Death of a 3-month-old girl in March 2019. Tracy was found deceased at home. Criminal investigation commenced by police and care proceedings instigated for siblings. Tracy was the youngest of three siblings; all had recently been made subject to a Child Protection Plan for neglect. In 2018, an anonymous referral regarding malnourishment resulted in sibling made subject to Child in Need. Family history of domestic abuse; father arrested on several occasions and had restraining order not to contact mother. Concerns about parenting capacity and neglect. Maternal history of depression, alcohol and cannabis use. Several agencies tried to engage with mother and offered to provide services within the Early Help Assessment Tool (EHAT); all offers of supports were refused. Learning includes: responsibility to initiate an Early Help Assessment (EHAT) is that of any professional who is working with a child and/or family; lack of support and alternative options available to professionals when responding to a persistent refusal of services; anonymous reports of safeguarding concerns can create a challenge for professionals in identifying the facts and responding to safeguarding concerns in a timely and evidence based approach. Recommendations include: produce a pathway for professionals which details what support, processes and resources are available for engaging resistant families; agency access to policies which detail how they should respond to refusals to engage, share information and escalate concerns into statutory intervention; ensure that information is available to the public on the timeliness of reporting concerns and outcomes available to agencies in response to those concerns.
      
    Serious Case Review No:  2020/C8153  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   Official Sensitive Government Security Classifications April 2014         1                          Serious Case Review   Child Tracy   Overview Report – Final Version                                                           Official Sensitive Government Security Classifications April 2014         2          CONTENTS        Section                            Page       1. Circumstance which led to a Serious Case Review.        3                 2. Methodology.                        4             3. Terms of reference (including review period and rationale).        5           4. Overview of what was known to agencies.                                5      5. Analysis.                                     12       6. Conclusion.                                           16      7. Summary of learning and recommendations.             17             Appendix A    Serious Case Reviews                                  19                     Official Sensitive Government Security Classifications April 2014         3      1. Circumstances which led to a Serious Case Review.      Key Individuals   Referred to as:   Tracy   Child Victim   Sibling   Sibling 1   Sibling   Sibling 2   Mother of Tracy   Mother   Father of Tracy   Father      1.1 Pseudonyms have been used throughout the report, for key individuals and professionals who worked with Tracy and her family.      1.2 Tracy died in March 2019.  At the time of her death she was 3 months old.  Tracy was the youngest of three children, all of whom had recently been made subject to a Child Protection Plan for neglect.     1.3 Tracy was found unresponsive at home, an ambulance was called and despite attempts at resuscitation, she was pronounced dead.  Police commenced a criminal investigation and Children’s Services commenced child care proceedings in respect of Sibling 1 and Sibling 2.   1.4 There was a history of domestic abuse within Tracy’s family, concerns had also been raised about parenting capacity, neglect of health and care needs of the children. There were allegations of substance misuse and Mother had presented as uncooperative with Professionals.     1.5 In October 2018 the case had been opened as Child in Need following concerns in an anonymous referral regarding malnourishment, and that Tracy’s siblings and their Mother had been seen in the street in the early hours.  This referral was before the birth of Tracy.  In January 2019, further concerns were raised regarding the health of Sibling 1 and the case was progressed to Child Protection for all three children.   1.6 Following Tracy’s death, and in accordance with procedures, a strategy meeting and Sudden Unexplained Death in Infants (SUDI) meeting were held.  A decision was reached that the case reached the criteria for a Serious Case Review.         Official Sensitive Government Security Classifications April 2014         4            2. Methodology.      2.1 An Independent Chair and Author were appointed who are experienced in undertaking serious case reviews.  Neither the Chair nor Author had previously worked for any of the agencies engaged within the review.   2.2 A Review Panel was established, its members gathered and analysed data, agreed Key Lines of Enquiries, reviewed practice and agreed the content of drafts and the final report.  The Review Panel met on three occasions, meetings were chaired by the Independent Chair, minutes and key actions were produced.   Job Title  Organisation  Detective Chief Inspector  Police  Report author  Independent  Education Officer  Local SCB   Designated Nurse  Safeguarding Children  Clinical Commissioning Group  Chair  Independent  Service Manager  City Council Children’s Services  Co-ordinator  Local SCB    2.4 Written contributions and chronologies were received from all agencies involved within the review.  Where additional information was requested this was provided to the Chair and Author.     2.5 The review used a systems-based approach to analyse information and key events.  The findings are presented in Section 7 using recommended best practice in identifying improvement and learning.    2.6 The Independent Chair wrote to Mother informing her of the review.  At the time of writing this report legal constraints prevent the review panel speaking  to Mother. The review panel made the decision for the Father of Tracy not to be contacted and informed of the review.     Official Sensitive Government Security Classifications April 2014         5      The panel felt that it was important to give Mother the opportunity of engaging with the SCR to see if it could be established why she was resistant to the help and support being offered by professionals. If there were specific reasons it would enhance the learning and probably assist agencies in working with non-cooperative families.        Terms of Reference.     3.1 The Review Panel agreed that the period under review would be from mid November 2017 (12 months prior to birth) and up to a date in March 2019 (death of Tracy).   3.2 The Review Panel agreed not to set specific terms of reference.  The combined chronology was reviewed during the first panel meeting and Key Lines of Enquiries identified to allow for a wider exploration of important events relevant to safeguarding practice and systems.   3.3 The Key Lines of Enquiries focused on:   • Agencies knowledge and responses to domestic abuse.  • Agencies responses to identified needs with the family.   • Was the decision making and the assessed thresholds appropriate?   • Was the response of agencies to third party, including anonymous, referrals appropriate?   • Was escalation on the case undertaken at the right level and pace?   4. Agency Overview.       4.1 Agency involvement prior to start of review date.   4.1.1 Mother had a history of depression, alcohol and cannabis abuse.  Records stated that Mother had limited support with extended family members.  These vulnerabilities were identified during her pregnancy with Sibling 1, but Mother declined professionals’ offers of support and referral to specialist teams.      4.1.2 Mother engaged well with professionals during her pregnancy.  Sibling 1 was born in April 2014.  There were no concerns at birth, and Mother and baby were discharged early.  Mother continued to engage well with professionals following the birth, and not long after, she moved into her own accommodation.     4.1.3 In July 2014, Health Visiting services attempted to see Mother and Sibling 1 to discuss weaning.  There were a number of failed encounters, and on one occasion a male answered the door, he Official Sensitive Government Security Classifications April 2014         6      reported that he was the Father, but stated Mother must have forgotten the appointment as she was not in.  Entry was not gained.    4.1.4 Children’s Social Care received a referral in July 2014 from a floating support worker who reported that Mother was threatening to harm herself and Sibling 1 due to rat infestation within the property.  Mother had moved out of the property to live with family.  Pest Control were due to attend the property.  A  Social Worker visited Mother and it was agreed she would continue to be supported by Health Visitor, GP and Children Centre.   4.1.5 In September 2014 Mother attended at hospital where it was confirmed that she was pregnant with Sibling 2.  On 17 September 2014 Police attended a report of a verbal argument between Mother and her extended family.  This incident was shared with Children’s Social Care at the beginning of October 2014.     4.1.6 Mother informed a midwife in October 2014 that she had ceased using cannabis in May 2014 and continued to deny cannabis use in further appointments.  Mother declined to share details of the Father of Sibling 2.     4.1.7 On 23 December 2014 Police attended a reported domestic incident at the home address of Mother.  Father was trying to gain entry to the property and had damaged a window.  Mother and Sibling 1 were not at the premises.  Details of the incident were shared with Children’s Social Care.   4.1.8 At the beginning of January 2015 Mother was involved in a domestic abuse incident in another area with Father.  Children’s Social Care completed a single assessment which took account of both recent incidents.  The case was  heard at MARAC1 (Multi Agency Risk Assessment Conference) in February 2015.  Mother signed a written agreement not to have contact with Father and the case was closed in March 2015.     4.1.9 In April 2015 Sibling 2 was born.  Father was present during birth. Routine questions on domestic abuse were asked but Mother made no disclosures.   4.1.10 In April 2015, Health Visiting made a home visit with Mother and Sibling 2 during which she reported that Father was staying with them until the following week before he returned to where he was living.  The flat was reported to be cluttered, Father was seen to be tidying up; there was no carpet in hall and on staircase.     Official Sensitive Government Security Classifications April 2014         7      4.1.11 The day after this visit Police received a report of a domestic abuse incident.  Mother had been head butted by Father.  Sibling 1 and 2 were present during this incident.  Mother attended at hospital with facial bruising, blurred vision and haematoma to left side of head.  Father was arrested and charged with offences of assault occasioning actual bodily harm and threats to kill.  The incident was shared with Children’s Social Care and the case referred to   MARAC.  Mother was referred to the IDVA (Independent Domestic Abuse  Advocate) service.  Mother moved to live with family until she was re-housed.     4.1.12 Children’s Social Care completed a single assessment to review the parenting capacity of Mother.  A Child in Need meeting was held.  Mother declined Early                                             Help Assessment (EHAT) support, Father was in custody and Mother was seen to be engaging with professionals.  Advice was given to Mother should she resume her relationship with Father that the case could be escalated to child protection processes. The case was closed.   4.1.13 In February 2016 a neighbour contacted the front door service and reported concerns regarding the care of Sibling 1 and 2.  The Health Visitor informed the Social Worker that Mother did not engage and that the Health Visitor had no concerns; however; the Health Visitor did report that Mother would benefit from parenting classes. Mother was contacted and denied the concerns.  The incident was closed with the agreement of a Manager.   4.1.14 In July 2016 the two-year developmental check of Sibling 1 was completed.    Some concerns were noted regarding diet, dental care, Mother’s emotional warmth and ability to provide guidance and boundaries as well as environmental factors in relation to the living conditions of the property.  The  Nurse advised on a Speech and Language Therapy (SALT) referral but Mother declined and stated she felt the speech will improve once the child started nursery in September.    4.1.15 The identified concerns were discussed with a Team Leader and Safeguarding  Nurse, who advised Health Visitor to log them with the front door service and complete an Early Help Assessment Tool (EHAT) if Mother agreed for extra support.  A further home visit was undertaken and EHAT discussed with Mother and Maternal Grandmother.  An information leaflet on EHAT was left for Mother to read.  Mother declined the support of EHAT.   Official Sensitive Government Security Classifications April 2014         8      4.1.16 Sibling 1 came to attention of several Health professionals due to dental decay.  Mother did not follow up the dental appointments.   4.1.17 In March 2017 an anonymous referral was received by in relation to Sibling 1 and 2, which stated that they believed the home was being used as a ‘crack house’ and the children were constantly crying and screaming through the night.  The referral was triaged with a recommendation for Early Help and forwarded to the Children’s Centre to initiate engagement with Mother.   4.1.18 The Children’s Centre were unable to contact Mother by telephone and home visits. The Children’s Centre Manager made the decision for the referrer to be informed of the outcome and the case was closed.     4.1.19 Sibling 1’s attendance at Nursery declined from May 2017 onwards.  A home visit by the Community Nursery Nurse identified further concerns.  Mother reported to have forgotten about Sibling 1’s dental appointment.  A further referral would be made.  Mother was observed speaking inappropriately to the children, appropriate advice was given.  Despite a slight improvement in Sibling 1’s speech, an assessment in February had identified that the speech  was significantly below the normal range.  A further assessment was arranged for July 2017.    4.1.20 In July 2017 Police attended an incident during the early hours of the morning between Mother and Maternal Grandmother.  Mother was reported as being drunk and threatening to ‘glass’ her Mother.  Sibling 1 and 2 were present.   Police Officers recorded that the children did not appear to think there was anything unusual about what was occurring despite both women screaming at each other, and that it appeared normal for them to be awake at that hour.     4.1.21 By October 2017 Sibling 1 had failed to attend further dental appointments.  The Health Visitor had been unable to contact Mother on a home visit.  This visit was to discuss EHAT with Mother, as well as the children’s development, attendance at Nursery and medical appointments.  It was recorded that the  family had not been seen by the GP since December 2016.  An appointment was made for Sibling 1 to attend for pre-school booster.      4.2 Agency involvement within timescale of review.    4.2.1 Sibling 1 did not attend the pre-school booster appointment.   Official Sensitive Government Security Classifications April 2014         9      4.2.2 The Health Visitor was denied access to the house by Mother during a home visit in January 2018.  Mother stated that the visit was inconvenient, as she and her children were asleep.  A further appointment was arranged.    4.2.3 The Health Visitor completed a home visit in February 2018.  Sibling 1 was seen to be wearing a nappy and looked pale and thin, a poor diet was reported, and the child appeared tired throughout the visit.  Mother stated that Sibling 1 had been referred to the Dental Team but that she did not want the child to go under anaesthetic and preferred to wait for second teeth to emerge. A referral was made with Mother to attend at the GP to review diet and iron levels.  Communication skills were recorded as poor.    4.2.4 The Health Visitor recorded that Mother displayed an indifferent approach to advice regarding both children and no warm interaction was noted during the visit. Mother appeared in low mood and stated that she was unwilling to accept professional advice around parenting and would do things her way.  The Health Visitor assessed the family and noted them to be at level 2.  (Child has additional, or emerging, needs which may require support. Consider an Early Help Assessment EHAT.) EHAT was discussed with Mother who stated she would contact the Health Visitor if she wanted to progress.   4.2.5 In April 2018 Mother was involved with an altercation with a neighbour during which Mother was assaulted.  Both children were present during this incident.   4.2.6 By May 2018 Sibling 1’s Nursery had started to identify concerns. The Inclusion Manager contacted the Health Visitor and was provided with background information in relation to the family.  The Front door service advised the Inclusion Manager to gather more information and to record these on a Referral Form if appropriate.  The Inclusion Manager was unable to contact Mother and obtain details for the Referral Form.    4.2.7 Mother attended hospital in May 2018 where it was confirmed that she was pregnant with Tracy.  Routine enquiry was undertaken surrounding domestic  abuse - no disclosures were made.  Mother left the hospital before treatment finished.     4.2.8 On the afternoon of 15 May 2018 the School Inclusion Manager and Nursery Teacher completed a home visit.  The house was in darkness and Mother stated that she, and the children were asleep.  A discussion took place regarding lack of attendance of Sibling 1, several options Official Sensitive Government Security Classifications April 2014         10      were discussed, and Mother agreed to Sibling 1 being picked up.  The following day when staff went to collect Sibling 1 Mother stated that the child was ill and would not be attending at Nursery.     4.2.9 The School Inclusion Manager discussed their concerns with the Health Visitor and were advised to open an EHAT in order to try and engage Mother with access to Early Help.   4.2.10 In June 2018 Sibling 1 attended at Nursery and was seen to be very pale, withdrawn and unsteady on their feet.  The Nursery felt that the child’s shoes were too tight and raised this with Mother.  The following day Sibling 1 attended in sandals.  The Inclusion Manager continued to be in daily contact with Mother and supported her to complete the Primary Transfer Form (education) for Sibling 1 for September 2018.  The EHAT was not progressed.   4.2.11 Towards the end of June 2018 Mother reported a breach of restraining order and assault by Father to the Police.  The assault had occurred two weeks previously whilst Father had been staying at the property.  Father was subsequently charged with a number of offences and the case was referred to MARAC.  Details of the incident were shared with agencies, including Children’s Social Care.   4.2.12 In July 2018 the case was allocated to a Social Worker.  A single assessment was commenced which concluded with a recommendation for EHAT and allocation to domestic violence worker. Mother had acknowledged the impact on the children in relation to the domestic abuse.  As Mother was already engaged with an IDVA, a decision was made not to allocate to a domestic abuse worker.  The EHAT was not progressed.     4.2.13 Mother attended a health appointment in August 2018 in relation to her pregnancy.  Details of the pregnancy, including a referral form for the unborn child were shared with Children’s Social Care.  Staff were informed that the  case had recently been stepped down to EHAT, and that the Social Worker who completed the single assessment was not aware that Mother was pregnant.   4.2.14 Towards the end of August 2018 Sibling 1 and 2 witnessed a domestic abuse incident between Maternal Grandmother and her partner.  Police attended this incident and shared the matter with Children’s Social Care.  A decision was made to undertake a joint visit with a worker from the Children’s Centre and the domestic violence worker.   Official Sensitive Government Security Classifications April 2014         11      4.2.15 In September 2018 staff from the Children’s Centre visited Mother.  Mother complained that the staff had woken her up (the visit was mid-afternoon).  The purpose of the visit was explained to Mother which included the offer of services and help.  Mother refused to engage.  Staff queried why both children were in bed, and not in school.  Mother stated she could not be in two places at once.  Although staff did not gain entry to the house they reported that the house appeared to smell, was messy and unkempt from what they could see through the front door.  The visit was discussed with a Manager who decided to override Mother’s refusal to consent and approved contact to be made with agencies engaged with the family.   4.2.16 Two days after this visit a midwife visited Mother at home and offered her enhanced team care for the pregnancy. Mother refused and stated she wished to continue with the care from the Community midwife.   4.2.17 By October 2018 several professionals were trying to engage with Mother, these included midwifery and the Children’s Centre.  Mother had failed to attend appointments with the midwife and had declined iron supplementation and influenza immunisation as recommended by her G.P.   4.2.18 In October 2018 Children’s Social Care received an anonymous referral reporting concerns that Mother and children had been seen out in the early hours of the morning and the children were dirty and malnourished.  The case was allocated to a Social Worker to complete a single assessment.  Contact was made with professionals involved in the family.  Mother was seen by a Social Worker and denied the allegations.  The children were seen and reported not to be malnourished.   4.2.19 In November 2018 Sibling 2 lost their place at Nursery due to nonattendance.  Tracy was born.  Home conditions were reported as poor.  Mother and Tracy were discharged the following day.   4.2.20 In December 2018 a Health Visitor conducted a home visit and recorded that Mother and three children, were all sharing the same bedroom.  A Manager in  Children’s Social Care reviewed the single assessment and requested further information in respect of development, weight, height and registration with GP and schools.   4.2.21 In January 2019 Children’s Social Care were still engaged with the family.  Concerns had been raised in relation to iron deficiency for Sibling 1.  Mother was still presenting as hostile and not co-operating Official Sensitive Government Security Classifications April 2014         12      with Professionals.  Mother was reported to not accept health concerns and continued to refuse support.  Mum did not attend her post-natal appointment.  Tracy was not taken to her 8 week check-up appointment.   4.2.22 Towards the end of January 2019 a Child in Need meeting was held in the family home.  Mother was defensive and continued to refuse support.  Mother  was informed of the expectations of her, and that the case would be progressed to Child Protection if concerns continued.     4.2.23 Sibling 1 attended at the GP for blood tests and was referred to hospital. Sibling 1 was severely anaemic.  Concerns were also noted on dental decay and poor diet, a slight heart murmur was also detected.  Due to the level of concerns the case was progressed to Child Protection and Child Protection Conference convened.  A home visit was undertaken with Mother who did not consider the concerns to be substantiated.   4.2.24 In February 2019 a school placement was identified for Sibling 1.  The School made several attempts to meet with Mother to discuss the placement, which was initially refused as Mother stated she wanted Sibling 2 to attend the Nursery at Sibling 1’s school.   4.2.25 By the end of February 2019 Sibling 1 had started to attend school.  Sibling 2 was attending a Nursery; this attendance was achieved with the help of Maternal Grandmother.   Sibling 1 had visited a dentist and recent blood tests had identified that the child’s iron levels had started to increase.   4.2.25 On 6 March 2019 an Initial Child Protection Conference was held.  All three children were placed on a Child Protection Plan at risk of neglect.  The plan identified the concerns of domestic abuse, neglect of health, dental needs, education and nursery, concerns about parenting capacity and non engagement of Mother with services.     4.2.26 In March 2019 Tracy was found deceased at home.  A criminal investigation commenced.  Safeguarding processes were commenced for Sibling 1 and  Sibling 2.          5. Analysis.     Official Sensitive Government Security Classifications April 2014         13      5.1 The Review Panel identified several Key Lines of Enquiries.  These are   summarised and used within this section to analyse key themes during the time period of the review.   5.2 Agencies knowledge and responses to domestic abuse.   5.2.1 There were several domestic abuse incidents reported to the Police.  These involved incidents between Mother and Father, and incidents involving Mother and her extended family.  The children were present during the incidents and reports from the Police stated that the children did not appear to be affected by the nature of the incidents. This observation appears to have been based on the assumption that the children had normalised the adults’ behaviour.  Father was arrested on two occasions and charged with criminal offences. He also had a Restraining Order not to contact Mother.    5.2.2 The Police shared details of the incidents with Children’s Social Care and Health Professionals.  The Police process of sharing information changed during the timescale of the review and now information is shared quicker and directly with agencies following the investment in technology.  Mother was referred to MARAC on three occasions.  Services were continually offered to Mother; however, she did not engage with any domestic abuse services.      5.2.3 The Maternity Trust would not have been aware that Mother had been involved in domestic abuse when she attended in May 2018 in relation to the pregnancy with Tracy, as the previous incidents had occurred outside of the agreed timescales for information sharing within the current policy.    5.2.4 The assessments undertaken by Children’s Social Care recognised the risk factors associated with domestic abuse and this was made clear to Mother during the assessment in 2015, should she have resumed her relationship with Father.  However; there was a lack of engagement with Father in the completion of these assessments.  There are numerous research papers which identify the benefits to engaging with father’s during assessments and child protection work1.      5.2.5 Mother was seen as a protective factor within the assessments, having reported the abuse to the Police and engaged with agencies.  However; there was a delay of two weeks in Mother reporting the incident in June 2018, during which Father had returned to live in the family home                                         1 https://www.communitycare.co.uk/2018/02/19/working-fathers-key-advice-research/      Official Sensitive Government Security Classifications April 2014         14      two weeks, despite being in breach of a civil order and a previous written agreement with Children’s Social Care.  The details surrounding Mother’s delay in reporting were not identified during the assessment.    5.2.6 All agencies engaged in the review showed a detailed knowledge and awareness of domestic abuse and the impact on children.     5.3 Agencies responses to identified needs with the family.   5.3.1 The Review Panel found clear evidence that Professionals had identified the family had additional needs and attempted to progress this through the EHAT.    This was the correct response to the needs that had been identified.  The EHAT was explained to Mother on more than one occasion.  Documented information was also given.     5.3.2 During the single assessments undertaken by Children’s Social Care the voice of Sibling 1 and Sibling 2 was captured and documented.  Tracy’s voice was identified through observed interaction with Mother.  There were no direct recordings of the voice of the child within the health records held by community health services. It is felt that this was possibly due to the young age of the children when they were seen and issues that had been noted around speech development.   5.3.3 There was some good examples of information sharing on the case between Universal services, but this focused on individual incidents rather than a pooling together of all information, including historical information which may have identified the need for earlier intervention.     5.3.4 Mother’s refusal to accept the offers of EHAT and additional services had to be accepted by agencies, as currently there is no policy or process which allows them to refer their concerns when the threshold for statutory intervention has not be reached, and the engagement with Mother should be undertaken with consent.  This has been identified as an area of learning  5.3.5 5.3.4 Working with Mothers who are resistant or obstructive is a challenge for all professionals who should always remember the welfare of the child is paramount.  To assist Professional information and resources should be available to Professionals to assist them to engage and work with resistant families.   5.4 Was the decision making and thresholds reached on the case appropriate?   Official Sensitive Government Security Classifications April 2014         15      5.4.1 In terms of the threshold for Early Help it is clear despite repeated attempts  Mother did not engage with Health, Education, Children’s Centre, this included  the offers of access to classes and visits from a Link Worker.  The difficulty that this created for Professionals is described within 5.6.2.     5.4.2 The single assessments undertaken by Children’s Social Care were appropriate and relevant to the concerns that had been raised.  However; there were no specialist assessments and Mother declined services from other agencies which might have led to mental health or drug use assessments.    5.4.3 The pattern of assessments showed the need to take history and referral into account. There was little evidence of agencies coming together to pool assessment information until the Initial Child Protection Conference.    5.4.4 Although domestic abuse was frequently the reason for referral, it may have masked that the children were neglected in terms of universal health and education.  Mother refusal to engage and accepted services is documented across all agency’s records.  The Graded Care Neglect Profile2 could have been used to assess neglect within the family by agencies at a number of key episodes within the review timescales.   However, training on the Graded Care Neglect Profile2 was still in the early stages of being delivered to Professionals during the timescales of this review.      5.4.5 By 2018 the concerns about the family were more serious, there had been the serious assault in June 2018 and an anonymous referral.  There were considerable health concerns with anaemia and dental decay, and the continuing non-engagement with Early Help. There was some delay with the single assessment and Child in Need planning towards the end of 2018, and it would have been beneficial for an earlier multiagency meeting to have been held to inform the single assessment and consider the appropriateness of a pre-birth assessment in respect of Tracy.   5.4.6 By the time the threshold for Child Protection had been reached the Review Panel began to see evidence that Mother was starting to engage with Professionals.  With hindsight, the Review Panel recognised that Mother’s tactics of brushing away professionals worked for her and masked what was really happening in her life; an earlier more robust approach towards her was required.  Unfortunately, this engagement came a short time before the death of Tracy.   Official Sensitive Government Security Classifications April 2014         16      5.5 Was the response of agencies to third party, including anonymous, referrals appropriate?   5.5.1 There were delays in the information being reported to Children’s Social Care by third party and anonymous referrers.  The Review Panel were informed that it is routine practice for all late referrers to be advised of the necessity to report concerns at the time, either to Children’s Social Care or the Police.    5.5.2 The Review Panel recognised the difficulty that agencies had when responding to anonymous concerns and the ability of prioritising these incidents within an existing workload.  Anonymous referrals can provide agencies with useful information, particularly if they are already dealing with concerns, but they are difficult to assess and process when there has been a delaying in reporting and the nature of the concerns are denied when contact is made with the family.   5.5.3 In this case the concerns were raised with Mother, who denied the allegations and made inferences that the referral had been malicious.  There was no evidence found to substantiate the concerns that had been raised.    5.5.4 There is evidence that information was shared between the Health Visitor and Social Worker at the time of the allegations were made, a number of concerns were discussed, which were already known to agencies and being addressed.  There was no direct reference in relation to any known evidence of malnourishment.     5.5.5 The reluctance of referrers to report concerns at the time is an area of learning identified within the review, including what actions professionals can undertake following reports being made, and how this is communicated to referrers.    5.6 Was escalation on the case undertaken at the right level and pace?   5.6.1 Agencies did identify that Mother and the children would have benefitted from additional support.  Several agencies attempted to engage with Mother and offered to provide services within the EHAT.  The EHAT was explained to Mother and written information provided, but Mother refused all offers of support.   5.6.2 In order for the EHAT to have been implemented, Mother needed to consent to the process.  The Review Panel identified the difficulty that this situation created for professionals, when additional needs had been recognised, but due to a lack of consent the level of concerns did not amount to statutory intervention and escalation; however, the Official Sensitive Government Security Classifications April 2014         17      Panel did identify that a Professionals’ meeting could have been held to share information and concerns.  The Review Panel identified this as an area of learning.  5.6.3 In September 2018 a Children’s Social Care manager overrode Mother’s refusal to share information with other agencies. That was an appropriate escalation of concerns.     5.6.4 Six single assessments were undertaken by Children’s Social Care between  2015 – 2019.  The first two assessments dealt with the referring issue of  domestic abuse.  These were closed as the Perpetrator was not in the household. The assessments identified emerging issues of support needs, but Mother declined services.   5.6.5 The third assessment in 2017 was about a single issue which Mother denied. The fourth assessment took place following a serious domestic abuse incident in June 2018.  This identified that Mother was having continued contact with Father, which was impacting on the children.  Following identification of the issues the case was stepped down to Early Help; however there was no engagement with the plan and this was not escalated back. It was not until an anonymous referral was seen that the case was re-opened to Children’s Social Care in October 2018.   5.6.6 From October 2018 the case was opened for assessment and Child in Need as there had been clear allegations and information of neglect within the family. The Team Manager recognised the need for a fuller assessment in December 2018 and the assessment was updated in 2019 which progressed to an Initial Child Protection Conference.     5.6.7 It was appropriate to undertake a Child in Need plan first, despite Mother having already shown a longstanding reluctance to engage with agencies.  The escalation to Child Protection was correct and by the time the case was heard at an Initial Child Protection Conference the health needs of Sibling 1 were starting to improve.    6. Conclusion.      6.1 The Review Panel did not identify any action, or inaction by any professional that was a critical factor in the death of Tracy.  Many of the concerns within the review related to the Sibling 1 and Sibling 2, prior to the birth of Tracy.   What the review established is that had the case not been progressed to Child Protection then the health and social needs of Tracy would not have been met by Mother.        Official Sensitive Government Security Classifications April 2014         18      6.2 Mother was repeatedly offered help and support and it was clear to the Review Panel that Professionals were trying to engage with Mother within an   Early Help setting.  However; it was only when the case came into Child Protection, in January 2019, that Mother started to engage with professionals, which given the potential consequences at stake for Mother could have been seen by her as her only option.         6.3 The learning from this Serious Case Review does create a challenge for the SCB; in providing Professionals with policies and processes to engage with resistant parents and ensure that the needs of children are being met through Early Help and Universal Services.        6.4 The Review Panel acknowledges that Mother should be provided with an opportunity to contribute to the review, to inform the learning in relation to  how agencies engage with resistant families and accessibility to appropriate services.  Until this can be progressed the Review Panel recommend that the report is not finalised.  This does not prevent the recommendations being progressed.       6.5 The Review Panel was unanimous in believing that the Tracy Serious Case Review should be published in a manner that would make identifying the children and family very difficult. The prime reason was the need to protect the children for public intrusion and identification.       7. Summary of learning and recommendations.     7.1 Resistant Families        Learning   7.1.1 The responsibility to initiate an EHAT is that of any Professional who is working with a child and/or family, this is regardless of their role or agency within which they are working.  The completion of an EHAT does not rest solely with Children’s Social Care.   7.1.2 Early Helps allows agencies to engage with families as soon as concerns are identified, and to work together in a co-ordinated approach to improve outcomes for children.  The implementation of Early Help relies upon consent.      7.1.3 There were several examples within this review when Professionals offered an EHAT to Mother which she refused.  This could have provided Professionals with an opportunity to share their concerns, Official Sensitive Government Security Classifications April 2014         19      which may have identified evidence to support escalation of the concerns and override Mother’s consent.     7.1.4 Where there is a refusal to accept Early Help agencies must have a clear understanding of the reason and rationale behind this decision.  Agencies working in the field of Early Help have a responsibility to children to ensure that services are accessible to their address their needs without which there would be and adverse impact on their life experiences.   7.1.5 The review highlighted the current lack of support and alternative options available to Professionals when responding to a persistent refusal of services to ensure the needs of children are met at all levels of the threshold of need.          Recommendation 1   A pathway for Professionals is produced which details what support, processes and resources are available when engaging with resistant families.        Recommendation 2   The SCB ensures that agencies have access to policies which detail how they should respond to refusals to engage, share information and escalate concerns into statutory intervention.   7.2 Responding to third party and anonymous referrals        Learning   7.2.1 All members of the public have a duty to report safeguarding concerns to allow for identification and where necessary intervention by agencies.  How  and when people do this will vary depending on individual circumstances.  On occasions the reports are anonymous, for fear of identification and/or reprisals, and can be made sometime after the event that led to the original concerns.  These situations create a challenge for professionals in identifying the facts and responding to safeguarding concerns in a timely and evidenced based approach.     7.2.2 There is a common myth amongst the public that once concerns are raised, Children’s Social Care will respond and undertake safeguarding processes based on that information alone.  The complexity and dynamics of Early Help and Safeguarding are not routinely known to the public. In fact, it is fair to say that unless an individual has experience of safeguarding, either professionally or personally, they Official Sensitive Government Security Classifications April 2014         20      would not be expected to know the policy, processes and legislative structure that agencies work within.          Recommendation 3      Reviews are carried out of the current process and information on how safeguarding concerns can be raised by the public; including how the expectations of the referrer will be met and communicated.          Recommendation 4      The SCB ensure that information is available to the public detailing the importance on the timeliness of reporting concerns, as well as, the outcomes that are available to agencies in response to those concerns.    Appendix A   Serious Case Reviews    1. Working Together 2015 outlines specific criteria under which a Serious Case   Review must always be undertaken by applying Regulation 5 of the LSCB   Regulations 2006. For this Serious Case Review Regulation 5(2)(a) and 5(2)(b)(i) applied, that being that the child had died, and abuse or neglect of the child is known or suspected.      2. A Serious Case Review is one 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.’ Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 require LSCBs to undertake reviews of serious cases in these specified circumstances and to ‘advise the authority and their Board partners on lessons to be learnt’.      3. Working Together 2015 requires that Serious Case Reviews are conducted in such a way which:      a) Recognises the complex circumstances in which professionals work together to safeguard children;   b) Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   Official Sensitive Government Security Classifications April 2014         21      c) Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   d) Is transparent about the way that data is collected and analysed; and   e) Makes use of relevant research and case evidence to inform the findings.                         