Serious injury of a 2-month-old baby boy in September 2011. Child S was found home alone with visible bruising. Examination later revealed multiple injuries including fractures and a brain injury. Child S and both his half siblings were subject to child protection plans at the time of the incident. Mother pleaded guilty to wilful cruelty and three counts of grievous bodily harm, for which she received a community sentence. Mother was subject to a child protection plan as a child and lived in foster care for two years from the age of 5. Mother had learning and emotional difficulties and a history of domestic abuse and alcohol misuse. Mother told GP that Child S was unwanted and she was considering adoption. Mother was well known to agencies, including police, and was arrested two years prior to the incident for being drunk in charge of a child. Identifies lessons for practice concerning insufficient recognition and assessment of risk factors including: resistance, parental vulnerabilities due to childhood experiences, bruising to non-mobile infants, alcohol misuse, the impact of learning disability on parenting capacity and the meaning of the child to the mother. Makes various interagency and single agency recommendations.
      
 Title:  Overview report on the serious case review relating to Child S: executive summary and overview report. LSCB: Surrey Safeguarding Children Board Author: Jane Wonnacott Date of publication: [2014]  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.                         1           Overview report on the  SERIOUS CASE REVIEW  relating to  Child S   Executive Summary  and Overview Report   Report Author Jane Wonnacott  MSc MPhil CQSW AASW  In-Trac Training and Consultancy Ltd 2  CONTENTS  EXECUTIVE SUMMARY                   Page  1. Introduction 2. Case summary 3. Review findings 4. Conclusion and recommendations 3 5 10 15  OVERVIEW REPORT  1. Introduction 2. The serious case review process 3. Family background 4. Professional involvement with Child S and his family 5. Thematic analysis of professional practice 6. Lessons learnt 7. Conclusion 8. Overview recommendations 9. Individual management review recommendations 17 18 24 25 53 73 74 75 79  3 EXECUTIVE SUMMARY 1. INTRODUCTION 1.1 This serious case review was undertaken because of a critical incident in September 2011 when a two month old baby, Child S, and his one year old half sibling (Half Sibling 2) were found home alone and Child S was seen to have a bruise on his forehead.  He was subsequently found to have serious injuries including fractures and brain injury.  Both children and their half sibling age four (Half Sibling 1) were subject of child protection plans at this time. Mother, who lived alone with the children, was charged with Grievous Bodily Harm and Neglect. Mother pleaded guilty to wilful cruelty and three counts under section 20 of grievous bodily harm and in September 2013 received a community sentence.  1.2 At the point of the critical incident, the case was referred to the Surrey Serious Case Review Group whose initial conclusion was that the criteria for a serious case review were not met.  Further information was requested and the case was kept under continual review.  As a result of additional information requested from both Health and Social Care the decision was made in October 2012 that the criteria for a serious case review had been met.  A panel, chaired by the independent chair of Surrey Safeguarding Children Board, was appointed to oversee the serious case review process and an independent author commissioned to provide the final overview report.  It was agreed that the review would be completed as far as possible prior to the criminal proceedings and immediate action taken to rectify any practice problems identified by the review.  The final review report would be finished at the close of the criminal proceedings when family members would have an opportunity to contribute their views.  1.3 It should be noted that this review took place in line with the guidance set out in Working Together 2010 as the current guidance (Working Together 2013) was not in place at point the review started.  This means that the information obtained for this overview was gained from individual management review reports and the overview author did not talk directly to any of the practitioners 4 involved.  The potential limitations of this process have now been recognised nationally and locally in relation to understanding “why” events occurred. Where there are gaps in information this has been identified within the report and relevant recommendations made.  Current reviews within Surrey are ensuring that a more flexible approach is taken which includes full involvement of practitioners and opportunities for lead reviewers to talk directly to those who had contact with the family.  1.4 The panel agreed the terms of reference for this review.  Individual management review reports were requested from all organisations that had significant contact with Mother and her three children from the time that she was pregnant with Half Sibling 1.  All individual management review authors attended a full day meeting of the serious case review panel in order to discuss their reports, hear from other individual management review authors and identify emerging lessons from the process.  Final individual management review reports, recommendations and action plans were scrutinised by the panel and the information used to inform the final overview report findings, recommendations and composite action plan. 1.5 A health overview report was prepared by the designated nurse in order to inform health commissioners of the issues from the review and any actions to be taken at the point health services are commissioned.  This has informed this final review report. 1.6 A report, recommendations and action plan was received by Surrey Safeguarding Children Board on 25 May 2013.  Following conclusion of the criminal proceedings family members (Mother, Aunt and Maternal Grandmother) were offered an opportunity to contribute to the review. Mother was not at home at the appointed time but Maternal Aunt met with the overview author and the Surrey case review officer.  We are very grateful for her time and input and have referred to the content of the discussion within the body of the report. 1.7 The final report was received by Surrey Safeguarding Children Board on 21st November.  It was agreed that the Quality Assurance and Evaluation sub 5 group would continue to hold individual organisations to account for the implementation of individual management review action plans as well as oversee the actions required in relation to overview report recommendations and provide regular updates on progress to Surrey Safeguarding Children Board. 1.8 Following the acceptance by Surrey Safeguarding Children Board, a letter was received from foster carer who had looked after Child S following the child’s removal from home.  Whilst some of the issues raised in the letter fell outside the scope of this review, it was necessary to obtain some further information from Kingston Hospital.  This did not affect the findings and recommendations from this review but did cause a delay in publication.  2. CASE SUMMARY 2.1 A review of the records revealed that Mother had been known to the locality team as a child.  She was on a child protection plan for sixteen months from the age of two and placed in foster care on a care order from the age of five to seven. Records indicate that as a result of her experiences she suffered mild learning disabilities and emotional difficulties and was the subject of a statement of special educational need.  There was no further involvement beyond universal services until May 2006, when mother was twenty three, although health records do note information from Mother that she was homeless from the age of sixteen following physical abuse within her home. 2.2 Just prior to the birth of Half Sibling 1, when Mother was pregnant, Children's Social Care was notified by the Surrey Police of allegations of domestic violence against Mother.  However, at this time the main issue was seen to be housing and there was no further action. 2.3 Half Sibling 1 was born in September 2007, following which there were further allegations of domestic violence.  There were also the first indications of Mother’s reluctance to engage with services, with Half Sibling 1’s first health check and immunisations being late.  At this point Community Health Provider 6 1 had assessed Mother as needing an enhanced health visiting service and referrals were made to Children's Social Care by Surrey Police and the health visitor.  A strategy discussion was held but there was no further action by Children's Social Care until January 2008 when Mother receive d a police caution for being unfit to look after a child due to drunkenness. This incident took place out of hours and Half Sibling 1 was placed with Maternal Grandmother overnight, being returned by the social worker to the care of Mother the next day after hearing Mother’s version of events. 2.4 A child protection conference was held in February 2008 and Half Sibling 1 was made subject of a child protection plan under the category of neglect.  At the review child protection conference in June 2008, the social worker and the health visitor recommended a change from a child protection plan to a child in need plan.  There is evidence of effective challenge from the conference chair who felt that a child protection plan was still required since there was insufficient progress and little evidence of sustainability in respect of domestic abuse, use of alcohol and engagement with a parenting programme. 2.5 Prior to the next review conference there were three domestic abuse incidents.  Police expressed concern about the state of the home and during the second and third incident noted that Mother had been drinking and kept changing her account.  However, although concerns about alcohol were noted, the social worker assessed that the child protection plan was progressing well, Half Sibling 1 was thriving and the case could be managed as child in need rather than child protection.  However, it was the decision of the conference chair in October 2008 that Half Sibling 1 should remain on a child protection plan under the category of emotional harm, rather than neglect, as the primary concern had shifted to Half Sibling 1’s continued exposure to domestic abuse. 2.6 Following the child protection conference Mother moved accommodation, and responsibility for health visiting moved from Community Health Provider 1 to Community Health Provider 2.  A family health needs assessment noted that Half Sibling 1 was attaining normal development. 7 2.7 Throughout this period and up until the review child protection conference in February 2009, there were no reported incidents of domestic abuse and both social work and health visitor records note that Half Sibling 1 was making good progress and Mother’s engagement with the child protection plan was positive.  At the review conference the decision was made to remove Half Sibling 1 from a child protection plan, and a child in need plan was put in place. 2.8 In May 2009 there were two incidents on the same day where the Surrey Police were aware that Mother was drunk when caring for Half Sibling 1.  On the first occasion she was with Father of Half Sibling 1 and on the second Police were called to Mother’s flat and found her to be apparently drunk and unconscious on the sofa.  Half Sibling 1 was found lying face down on a mattress in the bedroom, wearing a soiled nappy.  Mother was arrested and charged with child neglect, Half Sibling 1 was removed to the care of Maternal Grandmother and a written agreement was put in place. 2.9 The Crown Prosecution Service decided that the case for child neglect was not made out.  Mother could not be charged with being drunk in charge of a child since the incident had taken place within the family home.  Half Sibling 1 remained living with Maternal Grandmother until July 2009 when she was returned to the care of her Mother.  During this period Mother was encouraged to seek help with her alcohol misuse and saw the GP, who noted from Mother’s own self-report, ‘binge drinking’.  She was referred to alcohol misuse services where she was seen in August and assessed (again via self-report) as showing no signs of drink dependency or binge-style use.  In August Half Sibling 1 was noted to be thriving in Mother’s care. 2.10 Children's Social Care closed the case in November 2009.  At this point the Surrey Police had been told by Mother during a domestic dispute that she was pregnant but she denied this when asked by the health visitor.  It became clear in January 2010 that Mother was pregnant with Half Sibling 2 who was born in June 2010.  Throughout this pregnancy Mother attended no antenatal care appointments.  Children's Social Care were briefly involved again following a referral both from the hospital midwife and the police after another 8 incident of alleged domestic violence.  By August 2010, when Half Sibling 2 was two months old, Children's Social Care had formed the view that Mother was doing well and the case was closed. 2.11 From this point until Mother’s pregnancy with Child S there were two further domestic disputes recorded by the Surrey Police, and Half Sibling 1 started nursery.  Like Half Sibling 1, Half Sibling 2’s registration with the GP was delayed and she also was not taken by Mother to arranged appointments for immunisations.  Regular visits and weighing by the health visitor and nursery nurse revealed concerns about Half Sibling 2’s failure to thrive and developmental delay. 2.12 By January 2011, when Half Sibling 2 was seven months old, Mother was pregnant and approached Children's Social Care as she did not wish to keep the baby and her sister wanted to adopt the child.  A joint assessment was carried out by a social worker from the adoption team and assessment team; the resulting initial assessment recommended that Mother and her sister be given advice about private adoption, and the case closed. 2.13 At the point of closure the health visitor noted that Half Sibling 2 had two bruised eyes, which Mother explained had occurred as a result of a fall from a sofa. Due to developmental delay Half Sibling 2 was a non-mobile infant at this point.  The assessing social workers were also aware of these bruises, but neither they nor the health visitor felt that they warranted further action at that time. 2.14 During her pregnancy with Child S, Mother attended no antenatal appointments.  The case was once more opened by Children's Social Care and concerns noted about the physical environment within the home and Mother’s alcohol use, which continued throughout her pregnancy.  These concerns continued after the birth of Child S and a tight visiting plan was agreed between professionals when Child S returned home from hospital.  It is clear that at this point Mother was very unhappy about the involvement of Children's Social Care.  An unannounced visit by the social worker found all three children in the home alone, with Mother having ‘popped out for two 9 minutes’.  During this visit Child S was noted to have an injury to his toe. No action was taken in respect of the children being home alone or the injury. 2.15 A child protection conference took place in August 2011 and all three children were made subjects of a child protection plan under the categories of neglect and emotional abuse, and case transferred from the Children's Social Care assessment team to the child protection and proceedings team. 2.16 A legal planning meeting took place at the end of August when Child S was six weeks old, the conclusion of which was that more information needed to be collated before a decision could be made.  The Children's Social Care individual management review outlines a number of concerns about the effectiveness of this meeting with a lack of chronology and social workers attending without a well organised and documented case.  There were also differences of opinion between social workers, with the assistant team manager from the assessment team feeling there was sufficient evidence to support legal intervention, whereas workers from the child protection and proceedings team (who had begun working with the case more recently) felt unconvinced due to Mother’s ‘recent engagement’. 2.17 A pattern of missed appointments continued, along with Mother’s clear reluctance to work with social workers.  Child S at the age of eight weeks had failed ten health appointments, a concern which was notified to the health visitor by the GP. 2.18 During a home visit the health visitor noted an injury to the hand of Child S and also that he appeared to be in pain when the injury was dressed.  This was communicated to the social worker and Mother was encouraged by both the social worker and the health visitor to take Child S to the GP.  This appointment was not kept and the next day the family support worker conducted an unannounced visit to the home.  Half Sibling 2 could be heard crying but no adult was in the flat.  When Mother returned, the flat was found to be in a very poor state.  Child S’s injured finger was apparent, as was a bruise on his face covered by cream.  Mother could give no explanation for the bruise.  The family support worker alerted the social worker, Child S was 10 taken to Hospital 2 and initial examination revealed injuries indicative of physical abuse.  The decision was made by the Local Authority to issue care proceedings in respect of all three children.  3. REVIEW FINDINGS 3.1 This review identified a number of areas of practice where lessons could be learned and work with children and families improved.  Many of these lessons relate to the need for a better recognition and response to the various factors that indicated potential risk to children.  Alongside these there are other lessons relating to the skills and support that practitioners need in order to be able to work effectively in such complex situations.  Recognising risk  3.2 There were a number of factors present in this case which are known to be associated with risk to children, yet these were not adequately assessed as a whole and a judgement made as to how safe the three children were in their mother’s care. Because this assessment did not take place, plans to protect the children were not sufficiently robust, particularly in relation to measuring whether sufficient change had taken place to reduce the risk of harm.  3.3 Factors that should have alerted professionals included:  Mother’s unwillingness to engage with services and failure to access antenatal care, particularly during the second and third pregnancies  Persistent misuse of alcohol whilst caring for the children  Recurrent allegations of partner violence  Half Sibling 2 ’s failure to thrive and developmental delay  Failure to provide adequate supervision and leaving the children at home alone  Bruising and injuries on non-mobile infants  Mother’s potential vulnerabilities due to her childhood experiences 11 3.4 There is little evidence that assessments at any time adequately analysed the interaction between these known risks and the protective factors within the environment. The accumulation of risk factors over time was not recognised and by the time of the legal planning meeting less than a month prior to the significant injuries, the information had not been collated by social workers and presented in a way that allowed the lawyer to make a reasoned decision at that point as to whether the threshold for proceedings had been met. Failure to provide adequate evidence to such meetings at that time is recognised as a problem by Children's Social Care who have taken steps to re focus on the importance of chronologies and ensure that legal planning meetings do not take place within adequate written evidence being provided. Recognising the significance of history 3.5 Information was available to Health and Children's Social Care about Mother’s experience of abuse in her own childhood and her time as the subject of a care order. The files were not retrieved from archive in order to inform assessments and known information was not used effectively either as part of the analysis of risk or to understand of Mother’s response to help being offered.  A consideration of family history and current family relationships was important since Maternal Grandmother was source of support and had sole care of Half Sibling 1 for three months. 3.6 It was clear to the serious case review panel that retrieving information could be time consuming and, in the case of Mother’s education records, the panel were not able to retrieve these at all due to an administrative problem.  This process needs to be addressed and in order to do this understanding the current barriers to retrieval is important since busy practitioners need smooth, efficient systems in order to support them in their work. The impact of alcohol use on parenting capacity 3.7 In this case alcohol use was overt and happening throughout the last pregnancy.  Despite this overt use, in combination with other stressors, practitioners did not at any time appear to define this clearly as a child 12 protection issue and work together with substance misuse services to pool information and fully assess the risk of harm. 3.8 Why this is the case needs further exploration, starting with the recognition that alcohol is a socially acceptable drug and therefore may be less likely to cause alarm than illegal drug use.  It is of note that a framework to assist assessment in cases of substance misuse was in place as part of child protection procedures during the timeframe for this review.  At no time was this used in this case, possibly as alcohol was not viewed in the same way as other substances (such as illegal drugs) which were believed to be the focus of the framework. Bruising and injuries in children who are not independently 3.9 Where bruising is seen in children who are not independently mobile, this should raise concerns and prompt professionals to consider the possibility of abuse.  In this case there were three instances where injuries were seen and immediate action was not taken under child protection procedures.  Surrey Safeguarding Children Board therefore needs to raise awareness of the significance of bruising and injuries in non-mobile babies and take steps to ensure that all practitioners are aware of the action to take if this is found to be present. Recognising the interface between child neglect and physical abuse 3.10 Although actions were taken by social workers in respect of physical neglect there was insufficient understanding in Health and Social Care that chronic neglect may be associated with physical abuse. As a consequence the signs and indicators of physical abuse were missed. Meaning of the child 3.11 Whereas Mother’s relationship with and care of Half Sibling 1 did not cause significant concern, there were clear indications that her feelings towards her younger two children were more complex.  In respect of Half Sibling 2 Mother initially denied she was pregnant and then avoided antenatal care.  There was 13 a reported adversarial relationship with Half Sibling 2’s father and Mother told the health visitor that she was disappointed that Half Sibling 2 looked like him. Child S was known to be unwanted and Mother had considered adoption. 3.12 All these factors should have informed professional assessments when Half Sibling 2 was failing to thrive and injuries were noted both on Half Sibling 2 and Child S.  Professionals should have been alert to the fact that in this case there is evidence that both babies may have had a particular meaning to Mother which led to them being more at risk of harm.  Supervision of the health visitor and within Children's Social Care did not enable exploration of this aspect of the case. Assessing the impact of learning disability on parenting capacity 3.13 Records within the locality team indicated that Mother may have had learning disabilities and she told the health visitor that she was unable to read or write and therefore ignored mail.  The nature and extent of any disabilities were not assessed and this information used to inform assessments and the help given to the family. Working with fathers 3.14 There are three fathers in this case, although the identity of the father of Child S has not been confirmed. Where the identities of the fathers are known the impression from the records is that they were mainly thought of in terms of potential risk, rather than having anything positive to contribute to assessments and plans. This has been a feature of previous serious case reviews in Surrey, and Surrey Safeguarding Children Board will need to understand why previous actions as a result of the reviews have not made a positive impact on practice in this case Working with resistance 3.15 There are numerous examples throughout the chronology and individual management reviews of Mother failing to engage with services and/or being openly hostile and resistant to help.  Equally there are other occasions where 14 she appeared to develop reasonable working relationships with individuals but still there was little evidence of sustained improvement in her capacity to provide safe, appropriate care for her children. 3.16 Mother’s resistant or avoidant behaviour is most striking in relation to the number of failed health appointments.  However, there was insufficient analysis of implications of missed appointments for the children and of lack of antenatal care. 3.17 Working with resistance requires workers to have highly developed interpersonal skills as well as to manage their emotions effectively in order to prevent either collusive or overly oppressive styles of interaction.  There is no evidence that supervision in Health or Children’s Social Care explored the impact of working with resistance on the practitioner and the effect that this could have on professional responses. Working effectively together within and between organisations 3.18 There are some examples of effective communication as well as a number of instances where a greater degree of positive inter- or intra- agency work would have helped to identify risks.  Generally, however, communication issues were not a major feature of this serious case review. Management and supervision 3.19 It is apparent that at several points in this case there were opportunities for managers and/or supervisors to make a positive difference through encouraging staff to critically reflect on their practice.  This should have included an exploration the factors that may have affected their decision making including values, attitudes, assumptions, knowledge, experience and workload.  The importance of effective management and supervision was particularly apparent in the case of the health visitor and the newly qualified social worker.  In the later situation, the history of the case should have led to recognition by managers that it was too complex for a newly qualified social worker without intensive support and supervision, yet there is little evidence of effective supervision or management oversight. 15 Learning lessons from previous SCRs – barriers to improving practice 3.20 Many of the issues identified within this serious case review are similar to those that have been identified before, both within Surrey and elsewhere within England.  There is little indication that these lessons from previous reviews have been used to inform practice.  Further work is therefore needed by the Safeguarding Children Board to understand the barriers to embedding learning into practice and ways of overcoming these.  4. CONCLUSIONS AND RECOMMENDATIONS 4.1 The conclusion of this review must be that there were a number of missed opportunities to prevent the serious injuries to Child S, as well a delay in acting when injuries were apparent.  Missed opportunities pre-date Child S’s birth with evidence that more effective risk assessments from the time of Mother’s first pregnancy may have resulted in different actions when Mother was known to have been pregnant with Child S.  In particular, prior to Child S’s birth, there was a failure to recognise the likely significant harm experienced by Half Sibling 2.   4.2 The most significant missed opportunities were:  Lack of any risk assessment at the point that Mother was charged with child neglect.  This assessment could have been used to inform the decision to close the case when mother was known to be pregnant with Half Sibling 2  No action taken to assess risk at the point that Mother was enquiring about the adoption of unborn Child S and bruising was noted on the face of Half Sibling 2 who, at that point, was a non-mobile infant  No action taken to consider removal of the children who had been left at home alone and to arrange a child protection medical to examine the injury to Child S’s toe in August 2011  Failure to act immediately when the Child S was found with an injury to his hand and was clearly in pain. 16 4.3 There is little learning about risk to children that is new in this case.  The issues that have emerged have been known for several years both from research and previous local reviews, yet did not consistently inform actions.  As a consequence, many of the recommendations will focus on reminding organisations and practitioners of the knowledge and skills that should be utilised in everyday practice.  However, this needs to take place alongside a deeper exploration by the Surrey Safeguarding Children Board of the barriers that prevent known knowledge being implemented in practice. 4.4 Specific recommendations have been made to improve practice. These have been developed into an action plan which is in the process of being implemented and will be actively monitored by Surrey Safeguarding Children Board. 17 OVERVIEW REPORT 1. INTRODUCTION 1.1 This serious case review was undertaken because of a critical incident in September 2011 when a two month old baby Child S and his one year old half sibling (Half Sibling 2) were found home alone and Child S was seen to have a bruise on his forehead.  He was subsequently found to have serious injuries including factures and brain injury.  Both children and their older half sibling (Half Sibling 1) were subject of child protection plans at this time.  Mother was charged with Grievous Bodily Harm and Neglect.  She later (at the point of trial) pleaded guilty to wilful cruelty and 3 counts under section 20 of grievous bodily harm and in September 2013 received a community sentence 1.2 The case was referred to the Surrey Strategic Case Review Group whose initial conclusion was that the criteria for a serious case review were not met.  The Strategic Case Review Group frequently reviewed the case and considered further evidence including an individual management review by Health.  In February 2012, the group agreed that the evidence from the individual management review did not meet the criteria for a serious case review and therefore the recommendation of the group was that a Serious Case Review should not be undertaken by the Surrey Safeguarding Children Board. 1.3 Following further discussion, in April 2012 the Independent Chair of Surrey Safeguarding Children Board Chair requested Children’s Social Care to undertake a review of their practice in response to the contact by Mother in April 2011 when she was pregnant with Child S.  Following the conclusion of the criminal investigation in August 2012 and the information contained in the subsequent chronologies requested by the Serious Case Review Group and discussed in October 2012, a recommendation was made that a serious case review be undertaken.  Alex Walters, Surrey Safeguarding Children Board Independent Chair, agreed to hold a Serious Case Review on 24 October 2012. 18 1.4 The reason for the review was that a child had sustained a potentially life threatening injury or serious and permanent impairment of physical and/or mental health and development through abuse or neglect and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children.1 2. THE SERIOUS CASE REVIEW PROCESS 2.1 It should be noted that this review took place in line with the guidance set out in Working Together 2010 since the current guidance (Working Together 2013) was not in place at point the review started.  This means that the information obtained for this overview was gained from individual management review reports and the overview author did not talk directly to any of the practitioners involved.  The potential limitations of this process have now been recognised nationally and locally in relation to understanding “why” events occurred.  Where there are gaps in information this has been identified within the report and relevant recommendations made.  Current reviews within Surrey are ensuring that a more flexible approach is taken which includes full involvement of practitioners and opportunities for lead reviewers to talk directly to those who had contact with the family.  2.2 A serious case review panel was appointed to oversee the review.  The panel members for this review were:  Alex Walters, Chair Surrey  Panel Chair Safeguarding Children Board   Safeguarding Board Manager Surrey Safeguarding Children Board  Designated Nurse for Child  NHS Surrey Protection  Detective Inspector Public  The Surrey Police Protection and  Investigation Unit                                                            1 HM Government (2010) Working Together to Safeguard Children London DCSF Paragraph: 8.11 19  Safeguarding Children Advisor SCC Early Years and Child Care Service  South-East Area Education Officer Schools and Learning  Manager SCC Legal and Democratic Services  Area Head of Service SCC Children’s Services  Terms of reference and scope of the review  2.3 It was agreed that the purpose of the review would be to:  establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children;   identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and   improve intra- and inter-agency working and better safeguard and promote the welfare of children.  2.4 The following specific issues were identified as needing to be considered from the preliminary review of information available to the Strategic Case Review Group;  1. Was any information known by any agency about parental mental health issues, and or substance abuse, if so was appropriate consideration given to how this impacted on parenting capacity?   2. Was any information known by any agency about domestic abuse or parental antisocial behaviors, if so was appropriate consideration given to 20 how this impacted on parenting capacity and were appropriate referrals made?  3. Was the level and extent of agency engagement and intervention with the family appropriate?   4. Did agencies communicate effectively and work together to safeguard and promote the children’s welfare?  5. Were appropriate assessments undertaken in a timely manner, was the quality adequate and did they include all historical information?  6. Were fathers and extended family members included in assessments?   7. Were the decisions and actions that followed assessments appropriate and were detailed plans recorded and reviewed?  8. Were any safeguarding issues in respect of Child S, Half Sibling 1 and Half Sibling 2 identified and acted on appropriately and in a timely way by all agencies?  9. Were missed appointments and failure to engage considered as indicators of neglect?  10. Were the children’s views and wishes sought and taken account of in assessments and planning? Did this include the presentation of young non-verbal children being fully considered?  11. Was race, religion, language, culture, ethnicity or disability a factor in this case and was it considered fully and acted on if required? How was the uniqueness of this particular family recognised?  12. Were there any organisational or resource factors which may have impacted on practice in this case? 21  13. Were appropriate management/clinical oversight (supervision) arrangements in place for professionals making judgments in this case?  14. How did the multiagency system enhance or impede effective practice and outcomes for this family?  15. Consideration should also be given to the areas identified in Working Together 2010, page 245, for analysis of involvement that is not covered by the above specific issues  2.5 Authors of individual management reviews, serious case review panel members and the author of the overview report were also asked to bring to the attention of the serious case review panel chair any other matters identified which appeared to fall within the scope of the review if they thought that there were lessons to be learnt either for an individual agency or for the Surrey Safeguarding Children Board.  2.6 Authors of individual management reviews who identified other significant issues not falling within the scope of the review were asked to bring them to the attention of a senior manager within their agency. Consideration was also to be given to the findings of recent serious case reviews both locally and nationally.  2.7 It was noted that the terms of reference were provisional and would be amended if new information came to light  Time period for the review  2.8 The principal focus of the serious case review was identified as from 1 January 2007, the start of the pregnancy for Half Sibling 1 to the 16 September 2011, the day after the three children were removed from the family home. The review invited all agencies to provide a summary of all 22 significant events and relevant family history outside the specific scope and timescale, where this would help to inform the overall analysis.   Information gathering  2.9 Contributing agencies were asked to identify an individual management review author to compile:  a chronology of the agency’s contact with the family using the SSCB template  an analytical IMR and   an agency action plan to address any learning arising.  2.10 Individual management review authors were required include the following: five components:  Introduction  Narrative  Analysis of involvement  Lessons learned / findings or conclusions  Recommendations  2.11 Individual management review reports were requested and received from: 1. Community Health Provider 1 in respect of health visitor involvement from March 2007 – November 2008 2. Community Health Provider 2 in respect of health visitor involvement from November 2008 onwards 3. Hospital 1 in respect of midwifery involvement 4. Hospital 2 in respect of midwifery involvement with the youngest child 5. The locality Team in respect of involvement by Children's Social Care and Legal Services 6. Education in respect of nursery involvement with the oldest child 7. Locality GPs 8. The Surrey Police  23  2.12 Reports for information were received from: 1. The Housing Trust 2. Domestic Outreach Service Council   2.13 A full integrated chronology some three hundred pages long was prepared and used as the basis for understanding the way in which professionals worked with the family and each other in this case.  2.14 All individual management review authors attended a full day meeting of the serious case review panel in order to discuss their report, hear from other individual management review authors and identify emerging lessons from the process. This aspect of the review took place as a result of learning and feedback from previous serious case reviews. Further information, where this was required, was sought by the panel and provided by the authors. Final individual management review reports, recommendations and action plans were scrutinised by the panel and the information used to inform the final overview report findings, recommendations and composite action plan.  2.15 A health overview report was prepared by the designated nurse in order to inform health commissioners of the issues from the review and any actions to be taken at the point health services were commissioned. This has informed this final review report.  2.16 A report, recommendations and action plan was initially received by Surrey Safeguarding Children Board on 25 May 2013 and work began to implement the recommendations.  A final report, following conclusion of the criminal proceedings was received on 21 November 2013.  Following the acceptance by Surrey Safeguarding Children Board, a letter was received from foster carer who had looked after Child S following the child’s removal from home. Whilst some of the issues raised in the letter fell outside the scope of this review, it was necessary to obtain some further information from Kingston 24 Hospital.  This did not affect the findings and recommendations from this review but did cause a delay in publication.   Family involvement in the review  2.17 Relevant family members were made aware of the serous case review process but due to the pending criminal proceedings no further contact with the family was possible until they concluded. Following conclusion of the criminal proceedings family members (Mother, Aunt and Maternal Grandmother) were offered an opportunity to contribute to the review. Mother was not at home at the appointed time but Maternal Aunt met with the overview author and the Surrey case review officer. We are very grateful for her time and input and have referred to the content of the discussion within the body of the report.  The overview report  2.18 This overview report has been prepared by Jane Wonnacott, Independent Consultant, who has extensive experience of completing serious case reviews.  2.19 Since the report has been prepared with the knowledge that it will become a public document, personal family information and specific geographical details and organisational titles that may identify the family has been kept to the minimum, although there is full disclosure and discussion of relevant professional interaction with the family. The individual management review process has confirmed that issues of practice and performance have been addressed by individual agencies.  3. FAMILY BACKGROUND  3.1 The Mother of the three children who are subjects of this review was born in Surrey and was the middle child of three.  She has an older sister, and a 25 brother twelve years younger than her.  The locality team have records of involvement with the family when Mother was a young child, which were retrieved from archive in order to assist this review.  3.2 Mother was on a child protection plan for sixteen months from the age of two due to concerns about emotional abuse and neglect by her parents.  The case was closed to Children's Social Care three months after Mother was removed from the child protection plan.  3.3 When Mother was five and half years old Maternal Grandmother asked for her to be placed in foster care as she was unable to cope with her behaviour.  Due to further concerns about abuse, the Local Authority was granted a care order and Mother remained in foster care until aged seven when the care order was discharged.  Records indicate that as a result of her experiences she suffered mild learning disabilities, emotional difficulties and a statement of special educational need.  There was no further involvement beyond universal services until May 2006 just prior to the time frame for this review, although health records do note information from Mother that she was homeless from the age of sixteen following physical abuse within her home.  4. PROFESSIONAL INVOLVEMENT WITH CHILD S AND HIS FAMILY  4.1 Between May 2006 and February 2007, prior to the birth of Half Sibling 1, Surrey Police noted seven calls from Mother alleging domestic violence.   During one call she informed the police officer that she was pregnant, a domestic abuse risk assessment was completed and assessed Mother as high risk.  Support was offered by Surrey Police domestic violence team and a notification sent to Children’s Social Care.  4.2 A further call from Mother to the police resulted in another notification being sent to Children’s Social Care since Mother was alleging that Father of Half Sibling 1 had kicked her and she was now homeless.  She was noted to 26 possibly be intoxicated. There is no record that Children's Social Care responded to the police notification and the Children's Social Care individual management review comments that this was because the incident was prior to Mother having any children. However, a previous police notification had noted that Mother was pregnant and it would have been appropriate for Children's Social Care to consider whether an assessment was necessary.  4.3 Mother was seen for a pregnancy assessment at Hospital 1.  This resulted in a referral to both Children’s Social Care and a health visitor in the area of Community Health Provider 1 due to the fact that she was sleeping on her parents’/friends’ sofas.  There is no record that any questions were asked about potential domestic violence at this point.  4.4 In April 2007, the midwife made a referral to the locality team, expressing concern that Mother was thirteen weeks pregnant and homeless.  The midwife asked for support in finding suitable accommodation for Mother prior to the birth of her child. The midwife was advised that there was no role for Children's Social Care as it was deemed to be a housing matter but to re-refer if there were still concerns nearer the birth.  There is no indication that the information from the hospital was considered in the light of previous information about Mother’s childhood experiences or the more recent Police notifications.  4.5 In May 2007 Mother moved to a hostel and in July she was referred to an organisation offering support with practical tasks. However, evidence from the records indicated that Mother declined to engage with the support on offer.  4.6 Half Sibling 1 was born at Hospital in September 2007 and the next week the health visitor completed an initial assessment resulting in the family being offered an enhanced health visiting service.  The health visitor had been Mother’s health visitor when she was a child and therefore had knowledge of the family history and circumstances that had led to Mother’s time in care. There is no evidence that the implication of this was discussed with any other professional. 27  4.7 During November 2007 Surrey Police were called three times to Mother’s flat.  On one occasion she was found to be intoxicated and the father of Half Sibling 1 found to be in possession of drugs although he denied assaulting Mother.  On the second occasion Mother alleged Father 1 was an illegal immigrant and on the third occasion Father of Half Sibling 1 assaulted a Police officer. On the first and third occasions, a child at risk notification for was sent to Children's Social Care. Half Sibling 1 was, however, noted to be well cared for.  4.8 The third incident was followed up by a Strategy Discussion and a risk assessment was recommended at this point.  However, there is no record of a risk assessment or an initial assessment on the Children's Social Care files.  4.9 During December 2007 the Borough Council informed both the health visitor and Children's Social Care that Mother was to be declared intentionally homeless for rent arrears caused by cancellation of her housing benefit. Records show that Mother had not engaged with housing officers, cancelling appointments and stating that the baby had GP appointments.  In fact, during this period, the health visitor became aware that Mother had not attended the GP or local hospital and had not commenced Half Sibling 1’s immunisations. A referral was made to Children's Social Care, followed up by a telephone call.  It appears that Children's Social Care decided initially not to take any action but the health visitor strongly objected and a social worker visited the home.  Half Sibling 1 was noted to be a happy baby and Mother had made arrangements to repay her rent arrears.  Mother at this point had still not registered Half Sibling 1’s birth and the baby was not registered with the GP, nor had immunisations commenced.  4.10 Half Sibling 1 (age seventeen weeks) was seen by the GP for her six-eight week developmental check.  She was also assessed by the health visitor who spoke with Mother about her non-compliance.  At this point Mother told the health visitor that she was unable to read or write and tended to ignore mail. 28 There is no evidence that at this point or later any organisation verified this information or established the extent of any learning difficulties.  4.11 One evening in January 2008 Surrey Police were called to a domestic incident in the street which resulted in Mother receiving a police caution for being unfit to look after her child, and a drugs offence. The emergency duty team were contacted and Half Sibling 1 was taken into Police Protection and was briefly placed with Maternal Grandmother. Following a home visit during the day the social work heard Mother’s description of events and agreed that Half Sibling 1 could be returned to Mother’s care. There is no record of contact with the health visitor regarding this incident until five days later.  4.12 A ‘update’ strategy discussion was held in February 2008 and it was agreed that the criteria were met for a child protection conference.  When Mother was called to inform her of this decision, she said she was too busy to see the social worker that week, and that the home visit would therefore have to be the next week. There was communication between the GP and health visitor at this point regarding Mother’s arrest, and the GP left a message for the social worker to call him back, leaving a mobile number should this be needed.  There was no record of any call back from Children's Social Care.  4.13 A Core Assessment was completed in February 2008.  The Children's Social Care individual management review author comments that the assessment was not analytical, repeated the observations made by referrers and relied on Mother’s own views regarding her parenting capacity. The report for the initial child protection conference did contain some information about Mother’s own experience as a child, including the fact that she was subject of a care order, but this information is described by the individual management review authors as ‘superficial’.  4.14 It seems as though the social worker misunderstood the purpose of the child protection conference as the health visitor was not initially invited as she was not expressing concerns. When this was queried by the Children’s Services Safeguarding Unit she was subsequently invited and attended the conference 29 where Half Sibling 1 was made subject of a child protection plan under the category of neglect.  The important role of the conference in ensuring information is shared was apparent as it was only at the conference that the health visitor became aware of five previous domestic abuse incidents that she had previously not known about. After the conference the health visitor wrote a letter to the Named Nurse, expressing her concerns regarding lack of professional communication and stating that she felt the Children's Social Care were minimising the concerns surrounding the baby’s well-being.  The Named Nurse forwarded this letter to a Children’s Services service manager, but there is no evidence in the health services records of any response to this letter.  It should be noted that around this time there were a number of management changes within Children's Social Care that may have contributed to this outcome.  4.15 In April 2008 the case was transferred from the Children's Social Care assessment team to the locality team. No transfer summary was completed. Child protection practice within Surrey at this time had been identified by external inspection as poor and the practice in this case was symptomatic of the conditions of the time with a delay in the first statutory child protection visit after the conference.  There is however evidence of the new social worker engaging with Mother,  discussing the requirements of the child protection plan and making a referral to a parenting group.  4.16 There is evidence of one core group meeting taking place prior to the review conference, with the second meeting being cancelled by Children's Social Care.  It is unclear from the records how effectively the core group worked together to identify the change that should be evident in order to improve outcomes for Half Sibling 1.   4.17 At the review child protection conference for Half Sibling 1 in June 2008, the social worker and the health visitor recommended a change from a child protection plan to a child in need plan. There is evidence of effective challenge from the conference chair who felt that a child protection plan was still required since there was insufficient progress and little evidence of 30 sustainability in respect of domestic abuse, use of alcohol and engagement with the parenting programme.  4.18 In June 2008, police visited Mother following a call asking for help. When the police visited, Mother was not found to be at risk but concern was noted about the state of the room including a mattress that was on the floor with food around it.  Children's Social Care was notified and a social worker contacted Mother by telephone and reminded her of the next core group meeting three days later. The discussion at the core group did not reflect the police referral as the child protection plan was noted to be going well and that Mother and Half Sibling 1 would be moving to a new flat. This optimism was reflected in a social work supervision record which noted ‘house move imminent, and plan progressing very well’.  4.19 Social work visits during this period noted no concerns about the care of Half Sibling 1 and recorded that there was no contact with Father of Half Sibling 1.  However, in August the police notified Children's Social Care of a domestic abuse incident where Mother had alleged assault by her ex-partner (Father of Half Sibling 1).  The police records note that Mother had been drinking and kept changing her account and that Half Sibling 1 appeared well but cried when Mother raised her voice.  There is no evidence that the health visitor was aware of this incident.  4.20 A duty social work visit took place three days later and Mother reassured the social worker that Half Sibling 1 had not witnessed the assault. Half Sibling 1 was noted to look happy, her bedroom clean and nicely decorated, and Mother appeared sober. A further visit by the allocated social worker took place five days later which also noted no concerns.  Supervision the same day notes that the dominant concern was alcohol and that the Maternal Grandmother was supportive.  Mother had been referred to an alcohol treatment service and the outcome of their assessment was awaited.  There was also a note to ‘talk to legal’.  31 4.21 A further supervision record in Children's Social Care in September 2008 noted that the plan was going well and should be moved to a child in need plan at the next conference.  The analysis of the alleged assault was that ‘There had been “one minor incident that did NOT place [Half Sibling 1] at risk”’. This analysis does not appear to have focused on Mother’s alleged intoxication or Half Sibling 1’s response when she raised her voice.  4.22 In September 2008 Surrey Police received a further call from Mother alleging domestic violence but the alleged perpetrator had left the address. She was noted to sound drunk.  The records sent to Children's Social Care stated that the flat was not in good condition.  A visit by a social worker to Mother two days later appears not to have included discussion about this incident, and notes that Half Sibling 1 was ‘truly thriving’ in her new home and that the house was decorated to a good standard.  4.23 A child protection conference in October noted continued evidence of domestic abuse and use of alcohol although Mother had made progress in other areas.  Once again the health visitor was unaware of the domestic abuse incidents prior to the conference.  The Chair formed the view that Half Sibling 1 should remain on a child protection plan under the category of emotional harm, rather than neglect, as the primary concern had shifted to Half Sibling 1’s continued exposure to domestic abuse.  4.24 Twelve days later the social worker visited the home and explained to Mother that they and their manager were surprised at the continuing child protection plan and that they had spoken to the Chair, who had agreed to bring the next conference forward to three months.  The view of the social worker and their manager remained positive about progress. Half Sibling 1 was noted to be ‘well, happy, and advanced for her age’ and Mother described as ‘a natural mother’.  A supervision record noted that although the police had concerns about Mother’s continued involvement with Father, these concerns were based on ‘feeling’, not evidence.  32 4.25 As Mother had moved accommodation responsibility for health visiting services transferred to another area (Community Health Provider 2) and the new health visitor completed a home visit to Mother. At this visit Mother told the health visitor about an extensive history of neglect and abuse in her childhood, continuing into adult relationships.  A family health needs assessment noted that Half Sibling 1 was attaining normal development.  4.26 The health visitor discussed the case in safeguarding supervision in December 2008 and noted ‘good interaction between Mother and child’.  It was agreed that health visiting contact with the family should be combined between two health visitors with the second health visitor covering from time to time, due to the primary health visitor working part time.  4.27 The core group in December 2008 was cancelled due to staff sickness and the next meeting took place in January.  Throughout this period and up until the child protection conference in February 2009, there were no reported incidents of domestic abuse and both social work and health visitor records note that Half Sibling 1 was making good progress and Mother’s engagement with the child protection plan was positive.  At the review conference the decision was made to remove Half Sibling 1 from a child protection plan and a child in need plan was put in place.  4.28 Eleven days after the child protection conference, police received a report of a domestic incident at Mother’s address.  As a result of this incident, Father of Half Sibling 1 was sectioned under S136 of the Mental Health Act and taken to hospital, and a domestic abuse risk assessment assessed Mother as a high risk repeat victim.  Social work visits continued and Mother was put in touch with domestic violence outreach although they were unable to engage with her at this point.  4.29 A child in need meeting received many positive reports about Mother’s ability to care for Half Sibling 1.  The agreed action plan was for Mother to be assisted in liaising with Housing regarding the maintenance of the flat and to attend the domestic violence outreach team in order to discuss the 33 appropriate order to decrease the likelihood of Father of Half Sibling 1 returning to the home address.  Once the court order was in place, Mother was to contact the social worker so that they could carry out their last home visit and close the case.  This plan to close the case if an injunction was obtained was agreed in supervision with the social worker the next day  4.30 Ten days after the child in need meeting in May 2009 Mother made a 999 call to the Surrey Police during which she appeared to be intoxicated.  When the police attended they found Mother was drunk and was pushing Half Sibling 1 in a pram in the company of Father of Half Sibling 1.  She was warned about her behaviour and Father of Half Sibling 1 said that he was looking after his child and there was no indication that he had been drinking.  A child at risk notification was completed for Half Sibling 1.  4.31 On the evening of the same day the police were alerted to concerns about Mother’s behaviour and when they  visited her address, Mother was inside, lying on the sofa and would not open the door.  The police forced entry and Mother appeared unconscious through drunkenness and, once roused, became aggressive towards the police.  Half Sibling 1 was found lying face down on a mattress in the bedroom, wearing a soiled nappy.  It is recorded that she appeared unfazed by the incident. Mother was arrested for child neglect and Half Sibling 1 was passed into the care of Maternal Grandmother.  In interview, Mother denied being drunk and was bailed with one bail condition not to remove or attempt to remove Half Sibling 1 from the care of Maternal Grandmother.  At this point Mother informed the police that she would get the child back, and the police immediately made Half Sibling 1 the subject of police protection.  4.32 The next social work visit was four days later when Mother and Half Sibling 1 were seen at the home of the Maternal Grandmother. Mother continued to deny her drunkenness and claimed that Father of Half Sibling 1 had only been there to help her.   She was informed that the local authority would be seeking legal advice and convening a strategy meeting.  No assessments were 34 proposed in relation to Maternal Grandmother’s capacity to look after Half Sibling 1.  A written agreement was put in place which stated: (i) Mother to fully co-operate with Surrey Police investigations and not to remove Half Sibling 1 from Maternal Grandmother’s care (ii) Mother to contact her GP to seek help with alcohol misuse (iii) Mother to seek an injunction order in relation to Father of Half Sibling 1 (iv) Mother’s contact with Half Sibling 1 to be supervised by Maternal Grandmother (v) Any failure to follow any of the above may lead to the local authority instigating Public Law Outline protocol with likely risk of family court proceedings being issued  4.33 A copy of the written agreement was sent to Mother’s GP and the health visitor was informed of recent events by telephone.  4.34 The same day as the social work visit there is a record that the domestic violence outreach team spoke to Mother following a self-referral.  No outreach support was required as the issue was a dispute with a neighbour.  4.35 On 9th June CPS advised the police that it was not in the public interest to charge Mother, as provisions for an offence of neglect were not made out and the matter was best dealt with by social services.  4.36 At a social worker visit to the Maternal Grandmother’s, contradictory information was given to the social worker by Maternal Grandmother and Mother.  Mother told the social worker that she had contacted the domestic violence outreach services to seek support in gaining an injunction against Father of Half Sibling 1 and that she had spoken to the GP about her alcohol abuse.  Maternal Grandmother, however, spoke privately to the social worker confirming that Father of Half Sibling 1 still lived with Mother and that Mother had threatened Maternal Grandmother saying she would not speak to her if she told anyone.  There is no evidence within the chronology that Mother had spoken with the GP. 35  4.37 The next day the social worker checked with domestic violence outreach who confirmed that Mother had not sought advice from them about an injunction.  A referral was made to the team by the social worker and during a telephone conversation Mother was advised that she would not be able to apply for a non-molestation order at that time as there had not been any recent abuse and she did not have Father of Half Sibling 1’s address.  She was advised to report any incidents to the Police and contact the team again if the situation changed. Despite this advice, Mother continued to inform Children's Social Care that she was in the process of obtaining an injunction and had consulted with the GP who was referring her to alcohol rehabilitation.  There is no evidence of such a referral in the chronology.  4.38 In supervision it was noted by the social worker and their supervisor that Mother and Maternal Grandmother were only superficially compliant with the plan.  In the light of this, there appears to have been no discussion as to whether it was safe for Half Sibling 1 to remain with Maternal Grandmother.  At the beginning of July 2009 the decision within Children's Social Care, following a management discussion, was that work needed to continue under the written agreement and child in need plan which would be reviewed at the start of August.  4.39 In July, Mother was seen at the GP surgery and noted to have ‘problems with Social Services in relation to looking after baby daughter’. Binge drinking was also noted and she was referred to Alcohol Misuse Services.  The next day, the GP received a letter from the social worker requesting information regarding alcohol misuse and its impact on parenting but there is no record of a response to this letter.  4.40 The health visitor discussed the case in safeguarding supervision during July and the action agreed was for the health visitor to liaise with the worker regarding plans, and to see Half Sibling 1 at Maternal Grandmother’s home.  36 4.41 From this point it seems that Children's Social Care was planning for Half Sibling 1 to be returned to Mother.  The understanding was that Father of Half Sibling 1 was not living with Mother and that she should ‘if possible’ seek an injunction/non-molestation order.  Mother was noted to be aware of the consequences should she break the written agreement.  There is an e-mail on file from the conference chair to the social worker expressing concerns that the original issues that had led to the child protection conference had not been resolved, and advising the social worker to discuss further with their manager.  The social worker was reminded to consider the plan in the light of earlier serious case reviews.  4.42 The Domestic Abuse Outreach Service received two contacts from the social worker asking about the possibility of a non-molestation order.  A worker met with Mother but since the situation was the same as at the point of the previous contact (i.e. no further incidents and ex partner’s address not known) the advice remained that it was not possible to apply for a non-molestation order.  4.43 Half Sibling 1 was returned to the care of Mother at the end of July 2009, the reason apparently being that Maternal Grandmother had a holiday booked.  In August the case was transferred to a family support worker. During this period there were generally positive reports about Half Sibling 1’s progress and at a child in need meeting Half Sibling 1 was reported to be thriving in Mother’s care whilst supported by Maternal Grandmother.  4.44 During August, GP records note that Mother was seen in August by alcohol misuse services and assessed (again via self-report) as showing no signs of drink dependency or binge-style use.  4.45 In November 2009 Mother called the police to a domestic dispute over payment for a puppy. During this event, Mother disclosed that she had just found out she was pregnant.  Children's Social Care were informed as the police had noted that the address was in a poor condition with rubbish on the 37 floor.  In addition, the puppy had urinated on the floor and appeared to be undisciplined.  4.46 When the health visitor visited, Mother denied being pregnant.  The social worker attempted to visit the next day, but there was no answer and, following a planned home visit, the case was closed.  4.47 It is now clear that Mother was pregnant as in January 2010, the GP referred Mother to hospital for antenatal care.  The expected date of delivery was July 2010. In March 2010, Hospital 1 referred to both the health visitor and Children's Social Care in view of Mother’s previous history.  4.48 In March, Mother called the Surrey Police with various allegations about Father of Half Sibling 2.  A child at risk notification was completed for Half Sibling 1, and a domestic abuse risk assessment completed with Mother being assessed as high risk.  A referral was sent to the domestic violence outreach team.  The next day, Children's Social Care noted the child and risk form and recorded that the police had no concerns about the children and apparently decided that an immediate social work visit was not necessary.  4.49 A member of the domestic abuse outreach team spoke to Mother on the phone. They were informed by her there was now no problem as her partner had left and she was therefore told to ring the team if her partner continued his abusive behaviour and she wanted to apply for an injunction.  4.50 During March, as a result of the police notification, Children's Social Care contacted the midwife at the hospital to discuss the organisation of a multi-agency meeting.  A letter was sent to Mother with a date for an initial assessment.  4.51 Mother again called the police in April 2010 reporting a dispute with a neighbour. An appointment was made for a Neighbourhood officer to attend the address but Mother cancelled the appointment as the situation seemed to have been resolved.  No further action was taken.   38 4.52 During April Mother missed two antenatal appointments at the Hospital.  The midwife contacted Children's Social Care and was advised that a new social worker had only just been appointed to the case.  A management review of the case in Children's Social Care in April 2010 recorded an agreed action plan that a core assessment was to be completed, that more information was required about Father of Half Sibling 2, and more information was required about Mother’s alcohol consumption.  4.53 At a strategy meeting in April it was decided that the threshold for S47 enquiries was not met, and social work visits should continue to complete the core assessment.  The Children's Social Care individual management review notes that during this period the social worker formed a good relationship with Mother.  4.54 By the end of May Mother had not attended any of her antenatal appointments and Children's Social Care were informed.  During this period there was clear evidence that Mother was giving contradictory information to various professionals.  4.55 The information obtained by the social worker from Mother was generally positive, with Mother stating that she had no further contact with Father of Half Sibling 2 and that she was no longer drinking alcohol or taking drugs.  Half Sibling 1’s development appeared good and the home was described as clean and tidy.  There is no evidence in the chronology that a pre-birth assessment was completed.  4.56 Half Sibling 2 was born in June 2010 in Hospital 1.  It was clear that Father of Half Sibling 2 was in contact with Mother at this point and there is evidence that the social worker liaised with the hospital, the health visitor and the police regarding any potential risks from Father of Half Sibling 2.  The message from the police that there was nothing to indicate that Father of Half Sibling 2 would pose a risk.  39 4.57 Prior to Half Sibling 2 leaving hospital, a discharge planning meeting took place and a written agreement was signed by Mother.  4.58 At the first health visitor visit, the health needs assessment was not updated.  During the visit Half Sibling 1 was seen to help herself to meat from the fridge and eat from the packet.  Mother said she had not eaten her dinner.  On respect of Half Sibling 2 initial reports from the midwife and the health visitor indicate that she was feeding well and gaining weight.  4.59 By August, the health visitor records note that there was some uncertainty as to whether Mother was feeding Half Sibling 2 appropriately and she was asked to reduce feeds.  Follow up was arranged by a nursery nurse who, when they visited, recorded that there was some difficulty in establishing a picture of feeding from the Mother.  At the end of August the locality team, following consultation with the health visitor and the police, decided that Mother was doing well and that the case should be closed.  4.60 At the start of September 2010 the health visitor made an unplanned home visit to ask Mother to sign the paperwork for a nursery placement for Half Sibling 1.  The health visitor records note that she thought she could smell alcohol on Mother’s breath but did not challenge her about this. Other concerns known to the health visitor at this point were the fact that Half Sibling 2 was not registered with a GP, nor had she commenced immunisations.  This did not happen until November 2010.  4.61 The nursery conducted a pre-admission home visit.  There are no records of this visit, but the workers involved do recall that the flat was grubby and that they considered that Mother might have possible learning difficulties.  They assumed that the health visitor would pick up on the concerns around the grubby flat.  There was therefore a missed opportunity at this point to join up information between the health visitor and early years provider.  This would have been particularly helpful as, although the nursery did not identify any concerns, a pattern emerged of non-attendance with no reason for absence 40 recorded; for example, in November she was noted to have attended two out of three sessions and in December 2010 two out of five sessions.  4.62 There were two police contacts regarding Mother in October 2010; firstly, Mother reported a male (not one of the babies’ fathers) trying to get into the flat.  The male, aged 19, was drunk and handed by the police back to his mother.  On the second occasion, a neighbour called to say there was a disturbance at the address with a male banging on the door. Mother informed the police that there no problems.  There was a further incident in November when Mother reported eggs being thrown at her front door.  4.63 Half Sibling 2 missed three appointments for her second set of immunisations and these were not given until 25 August 2011.  In addition, the health visitor recorded a falling centile for weight for Half Sibling 2 at a visit in December 2010.  Mother failed to attend clinic appointments and when Half Sibling 2’s weight was reviewed at the end of January 2011 it was noted between the 2nd and 9th centile, having been at the 25th centile at birth.  There were a number of attempted contacts but Half Sibling 2 was not weighed again until April 2011, when she was below the 9th centile and by June 2011 her weight had fallen to the 4th centile.  At an unplanned home visit by the health visitor there was a noted inconsistency between the amount Mother stated Half Sibling 2 was eating and the recorded weight and she was defensive when asked about Half Sibling 2’s diet.  4.64 The health visitor recalls that as a result of these concerns she had considered a referral to Children's Social Care, and discussed Half Sibling 2’s weight loss with the GP who advised waiting for a further review of her weight.  There is no record of this verbal communication within the GP records and the health visitor did not take any further action in respect of a referral.  4.65 During this period where there were concerns about Half Sibling 2’s failure to thrive. In January 2011, Children's Social Care contact centre received a telephone call from Mother’s sister who informed them that Mother was pregnant with her third child and that her sister wanted to be a private foster 41 carer for the child when it was born.  Mother and Half Sibling 1’s history was reviewed and, in the light of concerns, it was decided that a pre-birth assessment was required if the pregnancy were to continue.  4.66 A phone call was made to Mother by Children's Social Care in February 2011, during which it was confirmed that Mother had not yet decided whether to give up her unborn child.  She agreed to a pre-birth assessment and to Children's Social Care contacting her GP to establish whether the pregnancy was still ongoing after a couple of weeks.  This pre-birth assessment did not take place as the assessment team social worker (who had been qualified for one month) was advised by her manager that an initial assessment was all that was required in view of the nature of the self-referral.  The social worker requested information from the school and GP but did not receive information from either of them and the health visitor indicated to the social worker that she did not have any concerns.  4.67 At the beginning of April, Mother telephoned Children's Social Care, explaining that she was five months pregnant but she didn’t wish to keep the baby and that her sister wanted to adopt the child.  According to Maternal Aunt, at this point the plan was for her to take the baby home from hospital and she therefore began to prepare for this by buying baby equipment.  4.68 A week later a visit was carried out jointly by the newly qualified social worker from the assessment team and a social worker from the adoption and permanency team.  Half Sibling 2 was with Maternal Grandmother and was not seen at this visit.  The resulting initial assessment recommended that Mother and her sister be given advice about private adoption and the case closed.  The initial assessment did acknowledge that both parties would need post-adoption support, and the assessment team social worker assumed that this would be carried forward by the adoption team.  4.69 Maternal aunt’s recollection of this event is that she and Mother were told that they should contact the permanency team when the baby was born.  No 42 advice was given at that stage about what to do about finance, legal and practical arrangements at the point that she took the baby from hospital.  4.70 Meanwhile also in April, following a home visit, the health visitor recorded that Half Sibling 1 said that she had seen ‘Dad’ outside although this was denied by Mother.  Health visitor records note bruising to both eyes that had almost faded, the explanation given by Mother that this had been caused by a fall from the sofa. No further action was taken by the health visitor in respect of this information.  The health visitor at this point was unaware of the pregnancy and did not find out about this until a phone call from the social worker later that day.  As well as informing the health visitor about the pregnancy, and their plan to close the case, Children's Social Care also sent a fax to the GP informing them that Mother was due to give her baby up for adoption within her own family.  4.71 The chronology notes that the social worker contacted the health visitor two days later for more information regarding the bruising on Half Sibling 2’s face.  It is not clear how the social worker knew of this bruising since Half Sibling 2 had not been present during the social work visit and there is no record of the health visitor discussing the bruising with another professional.  The health visitor informed the social worker of Mother’s explanation that she had left Half Sibling 2 on the nook of the settee when she went to fetch her nappy and Half Sibling 2 had taken a tumble, bruising her nose and the surrounding area.  The health visitor said it was healing at the moment and it was mother’s judgement rather than the bruise which was a cause for concern.  The health visitor stated that in spite of this she felt Mother tried her best, talked to her own mother and sought advice when she was worried.  The social worker’s view at this time was that Mother presented as acknowledging that she had difficulties, was determined to improve, could not countenance a termination and wanted to do her best for her unborn baby.  There is no record that any further action was taken by either the social worker or the health visitor in respect of two bruised eyes on a non-mobile baby.  4.72 The case was closed by Children's Social Care six days later. 43  4.73 During this period Half Sibling 1 continued at Nursery with continuing absences, the reasons for which were not recorded  4.74 In June 2011 that the health visitor visited Mother to follow up on news of the pregnancy.  Mother was not home and the health visitor received information Mother had not attended any antenatal appointments during this pregnancy. This was followed up with Hospital 1 to confirm that Mother was not booked for antenatal care.  The health visitor arranged for Mother to see the GP who confirmed that she was 31 weeks pregnant; the baby was unwanted, and her sister was planning to adopt. A referral was made to Hospital 1 for maternity care.  The referral letter referred to a concealed pregnancy.  4.75 At this point Half Sibling 2’s weight had dropped to the fourth centile, and the health visitor planned weekly weighing and Mother was asked to take Half Sibling 2 to the GP.  There is evidence of some improvement in feeding and weight gain although Half Sibling 2 was on several occasions reported to be staying with a friend of Mother’s when home visits were made and it is therefore not clear whether the weight gain was in fact due to Mother’s actions.  4.76 Due to Mother’s non-attendance at antenatal appointments, Hospital 1 contacted the referral information officer at Children's Social Care and was informed that the agency was aware of the pregnancy and an initial assessment would be carried out as Mother had told the midwife that she was going to keep the baby.  However, the case was not allocated due to an ‘exceptional volume of cases’.  4.77 Mother’s antenatal care was transferred to Hospital 2 as this was more convenient for her and Children's Social Care were informed that Mother had failed to attend five appointments and had no antenatal care.  The Hospital 2 midwife had tried to visit three times, without success and the midwife was concerned there was no plan post-birth.  44 4.78 Although the case could not be allocated, the assistant team manager from Children's Social Care conducted a home visit in order to ensure that the children were seen.  The assistant team manager gathered comprehensive information in respect of the recent history and identified concerns about the condition of the home that was so poor that Mother was instructed to clean it that night with the help of the Maternal Grandmother.  4.79 A follow up visit was conducted the next day and concerns about the state of the kitchen and bathroom had been addressed by Mother.  A strong smell of alcohol was noted from Mother and when confronted, she said she had vodka and Red Bull.  There was an open can of rum and cola, plus two cans in the fridge and another glass of vodka and Red Bull.  These were disposed of in the presence of the social worker.  4.80 The next day the nursery nurse conducted a planned home visit and it was noted that Half Sibling 2 had gained no further weight. She was now sitting but unstable (Half Sibling 2 was 1 year 1 month at this point).  On the same day a strategy discussion took place between Children's Social Care and the police, without the involvement of health professionals.  A single agency investigation was agreed (records indicate that the health visitor received a copy of the strategy meeting minutes a month later).  4.81 The health visitor telephoned the social worker to share concerns about:  Mother systematically failing to engage with the service.  Not booking herself in until she was 32 weeks pregnant and saying she had registered the pregnancy with the GP and hospital which was not true.  The health and development needs of Half Sibling 2, including failure to thrive. Half Sibling 1 was noted to be doing quite well. During this call the social worker was noted as saying that she felt that the children should be removed from their Mother’s care although there is no evidence that this was the formal position of Children's Social Care at that time. 45  4.82 The health visitor discussed the case in safeguarding supervision in July 2011 and the resulting action plan was for the health visitor to liaise with the social worker and community midwife regarding the interagency plan.  4.83 Child S was born on the way to Hospital 2 in July 2011 and was placed in the Special Care Baby Unit.  It would appear Maternal Aunt received a call from Mother saying that the baby had been born and named.  It was at this point that Aunt said that she realised that she would not be taking Child S home with her from hospital.  4.84 Hospital records note that Child S was extremely jittery, had increased muscle tone, and neonatal drug withdrawal observations were commenced.  Information from Kingston Hospital indicates that all diagnostic tests were to the expected standard.  These observations relate to the impact of drug rather than alcohol use on the baby and Child S did not require any treatment. Contact was appropriately made with the social worker to discuss the need for a discharge planning meeting.  At this point there is some confusion within the Children's Social Care records as to whether formal section 47 (child protection) enquires had been commenced as there is a note that ‘single agency investigation had just been agreed in view of the concerns while completing the IA’, but no record of this decision being made as a result of a strategy discussion involving police and health colleagues.  4.85 The social worker made an unannounced visit to Mother and thoroughly checked the state of the home. During this visit Mother (who was noted to be under the influence of alcohol but not drunk) was informed that this was a child protection investigation and that the condition of the home was not acceptable. Issues recorded were:  Empty vodka bottle in the bin  Mother’s explanation for drinking vodka was that she was drinking so she could get more strength and keep awake  Mould in the fridge 46  Not enough food in fridge and cupboards  4.86 The social worker informed the team manager that it was not safe for Half Sibling 1 and Half Sibling 2 to remain in the home in the state it was in (Child S was still in hospital) and that Maternal Grandmother was not able to have the children to stay although she would visit that evening and help Mother clear up.  This course of action was agreed by the team manager.  4.87 The next day when the social worker visited a lot of progress was noted but the kitchen needed to be cleaner. Half Sibling 2 was noted to be dressed appropriately but was again in a car seat.  The social worker visited again at 18.00 hrs and was satisfied that the property was now in a hygienic state.  4.88 The discharge planning meeting at Hospital 2 included hospital staff, the health visitor, social worker and Mother.  Child S was noted to be fit for discharge from a medical point of view and the social worker’s view was that there was no evidence to show that Mother would directly or deliberately harm Child S and he could therefore be discharged.  Concerns were noted as.  Lack of time for Mother to bond with Child S  Mother not coping with child care, and a premature baby could aggravate the situation  Financial difficulties  Mother not maintaining property in an acceptable state  Mother’s smoking presenting a hazard to Child S  4.89 The action plan from the meeting was:  Matron to see if Maternal Grandmother could support with child care on Saturday so that Mother could have at least 24 hrs with Child S under observation and go through the discharge protocol  Child S to be discharged the following Sunday  Social worker and family support worker to visit the family 2-3 times per week (Monday, Wednesday and Friday) 47  Health visiting team and nursery nurse to visit on Tuesday and Thursday for the first week  Mother to register the birth within the first week  Social Worker to liaise with management regarding financial help with travel.  Initial child protection conference to be convened  Mother to keep all appointments  Mother to give basic care to her children and ensure home was safe and hygienic.  4.90 Child S was cared for by Mother overnight prior to his discharge home on Sunday when he was twelve days old.  The visiting pattern between professionals started as planned the next day and no concerns were noted in the Children’s Social Care records.  On the Tuesday the health visitor records note that Mother stated doubts about her ability to maintain adequate care, Half Sibling 2 had not been taken for medical appointments and Half Sibling 1 (age 3 years 11 months) was playing outside unsupervised.  When Mother was asked about this she said that Half Sibling 1 was used to this and would return. Half Sibling 1 was then noted to say that she was hungry and helped herself to food from the fridge.  These observations were not shared with Children’s Social Care.  4.91 On Wednesday during the social work visit, Half Sibling 2 was not there and was reported to be with a friend of Mother’s, Half Sibling 1 was playing outside supervised by a neighbour and the property was clean and presentable.  Half Sibling 2 was also not there the next day when the health visitor called and Mother was noted to talk negatively about Half Sibling 2 as a baby.  4.92 The family support worker visited on Friday and made a detailed record of the visit. Mother was noted to have ‘excellent interaction’ with all her three children although there is no detail as to what this meant.  The state of the home was not as bad as previously but there were indications that Mother was finding maintaining standards a struggle. 48  4.93 During the following weekend the community midwife made two planned home visits.  On the first occasion, Mother did not allow the midwife into the house as family and friends were visiting and on the second no one was at home.  The community midwife visited again on Monday and let the health visitor and social worker know that were no midwifery concerns.  4.94 On the Monday there was also a visit to the home by the family support worker together with the social worker.  There were no improvements in the condition of the home since Friday and Half Sibling 2 was noted to be lying in her cot.  The record notes concern about her developmental delay, and that she was always found without much attention.  Her upper feet were also noted to be dirty.  4.95 The health visitor visited as planned on the Tuesday.  Maternal Grandmother was looking after the children whilst Mother was reported to be out registering Child S’s birth.  Maternal Grandmother was recorded as telling the health visitor that Mother did not feed the children properly.  There is a record in the Children’s Social Care file of a text message from the health visitor saying all was going well for Child S.  It noted little weight gain for Half Sibling 2 and that she had stayed at a friend of Mother’s from Tuesday to Friday the previous week.  The message also noted that the health visitor would be visiting again on Wednesday the following week.  4.96 On the Tuesday there is a record by a new social worker that they had found this case allocated to them in their work tray.  It is not clear from the chronology why there was a change of worker at this point.  There is also a note that the record of outcomes for was overdue and that this would be completed with a view to progressing the case to initial child protection conference.  4.97 The chronology then indicates that the same social worker who had visited on the Monday visited the home on the Wednesday as Half Sibling 2’s feet were 49 cleaner than on the last visit. Half Sibling 2’s weight was discussed and Mother was noted to be interacting well with her.  4.98 A nursery nurse visited on the Thursday and a family support worker on the following Monday.  During the visit by the family support worker, Mother said she would not be able to attend the forthcoming child protection conference as she could not get all children ready and out of the house for a 09.20 hrs meeting.  Later that evening Mother called the Surrey Police reporting an assault by a neighbour and was found by the Police to be intoxicated.  The police report notes that the officer concerned did not believe that the children were present at the time and therefore did not notify Children's Social Care.  4.99 The planned visit by the health visitor that week was cancelled by Mother but the social worker called unannounced to share the child protection conference report.  There was no reply, and whilst the social worker was there Mother returned saying she had popped out for two minutes.  The children were sleeping inside the house. Child S was four weeks old at this point.  4.100 The focus of the visit was the fact that Mother did not wish to attend the child protection conference as she felt judged and also did not have anyone to leave the children with.  During the visit it was noted that the children had not had anything to eat that morning except biscuits and Mother said that she would give them eggs and bread when the social worker left (the time of visit is not clear).  Half Sibling 1 pointed out a cut on Child S’s toe, an injury for which Mother had no explanation other then he might have cut himself with his nails.  The social worker reported this to the assistant team manager who asked for the injury to be bought to the attention of the child protection conference and for the family support worker to care for the children to enable Mother to attend.  There is no confirmation that the issue about the children being left alone was shared with the manager or considered to be serious child protection concern.  4.101 Mother declined the offer of a family support worker to care for the children during the child protection conference and reiterated the fact that she did not 50 want to face professionals who were going to tell her that she was a bad parent. At the conference in August 2011, all three children were made subject of a child protection plan under the categories of neglect and emotional abuse.  The plan was very similar to previous plans and included  Mother to ensure children’s needs were met and comply with announced and unannounced visits  Professionals to work together to ensure that the children’s needs and developmental milestones were met  To consider engaging with alcohol and domestic abuse services  4.102 There is no evidence at this point that any assessment had included consideration of parental motivation to change or the extent of Mother’s alcohol misuse.  4.103 It should be noted that no one from Half Sibling 1’s nursery attended the conference or sent a report.  It seems that the nursery was notified verbally that the case was child protection just before the school holidays in July and received a formal letter to the conference during August.  This was not opened by the school until September.  4.104 The same day as the conference, the case was transferred to the child protection and proceedings team in Children's Social Care.  A planned home visit took place by the new social worker during which Mother continually stressed that she did not need support, asked the social worker to leave because she said they were upsetting her and said she would not let anyone from the social worker’s team into the home.  A planned health visitor visit for the next day was cancelled by Mother as was a planned visit by the nursery nurse two days later. Mother did attend a core group meeting where she was noted to be resistant and defensive.  4.105 A legal planning meeting took place at the end of August when Child S was six weeks old, the conclusion of which was that more information needed to be collated before a decision could be made.  The Children's Social Care 51 individual management review outlines a number of concerns about the effectiveness of this meeting with a lack of chronology and social workers attending without a well organised and documented case.  There were also differences of opinion between social workers, with the assistant team manager from the assessment team feeling there was sufficient evidence to support legal intervention, whereas workers from the child protection and proceedings team (who had begun working with the case more recently) felt unconvinced due to Mother’s ‘recent engagement’.  4.106 At the age of six and half weeks Child S’s weight gain was noted by the health visitor to be good.  Half Sibling 2 (now age fourteen months) was recorded as now being on the 9th centile and regularly staying with a friend who had two children.  The social worker visited the same day and Half Sibling 2 was noted to be crawling and there were some positive aspects in the home environment such as it being ‘clean and tidy’, the temperature in Child S’s room being ‘about right’ and food not out of date in the fridge.  Other issues noted were mould in some of the rooms and the fact that the cooker was not working and Mother was relying on a microwave.  4.107 Mother was not in for the next planned home visit by the health visitor and she did not keep an appointment with the GP for Child S’s developmental check the same day.  She also failed to take Child S to an appointment at Hospital 2. Child S at the age of eight weeks had failed ten health appointments, a concern which was notified to the health visitor by the GP.  4.108 A social work record notes the failed appointments and the social worker rang the nursery to ascertain whether Half Sibling 1 was attending and was informed that Half Sibling 1 was not expected to resume nursery until later in September.  4.109 Later that day the social worker and a new family support worker made an unannounced visit.  The records describe the house as dirty and cluttered and she was made aware that the condition of the flat was not acceptable.  The 52 issue of the missed appointments was discussed and Mother is noted to have made excuses.  4.110 The health visitor visited two days later and Mother was noted to be upset as the visit was early and unexpected.  She was also noted to be tearful and angry and not wanting social work intervention. On the visit the following was observed:  Half Sibling 2 good weight gain  Half Sibling 2 immature crawling and not pulling to stand as had been reported by Mother  Half Sibling 2 – no further immunisations  Child S weight static (unusual in a bottle fed baby)  Child S – injury to right hand which Mother could not account for. Child S described as tense and rigid and screamed in pain when the health visitor bathed the wounds The health visitor communicated the outcome of this visit to the social worker immediately and the social work records note all of the above issues plus the fact that the health visitor said Child S was a tense little boy who had not started making eye contact and that Mother had said she would not open the door to the family support worker as working with her was optional.  As well as speaking to the social worker the health visitor also alerted a covering colleague since she would be out of the office the following day  4.111 Following the conversation with the health visitor, the social worker called Maternal Grandmother to advise her of the latest concerns.  The social worker was unable to get through to Mother on the phone and agreed with Maternal Grandmother that her sister would call at the house at 15.00 hrs and ask Mother to ring the GP for an appointment.  The next day the health visitor was informed by the GP surgery that Mother had rung to ask for an appointment for an infected hand, had declined an early appointment and accepted one at 16.50 hrs.  However, when the health visitor spoke to Mother, she said she could not attend the GP’s surgery that day.  She was strongly advised by the health visitor to attend the next morning at 09.00 hrs. 53 4.112 The day after the call from the health visitor advising of Child S’s injury and the other concerns the family support worker conducted an unannounced visit to the home.  Half Sibling 2 could be heard crying but no adult was in the flat. When Mother returned the flat was found to be a very poor state.  Child S’s injured finger was apparent as was a bruise on his face covered by Sudocrem.  Mother could give no explanation for the bruise.  The family support worker alerted the social worker  4.113 Child S was taken to Hospital 2 and initial examination revealed a fractured skull, old and new bleeds and a blood spot at the back of his eye.  Child protection medicals were also carried out on Half Sibling 1 and Half Sibling 2 who were found to be medically fit.  Half Sibling 1 was removed from home into the care of Maternal Grandmother and Half Sibling 2 also removed into the care of a family friend (for whom the required assessments were undertaken) until foster placements were found.  The decision was made by the Local Authority to issue care proceedings in respect of all three children.  5. THEMATIC ANALYSIS OF PROFESSIONAL PRACTICE Recognising risk 5.1 Individual risk factors will be explored in more detail later in this section, however, it is important not to lose sight of the whole picture and to consider the opportunities available to practitioners to recognise the accumulating concerns over time and assess the potential risk to the children.  There were a number of factors present in this case which are known to be associated with risk to children, yet these were not adequately assessed as a whole and a judgement made as to how safe the three children were in their mother’s care.  Because this assessment did not take place plans to protect the children were not sufficiently robust particularly in relation to measuring whether sufficient change had taken place to reduce the risk of harm.  5.2 Examples of accumulating concerns are:  Alcohol misuse when caring for child and/or pregnant (all three children). 54  Recurrent allegations of partner violence (Half Sibling 1 aged one noted to cry when Mother raised her voice).  Ongoing lack of engagement with a variety of services but most significantly lack of antenatal care during second and third pregnancies and delayed GP registration and immunisations for all the babies.  Lack of provision of appropriate food and supervision after the birth of Half Sibling 2 with Half Sibling 1 noted to be helping herself to food, playing outside unsupervised / hungry.   Half Sibling 2’s failure to thrive and significant developmental delay.  Lack of evidence of emotional bond between Mother and Half Sibling 2 with Half Sibling 2 being looked after for long periods by others.    Mother wishing to give Child S up for adoption when she found she was pregnant.  Bruising on a non-mobile baby (Half Sibling 2’s two bruised eyes).  Child S being a ‘jittery’ baby (possibly associated with Mother’s alcohol use).   The stress associated with caring for three babies under the age of four at the time of Child S’s birth.  Mother’s expressed doubts to the health visitor about her ability to maintain adequate care following the birth of Child S.  Half Sibling 1 playing outside unsupervised following Child S’s birth and saying she was hungry.  Children found by a social worker at home alone whilst Mother ‘popped out’ one month before the significant incident.  5.3 There is little evidence that assessments at any time adequately analysed the interaction between known risk and the protective factors within the environment.  The need for such an approach became particularly acute following the birth of the second and third children when stressors within the family environment increased, yet there is little evidence of an associated increase in factors that were likely to reduce the likelihood of harm.  55 5.4 Factors that are known to be associated with risk to babies and very young children (Ward et al 2012)2 include parents who have experienced abusive childhoods themselves and have not come to terms with the abuse, substance misuse, intimate partner violence and environmental stressors such as housing.  Significant protective factors are the presence of a supportive non-partner, wider family and informal support and parent’s insight understanding and capacity to change.  Severe risk of harm is most likely where there is an absence of protective factors particularly evidence of the parent’s capacity to change.  5.5 In this case a number of risks were present yet there was little evidence of the mitigating effect of protective factors.  Misuse of alcohol is a theme running throughout the chronology with no evidence of willingness on Mother’s part to address this and there is consistent evidence of no engagement with services.  In addition it is likely that she was adversely affected by her own childhood experiences and there was no attempt to understand these or the impact they may have on her as she became a parent.  There was an overreliance on the support of Mother’s family as the one protective factor, without any evidence of a detailed assessment of family dynamics and relationships.  5.6 Within this overall context, the accumulating concerns from the birth of Half Sibling 1 onwards should have worried professionals.  Not all concerns were known to social workers, particularly when the case was closed to Children's Social Care two months after Half Sibling 2’s birth until Mother‘s pregnancy with Child S.  During this period it was the health visitor who had most contact with the family and was aware of the concerns about failure to thrive.  Surrey Local Safeguarding Children Board has been assured through its routine monitoring mechanisms that relevant action has been taken by the health organisation involved in order to improve the knowledge and skill of practitioners.                                                             2 Ward, H., Brown, R., and Westlake, D. (2012) Safeguarding Babies and Very Young Children.  London: Jessica Kingsley Publishers. 56 5.7 By the time of the legal planning meeting at the end of August 2011 all the information should have been collated by social workers and presented in a way that allowed the lawyer to make a reasoned decision as to whether the threshold for proceedings had been met.  Instead, at this point there were disagreements between the assistant team managers from assessment team and child protection and proceedings team and they did not present sufficient documentary evidence to the meeting.  5.8 Disagreements appear to have been influenced by the fact that the child protection and proceedings team had recently taken over the case and were more optimistic that recent changes could be sustained.  Children’s Social Care are also aware that at that time there was inconsistent practice in relation to the quality of evidence provided to legal planning meetings and this was also affected by a lack of focus on the importance of chronologies within the service (which has now been addressed by a Children's Social Care recommendation).  Steps have now been taken to ensure that no legal planning meeting takes place without the necessary written documents being provided as evidence prior to the meeting.   Recognising the significance of history 5.9 There was no indication that at any time practitioners sought relevant information about Mother’s experience as a child and used this to inform an assessment of the support she was likely to need as a parent in her own right.  This was despite it being known by social workers and health visitors that she had been in care as a child.  Where information was already known to individual practitioners due to their previous involvement (in this case the first health visitor) the significance was not recognised; neither was the information shared appropriately with others in the network.  The historical information was particularly significant in respect of the quality of support that might have been available from the wider family and their role in providing alternative care for Mother’s children.  The health visiting records contain information that Mother moved out of home as a teenager due to abuse and in June 2009 it was recognised that both Mother and Maternal Grandmother were only superficially compliant with the child protection plan, yet there is no evidence 57 that this superficiality was understood in terms of previous information relating to previous family history and relationships.  5.10 When the decision was made to place Half Sibling 1 with Maternal Grandmother there was no information available to the emergency duty team on the electronic records about the suitability of this placement, nor was there any further assessment by social workers of her as a carer when Half Sibling 1 was placed there for two months.  There was also no detailed exploration of history at the point that Mother’s sister was being put forward as a possible adoptive parent.  5.11 It was only when the information about family history was sought for this serious case review that the similarity between Mother’s own experience as a child and her parenting of her own children was recognised.  Paper files had to be retrieved from archive for this data to be available even though by this point all three children had been removed from Mother’s care.  Despite the serious injury and removal of the children no one had accessed this significant information and it seems that at no point did anyone consider the question of missing information.  5.12 Why this was the case in Children's Social Care seems to stem from the fact that information was not retrieved at the point of first contact and from then onwards it was assumed that assessments contained all relevant information.  The challenges of maintaining a questioning mind-set are illustrated by the comment of one social worker that an assessment had already been undertaken, they assumed they therefore had all relevant information and it was therefore not their role to undertake another assessment.  A child protection conference chair also commented that they were reliant on information provided to them and they were unaware of the extent of Mother’s history.  5.13 It was clear to the serious case review panel that retrieving information could be time consuming and in the case of Mother’s education records, the panel were not able to retrieve these at all due to an administrative problem.  58 Understanding the barriers to retrieval within the administrative system is important since busy practitioners need smooth efficient systems in order to support them in their work.   The impact of alcohol use on parenting capacity 5.14 Unlike many cases where alcohol use is hidden or minimised, in this case alcohol use was overt and happening throughout the last pregnancy.  Despite this overt use combined with other stressors, practitioners did not at any time appear to clearly define this as a child protection issue and work together with substance misuse services to pool information and fully assess the risk of harm.  5.15 There are ten instances within the chronology where Mother is noted to be drunk when pregnant and/or actively looking after one or more of her children.  On all but two occasions records are clear that Children's Social Care were informed and from time to time there is mention in social work records or assessments that alcohol use was  factor affecting parenting.  However, at no time were the actual risks associated with alcohol use articulated and analysed.  The reason for this seems to be that social workers were lulled into a false sense of security by a lack of concern expressed by the GP or the alcohol misuse service.  Both these services relied on self-reporting by Mother whereas social workers and police officers had clear evidence of significant use that was directly impacting on parenting capacity.  5.16 Prior to the birth of Half Sibling 2 even where alcohol misuse was suspected, professionals were distracted from naming the risk and challenging Mother.  For example in August 2008 Mother was found to be drunk whilst looking after Half Sibling 1 and it was noted that Half Sibling 1 cried when Mother raised her voice.  Alcohol was recognised to be a concern but this did not detract from the dominant social work view that there were no concerns about the care of Half Sibling 1 or her safety.  Again, in September 2008, Mother was again drunk when caring for Half Sibling 1 but two days later the social worker noted that Half Sibling 1 was ‘truly thriving’ in her new home.  59 5.17 The failure by the health visitor to speak to Mother about her alcohol use when she thought she could smell alcohol on her breath at an unplanned home visit when Half Sibling 2 was three months old highlights the need to equip professionals with the knowledge, confidence and skills to address concerns about alcohol use.  This failure to address the issue was despite knowledge that alcohol misuse had been a previous concern.  5.18 A similar lack of focus on alcohol as a significant cause for concern can be seen eight days prior to the birth of Child S when Mother was noted by the social worker to smell strongly of alcohol and she admitted drinking vodka and Red Bull.  Other alcohol was seen in the flat and was disposed of in the presence of the social worker.  At this time the focus was on the lack of hygiene within the flat and there is also evidence of lack of appropriate stimulation for Half Sibling 2 who was sitting in a car seat.  It is also significant that Half Sibling 1 appears to be worried about her Mother as she is noted to be playing outside and occasionally coming in to ‘check on her mum’.  There is little evidence that the extent of alcohol use was shared by the social worker with health professionals who should have been made aware of the extent of alcohol use this late in pregnancy.  Risks were also not properly analysed in the light of the care being given to the children.  5.19 It is hardly surprising that Child S was a ‘jittery baby’, yet the risks associated with Mother’s alcohol use continued to be minimised.  The comment at the discharge planning meeting that it was safe for the baby to return home as Mother would not deliberately harm him does not take account of the unintentional harm associated with alcohol use and young babies.  5.20 Brandon et al (2013)3 in their study of neglect and serious case reviews note that professionals can be falsely reassured by an apparently good relationship between parent and baby and comment,  ‘A good relationship between a baby and parent cannot keep the infant safe for example when co-sleeping with a                                                            3 Brandon, M., Bailey, S., Belderson, P., and Larsson, B. (2013) Neglect and Serious Case Reviews. University of East Anglia/NSPCC. Page 77  60 parent who has consumed drugs or alcohol’.  Assessments therefore need to look both at the intrinsic risks associated with parental behaviour, alongside parent/child relationships and day to day care. In this case in respect of Half Sibling 1 the focus was on the latter two issues at the expense of the former.  By the time Half Sibling 2 was born there was sufficient evidence to suggest that all three aspects of care were compromised.  5.21 Police consistently recorded concerns about alcohol when Mother was found drunk and apart from one occasion (when the officer did not believe the children to be present) notified Children's Social Care.  Mother received a police caution for being unfit to care for a child when under the influence of alcohol and drugs and on another occasion was arrested for child neglect whilst unconscious, apparently through alcohol, whilst caring for a child.  It is clear that on the latter occasion the Surrey Police took this matter particularly seriously and a file was submitted to the CPS.  The Police had been unable to charge Mother with being drunk in charge of a child as this offence is only applicable when the carer is drunk in a public place.  In this instance Mother was drunk (unconscious) in her own home and therefore neglect was the only applicable offence.  It was however the view of the CPS that the case for neglect was not made out and the serious case review panel were disappointed that this decision meant mother was not held to account for her actions at this time.  5.22 Following Mother’s arrest for neglect (as a result of being drunk within the home) and the placement of Half Sibling 1 with Maternal Grandmother, Half Sibling 1 was returned home to Mother two months later at the point that Maternal Grandmother was due to go on holiday.  It seems that decision making may have been influenced by neither the GP nor alcohol misuse services expressing any major concerns and viewing Mother’s alcohol use as ‘binge drinking’.  5.23 This concern about health and social care workers not seeing or addressing parental alcohol misuse is recognised in a report by Alcohol Concern and The 61 Children’s Society (2010)4.  They note children in families where alcohol is a serious issue for parents is frequently not addressed ‘until problems escalate, and even then, parental alcohol use is not always recognised or recorded’.  There is clear evidence in this case of a lack of rigour and persistence in addressing issues relating to alcohol.  The health visitor smelt alcohol but did not challenge Mother and the plan in August 2011 said that Mother should ‘consider’ engaging with alcohol and domestic abuse services rather than this being seen as an essential element of safe care.  5.24 Why this is the case needs further exploration by the Surrey Safeguarding Children Board, starting with the recognition that alcohol is a socially acceptable drug and therefore may be less likely to cause alarm than illegal drug use.  Another possible explanation is a reliance on ‘experts’, with the first health visitor telling the individual management review author that they did not recall being asked by the child protection conference to explore the role of alcohol in Mother’s life, and that in any case she would have challenged this as she felt that she was not an expert in this area.  It is of note that a framework to assist assessment in cases on substance misuse was in place as part of the locality child protection procedures during the timeframe for this review.  At no time was this used in this case, possibly as alcohol was not viewed in the same way as other substances (such as illegal drugs) which were believed to be the focus of the framework.  5.25 As a result of a lack of focus on the impact of alcohol misuse on parenting Children's Social Care apparently did not consider inviting alcohol misuse services to child protection conferences nor to work effectively together to carry out joint assessments.  As a result the alcohol misuse service only had Mother’s self-report rather than the full history known to Police and Children's Social Care.  It seems the GP also did not consider the full picture and ensure that this was known when a referral was made to the specialist service.                                                            4 Delargy A. et al (2010) Swept Under the Carpet – Children Affected by Parental Alcohol Misuse. Alcohol Concern & The Children’s Society 62   Bruising and injuries in children who are not independently mobile  5.26 Where bruising or injuries are seen in children who are not independently mobile, this should raise concerns and prompt professionals to consider the possibility of abuse.  In April 2011, when Half Sibling 2 was nine months old and not able to sit independently, the health visitor noticed two bruised eyes and too easily accepted the explanation given that she had fallen off the sofa.  At this point Half Sibling 2 was known to be failing to thrive and living in circumstances where there were a number of stressors.  Good practice would have been to refer formally to Children's Social Care and request a medical examination.  5.27 Communication in respect of the bruising to Half Sibling 2 appears muddled with one of the social workers responsible for talking to Mother about the proposed adoption of her third child asking the health visitor for information about the bruise.  According to records this social worker had not seen Half Sibling 2 and it is not therefore clear how they came by this information.  Having been reassured by the health visitor that Half Sibling 2 was not seriously harmed and Mother ‘tried her best’, the management decision within Children's Social Care was to speak to Mother and encourage her to take her child to the doctor.  The discussion with Mother did not take place until the next day and records refer to a general discussion about Mother taking her children to the doctor.  There was no follow up to ensure that the advice had been heeded and in fact, since the focus was on the adoption request, the case was closed five days later.  There is no indication that either the health visitor or the social worker carrying out the initial assessment assessed the bruising from an understanding of the rarity of bruising in non-mobile infants (less than 1%)5 or within the context of previous concerns about parenting and Half Sibling 2’s failure to thrive.  The social worker involved at this point was very newly qualified and there was a lack of robust supervision which allowed for critical reflection on the information available.  More effective                                                            5 Maguire, S., Mann, M.K., Sibert, J., and Kemp, A. (2005) ‘Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Archive of Disease in Childhood. 90 182-186 63 support and supervision at this point may have reduced the likelihood of the apparent over reliance by the social worker on the opinion of the health visitor.  5.28 There were two unexplained injuries to Child S that came to the attention of professionals.  The first injury was a cut on his toe when he was one month old, seen by a social worker.  The context for this visit was that the previous day’s visit by the health visitor had been cancelled by Mother and when the social worker arrived, the children had been found at home alone whilst Mother ‘popped out’.  The management decision was that the injury should be brought to the attention of the child protection conference the next day, whereas a more appropriate response would have been to arrange a medical examination and to consider emergency removal at this point.  5.29 The second unexplained injury was first seen by the health visitor the day before the serious injuries were identified.  Child S is noted to have an injury to his right hand and significantly, is described a tense and shaking when first held.  This information was conveyed verbally to a social worker but its potential seriousness appears not to have been understood since the response was to ask Maternal Grandmother to ensure that Mother took Child S to the GP.  An unexplained injury in a young baby subject of a child protection plan, especially where this is the second injury in a short space of time, should have immediately prompted a child protection medical examination.  5.30 The family support worker acted promptly the next day in respect of the finger injury and the bruise on Child S’s face covered with Sudocrem and as a result all three children were removed from Mother’s care. T his was good practice in line with procedures which needs to be promoted by Surrey Safeguarding Children Board through raising awareness of the significance of bruising in non-mobile babies and taking steps to ensure that all practitioners are aware of the action to take if this is found to be present. 64 Recognising the interface between child neglect and physical abuse 5.31 It is notable that the health visitor told the review that they had not clearly understood the link between chronic neglect and physical abuse.  Although this was not articulated in the same way by social workers, practice evidence would suggest a similar lack of understanding.  Comments within the social work records noted the quality of the home environment and immediately before and after the birth of Child S and social workers were diligent in making expectations clear to Mother and following through on agreed actions.  However, both social workers and the health visitor were less robust in their response to evidence of physical injuries such as the bruising to Half Sibling 2 and the injury to Child S’s finger.  There was insufficient understanding that chronic neglect may be a driver for physical abuse and the association between the two (Brandon et al 2013)6.  This is similar to the ‘neglect mind-set’ which precludes other forms of harm being considered (Brandon et al 2009)7 and indicates the challenge in working with complex situations which require the practitioner to hold a number of possibilities in mind.  5.32 In this case it is possible that Mother’s feeling that she could not cope (as expressed to the health visitor) was confirmed to her by her struggle to provide basic care leading to frustration and blaming/punishing the child.  This is similar to the ‘care conflicts’ described in a previous study of child deaths (Reder et al 1993)8. The lack of focus on the relationship (specifically bonding and attachment) between Mother and her younger two children appears to have prevented consideration of the possibility that she could deliberately harm her child.  The fact that there has been knowledge in the child protection field for some twenty years that could have informed practice in this case is testament to the need for organisations to ensure practitioners have sufficient knowledge and then support them to apply this in practice through effective management and supervision.                                                            6  Brandon, M., Bailey, S., Belderson, P., and Larsson, B. (2013) Neglect and Serious Case Reviews. University of East Anglia/NSPCC. Page 64. 7 Brandon, M., Bailey, S., Belderson, P. Gardner, R., Sidebotham, P., Dodsworth, J., Warren, C., and Black, J. (2009) Understanding Serious Case Reviews and their Impact. DCSF- RR129 page 50 8 Reder, P and Duncan, S and Gray, M (1993) Beyond Blame: Child Abuse Tragedies Revisited. London: Routledge. 65   Meaning of the child 5.33 Assessments in this case would have benefitted from consideration of the potentially different meaning that each child had for Mother.  The significance of understanding the meaning of individual children within families has been recognised as an important aspect of child protection practice over several years9,10.  All children will have psychological meaning to their parents and in most cases this is not at all problematic.  However, there can be problems where children have negative associations such being unplanned or unwanted, the result of rape or violence, or are perceived to be difficult or problematic from birth.  In this case there is evidence that both Half Sibling 2 and Child S may have had a meaning which contributed to abuse and/or neglect.   5.34 In respect of Half Sibling 2 Mother initially denied she was pregnant and then avoided antenatal care.  There was a reported adversarial relationship with Half Sibling 2’s father and Mother told the health visitor that she was disappointed that Half Sibling 2 looked like him.  All these factors should have informed professional assessments, when Half Sibling 2 was failing to thrive and there it was clear that she was frequently being looked after by carers other than her mother.  5.35 Child S’s was an unwanted pregnancy and it was unlikely that, given the family history and relationships, adoption by Mother’s sister would be smooth.  It was not good practice to close the case after an initial assessment with records showing that advice had been given about private adoption.  Maternal Aunt recalls being told to contact Children's Social Care again when the baby was born and feeling surprised that no advice had been given such as what to do about finance and practical arrangements when she took the baby from hospital.  The case should have been kept open throughout the pregnancy in                                                            9 Reder, P., Duncan, S., and Gray, M. (1993) Beyond Blame: Child Abuse Tragedies Revisited: London: Routledge  10 Reder, P and Duncan, S. (1995) ‘The Meaning of the Child’ in Reder, P and Lucy, C. (eds) Assessment of Parenting. London: Routledge.  66 order to ensure that any necessary pre-birth assessments were carried out.  The reason that did not happen seems to have been due to a lack of easily available background information to inform the initial assessment process as a result of the changeover from one electronic system (Swift) to another (ICS).  There were also pressures on staffing at the time which meant that the case was allocated to a new social worker who received no effective supervision.  5.36 Even if the pre birth assessment had occurred, once it was clear that Mother was keeping Child S, her feelings toward this baby should have been explored and Mother’s previous request to have him adopted by a family member should have informed a more thorough assessment of Mother‘s capacity to bond with the baby and provide appropriate emotional warmth and safe care.   Assessing the impact of learning disability on parenting capacity 5.37 Records within Children's Social Care show that Mother had mild learning disabilities, emotional difficulties and a statement of special educational need and she told the health visitor that she was unable to read or write and therefore ignored mail.  The nature and extent of any disabilities were not assessed and this information used to inform the help given or the risks to the children.  Whilst learning disability does not alone increase risk, attention does need to be paid to ensuring that the right type of support is in place.  Additionally, the presence of a learning disability may ‘compound other difficulties affecting the lives of families’11, and in this case the possibility should have been considered as one of the many interacting risk factors and actively excluded or included as a significant factor.   Working with fathers 5.38 There are three fathers in this case, although the identity of the father of Child S has not been confirmed.  Where the identities of the fathers are known and in some cases considerable efforts made to locate their whereabouts, the impression from the records is that they were mainly thought of in terms of                                                            11 McGaw, S. Newman, T. (2005) What Works for Parents with Learning Disabilities. London: Barnados. Page 7 67 potential risk, rather than having anything positive to contribute to assessments and plans.  5.39 In some records fathers are absent, for example there is no reference in health visitor records at time of Half Sibling 1’s birth as to whom her father was or, indeed, who was Mother’s partner at that time.  Engaging with fathers has been a theme from previous Surrey serious case reviews and the requirement to include fathers and male carers in assessments has been reinforced via the delivery of serious case review findings workshops, circulation of learning from serious case review leaflets, inclusion of a training course in the annual training programme with a focus on engaging fathers, audits included in the quality assurance programme and activity via area groups to identify barriers.  Further consideration needs to be given as to how to most effectively work with fathers particularly where they are seen as peripheral to the lives of their children or a potential risk.  Working with resistance 5.40 There are numerous examples throughout the chronology and individual management reviews of Mother failing to engage with services and/or being openly hostile and resistant to help.  Equally, there are other occasions where she appeared to develop reasonable working relationships with individuals but still there was little evidence of sustained improvement in her capacity to provide safe appropriate care for her children.  The one organisation that that she approached consistently of her own volition for help was Surrey Police in relation to threats of violence or altercations with neighbours and acquaintances.  5.41 Mother’s resistant or avoidant behaviour is most striking in relation to the number of failed health appointments which are too numerous to mention individually.  Despite this being a known risk factor there was insufficient analysis of implications of lack of antenatal care for Mother or postnatal care for the babies.  Specific examples of resistant behaviour are: 68  Half Sibling 1 not registered with a GP until seventeen weeks old; immunisations and eight week check overdue despite reminders (similar delay in respect of Half Sibling 2)  ‘Too busy’ to see a social worker (February 2008)   No antenatal care for second and third pregnancies  Giving contradictory information to different professionals  Informing Children's Social Care that she had seen the GP when she had not  Giving unclear information to professionals e.g. note from health visitor that there was ‘some difficulty in establishing a picture of feeding from mother’  Avoiding midwives visits after the birth of Child S  Overt hostility to social work intervention after the birth of Child S  5.42 At no time is there any evidence that the cumulative effects of her behaviour were analysed in terms of potential risk nor were the reasons for resistance explored and attempts made to address them within child protection or child in need plans.  For example, it is likely that the extended family had views about social work intervention from past experience and that this would have affected the response of both Mother and Maternal Grandmother.  In such a situation resistance should have been assumed, explored openly with Mother and plans set out clearly what was expected and contingencies for situations where change was not achieved.  Discussions with Maternal Aunt confirmed that this would have been the best approach.  5.43 The eight steps identified by Ferguson (2011)12 on working with involuntary clients may therefore have provided a useful framework in this case: 1. Recognise authority and assume conflict and not co-operation 2. Encourage openness and honest expression of feelings 3. Identify what the resistance is really about and what is working well 4. Identify the dangers to the children                                                            12 Ferguson, H. (2011) Child Protection Practice. Basingstoke: Palgrave Macmillan. 69 5. Identify what is not negotiable 6. Identify what is negotiable 7. Formulate a child protection plan 8. Be clear about criteria for progress  5.44 Some workers developed particular tactics for managing Mother’s reluctance to engage.  For example, the first health visitor asked Mother to attend clinic rather than arrange a home visit and risk the family not being there with the attendant consequence that the home environment was not seen.  5.45 There were latterly examples of social workers being clear about expectations in relation to basic hygiene and being persistent in following up tasks set.  However, the work did not take place within an overall understanding of the reasons why non-cooperation was likely, all the potential risks to the children; for example those associated with alcohol misuse or lack of emotional warmth.  5.46 Working with resistance requires workers to have highly developed interpersonal skills that allow for authoritative practice (Forrester et al 2012)13.  Such skills will require workers to effectively manage their emotions in order to prevent either collusive or overly oppressive styles of interaction, yet there is no evidence that supervision in Health or Children’s Social Care explored the impact of working with resistance on the practitioner and the effect that this could have on professional responses.   Management and supervision 5.47 It is apparent that at several points in this case there were opportunities for managers and/or supervisors to make a positive difference through encouraging staff to critically reflect on their practice.  This should have included an exploration the factors that may have affected their decision making including values, attitudes, assumptions, knowledge, experience and                                                            13 Forrester, D., Westlake, D., and Glynn, G. (2012) ‘Parental Resistance and Social Worker skills’ Child and Family Social Work. 17 118-129. 70 workload.  For example the nursery staff visiting the home could have been encouraged to explore their views regarding the physical environment and their assumption that the health visitor would be dealing with any issues.  Hospital staff could have been encouraged to consider whether further follow up was needed after referrals had been made to Children's Social Care and on many occasions, health visitors and social workers could have been challenged to consider whether they were being over optimistic about Mother’s capacity to parent, their use of research knowledge to inform analysis and the correct use of child protection procedures.  5.48 The importance of effective management and supervision was particularly apparent in the case of the newly qualified social worker.  The history of the case should have led to recognition by managers that it was too complex for a newly qualified social worker without intensive support and supervision.  The management advice that a pre-birth assessment was not required was inappropriate but the newly qualified worker would not have felt confident to challenge this.  Supervision did not explore the potential implications of bruising on a non-mobile infant and support the social worker in taking positive action to safeguard the child.  5.49 The panel have received information from Children's Social Care that they are adopting the recent national guidance in respect of supporting and assessing newly qualified social workers.  This assessed and supported first year in employment (ASYE) should ensure improvements in the quality of supervision and opportunities for reflective practice in the future.  It will be important that the implementation of the ASYE year is carefully monitored including receiving feedback from newly qualified social workers regarding the quality of supervision they receive.  This is not specifically in the Children's Social Care action plan and is therefore subject of an overview report recommendation.  5.50 Health provider 2 has reflected on the lessons emerging from the review in relation to supervision practice and there is a comprehensive action plan aimed at improving the quality of supervision in the future.  71 Working effectively together within and between organisations 5.51 There are some examples of effective communication as well as a number of instances where a greater degree of positive inter- or intra- agency work would have helped to identify risks.  5.52 Surrey Police did consistently notify Children's Social Care of domestic disputes and violent incidents affecting the children.  During earlier episodes the health visitor was not informed but procedure has now changed and health organisations receive the same notification of a child at risk as Children's Social Care.  5.53 Midwifery departments in hospital also consistently made appropriate referrals to Children's Social Care when Mother was pregnant and there were clearly potential risks.  However, there was less evidence of any challenges to Children's Social Care when referrals were not acted upon.  5.54 There was some degree of misunderstanding within Children's Social Care about the purpose of a child protection conference in 2008, when the health visitor was not initially invited because they had no concerns.  Following on from child protection conferences, records do not show evidence of effective core group working.  There is little to indicate that the child protection plan was translated into a detailed working tool and that criteria for change linked to outcomes for the child were clearly articulated.  5.55 The potential importance of information held within school nurseries does not appear to have been fully appreciated by either the nursery staff or others.  The nursery did not recognise the significance of non-attendance by Half Sibling 1 and there is no evidence that the nursery was approached for information until a child protection conference was convened.  There was an opportunity at the time Mother was first pregnant with Child S to liaise with the nursery and information at this time would have revealed no concerns about Half Sibling 1’s care but a pattern of continuing absences.  It appears that there was no thought given at the point of telephone contact at the end of July 2011 between the social worker and the child protection liaison officer in the 72 nursery to ensuring that information from the nursery would be available to the child protection conference despite the intervening school holiday.  As well as lack of proactive liaison there is also evidence within the Children's Social Care records (although not mentioned within the nursery report) of a less than helpful response from the nursery when a social worker rang in early September to ask whether Half Sibling 1 was attending.  Good child protection practice depends upon positive working relationships and the detail of the interaction would indicate evidence of poor communication and problematic professional relationships between Half Sibling 1’s nursery and Children's Social Care.  5.56 Assumptions were made about roles and responsibilities with the nursery nurses visiting the home at the point of Half Sibling 1’s admission assuming that the health visitor would pick up concerns about grubby flat.  A more appropriate response would have been to contact either the health visitor or Children's Social Care to discuss their concerns.  5.57 In June 2011 no health professionals were involved in the strategy discussion despite knowledge that there were concerns about lack of antenatal care and significant health visitor involvement.  Government guidance at this time was clear that strategy discussion should include ‘local authority children’s social care, police, health and other bodies as appropriate’.14  Learning lessons from previous SCRs – barriers to improving practice 5.58 Many of the issues identified within this serious case review are similar to those that have been identified before both within Surrey and elsewhere within England.  There is little indication from the chronology that lessons from previous reviews have been used to inform practice. For example, within Surrey the Child B review in 2008 highlighted alcohol misuse, the use of chronologies and using historical records; the Child T review in 2008 noted the need for improved risk assessments particularly in situations of domestic violence and drug and alcohol misuse.  In addition more recent reviews have                                                            14 HM Government (2010) Working Together to Safeguard Children. Paragraph 5.56. 73 resulted in the Surrey Safeguarding Children Board promoting the involvement of fathers in assessments.  The social worker in July 2009 was reminded by the conference chair to consider the plan in the light of earlier serious case reviews, but there is little evidence that this occurred.  5.59 There is some evidence that the working context up to 2009 may have affected the capacity of both health and social care to work with families in line with known good practice since at this time Surrey was responding to an adverse Joint Area Review report which affected all organisations.  There was also adverse publicity regarding Children's Social Care which resulted in several management resignations, changing line management and structural change which impacted on capacity in all parts of the organisation.  These factors are likely to have affected the capacity of the organisations to learn lessons and improve practice.  However, by 2010/11 new management arrangements were in place and there was a greater degree of stability, yet child protection practice, particularly in relation to effective risk assessments and use of child protection procedures (particularly strategy discussions and medical examinations) was not evident.  Further work is therefore needed by the Safeguarding Children Board to understand the barriers to embedding learning into practice and ways of overcoming these.  6. LESSONS LEARNT 6.1 One fundamental reason for the practice problems appears to be a loss of focus particularly within Health and Children's Social Care on basic child protection practice.  Social workers did not consistently follow child protection procedures particularly in relation to conducting child protection enquiries and taking immediate emergency action when young children were found at home alone.  Appropriate medical examinations were not arranged where there were injuries, and strategy discussions did not include health professionals.  Recognition of the signs and indicators of abuse appears to be lacking in health and social care particularly in relation to the significance of injuries in non-mobile babies and health professionals did not alert Children's Social 74 Care early enough to concerns about Half Sibling 2’s failure to thrive and developmental delay.  6.2 In addition it appears from this review that the utilisation of current knowledge in relation to the overall assessment of risk is not well enough developed.  There were too many examples from 2007 through to 2011 of situations where risks were either not noticed or were not responded to particularly in relation to parental alcohol misuse and failure to engage with services.  Organisations need to therefore ensure that practitioners are aware of and use the most appropriate frameworks within their own context and that these are informed by an up to date evidence base.  6.3 The complexity of this situation undoubtedly affected responses and there is a need to support practitioners in working with complex situations where they may be many different issues to address.  This must include the opportunity for skill development in working with highly resistant families, alongside supervision which addresses the emotional impact of this work as well as allowing time for examination of the biases and assumptions that may be driving practice.  In this case there is little evidence of either the required skills or effective supervision with the result that practitioners focused on neglect at the expense of risk of physical harm and did not work effectively with Mother in relation to her failure to engage with the services provided.  7. CONCLUSION 7.1 The conclusion of this review must be that there were a number of missed opportunities to prevent the serious injuries to Child S as well as a delay in acting when injuries were apparent.  Missed opportunities pre-date Chid S’s birth with evidence that more effective risk assessments from the time of Mother’s first pregnancy may have resulted in different actions when Mother was known to have been pregnant with Child S.  In particular prior to Child S’s birth there was a failure to recognise the likely significant harm experienced by Half Sibling 2.  75 7.2 The most significant missed opportunities were:  Lack of any risk assessment at the point that Mother was charged with child neglect. This assessment could have been used to inform the decision to close the case when mother was known to be pregnant with Half Sibling 2  No action taken to assess risk when bruising was noted on the face of Half Sibling 2 who, at that point was a non-mobile infant  At the point mother was asking about adoption, insufficient attention being paid to the underlying reasons for her request and the likely impact on her capacity to safely care for Child S when she decided to keep him.   No action taken to safeguard the children who had been left at home alone and to arrange a child protection medical to examine the injury to Child S’s toe in August 2011  Failure to act immediately when the Child S was found with an injury to his finger and was clearly in pain  7.3 There is little learning about risk to children that is new in this case.  The issues that have emerged have been known for several years both from research and previous local reviews yet did not consistently inform actions.  As a consequence, many of the recommendations will focus on reminding organisations and practitioners of the knowledge and skills that should be utilised in everyday practice.  However, this needs to take place alongside a deeper exploration by the Surrey Safeguarding Children Board of the barriers that prevent known knowledge being implemented in practice.  8. OVERVIEW RECOMMENDATIONS 8.1 There was inadequate recognition by a number of professionals of the significance of the interacting risk factors in this case including: failure to engage with services, lack of antenatal care, substance misuse, domestic violence, ambiguous feelings towards two pregnancies and a troubled parental history as a child.  76 Recommendation one 8.2 Surrey Safeguarding Children Board should assure themselves that Children's Social Care, Health Organisations and those responsible for providing domestic abuse, substance misuse and mental health services to adults are using evidence based tools to assess potential risk to children and that these are embedded in practice and practitioners are trained in their use.  8.3 Practitioners did not fully appreciate the implications of parental misuse of alcohol and take action to reduce risk to the children.  Recommendation two 8.4 Surrey Safeguarding Children Board should raise awareness across the partnership of the impact of parental alcohol misuse and take steps to ensure that:  Commissioners of alcohol misuse services assure themselves that these services are fit for purpose in respect of their role in safeguarding children and that they provide advice and consultation to professionals working with children as well as direct work with parents.  The roles and responsibilities of professionals in both adults and children’s health and social care services are clear in respect of parental alcohol misuse  Specialist alcohol misuse services are invited, and contribute to child protection conferences where alcohol misuse is an issue  Child protection plans adequately address and measure change where alcohol misuse is an issue  8.5 Practitioners in Children’s Social Care and Health did not recognise the significance of bruising/injuries in non-mobile babies and the panel are aware that this is also an issue in a concurrent serious case review.  Recommendation three 8.6 Surrey Safeguarding Children Board should raise awareness regarding the significance of bruising in non-mobile babies and take steps to ensure that all 77 practitioners in partner agencies, and particularly in Health and Children's Social Care are aware of the steps to take if this is found to be present.  8.7 Practitioners in Children’s Social Care and Health did not ensure that when a child on a child protection plan sustains an injury this is examined by a suitably qualified and experienced doctor.  Recommendation four 8.8 Children’s Social Care and Health organisations should reinforce the correct use of child protection procedures where there is suspected physical abuse, including ensuring that child protection medical examinations are carried out.  8.9 Accessing mother’s own historical records presented challenges to the review team and this lack of access also fundamentally impacted on practitioners in this case.  Recommendation five 8.10 Surrey Safeguarding Children Board should require all partner organisations to review their processes for accessing historical family information and ensure that all practitioners are aware of the process and retrieve and analyse information when a parent has been in the care of the local authority, on a child protection plan as a child, or subject of a Statement of Educational Need.  8.11 This case has features similar to those found in previous serious case reviews in Surrey including: engaging with fathers, recognising the significance of family history, risk assessment in situations of domestic violence, substance misuse and working with resistant families.   Recommendation six 8.12 Surrey Safeguarding Children Board should take steps to understand the barriers to implementing learning from serious case reviews and develop a strategy to address any barriers identified.  78 8.13 Working with resistant families requires practitioners to have highly developed interpersonal skills supported by effective supervision which addresses the emotional impact of such work on the practitioner.   Recommendation seven 8.14 Surrey Children's Social Care and Community Health Organisations should review their staff development programmes and assure the Surrey Safeguarding Children Board that these include support or practitioners in developing and sustaining skills in working with avoidant families.  Recommendation eight 8.15 All organisations should ensure that practitioners receive effective supervision which enables them to reflect critically on the factors that may be impacting on their practice including the emotional impact of the work, personal biases and intuitive responses.  Recommendation nine 8.16 Surrey Children's Social Care should ensure processes are in place for monitoring the effectiveness of the ASYE programme which includes a focus on the appropriateness of case allocation and the quality of supervision and management oversight in individual cases.  8.17 When the case was closed to Children's Social Care there were missed opportunities for a more structured approach to the assessments undertaken and help given to the family.  Recommendation ten 8.18 Surrey Safeguarding Children Board should promote the use of early help assessments.  Health organisations in particular should ensure that these assessments are routinely used where there are concerns about a child and inform decisions about when a referral should be made to Children's Social Care.   79 Recommendation eleven 8.18 Surrey Safeguarding Children Board should require partners to ensure that when a case is closed by Children's Social Care but support is still required, “step down” procedures ensure that appropriate help is provided to the family underpinned by a clear outcome focused plan.  9. INDIVIDUAL MANAGEMENT REVIEWS RECOMMENDATIONS  Ashford and St Peter’s Hospitals NHS Foundation Trust 9.1 Ensure that a robust system of delivering and monitoring safeguarding supervision is developed and implemented in the organisation  9.2 Improve training and awareness in safeguarding updates to view the patient receiving antenatal care holistically and not in isolation.  9.3 Review and redevelop maternity documentation that supports a holistic approach during the antenatal assessment.  9.4 Review and raise awareness of best practice guidelines for documentation.  9.5 Review and strengthen the management processes within the organization for patients who ‘did not attend’ appointments and late antenatal bookings.  9.6 Development and implementation of internal referral form for Named Midwife and Named Nurse.  9.7 Develop a system to enable all referrals that are made to external agencies can be tracked and monitored.   Central Surrey Health 9.8 Review safeguarding supervision within Central Surrey Health  9.9 Establish clear understanding of roles and responsibilities when providing Safeguarding advice and support to practitioners. 80 9.10 Review safeguarding training provision within Central Surrey Health.  9.11 Review family health needs assessment  9.12 Review current links and care pathways between Health Visiting service (0-19 teams) and local maternity units.  9.13 Evidence that the organisation has a robust process for following disciplinary processes where there are concerns regarding professional practice or record keeping.   Elmbridge Housing Trust 9.14 All front line officers involved in housing management at Paragon CHG undertake regular Safeguarding training.  9.15 Managers in all agencies work more closely together and encourage greater liaison at the front line.  9.16 Tenancy Service Officers ensure they undertake and record all Starter Tenancy Monitoring visits in first year of the tenancy.  9.17 Any incomplete referral for temporary or permanent housing be returned to the originator for completion of all background information  Surrey Children’s Services 9.18 A chronology to be started at an early point in the life of the case and to be a piece of ongoing work and a tool for analysis and supervision.  9.19 For supervision notes to address each aspect of the plans and record the risks and to outline a clear plan of work.  9.20 Where there are issues of domestic violence and alcohol abuse for cases not to be closed until the parent has provided clear evidence of a sustained commitment to change. 81 9.21 Where a parent of a child referred to children’s Services has themselves been known to the Local Authority as a consequence of Child Protection concerns, has been on a Child Protection Plan, or Looked After:  Their own early history should be examined with a view to an assessment of their own patterns of childhood attachment.  9.22 For training to be delivered to workers about disguised compliance.  9.23 For training and assessment tools to be available to workers in the effects of alcohol abuse on parenting that enables them to understand how they can address these issues without reliance on specialist agencies.  9.24 For supervision to retain a focus on the difference between the child’s presentation and the parent’s behaviour so as to enable workers not to be deceived by one into believing that the other is not problematic.  9.25 For an effective system of liaison between transferring and receiving teams to be established to minimise hiatus and re-evaluation.  For instance to enable family support workers to continue visiting during the handover period to enable the same frequency of visiting during allocation processes.  Surrey Education 9.26 Consider if systems can be developed to monitor and manage poor attendance of early years children under statutory school age in both the maintained and PVI sector.  9.27 Evaluate and monitor new non-attendance process for early years.  9.28 Ensure all early years settings have sufficient processes in place to provide adequate responses during holiday periods for child protection matters.  9.29 Evaluate effectiveness of the current information gathering and sharing processes used by early year’s settings.  82 9.30 Develop the tools necessary to ensure a consistent approach across all sectors.  9.31 Joint working between Early Years and Children’s Services of placements in high quality early years settings for LAC and CIN children.  9.32 Early years sector management to review record retention procedures by all categories of early years settings to ensure DPA is observed and complied with.   Surrey GPs 9.33 All GP practices have an in-house protocol for the appropriate follow-up of children whose parents/carers repeatedly failure to attend for planned appointments, including immunisations,  9.34 All GP practices are aware of appropriate Read coding and data entry in relation to current and past safeguarding children concerns.   Surrey Police 9.35 The Head of Public Protection should ensure that all PPIU staff including supervisors and managers receive appropriate specialist training to equip them for investigating incidents of domestic abuse.  9.36 The Head of Public Protection should ensure all officers employed in the role of PPIU supervisor have received appropriate training to enable them to carry out / review DASH risk assessments and identify cases that should be referred to a MARAC.  Virgin Care 9.37 That all Virgin Care 0-19 practitioners are able to utilise a child focused family needs assessment tool to determine plan of health intervention. 