Neglect of a 17-year-old boy, who was admitted to hospital in November 2020. Young Person S was presented in a poor physical and mental state, and was transferred to a psychiatric hospital where he was assessed as experiencing first episode psychosis. Learning includes: the importance of multi-agency professionals understanding mental capacity and applying the law in relation to an individual's decision-making; assessing parenting capacity with multi-agency input; understanding parental and adolescent mental health and its impact on the family, and the need for a Think Family approach; understanding domestic abuse across familial relationships; the importance of multi-agency input into assessments and safeguarding strategies prior to case closure; when engagement is not easily achieved, the need for professional curiosity about why a family may not be engaging; the importance of seeing children, including seeing them alone, when there are worries about a child's welfare. Recommendations include: the development of a Think Family protocol; partnership organisations have the necessary processes in place for shared responsibility of child and adult safeguarding, including systems for information sharing; auditing the quality of child and family assessments; case closure processes ensure the rationale for closure is recorded, and outline what is expected practice when there are difficulties engaging with families; government officials consider the impact of legislative restrictions on elective home education, and how these can potentially leave young people more vulnerable.
      
 Title:  Young Person S – local safeguarding practice review. LSCB: Bexley S.H.I.E.L.D. Author: Deborah Angus Stewart Date of publication: 2022  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         Young Person S – Local Child Safeguarding Practice Review  Bexley S.H.I.E.L.D. Independent Reviewer – Deborah Angus Stewart– November 2021  This final report completed by: Amanda Gillard (Practice Learning and Review Manager, Bexley S.H.I.E.L.D., March 2022)             2  Foreword  This report includes the findings and learning as identified by Deborah Angus Stewart (Independent Reviewer) who was commissioned by Bexley S.H.I.E.L.D. to complete an independent Local Child Safeguarding Practice Review (LCSPR).  While the focus of the review was primarily on Young Person S, the reviewer considered findings in relation to how services responded to all individuals in the family and how this impacted on Young Person S. This report therefore references professional involvement with other members of the family where relevant. Introduction     This LSCPR was conducted in response to concerns about the neglect of a 17-year old young man (Young Person S). There was concern regarding how agencies worked together in the context of Young Person S’s neglect, isolation, mental ill health and poor educational development.  At the time of the incident Young Person S lived at home with his parents Mr S and Mrs S and his two sisters Ms T (19) and Ms V (16).  The family were known to Police, Education, Primary and Secondary healthcare services, Children’s and Adolescent Mental Health Services (CAMHS), Children’s Social Care, and Adult Mental Health services. At the time of the notifiable incident, Young Person S and his sister Ms V were not open to Children’s Social Care.   There had been involvement from CAMHS and Children’s Social Care some months prior to the incident.  Young Person S was past compulsory school age at the time of the notifiable incident and contrary to what was understood, was not in education or training (NEET).   Young Person S and his sister Ms V (aged 16) were not open to Children’s Social Care at the time of this incident. Ms V was in regular school attendance and receiving pastoral support in school.   The family came to the attention of police and the London Ambulance Service in November 2020 due to Ms T reporting that her brother had been acting aggressively toward her and that his mental health was apparently deteriorating.   Police and ambulance crew in attendance to the home, observed Young Person S to be in a poor physical state and were concerned about his environment and for his mental health which they decided needed to be assessed at a hospital.    Young Person S and his father were escorted to hospital. While waiting for assessment Young Person S left with his father, before a thorough assessment could be completed.   3  Young Person S presented again the following day to hospital A with his father and was noted to be mute, hypertensive and tachycardic.   Young Person S was transferred to a psychiatric hospital (Hospital B) for further assessment and was assessed as experiencing a ‘First Episode Psychosis’.  Staff were concerned about the physical and mental state in which he arrived and considered that this would not have developed over a short period of time. The hospital therefore questioned what involvement there had been with other agencies, and the level of assessment and monitoring which had been in place. Hospital B referred the matter to Bexley S.H.I.E.L.D., the safeguarding partnership for children and young people.  The matter was referred to the Child Safeguarding Practice Review (National) Panel as a notifiable incident due to concerns about multi-agency working in the community. A Rapid Review was convened, and the outcome was to recommend a LCSPR although the Rapid Review also identified learning for Adult Services. Terms of Reference  The time period for the review is from March 2017 to November 2020. This was to allow for consideration of Young Person S’s experience of secondary education and to better understand the family’s involvement with other agencies during this period and up to November 2020 when the serious incident was reported.   This included an expectation that where relevant additional historical information prior to this would be summarised when this provided context to the analysis and findings of this review. Some of the information in this report includes reference to other members of the family.  The Learning from Practice Group met to agree the scope of the review and requested specific information about the following areas: • The identification and response to risk (individually and on a multi-agency basis) for the parents and the children including the following areas: parenting capacity, mental health, parental conflict, domestic abuse, and resistance to engagement. • Assessing the children’s lived experience and the capturing of the voice of the child.  • Practitioners’ understanding of policies and procedures and how they support their work – e.g. mental capacity.  • The extent to which the current Covid-19 crisis has impacted on the circumstances of Young Person S and his family and on the capacity of the services to respond to their needs.  Approach  Information was gathered by way of individual management reports, chronology of involvement and via reflective discussions with practitioners as part of a Learning Event. This included representatives from across the partnership who had most  4  recently been involved with the family as well as others who had historical knowledge and involvement.  Family Participation  The child’s parents and young adult siblings were informed of the decision to carry out a Child Safeguarding Practice Learning Review and were invited to meet with the review author and a member of the review panel. However, neither parent responded.   Young Person S did not have capacity to engage at the time.   The allocated social worker to Young Person S was kept informed and asked to share any learning. The process was supported by the Learning from Practice Panel members.   The siblings to Young Person S were also invited to meet with the reviewer but declined preferring to be kept informed by their social worker and support worker.  Both siblings to Young Person S have been written to by the Safeguarding Partnership detailing what changes have been made as a result of the learning from the review. Immediate Steps Taken   Following the initial referral into the S.H.I.E.L.D. partnership, a case mapping was completed to provide an opportunity for practitioners and managers from Children’s Social Care to reflect on what was known about the family and to ascertain the needs of the children Ms V aged 16, and Ms T aged 19 who at the time remained living in the family home.   The case mapping provided opportunity to signpost Ms T (19 years) to support from housing, and advocacy, and SOLACE (Domestic abuse services) to ensure she had access to the necessary support.  A Child and Family Assessment was initiated in respect of Young Person S and Ms V and arrangements made for regular review from senior management.    An Initial Child Protection Conference was held and Young Person S and Ms V were both made subject to child protection plans.   Following psychiatric assessment, Young Person S was placed under Section 2 of the Mental Health Act. Legal steps were taken to secure his treatment plan beyond the initial 28 days and care proceedings were commenced.   Legal planning commenced in respect of Ms V (16 years) and she was made subject to an Interim Care Order in January 2021.   Ms V was offered alternative care arrangements, and with support from the allocated social worker and with preparation was agreeable to move to live with foster carers.   5  Mr S was eventually rehoused following ongoing conflict between the parents and Mrs S was offered a treatment plan from adult mental health and monitored closely by her treatment team  In February 2021, S.H.I.E.L.D. jointly with the Adult Safeguarding partnership and senior leads in Adult Social Care, Adult Mental Health and Children’s Social Care met to reflect on the immediate learning identified through the Rapid Review process. It was agreed that there was learning for how the multi-agency network had responded to and worked with the family.   A recommendation was made to immediately draft and develop a ‘Think Family Protocol’ together with a training schedule to support the implementation of this approach and to highlight the learning across the partnership. The protocol was completed and jointly overseen by the Adult’s and Children’s Safeguarding Partnership Teams and launched in October 2021. This compliments the existing Signs of Safety Practice model adopted by Children’s Social Care.   Mental Capacity Training and Care Act training were made readily available and joint Training for Children’s Social Care and Adult Services was scheduled for 2021. This is ongoing.  What is ‘Think Family’ workshops took place as part of the Multi-Agency Learning Forum in Spring 2021 and which is responsible for the dissemination of learning and continual review of impact of the learning from reviews. Summary of Professional Involvement  Background history The family have come to the attention of Police, Children’s Social Care, and health services in Bexley since 2001 as a result of Parental Mental Health, and conflict in the parental relationship and the impact of this on their capacity to parent.  At the time of the review there was limited information about the parents own childhoods and social histories in the assessment reports completed.   Mrs S (mother), is diagnosed with Paranoid Schizophrenia. She has experienced periods of instability since 1994, when she was first detained under the Mental Health Act, with further admissions in 2007, 2015, 2016 and 2019.   It is known that the mother has accessed in-patient treatment voluntarily on occasion but in the main has required treatment under section in crises as a result of not taking her medication and or refusing to access the recommended help in order to manage her mental health.   At the time of the review Mr S (father) engaged consistently with the family GP in managing his medication due to his diagnoses of Schizophrenia and recovery from a history of drug use, although he was not accessing any therapeutic services, to help with his mental health.    6  The family were all registered with the same family GP for the past 16 years.  The family have come to police attention historically due to incidents of parental conflict, and in recent times in 2019, and 2020, when the mother has been experiencing mental health crises.   Young Person S was subject to a child protection plan in 2004, under the category of neglect and again in 2012 under the category of emotional and physical harm.   Young Person S had been known to CAMHS in 2018, 2019 and 2020.  Child protection plans were in place for all three children in 2012, with Young Person S and his sibling Ms V moving to live in Essex in 2013 and being placed on Child in Need Plans.  Ms T was moved to a Child in Need plan in 2013.   All three children had been subject to Child in Need Plans following concerns about the mother’s deteriorating mental health in May 2015, and then closed three months later due to non-engagement.  Young Person S had previously attended 4 schools; including one school in Essex and had experienced two periods of Elective Home Education (EHE)  and one period of being a ‘child missing education’.  Ms T (Sister to Young Person S) at ages 17,18 & 19 independently requested support from health, housing, and Children’s Social Care, and accessed support from Child and Adolescent Mental Health Service.   Children’s Social Care have completed six separate child and family assessments between 2014 and 2020, and prior to this reported serious incident.   Four assessments had taken place within the scope of this review, in 2018, 2019, and 2020. Each assessment concluded with no further action aside from one referral to the early help service in 2019, but the parents declined any support.   The parents to Young Person S, Ms T and Ms V did not accept that any of the concerns raised in any of the assessments warranted Children’s Social Care support and declined offers of support from Children’s Social Care and/ or early help services.  During the course of this review and prior to in the practitioner event held in November 2020, Children’s Social Care and other agencies reported that Mrs S experienced difficulties in engaging with professionals and she could be avoidant, hostile on occasion, obstructive, and dismissive of concerns.  Mr S did on occasion report concerns, but was reported to be inconsistent in his approach to engagement with Children’s Social Care. This is explored further later in the report.     7  Key Episodes January to May 2017 Mrs S had elected to home educate Young Person S in 2013, while living in Essex, but Young Person S returned to school in Bexley in 2015.   Between January and March 2017 Young Person S experienced internal exclusion for defiance; being intimidating; continued rudeness; verbal abuse to staff, and disruptive behaviour. He was at this time however, reported to be working well with his studies.   Mrs S was notified on every occasion with regard to Young Person S’s challenging behaviour and according to the school, she responded by wanting to home educate Young Person S, although the school were never sure of her rationale.   When Young Person S could communicate and was withdrawn from school by his Mother to be educated at home, it was not evident that he was given the right to choose the location for his education or the nature of any educational provision; or if he expressed his views as part of the process.   Young Person S began a second period of home education in Bexley from March 2017. He had also experienced a period of home education in Essex in 2013.  There was limited information sharing between Essex and Bexley in relation to Young Person S’s home education, at the point when Young Person S returned to live in Bexley.   After an unknown period, he stopped going out and had no independent access to friends or professional agencies, thus his isolation grew, as did the potential for his neglect.    The Elective Home Education (EHE) Service in Bexley operates in line with the DfE guidance, April 2019, and has contributed to the recent London Councils submission to the Education Select Committee on EHE. This Review is advised that parents can declare home education at any time, as allowed by legislation and that when the EHE Service become aware that parents are considering home education, a discussion is held to ascertain the reason, and if there are any issues with school attendance; school support or behaviour issues, then the service offer to liaise with relevant professionals to try and overcome any difficulties, usually resulting in the child remaining in school.   The EHE service advised the reviewer that when parents first declare EHE, they are provided with information about learning resources, GCSE examination centres, and Youth Advisory Services. Following this, parents are contacted within 3 weeks to discuss provision, followed by an education review.   In relation to Young Person S, EHE was confirmed by Education Services on 4th of April 2017. This was within the expected time frame of 3 weeks of when EHE period commenced.  In the meantime, Mr S was noted by the GP to be suffering from fatigue, whilst Mrs S was due a mental health review that month. It would appear that EHE, education services or schools were not aware of parental mental ill health, and there is no evidence that any information was shared in relation to mental health at this point.  8  On the 4th May, an EHE Review meeting was held at the family home with the EHE Officer, Young Person S, and his mother. This was within expected time frame of 12 weeks from declaration of EHE. The Officer decided that the home education in place was ‘suitable and in place’. A range of educational resources were shared, and Mrs S advised the officer that Young Person S enjoyed maths and cookery.  It is not clear if the officer concerned spoke with Young Person S individually to hear his views.   A second visit, in the form of an educational review, was scheduled but did not take place due to human error, but support was offered via letters, which was rejected by the parents.   This resulted in a missed opportunity to seek assurance of Young Person S’s education and wellbeing. Parents are encouraged to contact the service should the situation change, or they require support. Neither parent contacted the service, and it is highly unlikely that the mother would have done so given her history of engagement with services overall, and there was a strong possibility that the father would not have gone against Mrs S’s wishes.  There was confusion about the length of time Young Person S had experienced EHE, Children’s Social Care believing it to be two years when it transpired to be nearer four years.   When Young Person S was moved by his mother into EHE, the School advised the Review that there was a was a lack of awareness that he was a ‘vulnerable’ child, and records did not indicate Children Social Care involvement at the time. However, as acknowledged by EHE Services in Bexley, there was a missed opportunity to monitor any progress and or his developmental or support requirements – which was likely to have contributed to Young Person S’s isolation, his poor educational attainment, and the potential for neglect. This was a systemic error which they have now remedied.    In the Spring 2017 Ms T was diagnosed with depression and was receiving support and treatment from the GP and CAMHS, and was discharged in June of 2017. This period coincided with Mrs S’s decision to withdraw Young Person S from Secondary School, and was during the period of disruptive behaviour exhibited by Young Person S.  It is not clear what enquiries would have been made when deciding on whether to challenge a request to home educate at this point. It is possible that the GP and Children’s Social Care were not made aware of Young Person S being home educated at this point.   Current practice in Bexley does not support home education for children and young people who are open to Children’s Social Care and subject to Child in Need or Child Protection plans.   All parents opting to home educate their children are encouraged to access social activities with other families who home educate to ensure young people have the opportunity to meet with their peers, although this is voluntary and dependent on individual choice.   9   It is acknowledged that at the time of a request for home education, there were no apparent and current mental health issues reported in relation to the parents which would have been seen to impact on home education. However, the older sibling had presented with depression, and there had been a long history of instability within the home due to the mother’s poor mental health. There had been conflict in the home and allegations of physical abuse and domestic abuse over many years, and this ought to have been considered in the context of how conducive home education was and how stable this situation would be for Young Person S. As Young Person S was not open to Children’s Social Care at this particular time, there was no expectation it seems from agencies that there should be any multi-agency liaison.  There was limited information sharing between agencies about mental health within the household, which resulted in a fragmented understanding of the potential risks and disruption to Young Person S.   Key Learning The assessment to determine whether home education was suitable for Young Person S or not would have benefited from information from health services including adult mental health. In the event that there were no grounds to open Young Person S to Children’s Social Care, there would at least have been more awareness across the partnership agencies of his situation, support needs, and potentially the needs of the siblings.   Key Episodes 2018  The GP who monitored Ms T, was aware that her low mood remained, and she was re-referred to CAMHS in January 2018. The latter was a missed opportunity to explore why she had a low mood, and or to consider any other referrals.  By May 2018, Ms T had reported to the housing department and Children’s Social Care that she was homeless; was unhappy at home; that her mother was aggressive and that she had been a young carer since she was 13, (then aged approximately 17) but the case was closed without further action.   This presentation did not prompt a Young Carers assessment which was a missed opportunity to consider Ms T’s needs and possibly Ms V and Young Person S’s roles within the home, and particularly in light of both parents being known to the GP and adult mental health services due to ongoing mental health issues There was limited curiosity into the domestic abuse which may have been occurring within the household, and the physical and emotional impact of this on other children in the home.   Ms T was seen by CAMHS in July 2018 and in September 2018, Ms T attended a Local Emergency Department with suicidal ideation; having taken a small overdose of paracetamol tablets and refusing to return home. She was admitted to an Adolescent Mental Health Unit where she stayed for a week.    By 1st October 2018 Ms T was receiving weekly support from CAMHS, and a Child and Family Assessment was commenced following Ms T’s admission to hospital.   10  Children’s Social Care identified in this assessment that Young Person S had been out of formal education ‘since 2015’.  Therefore, by this time Young Person S had been out of education for a total of nearly 4 years, given he also experienced a period of home education, while living in Essex.   Children’s Social Care appropriately recorded in the Child and Family Assessment their concerns about Young Person S not being seen by professionals ‘on a regular basis’, and that his ‘academic level (was) unknown’.   The Child and Family assessment noted that ‘If Young Person S does not receive appropriate support regarding his education, he may not achieve his potential’.   Ms T and Ms V reported that Young Person S was not receiving education in the home.   In November 2018, The Child and Family Assessment was completed, and transfer was made internally to the Family Wellbeing Team, which would be expected practice when families require ongoing support, and do not meet the criteria for statutory intervention. The family did not access any of the support recommended, and the family were noted as not being willing to engage. The case was therefore closed.   The family GP was made aware of the referral of the family to Family Well-being. There was no update as to whether the family had engaged or not, so it is possible that the GP had assumed the family were being supported.  Key Learning Ms T would have benefited from a referral for support in relation to domestic abuse and a DASH risk assessment being completed. This is current expected practice. (Multi-agency DASH risk assessment training has been rolled out to partnership agencies in Bexley during 2020 and 2021 and is now mandatory training).   Decision making regarding next steps at the end of the assessment in 2018 would have benefited from more in-depth reflection in supervision and or via management oversight, as to previous involvement, patterns of engagement and the history of concerns. There was limited multi-agency input in order to determine whether or not statutory services would have been more proportionate at this point.   It appeared that Ms V was known to maintain good school attendance and worked well, but there was little curiosity evidenced in relation to how parental mental health, her brother’s difficulties, and the domestic abuse which was occurring maybe affecting her daily experience of living in the household. This raised pertinent questions of how; when and if, her needs were considered sufficiently in 2018 and or in previous assessments  Previous assessments did not focus sufficiently on the individual experiences of all the children and adults within the home and or how mental health and conflict would be impacting, particularly in relation to Young Person S’s education and personal development, despite Children’s Social Care identifying his social needs and obvious isolation.    11  The approach to the assessment and limited input from other agencies resulted in what could be considered as premature closure of the case and limited support being provided to the children in the family.   Key Episodes 2019 Police, CAMHS, the GP and Children’s Social Care were all involved with the family in 2019.    The family came to the attention of police in February 2019 following a family friend reporting that Young Person S had made comments to them about abusive behaviour from Mr S towards his sister and that Mr S had been giving Young Person S medication. A Sec 47 enquiry took place but no offences were deemed to have taken place and the outcome of the enquiry was ‘no further action’.   Police have since confirmed that all the young people concerned were interviewed in relation to allegations. At the time of the enquiry it is not clear whether Young Person S and his siblings were seen away from the home and this is not detailed in the records provided.   The review considered the potential significance and importance of this in the context of the children feeling able to speak freely within the home due to the fact it was known the children had previously spoke of being actively discouraged from speaking with professionals, and due to the fact that there had been domestic abuse and what is now considered incidents of coercion and control.   A Child and Family Assessment followed. Young Person S was not seen during the course of this assessment, and again concerns were raised regarding his isolation and not being in training and or college; him not receiving appropriate education from parents.  A Children’s Social Care social work visit took place on 1st March 2019, and concerns were raised about Young Person S being home schooled, as it appeared to the social worker that he was not receiving appropriate education and was isolated. A further home visit was arranged, but no action taken to consider his post 16 education.    In April 2019, at a scheduled home visit, Ms T and Ms V disclosed to Children’s Social Care that their brother, was not leaving the house; would not talk to anyone and could be violent and aggressive. It is not evidenced that any referrals were made to SOLACE (domestic abuse support provider) in respect of the siblings reports about Young Person S’s behaviour towards them from Children’s Social Care.  In accordance with expected practice, the visiting social worker tried to talk with Young Person S, but he refused to come out of his room. The social worker raised concern about Young Person S with his father at the visit, who advised the social worker that Young Person S could do what he wanted, and it was nothing to do with Children’s Social Care.   A joint visit with CAMHS and Children’s Social Care also took place in April 2019, CAMH’s recommended that Children’s Social Care offer support to Young Person S  12  to access social and educational activities. CAMH’s recommended to Children’s Social Care that there needed to be more work completed with the family. They did not consider they were in a position to support Young Person S further without there being input from Children’s Social Care in the first instance.   This indicated that there was a need to work with the parents and Young Person S in order to address concerns rather than to just focus on the perceived therapeutic needs of Young Person S.  Children’s Social Care closed the case in May 2019 and report that the family were not willing to accept advice or support. This was a further missed opportunity to consider whether in light of the history there was cause for Children’s Social Care to adopt a more assertive approach.  Throughout 2019, Mrs S continued to attend GP mental health reviews and receive treatment from the GP, for continued low mood.    In early September, Mr S called the ambulance service worried about his wife’s mental health, noting she appeared dazed, and was observed walking up and down the road exhibiting poor mental health.   Ambulance services referred the incident to MASH, who undertook various checks, and the outcome was ‘no further action’. This was a further missed opportunity to explore the family situation and to consider what support may have been required by the children and young people in the household.  Three weeks later Mrs S was admitted to a mental health hospital with confusion following substance abuse. It is not evident that a referral was made to Children’s Social Care on this occasion in respect of any concerns with regard to Young Person S, Ms T and Ms V. Ms T may also have required support from adult services.   Mrs S had been reported to be non-compliant with medication in 2019, largely by her husband. She denied using substances but tested positive for cannabis. On discharge from her hospital admission, professionals were unable to engage with her in the community, (albeit Intensive Care Coordination from Oxleas Mental Health Trust was in place from 3rd October until June 2020 and the Home Treatment team tried to assist in July 2020).    The GP and the practice staff engaged in prompt communication via phone and email with Adult Mental Health Services, and with Children’s Social Care and CAMHS, and worked hard to provide the assistance, protection and healthcare required by all of the family members.   The GP added notes to all family member’s records, particularly in relation to alleged abuse from Mrs S to Mr S.   During late October, Bexley Youth Advice Service made a follow up home visit to Mrs S regarding Young Person S’s September choices, and she advised them that he was at College A, studying sport, which was not the case.  An external visit to the doorstep of the home was an opportunity to be professionally curious, and whilst it is not normal  13  practice to doubt a parent’s word, Bexley Youth Advice Service have adjusted their documentation to explicitly prompt community callers to consider if there are any safeguarding concerns. This aligns with the same process as EHE officers and connects to Bexley Youth Advice Service’s regular training around safeguarding matters.  Key Learning The events described above highlights learning in relation to creating the right conditions to ensure young people can where possible speak of their own experience, wishes and feelings, and be a part of decision making.  It also highlights the importance of the voice of the child and it would be prudent for professionals from across all partnership agencies to reflect on how professionals made sense of the information shared by the siblings during visits, and through individual interviews.  Young Person S was deemed to have capacity and to be able to make his own decisions, but it is difficult to understand how this view was reached when he had not been seen by the social worker and or CAMHS for any period of time.  The decision by CAMHS to discharge Young Person S, coupled shortly later, with the Children’s Social Care decision to end their involvement, left Young Person S and the family unsupported, albeit parents were offered the chance to call CAMHS, if circumstances changed.   Given parental history of a lack of engagement, and what appeared at times to be fear of services (on behalf of Mrs S) and her domination in the family - it would seem unlikely that she would have requested help.   Mr S may have been a more reliable source, but given the circumstances, disagreements, and domestic abuse allegations, there could have been more healthy scepticism about the parent’s reporting they needed support.  Mr S’s capacity to engage openly and honestly about what was happening in the home was inconsistent.  Adult mental health services responsible for the mother’s care while in hospital could have demonstrated more curiosity into who else was in the home and what support might be required upon her discharge. There was no consideration of the children’s needs on this occasion and no action taken to ensure the children would be supported, and or liaison with other services who would have been best placed to assess the home situation.  A referral to Children’s Social Care or at the very least sharing of information would have been expected good practice.  This would have again flagged the instability in the home and potentially have identified support needs for the children individually and also in respect of Mr S. The role of Mr S in relation to parenting and his capacity to ameliorate stress in the home is not addressed sufficiently in previous assessments, and therefore it remained unclear as to his capacity to safeguard.   14   Referrals were not made to SOLACE by GP and or Children’s Social Care, and or from Adult Mental Health Services.  DASH assessments were not completed by Children’s Social Care and or any other agencies following disclosure of violence from Young Person S to his sisters, which was a missed opportunity to better understand the home situation.    Key Episode 2020  In early February, Mr S raised concerns with the GP about his son’s behaviours and requested a home visit. The GP made an urgent referral to CAMHS, which was good practice. It was discussed on the day of receipt, which was also good practice, and between the 12th and 14th February four phone calls were made to gather information (three to Mr S and one to MASH).  As a referral to CAMHS was in progress it was agreed to await this and no home visit was made.  Between the 12th February and 23rd March, CAMHS made twenty-nine contacts to ascertain information about Young Person S (twelve family phone calls; nine social care contacts; three home visits; three texts and response to two crisis line calls).   Mr S had contacted Crisis Line on the 18th February reporting Young Person S was being aggressive and urinating on the floor. It is believed that a CAMHS Doctor visited Young Person S the next day, but he refused to engage and consequently, was not seen.   Mr and Mrs S gave background history about their 17-year-old son, and expressed current concerns, stating he had been ‘expelled’ from school (which was not true); Parents advised Young Person S was urinating in his room and the garden; had reduced his self-care; had increased anxiety about leaving the house and that he was laughing without explanation. It was also noted that he was increasingly violent to Ms V. Parents noted his big appetite, cooking for himself and enjoying painting and decorating.   CAMHS completed a genogram; noted relationships and parental mental health; conducted a risk assessment and considered the risk of exploitation and self-harm as low for Young Person S, and set out a safety plan for him.   Following this meeting, CAMHS decided Children’s Social Care support would help the family, and that Young Person S presentation was likely to be linked to social isolation; a lack of meaningful activity and the way in which he was being supported at home. Questions about his access to training and or post 16 education were not explored in detail, and there was no exploration of his aggressive behaviour within the home and towards his sisters  At the end of the month CAMHS made a referral to the Family Wellbeing service (with parental consent) and made a follow up call to MASH, to share information and request advice. They also made daily checks with the parents about Young Person S and progressed the referral to Children’s Social Care, all of which was good practice.        15  On the 22nd February Mrs S called police saying Young Person S was throwing glasses down the stairs and urinating, advising she was scared to approach her son. No police action took place, but a (MERLIN) report was shared with Children’s Social Care. Police have advised that a DASH Assessment should have taken place.  On 25th February an alert was received by Children’s Social Care, from a neighbour saying that Young Person S was indecently exposing himself.   By the 28th February, the police and CAMHS referred Young Person S to Children’s Social Care.   Children’s Social Care acknowledged concerns about Young Person S’s behaviour and the difficulties in management of him in the home, his isolation and the fact he was not in any training. On the 5th March, a joint visit between CAMHS and Children’s Social Care took place.  CAMHS were by now aware that Young Person S had not started college the previous September; that he had limited support from Youth Advisory Services (mainly letters) and that he was not leaving the house; refusing to meet professionals; had no contact with anyone outside of the family; and had no phone and was extremely isolated and anxious.     CAMHS visited Young Person S again on the 28th of February, and again, he did not engage. Both parents were present. CAMHS advise that they did not wish to pressure Young Person S, and accepted his resistance to engage to prevent distress or behavioural escalation. Parents advised of recent improvement, seemingly not urinating in his room; nor laughing to himself at night, sleeping well and having a new bed.   They reported speaking positively to him; offering him more reassurance and seemingly saying that they wondered if this had helped. He was seen by the visiting doctor using a downstairs toilet but then returned to his room, and it was thought Young Person S was listening upstairs.    A plan was made, with parental agreement to pre-empt crisis: which was for them to encourage Young Person S to join activities; give him feedback for positive behaviours: spend time with him thinking about his future, and to provide gentle encouragement for him to go out. This was accepted and parents also agreed to the joint visit from CAMHS and Children’s Social Care on the 5th of March.  A further referral was made to Children’s Social Care due to poor mental health and behaviours, and a Child and Family Assessment commenced.   The GP contacted CAMHS to follow up on the original referral, which was good practice, and was advised that Young Person S case was still being assessed.  On 5th March the joint visit took place. The CAMHS Doctor was aware of the family history from the NHS RIO system – which was good practice. Young Person S did not engage and remained in his room, was not seen and did not speak, even through the door.    16  The CAMHS Doctor assessed Young Person S as presenting with acute social withdrawal and isolation but did not believe Young Person S to be psychotic. Mr S reported that his son was mugged at 14 and then stopped going out, and that he (Mr S) became paranoid when he went out, and that Young Person S ‘may have picked it up from him’. Mrs S added that she became anxious in large crowds.  The CAMHS Doctor noted that Mrs S ’s admission to hospital in September 2019 may have impacted on Young Person S not accessing further education and considered that Young Person S’s social withdrawal and social isolation made sense in context of the information received.   The CAMHS Doctor believed that targeting this, and enabling Young Person S to move into education, was the preferred approach. Later, the case was discussed with the CAMHS clinical Lead, and it was decided that Young Person S could be discharged to the care of his GP and that Children’s Social Care could re-refer if necessary and parents also agreed to contact CAMHS, the GP or Children’s Social Care if Young Person S deteriorated.   The GP practice had signposted Mr. S to domestic abuse services and were aware that both parents (particularly Mrs S) would raise concerns, and then push help away - and initially, when Mrs S refused to give consent for CAMHS to share information with other services, Mr S had consented. CAMHS advise that professionals rely on those with parental responsibility to seek support and that in the past, Mr S, had done this, and shown he could be proactive by going to his GP. It was acknowledged by them that his efforts were not always consistent).    It is positive that the GP referred Mr S to SOLACE for advice and support in relation to being a victim of domestic abuse. It was known at this point that there were three young people in the household also, but there was limited reflection on how domestic abuse may be impacting on them which left all members of the household vulnerable.  When Mr S was referred to SOLACE, regarding domestic abuse, there is acknowledgement that a MARAC referral should have been pursued; that children’s details should have been gathered and a MASH referral made for them.   On the 6th March, CAMHS held a professional discussion with Children’s Social Care, which was good multi-agency practice. Children’s Social Care offered to write to Young Person S, to arrange to meet him, away from his home, and to consider a referral for mentorship.   Children’s Social Care at that point seemed to recognise the need for intervention and to be assertive and planned to complete a Child in Need Plan, aware they could return to CAMHS for assistance, if required.   CAMHS closed the case and parents were contacted, and advised of the plan to support Young Person S, which was good practice.   Both parents agreed with the proposals, and a discharge summary was sent to the GP, Children’s Social Care.  and the family, all of which was good practice.      17  On the 24th April, Mrs S contacted Children’s Social Care, reporting Young Person S had very much improved; stating he was now coming downstairs; cooking; going out in the garden; joining the family for conversations and that there were no current concerns.   The social worker asked to talk to Young Person S, but this was refused. Children’s Social Care had previously noted that Young Person S was not engaging; nor accessing appropriate education ‘despite support and encouragement from parents and professionals’ and that he ‘appeared to have capacity and ability to make choices for himself’ and that: ‘his parents demonstrated an understanding of his difficulties and continue to support and encourage while monitoring his health and wellbeing’.    On the 29th April 2020 the Child and Family Assessment was complete and the family were sign posted to the Well Being Service, but they refused support. The case was subsequently closed.    CAMHS advised that when clinicians were assessing Young Person S they were aware of Young Person S’s own complex social history. Their formulation being that Children’s Social Care input needed to be put in place before any improvement of Young Person S mental state could occur; and that the serious deterioration of Young Person S occurred after their involvement had ended.   CAMHS have advised the Review that when Young Person S was discharged, they had confirmation from Children’s Social Care that he would be assessed and provided with appropriate support.   Suggestions were made by Children’s Social Care with regard to enabling Young Person S to engage with the community to reduce his isolation, for example.   The decision therefore made by Children’s Social Care to close the case, owing to Young Person S parents refusing support, without a discussion with CAMHS, would seem to have been premature and not compliant with what CAMHS believed was going to happen.   In October 2019, Mrs S was admitted to mental health services and in June  2020, Mrs S was discharged from mental health services, but she was later readmitted to hospital in July, following contact with Crisis Line and the Ambulance Service advised Children’s Social Care about her mental ill health. Children’s Social Care contacted Mr S to offer support, however he refused, and was unwilling to engage. No further action was taken, and the case was again closed. This was a missed opportunity to review and evaluate the home situation.   When Mrs S was discharged a multi-agency, discussion did not take place, and there was no face-to-face contact from the doctor or Care Co-ordinator (this could have been attributed to Covid-19 restrictions).    On the 8th August, a Youth Support Advisory Team member visited the home address to discuss Young Person S education plans. Young Person S was again not seen, and Mrs S refused to provide a contact number.    18  On 11th August Mr S reported he was a victim of domestic abuse from his wife. Given Mr S’s mental health issues, he would have been considered as an adult with care and support needs and a referral to adult safeguarding should have been made. This would also have been an opportunity to alert Children’s Social Care to the alleged conflict between the parents, and allegations of abuse towards the father.  It was identified that three children aged 15, 17 and 19 were at home, but details only taken for Ms V then aged 15. A risk assessment was set up for the following day and safety advice was given.   A risk assessment followed in August 2020. The GP was informed that a police report had been made, but no action would be taken from mental health services. Mrs S had assaulted her eldest daughter, Ms V grabbing her face and scratching her arms, but no referral was made to SOLACE by Police. This was a missed opportunity to consider in more detail all members of the household and what support may be needed.     The risk assessment score for Mr S was 13/24 and following a conversation at Service Manager level, a MARAC referral was indicated, and the case was allocated to an IDVA.   On the 17th August the IDVA contacted MARAC to see if any other referral had been received. Contact with Mr S was attempted four times on the 17th, without success.   On 2nd September MASH were advised about the deterioration in Mrs S’s mental health and a week later, on the on 9th of September the IDVA service closed Mr S’s domestic abuse case. A MARAC referral was never made. This resulted in limited safety planning.  Mrs S was arrested for assaulting Ms T, yet it would appear Ms T was not referred to SOLACE by Police or by the GP. Ms V was 15 years old at the time and police would have been aware of her age, and did not follow up with Children’s Social Care. The GP was fully aware of the children in the household having been the family GP for 16 years.  SOLACE have acknowledged that their practices warranted improvement, in relation to Think Family; the quality of assessment and the impact of the complexity, on their decision making. They had no knowledge of Young Person S, because they had not asked enough questions to Mr S, with regard to others in the household, or children in the family. SOLACE have advised the review of the changes they will be making in safeguarding training, including a focus on professional curiosity.   During October 2020 when Mrs S contacted the GP Practice because Young Person S had a sore throat and antibiotics were issued, Young Person S was not seen, and again in November, she reported he was soiling himself in a telephone consultation and declined to speak to the GP over the phone. It could be argued that a more assertive approach could have been made to see the patient, however this was during the Pandemic, which may have had influence on such decision-making.   Police and ambulance were called to the family home by Ms T on the 6th November and which resulted in Young Person S requiring urgent psychiatric treatment.   19   Police and ambulance experienced obstruction from Mrs S in being able to see Young Person S. He was eventually taken to hospital for assessment.  When Young Person S was found in a state of neglect, the police priority was to ensure agreement about safety of the children; whether or not there were criminal matters to pursue, and what would be in the best interests of the children.   The Police visiting the home on the 6th November had considered Ms T as a protective adult and Ms V and Ms T remained in the home. Police did not explore the vulnerability of Ms T and or Ms V in relation to the mother’s mental health and the history of violence towards Ms T, or complete DASH assessments.  Police accepted post Rapid Review that there could have been more awareness demonstrated as to the vulnerability of Ms T and Ms V.  SOLACE have advised the Review that multi-agency working could have ‘been stronger’ and that in August 2020, both MARAC and children’s and adult safeguarding referrals should have been made, which were not.   It is evident that there could have been greater co-ordination from Children’s Social Care, in pulling together all professionals to share information, share knowledge, and current and historical concerns, with regard to the multiple layers of risk that this family faced, as a whole.    The GP Practice has advised the Review of the impact of Young Person S not having the ability to communicate with services, which in their view potentially delayed the awareness of the seriousness of Young Person S state of neglect. They opined that Mrs S ‘played down’ the situation on his behalf. There have also been references made to the Review where Ms T and Ms V were advised by their mother not to talk to others about the state of affairs at home, which again could have served to minimise the risk Young Person S faced. Such requests would also constitute coercion and control.   Key Learning The fact that Young Person S was not seen during the scoping period of the Review other than very briefly in passing by any professional, brings into question, how well any professional was able to understand his situation and what he experienced.   Findings from the national Voice of the Child Report established that practitioners focused too much on the needs of the parents (especially vulnerable parents), overlooking implications for the child.   Mental Capacity assessments are decision and time-specific and a Mental Capacity Assessment could have taken place, by Children’s Social Care, or CAMHS, in order to ascertain if Young Person S had the capacity to take the decision not to be seen by CAMHS personnel.   It should be acknowledged that both agencies found themselves working in challenging circumstances, and seemingly did not believe that Young Person S was  20  at risk of significant harm, and without a warrant, a forced entry could not have been made.   This is accepted. CAMHS have in hindsight advised the Review that at the time, Young Person S was presenting as ‘at risk’ in relation to his mental state, with early indicators of psychosis.  CAMHS are not commissioned to manage the first episode of psychosis service. However, this would not have prevented CAMHS or Children’s Social Care making a referral of concern to the relevant professionals, i.e. that Young Person S was possibly experiencing early psychosis. Both agencies have accepted this.  CAMHS have advised the Review that assessing Young Person S was limited by his unwillingness to engage and that at the time reports from his parents did not imply that he did not have mental capacity to make his own decisions. Practitioners and doctors were unable to make observations about the interactions between parents and Young Person S, and were overly reliant on parental reporting.   The continuation of Children’s Social Care and CAMHS professionals not seeing Young Person S, diluted joint efforts to assess him fully and comprehensively.   There was an over reliance on the credibility of parental reporting; and a lack of challenge from all professionals to the barriers that the parents posed, alongside a clear lack of professional understanding with regard to changing parental mental capacity and inconsistent parenting ability.    The parents’ refusal to access support should have prompted more curiosity as to the repeat notifications and what was preventing stability from being achieved.   There had been inconsistencies in the information provided to Children’s Social Care and other agencies.  The family had experienced a number of interventions in the months prior as a result of Young Person S’s deteriorating behaviour and presentation.  A more assertive approach was warranted on completion of the assessments in April 2020 at this point to test out whether stability could be achieved and sustained rather than to close the matter down.  Practitioners referred to trying to make contact or offer support to Young Person S and the family, but found the behaviour of Mrs S, frequently aggressive, volatile, and threatening towards them.   There is evidence, from national LCSPRs that practitioners failed to make the connection between the difficulties that they themselves experienced in these situations and the likelihood that the children in the family were also experiencing the same stressful, inconsistent and sometimes abusive behaviour.    21  When professionals from any agency have concerns about their own personal safety, they must always consider the implications for children from exposure to the same risk factors.  In addition to this, escalation to managers and the effective use of professional supervision should be considered.     The practice-related learning themes are summarised in Appendix 1. Findings        A Complex family social history, Think Family, assessment, decision making and prevention       It is very evident that this case brings a complex social and complex health family history to all professionals involved.   This review highlights the importance of early intervention and partnership working across different geographical locations and organisations, and it also highlights the importance of the ‘Think Family’ approach across Adult and Children’s Services in order that needs are met.    Given the extensive background regarding parental mental health, substance use and domestic abuse within the home, these are suggestive of a pertinent social history, complexity, and vulnerability, which leads professionals to retrospectively consider the hidden harm which may have been escalating, particularly during the Covid-19 pandemic and subsequent restrictions.   The case also highlights the importance of the voice of the child and consideration of the daily lived experiences of the children and young people in this household.   All partners who are responsible for deploying Think Family, in their practice, must note that the likelihood of risk and harm to children increases when a child lives with an adult with vulnerability factors such as poor mental health, domestic abuse, and substance use, and that the risk increases when more than one of those factors is present and if more than one parent is affected.       Given the complexity of the family in question, the legislative guidance set out within Working Together 2018 and updated in 2020, strongly points to all three children in this case being at increased levels of risk.   The approach taken when completing assessments did not always adopt a Think Family Approach, or take account of the family’s longstanding historical issues, such as the domestic conflict between the parents; both parents substance use; the fact that both parents experienced mental illness; that both had issues with consistent  22  parental capacity; the health and well-being of all of three children, and a multi-agency approach to working, was not always evident. Relevant agencies were involved with the family and assessments were regularly made, but working and planning together was sparse, with exception to the joint visit made to assess Young Person S in March 2020, where the outcomes of the psychiatric assessment were made clear, and a CAMHS ‘open door’ offer was made.  The findings confirm that not enough consideration or due regard was given to a wide range of historic, but known factors; their interplay, and the thematic trends, that can be seen in relation to prevention of Young Person S deterioration and his poor mental health; family risk assessment and family risk management. The child and family assessments would have benefited from multi-agency input and while there was professional curiosity into the educational and social needs of Young Person S, there was limited follow up and impact once professionals were aware.  The voice of the child both in relation to Young Person S and his siblings did not stand out strongly enough and there was over reliance across partnership agencies on parental reporting.  The quality of various assessments fell short in ensuring effective intervention to bring about positive and long-term change for Young Person S and his siblings and there were on reflection many missed opportunities to better understand the family situation, but also key points when referrals and other assessments should have been completed, for example DASH assessments, Young carer assessments, referrals to Housing, MARAC, SOLACE, CAMHS and referrals to Adult Mental Health, and Children’s Social Care.  Over-reliance on parental reporting, Young Person S not being seen and case closures      Review findings have confirmed that there was an over reliance on parental reporting which prevented the voice of the child being heard, by all agencies. It is clear that there was a ‘good will’ based desire for agencies to believe what they were being told by parents, however this information was frequently inaccurate and not always considered in the context of parental mental health diagnoses.   Young Person S was not seen by the Elective Home Education (EHE) Service, Children’s Social Care, and or CAMHS sufficiently to make assessments of his needs at key times; the voice of his siblings was not considered as strongly as could have been which may have helped to inform agencies better on the lived experience of all the children including focus on the health, well-being, and safety of all of the children.    23  Lack of professional curiosity; information sharing and multi-agency planning      There was a tendency to close down involvement due to reluctant engagement from the parents, resulting in premature closure, and on occasion a poor response to domestic abuse referrals; there was a lack of opportunity created by all agencies to share information and to coordinate a joint response. A Think Family Approach would have allowed for agencies to adopt a more coordinated approach to working with wide ranging difficulties being experienced by the children and their parents, and to draw on expertise from the relevant agencies in agreeing responses.  MARAC and domestic abuse referrals were not always made both in respect of Ms T and or Mr S in 2019, and 2020 which increased risk for the family and prevented opportunities for closer working together.   Historic academic information was not always gathered leading to the carriage of misinformation and an inaccurate view about the length of time Young Person S was out of mainstream education; his isolation; his lack of contact with professionals or social systems and therefore increasing the risk he faced.   There was limited professional curiosity and information about what had happened to Young Person S in his past included or referenced in a number of assessments; limited information in assessments as to why he was being home schooled, and no evidence of escalation to flag worries when the quality of home-schooling was in question.   There was little reflection on why Mrs S had left to live in another borough with only two of her three children, and what contact there had been between family members during this period.  There was also a lack of professional curiosity with regard to the domestic abuse that was being experienced by Ms T and the psychological impact of this on both her and her sibling Ms V. Overall, there was a lack of shared analytical thinking.  There was a high degree of information beset within different agency systems. Individual agency narrative was not passed on, which hindered decisions about possible interventions.  Deployment of the Mental Capacity Act: Young Person S unable to communicate with professionals in the context of his neglect and the difficulties presented by the environment      It is accepted that Young Person S has experienced neglect and that he was in a poor physical and mental state when admitted to hospital for further assessment in 2020.   The review findings raise questions about professional understanding and knowledge of The Mental Capacity Act, and its application in the community.    24  The Act applied to Young Person S from the age of 16, which would have been from March 2019 onwards, and it is of concern that his capacity was not assessed until he was due to be discharged from hospital in Spring 2021.    Professionals and services were aware of Young Person S in the community and the various reported issues such as: his isolation; odd behaviours, domestic abuse toward his sister; inappropriate urination; refusing to come out of his bedroom and not being in mainstream education.   When home visits were made by services, Mental Capacity Act Assessments were not made, which was a missed opportunity. This was in the context of a difficult environment, and Young Person S’s refusal to be seen and parental preferences. Young Person S had the right to be enabled to make a decision and or be assessed to make it, without due parental influence and without professionals paying heed to that.   The difficulties that were presented in the environment in which professionals attempted to assess Young Person S has been acknowledged, however it can be concluded that professional curiosity and healthy scepticism regarding Young Person S needs being met, should have prevailed, in spite of what seemed to have been the fear and anxiety created in some staff with regard to violence in the family; potential and real aggression and expressed anger from Young Person S mother.   The fact that Mrs S was regarded as very volatile and potentially violent is likely to have constrained the effectiveness of practice and engagement in this case. On many occasions, various professionals were not allowed into the home, were prevented from seeing mother and the children or were unable to make contact with her or Young Person S’s father. When a parent/parents do not engage for whatever reasons, it is not enough to allow those reasons to cause a service to close a case or to stop trying.       The need to respect privacy of parents can lead to an inadequate focus on the child, with too much attention paid to forming a trusting relationship with the adults.  Reflective supervision and skilled management oversight is key in addressing such issues.   The impact on the family of mental ill health and their children living with hidden harm     It is formally recognised in Working Together that children may be at greater risk of harm or need additional help, in a family where parents: have mental health problems; substance or alcohol misuse; have violent relationships; where there are complex needs or if a child/children or adult has a learning disability. All these characteristics featured in the family concerned.   It can be concluded that Young Person S and his siblings, experienced a negative impact in relation to his parent’ prevailing mental ill health. Mr S did request help for his son on at least two occasions, but advice was rarely followed up and his acceptance of professional support was inconsistent. It is highly likely that his wife’s mental health issues, and behaviours impacted on his ability to engage amid the likelihood that his support for Young Person S was likely to be opposed.   25   Professionals might have underestimated the children’s experience of living with a father who had schizoaffective disorder and a mother who had paranoid schizophrenia, because on the face of it, Mr S appeared more stable and he engaged well with his medication. However, his ability to protect and prioritise the needs of the children was not sufficiently assessed. It is evident that some professionals with the lawful responsibility to assess, were unaware of the symptoms of these illnesses; how they manifest and the consequent impact this can have on a young person, on their development, and on parental decision-making. The impact of these diagnoses on ability to work with and build trusting relationships with professionals needs also to be considered.    The Review concludes that some agencies showed a lack of recognition of the importance for families to be supported, when affected by mental illness and that how any intervention should optimise successful parenting and the importance of considering the impact on the child if parents do not access the support required.   Intervention should also assess and recognise that mental illness can impact on both parenting ability, parental insight, and recognition of their children’s needs and this should be considered in assessment for child protection, child and family consideration and care proceedings.       Elective Home Education (EHE) was in place for a total of 4 years, in the case of Young Person S. The Review is aware that legislation does not place any obligation on a School to support parents or pupils, in EHE circumstances, unless there are clear safeguarding reasons why this would not be viable. In Bexley, the practice is to not agree home education when children are subject to child protection/child in need plans. Young Person S was not open to Children’s Social Care for long periods when he was home educated. In the most recent assessments dating back to 2018 and 2019 he would have been approaching the end of his compulsory school career.   Legal obligations on the Local Authority applied to both Essex County Council and The London Borough of Bexley - where their duty existed on the grounds that Young Person S was observed as not receiving a suitable education.  It is not clear how this was followed up at the time and what action was taken to address it.  In this case it would appear that Young Person S got lost in the EHE processes. Children’s Social Care and EHE could have been more pro-active in asserting concerns.    Safeguards were also unable to be applied to Young Person S as his case was not able to be referred to the School Nursing Service, because he did not have an EHCP; a CP or CIN plan and parental consent was required, which was not given. Young Person S’s father was not approached because he was not on the home/school contact form.   In a case such as this, legislative restrictions on information sharing for EHE children restricted safeguarding the child from harm.    26  The findings from this LCSPR have prompted a review of all young people who are home educated to assess whether the education they are receiving is appropriate and being provided (and appropriate action taken where it is deemed unsuitable). A multi-agency audit has been undertaken, sampling cases currently open to EHE, to determine that there are no opportunities missed for cross-agency referrals or working. This process is being embedded into regular quality assurance practices.   The Children as Young Carers     This Review concludes that the position, circumstance and status as the children of this family being young carers was largely undetected by services, up until November 2020. A Young Carer’s Assessment would have determined more accurately the support needs of the children.   Ms T reported to a social worker and a housing officer in 2018, that she had been undertaking a caring role since she was 13 years of age.  This would have been an opportunity to explore the roles within the family and to ascertain whether Young Person S and Ms V were also likely to become young carers. There is a duty to consider whether there were any children involved in providing care, and if so, to consider the impact on the child.  CAMHS advised that albeit Ms T and Ms V were discussed in one of their assessment sessions, the two girls were ‘not the focus of the assessment’ and consequently, CAMHS explained were not referred for assessment as young carers.   Albeit Young Person S was the focus of the assessment, he was also not considered to be a young carer, when he may have been, or previously been.   CAMHS have acknowledged that going forward, this ‘could be thought about more explicitly in future,’ in relation to young people, particularly when their parents are known to adult mental health services, or have a known mental health diagnosis, and that their staff will be encouraged to use tools that are currently in place.   The secondary school were unaware that there were any young carers in the household and report that Ms V did not present with any significant concerns whilst at school but was offered support from the pastoral team.    SOLACE was unaware of the other children, because information about them was not gathered, and SOLACE have acknowledged they did not explore this adequately and or exercise professional curiosity.  Impact of Covid-19 on children’s/family circumstances and on capacity of services to respond to needs     The Child Safeguarding Practice Review (National) Panel requested that the Rapid Review consider any Covid factors which may have impacted on the family situation and or on service delivery. The Bexley Learning from Practice Panel considered the current situation and past history of involvement with services and considered that  27  concerns relating to multi-agency response and decision making were present prior to Covid and that positively, there was direct contact with agencies during lockdown.   From Children’s Social Care’s perspective, Covid did make an impact in so far as not being able to undertake face to face visits to see Young Person S when he was in hospital from November 2020. Video calls were made to stay in touch and help from ward staff was given. Face to face visits were able to take place at a later date with the use of PPE.       Police involvement in this case was not affected by the pandemic.   There was minimal disruption noted with regard to GP contact with the family. Some consultations were conducted by phone, which was normal pre-Covid practice for them.   All CAMHS contact took place before Covid restrictions came into place and home visits were conducted as normal. Ms V’s school-maintained contact with her through lockdown, via regular contact with parents by the school pastoral team and her engagement and online learning was closely monitored.    Bromley Healthcare, Bexley 0-19 School Nursing service, commented that the Covid-19 pandemic may have exacerbated the families’ social isolation and capacity to acquire and access help, accentuated by support restrictions, which may have heightened ‘concerning features of mental health’ and possibly increased the potential for family conflict. They have added that: ‘Professional curiosity may encourage us to  consider whether school closures due to the pandemic enhanced the opportunity to  disengage from formal educational provision’.  It is possible that Covid-19 impacted on the mental health of both parents, particularly as there was limited informal support available. The mother displayed heightened anxiety when police and ambulance visited the home in 2020 referencing her fear of Covid.   Recommendations Bexley S.H.I.E.L.D. and its associated statutory partners should seek   assurance that:  1. A Think Family Protocol is developed which is branded with strong senior leadership and given a high strategic profile and associated practice is coordinated, multi-agency, effective      and underpinned by timely information sharing.  2. All partnership organisations have the necessary processes in place to bring about a shared responsibility to child and adult safeguarding. Including systems for information sharing and processes for supporting Think Family approach and monitoring compliance.  3. There is the provision of ongoing training and practice development for relevant staff across the partnership to ensure that they are competent to deliver their  28  lawful responsibilities in accordance with a)Think Family; b) Mental Capacity c) Education; d) Domestic Abuse; e) Young Carers.  4. Multi-agency assessment protocols and practice guidance are reviewed to ensure they support the embedding of a Think Family approach, and incorporate opportunities for multi-agency discussions and review of the effectiveness of plans and decision making.  5. Children’s Social Care service improvement plans to include audit of the quality of Child and Family Assessments.   6. Case closure processes includes ensuring supervision records include the rationale for closure, and what is expected practice when there are difficulties with engaging with families and when concerns are ongoing.   7. National Recommendation - that relevant government leads note the findings from this review and consider the impact of legislative restrictions on Elective Home Education (EHE) and how this can potentially leave young people more vulnerable.    Updates since November 2020  Think Family training was initiated in 2019, as part of recommendations from priority work on Parental Mental Health, and has been ongoing since this time. Think Family will remain a focus throughout 2022.   The impact of learning on practice is scheduled to be tested out through the multi-agency learning forum, and learning from practice sub group, overseen by Bexley  S.H.I.E.L.D. on an ongoing basis.  Bexley S.H.I.E.L.D. with funding from the Department for  Education completed an evaluation programme between May 2021 and February 2022 including a focus on the impact of Think Family practice, parent participation, and Bexley’s approach to learning in practice. A final evaluation report was submitted to the Department for Education in February 2022 and Bexley S.H.I.E.L.D Executive are monitoring the progression of all future plans identified through the programme.   Bexley Safeguarding Adults Board and the Community Safety Partnership remain involved in all learning activities and there is ongoing review of the joint training to support the embedding of learning (for example, in relation to adult mental health, mental capacity, the Care Act, domestic abuse and Think Family practice).  Children’s Social Care service plans for 2022 include the monitoring of the quality of assessments and the supervision and management oversight of records.      29  Appendix 1 – Practice-Related Learning Themes   • The importance of multi-agency professionals understanding mental capacity and applying the law in relation to an individual’s decision making.   • Assessing parenting capacity with a joined-up approach including input from specialist services, CAMHS, Adults and Children’s Social Care, Adult Mental Health, Education.   • Understanding parental and adolescent mental health and its impact on the family including siblings and the need for a Think Family approach  • Understanding domestic abuse across familial relationships, understanding pathways and referral processes for support, and using intervention skills particularly when support is refused   • The importance of multi-agency input into assessments (and their ongoing review and follow-up), safeguarding strategy, and decision-making prior to case closure.   • Healthy scepticism and professional curiosity when working with families and the ability and skill to challenge parental views and their narrative.   • The importance of assessments and reviews including the reflecting on and impact of family history as well as strengths.  A clear analysis of ongoing worries and what needs to change and the skills to deduce capacity for change.    • When engagement is not easily achieved, the need for professional curiosity about why a family may not be engaging, for example mental illness, trauma, learning difficulties, fear of loss, being unable to coerce family members, loss of power and control, loss of benefits to fund the household, substance abuse, debt, fear of being found out.   • Non-engagement resulting in a young person’s case being closed or ‘no further action’. The importance of including an analysis of the impact on the child/young person if there is no engagement.   • The use of tools in assessment / Harm Matrix / clear danger statements and safety planning.   • Importance of Family Network meetings in identifying support and who can be involved to support the child/ren and their family.   • The importance of seeing children, including alone when there are worries about a child’s welfare.   • Understanding consent and when this can be over-ridden.   • The ability of staff to deploy Mental Capacity Act law and assessments to 16+ children.         