Non-accidental injuries sustained by a 4-year-old girl of Nigerian heritage in June 2015. Child G1 was found to have broken ankles, 29 suspicious injuries including a possible fracture to her spine. Her mother and partner were each given custodial sentences of six years. Child G1 and her 7-month-old sibling were placed in foster care. Child G1's mother and father were in a relationship which ended in late 2012 after which Child G1 and her mother moved in with her mother's partner and adult son. Concerns were expressed after Child G1 started nursery school in 2013 and primary school in 2014. Referrals were made by the school to children's social care (CSC) about injuries to her forehead, and information about stealing, taking extra food, aggressive behaviour towards other children and animals and absences were passed on. In May 2015, a referral from school to CSC triggered a Child and Family Assessment. Child G1's mother attributed these injuries to Child G1's father; she also made allegations of domestic abuse against him. Child G1's father was seeking access to his daughter through the Family Court. Child G1 said her injuries were caused by her mother's partner. Findings identified include: the power of the adults' narrative in drowning out the voice of the child; high caseloads leading to superficial assessments; approaches to domestic abuse that did not allow for the possibility of malicious allegations. Recommendations include: that disclosure by children must be given priority and investigated; information gathering on all members of the household should be a basic requirement of practice; the development of a culture of challenge and reflection to enable practitioners to question what they are told.
      
 Title:  Child G1: serious case review. LSCB: Manchester Safeguarding Children Board Author: Sian Griffiths and Deborah Jeremiah Date of publication: 2018  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.                               CHILD G1  SERIOUS CASE REVIEW This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 15th May 2018    Independent Reviewers:  Sian Griffiths and Deborah Jeremiah  MSCB Child G1 SCR Page i Contents 1. INTRODUCTION ........................................................................................................................................ 1 1.1 The circumstances that led to this Review ........................................................................................ 1 1.2 Methodology ...................................................................................................................................... 2 1.3 Family Composition ........................................................................................................................... 4 1.4 Contribution of family members ....................................................................................................... 4 2. SUMMARY OF THE CASE AND AGENCIES’ INVOLVEMENT WITH THE FAMILY ........................................ 8 2.1 Background history ............................................................................................................................ 8 2.2 February to May 2013:  First contact with services ........................................................................... 9 2.3 May & July 2013: Private law application made by the father & CAFA assessment commenced by CSC ..................................................................................................................................................... 9 2.4 September to November 2013: Child G1 begins school & school make two safeguarding referrals to CSC ............................................................................................................................................... 10 2.5 November & December 2013: Child Protection Medical ................................................................ 11 2.6 February 2014: School note another injury ..................................................................................... 12 2.7 May 2014: Section 7 report is prepared for the Family Court ........................................................ 12 2.8 September 2014: Child G1 begins at primary school & is referred to school counsellor ............... 13 2.9 December 2014 – March 2015: Child G1 has further injuries & says their mum & dad caused them ................................................................................................................................................. 14 2.10 May 2015: A further referral from school to CSC triggers a full Child & Family Assessment ....... 15 2.11 June 2015: Child G1 is taken to hospital & the injuries identified ................................................ 15 3. APPRAISAL OF PRACTICE AND ANALYSIS ............................................................................................... 17 3.1 Introduction and Overview .............................................................................................................. 17 3.2 Response to early contacts and referrals ........................................................................................ 18 3.3 Responding to further concerns: Autumn 2013. ............................................................................. 20 3.4 The impact of domestic abuse allegations ...................................................................................... 24 3.5 Assessment within Private Law Proceedings ................................................................................... 27 3.6 Continuing pattern of concerns ....................................................................................................... 29 3.7 A new referral leading to a new assessment ................................................................................... 31 3.8 The role of the Private Law Proceedings ......................................................................................... 32 3. The power of the adults’ narrative in drowning out the voice of the child ...................................... 33 4. CONCLUDING COMMENTS .................................................................................................................... 36 5. LEARNING POINTS AND RECOMMENDATIONS FOR THE BOARD .......................................................... 38 5.1 Learning points for consideration as part of the ongoing Improvement Plan ................................ 38 5.2 Recommendations for the Board: ................................................................................................... 38 APPENDIX A: Additional individual agency recommendations/actions already undertaken ................... 39 MSCB Child G1 SCR Page 1 of 39  1. INTRODUCTION 1.1 The circumstances that led to this Review 1.2.1. In the summer of 2015, four year old Child G1 was taken to the Paediatric Emergency Department of their local hospital by their mother who said that G1 had fallen the night before and had hurt their ankles.  On admittance to hospital Child G1 was identified as having two broken ankles as well as a significant number of other injuries which were quickly identified as being non accidental.  Child G1 was made subject to an Emergency Protection Order, followed in due course by a Care Order and both G1 and their sibling were placed in foster care.  Charges were subsequently brought against G1's mother and stepfather who were eventually each given a custodial sentence of six years.  1.2.2. The case of Child G1 was referred to the Manchester Safeguarding Children Board in July 2015, within a month of their admittance to hospital.  Child G1’s case had met the criteria for a Serious Case Review as identified in Working Together to Safeguard Children 20151, in that there was information that:    (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.  1.2.3. The Review was commenced in September 2015 and it was recognised that due to a number of factors, including its potential complexities and an outstanding criminal investigation, it was unlikely to be completed within the normal 6 month period.  An independent Reviewer, Deborah Jeremiah, was commissioned to work with another internal lead Reviewer from one of the statutory agencies.  The internal lead Reviewer had to stand down shortly afterwards due to ill health and in January 2016, a second independent lead Reviewer, Sian Griffiths, was commissioned.   1.2.4. It is the case that final completion of this Review has been significantly delayed largely due to the ongoing criminal investigation and internal disciplinary procedures within the Local Authority which prevented key staff from being interviewed until the summer and autumn of 2016.  The court proceedings relating to the mother and stepfather were not concluded until the end of 2017.  1.2.5. A comprehensive draft report identifying the key learning was completed in early 2017, but it was recognised that it would not be possible to produce a version for publication until the end of the criminal justice process.  The decision was therefore made that the draft version of the report would be taken to Manchester Safeguarding Children Board in February 2017 to enable work to begin on responding to the findings and recommendations.  1.2.6. After the mother and Adult A (the stepfather) were sentenced, contact was made with them both, as well as with Child G1’s father, to ask if they would be willing to contribute to the report.  All three agreed and arrangements were put in place for the lead Reviewers to visit each of them.  However, when the mother met the Reviewers she made it clear that she and                                                       1 Working Together: HM Govt 2015 MSCB Child G1 SCR Page 2 of 39  Adult A were continuing to deny any offence and she was able to contribute little to the learning.  As a result, a decision was made in consultation with the Independent Chair of the Board not to go ahead with the meeting with Adult A on the basis that it would not be proportionate to do so.   The contributions from Child G1’s father and mother are summarised in Section 1.4 below.  1.2 Methodology 1.2.1. Statutory guidance within Working Together requires Local Safeguarding Children Boards to have in place a framework for learning and improvement, which includes the completion of Serious Case Reviews.  The guidance establishes the purpose as follows:  Reviews are not ends in themselves. The purpose of these Reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from Reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. (Working Together, 2013:66)  1.2.2. The statutory guidance requires Reviews to consider: “what happened in a case, and why, and what action will be taken”.  In particular,  case Reviews 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.   1.2.3. The Review was initially commissioned as a SCIE Learning Together Review. However, the Chair of the Local Safeguarding Children Board asked for the Review to be expedited in December 2016 in order to enable the learning to be assimilated into work planning in the early New Year.  As this new timescale would not have allowed some key aspects of the Learning Together methodology to be completed, it was agreed with the Reviewers, SCIE and the Chair of the Board that it would be finalised outside of the Learning Together methodology.  1.2.4. The methodology used for this Review was underpinned throughout by the principles outlined in Working Together, including the need to use a systems approach.    In particular this approach recognises the limitations inherent in simply identifying what may have gone wrong and who might be ‘to blame’. Instead it is intended to identify which factors in the wider work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely.  A central purpose therefore is to move beyond the individual case to a greater understanding of safeguarding practice more widely.  1.2.5. This Review was led by two independent Reviewers, Deborah Jeremiah and Sian Griffiths both of whom are Accredited SCIE Learning Together Reviewers. The Author of the Review MSCB Child G1 SCR Page 3 of 39  is Sian Griffiths who has significant experience in undertaking Serious Case Reviews.  Both Reviewers are independent of all the agencies involved.  1.2.6. The Independent Reviewers worked with a Review Team from the key agencies in Manchester who had involvement with the family.  The Review team was made up of senior managers and safeguarding representatives as follows.  Organisation  Representatives CAFCASS Senior Service Manager Central Manchester University Hospitals NHS Foundation Trust (CMFT)  Head of Safeguarding  Designated Doctor for Safeguarding Children  Named Nurse for Safeguarding Children Greater Manchester Police Detective Inspector, Safeguarding Vulnerable Persons Unit City Wide NHS Safeguarding Team (Commissioning and Quality) Head of Safeguarding Manchester Children’s Social Care Service Manager  Manchester Children and Families Directorate (Education) Education Caseworker Pennine Acute Hospitals NHS Trust Named Midwife-Safeguarding    Both Greater Manchester Police and Manchester Children’s Services representatives were subject to change on more than one occasion.  1.2.7.  The Review process included:  seven meetings of the Review team  two joint meetings with the Review Team and identified front line professionals  analysis of significant episodes with the Review Team  individual conversations with 18 professionals who had significant contact with the child and/or their family (some professionals could not be spoken to e.g. because they were no longer working in the city)  discussions with other relevant professionals.  1.2.8   The Review had access to a range of documentation including:  comprehensive combined chronology   report from Independent Police Complaints Commission  Children’s Social Care records, including Section 7 Report2 and Children and Family Assessment Reports  Judgement in the Family Court Hearing in the Care Proceedings relating to Child G1 and their sibling.3                                                       2 Section 7 Report:  A report prepared under Section 7 of the Children Act 1989 regarding a Private Law Application. 3 The Family Court judgement is a confidential document provided for reference within the SCR, but the contents of which cannot be published without the permission of the Judge. MSCB Child G1 SCR Page 4 of 39   Child Protection Medical Report prepared December 2013  Court Orders.  1.2.8.  The timeframe under consideration for this Review was 26h February 2013 – 23rd June 2015   The starting point was chosen as this was the first occasion in which Child G1 came to the attention of statutory agencies.  The end date follows the admission to hospital and the actions taken to ensure Child G1 and their sibling’s safety.  1.2.9. The initial commissioning process identified the following key issues for consideration within the Review, however these were not intended to limit any other learning which might emerge:    i. To test out the quality of assessments around this child given the background of the birth family and mother’s partner. ii. To consider what barriers are apparent to information sharing.  iii. To look at professional responses when mother states historic domestic abuse is the reason for the child’s behaviour iv. To consider how education responds when  a child is making disclosures of  abuse at school and demonstrating concerning behaviours  v. To consider the effectiveness of multiagency working around this family and their complexities vi. To consider how medical information is shared across agencies when a child has presented on numerous occasions vii. To consider risk management when a new adult comes into the family.   1.3 Family Composition 1.3.1 The family members referred to in this Review are as follows:  Family member Identifier Age at point of critical incident Subject of the SCR Child G1 4 years 10 months Sibling Sibling G1 7 months old Mother Mother 30’s Father of Child G1 Father 30’s Mother’s partner Adult A 30’s Mother’s partner’s child Adult B 19 years old  1.4 Contribution of family members 1.4.1. Description of Child G1.  The picture of Child G1 that has come through this Review is a complex and in many ways a contradictory one.  G1's nursery teacher described Child G1 arriving in class on their first day and making an immediate impression.  When they started at nursery, Child G1 greeted the teacher with their arms outstretched saying “I’m here”.  The teacher described G1 as “a loveable character, a joy, they had a good sense of humour”. However this picture became more complex over time as Child G1 began to show increasingly worrying behaviour.   MSCB Child G1 SCR Page 5 of 39  1.4.2. At times, particularly by the time they had moved into primary school Child G1 could appear almost shy and could be very cautious about what they said to professionals.  The school counsellor described G1 as a child who would take great care with things they played with.  The counsellor also experienced Child G1 as a child who talked little about family and never talked about what they did at home.  1.4.3. Child G1’s father.  As Child G1’s father was a potential witness in the criminal trial, it was not possible to meet with him until after this was completed.  Therefore in the spring of 2018 the Independent Reviewers arranged to meet with him at his home with his wife. The Reviewers were very grateful to both the father and his wife for their time and willingness to contribute to the Review.  The following is a summary of his experience, as he told it to the Reviewers.  1.4.4. Child G1’s father had lived with the mother for several years and although they were short of money, he believed they were happy.  However, in early 2013, when Child G1 was not yet three years old, the mother moved out suddenly to live with Adult A.  Child G was initially taken to live with their maternal grandparents, however the mother then contacted the police and made allegations about them.  The police arranged to collect Child G1 and took G1 to the mother and Adult A.    1.4.5. The father was subsequently contacted by the police who were investigating allegations made by the mother that he had hurt the mother and Child G1 and raped the mother.  He was told he could not have any contact with either mother or child.  “The allegations against me were total lies… and I was desperate to see my child”.  Although he was arrested he was never charged as a result of any of these allegations.  The father told both the police and Children’s Services that he was concerned about his child, as he understood from a relative that Adult A had left a previous partner, that there had been concerns about him in that family and that he was not allowed to see his own children.  Father was very worried and asked several times how it could be that his child would be safe living with Adult A if this was true.   1.4.6. On one occasion he was told that Child G1 had a facial injury and told a different social worker that he was concerned and why.  He showed pictures of Child G1 that he had on his phone to demonstrate that he had had happy times with them. However, nothing happened and he felt that Children’s Services never listened to what he told them. When the school term started in September he attempted to see G1, but was visited by the police who told him not to make contact and that he would have to take the matter to Family Court.  Throughout all this time he had no contact with his child.  1.4.7. The father did make an application to the Family Court to see his child.  The allegations that had been made against him were repeated by the mother to the Court.  He was at first allowed indirect contact, sending a card to his child and then a Court Order was made for contact supervised at a Contact Centre.  He described how pleased his child was to see him and he gave G1 a teddy bear which they really liked.  However, at the end of the contact Adult A refused to allow Child G1 to keep the teddy bear and the meeting ended with both father and child in tears.  Supervised contact took place on one more occasion.  The father described this time being very difficult.  Child G1 was very quiet and would look to their MSCB Child G1 SCR Page 6 of 39  mother and Adult A before doing anything.  Child G1 knelt before Adult A, something which was never part of the father’s culture, or of any African culture as far as he knew.  After this Child G1 was not brought to see him again and that was the last time he saw G1 before they were taken into foster care.  1.4.8. The father said that a Cafcass officer had been told to complete an investigation, but this was then passed to a Local Authority social worker to complete.  He was aware that a report had been prepared for the Court hearing, but did not feel he had been properly consulted or listened to.  He has since found out that the mother made lots more allegations about him hurting his child, which simply were not true.  The effect was to stop him seeing his child.  He felt that social workers just believed everything that the mother told them, without even talking to him.  1.4.9. The father was very worried about his child’s safety and could not think of anything else he could do, or anyone else he could talk to who might take some action. He described this very powerfully as having a serious impact on his emotional health and causing him to become very depressed.  He was never told about any of the injuries that Child G1 had sustained, or asked about the explanations that the mother and Adult A gave for these injuries.   1.4.10. “If someone had listened in 2013 and 2014, I believe my child would have been saved from abuse and harm….how staff thought my child was in a safe environment, I do not know.  I told everyone what I knew about Adult A and his previous family…. My child is still not with me, they are in foster care and damaged by the abuse… they require specialist support…the impact on me of losing them has been great”.  1.4.11. The father talked in a very measured way, but with visible sadness, about what had happened to his child as well his own sense of loss. He remains frustrated about the limited contact he still has with Child G1, but could accept that G1 would need long term specialist care and that required him to be patient about further future contact.  1.4.12. The mother agreed to meet with the Independent Reviewers and this was arranged with the Offender Manager in the prison.  On arrival she was initially said to be too distressed to meet, but soon afterwards did agree to attend.  She was very quietly spoken and reserved, but the very visible distress that had been described to the Reviewers was not in evidence during the meeting.   The mother’s description of her experience is as follows.  1.4.13. The mother began by saying that she would have benefitted from referrals for extra help about parenting from social workers as although she could look this up on the internet, a course would have helped her look after her children.  The mother was not able to explain to the Reviewers more specifically what sort of help she felt she needed.  She also said that she now wished she had taken Child G1 to the doctor’s after their ‘fall’, instead of giving them Calpol, which she had been told by previous doctors she should give the child for pain.  1.4.14. The mother spoke at most length about the father’s behaviour and her feelings towards him.  She said that they had met when she was young and had been subdued by him within a controlling relationship.  When the school asked her about Child G1 biting and hitting out at their friends, she believes this was because G1 was reacting to the time they lived with G1's MSCB Child G1 SCR Page 7 of 39  father. She said that he did not respect her as a person or as a woman and that he threatened her if she were to tell the police.   1.4.15. Her own father who is a Christian Pastor did not agree with her having a relationship with the father, who is a Muslim, so she felt shame and could not tell anyone about how he was controlling her.  The only person she told was her sibling who told her not to tell anyone.  She feared violence if she left him.  The mother felt that police and psychologists should have been more involved at this time, but again could not specify what help she would have wished for.  She could not recall anything in particular about other services, such as the IDVA or the psychologist who was involved with Child G1 after her separation from the father.  1.4.16. The mother said that the father took her to Court even though she had never tried to stop Child G1 seeing their father.  When he did see G1 at the Contact Centre she said he called Child G1 by a Muslim name which upset G1, that he said Adult A was not G1's real father and that Child G1 had not recognised him.  1.4.17. When talking about the injuries to Child G1, the mother always spoke in terms of them being ‘falls’ or ‘accidents’.    She also repeated some of the allegations about the father physically abusing Child G1.  When reminded that she had been found guilty in Court, she made it clear she did not accept the verdict.  She explained that Adult A, who is imprisoned elsewhere, is still her partner.  1.4.18. The Reviewers would wish to thank the mother for agreeing to meet with them.     MSCB Child G1 SCR Page 8 of 39  2. SUMMARY OF THE CASE AND AGENCIES’ INVOLVEMENT WITH THE FAMILY The following is a factual summary of what is now known about the family and their involvement with agencies.   This Review considered a period of two years during which there were a significant amount of contacts with the family, with a number of repeating patterns of events both in the family and by those responding to it.  This summary will identify the most significant events, but does not aim to produce a detailed description of everything that took place.  Exploration and analysis of these events, including judgements of the quality of practice and, crucially, what is known about why professionals and services responded in the way they did will be considered within Section 3:  appraisal and analysis.   2.1 Background history 2.1.1. There was limited reliable information available to the Review regarding Child G1 or their mother prior to the time period under consideration.  G1's mother and father were understood to have begun a relationship in around 2005 which ended in late 2012 or early 2013.  The mother’s parents lived in the Manchester area, but it is unclear how long she had been living in the UK.    Child G1 and their mother attended a number of events at their local Sure Start Centre, but no information of significance has been identified as a result.    Following the parents’ separation Child G1’s mother is understood to have been homeless for a period.  During this time, Child G1 was cared for by their maternal grandparents.  2.1.2. Adult A came to the attention of Manchester Children’s Social Care in 2010 when he lived at the same address with a previous partner and four children.    His partner at that time was assessed as high risk of domestic abuse and referred to the MARAC4.  The children were all made subject to Child Protection Plans in 2010 under the category of emotional abuse, in the context of the youngest child’s behaviour at school and the risk of them being exposed to further domestic abuse. One of the four children was Adult A’s son (Adult B). The children were removed from the plan when they and their mother left Adult A in 2011.  2.1.3. Child G1 and their parents have all been identified as Black. The mother is understood to have come to the UK from Nigeria as a young teenager and during the course of this Review was seeking to obtain leave to remain in this country.  It is now understood that the father also came to the UK from Nigeria and was seeking asylum, but his status at the beginning of these events was not clear.  Adult A is understood to be Black British, also with Nigerian heritage.  Child G1’s mother is a Christian, mother's father being a pastor of an evangelical Christian church in the city.  Adult A is a Catholic and is understood to have attended church with the mother and Child G1. Almost no information has been available in relation to Adult B.  2.1.4. Little information that is verifiable was available to the Review regarding Child G1’s father prior to meeting him.  He confirmed to the Review that he is a Muslim, but that he respects all religions and had always had a good relationship with the mother’s Christian parents.                                                           4 MARAC:  (Multi Agency Risk Assessment Conference).  Multi-agency assessment meeting in relation to serious domestic abuse.  MSCB Child G1 SCR Page 9 of 39  2.1.5.  There is no information to suggest that any of the family members had any physical health or special needs.  2.2 February to May 2013:  First contact with services 2.2.1. Between February and May 2013 Child G1 was living with their mother, mother’s partner, Adult A, and his 16 year old child (Adult B) in Adult A’s home where he had lived since 2009. During this period there were four occasions when potentially significant information was made available to Children’s Social Care (CSC) or the police.  On two occasions the mother contacted the police making allegations that she was subject to domestic abuse from Child G1’s father.  On both occasions she was referred to the Domestic Abuse Unit of the police who then notified CSC.  On both occasions no further action was taken by the police.  On the second occasion when the mother stated she was receiving threatening phone messages from Child G1’s father, these messages were viewed by the police and not found to be threatening.  2.2.2. Notifications to CSC went  to the First Response Team whose role it was at that time to consider all new referrals and notifications and decide whether these should be referred on to the locality team for further assessment or not.  The First Response team made standard enquiries with police and the Health Visitor who had no concerns, although Child G1’s two year development check was overdue.  No further action was considered necessary by CSC.  2.2.3. Two weeks later, Adult A, describing himself as a family friend, contacted CSC to tell them that Child G1 and their mother had moved in with him temporarily.  He had been involved with Manchester Children’s Social Care previously and had been told he should inform CSC if a child was living with him again.  The First Response team made enquiries with the authority in which the previous family were now living.  Their enquiries confirmed that when Adult A lived in this family the children were made subject to a Child Protection Plan which was since closed.  No further action was taken by CSC.  2.2.4. In March 2013 CSC received an anonymous letter which referred to Adult A’s history with his previous partner, including reference to domestic abuse.  The letter went on to say that Adult A and Adult B were abusing Child G1 and that CSC needed to intervene.  A decision was taken by the First Response team to take no further action.  2.3 May & July 2013: Private law application made by the father & CAFA assessment commenced by CSC 2.3.1. In May 2013 Child G1’s father made an application at the Family Court for contact with his child. This was initially subject to routine safeguarding checks by Cafcass5 including conversations with both the mother and father.  During their discussions the mother made allegations both of domestic abuse, including rape, and threats against herself which Child G1 had witnessed.  The Cafcass officer made a safeguarding referral to CSC, noting that there might be escalating harassment, but that the mother had not accepted professional support or reported incidents to the police. A few days later Child G1’s mother attended the police station to report that she had been raped by Child G1’s father on several occasions during the previous three years.                                                        5 Cafcass is the Children and Family Court Advisory and Support Service MSCB Child G1 SCR Page 10 of 39   2.3.2. The allegations of rape made by the mother were subsequently investigated by the police Serious Sexual Offences Unit (SSOU).  The investigation, which is described as thorough by the IPCC, was closed in February 2014 having concluded that the allegations were ‘more likely than not to be false’.  This information was not shared with other professionals.    2.3.3. Three days after the mother made her allegations to the police, CSC First Response team received another anonymous referral, stating that Adult A was abusing Child G1, but that the mother was too scared of Adult A to take action.  No further action was taken by CSC.  2.3.4. As a result of the mother’s allegations she was referred to the MARAC and to Children's Social Care.  She was also referred to the Independent Domestic Advice (IDVA) Service and an IDVA officer was assigned to her. Cafcass had considered undertaking a CAADA-DASH6 assessment but confirmed that this would be completed as a result of the MARAC referral.  The IDVA officer provided the mother with practical support and advice, including helping her to access legal advice. The mother described being subject to Honour Based Violence from her family as well as ongoing harassment from the father and others she believed were linked to him. The IDVA remained involved with the mother until November 2013. The court process regarding his application for contact with his child was in progress throughout the following few months concluding in May 2015 when care proceedings were issued.  2.3.5. Following the notification to CSC from the Police Domestic Abuse Unit regarding the mother’s allegations, it was agreed that an Initial Assessment should take place.  This was allocated to a social worker and the assessment commenced in July 2013.  The allocated social worker undertook a home visit to the family accompanied by another social worker.  However the allocated social worker left the department in October 2013 before the assessment had been completed.  2.4 September to November 2013: Child G1 begins school & school make two safeguarding referrals to CSC 2.4.1. Child G1 began at the nursery class of School A in September 2013.  In October staff noticed that G1 had a bump on their head and Child G1 said “my daddy bites (or beats) me”. It was difficult to be sure which G1 had said. The school made an immediate referral to CSC and a strategy meeting7 took place.  Two different social workers and two police officers, a Detective Constable and a Detective Sergeant from the Public Protection Investigation Unit (PPIU) attended at the school and interviewed Child G1, their mother and the mother’s partner, Adult A. Child G1 repeated their comments to one of the social workers, but the mother said that Child G1 had fallen and explained that they must have been referring to their birth father who was violent to them in the past.  The school also passed on some developing concerns about Child G1 taking extra food in school and having quite a few absences.  Child G1 was accompanied to hospital by the social workers where the marks to their forehead were assessed as compatible with the explanation given by their mother,                                                       6 CAADA-DASH – a risk assessment checklist in relation to domestic abuse. 7 A Strategy meeting/discussion is required whenever there is reasonable cause to suspect that a child is suffering, or likely to suffer significant harm.  This should include Children’s Services, the police, health and any other appropriate body.  MSCB Child G1 SCR Page 11 of 39  although non-accidental injury could not be ruled out.  There were no further injuries.  Child G1 also had old scars on their body, which the mother explained were caused by G1's birth father.  Health staff offered to arrange a Child Protection Medical, but the social worker declined this.    2.4.2. The police investigation was closed and no further action was taken by Children’s Social Care.  2.4.3. Four weeks later, in November 2013, the school made another referral to Children’s Social Care as they have seen two further new marks on Child G1’s forehead and they had again said that “daddy beats me(bites) me”. A social worker who had previously been involved and was now reallocated, made a home visit that evening and the mother explained that Child G1 had again fallen and also scratched their head themself.   The following day the mother took Child G1 to the Paediatric Emergency Department, and staff there contacted the social worker.  The case had remained open to this social worker who arranged a strategy meeting, which took place at the school and was attended by School A’s safeguarding lead, the Detective Constable and another trainee Detective Constable.  The police requested that a Child Protection Medical take place.  2.5 November & December 2013: Child Protection Medical 2.5.1. The Child Protection Medical identified two different categories of marks on Child G1.  Those marks which had led to the referral being made by the school were concluded to be consistent with the explanation of a fall given by the mother.  A second group of older marks were identified as historical non-accidental injuries.  The mother said that these had been caused by Child G1’s birth father and repeated that this was the explanation for Child G1 saying “daddy beats me”.  2.5.2. The doctor undertaking the medical made a number of recommendations in their report:  Child G1 to be registered with a dentist as soon as possible  Mother to ensure that Child G1’s Health Visitor is able to complete the two year developmental check  Child G1 to be referred to the weight management team  Nursery to monitor Child G1’s attendance  Referral to the CAPS team8 in response to Child G1 reportedly suffering nightmares as a result of their father’s abuse.  The doctor also stated in their conclusion that the police should investigate the allegations of abuse by Child G1’s father.  2.5.3. The doctor told the social worker their findings at the end of the examination and the final Child Protection Medical Report was sent to the police, Children's Social Care, the GP and the Health Visiting Team.  The recommendations of the report were noted in the social work files, but not the conclusion that the allegations of historical abuse should be investigated                                                       8 CAPS team:  A service providing early intervention and support to families with children experiencing emotional and behaviour problems MSCB Child G1 SCR Page 12 of 39  by the police.  The police received the report, but it was later filed by an administrative officer without being reviewed by a police officer.  No police investigation was undertaken.  2.5.4. At the end of November Child G1 was taken to their GP by their mother and referred on to Paediatric A&E with a reported sore arm and scratch to their eye. G1's arm was x-rayed, but no fractures found.  The mother told the hospital staff about their contact with Children’s Social Care and the hospital contacted the social worker to inform them.  They were told that Children’s Social Care had no concerns about Child G1.  2.5.5. The Child and Family Assessment, which had been initiated in July 2013, was now completed by this social worker.  The assessment, which noted that CAPS and the Health Visitor were involved with the family, concluded there were no safeguarding concerns and closed the case at the end of January.  School A was informed of this decision.  2.5.6. Child G1 had been referred to the Weight Management Service following the Child Protection Medical, as despite the school’s concerns about G1 ‘stealing’ food, G1 was in fact overweight.  Child G1 was seen by the Service but found to be within the acceptable health range and advice was given to the mother.  The school continued to note concerns at times about Child G1 taking extra food or taking food from other children’s plates.  2.5.7. In January 2014 Child G1, their mother, and mother’s partner, Adult A attended the first appointment with a Clinical Psychologist at the CAPS service.  The Psychologist noted a range of behaviour of interest in both adults and Child G1, including over compliant behaviour from Child G1.  The family only kept two of their appointments with the CAPS service, at this time, but the option was left open for them to return. However later in the year the mother returned to see the Psychologist to ask for them to write to the Family Court in the Private Law proceedings stating that Child G1’s father should not have contact with G1, which the Psychologist was not willing to do.  2.6 February 2014: School note another injury 2.6.1. At the end of February 2014 the school made a ‘note of concern’ in their records as Child G1 had a sore lip.  Child G1 initially said they had burned themself on a cup of tea and then again said ‘daddy bit me’.  Child G1 had been kept off the previous day.  Adult A also phoned the school to say that Child G1 had a sore lip, but gave no other explanation.   2.6.2. The following month Child G1’s mother was confirmed as pregnant and booked into ante-natal services.  2.7 May 2014: Section 7 report is prepared for the Family Court 2.7.1. In January 2014 the Family Court ordered a Section 7 report be prepared by Manchester Children’s Social Care regarding Child G1’s father’s application for contact with his child within Private Law proceedings. Cafcass had been asked to provide further safeguarding checks prior to this point but had encountered difficulties due to problems accessing correct information from the adults and repeated failures to get information from Children’s Services.  Given the history of involvement with Children’s Social Care the Court ordered that the Section 7 report be undertaken by CSC and the case was closed to Cafcass.  In May 2014 it is recorded that the Report had been allocated to a new social worker. MSCB Child G1 SCR Page 13 of 39  2.7.2. The Section 7 report was completed on the basis of interviews with Child G1’s mother, father, Adult A and observation of Child G1, along with phone conversations with school staff, and access to CSC’s records.    It concluded that Child G1 should only have indirect contact with their father by way of letters, due to the trauma that they had experienced from him.  It stated that there were no safeguarding concerns and no involvement required from the Local Authority. It is not clear if the report was signed off by a team manager or went straight to the authority’s legal department.  2.7.3. Child G1’s behaviour in school at this time had still been causing some concern.  School described some improvement in their taking food and becoming distressed when they were not allowed further helpings.  However G1's aggressive behaviour with other children was continuing.  2.7.4. A Court Order was made in the Family Court in June 2014, providing for indirect contact between Child G1 and their father, but also adjourning for both parties to provide statements about their positions and for the mother to provide reports from the Child’s GP and her ‘psychiatrist’.  Cafcass was asked to undertake enhanced police checks regarding the police investigations that had followed the mother’s allegations against Child G1’s father the previous year.  2.8 September 2014: Child G1 begins at primary school & is referred to school counsellor 2.8.1. In September Child G1 moved to the primary school (School B).  The new school was aware from School A that there had been concerns about Child G1’s behaviour and had also been told by them about the allegations that G1 and their mother had experienced abuse by the father.  Arrangements were made for Child G1 to see the school counsellor and G1 was placed on the Additional Needs Register.  At the early sessions, the mother, Adult A and Adult B also attended and so the counsellor made arrangements to see Child G1 in school time.  2.8.2. From the outset the school recorded concerns about Child G1’s behaviour, including aggression to other children and school pets.  There were continuing incidences of Child G1 ‘stealing’ food during their time in the school. In October Child G1 told the school counsellor that their mum and Adult A hit them in the stomach and they wanted it to stop.  Child G1 did however afterwards withdraw this.   The school made an immediate referral to Children’s Social Care and it was passed to the locality team for assessment.  The same social worker who had undertaken the Section 7 Report, made a home visit after school and found Child G1 to be in bed.  Child G1 was crying and told the social worker they were unhappy.   The outcome was to undertake a Child and Family Assessment.  This was not completed until February 2015.  2.8.3. Two days later Child G1 arrived at school with their ‘uncle’.  Child G1 was crying and their uncle said that G1's feet hurt, however G1 showed no further sign of distress during the day.  2.8.4. Also that month at a Family Court Hearing, a further order was made requiring the mother to provide a statement regarding allegations against the father, as well as the medical reports she had previously referred to as this had not been complied with.  The Court also repeated its order to Cafcass to complete its task of contacting the police as previously MSCB Child G1 SCR Page 14 of 39  required.  This was completed and the investigation outcome, which was that there had been no action taken against Child G1’s father as a result of the mother’s rape allegations, was reported to the court. A Review hearing was listed for the end of December.  At that Review hearing the Court was to determine the listing of either a Finding of Fact hearing relating to the allegations, or a Final Hearing.   2.8.5. Child G1’s sibling was born in November.  School staff described Child G1 as ‘always being hungry’ from around this time.  2.9 December 2014 – March 2015: Child G1 has further injuries & says their mum & dad caused them 2.9.1. In December Adult A phoned the school and told them that Child G1 had bumped their head on a cupboard.  The school instructed Adult A to take Child G1 to the GP or A&E and followed this up to ensure G1 had been.  The examination at Paediatric A&E concluded that the bump was compatible with the explanation given by the mother.  The next day Child G1 was kept off school, according to Adult A because this was the advice from the hospital, although this does not seem to be the case.  When G1 came into school the following day Child G1 told staff that their “daddy” hit them with a spoon.  The school immediately reported this to the social worker who made a home visit.  Child G1 was seen their own and told the social worker that they had hit their head on a table.   No further action was taken.  2.9.2. The Family Court hearing in late December resulted in an agreement that Child G1 should see their father fortnightly at a contact centre.  It was recorded that the Cafcass Safeguarding Checks were complete and there was no further role for Cafcass.  The Court listed the matter for Dispute Resolution in April 2015.  2.9.3. In mid-January 2015 Child G1 was taken to Paediatric A&E during the early hours of the morning with a significant burn to their arm. The explanation was that G1 had got up in the night when their mother was making a feed for their sibling and spilled hot water from the kettle on their own arm, although there were different variations of this explanation given at different times to various professionals.  G1's arm was ‘blistered and very sore’.  Child G1 was referred to the Burns clinic for follow up treatment.  The MASH9 team were informed by the hospital and they in turn informed the social worker. The School also informed the social worker when they received the information from the family.  2.9.4. The social worker undertook a home visit and subsequently told the school that the burn was in keeping with the explanation.  The Head of School B spoke to the social worker about the chronology of events and their continuing concerns.  Following Child G1’s first follow up visit at the end of January 2015 the Burns Clinic contacted the GP and the social worker for further information and a social history.  The social worker told them that they did not have any major safeguarding concerns and was undertaking an assessment. That assessment was completed the following week and concluded there was no reason for continuing Social Care involvement.  Child G1 was not taken to the two following appointments at the Burns Clinic                                                       9 The MASH team (multi-agency safeguarding Hub) had now replaced the First Response team in dealing with initial referrals and notifications. MSCB Child G1 SCR Page 15 of 39  2.9.5. The school continued to record concerns about Child G1, relating to food, their behaviour and that G1 would sometimes come into school crying.  When the class were making Mother’s Day Cards, Child G1 wrote something illegible in their card, but told their teacher that it said:  “To mum, you are going to prison, but you do not know”.  School spoke to mother about the various concerns and also arranged for the school nurse to speak to mother again about Child G1’s eating.  2.9.6. Child G1 was at this time meant to be having contact with their father at a contact centre, twice a month.  The mother was unhappy about it and told the school that it was impacting on Child G1’s behaviour.  At the Family Court hearing in April a new order was made that Cafcass prepare a Section 7 Report regarding Child G1’s contact with their father and that the report should give consideration to whether a Guardian should be appointed to represent Child G1 in the proceedings.   Cafcass attempted on more than one occasion to obtain Safeguarding Checks from Children’s Social Care without success and this, combined with a delay in receiving the order from the Court led to Cafcass obtaining an extension until August in order to complete the report.  2.10 May 2015: A further referral from school to CSC triggers a full Child & Family Assessment 2.10.1. On 7th May 2015 the school made another referral to Children’s Social Care as Child G1 had a swollen lip which had scabbed over.  The mother said that G1 had fallen in school, but the school was confident that this was not the case.  The school also made a point of stating that there was now a younger sibling in the family. A social worker from a different team, who was new to the case, went to the school to see Child G1.  After the social worker had left Child G1 told a teacher that the teacher would have to wash their clothes, or their father would beat them harder.  This information was immediately forwarded to the social worker who was allocated the task of undertaking a Child and Family Assessment the following week.  A family support worker was asked to prepare a chronology.   2.10.2. During May the school shared more information with the social worker including about Child G1’s eating and that G1 had not been taken to the Burns clinic appointments or to complete the work with CAPS.  They also recorded that Child G1 was demonstrating inappropriate, sexualised behaviour in school and on one occasion punched another child in school.  School were concerned that there was about to be a two week break, and the social worker agreed to undertake  further home visits. The social worker spent time with Child G1 alone in their bedroom but Child G1 did not make any further disclosures.  The social worker was concerned and agreed with their supervisor that they would work on building rapport with Child G1 and collecting further information.  However the mother then said that they would be away in London and Liverpool and a visit could not be arranged until 4th June. The social worker was therefore only able to undertake one home visit before Child G1 was admitted to hospital.  2.11 June 2015: Child G1 is taken to hospital & the injuries identified 2.11.1. On June 1st Child G1’s mother visited the GP as an emergency asking that an old injury caused to her by the father in 2010 be documented.  Child G1 and their sibling as well as Adult A also came into the consultation room.  The GP examined the mother’s old injury and told the mother that they would provide a report if this was requested formally by her solicitor.  The GP did not have the opportunity to see Child G1 walking.  MSCB Child G1 SCR Page 16 of 39   2.11.2. Two days later Child G1 was taken to Paediatric A&E by their mother, with a reported ankle injury said to have happened when G1 fell down the stairs the previous day at 6.00pm.  The hospital identified numerous bruises and abrasions and contacted Children’s Social Care for further information.  The Consultant in Emergency Medicine was concerned about the delayed presentation and the other bruises and marks on Child G1.   2.11.3. Child G1 was admitted to the Paediatric ward and following X-Rays it was identified that G1 had fractures to both ankles.  The Consultant Paediatrician concluded that the injuries were not consistent with the explanation and that the ankle injuries might be as much as seven days old.  It was ultimately identified that Child G1 had 29 suspicious injuries including a possible fracture to their spine.  Child G1 remained on the ward. Whilst Child G1 was in the hospital, the social work team put a rota together so that G1 would not be left alone.  A Strategy Meeting at the hospital the following day resulted in an Emergency Protection Order being obtained.  This was followed by the granting of an Interim Care Order in relation to both Child G1 and their sibling, who were placed in foster care. Both the mother and Adult A were interviewed by the police and were subsequently charged with Causing or allowing a child to die or suffer serious physical harm10 and Assault/ill-treatment/neglect/abandon a child/young person to cause unnecessary suffering/injury.    They were both subsequently found guilty following a trial.                                                          10 Domestic Violence, Crime and Victims (Amendment) Act 2012, Section 5 MSCB Child G1 SCR Page 17 of 39  3. APPRAISAL OF PRACTICE AND ANALYSIS 3.1 Introduction and Overview 3.1.1. This Section will appraise the significant aspects of practice that have been identified during this Review and use examples to establish the principal areas for learning that have emerged.  It will evaluate whether the practice met required standards, given the information available to individual professionals or their services at the time.  In order to help us understand why practice met or did not meet good standards, the analysis will also take into account professionals’ working context, which in turn will lead to conclusions about what was supporting the services to achieve good practice and what was getting in the way. The key learning points will then be identified and will form the basis for action to be considered by the agencies along with a number of specific recommendations.  3.1.2. Over a two year period Child G1 was subject to a succession of injuries within their home the causes of which were deliberately obscured by G1's carers.  The injuries themselves have now been clearly attributed, by both Criminal and Family Courts, to the mother and mother’s partner.  However, what is not established is why this child was subject to such a sustained degree of abuse, accompanied as it was by emotional abuse and neglect.  The medical assessments as well as Child G1’s disclosures would also suggest that at least some of the injuries were caused deliberately.  Whatever lay behind the treatment of Child G1, what is clear is that there were fundamental weaknesses in the safeguarding system which meant what was happening to Child G1 failed to be understood or responded to for far too long.  3.1.3. Prior to being admitted to hospital in June 2015 Child G1 was subject to two Section 47 investigations, a Child Protection Medical, an assessment for the Family Court under Private Law and a number of other referrals to Children’s Social Care.  At each point good investigation and assessment practice could have led to an understanding that this was a child at risk of significant harm.  Despite this Child G1 was never subject to either a Child Protection Plan or a Child in Need Plan.  The absence of good quality assessment was a constant throughout this two year period until May 2015 when a different approach was adopted, although unfortunately this was too late to prevent the injuries which led to Child G1 being admitted to hospital.  3.1.4. The abuse Child G1 was experiencing took place despite continuing referrals made, in particular by schools, as well as the attempts by some professionals to better understand G1's experience. Other professionals lacked information that might have impacted on their understanding of the family.  What is also apparent is that this represented a repeating pattern of mistakes in understanding Child G1’s experience.  This had a cumulative effect and often reinforced subsequent misconceived responses as to what was happening.  That this pattern of practice was allowed to continue for such a long period illustrates serious weaknesses at this time within the Local Authority in ensuring good quality assurance, staff support and supervision as well as a proper focus on the child’s experience.  3.1.5. The following section has therefore been structured to examine the significant periods of contact between Child G1 and relevant services, as well as identifying repeating patterns of response across the agencies that impacted on the safeguarding response during the period concerned. MSCB Child G1 SCR Page 18 of 39  3.2 Response to early contacts and referrals 3.2.1. In the first few months of 2013 there were five occasions when information was provided to the First Response team of Children's Social Care and which required a decision as to whether further assessment was necessary.  On each occasion no further action was taken. This included: notifications from the police that the mother had made allegations about domestic abuse against the child’s father and her own parents; a call from the mother’s partner; and two anonymous referrals.  Whilst individually these would not necessarily have justified an assessment, cumulatively they should have raised some concerns.  Most particularly the self-referral by mother’s partner, Adult A, should have triggered a more robust investigation.  Irrespective of whether this would have led to any further intervention by Children’s Services at this point, what it should have done was provide a sound base of information about the family in the event of any further concerns being raised.  3.2.2. Checks were made by the First Response team with another Local Authority which held the previous records from Manchester regarding Adult A.  However information that was recorded was inadequately detailed and failed to demonstrate more than a superficial analysis of their significance.   Checks were also made with the Health Visitor, who had no concerns, although Child G1’s two year development check was outstanding and the Health Visitor said they would now undertake this.    3.2.3. The two year developmental health check was not in fact finally made until January 2014 by which time Child G1 was almost 3 ½ years old.  What we do know is that the Health Visitor arranged three home visits following these two referrals, but either no-one was at home, or Child G1 was said to be away. The two year development check acts as an important safeguard for pre-school children and this delay clearly did not meet standards of expected practice.   Whilst it has not been possible to identify the specific reasons for Child G1’s check being delayed, it is the case that at this time the Health Visiting Service was under extreme pressure due to a service wide staff shortage at a national level at this time. “Numbers of health visitors have been in decline. In too many areas, there are just not enough health visitors to offer all families the support they need”11. Caseloads of some Health Visitors in Manchester had reached 1,000 children meaning that only those children formally identified as being at risk could receive more than the minimum required service. Given that there were subsequent further contacts about Child G1 with the Health Visiting Service by both school and Children’s Social Care during the months following the referrals to CSC, this is a child who should have received a better service.    3.2.4. What is apparent is that the response to the early referrals and notifications about the family in the spring and summer of 2013 was wholly inadequate by standards of good practice.  Information that was sought was not then properly considered or understood, most significantly the information regarding the previous involvement of Adult A with Children’s Social Care.  What was also not recorded was that the mother of the children linked with Adult A had been assessed as at high risk of domestic abuse and made subject to a MARAC.  Nor was it recorded that the reason for the Child Protection plan being closed was that the mother and children had moved into a refuge, not that the situation had improved while Adult A was in the family. There was information in police intelligence which merited more                                                       11 DoH Feb 2011 (p8) MSCB Child G1 SCR Page 19 of 39  concern, but this was either not obtained, or not noted. This existing information alone should have triggered further investigation or assessment, but when subsequently  combined with two anonymous referrals stating that the mother and child were at risk from Adult A it should again have led to a more questioning response. Neither is there evidence of any consideration as to why Adult A had presented himself to CSC, something which is unusual and could have suggested an adult who was keen to be in control of the way he and the family were viewed.  3.2.5. The approach taken was too superficial and appeared over reliant on the children within Adult A’s previous family no longer being subject to Child Protection procedures.  Good practice would have been to make further inquiries on the basis of the information available.  Crucially there should have been a robust system in place for challenge and reflection.   There is no evidence that there was an effective management oversight or quality assurance process in place which could have acted as such a challenge to the social workers’ thinking. Equally there is no evidence that there was proper challenge and support to team managers as to how to maintain a focus on the child given high workloads and resource difficulties.  This lack of good quality assurance and support is a repeated theme throughout this Review.  3.2.6. The decision making and the management oversight here can only be understood in the context of the circumstances at the time, both within Children’s Social Care as a whole but also specifically within the First Response Team.  It is now fully recognised that Manchester Children’s Social Care was during this period, facing serious problems and in 2014 was judged as inadequate in an Ofsted inspection.  A significant underlying cause of the problems in practice were the very high caseloads and large numbers of cases awaiting assessment. The consequences of these problems have been powerfully highlighted during the response to Child G1.    3.2.7. The First Response team had already been identified as not functioning well by a recent Peer Review.  As a result a previous team manager had been instructed to return to the team to sort out the problems.  That manager described arriving to a backlog of 157 ‘contacts’12.  This manager described being told to undertake only basic checks and sign them off as quickly as possible.  Routinely the team of eight social workers was required to deal with 2,500 contacts a month.  The manager states that they raised their concerns about the safeguarding implications both on arrival in the team and over subsequent months and continued to highlight their concerns by e-mail and telephone.  The manager described feeling isolated, a lack of support, and with no long term plan for managing the throughput of work. The manager also felt that there were problems with the strength of some staff in the team, who did not all have the skills and experience necessary for the complexity of the task.  The manager recognised that they were not able to provide the level of quality assurance and overview that was needed by the team.  3.2.8. The inevitable effect of this context was to undermine the quality of the work undertaken by the team, something which has, since the Ofsted inspection, been fully recognised.  As a                                                       12 ‘Contacts’ is the terminology used to describe any new notifications or referrals that come into children’s social care.  Decisions are then made whether they require further investigation or a referral to a locality team for a formal assessment. MSCB Child G1 SCR Page 20 of 39  result of the Ofsted improvement planning process Manchester has developed a MASH13, which whilst still managing a high workload is now better resourced and has begun to evidence improving practice and full screening of all new referrals.   3.2.9. The absence of a clearly recorded and accessible chronology of events was also a significant weakness in Child G1’s case and was something that should have been initiated from the outset.  The completion of a chronology should have been a service requirement not just in theory, but also as it was actually supported and overseen in practice by the organisation.  There was little to evidence that this was the case at the time.  As part of the improvement planning, the importance of chronologies has been given significant attention, including the requirement that a case is only transferred to a new team, when a complete chronology is on the file, beginning at the point of referral.   3.2.10. There is evidence that significant improvements, particularly a substantial increase in staffing have now been put in place at the point of referral to Children’s Social Care.   This however should not lead to the conclusion that there is nothing further to be learned from Child G1’s case.  What is required, as well as an increases in staffing, and better management of chronologies, is also an ongoing and major shift in culture and expectations as to what constitutes good child focussed practice, something which will only be achieved over a significant period of time.  The authority will therefore need to evidence improvements in practice and support to staff in these ‘front door’ positions on a long term basis.   3.3 Responding to further concerns: Autumn 2013.  3.3.1. When in June 2013 Child G1’s birth father applied to the Family Courts for contact with his child, Cafcass’ initial safeguarding inquiries led them to make a referral to Children’s Social Care.  The triggers for this referral were in relation to the concerns about Adult A’s previous involvement with Children’s Social Care; allegations by the mother of serious domestic violence, sexual assault and increasing harassment by the father and that the mother had not accepted professional support on behalf of herself and Child G1. The Cafcass officer found both parents’ contributions confused and also felt the mother was evasive in their initial conversation.   3.3.2. When shortly afterwards the mother repeated these allegations to the police this appropriately led to a referral to MARAC and the IDVA service as well as an investigation by the Serious Sexual Offences Unit.  At this point the allegations being made by the mother had increased in severity including reference to multiple rapes, Honour Based Violence by her own family and threats by the Child G1’s Muslim father to bomb Christian churches. These allegations and the responses to them will be considered further at section 3.4.  3.3.3. A Child and Family Assessment was commenced by the locality team within Children’s Social Care in July 2013, but work on it was not completed until November 2013, partly because the initial allocated social worker left in October.  The allocated social worker had undertaken a home visit with a colleague and at this point the mother had made more allegations about the father including that Child G1 had been ripped from her while                                                       13 The Multi-Agency Safeguarding Hub (MASH) is a system which co-locates key agencies, including police, local authority children’s social care, and others, at the ‘front door’ of CSC, to share information and decide on appropriate responses to child protection referrals. MSCB Child G1 SCR Page 21 of 39  breastfeeding and then witnessed their mother being raped.  The assessment did not reach a conclusion before the allocated social worker left the team.  This suggests there was no sense of urgency or recognition that Child G1 could have been at risk.  The assessment then subsequently drifted into covering the two referrals from school made in the autumn of 2013.   3.3.4. The response to both referrals made by School A’s Principal, who was also the safeguarding lead, at the school nursery is very worrying.  On each occasion Child G1, who has been in school for only a month had marks on their forehead and said to school staff that their ‘daddy’ had beaten them.  The response of the school was immediate and reflected expected safeguarding practice.  Other information of concern, such as Child G1’s absences from school, as well as appearing hungry and ‘stealing’ and hiding food was also shared. The school hosted both strategy meetings and on the first occasion arranged for Child G1 to be kept in school and for the mother and Adult A to come to school to be interviewed.   3.3.5. On both occasions the mother and her partner provided explanations to social workers that Child G1 had fallen. On the first occasion, Child G1 was said to have fallen while carrying food upstairs. Although on another occasion it was said that the mark on their forehead had been there since birth. On the second occasion it was said that G1 had fallen again and also scratched themself.  The explanation given in relation to Child G1’s words ‘daddy beats’ was that G1 experienced violence from their birth father and this is what they were referring to. There is no indication that any serious consideration was given to the possibility that this was not true and that G1 might in fact be referring to Adult A.  Child G1 had been registered at school with Adult A’s surname, not their birth father’s, and there was other information to demonstrate that G1 called, and was required to call, Adult A ‘daddy’.    3.3.6. The lack of questioning and what is often referred to as ‘healthy scepticism’ about the explanations is striking. There is no consideration as to why a three year old child was carrying a plate of food upstairs unsupervised.  Neither is there evidence of any consideration as to whether a child of this age could make a connection between an accidental fall and the actions of a father who they had not seen for at least eight months.  The social workers did note that  the mother spoke in very negative terms about the father in front of Child G1, including that he  had raped and beaten her in front of Child G1.  Whilst this was noted, it apparently led to no consideration as to whether the mother might be influencing Child G1.  The school Principal noted that the child’s mother and Adult A showed no emotion while waiting for the police and social workers to arrive, which was unusual in their experience.  The Principal also noted that Child G1 appeared reluctant to go with their mother when the social worker told them they could do so.  However, there are no recordings reflecting similar observations in the social work records.  3.3.7. On the first occasion Child G1 was taken to hospital by the social workers, hospital staff were informed that both the mother and child were ‘victims of violent physical abuse’ from the father.  It was concluded that the mark on G1's forehead ‘appeared to be compatible’ with the explanation given by the mother.    No explanation is recorded for the decision to decline the offer of a Child Protection Medical. The conclusion instead was that no further action was required by Children’s Social Care.  On the basis of the medical view about the compatibility of the marks on Child G1’s forehead with the explanation of their carers, the MSCB Child G1 SCR Page 22 of 39  police also closed their investigation. On the second occasion, which was just a month later the school again referred Child G1 after another apparent fall and further marks on their forehead.  At the strategy meeting on this occasion both the school and the police recommended a Child Protection Medical take place and this was arranged in line with standard practice to be undertaken by the community paediatric service.  3.3.8. Based on the information available to the doctor undertaking the Child Protection Medical, the report provided was thorough and coherent.  The social worker was given immediate feedback and the report itself was sent to all the relevant agencies, most particularly the police and Children’s Social Care.  That report made a number of recommendations for onward referrals, including for dental care and to the CAPS (Children and Parents) Service.  Most significantly it reached an explicit conclusion that the older marks said to have been caused by Child G1’s father should be investigated by the police. Neither the police, nor Children’s Services responded to this conclusion and no investigation took place.    3.3.9. The IPCC report has analysed in depth the reasons for the lack of a police response to the medical report.  It concluded that there was no system in place to ensure that medical reports were routinely read before the case was closed.  On this occasion the officer who generally reviewed the reports when they came in to the Police Public Protection Unit was on sick leave, as a result of which this report was simply filed as an administrative task.  Action has since been taken by Greater Manchester Police and it is now a requirement for all medical reports to be Reviewed and signed by the Officer in Charge before a case can be closed.  The IPCC concluded that it was possible that one of the police officers had seen the report on its arrival into the office but placed it for filing without reviewing the contents.  This was subject to a recommendation by the IPCC and management action in the form of development plans was delivered to two police officers as a result.  3.3.10. There is no explanation as to why the conclusion of the medical was not acted upon by the social worker.  The other five recommendations from the Child Protection Medical report have been copied across to the social work assessment, but there is no reference to the necessity for a police investigation.   The most obvious explanation is that the social worker had read the recommendations, but not the conclusion itself, though this is speculative.  The pressures arising from social workers’ workloads may have been a contributory factor in this information being missed.  However, given the significance of a Child Protection Medical, this would still be of serious concern.  It is also the case that irrespective of the doctor’s recommendation the social worker in any event recorded the allegations in the Assessment, including that the father had hit Child G1 with a belt and a stick and scarred their back and neck with a ‘religious spray’.  It would be expected that a social worker would take action or advice when such historic allegations are made against a named individual.  Once again there do not appear to have been adequate safeguards in place to ensure that management oversight at key decision making points.  3.3.11. The way that decision making regarding Child Protection Medicals took place raises some significant questions for both Children’s Social Care and the police.  It would appear in this case that when deciding whether or not to seek a Child Protection Medical there was too great a focus on an individual injury rather than consideration of what the medical might, or might not, be able to contribute more widely to the understanding of the child’s experience.  MSCB Child G1 SCR Page 23 of 39  There is no evidence that the request for the medical had any wider goal other than to provide a view one way or another as to the cause of the mark on Child G1’s head.  Neither the police nor Children’s Social Care staff demonstrated curiosity about the history of abuse towards Child G1 as stated by the mother. The lack of clarity about why a medical was felt necessary on the second occasion, but not the first, is also of interest.  It is difficult not to reach the conclusion that the medical was viewed more as a task to be achieved, than an important means to build up a picture about Child G1.  3.3.12. It is not the case that the doctor’s conclusion was in any way ‘hidden’ within the report, it was quite clearly identified.  Nevertheless with hindsight the doctor concerned reflected that it would have been better to highlight it further.  It is now the case that doctors undertaking Child Protection Medicals are also required to complete a form identifying their initial medical conclusions at the time of examination and this form is given to the attending social worker and then attached to the final report.  3.3.13. The Child Protection Medical was also copied to the GP and to the Health Visiting team neither of which sought information about the conclusion.    The school staff did not have access to the report and were reliant on what they had been told by the social worker. The role of other agencies in challenging the lack of action by a statutory agency, in this case the police, also requires consideration. It is the conclusion of this Review that it would be unrealistic to expect   these professionals to take on a role in chasing up other agencies in order to check they had completed their own allocated tasks.  The health professionals had no more than an occasional role with the family; they were not part of a team around the child in any formal sense and could not be reasonably expected to take responsibility for following this up.   3.3.14. The conclusion reached by Children’s Social Care was that: the concerns about Child G1 were not substantiated; there were no safeguarding concerns; the family would be receiving support from other agencies.  Therefore the case was closed.  From a criminal perspective it was reasonable for police officers to take no further action in relation to the current carers.  However, it is the very clear view of this Review, that taking into account what information was available to Children’s Social Care, the decision to take no further action was not good practice.   There were a number of unresolved concerns, the most significant being Child G1’s own words.  G1's words and actions, however appear to have been completely overshadowed by the narrative supplied by the parents.  This was combined with an over reliance on other agencies to deal with individual identified presenting problems in the absence of any multi-agency plan and an interpretation that the lack of medical evidence of abuse, meant that there was no abuse.  3.3.15. The assessment, started in July 2013, was not formally given to the manager to be signed off until January 2014 and the manager accepted the social worker’s conclusions.  The length of time this assessment took to complete is very poor practice and with the changes of social worker it is unclear when, how and by whom some of the information had been gathered.  These changes in social worker are in themselves a contributory factor, particularly given the lack of a written chronology, in blurring the history of Child G1.   MSCB Child G1 SCR Page 24 of 39  3.3.16. The role and effectiveness of management oversight and quality control of this assessment therefore merits further reflection not least as the manager in this case was a social worker who was recognised as skilled and knowledgeable. The manager had recently been promoted to the role following a reorganisation.  They had specifically raised concerns with management about whether they were best suited to this new role.  Despite having raised these concerns, this team manager was not provided with any training or other support once in post.  The team manager's own supervision was minimal and they were based in an office away from peer support.  The team’s caseload was at the time the highest in the district, with significant staff turnover and too many agency workers.   In this context, and given that key information which might have indicated a need for an urgent Review of Child G1’s circumstances, was not either highlighted or included in the Child and Family Assessment, the risks to the quality assurance processes were highly likely to be increased.  3.3.17. Overall, what can be seen here is an ineffective S47 inquiry with superficial analysis, incomplete information collection, lack of challenge, and a lack of focus on the child rather than the adults.   Information provided to this report is that since this time there have been significant changes in the approach to practice and management oversight of the overall S47 investigation process, which would include as a matter of course the oversight of Child Protection Medicals.  An overview of the improvements undertaken by the Authority following the 2014 Ofsted report and the implications for the learning arising from this Review follows at the end of this analysis.  However, the issue of improving good practice regarding Child Protection Medicals will be subject to a specific finding at the conclusion of this report.  3.3.18. The issue of the management oversight of practice and the support provided to team managers is a repeating feature of this Review and will also be considered again.   3.3.19. Although all five of the Community Paediatrician’s recommendations were followed up by the relevant agencies, the explanation for all the concerns in relation to Child G1 was now presented to the agencies as being related to the historic abuse G1 was said to have experienced from their father. In the absence of any continuing multi-agency plan, there was no means to reflect on whether any of these recommendations was either being followed or led to improving outcomes for Child G1.    3.4 The impact of domestic abuse allegations 3.4.1. The degree to which domestic abuse impacted on Child G1’s life is highly significant, though not in the way which was presented to and believed by professionals.  What is powerfully apparent across the two years subject to this Review is the way in which allegations of domestic abuse were effectively used by the mother to distract services and quickly became understood as facts which did not appear open to challenge.  3.4.2. In the summer of 2013 as a result of the mother’s allegations made to the police a number of steps were taken in line with recognised good practice.  Particularly:  instigation of a police investigation into the allegations of rape  referral to Victim Support   referral to the MARAC, in order to provide the mother with the necessary advice and support regarding risk of domestic abuse MSCB Child G1 SCR Page 25 of 39   allocation of an officer from the IDVA service to support the mother. 3.4.3. The police investigation by the SSOU (Serious Sexual Offences Unit) although overly slow in completion was forensic and thorough.  It concluded that not only was there no proof of the mother’s allegations of repeated sexual assault, there was in fact ‘overwhelming evidence’ that she had been dishonest.  This conclusion about the mother’s honesty was a potentially crucial piece of information which should have impacted significantly on the approach to safeguarding Child G1.  However, the investigation was undertaken by the Serious Sexual Offences Unit, not the Public Protection Unit (PPIU) and throughout the course of the investigation there was no communication between the two.  The two units were not only different parts of the organisational structure, they were also in separate locations within the city.  There was no natural overlap between the two teams and no system in place to link the significance of such allegations of adult sexual with child safeguarding.  This was a significant weakness and it is understood that changes have been made to close this gap within police practice.  Information about these improvements will need to be shared with the Board.   3.4.4. It is of concern that the police officers from the PPIU involved with the S47 assessment did not access from the outset the full intelligence about either Adult A or the investigation into the mother’s very serious allegations against the father.  The police investigation into the allegations of rape made by the mother against the father was slow to conclude but by February 2014 the outcome could have been ascertained.  In December 2014 the Family Court were provided with the outcome of the police investigation by Cafcass, but there was no reason at this point for the information to have been forwarded from the Family Court to Children’s Social Care. That the outcome of this very significant allegation had not been sought directly by Children’s Social Care, despite the allegation continuing to be referred to as evidence of concern about the father, was very poor practice. Like many of the identified problems we do not know if there was a specific reason for this particular lack of follow up.  It is however probably best understood in the context of the overlapping factors that were known to be impacting on the quality of work in Children’s Social Care combined with the powerful impact on professionals of the mother’s story.  3.4.5. The referral process to MARAC was undertaken by a Victim Support officer, and as is sometimes inevitably the case the information was predominantly based on information from the alleged victim and is clearly identified as such.   However the MARAC Action Plan, which identifies the work required by various agencies phrases some of the allegations as if they were facts.  What is also included in the MARAC referral is the allegation being made by the mother that the father has physically abused Child G1.    3.4.6. A key action arising out of the MARAC was referral to the IDVA (Independent Domestic Violence Advisor) who offered the mother personal and practical support.  The IDVA who worked with the mother was experienced, properly trained and supported. The IDVA was clearly methodical in providing the service to the mother, linking her with legal advice regarding the Family Court proceedings and encouraging her to report ongoing concerns to the police.  The IDVA’s normal practice would be to try to meet the individual at least once, although on this occasion, they were only able to speak to the mother by phone.  This was not entirely unusual and did not impact on the service the IDVA was able to provide.   MSCB Child G1 SCR Page 26 of 39  3.4.7. It is evident that the IDVA fulfilled their role exactly as was required of them and did so with care.  However, the information provided by the IDVA to the Review has highlighted what is a very difficult challenge to the IDVA Service.  It is now clear that the mother was attempting to use services to help her manipulate other processes and to develop her narrative that Child G1’s father should not be allowed to see his child as he was the cause of any distress Child G1 might exhibit. The fundamental ethos of the IDVA service is to believe and support those with whom it is working, as a counterbalance to the negative responses many victims may have experienced, or feared, from friends, family or professionals.   The established approach is to believe what is being said unless given a good reason not to.  This is a deeply rooted feature of the culture for IDVAs based on the importance of ensuring victims of abuse feel listened to and believed.  But in this case the continuing presumption of the mother’s honesty was mistaken.  The culture of the organisation, so important to the vast majority of its users, appears to have prevented the IDVA listening to some of their own responses to what they described as ‘bizarre’ aspects to the case.   3.4.8. Throughout her contact with professionals, the mother often provided contradictory information, and at times made surprising allegations and claims that might have been expected to raise alarm bells.  One of the most striking examples is that she told various professionals that she was subject to Honour Based Violence.  She explained that her own father, who was the founder of an Evangelical Christian Church in the city, had tried to force her to allow Child G1 to be brought up in Islam.   The IDVA recognised this was a strange claim, but did not feel it was their role to question. In effect the mother was effectively able to reinforce her story by highlighting the support of the IDVA Service and her involvement with MARAC.    3.4.9. The Review has found very little direct evidence as to the degree to which the race, culture or religion of the family was taken into account when providing services to the family with the exception of the psychologist who attempted to seek information about issues of culture that they were presented with.  What is difficult to ascertain, and remains an unresolved question in this Review, is to what degree the allegations of abuse which were being linked by the mother to both culture and religion, may have been particularly effective in distracting the professionals from  any challenge.  3.4.10. From the records available and the actions taken, it is apparent that the social workers involved with the family accepted what they were told by the mother about domestic violence. “The mother presented as a young woman who was determined not to be bullied into remaining in or returning to a violent relationship.”   No attempts were made by CSC to contact the father other than in relation to his application to the Family Court and ultimately in the final weeks before Child G1 was admitted to hospital.   There was no evidence of critical questioning, whether directly with the mother, or elsewhere. At the same time despite the history of Adult A, the assurances that there was no domestic abuse in the mother’s relationship with him appear to have been accepted without question. A clear chronology of events and better recording of information from other agencies again would have shown that there were some significant discrepancies in what the mother had said.  However, the power of the adults’ narrative seems to have been so strong it remains possible that even a chronology would not have impacted in the absence of a worker with a more challenging approach.  MSCB Child G1 SCR Page 27 of 39  3.4.11. This view of the family situation was then developed and perpetuated from one contact to the next.  Language used in reports and agency records too often refers to the allegations as if they were statements of fact.  Other agencies were told by Children’ Social Care, not that a possible explanation for Child G1’s comments and behaviour was that they were remembering abuse by their father, but that this was the known cause of G1's behaviour.  The school was told by a social worker that when Child G1 said ‘daddy beats’ this referred to their birth father.  The psychologist at the CAPs service was left with the understanding that Child G1 has been a witness to domestic abuse and had been traumatised as a result.  The school counsellor was also told that the mother had experienced domestic abuse.  In the absence of a properly maintained record and chronology, or a challenge by a colleague or supervisor within Children's Services, the mother’s narrative became more and more established as a truth.  3.4.12. There has been a crucial shift in attitudes towards domestic abuse in many parts of society over recent years and for statutory services this has also led to a change to the way some services are provided, with a focus on encouraging and supporting victims to seek help.  The findings of this Review are in no way intended to undermine the progress that has been made.  However, the inherent risk is that services may fail to consider the possibility that this creates the opportunity for a small number of people to manipulate professionals, sometimes with very serious consequences.  What in particular was missing at key points when considering Child G1’s needs was any reflection on whether their mother had an alternative motivation for the allegations she was making.  Given the information that was available from June 2013, two potential alternative motivators should have been considered:  the need to deflect professionals from what was happening in the house and a desire to prevent Child G1 from seeing their father.  3.5 Assessment within Private Law Proceedings 3.5.1. The order by the Family Court for Children’s Social Care to undertake a Section 7 Report in January 2014 provided a significant opportunity to re-evaluate Child G1’s needs and particularly to better understand the allegations made against their father, both of domestic abuse and of physical abuse towards Child G1. However, the resulting report to the court was of very poor quality and failed to understand the significance of the mother’s narrative in the context of Private Law Proceedings.  As a result a key opportunity to intervene in Child G1’s life was lost.  3.5.2. There was a delay in undertaking the report due to difficulties in allocating a social worker and an extension was agreed with the Court.  Once again, a different social worker was allocated to undertake the assessment.  This social worker was newly qualified and it is evident from the outset that they had no experience or familiarity with the requirements of a Section 7 report.  However, the social worker sought advice from their manager and other colleagues and made use of a report format that they had been given.  3.5.3. The Section 7 report lacks analysis and accepts the information provided by the mother and her instruction not to talk to the child about their father.  The father denied all the allegations which he said were made to prevent him having contact with Child G1, but this was not reflected in the report and information from the police which would have supported his position was not obtained.  Gaps and discrepancies in the information in the report are MSCB Child G1 SCR Page 28 of 39  not explored and there is no reference to the conclusion of the Child Protection Medical with regard to a police investigation.  There is no analysis of the significance for Child G1 of maintaining a relationship with both their parents.  A substantial amount of information was copied from the CAFA prepared by a previous social worker without proper acknowledgement that this was the case.  3.5.4. The report concludes that there were no safeguarding needs requiring the involvement of the Local Authority and that “Child G1 should not be placed in a position whereby they have to see their father particularly as G1 is still engaging with child psychology due to the trauma suffered in relation to the abuse by the father.”   However, the mother had stopped taking Child G1 to CAPs after two sessions earlier in the year and only returned on one further occasion to ask for a report to be prepared for the family court to prevent the father seeing Child G1.  The psychologist had not agreed to this request.  3.5.5. A detailed analysis of this Section 7 Report has been possible within the context of this Serious Case Review, but would not have been realistically possible to the same extent at the time.  Nevertheless, given the quality of analysis the Section 7 report should not have been signed off by a manager or accepted by the Local Authority’s Legal Department.   The social worker’s team manager had worked with the social worker during the preparation of the report within regular supervision as well as by providing very frequent support and advice outside of formal supervision.  However, this line manager did not quality assure the final report due to being away during at the point it was completed.  It has not been possible to establish whether another manager signed off the Section 7 report as would have been expected. Information provided to this Review means that it is not possible to understand how the quality assurance systems failed to identify the problems with this report at this point.  Previous information, as noted about the pressures in teams and lack of adequate focus on quality at a strategic level, are likely however to represent some of the underlying factors.  3.5.6. What this Review has also revealed is that there were fundamental weaknesses at this time in the general approach to managing staff performance where issues relating to knowledge and skills were impacting on the quality of practice.  These weaknesses included:    lack of guidance and support  for new managers working with staff where who were not achieving required practice standards  lack of explicit requirements that staff take part in identified learning and development programmes.  employment practices which failed to clearly recognise the difference between an employees’ pay grade and their experience or capacity to undertake a particular role.  3.5.7. This Review is satisfied that the team manager had tried hard to support the social worker’s practice in difficult circumstances. That the practice at this point was ultimately of unacceptable quality appears to be linked directly not only to the wider problems facing this social work team, but also to the performance management culture as described above.    This Review has been informed that previously poor expectations in relation to performance management have been recognised and a range of actions taken, for example all newly qualified social workers are now required to be part of an enhanced ASYE programme MSCB Child G1 SCR Page 29 of 39  irrespective of their previous experience and an accredited development programme is being developed for new team managers.  3.6 Continuing pattern of concerns 3.6.1. Between the completion of the CAFA in January 2013  and May 2015 there were a significant number of referrals and other ongoing concerns, most of which did not result in assessment by CSC and none of which led to any form of planned multi-agency intervention.  Date Event 28 November 2013 Sore arm and eye.  Hospital referral to CSC who stated they had no concerns.   26th February 2014 Sore lip, seen at school.  Child G1 states “daddy beat me” (not referred to CSC) 6th October 2014 Child G1 tells school counsellor their mum and dad have been hitting them.  Referred to CSC, CAFA initiated 8th October2014 Child G1 tells school their feet hurt.   15th December 2014 Child G1 taken to Paediatric A&E with a bruised forehead.  Tells school staff that daddy hit them with a spoon.  Referral to CSC 9th January 2015 Child G1 in school with sore arm “my mum did it”.  Not referred to CSC 18th January 2015 Burn to Child G1s arm.  Referred by Paediatric A&E to CSC.   3.6.2. Proactive action was taken by both schools when Child G1 moved from the nursery school to primary school in September 2014 in that full information was shared and Child G1 was referred to the primary school counsellor and identified as having Additional Needs.  Within a month of arriving at School B Child G1 again made a disclosure about being hit at home and for the first time stated that their mother had hit them.  This was not only further information about possible abuse but given that Child G1 was now referring explicitly to their mother, it should have triggered a fundamental re-examination of what was taking place.  3.6.3. The case had remained open, although inactive, to the social worker who had undertaken the Section 7 Report and who now undertook the CAFA. Once again this assessment was not completed for almost four months by which time Child G1 has also suffered a significant burn.   There is no evidence in this assessment of any re-evaluation and little evidence of any new work.  The social worker undertook a home visit but closed down the conversation when Child G1 began to speak about their family.  Much of the assessment was taken directly from the previous assessments without being updated, with even Child G1’s age unchanged a year on. Again, the domestic violence and other allegations were recorded as if they were facts.  The rationalisation for no further action by the Local Authority relied on the ongoing involvement of ‘a number of professionals’ although the only professionals involved were the school staff and counsellor.  There was no real assessment of the risk as a result of these two incidents and no analysis of what Child G1 had now said about both their parents beating them. The assessment would not meet any standards of acceptable practice.  MSCB Child G1 SCR Page 30 of 39  3.6.4. The existence of a significant burn on a child of this age, should have triggered considerably more concern.  Staff at the hospital appropriately sought information from Children’s Social Care, but were assured there were no concerns. Again the fact that the injury was consistent with the explanation appears to have been seen as definitive.  Nothing suggests that the social worker properly considered the circumstances in which the injury is said to have happened, which at the very least highlighted a lack of parental supervision.  Neither was there any recognition that the explanation given changed in its detail.   3.6.5. It is the case that burns to children are common, with current estimations being that 10% are abusive14.  However, given the history of injuries that Child G1 had already experienced, G1's repeating comments about those injuries and the information available about Adult A, it is difficult to understand why this burn did not cause more concern and did not result in Child Protection procedures, or at the very least a Child in Need plan. By this stage there was a range of information to suggest the possibility that Child G1 might be experiencing other problems at home, whether that be abuse or neglect.  There were several indicators that could have led to such a hypothesis which should have been tested out including:  continuing concerns about Child G1 taking and hiding food at school  evidence of unusually compliant behaviour with stepfather  school absences  Child G1 spending significant time, including taking meals, in their bedroom  lack of appropriate toys and personalisation of bedroom  repeating accidents requiring medical attention  aggressive behaviour at school  missed health appointments.  3.6.6. By this point the two schools had raised referrals and specific concerns with Children's Social Care on around 15 occasions and shared a significant amount of information with the five social workers who were involved with Child G1 during these two years.  Both schools felt an enormous degree of frustration that Children’s Social Care did not seem to view Child G1’s situation with the same degree of concern that they did.  They describe frequent difficulty in getting feedback from social workers, which when it did come was often by e-mail and rarely face to face.  The school often took on a proactive role in relation to Child G1’s wider needs, for example in trying to encourage the mother to keep an appointment with the Burns clinic and informing CSC when this was not happening.  3.6.7. The impact over time on school staff was to lead them to gradually doubt their own judgement about the seriousness of what was happening.  The assistant head teacher at the primary school, an experienced safeguarding lead, talked about how difficult it was to trust your own judgement when on each referral a social worker, whose job was child protection, told them they had visited the home, spoken to the family and there were no concerns.  The Assistant Head felt they were worrying too much:   “We were passing information on and felt helpless.  The social work view was that everything was ok and we were exaggerating, kind of the naughty ones who worried too much.  We                                                       14 Research obtained from literature search by academic Review: http://www.core-info.cardiff.ac.uk/Reviews/burns  MSCB Child G1 SCR Page 31 of 39  were too trusting in Children’s Services and accepted that the social worker knew best.  I know now that I should have taken my concern to someone higher than the social worker”.  3.6.8. The school staff now clearly recognise that they should have escalated their concerns and this has been a distressing lesson for them.  As a result of the learning from this report the Education Directorate is considering including the issue of escalation in the learning outcomes of all education establishments. That professional teaching staff who knew the child well and had good reasons to be concerned ultimately lost confidence in their own judgement is not only a lesson for that group of staff, but also a powerful reminder to Social Care staff to take seriously the concerns of other professionals and also to inform them of what options are available to them if they are in disagreement.   3.7 A new referral leading to a new assessment  3.7.1. When in May 2015 the school made a further referral to Children’s Social Care, the case was allocated to another locality team and therefore a different social worker, due to lack of capacity in the previous  team. There is no doubt that this marked a positive change in approach, although the confused story around Child G1 continued to mask the potential urgency of their situation.  The school had continued to note concerns about Child G1’s behaviour and presentation, including ongoing problems over food and aggression to other children.  One incident which had caused particular disquiet was Child G1’s reference to their mother going to prison. When school spoke to the mother she provided explanations or denials for any behaviour the school identified.  Although no longer confident that their concerns about Child G1 would be taken seriously by social workers, the school  nevertheless made another referral when Child G1 was seen to have a scabbed and swollen lip, which the mother had said had happened at school.  3.7.2. The newly allocated social worker undertook a home visit and spoke to the school, and it was clear to them that they were very concerned about Child G1. Child G1 however told the social worker that they had cut their lip when running at school.  One of the pieces of information that was later e-mailed to the social worker, was that Child G1 had said at school that if they got paint on their clothes their ‘daddy would beat me harder.’  Such a specific disclosure from a child, should have triggered a more urgent response by, if not the social worker, then their manager.  That this comment did not have a more immediate impact seems to have been again a result of the smokescreen that had so effectively been put in place by the mother and the lack of any clear understanding of the history.  3.7.3. Nevertheless, it is apparent that the social worker was concerned about Child G1 and a decision was made by the manager that there should be a Child and Family Assessment.  The following week this social worker was allocated to undertake the assessment.  Although they were a newly qualified social worker, their team manager was confident in their ability, particularly their experience in engaging with children.   The school principle described a sense of relief when this social worker came to the school “I finally felt listened to”.   3.7.4. It was agreed that the initial focus should be on direct work with Child G1 developing a rapport and verifying information, including speaking to the father.   Child G1 had not made any direct disclosure to this social worker at the home visit, but the social worker felt this was not surprising given G1's age and that they were a stranger to Child G1.  It was agreed MSCB Child G1 SCR Page 32 of 39  for the first time that a chronology needed to be prepared and a support worker was given this task. The social worker was aware of the school’s concern that there was about to be a two week break and that school had recently made a further referral to the MASH as  Child G1 had been exhibiting further worrying behaviour.  The social worker attempted to put in place a further home visit the following week, but the mother said they would be away.  The next date the social worker was able to agree with the mother was therefore to be 5th June, which proved to be the day after Child G1 was taken to hospital.  3.7.5. In contrast to the previous poor quality assessments, the approach to this assessment was informed by an explicit plan of work.  One of the most significant aspects was the recognition of the need to develop a trusting relationship with Child G1 alongside verifying other information and production of a chronology.  A key feature at this point was not only the allocation of a more thoughtful social worker, but that this social worker was able to access and make use of good supervision.   3.7.6. The visit by the family to the GP two days before Child G1 was admitted to hospital has required careful consideration, as it is now known that the serious injuries to Child G1 would already have happened, which means that G1 was walking on two broken ankles.  The visit to the GP was for an emergency consultation by the mother, which in reality was not an emergency, she was seeking a report from the GP to support her attempts to prevent the father having contact.  The mother, Adult A, Child G1 and their sibling all attended.  The GP at no point saw Child G1 walking, indeed it is believed G1 was carried out of the surgery by Adult A.  The GP was appropriately focussed on responding to the mother, and had no reason to attempt to see Child G1 moving.  The surgery’s consultation rooms are exceedingly cramped. Having seen the consultation room it is evident how difficult it would have been to identify that one of the family group was injured, and how easy it would be for an adult to conceal what had happened.    3.7.7. The response of the medical staff when Child G1 was taken into hospital on 4th June 2015 was of a very high standard.  Concerns about the presentation were identified before the x-rays had confirmed the nature of G1's injuries.  Child Protection processes were quickly and effectively put into place.  Both health and social work staff provided care and support to Child G1 over and above that which was required of them.  Staff demonstrated a high level of empathy for Child G1’s situation; they ensured G1 routinely had company and themselves brought clothes and toys in for G1 while they were in hospital.  3.8 The role of the Private Law Proceedings 3.8.1. It is not within the remit of a Serious Case Review to analyse or assess the role and practice of the Family Courts.  However, a feature of this Review which has raised concern is that Child G1 was subject to an application within Private Law Proceedings which continued over a two year period without a satisfactory conclusion.  The interface between the Family Courts, Cafcass and the Local Authority is of importance in understanding the outcome for Child G1 and the overlap between Private Law applications and safeguarding concerns.  As such there would appear to be opportunity for further learning here.  3.8.2. It is evident that the court proceedings were subject to delay for a variety of reasons, many of which will be familiar to the Family Courts and do not have an easy resolution.  These MSCB Child G1 SCR Page 33 of 39  ranged from parental failure to attend court hearings and parental misuse of court processes to the requirement for Cafcass to have a Court Order before they can intervene in Private Law Applications. On a number of occasions delays were also a result of Cafcass not receiving court orders in a timely fashion.  With hindsight there is a strong argument to suggest that separate representation and appointment of a Guardian should have been considered before May 2015 and there may be value in considering with the court whether there was an opportunity to adopt this course of action at an earlier stage in proceedings.  The appointment of a Guardian for the child would have had the effect of underlying the seriousness of Child G1’s position from the Court’s perspective, which might in turn have impacted on the position of Children’s Social Care.  3.8.3.  Therefore, in order to seek better understanding of what action, if any, could be undertaken to improve the overlap between the Family Courts and statutory agencies in these circumstances, a recommendation is made that the Board share this Review with the relevant Designated Family Judge.  3. The power of the adults’ narrative in drowning out the voice of the child 3.9.1. What is all too apparent throughout the involvement of agencies with this family is the way that the mother and her partner were able to control the story, and the professional responses to that story, with such a remarkable degree of success.  This is particularly disturbing given that Child G1 specifically told professionals on many occasions that they were being beaten.   The parents presented in a way which often seems to have wrong-footed the professionals.  Mother was able to elicit sympathy from many of the professionals, who found her plausible and were drawn into her story.  Adult A was described, as calm, polite and level headed.  He worked in social care and used this information to both reassure and at times to implicitly threaten people.  The mother was willing to use highly charged allegations, including of Honour Based Violence and implied religious terrorism which clearly raised the temperature.    3.9.2. The professional response to the explanation given by the mother that Child G1 was experiencing trauma  and nightmares which led them to say ‘daddy beats me’ on waking, appears to have been to accept without question.  G1's behaviour and what they said, was effectively given a quasi-medical label.  In fact although very young children can of course be very badly affected by witnessing or experiencing abuse, care is needed not to apply adult explanations of causality to children’s responses. The social work response appears to have been to too willingly embrace the parental assertion that Child G1 was traumatised, despite the fact that a child of this age would be unlikely to express their feelings of distress in verbal terms, and should not  be ‘diagnosed’ by anyone other than a specialist professional.    3.9.3. What is highlighted here, and is seen elsewhere, is a risk that professionals, in this case, social workers, are tempted to accept explanations or reach conclusions that lie outside their expertise.  This emerges again in the references to ‘attachment’.  Attachment disorder is a familiar theory to professionals working with children and the concept of ‘attachment’ has become widely referenced in social work.   However although superficially ‘attachment’ is not a difficult concept, the reality of assessing attachment is a complex one which requires significant skill, care and time.  The  social work assessments of Child G1  stated that G1 had a ‘strong attachment bond’ to their mother, the evidence for which was based on a small MSCB Child G1 SCR Page 34 of 39  number of occasions when Child G1 was well behaved and responsive to their mother or was involved in activities such as drawing and singing which G1 clearly enjoyed.  This assessment of attachment was either unaware of, or did not take into account, other available evidence which would suggest that the relationship between Child G1 and their mother was altogether more complicated.   The description from school staff of the mother’s response to the first S47 assessment and Child G1’s reluctance to return to their mother at the end of the meetings; the ‘permission seeking behaviour’ described by the CAPS psychologist; the unwillingness to talk about family or domestic activities; significant time, including taking meals, spent alone in their bedroom.  These are behaviours that needed considerably more consideration and should have suggested a far more complex ‘attachment’ between mother and child than was concluded.   3.9.4. Some professionals clearly did have reservations about the parents although it is not clear if these were ever explicitly discussed.  Comments were made about Adult A’s dominant personality and about the mother’s willingness to talk about the father in extremely negative terms in front of the child.  The school counsellor considered the involvement of the wider family in the sessions with Child G1 was ‘inappropriate and unusual’ and made arrangements to see Child G1 alone at school.  Some of the stranger explanations for things given by the mother were questioned even if not directly challenged, for example that Child G1’s stealing of food was related to vitamins they had been given.  On a number of occasions the mother drew on ‘cultural’ explanations either to suggest criticism – the ‘religious spray’ she said was used by the father - or to deflect criticism - Child G1 kneeling in front of Adult A.  It is possible that these ‘cultural’ explanations carried a particular power, although they were of course, also simply one of a repertoire of distractions used to keep professionals from the truth.   3.9.5. The effectiveness of the adults’ command of events combined with a system which did not challenge allegations of domestic abuse and a social care system unable to cope with the pressures upon it, created a situation where the potential for such a serious outcome was more rather than less likely.  The skills and capability  of individual professionals is also clearly a factor here, but in considering the impact the adults had it is important to recognise that at least five social workers prior to May 2015 had accepted the adults’ story and many others who had been told this is what had happened, found it to be plausible.  As such the lack of challenge of the adult narrative cannot simply be explained as a result of individual worker’s weaknesses. What was needed was effective and constructive challenge and reflection with the practitioners, but this was not in place.  3.10 Communicating with Child G1 3.10.1. Finally, but possibly most importantly, this Review has identified some fundamental weaknesses in the way key professionals were able to communicate with and understand what Child G1 was trying to tell them.  As soon as Child G1 was in an environment outside their own home, they told their teachers in simple language that they were being beaten by daddy. One of G1's nursery teachers described feeling like they were “on standby waiting for Child G1 to make a disclosure”.   Child G1 repeated what they had said time and again.  As G1 got older and their language developed what they said became more detailed.  Child G1 told their teachers that both their mummy and their daddy hit them in the stomach and they wanted it to stop. Child G1 told their teacher that if they had paint on their clothes their MSCB Child G1 SCR Page 35 of 39  daddy would beat them harder.  Child G1's teachers believed G1, even though they began to lose confidence in their understanding over time and struggled repeatedly to ensure G1's voice was heard by the other statutory agencies.  3.10.2. With the exception of the final social worker, the social workers who spoke to Child G1 did so almost exclusively either immediately after injuries were raised as a concern with G1's carers, or in G1's own home, sometimes with the mother in the same room.  Little consideration seemed to have been given as to how to develop trust with Child G1 or how to provide a safe environment in which G1 might be able to speak.  When G1 retracted what they had said, this was accepted, instead of the original disclosure.  On one occasion which is particularly hard to understand the social worker consciously stopped Child G1 from talking about feelings in the family “they said that their mummy was not happy.  I changed the subject.”   3.10.3. In a young child, communication comes through behaviour, often significantly more than through verbal expression.  The school routinely identified many features of Child G1’s behaviour that worried staff who saw G1 daily and clearly cared very much about the child.  These behaviour traits would ebb and flow but never completely went away – ‘stealing food’, distress on arriving and leaving school, aggression with other children and on one occasion (minor) cruelty to school pets.  The school counsellor was one of the professionals who showed a level of curiosity about what Child G1 might be trying, consciously or otherwise, to communicate.  The counsellor was for example concerned that Child G1 had been coached as to what to say about injuries.  The counsellor also noted that Child G1 although not speaking, appeared to be trying to draw their attention to the burn scar on their arm.  3.10.4. Visits to the home provided a different opportunity to learn about Child G1’s world.  Potentially useful information was recorded including: the amount of time this very young child spent in their bedroom; the lack of toys in the house; Child G1 carrying their meal up to their room.  Yet this information did not appear to lead to any greater understanding of what G1's life might be like or whether G1's needs were being met by their carers.  3.10.5. The role of the carers was in fact a significant feature in preventing Child G1 from being heard.  The organisational pressures in Children’s Social Care and the focus on closing cases, also played its part.  There has emerged a strong sense of a culture at that point in which it was better not to ask too many questions.   What has been more difficult to establish is the degree of understanding and skill that social workers were drawing on in working and communicating with children.  Given how much Child G1 was telling people it is difficult not to reach the conclusion that some workers did not have adequate skills to work effectively with children or give adequate priority to the child’s view of their world.   3.10.6. The concept of listening to the ‘Voice of the Child’ is frequently a feature of Serious Case Reviews and is championed in social work as fundamentally important.   What we can see from Child G1 is that recording the ‘Voice of the Child’ is meaningless if that voice is not heard, understood and taken seriously.  The Review has been provided with information that during the time since these events, and again in the context of the Improvement Plan, considerable work has begun to improve skills within the Children's Services workforce in MSCB Child G1 SCR Page 36 of 39  this regard.  In particular there has been considerable investment in adopting ‘Signs of Safety‘, an established model for direct work with families, including specific materials to help in work with children.  The findings of this Review highlight the critical importance of developing this aspect of social work with families, including establishing a means to evidence any improvements in the outcomes for children and young people.   4. CONCLUDING COMMENTS 4.1. Child G1’s injuries were not caused by professionals, they were caused by adults whose role was to nurture and care for them.   What we now know is that those two adults deliberately and over a long period of time put barriers in the way of the services which should have intervened and protected Child G1.  The care for Child G1 and persistence of the staff from two schools in trying to get their concerns heard is a continuous thread in Child G1’s story. Staff within both the police and Children’s Social Care whose practice fell short of acceptable standards have been held to account through internal employment processes.  Nevertheless, it is clear that it was the safeguarding system as a whole which failed to protect Child G1 for far too long.  4.2. What has been identified is that significant underlying problems within the safeguarding system, failed to protect against weaknesses in individual practice or otherwise created circumstances in which the conditions that would have supported and encouraged good practice were too often not in place.  The most significant underlying systemic problems as identified in this Review included:  High caseloads and workload pressures leading to a loss of focus on quality of practice and the outcome for children.  A loss of focus and priority on ensuring good standards of quality assurance.   Approaches to allegations of domestic abuse that do not adequately allow for the possibility of malicious or manipulative allegations.  Inadequate development and support at an organisational level for effective supervision and reflective challenge to practice.  Lack of effective interface between systems responding to domestic abuse and sexual abuse allegations by parents with children’s safeguarding.  A multi-agency safeguarding partnership which did not adequately champion and support constructive challenge between professionals.  4.3. There are important lessons arising out of Child G1’s experience which point to underlying systemic problems and are relevant for all the services involved in this Review.  Nevertheless the analysis and learning has needed to be significantly focused on the role of Children’s Social Care (CSC).  Whilst it should be emphasised that safeguarding is not the sole preserve of Children’s Social Care, in this case the decision making and approach to assessment by CSC was fundamental to the outcomes for Child G1 and has been recognised as representative in many aspects of practice during this period.  What must be recognised is that the practice that has been evidenced in relation to Child G1 can only be understood in the context of what we now know was a seriously underperforming Children’s Social Care.    MSCB Child G1 SCR Page 37 of 39  4.4. The  underlying causes of the major practice failings as identified in this Review mirror to a very significant degree those identified in the 2014 Ofsted report regarding the Local Authority:  Very high workloads leading to superficial assessments.  Staffing problems – high turnover and over reliance on agency workers.  Pressure to close cases quickly.  Lack of supervision or practice challenge across grades.  Negative management culture.  Professionals in roles which they were not suited for (or supported into).  4.5. The ongoing Improvement Plan which followed the  Ofsted report has been focussed to a very significant degree on many of these same issues, crucially it prioritises management supervision and responding to the ‘voice of the child’.  In particular the following four key issue areas  were identified for priority during 2016/17: 1. Addressing high caseloads.  2. Demonstrating a good management of performance and practice. 3. Improving the quality of social work practice.  4. Improving the quality and accuracy of data and management reports.  4.6. In the context of a major Improvement Plan already underway since the events considered here, and where there was evidence that changes linked to learning from this Review were already being put in place, the Independent Reviewers agreed that a different approach to making recommendations and findings was justified.   4.7. It was therefore agreed that the degree to which the identified concerns remain of concern today, would most effectively be assessed by the Board and the Local Authority on receiving this report as part of the work already underway for the Improvement Plan.  The purpose being to ensure that the approach to learning from this Review was considered as an integral part of the work that was already being undertaken within the Local Authority Improvement Plan and the related Business Plan for the Board.   Prior to the Review being finalised and considered ready for publication, the Board would establish firstly if adequate action had already been taken to address the learning identified here and secondly what further actions might be necessary in the  context of the current work programme.  Where learning was not clearly linked to the Improvement Plan and Board Business Plan, separate findings or recommendations would be included.  4.8. The approach to the findings in this SCR is therefore to identify two categories for consideration:  Learning Points and Recommendations for the Board.    MSCB Child G1 SCR Page 38 of 39  5. LEARNING POINTS AND RECOMMENDATIONS FOR THE BOARD  5.1 Learning points for consideration as part of the ongoing Improvement Plan:  Disclosures of abuse by children whether made directly or indirectly through their behaviour, must always be given the highest priority and fully investigated.  Services need to ensure their systems and staff are able to recognise and intervene to halt the cumulative effect of repeated injuries or other concerns.  The development and maintenance of quality fully skilled staff, supported by the organisation to undertake work at the front door and to prepare high quality social work assessments should be afforded the highest priority by Children’s Social Care.  Robust information gathering for assessment particularly in relation to the history of all members of a household should be considered a basic requirement of practice.  A culture of challenge and reflection must be developed to enable front line practitioners to question what they are told; allowed to  admit they might be wrong; and  routinely give consideration to alternative hypotheses.   Where management oversight has lost focus on quality, outcomes such as those experienced for Child G1 risk being repeated.  The authority needs to satisfy itself that front line staff have well developed skills in understanding and communicating with children.   Medical assessments that an injury is ‘compatible with’ an explanation should not be confused with a judgement that something is not non accidental.  Think: Substantiated/not substantiated/not proven.  How confident can the authority be about the quality of Section 7 reports and the attention paid to quality assuring these reports? Consideration to be given to joint working with Cafcass to develop quality markers and training for Section 7 reports.  Where decisions about children’s needs or risks are reliant on a reassurance from, or belief that other agencies are taking action, this should be subject to a system of Review.  Is there a need for professional development across agencies on burns and physical abuse?  Use of labels and ‘diagnoses’ such as trauma or good attachment, need robust evidence and challenge.  5.2 Recommendations for the Board:  The Board to seek evidence from all partners as to how they provide sensitive services to the victims of domestic abuse, whilst maintaining appropriate caution when allegations are not yet proven.  The Board to examine the effectiveness of its escalation policy across agencies.  The Board to consider a work stream to develop a clear and shared understanding between Children’s Social Care, the police and community health services regarding the scope of Child Protection Medicals, their contribution to S47 enquiries and how recommendations are put in place.  The Board to share this Review with the relevant Designated Family Judge with a view to achieving further learning.  Greater Manchester Police to provide evidence to the Board that appropriate links are in place between the Serious Sexual Offences Unit and the PPU.   MSCB Child G1 SCR Page 39 of 39  APPENDIX A: Additional individual agency recommendations/actions already undertaken  Cafcass:    Developmental work in teams regarding the use of escalation processes.  Continuing work on the importance of the Voice of the Child, the significance of professional curiosity and reconsidering hypotheses.  Central Manchester University Hospitals NHS Foundation Trust: 1. A pilot of a full day Level 3 Safeguarding Children Training is currently in progress and will be implemented from January 2016. The training has been Reviewed to increase knowledge specifically relating to:  the barriers to safeguarding children, including professional curiosity, disguised compliance and the rule of optimism  the importance of communication between professionals across health services and other agencies to gain insight into the life of a child within the family and wider community  the importance of hearing and documenting ‘the Voice of the Child’.  2. A Safeguarding Record keeping Audit is identified on the work plan to take place in Quarter 4 (Jan – Mar 2017) and will include all aspects of safeguarding documentation.  Manchester City Council Education: Consideration of the use of escalation in the learning outcomes for all Manchester schools, educational establishments other than schools and the independent and voluntary sectors.  This could be facilitated through vulnerable children’s network meetings, MCC safeguarding training and Designated Person safeguarding training and briefings during the academic year.  Greater Manchester Police: Circulation of a ‘Lessons Learned Bulletin’ identifying the key single agency learning and recirculating relevant guidance. 