safety and wellbeing  6. The Head of Nursing for Children within LTHT should ensure that Appendix 4 of the LTHT Elective Treatment Access Policy is amended to include specific reference to the fact that children do not choose not to attend hospital appointments and where a parent or carer fails to ensure the child’s access to appropriate medical care or treatment this, in itself, can be neglect.  This should be achieved within three months of this Overview Report being approved by the LSCB. The outcome sought is that vulnerable children receive appropriate and necessary medical care that promotes their health and wellbeing  7. The Head of Safeguarding within LTHT should explore whether records relating to different children from the same household can be linked so that Emergency Department staff are aware if there are frequent attendances.  This should be achieved within six months of this Overview Report being approved by the LSCB.The outcome sought is that links are made with all children in a family where a particular child attends a hospital emergency department thus ensuring that all siblings are safeguarded    Child Y Overview Report  27 January 2015  54  Appendix 1 – Abbreviations  CAF  Common Assessment Framework CSWS  Children’s Social Work Service DNA  Did Not Attend EDT  Emergency Duty Team GP  General Practitioner (Doctor) KPE  Key Practice Episode LAU  Leeds Addiction Unit LCH  Leeds Community Healthcare LTHT   Leeds Teaching Hospitals NHS Trust LYPFT Leeds and York Partnership NHS Foundation Trust NHS  National Health Service SCIE  Social Care Institute for Excellence SCR  Serious Case Review ToR  Term of Reference   Child Y Overview Report  27 January 2015  55  Appendix 2 – References  Brandon, M. et al (2013) Neglect and Serious Case Reviews, University of East Anglia/NSPCC  Burgess, C. et al (2013); The State of Child Neglect in the UK, Action for Children & University of Stirling  Children Leeds (May 2012): Doing the Simple Things Better – A handbook supporting joint working  Department for Education (2008): Information Sharing: Guidance For Practitioners and Managers   Faulkner, G. (undated): ‘The Front Door’- Journey to an Outstanding Service. Report to Leeds Safeguarding Children Board  Fish et al (SCIE guide 24); Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence   HM Government (2013): Working Together to Safeguard Children  Leeds Early Start Service (September 2012): Early Start Service Handbook    Leeds Safeguarding Children Board (12 March 2014): Right Conversations, Right People, Right Time, Early help and our approach to responding to the needs of children and families in Leeds 2014 -15  Leeds Safeguarding Children Board (November 2013): One Minutes Guide No. 12, Child and Family Assessment  Leeds Safeguarding Children Board (November 2013): One Minutes Guide No. 13, Cluster Working  Leeds Safeguarding Children Board (November 2013): One Minutes Guide No. 14, Frameworki  Reder, et al (1993): Beyond Blame Child Abuse Tragedies Revisited. London: Routledge  Walker, S. (9 January 2014): Beyond Thresholds: A framework for better decision making for vulnerable children in Leeds. Report to Leeds Safeguarding Children Board  Wigley, L. (November 2013): Elective Treatment Access Policy.  Leeds Teaching Hospitals NHS Trust  