Chronic neglect of a 17-year-old girl, subject to a case review following her admission to intensive care after collapsing at home on 27 November 2013. Megan and her sibling spent periods subject to child protection plans under the categories of physical abuse and neglect and as Children in Need. Family issues included: chronic neglect, domestic violence, housing eviction, poor home conditions and financial problems. Megan had issues with: speech and language delay, poor co-ordination, poor hygiene, obesity, recurring head lice infestations, isolation, low self-confidence, bullying and poor school attendance. Findings include: lack of effective information sharing and analysis, lack of professional understanding of adolescent neglect, lack of professional consideration of Megans lived experience and professional focus on the level of service provided to the family as opposed to the impact services were having. Report uses a hybrid model to review the case, combining information from Individual Management Reviews (IMRs) with frontline practitioner engagement. Poses questions to Thurrock Local Safeguarding Children Board (LSCB) based on review findings. Includes Thurrock LSCBs response to the findings.
      
 Title:  Serious case review: “Megan”: overview report. LSCB: Thurrock Local Safeguarding Children Board  Author:  Tracey Sparkes Date of publication: 2016  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                               Thurrock  Local Safeguarding Children Board      Serious Case Review “Megan”   Published:- 4th February 2016 Author: Tracey Sparkes    2 1.   INTRODUCTION ...................................................................................................................................... 3 2.   REASON FOR THE SERIOUS CASE REVIEW .............................................................................................. 5 3.   SCOPE, TIMESCALE AND TERMS OF REFERENCE .................................................................................... 6 4.   BACKGROUND INFORMATION ............................................................................................................. 11 5.   CASE SUMMARY AND TIMELINE OF SIGNIFICANT EVENTS .................................................................. 15 6.   FINDINGS AND LEARNING .................................................................................................................... 20 7. KEY LEARNING ....................................................................................................................................... 52 8. RESPONSE TO SERIOUS CASE REVIEW FROM THE CHAIR OF THE THURROCK LSCB ............................. 54 Appendix A: Glossary ..................................................................................................................................... 56 Appendix B: Membership of the Megan SCR Panel ...................................................................................... 58 Appendix C: List of agencies involved with Megan during the time period of the SCR ................................ 59       3 1.   INTRODUCTION  1.1  This overview report is the property of the Thurrock Local Safeguarding Children Board (LSCB) as the commissioning Safeguarding Board.  Since June 2010, it is expected that all overview reports provided to LSCBs in England be published, unless there are exceptional circumstances. This overview report provides the detailed account of the key events and the analysis of professional involvement and decision making in relation to Megan and her family.  1.2  The overview report is primarily written with the intention of examining agencies systems and processes involved with the design, oversight or delivery of multi-agency safeguarding services.  It should provide accountability and information to other interested parties.  1.3  The report aims to balance maintaining the confidentiality of the family and other parties who are involved whilst providing sufficient information to support the best possible depth and range of learning required from a Serious Case Review (SCR).  1.4  The purpose of this review is for agencies to recognise, respond to and action the learning highlighted by this SCR. Its purpose is not to try and second-guess the judgments and decisions that various people and organisations made at the time of the events examined by the review. Hindsight can severely distort the clarity of information that was available and underplay the impact of time pressures, and the other influences and dilemmas that confront people dealing with a complex interplay of different factors.  1.5  It is important to note that this review covers a five-year period 2008 - 2013. Since then, Working Together to Safeguard Children (2013i and 2015ii) has led to a new approach to multi-agency working to safeguard children. As such, a number of working practices have changed. Therefore, the learning from Megan’s case is system specific and poses a set of questions for Thurrock Local Safeguarding Children Board about whether the review findings would still be valid in 2015 and, if so, how can the system and practice be further improved.                                                            i Education Department (2013) Working Together to Safeguard Children: a guide to interagency working to safeguard and promote the welfare of children.  London ii HM Government (2015) Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children     4 1.6   Working Together to Safeguard Children (2013) also provided new guidance for undertaking a Serious Case Review which requires that they should be conducted in a way which:  • Recognises the complex circumstances in which professionals work together to safeguard children;  • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  • Is transparent about the way data is collected and analysed; and  • Makes use of relevant research and case evidence to inform the findings.  1.7  LSCBs may now use any learning model, which is consistent with the principles in the guidance, including the systems methodology recommended by Professor Munroiii. The Thurrock LSCB agreed to undertake a review using a hybrid model, which involved an analysis of the case through Individual Management Reviews (IMRs) of the agencies that were involved with Megan between her 13th and 18th birthdays and front-line practitioner engagement. The IMRs were also used to present a combined chronology of events and interventions during those five years and to identify any themes in terms of practice and response. The combined chronology was presented and discussed at a practitioners’ workshop, where staff were able to consider in detail any missed opportunities and explore reasons for if and why it was difficult to work with the family at that time.  1.8 In reading this overview report, it is important to remain clear about the purpose of the overall review and of this overview report in particular. The review examines with the benefit of hindsight and with other analysis, if it is possible to identify whether alternative judgments and decisions could or should have been taken, and whether different outcomes might have been achieved for Megan. This is summarised in sections 5, 6 and 7 of the report. 1.9  The review aimed to be very challenging of all services for the purpose of building on the considerable knowledge and expertise that has developed in relation to the safeguarding of children in the UK.                                                             iii Munro, E. (2011) The Munro review of child protection: final report: A child centred system.  London RSO.   5 2.   REASON FOR THE SERIOUS CASE REVIEW 2.1  On 27th November 2013, Megan was admitted to the intensive care unit at hospital following a collapse at home. Megan was conveyed by ambulance in a state of peri-arrestiv to the resuscitation unit within the Emergency Department. Full cardiac arrest was prevented as she was put on a life support system. 2.2  While in intensive care, it was evident that Megan’s personal hygiene had been neglected as her body was dirty and she had head lice, which required intensive treatment. Megan was diagnosed with severe anaemia.v  2.3  During Megan’s treatment in hospital, her condition deteriorated. At this stage, her condition was described as critical. Megan required artificial ventilation (life support) for twelve days. Medical tests confirmed the further critical complication of a blood clot on her brain. As a result of this, Megan will now be on anti-coagulation therapy for life. 2.4  Regulation 5 of the Local Safeguarding Children Board Regulations 2006vi sets out the requirement for Local Safeguarding Children’s Board to undertake reviews of serious cases where:  (a) Abuse or neglect of a child is known or suspected; and  (b) Either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the Authority, their Board Partners or other relevant persons have worked together to safeguard the child.  2.5   On 12th August 2014, it was agreed that a SCR should be undertaken and the process   began. 2.6  Within this review all names have been anonymised to protect the identity of the family.                                                              iv Peri-arrest is the recognised period, either just before or just after a full cardiac arrest, when the patient's condition is very unstable and care must be taken to prevent progression or regression into a full cardiac arrest. v Megan’s haemoglobin concentration was 2.3 g/dl. The guideline normal values for a non-pregnant female are 11.5 – 16.5 g/dl. vi Regulation 5; CHILDREN AND YOUNG PERSONS, ENGLAND (2006) The Local Safeguarding Children Boards Regulations    6 3.   SCOPE, TIMESCALE AND TERMS OF REFERENCE  3.1   This review was commissioned in September 2014 and completed in November 2015.  3.2  A Megan SCR Panel was established in October 2014. This comprised a team of senior representatives from local statutory agencies who had no direct involvement with the case. A list of the membership of the Panel can be seen in Appendix B. The Panel members shared in the conversations, the analysis of documents, the identification of key practice episodes and contributory factors.   3.3  An Independent Author was commissioned from the database of nationally acknowledged authorsvii. Although the Independent Author has written the report, the SCR Panel has inputted to and shares its analysis and conclusions.  The Chair of the Megan SCR Panel was appointed from the LSCB Full Board and had no direct involvement in the case. 3.4  Although Megan and her family had been known to universal, specialist and third sector services for many years, the SCR Panel agreed that the review period would be from December 2008 to January 2014. This would cover the period from Megan’s 13th birthday until Adult Social Care became involved with the case when Megan was 18. The decision was to focus on Megan’s teenage years, as these were more likely to have impacted on the outcome. 3.5 The scope of the review, in respect of family information, is limited to Megan and her immediate family only. 3.6   The purpose of this Serious Case Review is to: - • Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children and young people. • Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result; and • As a consequence, to improve inter-agency working and better safeguard and promote the welfare of children and young people. 3.7   The Megan SCR Panel agreed the following questions for the focus of the SCR:                                                            vii Tracey Sparkes MSc, BA, HV (Dip), RGN was commissioned from the Association of Independent Chairs list of authors   7   Did all agencies work together to safeguard this young person? “The support and protection of children cannot be achieved by a single agency… Every service has to play its part. All staff must have placed upon them the clear expectation that their primary responsibility is to the child and his or her family.viii” Guidanceix is clear that all professionals have a duty to share information with other agencies when they become aware that a child is at risk of being abused or neglected. Some of the guidance also acknowledges that there are difficult situations where for instance the concern is not about abuse or neglect but about other aspects of the child’s welfare such as health issues, performance at school or where there is a niggling worry about the child who may be at risk.    Was the outcome preventable? The “outcome” in this case is taken as Megan’s collapse and admission to hospital. The SCR questions whether this could have been prevented if agencies had worked differently. The purpose of this and all SCRs is to provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence; to learn lessons to prevent this happening in the future.     Were the Southend, Essex and Thurrock Child Protection (SET) Procedures followed appropriately? These procedures have been in place since 2006 and refreshed in 2011 and 2015. The SET procedures are the guidance used by all local agencies to safeguard children in Essex.                                                               viii Lord Laming (2003); The Victoria Climbié Inquiry ix Royal College of General Practitioners (RCGP), General Medical Council (GMC), Southend Essex and Thurrock (SET) Child Protection Procedures 2006 and 2011, Working Together 2010 and 2013 and Intercollegiate Documents   8  Was the child’s voice heard? This SCR considers whether Megan’s voice was heard during the period of the review. Research from numerous Serious Case Reviews has identified the lack of the voice of the child. To this effect Ofsted in April 2011 undertook a thematic review specifically focusing on the voice of the child - learning from Serious Case Reviews. Their key findings identified five key messages: • The child was not seen frequently enough by professionals involved, or were not asked about their views and feelings • Agencies did not listen to adults who tried to speak on behalf of the child and who had important information to contribute  • Parents and carers prevented professionals from seeing and listening to the child • Practitioners focused too much on the needs of parents, especially on vulnerable parents, and overlooked the implications for the child • Agencies did not interpret their findings well enough to protect the child.   Was professional dangerousness a factor in this case? Professional dangerousness is defined as “the process whereby professionals involved in Child Protection work can behave in a way which either colludes with or increases the dangerousness of the abusing family.” x This SCR considers whether this played a part in this case.  In his research on working with resistant parents, Professor Brian Littlechild has observed that Parental resistance and avoidance can negatively affect the safety and well-being of children in protection work, posing significant risks to workers and children as a result of certain forms of power/control dynamics used by a small number of very challenging families in Child Protection work. The ‘rule of optimism,’ that can affect assessment and decision-making in Child Protection work, was first identified by Dingwall, Ekeelaar and Murray (1983)xi. The key concern here is                                                            x Morrison T, (1990), the emotional effects of child protection on the worker, practice 4(4), p262-4 xi Dingwall R, Eekelaar, J, and Murray, T 1983. The Protection of Children: State Intervention and Family Life. Basil Blackwell: Oxford.   9 that Child Protection professionals may wish to ‘see the best’ in people, and have hope and optimism that their interventions can help the safety and well-being of the child involved. This important set of attitudes can, however, also leave children being abused and neglected because of a lack of focus in agency procedures and national policies on resistance, which can hinder managers and practitioners recognising and responding to the effects of abusive and controlling power/control dynamics from parents, and the consequent risks the child faces (Laming, 2009xii; Marshall, 2011xiii).    Was the consideration of legal (criminal and care) proceedings affected by age? Evidence presented to a House of Commons Education Committee in 2012xiv heard of many concerns that the Child Protection system is not meeting the needs of older children (aged 14-18). This was characterised by a lack of services for adolescents, a failure to look beyond behavioural problems, a lack of recognition of the signs of neglect and abuse in teenagers, and a lack of understanding about the long-term impact on them. It was recommended that the Government urgently review the support offered by the Child Protection system to older children and consult on proposals for re-shaping services to meet the needs of this very vulnerable group.  3.8  In deciding the framework for the questions to be used for this review, the SCR Panel looked at historical Serious Case Reviews from across the country and best practice identified in order to agree the questions that would aim to obtain the best evidence and outcomes for this particular case and circumstances presented. Some minor amendments were made at the Megan SCR Panel meeting on 3rd October 2014. These                                                            xii Lord Laming 2009. The Protection of Children in England: A Progress Report.  The Stationery Office: London. xiii Marshall, J. 2011. Assessing the risk to children despite parental resistance.  In Taylor, B. (ed), Working with Aggression and resistance in Social Work. Learning Matters: Exeter. pp 79-93 xiv House of Commons Education Committee Children first: the child protection system in England  Fourth Report of Session 2012–13      10 questions were then used to form the basis of the IMR requests from agencies and incorporated within the Terms of Reference.  3.9 Agencies that had been involved with Megan during this timescale were asked for an Independent Management Review (IMR) to cover these issues and an action plan to address any improvements that were identified to prevent this happening again. The Thurrock Local Safeguarding Children Board (LSCB) provided an IMR template and the reports were quality assured and approved by the most senior officer of the reviewing agency. The following agencies have provided an IMR, using this approach: • Children’s Social Care • Thurrock Clinical Commissioning Group (CCG) on behalf of Thurrock General Practitioners (GPs) • North East London Foundation Trust • Basildon and Thurrock University Hospitals • The school Megan attended • Essex Police • CORAM 3.10  Other agencies that had not been so involved with Megan but who had had some contact with her were asked to provide a chronology of contacts and/or events. These were submitted by: • Education Welfare Services • CAFCASS  • Connexions • Troubled Families 3.11  The independent author also met with Megan’s college manager to discuss what happened when she was ill at college four days before her collapse. 3.12  All agencies involved with Megan were also asked for a summarised history of Megan and her family since her birth, highlighting key episodes or events. Appendix C shows a list of agencies involved with Megan during this timeframe.  3.13  The SCR Panel agreed that it would be useful to hold a practitioners’ event as part of the process to identify any learning that would not necessarily be captured within the IMRs and to enable front line staff to talk openly with their partnership colleagues around the case. The learning from this event has been captured in this review.    11 3.14  Megan and her mother contributed to the review by meeting with the LSCB Business Manager at the beginning of the SCR process. The independent author met Megan in April 2015 so that she could contribute to the report and returned to discuss the findings of the review in November 2015.  3.15  In light of learning from previous SCRs, both locally and nationallyxv the Megan SCR Panel were clear that they did not want this report to contain too many recommendations. Each IMR already contains an action plan of recommendations for individual agencies, which will be monitored through the LSCB Audit Sub-Group. Therefore, the IMR recommendations have not been replicated here. Instead, the Chair of the Panel and Independent Author of the report have facilitated a session with Panel members to identify the key learning from the report.    4.   BACKGROUND INFORMATION 4.1  Thurrock Profile Thurrock lies to the east of London on the north bank of the River Thames and within the Thames Gateway, the UK's largest economic development programme. Thurrock has a strong manufacturing and retail focused economy. There is a very significant regeneration programme centred on five growth hubs: Purfleet, Lakeside, Grays, Tilbury and London Gateway. Thurrock has a resident population of approximately 40,200 children and young people aged 0 to 18, representing 25% of the total population of the area. In 2012, 25.7% of the school population was classified as belonging to an ethnic group other than White British compared with 22.5% in England overall. Some 12% of pupils speak English as an additional language. Deprivation levels in Thurrock are consistent with the national average, but there are significant pockets of deprivation and inequality, with several areas falling within the 20% most deprived areas in England.  4.2  Megan and her family Megan lives with her mother (Karen), brother (Tom) and her father’s stepfather (Gary). Megan’s father (David) does not live with the family. Karen and David separated in 2005 and there has been no contact between the children and their father since then, although David had applied to the courts for contact. This application has subsequently been withdrawn and Megan and Tom have said that they do not want contact with their father. The family have agreed to exchange letters and photographs of the children via the Social Worker.                                                             xv Brandon et al: 2013. New learning from serious case reviews: a two year report for 2009-2011; Department for Education   12  The genogram below describes the family relationships. Figure 1     Megan’s biological father was imprisoned for domestic violence in August 2006. Both Megan and Tom witnessed a number of serious domestic violence incidents throughout their mother’s relationship with their father. They were reported to have resented their father and wanted no contact with him.  Megan had her own bedroom before Gary moved in to the house and took over this room. Since then, Karen (mother) and Megan have shared Karen’s bedroom. At the time of Megan’s illness, she was sleeping on a mattress on the floor of her mother’s bedroom. Tom has the third bedroom.  4.3  Birth to beginning of review December 1995 – December 2008 To assist in the understanding of Megan’s life prior to the agreed review period (2008 to 2013), this section of the report describes the key events that led to input from local services. In common with all children, Megan received universal services from General Practice and the community children’s services from South West Essex Community Services (now North East London Foundation Trust - NELFT) from birth until she left school in 2013. As most of Megan’s contacts were with universal health services during this time, the majority of this section relates to those contacts.   13 During this period, targeted services were involved when there began to be concerns regarding the ability of the parents to provide adequate parenting capacity for Megan from very early childhood. Community nursing records show that the health visitor made monthly and on occasions bi-monthly contact with the family, predominantly with the mother, to support maternal health and parenting of Megan and later of her sibling.  Concerns escalated following the birth of Megan’s brother, Tom, which resulted in statutory intervention to promote the health and well-being of the children. In March 1997, records indicate that a Section 47 enquiryxvi was considered. There is no information available about this referral and the outcome of the enquiry.  However, we do know that on 22nd August 1997, the children were subject to Child Protection Plans under the category of physical abuse and neglect. It is not clear what action was agreed at this stage, as minutes of the Initial Case Conference were unavailable for the review.  The concerns at this time were primarily about chronic neglect, domestic violence, housing eviction and the family needing financial support. When Megan was two years and her brother four months old, the children were on the Child Protection Register for neglect and physical abuse. They remained on the register between 22nd August 1997 until 20th December 1999 It is evident that, during this period, there was considerable input from agencies to support the needs of the children. The records show that the agreed action was for support with parenting to be provided by the Local Authority, Bluebell Parenting Centre. The Bluebell Parenting Centre is no longer in existence so it has not been possible to obtain an IMR from the organisation. However, notes from the archive indicate that the workers at Bluebell were very concerned about the family at that stage. For example, a report by a Family Centre worker for the Review Child Protection Conference on 7th June 1999 records that the parents’ commitment was superficial and they had no insight into why advice was being offered. This worker felt that change would not happen without priority being given to the children's needs. In the same month, a memo from a senior manager in the Children and Family Department to the Deputy Manager of Bluebell states "...........there are some issues that need to be addressed, particularly given that you seem to be suggesting that we might consider foster care for these children.”                                                             xvi Section 47 of the Children Act 1989 places a duty on LAs to investigate and make inquiries into the circumstances of children considered to be at risk of ‘significant harm’ and, where these inquiries indicate the need, to decide what action, if any, it may need to take to safeguard and promote the child’s welfare.   14 In December 1999, the children were removed from the Child Protection Register and stepped down to the category Child in Need. During this time Megan was referred to the Community Paediatrician regarding speech and language delay and poor co-ordination. The outcome of the assessment was that a 332 notificationxvii was made to support future educational needs. The initial health screening performed on school entry (universal screening delivered by school nursing service to all children on entry to school) was completed. This did not highlight any significant health concerns.  In terms of her health needs, Megan was prescribed an iron supplement in her early childhood. The reason for this is not evident. In 2007, a blood test recorded her results as normal.  The first documented recording of head lice infestation appears when Megan was three years old, when her GP at the time prescribed head lice treatment. In 2004, when Megan was eight years old, the school nurse records detail of a referral from the school regarding an ongoing concern with head lice infestation. It is not recorded as to whether face-to-face contact was made with Megan as a result. The records indicated that a standard letter and health promotion pack was sent to her parents. This was in line with school nursing procedure when an initial concern regarding head lice is raised.  The first indication of action about Megan’s increasing weight was during GP consultations between the ages of nine and 12 years old. During this period, her weight increased from 42kgs to 80.7kgs. At this stage, health advice was given and a weight management diet was commenced. When she was 11 years old, Megan experienced shortness of breath due to a high BMI of 34.75. At this stage (December 2008), the GP referred her to the MEND programme; an interactive health promotion programme which aims to reduce obesity in childhood by changing health behaviours. However, Megan’s mother did not take her to the MEND programme at this time, or following subsequent referrals.  During Megan’s early childhood there were a considerable number of contacts from agencies with the family providing opportunities to promote the health and well-being of the children. Recurrent themes are evident in the agency’s records.  They identified a poor standard of hygiene during Megan’s early childhood and that parenting support was needed.                                                              xvii A 332 notification is where a health agency feels a child may have a learning difficulty or special educational need. This process remains in place but is now known as a S23 notification.   15 5.   CASE SUMMARY AND TIMELINE OF SIGNIFICANT EVENTS  5.1   The main themes that have been identified in this Serious Case Review are: • Adolescent neglect; • The child’s voice; • Demonstrating outcomes; • Effective challenge; • Performance management; and • The role of health organisations. The impact these had on this case are described in more detail in Section 7 of the report. 5.2   Agencies continued to be concerned about Megan during the period of this review (December 2008 – December 2013). She and her family received a considerable amount of input to address concerns about Megan’s own health and well being, her living conditions and her education. Megan and her brother were on a Child Protection Plan for issues of neglect between September 2012 and June 2013. They were on a Child in Need Plan between June 2013 and November 2013.  5.3   Despite agency input, Megan’s overall situation did not change in the five-year review period. Table 1 presents the significant events during this period of Megan’s life. Table 1: Significant events during the five-year review period Megan is 13 Description of significant event June 2009 Megan was a victim of Actual Bodily Harm (ABH). The person responsible punched her in the cheek, causing bruising and reddening. The suspect received a reprimand. November to December 2009 Megan had three contacts with the Health Improvement Practitioner in school. The aim was to work on a programme of dietary and exercise advice.   December 2009 Common Assessment Framework (CAF) completed by the school. Issues noted were: persistent problem with head lice and significant personal hygiene issues. Megan was reluctant to talk but said she felt isolated and lonely in school. She had low self-confidence and issues with bullying and no friendships at school. Her school attendance was 38%.    16 Megan is 14 Description of significant event January 2010 Multi-Agency Group (MAG) panel. Actions agreed: 1. School to monitor attendance and refer to Educational Welfare Service (EWS) if necessary; 2. Karen (mother) to be referred to Coram for support; 3. School nurse to offer support to Megan re: illnesses; and 4. Megan referred to MENDxviii and the Behaviour and Education Support Team (BEST). MAGs review date: June 2010. February 2010 Health Improvement Practitioner (HIP) met College Inclusion Support Officer, School Counsellor and EWO to discuss concerns. Megan had stopped engaging with the HIP.  School nurses noted ongoing problem with head lice and cleanliness issues. Megan had refused her school leavers’ immunisation. February 2010 The School Megan attended referred Megan to EWS regarding poor school attendance (41%). February 2010 EWS sends Karen (mother) an attendance warning letter  March 2010 School nurse records that Megan’s height is above the 50th centile and weight is above the 99.6th centilexix March – June 2010 Involvement of the EWS and Coram. Karen (mother) attends the Strengthening Communities Parenting Programme. In June, Megan has four weeks of perfect attendance. June 2010 First MAGs review August 2010 Case closed to EWS due to improvement in attendance. October 2010 School referred to IRT regarding ongoing and persistent problems of neglect. November 2010 Second MAGs review. Case closed to MAGs due to the school’s referral to CSC re: neglect.                                                             xviii The MEND programme is an interactive health promotion programme; one of the primary aims is to reduce obesity in childhood through change in health behaviours. xix UK-World Health Organisation (WHO) growth charts, 0-18 years. These are based on the WHO Child Growth Standards, which describe the optimal growth for healthy, breast-fed children                                                                                                                                          17 November 2010 Core Assessment (11-15) completed. Recommendation that the case to be referred back to MAGs. Megan is 15 Description of significant event March 2011 Karen (mother) wrote to the school to say that she was removing both children from school roll for purpose of elective home education March 2011 Children Social Care (CSC) closed the case April to Sept 2011  Five failed home visits by the consultant for Elective Home Education October 2011 Borough Attendance Panel held. Megan’s mother was invited but did not attend October 2011 Police carried out a welfare check – referred by EWO. November 2011 Failed home visit by the consultant for Elective Home Education  Megan is 16 Description of significant event April 2012 School Attendance Order issued.  April to May 2012 Eight failed home visits by Thurrock Pupil Support Service (TPSS)  May 2012 Megan on roll at Pupil Referral Unit (PRU). Case closed to EWS. Both children attended a two-day induction programme. On the third day they did not attend. May 2012 EWO at PRU referred Megan to CSC regarding school non-attendance and unkempt home environment.  May 2012 C100xx application by Megan’s father June 2012 Social Worker home visit. Megan expressed a desire for change in her circumstances in terms of her home environment, her weight problems, unresolved emotional issues (past bullying and witnessing domestic violence between her parents), to socialise and to have some form of education. June 2012 Court advised Local Authority to file a Section 7 report                                                            xx A Court Order for access to children following a divorce or separation   18 July 2012 Megan leaves PRU  Megan is 16 cont. Description of significant event July 2012 Core Assessment recorded on 04/12/2012 that the severity of harm was considered extremely high and, due to uncertainty re the future this could not continue. There had been no significant changes in school attendance and the unhygienic home environment and there was evidence that the children had suffered emotionally from witnessing parental DA. The assessment identified pattern of regression when services end. The Social Worker observed that the house was cold and there was no heating or hot water. July 2012 Referral to Police Child Abuse Investigation Team (CAIT). Agreement to take the case to Initial Child Protection Conference (ICPC). July 2012 Strategy discussion July 2012 Case closed to CAFCASS July 2012 Court ordered LA to file a copy of their Core Assessment by 16/08/2012 August 2012 Outcome of S47 enquiry recorded September 2012 Initial Child Protection Conference (ICPC). Children placed on Child Protection Plan under the category of neglect. October 2012 CAFCASS received a copy of the court order dated 24/09/2012, which recorded that Thurrock LA was to file a Section 37 report dealing with the issue of whether public law proceedings should be commenced.  There were two further orders received from 21/11/12 and 28/11/12 extending the final filing date for the Section 37 report to 30/11/12. October 2012 Case transferred to Family Support Team December 2012 Review Child Protection Conference cancelled as no one came to the meeting. December 2012 Review Child Protection Conference was held inquorate as had already been rearranged four times December 2012 Father withdrew his application for access.  The parties had agreed to exchange letters and photographs of the children via the Social Worker.      19 Megan is 17 Description of significant event December 2012 to February 2013  SW home visits recorded increasing concerns about the home conditions and the condition of the children February 2013 and March 2013 Core Group meetings held February 2013 Megan removed from roll at college due to non attendance April 2013 Family moved to temporary accommodation while works carried out on their home May 2013 Family referred to the Troubled Families service June 2013 Review Child Protection Conference. Megan and her brother stepped down to Child In Need August 2013 Child in Need review meeting November 2013 Child in Need review meeting. Decision to end involvement as no immediate concerns noted. November 2013 Megan seen at college and was very unwell November 2013 Megan was admitted to hospital December 2013 SW advised by the Hospital Safeguarding Nurse that Megan was covered from head to foot in lice and that she had never seen such a bad case. December 2013 Strategy meeting held at the hospital. Noted that Karen (mother) did not seem to be taking on concerns about the seriousness of her daughter’s condition        20 6.   FINDINGS AND LEARNING  6.1  The report considers the five issues agreed as the focus for the SCR in terms of the findings of the review and the learning from the review. Practitioners, through their IMRs and during the practitioner workshop, have identified the learning that is captured here. The learning supports what can be done to reduce the risk of a similar situation occurring.  6.2  To reiterate, the timeframe for the review is between December 2008 and December 2013. A summary of events before this timeframe is provided in section 3.2 of the report. 6.3   The findings and learning are detailed below. Did all agencies work together to safeguard this young person? Overall finding: Megan’s case highlights that despite a high level of inter-agency communication, there was a pattern of failures of effective inter-professional and inter-agency collaboration and information sharing in the following ways:  1.1 Referrals and their impact; and 1.2 A coordinated response to achieve outcomes.  1.1 Referrals and their impact Findings (evidence)  1.1.1 The records and multiagency reports indicate evidence of working together during statutory periods of intervention. However, none of the referrals had any impact on safeguarding Megan.   1.1.2 During the period covered by this SCR, there are a number of examples of appropriate referrals of the family for support and evidence of agencies working together with regards to concerns about Megan and her brother:   • Education made at least ten contacts with Children’s Social Care, expressing concerns about Megan’s welfare. The School Megan attended completed a Common Assessment Framework (CAF) in December 2009 and another in October/November 2010.  • In 2009, the police notified the Schools Protection Officer, who referred the children to Children’s Social Care following a visit due to non-attendance at school.    21  • Between February and August 2010, Karen (mother) attended 11 out of a possible 12 Parenting Support programmes delivered by Coram.  She further attended six out of a possible eight Parenting Plus Adolescent programmes between Jan and March 2011.   • In February 2010, the School Attendance Manager referred Megan to the Educational Welfare Service (EWS) expressing their concerns regarding school attendance. The EWS worked with the family and saw an improvement in Megan’s attendance. They closed the case in August 2010. In March 2011, Karen (mother) decided to educate the children at home. At this stage, the Consultant for Elective Home Education made a number of attempts to visit the family at home. A School Attendance Order was made in 16th April 2012, due to a lack of co-operation from Karen (mother). On 22nd May 2012, Megan was put on roll at the Pupil Referral Unit.    • In February 2013, housing services contacted Children’s Social Care (CSC) to let them know when the family was due to be evicted and other concerns regarding the property.   • In May 2013, CSC referred the family to the Troubled Families service.  • Agencies attended and contributed to the Multi-Agency Group (MAGs) panels, Child Protection Conferences and Child in Need (CIN) meetings and undertook tasks as part of plans to safeguard the young person.  • Police and other agencies have been part of strategy discussions and meetings and Section 47 enquiries.  • Agencies have made joint visits following concerns raised to safeguard the young person. 1.1.3  There are also examples of missed opportunities for referrals: • Although uniformed police officers had referred the family to Children’s Social Care, the first time Essex Police’s Child Abuse Investigation Team (CAIT) learned of the family was after Megan had been admitted to hospital.  • The Section 47 investigations in 2012 centered on the family’s move from their property to temporary accommodation and then back to their property. The state of the house at that time, and the reason for the move was that living conditions were extremely poor. Essex Police were consulted and a joint decision was made that this was a single agency enquiry for Children’s Social Care. 1.1.4  At the practitioners’ workshop there was a sharing of a combined timeline of incidences   and interventions. Practitioners at the workshop indicated that they had not been aware   22   of everything presented. This issue is not new to SCRs; most reflect a lack of     information sharing between agencies. In the most recent biannual review of SCRsxxi,   nineteen of the twenty SCRs reviewed contained recommendations relating to     information sharing between agencies. In Megan’s case, there were a number of     apparent barriers to successful information sharing between agencies. •  Information was not always shared with all the relevant agencies. For example,    the role of Case Conferences in this case did not work sufficiently well to     ensure that information was always shared with those who needed to know (see question three for a more detailed analysis of this);  • There was a lack of clarity about why information was being shared and what was expected to be done with it. For the person receiving the information, this meant that it was unclear whether action was expected as a result of receiving it. This also meant that the person sharing the information might have thought that by sharing it, some action would have happened. However, this was not always the case;  • When information was shared, analysis was lacking. 1.1.5  Moreover, each time a new referral was made, it focused on the present referral rather   than a joining up of the dots in relation to past concerns. For Megan, this meant that    each episode of intervention appeared to be viewed in isolation and previous historical   concerns raised did not seem to be considered as recurring themes. For example, the   impact on Megan of experiencing domestic abuse was not fully acknowledged nor acted   upon at that time. Her mother’s need for parenting support and lack of ability to change   did not lead to a different approach.  1.1.6  A recurring theme of this case is what Coram have reflected as the need for a more    systematic analysis of the case, including background history. This might have     promoted a more realistic assessment of the changes that could be reasonably     expected and the potential long-term sustainability of these changes.  1.1.7  As this review is historical, it is useful to consider whether improvements to systems    and processes have improved the ways agencies work together so that if Megan’s case   was live now, her situation would have been better handled. Since the timescale for this   review, a Multi-Agency Safeguarding Hub (MASH) has been put in place in Thurrock. In   terms of what impact this could have had if it was in place at that time, it is certain that it   would have had a role in bringing together information at the initial point to facilitate the   initial referral to CSC. It has improved the ability to share information between agencies                                                            xxi Brandon et al: 2013. New learning from serious case reviews: a two year report for 2009-2011; Department for Education   23   in Thurrock and enabled an enhanced police focus on Child Protection issues.   1.1 Learning – how to ensure that referrals have an impact Questions for the LSCB  1. How does the Board ensure that referrals contain the relevant history of the family so that  all agencies are aware of any recurrent themes? 2. How does the Board ensure that agencies avoid starting again and incorporate all previous  information? 3. How does the Board ensure that all practitioners share the information they have with  others – and also ensure that they take ownership of this? 4. How does the Board ensure that the impact of agreed interventions are evaluated and  outcomes described and shared?   1.2 A coordinated response to achieve outcomes. Findings (evidence)  1.2.1  As described previously, agencies missed opportunities for joint working to develop a    holistic picture of Megan’s needs. Megan had been a vulnerable child and her lack of    ability to deal with her basic activities of daily living went unrecognised when she     became an adolescent. Megan was not continually seen as an adolescent who was    being neglected.  1.2.2  General Practitioners (GPs) are in a prime position to identify vulnerable children.    Treating whole families over long periods of time, GPs have valuable insights into the   difficulties that some children face. However, GPs only see the lives of children in 10    minute snapshots and Megan was only seen at the practice on six occasions during the   scoping period (twice by the practice nurse and four times by the GP). The GP Practice,   with which Megan was registered at this time, was aware that Megan was placed on a   Child Protection and/or Child in Need Plan. Although they did not participate in Case    Conference meetings, there is documented evidence to show, on two occasions they    24   shared information, via telephone, with the family’s Social Worker. However, in this    case, there was a missed opportunity for GPs to fully engage in the Child Protection    and Child in Need process, as the plans were not sufficiently SMARTxxii to define the    roles of partner agencies and support their engagement. 1.2.3  Essex Police did make a link between the poor state of Megan’s home conditions and   her vulnerability. The police schools officer notified the schools Designated Lead and a  referral was made to Children Social Care. However, that information was not passed   onto the Child Abuse Investigation Team (CAIT), even though the family had been on   the radar of Social Care since 1997 for similar reasons.  1.2.4  The community health records indicate that there was a pattern of non-attendance of    Megan at appointments often Megan did not attend appointments (DNA) offered by the   school nurse, as she was absent from school on the days of the appointments. On one   entry there is suggestion of a joint home visit by education and health. However, the    aims of the visit are not indicated nor the expected outcomes of contact. There is no    documentation to establish if the visit was achieved and no indication of subsequent    actions proposed or taken. 1.2.5 There is the issue of Megan’s obesity. A place was again secured for the family to    attend the MEND programme to support Megan with changing her health behaviours    and achieves a balanced weight control.xxiii Karen (mother) agreed to participate in the   MEND programme but did not attend and when follow up from MEND facilitators took   place, she was then inaccessible by telephone. Although the school nurses all recalled   that Megan was “overweight,” the school nurse records do not reference any weight    monitoring or care plan to monitor weight. There is no documented evidence that the    school nursing service were aware of any concerns regarding Megan’s weight although   it is known that she was classified as obese throughout the whole period of the review.   1.2.6  It must be acknowledged that promotion of health is complex in nature, as it requires a   change in health behaviours to enable sustainability. It also requires a belief in the    benefit of the change, if an individual or in the case of a child, the child and carer, has to   believe in the benefit of change and the rationale for the proposed intervention.     However, the records and reports in this case have limited information on the expressed   views of the family in order to analyse or evaluate the family’s capacity to implement                                                             xxii SMART is an acronym for plans that are Specific, Measurable, Achievable, Realistic and Timely  xxiii The MEND programme is an interactive health promotion programme; one of the primary aims is to reduce obesity in childhood through change in health behaviours.   25   and sustain change. 1.2.7  In terms of non-attendance for heath appointments, it is now current practice that this is   recorded as “Child not Brought” rather than “Did not Attend”(DNA).  1.2 Learning – how to develop a coordinated response to achieve outcomes Questions to the Board  5.  How does the Board ensure that all agencies have an understanding of adolescent    neglect and the impact of this on the ability of the adolescent to change and challenge? 6.  How does the Board evidence the outcome of the multi-agency training to create a    better understanding and appreciation of the roles of other agencies? 7.  How does the Board ensure that all agencies draw on the wider healthcare team to    obtain as full a picture as possible of a child’s life to help them recognise those in need?  8.  How do agencies ascertain that families have adequate knowledge and the right skills   to follow change programmes? This includes identifying influences or barriers, which    may reduce their ability to actively change their health behaviours within the family and   support the health and well-being of their children.      2.1 Was the outcome preventable?  Overall finding: The “outcome” in this case is taken as Megan’s collapse and admission to hospital in November 2013. Due to the complex nature of Megan’s medical condition when she was admitted to hospital, it cannot be proved that her collapse was preventable. However, it is likely that the long-term neglect experienced by Megan contributed to her serious medical condition. This level of neglect was avoidable, especially given the numbers of agencies with detailed knowledge and concerns about Megan and her brother.    26 Findings (evidence)   2.1.1  When she was admitted to hospital, Megan’s medical condition was complex. Megan    had an extreme case of severe iron deficiency anaemia, which was life-threatening. At   this time, her haemoglobin levels were 2.3 g/dl. Normal values for a girl of her age are   11.5 – 16.5 g/dl. It was difficult to establish the primary cause of Megan’s medical    condition.  The Panel sought medical opinion regarding this and were advised that    contributory factors could be heavy periods, chronic head lice or poor nutrition. Anyone  with untreated iron deficiency anaemia are more susceptible to illness and infection, as   a lack of iron in the body affects the immune system (the body’s natural defence     system). 2.1.2  Megan was also suffering from two infections: Mastoiditis and Pneumonia. Mastoiditis   is a serious bacterial infection that affects the Mastoid bone behind the ear. Mastoiditis   usually occurs following an untreated middle ear infection. Bacteria from the middle ear   can spread to the inner ear, infecting the Mastoid cells of the Mastoid bone. One of the   potential complications arising from untreated Mastoiditis is a blood clot on the brain    and Megan did develop such a complication. 2.1.3  Two professionals were in contact with Megan in the days before her collapse.  The   college manager observed that Megan presented as being seriously unwell and that    she nearly collapsed when getting into the taxi. The college manager did not call an    ambulance on the day because Karen (mother) was with Megan. However, she did all   she could to raise her concerns by calling the Social Worker on the day, asking her to   call back within the hour to reassure her that something had been done. The Social    Worker did not, based on the evidence available, sufficiently grasp the seriousness of   Megan's health condition.    There appears to be an acceptance that Megan's mother would take reasonable action   to take her daughter to the GP, without full consideration of the context of neglectful    parenting. The incident at college took place on a Friday and Megan's admission to    hospital on the following Wednesday. The ability of the Social Worker to follow up on    the instructions given to Megan's mother to take Megan to the GP were impacted in part   by the weekend.    Consideration still needs to be given as to whether or not the Social Worker could have   been more pro-active within the three-four working days between Megan being reported   as unwell by the college and her collapse on the following Wednesday. It is unlikely that   legal action to ensure that Megan was seen by a medical professional could have been   secured within this time period and Megan's willingness (consent) to engage with any   27   medical examination at this period in time is unknown. However, a full understanding of   Megan's ongoing neglect should have led to an urgent home visit rather than a     reliance on Megan's mother taking reasonable action to secure medical attention. The   Social Worker needed to have physically seen Megan and her mother and not to have   relied on telephone methods of communication. 2.1.4  What is clear was that in the five months before her collapse, Megan’s condition     deteriorated. The college manager, who saw Megan at college in June 2013 reported   that she had seemed more relaxed than previously, was taking more pride in her     appearance and was wearing lipstick. She next saw her in November 2013, four days   before her collapse and that she looked very ill. It is not clear what was happening in    Megan’s life to lead to such a change. What is known is that the family had been moved   into temporary accommodation while their house was being refurbished, CSC visits    continued (although there is a lack of evidence about whether Megan was seen) and    Catch 22, a Family Support Service closed the case as Karen (mother) was noted as    taking on full responsibility and needing little support. We also know, from a note of a    meeting between Megan and her adviser at Connexions that Megan was not happy on   her course at college and only attended 20% of the sessions. During a home visit by her   Connexions adviser in 14th November, she stayed in bed, as she felt ill.  2.1.5  In relation to her experience of neglect, in order to achieve the optimum life chances for   Megan, early detection and intervention would have been paramount. Assessments    over the period of this review show that it was known that Karen (mother) was not able   to sustain improvements and would slip back into neglectful parenting. However, all this   knowledge and over such a long period did not lead to any sustained improvements to   Megan’s home situation. Neither did this knowledge lead to legal intervention being    sought to safeguard Megan from neglect. See Section 6 on the legal proceeding in this   case for more detail. Effective legal action was taken in relation to home education. 2.1.6  It is clear from this review that a significant number of interventions were made into this   family. However, the learning is about whether these made any impact and how     professionals make the link between intervention and impact. For example, there are    many examples of professional input which had a lack of impact on the outcome: • 28th May 2012, the Pupil Referral Unit expressed serious concerns about the home    environment. A follow up home visit by Children’s Social Care nine days later supported   that the home environment was very unhygienic. The Social Worker advised Karen    (mother) to clean the house. However, no other actions appear to have been      considered at that time.  • 11th September 2012 - the children were place on a Child Protection Plan for neglect    and physical abuse. This did not prevent the eventual outcome for Megan.   28  •  4th December 2012 - a Core Assessment recorded that the severity of harm to the    children was extremely high and could not continue. It was evident throughout the    assessment that there had been no significant changes in school attendance and the    unhygienic home environment. It was also evident at this time, that the children had    suffered emotionally from witnessing parental Domestic Abuse and that other children in   the community had attacked Meganxxiv. The Social Worker observed the house to be    cold and there was no heating or hot water. This assessment identified patterns of no   sustained improvements when services ended. Partners at the Initial Child Protection    Conference (ICPC) recommended that a Legal Planning meeting should be held.     However, this was not done.   •  4th June 2013 - despite the family history of not sustaining improvements, the Child    Protection Conference agreed that the children’s names should no longer be subject to   a Child Protection Plan and stepped down to Child in Need.   2.1.7  Throughout this period, although there were concerns about Megan’s poor hygiene and   social skills, most of the intervention was overly focused on the mother. Because of her   age, it was assumed that Megan was old enough to look after herself. It was not     recognised that she needed support to develop skills of self-care. 2.1.8  Despite the high level of intervention, there were many occasions during the period of   this review where the concerns of practitioners could have been escalated. It is not    clear why none of these concerns individually or as a pattern of concerns were not    analysed sufficiently to determine that the children were at risk of significant harm and   had met the threshold for legal action. This may have led to a different outcome for    Megan. The main missed opportunities for escalation are listed below.  Key opportunities for escalation  Date Agency/action Key opportunities presented April – September 2010 Megan is 14  Between April and July, a number of services were involved with the family. Megan’s school attendance improved and her appearance improved while this intense support was in place. However, the support stopped when the children were back at school and Megan’s attendance and appearance deteriorated again. It was not identified                                                            xxiv Police records 18/12/2009: PERSON RESPONSIBLE PUNCHED MEGAN IN CHEEK CAUSING BRUISING AND REDDENING MG11 OBTAINED - suspect received reprimand   29 that Karen (mother) could not cope without intensive support. 16/11/10 Megan is 14 Multi-Agency group (MAGS) Panel to Social Care Initial Response Team Issues identified at MAGS panel were ongoing poor hygiene, head lice, school attendance problem and school looking to escalate the issue. BEST worked with mother and mother completed parenting group. 24/11/10 Megan is 14 School to CSC School reported issues of the children's hygiene and impacted on their ability to make friends and being bullied. The home was described as being extremely unhygienic and there was a smell of damp from the front door. The children's clothes smelled damp and their personal hygiene was neglected. The children had persistent problems of head lice for the past year. The report described that the children could be aggressive and lash out in temper. Megan’s school attendance was 38%. The report also said that the family had been required to move into temporary accommodation due to unhygienic conditions. Megan had also had three school moves. 26/01/11 Megan is 15 Core Assessment  An opportunity to follow the Child Protection route was not taken up and a re-referral was made to MAGS to look at long-term support for the family and for the School Megan attended to follow the stage 2-procedure relating to school non-attendance. 24/02/11 and then 23/03/11 Megan is 15 Mother spoke of her intentions to remove children from school and home educate them during Social Worker home visit, followed up by letter to the School Megan attended. The mother suggested that the children would not be returning to the school. She suggested that this was due to alleged bullying. Karen (mother) decided to home educate both Megan and Tom. The school was opposed to the move to Elective Home Education as it would be difficult to monitor Megan’s welfare. However, the school did not make this point strongly enough and there is no evidence that senior staff intervened at a high enough level to show the depth of their concern. 25/03/11 CSC Records show that the case was closed to CSC.   30 Megan is 15 No indication of reason to close case.  07/06/12 Megan is 16  CAFCASS  CAFCASS completes safeguarding checks in respect of father’s private law application for contact with his children and advises the court that there are safeguarding concerns, that the Local Authority is involved and that a Section 7 report from them is required. As the Court ordered no further work to CAFCASS, the agency’s duties were discharged and the case is closed. The court orders received by CAFCASS show that the Court ordered the Local Authority to file its Core Assessment (26/07/12) and subsequently to file a S37 report (24/09/12). The recommendation was not to instigate care proceedings. December – the court allows father to withdraw his application. 20/07/12 Megan is 16 Strategy discussion between Thurrock IRT and police CAIT Concern expressed regarding the chronic neglect and referencing the long-standing involvement of Social Care since 1997 but despite the assistance nothing changes. No consideration was given by police to open a criminal investigation into neglect. It was noted that Tom had not been outside for six weeks.  24/10/12 Megan is 16 Statutory home visit Children were seen but not alone. Records state that the children seemed fine but that there were concerns about the home conditions.  18/12/12 Megan is 16 Multi-agency Child Protection Procedures Review Child Protection Conference did not recommend further action despite frustrations at the conference that there had not been any improvement. 25/01/13 Megan is 17 CSC home visit Social Worker reports that the house is a cause for concern and 25/01/13 house being cold and the children saying they were cold, dressed in skimpy clothes, there had been no heating in the house for over a month.      31  2.1 Learning – how to avoid this outcome happening again Questions to the Board  9. The outcome as defined was not avoidable, however the experience of neglect was.  Therefore, how does the board ensure the best possible (consistent) outcomes for children  and young people experiencing or at risk of neglect?    Were the Southend Essex and Thurrock (SET) Child Protection Proceduresxxv followed appropriately?  Overall finding: In line with local SET procedures, Megan was identified as child in need using a multi-agency approach. However, if all agencies had followed the local procedures, Megan’s situation should not have escalated. Procedures were not used by all agencies to underpin their practice or decision-making in the following ways: 3.1 Responding to indicators of neglect  3.2 Analysing and taking account of risk 3.3 Sharing information  3.1 Responding to indicators of neglect Findings (evidence) 3.1.1  It is clear from this review that Megan has experienced some levels of neglect     throughout her life. For the most part, this was chronic apart from those times when    supported interventions were in place and had a short-term impact. Neglect is a term    used throughout the IMRs and reflected throughout the records and correspondence                                                             xxv The SET Child Protection Procedures were developed in 2006 and refreshed in 2011 and 2015. There were no radical changes made to the procedures in place during the review period when they were refreshed. Therefore, this review is based on those refreshed in 2011.   32   reviewed. 3.1.2  The SET procedures (2011) lists child related and care related indicators of neglect, a   large number of which apply to Megan and her circumstances. So, although neglect    was recognised by agencies and interventions made, there was also a lack of clear    direction from the agencies about how to tackle this and how to protect Megan and her   brother. Interventions had little short-term and no long-term impact and their situation    did not change as a result.  3.1.3  Megan was identified as having a poor standard of personal hygiene in adolescence but   this was then considered to be self-neglect. There seemed to be limited knowledge of   the requirement of parental support to enable the young person to maintain personal    hygiene. CORAM offered the family support on this issue, working with the school and   Health Improvement Practitioner and seeing an improvement in Megan’s personal    hygiene at the time. However, the improvement was not sustained and there is no    indication of further exploration of factors, which could have influenced the ability of    Megan to maintain her personal hygiene.  3.1.4  During the scope of this review, Megan was seen on six separate occasions at the GP   practice: twice by the practice nurse for head lice and immunisation and four times by   the GP. In May 2013, Megan visited the GP and informed him that her Social Worker    had asked her to make the appointment. She reported to be starting college that day.    Megan was weighed and was 121kg (19 stone). 3.1.5  Agencies missed opportunities to involve Megan in the assessments undertaken, with   little evidence that her wishes and feelings were sought: this was particularly pertinent   during the Child Protection times/enquiry, when there is no evidence that Megan was    spoken to individually. 3.1.6  This review suggests that following questions were not fully considered by professionals   involved with Megan: • Was the home environment supportive of her health and well-being?  • Did Megan have the knowledge and skills to maintain her health and well-being? • Did she feel empowered to use her knowledge and skills?        33  3.2 Analysing and taking account of risk Findings (evidence)  3.2.1  Ofsted 2014 reported in their thematic review of neglect “nearly half of the assessments   did not take sufficient account of the family history. Even in those cases where the    family history was recorded, this was not always analysed in terms of patterns of     previous episodes of abuse and neglect. Implications for the child of the parent’s     own childhood experiences and the impact on their current parenting were not always   considered.” xxvi  3.2.2  The SET procedures (2011) state that it is rare that an isolated incident will lead to    agencies becoming involved with a neglectful family. Evidence of neglect is built up over   a period of time. Professionals should therefore compile a chronology and discuss    concerns with any other agencies which may be involved with the family, to establish    whether seemingly minor incidents are in fact part of a wider pattern of neglectful     parenting.  3.2.3  In Megan’s case, such a chronology is not apparent. The background history of these   children should have been an indicator to determine future risk but no one had a holistic   view of Megan’s situation. For example, in health, GP records did not indicate that the   level of Megan’s neglect. Neither was there any indication of any observation and or    interaction between the adult carers and the children. It is therefore difficult to ascertain   whether the GP practices had concerns and/or recognised that Megan was neglected.   GPs were not informed of all other agencies’ concerns e.g. they were not informed of    poor attendance, significant others in the household, step grandfather and other     concerns. 3.2.4  Information regarding concerns raised by other agencies was not recorded clearly in the   community nursing health record. Although there was clearly a good working      relationship between the school nurses and the lead for safeguarding in the school, this   was not evident within the records and the concerns raised and difficulties in working    with the family were not documented.                                                             xxvi Ofsted March 2014: In the Child’s Time – Professional Responses to Neglect https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419071/In_the_child_s_time-professional_responses_to_neglect.doc    34 3.2.5  Another example is that in 2009, police were in contact with the family through a     reported assault on the children outside their then school by other pupils. The officer    dealing with this crime was also the Schools Liaison Officer.  The Officer was involved    as a result of school absence.  The Officer carried out a home visit and discovered    home conditions so bad she and the School’s Attendance Manager referred the family   to Children Social Care via the Schools Protection Officer. No record however exists in   police databases of this referral and this later will have deprived investigators of a    complete picture. It was one of the gaps in knowledge that led to officers in 2014 to    report that they were not aware of the families living conditions in making their decision   not to pursue a criminal investigation after Megan was hospitalised.  3.2.6  The SET procedures (2011) also state “the analysis of the child’s needs and the     capacity of the child’s parents or caregivers to meet these needs within their family and   environment should provide evidence on which to base judgements and decisions on    how best to safeguard and promote the welfare of a child and where possible to support   parents in achieving this aim.” The fact that Megan’s situation did not improve, that the   indicators of neglect continued and that Karen (mother) continually failed to engage    showing that this evidence was not used to base decisions about how best to safeguard   Megan.   3.2.7  The SET procedures say: “decisions based on this analysis should consider what the    child’s future will be like if his or her met needs continue to be met, and if his or her    unmet needs continue to be unmet. The key questions are, what is likely to happen if    nothing changes in the child’s current situation? What are the likely consequences for   the child? The answers to these questions should be used to decide what interventions   are required when developing the Child Protection Plan and, in particular, in considering   what actions are necessary to prevent the child from suffering harm or to prevent a    recurrence of the abuse or neglect suffered.” There is no evidence in the individual    IMRs that these questions were asked. 3.2.8  Karen’s (mother) decision to home educate the children increased their vulnerability and   lack of contact with professionals. The bi-annual review of learning from Serious Case   Reviewsxxviihighlighted this as a continuing theme. That “children were missing or     invisible to professionals in a number of ways. These included young people who were   hardly consulted or spoken with, siblings who were similarly not engaged, young people   who were not seen because they were regularly out of the home or were kept out of                                                             xxvii Brandon et al: 2013. New learning from serious case reviews: a two year report for 2009-2011; Department for Education    35   sight, non-attendance at school, young people who absconded, ran away or went    missing and children who chose not to or were unable to speak because of disability,    trauma or fear.”    When Megan’s mother decided to home educate Megan and her brother, at this     particular point the children were at significant risk of harm as there would be no     professionals to monitor their education and their well-being. Despite this, Children’s    Social Care closed the case on the 25th March 2011. This closure of the case would    indicate that analysis of risk and future risk was not undertaken, as an assessment    should have indicated that nobody would be monitoring the children despite long     standing concerns by all agencies working with the family.  3.2.9  Currently there is limited procedural guidance for agencies regarding working together   when children are not attending mainstream school or are home educated. For     example, the community nursing IMR identified an inconsistency in practice across    school nursing teams regarding home visiting when children are not in school, and the   role of school nursing service for children over sixteen years. This suggests ambiguity   of the role of school nursing service when a child is not attending school. The school    nurses were not aware of a school nurse procedure in place to clarify the role of school   nursing when children are not in school.  3.3 Sharing Information Findings (evidence)  3.3.1  Information was shared between members of the Core Group and escalation  of     concerns is evidenced within reports submitted for Case Conference and Core     Groups.  However there are also many examples of incomplete or absent record     keeping, which have impacted on agencies ability to build up a picture and safeguard    Megan.  3.3.2  Sharing information through the Common Assessment Framework (CAF) process did   not work effectively to safeguard Megan. The CAFs completed in December 2009 and   October/November 2010 clearly identified deficiencies in the care of Megan but there is   limited information to ascertain if any change had occurred following early intervention.   The limited information may be an indication of an “out of sight” approach. An     assumption appears to have been made that as no recent concerns had been     highlighted, previous concerns had been resolved.  The information shared later     confirmed that the children had not left the family home and had no contact from any    professionals indicating that no evaluation following the CAF had taken place. There is   clear evidence of poor attendance at appointed contacts within health and      36   education records. It is likely that this pattern may have been evident in other agency    records which would have influenced the decision for professional to evaluate or re-   assess intervention. 3.3.3  The Case Conference process did not work effectively to safeguard Megan. These    should have been where a holistic view of her situation was shared and understood.  It   is clear that the governance of these groups were not sufficiently robust. It is also     unclear who was responsible for their effectiveness and actions. Agencies were worried   about this family but failed to attend Case Conferences. This raises a question about    how such meetings are valued by agencies.  3.3.4  Case Conferences and Core Groups should have been a significant venue for sharing   information between agencies. As such, they should have been seen as valuable by    agencies involved. However, Case Conferences were often cancelled due to non-    attendance of all agencies and therefore being inquorate. This culminated in a     Conference on 18th December 2012 being held despite being inquorate as it had     already been rearranged four times. This is despite the fact that Core Group meetings   on 18th September 2012 and 8th November 2012 identified that there were still concerns   of chronic neglect in the home environment and the mother was not complying with    agreed interventions. There is no record of what action the Core Group decided, despite   an Initial Child Protection Plan Conference contingency plan for a Legal Planning     meeting. A Child in Need network meeting was cancelled on 13th July 2013 as no one   attended.  3.3.5  Time constraints for attendance at Case Conferences by some agencies may have    been a contributory factor to lack of attendance. However, health professionals were not   always invited in time to Case Conferences, suggesting this was an administrative    issue. For example, the GP were only invited to one Case Conference (Oct 2012),    which they were unable to attend. As the GP had not seen Megan since May 2010, they   did not submit a report to the Conference. Also, the school nursing service received the   invitation for the Initial Conference after the date had passed.  3.3.6  The Case Conference notes record a number of goals and actions to support the family   but are incomplete and impact of agreed actions are not always recorded. Actions    included fortnightly (later monthly) visits to the family by the Social Worker – both     planned and unplanned. Heath support included addressing hygiene, and healthy    eating and other measures were aimed at addressing school attendance and      participation. Karen (mother) was to be offered support in the form of counselling and    parenting and the children’s wishes about seeing their father were to be sought.  There   were no records of any checks on Megan’s step-grandfather (Gary) that could feed into   the Case Conferences.    37 3.3.7  Moreover, Case Conference reports provide further examples of information being    shared but with a lack of clear explanation about what is expected or clarity that the    information has been received or actioned upon. For example, the school nurses     provided reports for the review conferences, but it is not recorded in the records if a    school nurse attended all of the meetings. An entry in the record (4th June 2013) relating   to the Review Case Conference states “access to the school nurse, to work alongside   GP” in regards to promotion of completion of immunisation programme and referral to   the dietician. There is no indication within the record that contact was made with the    school nurse and GP.  School nurses were not aware of Megan’s Child in Need Plan.   Therefore, Megan had no contact with the school nursing service during this the time of   statutory intervention and it is not clear how this was followed up.  3.3.8  The focus of the police has been on criminality and not safeguarding. This has meant   that, although SET procedures state that all agencies should make attendance at Case   Conferences a priority, Essex Police’s policy and procedures at the time stated that    CAIT would attend only the Initial and Transfer in Conferences and reviews if they have   a significant part to play in the investigation, otherwise a report would be sent.     Operationally there would always be the possibility that due to other incoming demands,   there may be occasions that the police will not be able to attend even the Initial Case    Conference. In Megan’s case, the CAIT were unable to attend due to a high priority    incident.  3.3.9  Some of the learning from this case is already being captured. The involvement of    Essex Police in Case Conferences and Core Groups is increasing. This would mean    that they would be able to raise questions about why there are no improvements in    cases such as Megan’s.  3.3.10  In terms of what would happen now, record keeping has improved across agencies over   the past three years, but it is recognised that further improvement is needed. Where it   has improved, auditing cases has driven this. As a result, practitioners are more able to   identify risks. Record keeping is now part of supervision meetings. Safeguarding is    becoming embedded through the identification of safeguarding leads, for example in GP   practices. Where record keeping still needs to improve, this relates to the quality of    recording, analysis of information and accountability.       38  Learning – how to ensure that SET Child Protection and Safeguarding Procedures are followed appropriately Questions for the Board  10.  How does the Board ensure that all agencies comply with record keeping      requirements of the current SET procedures? 11.  How does the Board ensure that agencies are equipped to recognise signs of neglect   and that the threshold for care proceedings to be initiated in cases of neglect are clearly   understood, constantly applied and monitored by all agencies and the LSCB? 12.  Should the Board adapt and expand Case Conference policies and procedures so that: • Technology is used to make case conferences more accessible to agencies, where   this is appropriate to clients and service users? For example, video or telephone    conferencing will enable agencies to contribute more regularly.  • It can be assured that case conferences are quorate and achieve their agreed    multi-agency functions? • It can ensure that checks are done on all relevant family members as part of Case   Conference procedures? • It can ensure that children’s health is discussed at each conference and appropriate   Care Plans put in place and documented in the records? • It can ensure that Child Protection Conferences and CIN meetings demonstrate    analytical assessment of risk in all cases? • It can be assured that the Children and Families Assessment would now capture    the family dynamic and impact on the child?   4. Was the child’s voice heard? Overall finding: Megan’s voice was not consistently heard and appropriately followed up. More focus could have been made to listen to her, to engage with her and to allow her to speak freely.  Findings (evidence)    39  4.1.1  The overall findings from this part of the review are that the only real opportunity for    Megan’s voice to be heard was when she was out of the house. However, she     remained unheard. Megan’s mother was almost always present whenever she was    seen, despite the fact that it is good practice for a child of her age to be seen alone. The   very few times that Megan did articulate her desire to change her situation, no one    acted upon this and records were not shared. 4.1.2  It is clear that there were numerous examples of attempts to engage with Megan     outside the home, despite her poor school attendance, home education and limited    opportunities to leave the home.  For example, the school Megan attended worked    proactively to develop friendship groups for Megan. The school also developed     excellent working relationships with the Health Improvement Practitioner (HIP), part of   the school nursing team, who worked with Megan on her personal health and     relationship issues.  4.1.3  The Connexions team and the college she attended developed a good relationship with   Megan and advocated for her to improve her situation in terms of education. They often   saw her on a one-to-one basis and observed that she was keen to be educated,     although she was shy and found it difficult to make relationships with her peers. 4.1.4  In 2009/10, school nurses reported that Megan would often attend “drop in” sessions at   school. However, these were held in an open room where there were other children    present. This environment did not promote confidentiality among peers or provide the   opportunity for in depth discussions without interruption. This was recognised and    appointments were arranged in a room that was more suitable for confidential     discussions and more in-depth assessment. This was positive practice. However, it did   remove Megan’s opportunity to “drop in” and Megan failed to attend these      appointments. When her non-attendance was followed up, this was with her mother,    rather than Megan, who advised that Megan was unwell and not in school. Following up   with parents was school nurse practice at that time. 4.1.5  There is little recorded of any direct dialogue between school nurses and Megan and    there is no evidence regarding recording of Megan’s decision making. A rationale was   not provided for Megan’s refusal of immunisation. Megan did not consent to      immunisations but there is no detail as to why this was her decision and any actions    taken to support her choice. There was also no recording of the expressed views of    Megan, despite the fact that school nurses recognised that:   “Her head was always held down; she did not give positive eye contact”   “She looked overweight and noticeable from the other children”   40   “She was always unkempt in her appearance, she looked “grubby.””   “She did not seem to be a happy child.”   There is also no evidence that home environment or additional factors were discussed   with Megan to ascertain if there were any other influences on her ability to meet her    own health needs.  4.1.6  There were opportunities to explore Megan’s perception of her health and social well-   being during the six consultations with GPs and practice nurses during the scope of this   review. However, there was only one entry in May 2013, when she attended the     practice alone and was asked why she was there. She said she had been asked by her   Social Worker to go. This is the only time the records show that Megan was spoken to.   From reviewing and analysing the GP records, there were no indications or      documentation to suggest that the views of Megan were ascertained or sought before   this. Nothing else is recorded with regards to this consultation. If anything was shared   with the GP relating to self or her family, nothing was recorded. 4.1.7  In 2010, Megan attended a number of one-to-one sessions with Thurrock’s Behaviour   and Education Support Team (BEST). These were held at school and were aimed at    addressing her self-esteem. There are records of seven such sessions and it is clear    that Megan engaged with these sessions, chatting happily and demonstrating a positive   attitude about her life and her future. She reported that the family were eating five    portions of fruit a day, experimenting with fish, doing 15 minutes a day exercise with her   mum and treating her head lice together. She also expressed a keenness to get back   into mainstream lessons. However, these sessions finished after seven sessions and it   is difficult to identify any impact; there is no indication that anything changed for Megan   in terms of her weight, hygiene issues or self-esteem. 4.1.8  Police officers planned but did not carry out an interview with Megan after her collapse   at home and her subsequent admission to hospital on 27th November 2013, to ascertain   the circumstances of the incident. This means her account was not obtained during the   police investigation.  4.1.9  The information indicates that the child’s voice was not heard when Megan was seen    at home. The Social Care records showed that Megan was not spoken to      alone during home visits. If she did speak to a Social Worker, her mother was always    present. On two occasions in June 2013, a student social worker did engage with Tom   alone but there is no record of what other attempts were made to speak to      Megan. Apart from the input of the student social worker with Tom, most of the     recordings state that he was mainly always upstairs in his bedroom and the Social    Worker did not see or speak to him. On some visits the Social Worker was told that both   children were upstairs asleep, which did not raise concerns given their ages, and     41   previous records that they had not left the home for weeks and months at a time. On    some occasions, the Social Worker spoke to their mother but did not see or speak to    the children. This practice is against procedure and can be seen as an issue of     professional competence. However, it was not identified as such during supervision    meetings with the Social Worker. 4.1.10  There was one key occasion when Megan did express clearly how she felt and     what she wanted to change. However, this was not followed up: • On 15th June 2012, Megan told the Social Worker that she would like a change in her current circumstances: home environment, her weight problems, unresolved emotional issues (past bullying and witnessing domestic violence between her parents) and being able to socialise, as well as having some form of education. Tom also said he wanted to deal with his weight issue. This was an ideal opportunity to engage the children and to make their voices heard. The records do not show whether any of the concerns were acted upon. 4.1.11  In terms of what would happen now, practitioners are much clearer about the need to    capture and take account of the voice of the child. For example, CSC now uses an    Adolescent Neglect toolkit to capture this.xxviii  Learning – how to ensure that the child’s voice is heard Questions for the Board  13.  How does the Board ensure that practitioners see and obtain the child/ young person’s   view at each contact and record the voice of the child in records and reports? 14.  How does the Board assure itself that children are seen on their own in accordance with   agencies’ policies and procedures? 15.  How does the Board ensure that all agencies involved with children and young people   listen to and consider their voice, record this and ensure that it is part of the story of this   child/young person in terms of provision? 16.  Should the Board consider developing new ways of engaging with teenagers?                                                              xxviii Wiffin, J: Assessment of Quality of Care for Adolescents    42  Was professional dangerousness a factor in this case?  Overall finding: Professional dangerousness is defined as “the process whereby professionals involved in Child Protection work can behave in a way which either colludes with or increases the dangerousness of the abusing family” xxix There are examples of professional dangerousness in this case. These focus on:  5.1 Professional optimism and not recognising disguised compliance;  5.2 Accepting lack of access to the home and to Megan on home visits; 5.3 Accepting the status quo for this family; 5.4 Recognising and responding to closure; and 5.5 Case closure and lack of management oversight.   Findings (evidence) 5.1 Professional optimism and not recognising disguised compliance   5.1.1  An indication of professional dangerousness in this case is the fact that the information   contained within records and reports throughout the years indicates an approach of    professional optimism and not recognising disguised compliance. 5.1.2  Professional optimism is where professionals wrongly assume positive outcomes for    children. In its key messages from learning from SCRsxxx, Haringey LSCB warns     professionals not to confuse an apparent willingness to comply with an actual     willingness to accept the need to change. 5.1.3  Disguised compliance has been used in many recent high profile Serious Case     Reviews. The words suggest that compliance is portrayed but when deeper      investigation takes place, individuals may be assessed as not truly compliant. It has                                                             xxix Morrison T, (1990), the emotional effects of child protection on the worker, practice 4(4), p262-4 xxx http://www.haringeylscb.org/key-messages-practice   43   been suggested that many parents are seen by professionals to be working together    and engaging with professionals but this is often at a superficial level and is not     sustained once direct support is withdrawn. 5.1.4  An Ofsted thematic report on neglectxxxi states, “parents were given too many chances   because professionals had not fully recognised or assessed the level of non-compliance   and were carrying on regardless. Overall the evidence in these longer-term cases is of   a failure by professionals and their managers to be consistent in identifying non-    compliance, and in some cases failing to assertively challenge parents who were not    engaging with plans.” 5.1.5  Megan’s case highlights a number of examples of professional optimism and disguised   compliance. It is noted in reports that mother engaged with professionals during periods   of statutory intervention and recently in Megan’s  adolescence. The community health   record (2010) indicates that the mother responded to telephone contact or follow up of   non-attendance of Megan at planned appointments but does seem to actively support   future attendance.    This appears to be a recurrent theme throughout Megan’s adolescence.  Although her   mother appeared keen to gain professional support she did not achieve any agreed    actions or facilitate the attendance of Megan at appointments. It is clear from the IMRs   and chronology that some interventions did seem to have an impact on Megan and her   family. For example the input from BEST, aimed at addressing her self-esteem. Megan   reported during these sessions that the family were eating five portions of fruit a day,    experimenting with fish,  doing 15 minutes a day exercise with her mum and treating her   head lice together. She also expresses a keenness to get back into mainstream     lessons. Another example is the input from CORAM that led to a short-term      improvement in Megan’s hygiene. 5.1.6  The Megan SCR Panel has discussed Karen’s capacity to change and concluded that   this was never assessed by the agencies working with her. Therefore, we do not know   whether she has the capacity or capability to change. 5.1.7  What is clear is that any change made was never sustained, either because Megan or   her mother did not respond to the intervention or because Megan or her mother only    gave the appearance that they were engaging. For example, the Core Assessment    completed in July 2012 states that, since the Coram Parenting Course had finished “she   has reverted to her previous parenting.” Where initiatives were put in place to support                                                            xxxi Ofsted March 2014: In the Child’s Time – Professional Responses to Neglect https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/419071/In_the_child_s_time-professional_responses_to_neglect.doc   44   this family (and there were many), there is little to show of any evaluation of outcomes   of effectiveness. Instead, it appears that there was over-reliance on processes. During   statutory interventions, there appeared to be improvements in both children’s health and   well-being. However, during this time there were a number of professionals working with   the family and the emphasis seemed to support a “task” approach to achieving the    actions required of the plan.  5.1.8  The evidence would suggest that there was an element of workers feeling helpless in    this case. For example, education had expressed their concerns to Children’s Social    Care on at least 10 or more occasions. The records show that the college manager and   Connexions workers also felt helpless that, although they expressed their concerns    about Megan’s well-being, CSC did not seem to share the extent of these concerns.    The notes of the Child Protection Conference on 18th December 2012 indicate     frustration about the lack of progress and improvement but do not identify any other    action. What the evidence does show is that the concerns have been long standing with   very little change despite the children’s ages.  5.2 Accepting lack of access to the home and to Megan on home visits  5.2.1  Professional dangerousness in this case can also be illustrated by the way in which    professionals gained or failed to gain access to Megan and her brother and did not    escalate this as a concern.  5.2.2  Between April – October 2011, during the time that Megan and Tom were being home   educated, the educational welfare service made eight attempts to review and support    the elective home education.  The difficulties in reviewing the education delayed the    subsequent School Attendance Order and their attendance at the Pupil Referral Unit.  5.2.3  Between June and November 2013, Megan and her brother were on to a CIN plan. We   now know, from the college manager’s records that Megan’s physical state deteriorated   significantly during this time. The records indicate that the Social Worker undertook at   least nine home visits of which at least five were aborted as no one was home. A record   from a visit on the 8th November 2013 states that the children were not seen, as they    were asleep upstairs. There is an expectation that bedrooms are seen during home    visits. However, the recording does not state the time of the visit and whether this was   normal behaviour for 17 and 18 year olds.      45  5.3 Accepting the status quo for this family  5.3.1  Professional dangerousness could also explain how the amount of contact with the    family and the frequency of home visits did not highlight that conditions had deteriorated   to such an extent that Megan required hospitalisation and extreme treatment for the lice   infestation. Did the agencies accept the status quo for this family? Previous Serious   Case Reviews have highlighted the importance of seeing, observing and hearing the    child/ young person. Serious Case Reviews stressed the importance ensuring that    practitioners’ observations are clearly recorded and the consequences that can arise    when this does not happen.  5.3.2  It is difficult to understand how the college tutor observed the deterioration in Megan’s   appearance since she had seen her five months previously, however the Social Worker   did not appear to have noticed this.  The Social Worker was the only person who was   seeing Megan consistently during this period and there is no recording that there were   concerns regarding her appearance. The Social Worker also saw Megan on the 22nd    November but did not mention in detail her observations except saying that she did not   look well. There was no record of any lice on her body or her general presentation. Five   days later, Megan was admitted to hospital, where doctors recorded that she was    ‘terribly unkempt’ and had lice all over her body, wherever there was hair. Nine days    after admission Megan’s skin integrity remained concerning as she had ground in dirt in   her sternal area, elbows, knees and on the knuckles of her toes. 5.3.3  It is not clear whether Megan’s health and presentation deteriorated in such a short time   between the 22nd and 27th November, or whether the Social Worker had not noticed/    observed concerns with regards to her presentation. If she had observed the      deterioration, the records do not show what, if any, action was taken.  5.3.4  In potentially accepting the status quo for this family, a specific point that needs to be    addressed is the lack of urgency in taking action by the Social Worker when Megan    became unwell. Medical support was not sought despite concerns about her condition   at enrolment and being physically sick as well as almost collapsing.   5.4 Recognising and responding to closure  5.4.1  ‘Closure’ is a well-known phenomenon identified from past Serious Case Reviews    when parents deliberately remove children from contact with the outside world and    home schooling can be one way of achieving this. A sign of closure in this case was the   46   withdrawal of the children from school by Karen (mother). Karen (mother) informed CSC   and the school on 24th February 2011 and 23rd March 2011 respectively that she was    removing Megan and Tom from the school they attended. She said that she would be   educating them at home. This is the standard procedure for any parent wishing to home   educate their children. Elective Home Education has been flagged as a serious issue in   a number of SCRs.xxxii Despite this, CSC closed the case on the 25th March 2011, two   days after the date of Karen’s letter. 5.4.2  On receipt of the information from the school, the Education Welfare Officer visited the   home to complete the Elective Home Education papers with Karen (mother). After a    failed home visit to do this on 04/04/2011, this was done on 27/04/2011. A process was   then put in place for home visits by the Local Authority Home Education Consultant.    Following five failed attempts by the Elective Home Education Consultant to contact the   family at home through pre-arranged appointments, a formal letter was sent to Karen    (mother) to contact the Consultant and following a further failed home visit, the     Consultant judged the home education to be inadequate. On 04/10/2011, Karen     (mother) was invited but failed to attend a Borough Attendance Panel, which lead to a   School Attendance Order being put in place.  5.4.3  Given the fact that Megan was in year 11 and the case had been closed to CSC, the    Local Authority carried out the appropriate actions in line with the guidance on Elective   Home Education.  However, the school has acknowledged in the IMR that it was     opposed to the home education but that there is no evidence that senior staff      intervened at a high enough level to show the level of concern. However, these     concerns may then have impacted further on decisions taken by CSC.  5.5 Case closure and lack of management oversight - why were professionals unable to act collectively to achieve positive outcomes?  5.5.1  A further indication of professional dangerousness in this case is the amount of case    closure and lack of management oversight. Despite the iterative concerns about     neglect, there is evidence that Children’s Social Care closed the case on at least six    occasions. The Child in Need review on 18th November 2013 decided that CSC should   end their involvement, as there were no immediate concerns noted in the meeting and                                                            xxxii NSPCC: March 2014. Home education: learning from case reviews  - what case reviews tell us about elective home education     47   that other agencies were still involved.  5.5.2  Within four days of that meeting, a tutor from Megan’s college contacted CSC as she    was concerned about Megan and felt she had deteriorated rapidly since she had last    seen her in June 2013. The Social Worker also saw her on the same day and stated    that she did not look well. It is not recorded who should have taken action to seek    medical intervention and why nothing was done.  5.5.3  The Social Worker involved in this case had twenty-one supervision sessions between   December 2010 and February 2014. The records of only two (in February and     December 2013) go into any detail regarding the Social Worker’s concerns regarding    the children’s circumstances. 5.5.4  There was no management oversight recorded before December 2012. The recordings   may have been written manually and are therefore not on the electronic system. During   this period, there were numerous recordings by the Social Worker of concerns by the    school and other agencies as well as their own observations. Most significantly was the   period between May and June 2012 where the records describe chronic neglect as    seen by the Educational Welfare Officer and the Social Worker. The children were    placed on a Child Protection Plan in September 2012. However, there is no recorded    management oversight of the concerns. 5.5.5  Following the case transfer to the Family Support Team there was a marked      improvement in supervision, which was usually monthly. Some of the supervision notes   miss details that were mentioned by the Social Worker in her notes. None of the     supervision sessions recorded show any evidence of reflective practice and looking    back at the family history to make sense of what the risks were. None of the supervision   records seen show how and why decisions were made; for example decisions to close   the case. 5.5.6  There is no evidence of case auditing between December 2010 and February 2014.    This would have helped managers to be aware of the concerns recorded on the case    notes, which would have led to improved decision making and planning. 5.5.7  There was no evidence that school nurses had sought Safeguarding Children     supervision during this time. The opportunity for all staff working within NELFT to     receive Safeguarding Children Supervision has been in place throughout the period of   this review.  The Safeguarding Children Supervision Policy within the organisation was   reviewed in July 2013. The Policy mandated the requirement for safeguarding children   supervision for all staff working directly with children and adults who are parents/carers   of children. The policy provides examples of cases that should be reviewed during case   management for identification for the requirement of Safeguarding supervision. An audit   48   is completed annually to ensure compliance with the policy and learning is shared at all   staff levels throughout the organisation.  Learning – how to avoid professional dangerousness Questions for the Board  17.  How can the Board be assured that staff have the knowledge and skills to recognise    disguised compliance and challenge parents where this is the case? 18.  How does the Board ensure that all professionals record the type of interaction between   child/young person and their parent/carer and share concerns with other relevant     agencies? 19.  How does the Board ensure adequate, recorded supervision and management     oversight of all cases where there are concerns?      49  Was the consideration of legal (criminal and care) proceedings affected by age? Overall finding for criminal legal proceedings: The fact that Megan had passed her 16th birthday meant that a criminal offence of neglectxxxiii could not be considered as an option.  Overall finding for care proceedings: There were a number of missed opportunities to instigate care proceedings during the period of the review.  6.1 Criminal Findings (evidence)  6.1.1  The inability of inter-agency efforts to successfully interrupt the pattern of behaviour and   poor living conditions of this family since at least 2009 reinforces the view that another   approach was needed.  That criminal investigation was at least one option that was    considered but not taken forward. While prevention is always preferred to prosecution,   prevention was not working in a sustained way.  6.1.2  There are two instances on the timeline for this review when the police could have    considered criminal neglectxxxiv. These were: •  In June 2009, the school police officer referred Megan to Social Care but did not let the  Child Abuse Investigation Team (CAIT) know. •  In July 2012, Social Care referred Megan to the police for Initial Child Protection Case  Conference (ICPC). This presented the police with an opportunity to assess the  neglect as criminal. 6.1.3  Other factors were: • The history of prolonged engagement with partner agencies; and                                                            xxxiii The offence of neglect is described under Section 1 (1) of Children & Young Persons Act 1933 as Cruelty to Persons under 16. This states: Section 1 of the Children and Young Persons Act 1933 creates offences relating to the treatment of a child or young person under 16 years by a person (who has attained the age of 16 years) who has responsibility for such child or young person. 1(1) If a person who has attained the age of sixteen years and has responsibility for a child or young person under that age, wilfully assaults, ill-treats (whether physically or otherwise), neglects, abandons, or exposes him, or causes or procures him to be assaulted, ill-treated (whether physically or otherwise), neglected, abandoned, or exposed, in a manner likely to cause him unnecessary suffering or injury to health (whether the suffering or injury is of a physical or a psychological nature) that person is guilty of an offence, and shall be liable xxxiv Ibid   50 • The absence of a direct causal link between Megan’s collapse and neglect. Whilst Megan was apparently dirty and unkempt with severe head lice these were not the most dangerous conditions she was being treated for. Medical opinion at the time was unable to directly attribute the clots or anaemia to any neglect cause and it was this together with the other factors that ended the investigation.  6.2 Care Findings (evidence)  6.2.1  Section 31 (c) of the Children Act 1989xxxv states no Care Order may be made with    respect to a child who has reached the age of seventeen (or sixteen in the case of a    child who is married). While the success of the intervention was questionable the     chances of a Section 31 Children Act application in these circumstances making a    significant difference was unlikely to improve the care of the children, one of whom was   almost 18 and the other not far behind. Both were deemed capable of making decisions   about cleanliness, hygiene and diet. 6.2.2  The view that Megan could make decisions was agreed by agencies at the Initial Child   Protection Conference in February 2014 – that Megan was “of an age where she is able   to make informed decisions and choices of her own.” 6.2.3  The key periods of time for assessing whether Care Proceedings should be taken    forward during the review period were as follows:  1. 23/03/2011 – Megan is 15. Karen (mother) decided to home educate the children, which increased their vulnerability and lack of contact with professionals. It should be noted that the School Megan attended was opposed to the move to Elective Home Education as it meant that it would be difficult to monitor Megan’s welfare. At this particular point the children were at significant risk of harm as there would be no professionals to monitor their education and their well-being.  No records have been seen as to how Karen (mother) would be home educating the children. 2. 25/03/2011 – Megan is 15. Children’s Social Care closed the case.  3. 11/09/2012 – Megan is 16. Initial Child Protection Conference.  4. 20/07/2012 – Megan is 16. Strategy discussion explored the use of police protection and legal proceedings. An ICPC contingency plan stated that a legal planning meeting should take place if Karen (mother) did not comply with the ICPC. She did not comply.                                                            xxxv The Children Act 1989; Guidance and Regulations; Section 31 (c)   51 However, the Legal Planning meeting was not followed up, despite ongoing frustrations from agencies about the lack of progress. 5. 18/12/2012 – Megan is 16. Review Case Conference (held inquorate as had been rearranged four times due to non-attendance of agencies involved).  6. Within Private Law Proceedings initiated by Megan’s father for contact, the safeguarding concerns were such that the Court ordered a S37xxxvi report, which would determine whether Megan’s circumstances reached the threshold for the instigation of Public Law Proceedings or any other support from the Local Authority. Two extension dates for this report were granted on 21/11/12 and 28/11/2012. The S37 report did not consider that Megan met the threshold. The judge permitted Megan’s father to withdraw his application as a safe agreement had been made between the parents for indirect contact. 6.2.4  In 2015, the Children’s Societyxxxviireleased some figures to support the need to give    16 and 17 year olds the same legal protection as younger children. These figures show   that 1 in 50 teenagers aged 16 and 17 are more at risk of abuse or neglect than any    other age group. Neglect itself is a complex phenomenon and difficult to definexxxviii. This   lack of clarity about what child neglect means has practical implications and                                                               xxxvi Children Act 1989: Powers of court in certain family proceedings. (1) Where, in any family proceedings in which a question arises with respect to the welfare of any child, it appears to the court that it may be appropriate for a care or supervision order to be made with respect to him, the court may direct the appropriate authority to undertake an investigation of the child’s circumstances. (2) Where the court gives a direction under this section the local authority concerned shall, when undertaking the investigation, consider whether they should— (a) Apply for a care order or for a supervision order with respect to the child; (b) Provide services or assistance for the child or his family; or (c) Take any other action with respect to the child. (3) Where a local authority undertake an investigation under this section, and decide not to apply for a care order or supervision order with respect to the child concerned, they shall inform the court of— (a) Their reasons for so deciding; (b) Any service or assistance which they have provided, or intend to provide, for the child and his family; and (c) Any other action which they have taken, or propose to take, with respect to the child. xxxvii The Children’s Society (2015); 16 and 17 year olds at greatest risk of abuse and neglect but are least protected xxxviii NSPCC (2007), Child Neglect   52   practitioners’ understandings of neglect can vary within and across different services.    This can lead to vital information in neglect cases not being picked up, information    being lost or not effectively communicated across agencies. 6.2.5  Changes to the department have meant that Child Protection Conferences are now    prioritised and police would now be more proactive and engaged with cruelty cases and   better at rationalising involvement and determining criminal neglect thresholds.  Learning – how to ensure that the consideration of legal proceedings are not affected by the age of the young person Questions for the Board  20.  How does the Board assure itself that agencies are clear about the grounds for and    ensure that consideration is given to criminal neglect (Cruelty to Persons under 16)    investigations?   7. KEY LEARNING  This Serious Case Review has identified the following themes for learning: 1. Adolescent neglect During the period of this SCR, neglect was not prioritised and there was a lack of understanding of the criminal threshold for cruelty. Some specific signs of adolescent neglect were also missed. For example, not every adolescent understands what they are expected to do if they have never been taught so assumptions were made about what appeared to be choices Megan was making about her sociability, her hygiene and her attendance.  2. The child’s voice Despite the fact that Megan stood out, had no friends and looked miserable, her voice or her lived experiences were rarely sought or heard. This was exacerbated by the fact that she was rarely seen alone at home and that her long period of home education resulted in fewer opportunities for her to express her needs.  3. Outcomes There was no lack of input into Megan and her family from a wide range of agencies over a number of years. What was missing was a focus on outcomes and questioning what difference   53 was this level of service input making. Too much reliance was put upon recording the number of interventions and self-reporting by Karen (mother) or Megan herself. 4. Effective challenge The Case Conference and Core Group meetings were not used to best effect in Megan’s case. Agencies did not attend or take an active part, invitations (to health staff) were not sent or sent late, Karen (mother) did not always attend and meetings were often cancelled as inquorate. This meant that key information was not shared and led to missed opportunities to review outcomes on a multi-agency basis (see above) and to challenge. 5. Performance management The high number and frequency of multi-agency interventions did not prevent the outcome for Megan. This raises a question about the adequacy of performance management, in terms of reflective supervision and review of records. This has been recognised in a number of IMRs. 6. The role of health organisations Recognising that many different health professionals may be involved in different ways with a child’s health and well-being can make the health arena seem complex to those in other agencies and affect engagement and communication. In this case, there was a lack of clear responsibility for one area of health to look at Megan’s health needs and ensure that referrals were followed up.     54  8. RESPONSE TO SERIOUS CASE REVIEW FROM THE CHAIR OF THE THURROCK LSCB Thurrock LSCB will make sure that all agencies have put in place effective responses which ensure that learning from this review improves the way professionals keep children safe in the future.   It is clear that the review has found a number of areas where multi agency working could have been better and missed opportunities for a different course of action and outcome for Megan.  This review has enabled professionals to look at their actions to see if there was anything that could be done in future to further improve working between agencies and safeguarding for children where neglect is the main contributory factor. The findings and issues for consideration from the review have been endorsed by those agencies involved who have already begun to make changes based on the review's findings. Family members have been involved during the process and contributed to the review and have been kept informed during the process.   Detailed learning plans have been produced by individual agencies in response to the findings and the questions posed to the Board by the Review Author.  The Board through its Serious Case Review (SCR) Sub Group will monitor the review and the progress of these plans on both a short and long term basis.  Thurrock LSCB undertakes:  • To oversee the implementation of single agency learning plans arising from this review and reflect on progress in the Annual Report.   • In overseeing the implementation, the LSCB will establish timescales for action to be taken, agree success criteria and assess the impact of the actions.  • The SCR Sub Group of the LSCB will actively monitor progress on actions from the agencies by requiring updates every other month.   • That all the findings from the Serious Case Review are assessed by the LSCB Training Sub Group to ensure multi agency programmes commissioned by the LSCB reflect the learning.  • All agencies that had involvement with this SCR have been asked to ensure their practitioners have been given feedback from the review prior to the publication of the final report.   • At the point of publication, to ensure that the wider workforce is aware of the learning, the LSCB will also publish a SCR booklet. This will set out the key findings from the review, and also offer links to further advice and guidance should practitioners need it.    55  • The learning from this review will be included in the next multi agency LSCB SCR briefing workshop  • A quarterly summary on progress on actions will be provided to the Full Board.  • Learning from this SCR will be incorporated into LSCB ‘Learning from Review Sessions’ delivered as part of the Learning and Improvement Framework.  • Thurrock LSCB will require partner agencies, as part of single agency Quality Assurance (QA) procedures, to undertake case file audit which incorporates a review of the findings identified.  • Thurrock LSCB Audit Sub Group will receive from single agencies ‘quality assurance audit reports’ which will provide findings from audit activity and detail of remedial actions implemented in response to any findings.   This Serious Case Review will be published on the Thurrock LSCB and NSPCC website to enable other Safeguarding Boards and Agencies to take any learning from the review.   Dave Peplow Independent Chair      56 Appendix A: Glossary ABH Actual Bodily Harm BEST Best Education Support Team CAF Common Assessment Framework CAFCASS Child and Family Court Advisory Support Service CAIT Child Abuse Investigation Team CSC Children’s Social Care DA Domestic Abuse DNA Did Not Attend EWO Education Welfare Officer EWS Education Welfare Service GP General Practitioner HIP Health Improvement Practitioner ICPC Initial Child Protection Conference IMR Individual Management Review IRT Initial Response Team LA Local Authority LSCB Local Safeguarding Children Board MAG Multi-Agency Group MASH Multi-Agency Safeguarding Hub MEND Mind Exercise Nutrition Do-It NELFT North East London Foundation Trust   57 Outcome In this review the terms refers to Megan’s collapse and admission to hospital PRU Pupil Referral Unit SCR Serious Case Review SCR Panel Senior representatives from local statutory agencies SMART Specific, Measurable, Achievable, Realistic and Timely SW  Social Worker TPSS Thurrock Pupil Support Service      58 Appendix B: Membership of the Megan SCR Panel  Job Title Agency Head of Children’s Social Care Thurrock Council Senior Service Manager CAFCASS Head of Child Abuse Investigation Essex Police Named Nurse for Safeguarding Children Basildon and Thurrock University Trust Hospital Head of Children’s Services Thurrock NELFT Strategic Leader, Learner Support/Principal Educational Psychologist Thurrock Council Designated Nurse for Safeguarding Children Thurrock CCG    Appendix C: List of agencies involved with Megan during the time period of the SCR  Agencies Involved Adults Social Care Basildon & Thurrock University Trust Hospital CAFCASS Catch 22 Children’s Social Care Connexions Coram College Education Welfare Family Mosaic FIP The School Megan attended Great Oaks Housing, Thurrock Council Inspiration Youth MEND Programme The College Megan attended Secondary School Open Door   60 Police Probation Pupil Referral Unit South East Essex College Thurrock Careers/Connections Thurrock Learning Troubled Families  