Death of a 3-month-old girl in March 2015 as the result of Sudden Unexpected Death in Infancy (SUDI). Emily was a twin and lived with her brother, mother, and maternal uncle. She and her brother were born prematurely and kept in hospital for longer than medically necessary because of concerns about mother's ability to look after their basic needs, due to perceived learning difficulties and lack of support. Professionals had voiced concerns about the amount of care provided and the level of control Emily's aunt had over her mother, who had history of depression and self harm. Emily's aunt visited the home daily, and there were domestic abuse incidents in the home between her and her brother. Shortly after discharge from hospital professionals identified a number of concerns, including low weight gain, poor home conditions, and significant nappy rash. A Single Assessment Framework was started when the twins were discharged but was not completed. Learning includes: the risks associated with twins and prematurity are not routinely articulated across multi-agency partners; there may be a tolerance of sibling violence that would not be accepted for intimate partners, which does not acknowledge the risk for children; professionals' overreliance on diagnosis fails to recognise the continuum of needs of parents who have learning or mental health difficulties; the lack of a multi-agency neglect framework and toolkit inhibits a shared professional understanding of neglect. Makes a number of recommendations in the form of questions to the LSCB around the additional needs of premature and twin babies; sibling domestic abuse; and professionals' understanding of neglect.
      
    Serious Case Review No:  2018/C7100  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.    1                                                    SCR: Emily Final Report                                                                                                                                                                                                       Local Safeguarding Children Board Serious Case Review Emily   Bridget Griffin  and Local Authority Service Manager  February 2018  2                                                    SCR: Emily Final Report Contents 1. Introduction ..............................................................................................................................3 1.1. Why this case was chosen to be reviewed ............................................................................. 3 1.2. Methodology Organisational learning and improvement ...................................................... 3 1.3. Reviewing expertise and independence ................................................................................. 4 1.4. Review Team ........................................................................................................................... 4 1.5. Case Group .............................................................................................................................. 5 1.6. Involvement of family members ............................................................................................. 5 1.7. Documentation ....................................................................................................................... 5 1.8. Specialist advice ...................................................................................................................... 5 1.9. Methodological comment ....................................................................................................... 6 1.10. Terms of Reference – Timeframe ....................................................................................... 6 1.11. Research Questions............................................................................................................. 6 1.12. Family composition ............................................................................................................. 7 1.13. Summary of case ................................................................................................................. 7 2. Appraisal of practice ..................................................................................................................8 2.2. Birth of twins, discharge of Mother and referrals to Front Door. .......................................... 8 2.3. Discharge home and escalating concerns. ............................................................................ 10 2.4. Referral to Early Help and response. .................................................................................... 11 2.5. Extended community response and escalating concerns. .................................................... 12 2.6. Completing the Single Assessment (SAF) .............................................................................. 15 2.7. What makes learning from this case more widely applicable? ............................................ 16 3. The Findings ............................................................................................................................ 16 3.1. Summary of findings ............................................................................................................. 16 3.2. Finding 1 ................................................................................................................................ 17 3.3. Finding 2 ................................................................................................................................ 20 3.4. Finding 3 ................................................................................................................................ 24 3.5. Finding 4 ................................................................................................................................ 28 3.6. Additional Learning ............................................................................................................... 32 Appendix 1: References .................................................................................................................... 34   3                                                    SCR: Emily Final Report 1. Introduction 1.1. Why this case was chosen to be reviewed 1.1.1. This Serious Case Review (SCR) was commissioned by the Independent Chair of a Local Safeguarding Children Board (LSCB) after a referral from the Regional Child Death Overview Panel (CDOP) requested that a serious case review should be considered. After consideration, the LSCB Serious Case Review Sub Group concluded that the circumstances surrounding the death of Emily1 met the criteria for a serious case review.  1.1.2. This Serious Case Review (SCR) is about the services provided to Emily and her family prior to her death in March 2015.  Emily was a twin who was three months old when she died; the cause of death was described by the coroner as “unascertained” which comes under the category of “sudden unexplained death in infancy” (SUDI).  1.1.3. The findings of this serious case review do not indicate that inter-agency practice or the practice of any individual or organisation could have altered the outcome of this case. However, inevitably, in any review of the professional response to a child death there will be lessons to be learnt, and so it is here.  1.2. Methodology  1.2.1. Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulation 2006 sets out the functions for LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances.  How serious case reviews are undertaken is not set out within the regulations, however “Working Together to Safeguard Children” (2015, 4;7) helpfully clarifies that; “Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.” 1.2.2. Statutory guidance requires SCRs to be conducted in such a way which:  recognises the complex circumstances in which professionals work together to safeguard children;   seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   is transparent about the way data is collected and analysed; and                                                            1 All names of family members have been anonymised  4                                                    SCR: Emily Final Report  makes use of relevant research and case evidence to inform the findings (WT 2015, 4:11) To comply with these requirements, the LSCB has used the Social Care Institute of Excellence (SCIE) Learning Together2 systems methodology and used a ‘Small Learning Together’3 approach in this SCR.   1.3. Reviewing expertise and independence 1.3.1. This SCR has been led by two people both independent of the case under review. The Lead Reviewer is independent of the Local Authority Council and the second reviewer is training under supervision from the independent lead and is a senior manager at the Local Authority Council. Neither reviewer had any previous involvement with this case. Together, for the purposes of this report, they are known as the Lead Reviewers. 1.3.2. The Lead Reviewers received supervision from SCIE as is standard for Learning Together accredited reviews. This supports the rigour of the analytic process and reliability of the findings as rooted in the evidence.  1.3.3. Bridget Griffin is an experienced Lead Reviewer and is accredited to carry out SCIE reviews and to mentor training lead reviewers.  1.4. Review Team  1.4.1. A team of senior managers was formed from the relevant agencies; these professionals are referred to as the Review Team. The Review Team work alongside and with the Lead Reviewers to ensure direct relevance to local systems to maximise the learning and included the following members:   Service Manager – Safeguarding and Quality Assurance Local Authority Children’s Services  Policy & Projects Officer Local Authority Housing Services Detective Inspector  Regional Police Force Area Manager Local Authority Early Help Services  Designated Nurse for Safeguarding Children  Local Clinical Commissioning Group Business Manager Local Children & Adults Safeguarding Board  Project Support Officer   Local Children & Adults Safeguarding Board                                                             2 Fish, Munro & Bairstow 2010 3 The core principles of Learning Together are fixed but the process is flexible and this results in a review that is proportionate. It enables the creation of a tailored process and product to fit with each particular situation.  5                                                    SCR: Emily Final Report 1.5. Case Group  1.5.1. The Review Team identified those professionals who had direct involvement with Emily and her family; these professionals are referred to as the Case Group. In line with a small Learning Together review a learning event was held with these practitioners facilitated by the Lead Reviewers. The purpose of this event was to understand the multi-agency perspectives about the services provided to Emily and her family, and to explore whether the learning in this case had wider significance to other children and families in the area. The workshop considered the research questions (see below) throughout the learning event and the information from this workshop supported the formulation of the findings reported within this review. 1.6. Involvement of family members  1.6.1. The involvement of family members is integral to any SCR. A member of the Review Team met with Emily’s mother to advise her of this SCR and to seek her views and participation. Unfortunately, Emily’s mother did not feel able to participate at this time and therefore her views are not reflected within this review. Emily’s father was not actively involved with the twins and so his views have not been sought. 1.7. Documentation 1.7.1. A range of documentation has been provided for the purposes of this SCR. These documents have been analysed by the Lead Reviewers and members of the Review Team and include, but are not exclusive to:  An integrated multi-agency chronology   Assessments completed by the Health Visiting Service, the Midwifery Service and Early Help  Minutes of the TAF meeting  Weight charts   Correspondence (letters and emails) between various professionals    Referrals to the local Front Door service for concerns about children (referred to as ‘Front Door’).  LSCB website (including the annual report and the threshold document)   Joint Strategic Needs Assessment   Relevant guidance and protocols between services   CDOP minutes  Post Mortem Report, Coroners Verdict and associated toxicology report   1.8. Specialist advice 1.8.1. The cause of Emily’s death has been determined and recorded following post mortem as ‘Unascertained’. Within the child death overview process ‘unascertained’ is recorded as Sudden Unexpected Death in Infancy (SUDI). It has been noted that there was a close proximity between Emily’s first immunisations and her death; this has been considered and thoroughly scrutinised by expert medical professionals who have concluded there is  6                                                    SCR: Emily Final Report no clinical link. The timing of these immunisations has been concluded as an unfortunate coincidence, with no causal link. Specialist medical advice has been reflected within this review. 1.9. Methodological comment  1.9.1. This SCR involved many multi-agency professionals and whilst every attempt has been made to include all the relevant professionals in the Case Group, this has not been possible. Where relevant, those professionals who have not attended case group meetings have been offered separate conversations. 1.9.2. As this SCR progressed, additional information was sought from newly identified professionals and as such this caused delay. Whilst this led to an extension of the timescale for completion, it has not impacted upon the findings. 1.10. Terms of Reference – Timeframe 1.10.1. The scope of the timeframe for this review was from 6th December 2014 to 12th March 2015. This timeframe was chosen as it covers the birth of the twins and the sad death of Emily. However, significant events relevant to the case prior to the start date of the timeframe were included in the chronology completed by each agency.  1.10.2. The agency chronologies were merged and used to produce an interagency timeline. This was carefully analysed by the Lead Reviewers and the Review Team and provided opportunity for Review Team members to raise questions and clarify their understanding of the circumstances of the case and the services provided.  1.10.3. These discussions informed the research questions and allowed key practitioners to be identified (who would be required to attend a learning event) and to enable the single and interagency practice in this case to be better understood.   1.11. Research Questions 1.11.1. Integral to the SCIE Learning Together methodology is the early formulation of ‘research questions’ to provide a framework for investigation and analysis. These questions were agreed at the initial review team meeting and identified the following aspects of multi-agency safeguarding work which the review team hoped to learn more about. 1.11.2. There were 3 broad areas of interest;  Labelling, specifically when using the term ‘learning difficulty’. Question 1:   How far do professionals have a shared understanding of the phrase ‘Learning Difficulty’ and how does this impact upon the multi-agency response?  Think Family, how co-dependent support can be assessed.   Question 2:  When providing services to adults who care for children, how are their vulnerabilities and their impact in the caring role assessed  7                                                    SCR: Emily Final Report and supported?  Multi-agency practitioners as a source of safety   Question 3: How do multi-agency practitioners secure effective intra and inter agency work?    1.11.3. In addition, at the request of the Child Death Overview Panel (CDOP), this SCR has considered the learning for the area in relation to safeguarding children from neglect.  During this SCR information emerged that enabled these research questions to be explored and where appropriate these have been covered in the relevant findings.  1.12. Family composition  Andrea  Mother  Emily Female twin Billy Male twin Charlotte Maternal Aunt Jake Maternal Uncle ‘Grandad’  Family Friend   1.13. Summary of case  1.13.1. Emily was a twin. She and her brother (Billy) were born on 6th December 2014, 6 weeks prematurely, to Andrea who was a single mother.  Both twins were initially supported in the Neonatal Intensive Care Unit (NICU) and later on a ward prior to discharge home with Andrea. The twins had been kept in longer than they medically needed because the midwives were concerned about Andrea’s ability to look after the basic needs of the twins, and about the level of support available to help her over the holiday period.   1.13.2. Andrea had some known vulnerabilities including difficult childhood and a history of depression and self-harm. She had secured employment as a carer for the elderly and had a close relationship with a family friend that she called Grandad. She took an active role in caring for him and he offered emotional support to Andrea in the care of the twins, however, he had chronic health problems. Andrea, as a new and single mother, had limited access to additional support to help her meet the needs of premature twins as both her natural parents had died, and she was no longer in a relationship with the twins’ father.   1.13.3. Andrea lived with her brother Jake and her sister (Charlotte) visited daily. Charlotte spent a lot of time with Andrea and the twins and was often present when professionals visited. There were concerns about the amount (and quality) of care Charlotte was providing to Emily and the level of control Charlotte had in her relationship with Andrea.  8                                                    SCR: Emily Final Report There were known domestic abuse incidents at Andrea’s address between Charlotte and Jake.   1.13.4. Shortly after the twins were discharged home, professionals identified cumulative concerns. Andrea was unable to establish routines for the twins and there were concerns about low weight gain, hunger, bleeding nappy rash, poor home conditions, lack of food or formula and the twins being inappropriately dressed.  1.13.5. Emily died at three months old. Her death was sudden, unexpected, and deeply distressing for all her family.   2. Appraisal of practice 2.1.1. The Appraisal of Practice forms an essential component of a SCIE Review. It considers the practice in this case, looking at multi-agency decision making, assessments and interventions from the time of Emily’s birth to her death. It aims to provide an explanation of ‘why’ things happened; outlining what got in the way of professionals being as effective as they wanted to be. Any issue identified that was common across more cases in the area is discussed in more detail in the findings, which are cross-referenced.  2.2. Birth of twins, discharge of Mother and referrals to Front Door 2.2.1. This period highlights the quality of referrals made to Front Door by Midwifery and the challenges of information sharing and risk assessment when working across multi-agency boundaries.   2.2.2. The twins were born prematurely at 34 weeks gestation. The close monitoring of midwives providing ante natal care to Andrea meant that Andrea’s vulnerabilities (including a history of overdose, long term depression and her responsibilities of providing care to her ‘grandad’) had been recognised and were clearly recorded; this was good practice. On the day the twins were born, senior midwives noted concerns about Andrea’s capacity to care for the twins, queried whether Andrea had a learning difficulty, and stated that urgent follow up was required. These observations were promptly recorded, which was good practice. At this point, the twins were on a ward and mother’s parenting was monitored. However, the use of the term ‘learning difficulty’, without adequate description of what this meant, and the very brief reference to Andrea’s ability to cope did not provide sufficient detail of the concerns that were observed. The added risk of caring for premature twins was not referenced and it was unclear what ‘urgent follow up’ meant. Articulating the risks associated with multiple births and prematurity is discussed in Finding 1 and responding appropriately to concerns about possible learning difficulties is discussed in Finding 4.  2.2.3. Three days later Andrea was discharged but the twins remained on the special care baby unit. Four days after her discharge a midwife visited Andrea at the home of ‘grandad’. This  9                                                    SCR: Emily Final Report was an opportunity to observe Andrea, without the responsibility of caring for premature twins, so that an understanding of potential parenting capacity could be gained and to form a view about what support she required within the community. Although the midwife appropriately noted concern about Andrea’s capacity to provide care to the twins, no detail was recorded about the substance of these concerns and this was an important omission. Three days later, the twins’ care was transferred to the health visitor. No joint visit or joint handover took place (which is acknowledged ‘best practice’) as the volume of work within the area did not allow for this at that time. 2.2.4. On 18th of December, whilst the twins were still in the special care unit, a referral was made to Front Door by the specialist safeguarding midwife. This referral was made 12 days after the twins were born as this allowed the midwifery team to gather enough information to make an informed referral.  2.2.5. A previous referral had been made to Front Door in the antenatal period but there was no record of the outcome on file. Front Door had responded to this referral and sent a letter recommending that Andrea was referred to the local children’s centre to access support. However, this letter was not received. With no recorded outcome, an assumption was made that the needs of the twins did not meet a Children’s Services threshold and in the absence of further correspondence from Front Door a referral to the Children’s Centre had not been made.   2.2.6. Regardless, the midwifery team could have referred Andrea to a Children’s Centre at a much earlier point during the ante natal period. It was not possible to ascertain why this referral was not made but the lack of awareness in the area within the midwifery service about the services provided by Children’s Centres (that can be accessed by making a direct referral) was thought to be a contributory factor.  2.2.7. A second referral to Front Door, made by the specialist safeguarding midwife on the 18th December, appropriately contained information about Andrea’s vulnerabilities and shared information received from the GP that Andrea did not have a diagnosed learning difficulty. Although some concerns about Andrea’s lack of engagement with the twins and her parenting capacity were briefly referenced, there was no specific information about the risks associated with prematurity or the risks associated with multiple births. Midwifery services operating from a special care baby unit are well placed to understand these vulnerabilities and have a responsibility to be explicit about these risks and to share their expertise with multi-agency partners so that accurate decisions about risks and thresholds can be made; but this did not happen. It was understood that relevant local guidance does not specify the need to articulate these risks and there is an assumption that multi-agency partners will understand these risks (and therefore there is no need to do this). This is an unsafe assumption. The risks of multiple births and prematurity and the sharing of expertise is discussed further in Finding 1.     2.2.8. Over the next few days discussions took place between a manager in Front Door and the specialist safeguarding midwife. During these discussions Front Door was advised that a  10                                                    SCR: Emily Final Report parenting assessment was ongoing and that this would continue as Andrea had been readmitted to the ward. Readmitting parents to support with preparation for discharge is usual for premature babies. Recorded in the referral form held in Front Door was that the specialist midwife stated that no concerns had been highlighted during this early part of the parenting assessment (although during this SCR the midwifery team have disputed this). Front Door concluded that the case did not reach a threshold for a safeguarding response and, based on the information recorded on the referral form, this was a proportionate decision.  2.2.9. The narrative nature of the correspondence by the midwifery team, the lack of clarity provided about the concerns (noted by three senior midwives), the lack of reference to the specific risks of prematurity and multiple births and the vague conclusion that Andrea required ‘support’ did not provide Front Door with the information they required to make an informed decision about risk. The quality of referrals received across agencies has been the subject of concern within the area and relevant issues are discussed further in Finding 1.   2.3. Discharge home and escalating concerns.  2.3.1. This period highlights the importance of discharge planning in providing an opportunity to share information, assess risk, co-ordinate care within the community and provide a timely response to vulnerable children.  2.3.2. On the 27th of December, Andrea, Emily and Billy were discharged home. The twins had been kept on the ward for an extended period because of the concerns and this was good practice. However, no discharge planning meeting took place and as there had been no previous visit to Andrea at home there was no information available to determine whether the home environment was safe for the twins, and no assessment of parenting capacity in the community. It was understood that according to the protocol available at this time4 discharge planning meetings only took place if Children’s Services were involved, even in circumstances such as these. That said, midwifery care continued until 40 days postnatal and this was good practice.  2.3.3. On the twins’ first night home, the twins were cared for separately; Andrea cared for Billy at the family home and Charlotte (maternal aunt) cared for Emily at her home.  Care UK5 received 2 calls from Charlotte who reported that Emily had been crying non-stop for 4 ½ hours. At the same time, Billy was bought into A&E by Andrea. Separately both twins were noted to be in considerable distress and it was concluded that the likely cause of this distress was hunger.                                                              4 The Expected Baby Protocol (2011)  5 Care UK is a British company providing health and social care. The company works with councils, Clinical Commissioning Groups and doctors to deliver care and support for older people and those with learning disabilities or mental health problems, as well as a range of healthcare services for NHS patients  11                                                    SCR: Emily Final Report 2.3.4. Two days after the twins were discharged, the community midwife made an initial visit to Andrea and the twins at the family home. The information received from Care UK and the Children’s Hospital was recorded on the GP and health visitor records and Andrea told the midwife about her visit to hospital with Billy. However, this was not discussed with Andrea and no comment was made about parental capacity in light of these events. The midwife noted several concerns including; ‘filthy’ home conditions, exposure of the twins to extreme temperatures, Andrea’s lack of comprehension about the needs of the twins (including the need to feed the twins regularly) and ‘man-handling’ of the twins by Charlotte. The midwife appropriately discussed these concerns with her safeguarding lead and made a referral to Front Door the next day. 2.3.5. It was a timely referral that covered some relevant areas, but the involvement of Care UK and the Children’s Hospital was not mentioned. Most importantly, the referral did not articulate the importance of the midwives’ concerns in the context of multiple births and prematurity, and no professional analysis or judgement on present or future risks was provided.  2.3.6. Front Door responded by stating they remained unclear about the risks and referred the family to Early Help. Based on the information provided in this referral, this was a reasonable response. However, as no professional judgement had been provided, Front Door were not supported in their decision making about risk. Had this been provided, it is the view of the Lead Reviewers and Front Door that the threshold for a child protection response would have been met. The quality of referrals and importance of articulating risk is discussed further in Finding 1.   2.4. Referral to Early Help and response 2.4.1. This period highlights the importance of multi-agency work in understanding and responding to neglect.  2.4.2. Four days after the twins were discharged, the midwifery parenting assessment was sent to Front Door. The parenting assessment was a copy of day to day ward staff observations that were hand written and not easy to make sense of. However, the specialist safeguarding midwife helpfully summarized the concerns in an email to Front Door. Although the key areas of concern were indicative of potential neglect the terms risk, child protection, safeguarding or neglect were not articulated and there was no reference to the particular vulnerabilities of multiple births and prematurity, again, this did not support colleagues in Front Door to make an informed decision about risk. The importance of articulating professional expertise is explored further in Finding 1. 2.4.3. As the case had been passed to Early Help, Front Door sent the information directly to the Early Help Service. Whilst there was no professional judgement in the information sent by  12                                                    SCR: Emily Final Report the midwifery team, it is the view of the Lead Reviewers and a manager in Front Door6 that this additional information should have prompted a review of the risks by Front Door to consider whether the threshold for a child protection assessment was now met. This did not happen and fell below expected practice7.     2.4.4. Twelve days later, an Early Help Social Worker visited the twins. The timing of this visit was in line with expected practice within the service, as the focus of the Early Help Services was on prevention and support, not on urgent child protection cases. There had been no management review of the available information, either in Front Door or in Early Help, and so there was no reason for the referral to be seen as anything other than a routine request for support. During the visit it was found that Emily was not at home as she was with Charlotte, and so a subsequent visit took place 2 days later when both Emily and Billy were present. These visits were an opportunity to form a view of parenting capacity and consider support needs, but this did not happen, and the focus of these visits was unclear. This was a missed opportunity to consider the experience of the twins and put in place a clear plan of service provision, including a timely multi-agency assessment, a child centred plan and reviewing mechanism. 2.4.5. At this time, some Early Help social workers had limited experience of under 5’s and the additional risks of multiple births/ prematurity. The service had been very recently restructured and some of the staff were new to the role and had limited recent experience of completing assessments (SAF’s8). The focus of the service was on prevention, and as a result practice was routinely focused on support needs, not on risk assessment. These issues had a detrimental impact on the services provided to this family and relevant issues are discussed in the Additional Learning.     2.5. Extended community response and escalating concerns.  2.5.1. This period examines the confusions caused by the absence of a multi-agency assessment and plan, minimisation of the impact of domestic abuse on children, and the delayed involvement of a Children’s Centre. 2.5.2. During a new birth visit to the twins, Andrea told the Health Visitor about a fight that had happened at home in front of the twins between her brother and her sister and she reported feeling bullied by her sister. The Health Visitor appropriately passed this information to Early Help. Early Help contacted the police who confirmed they had been involved in a domestic dispute at the home address. This information was recorded on the Health Visitor and Early Help files but nothing further was done. This information                                                            6 Who was interviewed as part of this SCR and asked to reflect on the decisions made over this period.  7 Considerable changes have taken place in the services provided by Front Door and Early Help since this time, relevant issues are explored further in the Additional Learning 8 Single Assessment Framework  13                                                    SCR: Emily Final Report suggested that the twins were exposed to domestic abuse and, despite frequent observations by professionals that the household regularly featured loud and aggressive behaviour, there was no consideration of how this violence and aggression may be impacting on the twins’ emotional world and development. The limitations of existing perceptions about domestic abuse and the impact on children, is discussed further in Finding 2.  2.5.3. When the twins had been at home for four weeks the Early Help Social Worker recognised that the family would benefit from the services offered by a children’s centre. Both the Health Visitor and Social Worker made referrals to different children’s centres to gain this support. They were aware that services provided by children’s centres in the area could provide appropriate support to this family, however, despite previous referrals to various children’s centres no such support had been secured. There was confusion about which children’s centre the family needed to be referred to and this resulted in significant delays. 2.5.4.  Children’s centres use a postcode database to identify which families fall within their reach area. When referrals are received outside the reach area, it is usual practice to pass the referral to the correct children’s centre. It was not possible to understand why this did not happen, but the result of these various confusions was that Andrea did not receive the support she needed. 2.5.5. Over the following few weeks, the family were visited regularly by a health visitor and were seen at the GP practice. The Health Visitor and a Tenancy Support Officer made clear observations about the care the twins were receiving and appropriately shared these concerns with the Early Help Social Worker, including; bleeding nappy rash, poor weight gain, the twins being cold to the touch and hungry, rough handling, poor hygiene standards, health and safety concerns (including the out of control behaviour of a dog in the household, lack of parental understanding of the risks posed to the twins by household objects or unhygienic living conditions) and Charlotte’s aggressive behaviour. Andrea was noted to be in financial difficulties, she seemed ‘disassociated’ and there were concerns about the twins witnessing violence in the household.   2.5.6. These concerns were appropriately shared amongst the professionals and were indicative of neglect, but this term was not used by any of the professionals involved and no changes resulted for the children. For children to be adequately safeguarded, clear guidance needs to be available to inform and underpin the work of safeguarding practitioners in this complex area. In the area, there is no specific framework or tools to support an understanding of neglect and this was felt to be significant in explaining why neglect was not considered. This is explored further in Finding 3.  2.5.7. At the end of January, the twins were due for a routine GP appointment alongside their first immunisations. The Health Visitor shared her growing concerns, about possible failure to thrive, with the GP. Sharing concerns, taking time to analyse the concerns and agreeing next steps, was good practice. The GP subsequently wrote a letter of referral to the  14                                                    SCR: Emily Final Report Community Paediatrician and the weight charts were included. However, the wider concerns did not form part of the letter of referral. 2.5.8. Based on the weights that had been plotted, the Community Paediatrician concluded there was no evidence of failure to thrive. The GP was informed, and the Community Paediatrician took no further action. At this point, although many of the professionals were very concerned, the multi-agency group appeared stuck as to the next steps. Whilst the referral to the Community Paediatrician was appropriate (and received a prompt response), the twins required a holistic assessment based on an informed understanding of neglect so that the full range of their needs/ experiences were considered alongside a judgement about parental capacity. The importance of understanding neglect is explored in Finding 3.   2.5.9. Twelve days later, a nursery nurse visited the family and made many detailed and astute observations about the care the twins were receiving and appropriately shared these concerns with Early Help. Concerns included; unsafe sleeping arrangements, Andrea’s lack of awareness of the risks presented to the twins by household hazards, significant nappy rash, the twins being naked and cold to the touch, Charlotte’s verbal aggression in front of the twins and her rough handling of them, feeding that was described as ‘functional’ (with no emotional warmth) and Andrea’s apparent fixation on a constricted feeding regime. The view of the Nursery Nurse was that the babies were exhausted from crying, due to hunger. Early Help advised that the twins should be seen by the GP for an urgent appointment.  2.5.10. The GP saw the twins promptly and noted they were low weight and, contrary to professional advice, Andrea confirmed she fed them water in between formula feeds.  The GP fed this back to the health visitor who appropriately sought advice from their safeguarding lead and contacted Early Help to request that the case was escalated, this was good practice.   2.5.11. The clear and succinct concerns of the Nursery Nurse, the immediate report made to Early Help, the follow up appointment made by the GP, the swift report made to the Health Visitor by the GP, the supervision accessed by the Health Visitor and the immediate request for escalation, were all good practice. The focus of the health professionals was correctly focussed on assessing the risk, cross checking with each other and referring for step up. 2.5.12. Early Help agreed to ‘step up’ the case to Front Door, to elicit a child protection response. The Emergency Duty Team (EDT) was contacted to request that a visit was made over the weekend.  EDT declined to visit the family on the basis that it was not an emergency. A follow up visit was booked by Early Help for the following Monday. As this was a case of chronic neglect, and not immediate risk, the decision by EDT was proportionate. However, no further attempt was made to step up the case to Front Door, either at the time or subsequently, and the professionals involved were left with a false impression that the referral to EDT constituted a failed attempt to ‘step up’ the case. It  15                                                    SCR: Emily Final Report was not possible to fully understand this confused response by Early Help, although the issues explored previously and in the Additional Learning are relevant.        2.6. Completing the Single Assessment (SAF)  2.6.1. This period looks at the impact of an uncompleted SAF on multi-agency decision making and risk assessment.   2.6.2. The Early Help Social Worker visited the family on the following Monday. During this visit, concerns highlighted by five professionals (health visitor, nursery nurse, tenancy support officer, children’s centre manager and GP) were briefly raised and advice was provided. Following this visit, a multi-agency Team around the Family (TAF) meeting was arranged to take place 10 days later (although this wasn’t shared with Andrea at the time).  Given the level of concerns around Andrea’s care for the twins, a prompt multi-agency meeting should have taken place sooner. This response was disproportionate to the risks in this case and left the professionals working with Emily without an assessment or plan.  2.6.3. By the 26th of February, the SAF, started by Early Help when the twins were discharged, remained incomplete (this was some 8 weeks after it had been started). As it stood, it was purely a narrative account of the information received at the original point of referral and by the time of the TAF (on the 26th of February) the information was out of date. As the SAF was never finalised, its contents were not shared with Andrea, her engagement with services was not discussed, and her views were not recorded. There was no information about the extent of professional concerns over the 8 weeks since the twins had been discharged, there was no analysis, no sense of the twins lived experiences, and no management oversight, this fell below expected practice. 2.6.4. At this time, there was little practice guidance policy/procedure in place to guide the work of the Early Help teams in relation to completion of the SAF and the TAF. There was scant management overview and guidance and the working relationships between Early Help and Children’s Social Care / Front Door were unclear. Since this time, there have been considerable changes within the Early Help service and as a result no finding has been made. However, relevant issues are discussed further in the additional learning.     2.6.5. The TAF meeting was the first opportunity for professionals to collectively share information, clarify the risks, and agree next steps. It was attended by Andrea, the Early Help Social Worker, children’s centre staff, the Health Visitor and the Tenancy Support Officer. There were no formal minutes of this meeting, however, the notes made by the Tenancy Support Officer indicate that whilst concerns were raised by professionals the overall focus of the meeting, and the plans that were made, focussed on Andrea’s needs and little reference was made to the needs of the twins. It was unclear what needed to change for the twins to be adequately parented and safeguarded from harm. The absence of formal notes and the focus of the TAF fell below expected practice. Importantly, whilst the meeting seemed focussed on Andrea’s support needs, despite frequent professional observations that Andrea may have learning difficulties, there was no consideration of the  16                                                    SCR: Emily Final Report impact of any learning difficulties on Andrea’s ability to care for the twins or on the reasonable adjustments that should be made by services.  Meeting the needs of adults with learning difficulties (diagnosed or otherwise) is discussed further in Finding 4.   2.6.6.  Emily sadly died two weeks after the TAF meeting. 2.7. What makes learning from this case more widely applicable? 2.7.1. The ‘Learning Together’ methodology uses an individual case to provide a ‘window on the system’, identifying whether the learning that has been identified in one case is more systematic and widespread, thereby leading to a broader understanding about what supports and what hinders processes and practice locally. The Findings for the Board are identified out of the appraisal of practice, and those areas of learning that provide the most significant illumination for wider practice are then prioritised. 2.7.2. This case highlights elements of good practice by the professionals involved. However this case also shows that despite individual dedication and enhanced levels of inter-professional communication and home visits, the lack of an informed, structured, multi-agency response meant that the service response was confused, leaving both Andrea and the twins without the services they most needed.     3. The Findings 3.1. Summary of findings 3.1.1. This section contains findings that have emerged from the SCR. Each finding lays out the evidence identified by the review team that indicates that these are not one-off issues. Evidence is provided to show how each finding creates risks to other children and families in future cases because they undermine the reliability with which professionals can do their jobs, and therefore provides useful organisational learning to underpin improvement. 3.1.2. Four priority findings were chosen because they represented areas of practice which were significant in how this case was managed, but which also reflected wider patterns of practice and the systems which underpin that practice. They relate to one of the six categories of underlying patterns. Each finding is set out in a way that illustrates:   How does the issue feature in this particular case?   How do we know this issue is underlying and not unique to this case?  What is known about how widespread this issue is?  What are the implications for the reliability of the multi-agency child protection system? 3.1.3. The evidence for the different ‘layers’ of the findings comes from the knowledge and experience of the Review Team and the Case Group, from the records relating to this case, other relevant documentation and from relevant research evidence.   17                                                    SCR: Emily Final Report 3.1.4. The remainder of this section explores the four Findings.                                     FINDING                     Typology  FINDING 1: The risks associated with twins and prematurity are not routinely articulated or understood across multi-agency partners resulting in a lack of clarity around the additional needs of these children and the services required.   COMMUNICATION & COLLABORATION IN LONGER TERM WORK FINDING 2: Current service provision in England is largely predicated on a formulaic understanding of domestic abuse that inadvertently leads to a tolerance of sibling violence that would not be accepted for intimate partners, leaving the risk for children unassessed and not acknowledged.  MANAGEMENT SYSTEMS      FINDING 3: The lack of a multi-agency neglect framework and toolkit inhibits a shared professional understanding of neglect resulting in a reluctance to name the cause of harm to a child as neglect and leads to a confused multi-agency response.   MANAGEMENT SYSTEMS FINDING 4: Professionals overreliance on diagnosis fails to recognise the continuum of needs of parents who have learning (or mental health) difficulties and the potential impact on children.  COMMUNICATION & COLLABORATION IN LONGER TERM WORK   Findings in detail  3.2. Finding 1  FINDING 1: The risks associated with twins and prematurity are not routinely articulated or understood across multi- agency partners resulting in a lack of clarity about the additional needs of these children and the services required.  Introduction 3.2.1. Babies are entirely dependent on their immediate caregivers, and a parent’s capacity to respond appropriately to the emotions and needs of their babies has a profound impact.  18                                                    SCR: Emily Final Report Becoming a new parent is a major transition; there are times when every parent feels under pressure and may struggle to cope with the stresses and responsibilities of their role. For parents of premature babies this can be a particularly challenging time, with additional challenges compounding this stress. “Premature birth is a significant stressor for parents and may adversely impact […] parenting behaviour” 9 3.2.2. Premature babies are defined by the World Health Organisation as those born before completing 37 weeks in the womb. This is an important issue as organ development over the last few months and weeks of pregnancy is vital. Premature babies can face particular physical and emotional challenges after discharge and if babies have been in a special care unit this may impact on quality of attachment between baby and parent. In addition, inevitably there will be a period of adjustment for babies after moving from an environment where they have been used to a fixed routine on the ward regarding feeding and sleeping, are familiar with an external environment that includes fixed light and temperature and where they are protected from common household dangers and infections.   3.2.3. Equally, there will be a period of parental adjustment. Evidence10 suggests that caring for premature babies can be stressful for any parent and as a result it can be harder to develop a good parent – child relationship. If compounded by the additional stress of multiple births and pre-existing parental vulnerabilities, it is imperative that the multi-agency network fully understands these complex needs and responds appropriately. This finding suggests that these vulnerabilities are not routinely articulated or understood, and this has a corresponding impact on the support that is provided.    How did this finding manifest in this case? 3.2.4. The twins were born at 34 weeks, and spent their first few weeks of life in a special care unit. Andrea was discharged 3 days after their birth, whilst the twins remained in special care, and during this time Andrea had intermittent contact. After two weeks, in line with usual practice, Andrea was readmitted and discharged with the twins five days later (just prior to the twins reaching full term). That night, calls were made to the emergency services by Charlotte and Andrea attended A & E as the twins were in some considerable distress; it was concluded that the probable cause of their distress was hunger. The next day, a midwife visited and was very concerned about the filthy state of the family home (including a significant number of health and safety issues), the feeding regime in place and Andrea’s overall care of the twins.                                                            9 Bilgin, A. and Wolke, Dieter. (2015) Maternal sensitivity in parenting preterm children: a meta-analysis. Pediatrics, 136 (1). e177-e193. ISSN 0031-4005 10 Cuthbert, et al (2011) All babies count: prevention and protection for vulnerable babies: a review of evidence (NSPCC)   19                                                    SCR: Emily Final Report 3.2.5. In the various referrals, assessments and correspondence between health professionals (including specialist midwives, community midwives, safeguarding midwives and a health visitor) and with Children’s Services (including Front Door and Early Help) whilst concerns were raised about Andrea’s vulnerabilities and her care of the twins (including but not exclusive to her feeding and handling of the twins), there were no references to the specific risks posed by multiple births and prematurity and no impact analysis of these combined factors (actual or predicted). Overall, the information passed to Children’s Services Front Door Team was characterised by a narrative description. As a result, the risks were not fully understood and the service response was both confused and delayed.  How do we know this issue is underlying and not unique to this case?   3.2.6. During the Case Group Meeting, members of staff from the intensive care unit were asked about whether it would be normal practice to articulate the specific risks associated with multiple births and prematurity when completing a parenting assessment or when referring to Children’s Services. It was confirmed that this is not routinely specified as there is an assumption that staff within Children’s Services would be conversant with these particular risks. It is understood that relevant local guidance available at the time) does not highlight these specific risks and this provides a partial explanation for why it is not common practice for these risks to be articulated.    3.2.7. In addition, staff were asked about discharge planning meetings and whether these were held in cases of multiple vulnerability (such as those identified in this case). Practitioners confirmed that unless Children’s Services are involved it is not routine practice to hold discharge planning meetings in these circumstances.  What is known about how widespread this issue is?  3.2.8. It was understood that this issue has been previously recognised by Front Door and there has been some joint work with midwifery services to improve the quality of the referrals so that an accurate judgement on risk and service provision can be made. However, a recent Serious Case Review in the area has identified the quality of referrals to Front Door from multi-agency partners as an ongoing safeguarding issue.  What are the implications for the reliability of the multi-agency child protection system? 3.2.9. Nearly 1 in 10 babies are born prematurely and many will spend time in a neonatal unit11. It is not known how many of these babies will have additional vulnerabilities because of their parents/family circumstances, or how many of these are multiple births, but research suggests that they are at increased risk of abuse and neglect. In a system that is working well, the expertise held by specialist staff within these units (and by staff based within the                                                            11 According to the Office for National Statistics, 52,160 babies - 7.3% of live births – in England and Wales were born prematurely during 2012: http://www.ons.gov.uk/ons/rel/child-health/gestation-specific-infant-mortality-in-englandand-wales/2012/index.html  20                                                    SCR: Emily Final Report community) will be used to its full advantage by incorporating this expert knowledge in assessments, referrals and in communication with multi-agency safeguarding colleagues. However, if assumptions are made about the knowledge of other professionals and an assessment of risk is regarded as the domain of others, the risks to children will not be understood and children will not receive the services they need.   FINDING 1: The risks associated with twins and prematurity are not routinely articulated or understood across multi-agency partners resulting in a lack of clarity about the additional needs of these children and the services required.  Summary Prematurity and multiple births are key factors to consider when assessing need. Staff within health services, including but not exclusive to midwifery services and neonatal staff, are well placed to provide multi-agency partners with expert advice about a baby’s needs and parental capacity to inform multi-agency decision making. In the absence of this, there is a danger that decisions about service provision will be ill-informed and the risks to children potentially unacknowledged.    Questions for the Board   How has recent work to improve the quality of referrals been evaluated? Is there a need for additional work to be completed to address the specific issues highlighted in this finding?  Is there a need to reconsider the criteria for holding a discharge planning meeting?   How will the Board evaluate required improvements?      3.3. Finding 2  Finding 2: Current service provision in England is largely predicated on a formulaic understanding of domestic abuse that inadvertently leads to a tolerance of sibling violence that would not be accepted for intimate partners, leaving the risk for children unassessed and not acknowledged.  Introduction 3.3.1. The Government defines domestic abuse as: “any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality.” The behaviour captured in this definition includes: “…a pattern of acts of  21                                                    SCR: Emily Final Report assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim”12. 3.3.2. A growing body of research13 has demonstrated that domestic abuse is not a single phenomenon and that types of domestic violence can be differentiated with respect to the dynamics, context, and consequences, and suggests that four patterns of violence can be identified:  coercive controlling violence where one person is violent and controlling  violent resistance, usually a form of self-defence  separation instigated violence, which occurs in the context of relationships ending; and  situational couple violence, the most common form of domestic abuse, which is conducted by individuals of both genders nearly equally and is likelier to occur among younger couples, such as adolescents.  3.3.3. From a child’s perspective all types of domestic abuse present risks to their physical and emotional wellbeing; a child living within loud and chaotic homes where there are regular arguments between household members will, regardless of the relationship between these household members, perceive this as a threat and this will inevitably lead to triggering a stress response.  If ongoing, this can have profound consequences for their development by affecting their brain neurons / pathways14 and research is increasingly suggesting that this can have a long-term impact on a child’s physical and mental health, and on their social relationships and learning.   How did this finding manifest in this case? 3.3.4. When asked to describe the household within which the twins lived, all practitioners spoke about this being both loud and chaotic with frequent arguments occurring between all the siblings. They spoke of Charlotte’s aggressive and controlling behaviour towards Andrea, particularly concerning the care of the twins.   3.3.5. During the 3-month period under review there were several occasions when it was clear the twins had been exposed to violence, including an occasion when the police were called to the home after a fight occurred between Charlotte and Jake in front of the twins. There                                                            12 https://www.gov.uk/domestic-violence-and-abuse    13 Working relationally with couples where there is situational violence’ A policy briefing paper from ‘The Tavistock Centre for Couple Relationships’ www.tavistockrelationships.ac.uk/policy. And: Johnson, M.P. (2008) A Typology of Domestic Violence: Intimate Terrorism, Violent Resistance, and Situational Couple Violence. The North-eastern series on gender, crime, and law. Lebanon, New Hampshire, US: UPNE  14 Such as: National Scientific Council on the Developing Child, 2005, 2007, 2010) Chaotic homes and school achievement: a twin study. Hanscombe KB, Haworth CM, Davis OS, Jaffee SR, Plomin R J Child Psychiatry. 2011. The role of chaos in poverty and children's socioemotional adjustment. Evans GW, Gonnella C, Marcynyszyn LA, Gentile L, Salpekar (1987). The physical environment and development of children. Handbook of environmental psychology (pp. 281–328). New York, NY: Plenum Press  22                                                    SCR: Emily Final Report was additional information to suggest that Andrea was regularly bullied and controlled by her sister and was unable or unwilling, because of her reliance on her sister to provide care to Emily, to effect any change in this relationship. Charlotte was recorded as taking over, shouting and using derogatory comments, breaking the stair gate in a rage, and Charlotte was witnessed as being loud and aggressive in front of the twins – making them visibly flinch. Despite these known concerns, the impact on the twins was not adequately considered.      How do we know this issue is underlying and not unique to this case? 3.3.6. Discussion within the Review Team and Case Group suggested that although they were clearly concerned about Charlotte’s behaviour towards both Andrea and the twins, they did not understand that this aggressive, controlling and violent behaviour could constitute domestic abuse, and struggled to articulate the impact of this behaviour on Andrea’s wellbeing or the children’s lived world. It seemed that this form of violence was not something that was considered when assessing risk.    3.3.7. Current training models and service provision for families experiencing domestic abuse can often be premised on a traditional assumption that domestic abuse is coercive and controlling violence (usually involving a male perpetrator and a female victim) and that this can only be construed as abuse if it involves an intimate relationship.   What is known about how widespread this is?  3.3.8. There is considerable research and available data on domestic abuse perpetrated by men on women, and about children living in these environments.15  3.3.9. Eight million people in the UK (24.4% of people between the ages of 16 and 59) have been victims of domestic violence and abuse (6.1% in the year 2011/12), and 25% of young people have witnessed at least one episode of domestic violence and abuse by the age of 18.16 One in seven (14.2 per cent) children and young people under the age of 18 will have lived with domestic violence at some point in their childhood.17 3.3.10. However, these statistics do not provide sufficient evidence about the nature of the domestic abuse that is being recorded and there is little current UK research about the diverse types of domestic abuse or the numbers of children affected.  3.3.11. Research completed by the Centre for Justice18 highlights the limitations of current perceptions and service response to domestic abuse:                                                             16 Early intervention in domestic violence and abuse Jonathon Guy with Leon Feinstein and Ann Griffiths 17 Early intervention foundation. Meeting the needs of children living with domestic violence in London Research Report Lorraine Radford, Ruth Aitken, Pam Miller, Jane Ellis, Jill Roberts and Ana Firkic Refuge/NSPCC (research project funded by the city bridge trust November 2011) 18 Domestic Violence, Breaking the Cycle a Report for the Centre for social Justice. Farmer and Callan 2012   23                                                    SCR: Emily Final Report The logical response to the power and control approach (to DA) emphasises providing safety and resources for female victims fleeing abuse, a punitive response to male perpetrators via the criminal justice system, prevention campaigns aimed at challenging patriarchal attitudes and treatment programmes that challenge and confront male perpetrators about the controlling and sexist motivations behind their behaviour. 3.3.12. The report asserts that a far more complex view needs to be taken both to the perceptions of domestic abuse and services adapted accordingly.  What are the implications for the reliability of the multi-agency child protection system? 3.3.13. A safe system considers the impact of any form of domestic abuse on victims and children, supports professionals to consider broader factors (that are not based on a gendered stereotype of this form of abuse), encourages a more nuanced understanding of what constitutes domestic abuse and ultimately invites different professional responses. 3.3.14. Current child protection systems are well established to consider risk when children are living in households where there is domestic abuse perpetrated within an intimate relationship, and commonly involving male on female violence. This is a well-known child protection concern; services are alert to the risks to children who are living in this environment and suitable services are available. However, holding a restricted view of what constitutes domestic abuse, and perceiving the impact on children as constrained within an established familiar construct fails to appreciate a child’s lived experiences and presents risks to the child’s immediate and long-term safety and development.    FINDING 2: Current service provision in England is largely predicated on a formulaic understanding of domestic abuse that inadvertently leads to a tolerance of violence perpetrated by siblings that would not be accepted for intimate partners, leaving the risk for children unassessed and not acknowledged.  Summary   To effectively safeguard children, professionals working with children and families need to be aware of the differences in the nature of domestic abuse and first and foremost consider the perspective of the child who is growing up in an environment where domestic abuse is present. As it currently stands, a formulaic service response and understanding of domestic abuse seems to prevail and this has significant implications for multi-agency safeguarding practice.   Questions for the Board   How well does current training provision address the issues highlighted in this finding?  Are any adjustments needed to ensure that services currently provided to victims and perpetrators of domestic abuse and to children reflect the latest research and the issues highlighted in this finding?    24                                                    SCR: Emily Final Report      3.4. Finding 3  FINDING  3: The lack of a multi-agency neglect framework and toolkit inhibits a shared professional understanding of neglect resulting in a reluctance to name the cause of harm to a child as neglect and to a confused multi-agency response.    Introduction 3.4.1. Emily’s sad death at 12 weeks old has been recorded as “unascertained” and therefore comes within the category of “Sudden Unexpected Death in Infancy” (SUDI). This is the term used to describe the sudden and unexpected death of a baby. Around 290 children under one die every year of SUDI in the UK. Most are babies under 6 months.19 Many of the known risk factors underpinning SUDI are consistent with and seen in cases of neglect. In this case, no link between the neglect experienced by Emily and her death was found. 3.4.2. While the causes of SUDI are not fully understood there are established risk factors and they include:  Dwelling in an area of perceived high deprivation  Smoking;  Parental mental health;  Domestic violence;  Premature/low birth weight;  Parental substance misuse;   Co-sleeping;  Parental alcohol consumption 3.4.3. The link between SUDI and neglect is reported in the 2012 biennial study of findings in Serious Case Reviews.20 3.4.4. Brandon highlights that neglect is a particularly difficult area of work for practitioners. Identifying multiple risks, naming concerns as potential neglect, working within the framework of support, monitoring and judging progress and finally determining whether the child protection framework is appropriate for intervention presents a challenge.                                                            19 Sudden Infant Death Statistics, Office of National Statistics, 2015. 20 Brandon et al 2012.  25                                                    SCR: Emily Final Report 3.4.5. Brandon emphasises the need to consider the importance of interacting risk factors, and states: “Our previous work 21 has emphasised the importance of an interacting risk perspective. This holds true for these cases of SUDI where interacting risk factors for example prematurity, parental smoking, alcohol misuse, deprivation and co-sleeping would have elevated the risk to the infants”  and goes on to say:   “…practitioner uncertainty regarding thresholds, criteria and what constitutes significant harm and neglect can lead to confused opinions. Unrealistic practitioner optimism may also result when small changes to a child’s circumstances are made which are given too much ‘weight’ when the overall risks remain unchanged. […] defining neglect in terms of the likelihood of significant harm or impairment to the child’s development rather than on whether the child has been harmed, may encourage practitioners to focus on whether a child’s needs are being met, regardless of parental intent.” 3.4.6. The use of tools is well recorded and noted in many SCR’s. Tools help measure and define risk, provide a framework to support practitioner assessment, increase the potential to bring objectivity and support multi-agency understanding of the family situation. In this case, it was found the neglect was not conceptualised by any of the professionals involved and the absence of framework and associated tools was found to play an important part in this.   How did this finding manifest in this case? 3.4.7. Initial professional contact at the booking appointment identified that Andrea had past vulnerabilities which would indicate potential risk and correctly referred on to a specialist safeguarding midwife. Subsequent contacts with health and medical professionals also correctly identified and recorded multiple concerns, with significant consistencies as evidenced in case recording by different professionals. These included Andrea’s historical vulnerabilities including low mood, self-harm and depression, lack of support to assist with parenting and her own concerns on how she will cope, and the more immediate risks following the twins’ discharge of the filthy conditions of the home. 3.4.8. Professionals openly raised concerns that Andrea may have low levels of understanding and queried a learning difficulty, noted she appeared disengaged from meeting the basic needs of feeding and changing and was unable to control or influence her family support. They noted poor weight gain, the twins often appearing distressed through delayed feeding, bleeding nappy rash, rough handling, functional feeding, Andrea appearing                                                            21 Brandon et al 2008  26                                                    SCR: Emily Final Report disassociated and often in low mood, the twins visibly flinching in response to the loud and aggressive behaviour within the household, an unsecured dog, and a lack of awareness about hygiene and the safety of the twins. 3.4.9. In response to the level of concern felt by professionals, a high level of professional activity took place and there was frequent communication between them to make sure that someone would see or speak to Andrea daily. Andrea’s acceptance of this level of contact was seen as positive, with small successes such as attending a children’s centre group being accepted as an indication of progress. 3.4.10. The missing element seen in this case and one of most crucial importance was that of a shared understanding between professionals of the interacting risks, the compounding impact of these upon the lived experience and long-term development of the twins and an unwillingness to name the possibility of actual or likelihood of neglect.   How do we know this issue is underlying and not unique to this case? 3.4.11. In this case it is notable that none of the tools available to help with an objective assessment of neglect or to address the numerous concerns were used. The lack of identification of neglect by all the professionals in this case, and a corresponding reluctance by the Review Team to name the harm the twins were suffering as neglect, suggest that the difficulties in conceptualising and naming neglect is not unique to this case.  3.4.12. In addition, during this SCR a review team member reviewed several cases held at early help level and found no evidence of neglect being named as part of a risk assessment, despite features being present.  3.4.13. The Lead Reviewers were told that the Signs of Safety (SOS)22 approach has been recently adopted in the area and that this approach discourages professionals using the term neglect, instead encouraging a descriptive account of parental behaviours and impact on a child (rather than use of a simple term such as neglect that in isolation is unhelpful to parents). The Lead Reviewers had some sympathy for this view and it is clear that the SOS approach is a very helpful way of articulating impact and balancing the risks and protective factors. However, in the absence of a specific neglect framework or tools (such as Graded Care Profile - GCP) 23 this may run the risk of dissipating professional concerns and may lead to confusions within the multi-agency network about how to frame the safeguarding risks and provide a timely response. What is known about how widespread this issue is?                                                             22 A solution-focused, strengths- based approach to social work practice; Eileen Munro, Terry Murphy and Andrew Turnell 23 The GCP scale was developed by Dr Srivastava in the early 1990s, GCP has been deployed in over 60 local authorities to help identify and intervene in cases of child neglect.  27                                                    SCR: Emily Final Report 3.4.14. Recent research and SCR’s demonstrate how multi- agency risk assessment and effective intervention in cases of neglect continues to present a challenge to safeguarding practitioners and services. 3.4.15. Neglect is the most common form of child maltreatment in England (Department for Education, 2013; Radford et al, 2011) and the USA (Sedlak et al., 2010). In England, almost half (43%) of child protection plans are made in response to neglect, and it features in 60% of serious case reviews (Brandon et al., 2012).24 A key and recurring theme throughout the previous biennial reviews has been the extent and significance of neglect in the children’s lives. This is evidenced yet again in this latest review for 2011-2014.25 3.4.16. Recent evaluation by the NSPCC26 of the use of a tool in the assessment of neglect (GCP) recognised that the use of this framework and associated tools enabled practitioners to identify risks and potential harm more effectively, particularly in cases of neglect, and assisted in either allaying concerns or effectively escalating concerns to secure an appropriate response. What are the implications for the reliability of the multi-agency child protection system?  3.4.17. If neglect is conceptualised within an informed framework, the causes of neglect are better understood, appropriate tools are used to understand the impact of neglect from a child’s perspective and services are more able to provide effective, timely, intervention. In a system that struggles to identify neglect, and as a consequence is unable to provide effective services, at best children will remain living in conditions that will have a detrimental long-term impact on their emotional, behavioural, physical and mental health, at worst the safety of children will be seriously compromised.            FINDING 3: The lack of a multi-agency neglect framework and toolkit inhibits a shared professional understanding of neglect resulting in a reluctance to name the cause of harm to a child as neglect and leads to a confused multi-agency response.   Summary   Neglect presents complex challenges to practitioners and services. It continues to be a common feature of serious case reviews and researchers, policy makers and child protection services remain concerned                                                            24 Missed opportunities: indicators of neglect – what is ignored, why, and what can be done? Research report November 2014 Marian Brandon, Danya Glaser, Sabine Maguire, Eamon McCrory, Clare Lushey & Harriet Ward – Childhood Wellbeing Research Centre 25 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 Peter Sidebotham, Marian Brandon, Sue Bailey, Pippa Belderson, Jane Dodsworth, Jo Garstang*, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen University of Warwick University of East Anglia 26 National Evaluation of the Graded Care Profile Robyn Johnson and Richard Cotmore NSPCC Evaluation department, Oct 2015   28                                                    SCR: Emily Final Report about the quality and consistency of service provision in tackling neglect. Equipping practitioners and services with an informed neglect framework and tools has shown to be effective in how neglect is understood, and how children are safeguarded.  Questions for the Board   Should the LSCB adopt a neglect framework and suitable tools to compliment use of the SOS approach across the multi-agency network?  3.5. Finding 4  FINDING 4: Professional overreliance on diagnosis fails to recognise the continuum of needs of parents who have learning (or mental health) difficulties and the potential impact on children.     Introduction  3.5.1. The shared understanding and the use of terminology for people with learning difficulties or learning disability continues to cause much confusion between professionals, with agencies publishing differing definitions and guidelines according to their professional background, commonly with an emphasis and reliance on meeting thresholds to achieve diagnosis.  3.5.2. National statistics show that up to 1 in 5 of any population is likely to have a difficulty in learning, the extent to which this may impair daily life or learning as a child and can often lead to a diagnosis by a medical professional or through chartered psychologists. Such diagnoses are determined by multiple factors and can either follow a medical route expressed through NICE guidelines or a psychological route through the British or American Psychological Society.   3.5.3. Intellectual functioning is usually determined through comprehensive testing and is frequently reported in age equivalents, where chronological age and comparative intellectual functioning are used to support description of usual cognitive functioning.  Adaptive and social functioning is a broad definition and relates to a person’s performance in coping on a day-to-day basis with the demands of their environment; in simple terms, “what they do”. In order to determine adaptive and social functioning it is usual to undertake assessment, using recognised scales and checklists and these are usually completed by professionals with the person in question and or family members/others.  3.5.4. This, in simple terms, sets out the familiar approach to any assessment, where accepted tools are used to determine whether diagnostic thresholds have been met. Receiving a diagnosis of a learning disability is important in medical and legal contexts and so, it follows, must be important within a safeguarding context, when parenting ability is being assessed. Consistent with any threshold, there will be some cases that do not meet the  29                                                    SCR: Emily Final Report required threshold for a learning difficulty diagnosis as the level of need is not significant enough. But it is too simple and too big a jump therefore to assume therefore that no learning difficulty exists. This leads to the crux of the matter when trying to determine safe and effective parenting.  Applying such a threshold potentially ignores significant numbers of the population because their levels of need are simply not “significant enough”.   3.5.5. Much time and energy could be spent on trying to determine a single, shared definition, however the reality is that this is likely to be unachievable and masks the questions of most importance here, which is how far does having a learning difficulty or disability, and to what level, impact upon a person’s ability to parent safely? Do professionals have a shared understanding of this and how do they take any such learning difficulty into account when assessing and identifying immediate or longer-term impact upon children? 3.5.6. This becomes even more complex as disability (which can include a learning difficulty) is a protected characteristic under the Equality Act 2010 (EA2010) and forms the legislative basis for the Public-Sector Equality Duty (PSED). Both the Equality Act and Public-Sector Duty are underpinned by the Human Rights Act (HRA). Under the HRA adults can self-declare a protected characteristic including where they have difficulties or impairments which may impact upon many areas of their life.  3.5.7. The Public-Sector Equality Duty (PSED) covers all public-sector employees and functions and is referenced in NICE guidelines. The PSED requires consideration of any protected characteristic and where this may apply for public sector employees to determine if they should apply any reasonable adjustments. Examples of reasonable adjustments include providing information in different formats or in different ways, offering services more flexibly and taking into account the protected characteristic in any assessment or allocation of service. Applying a reasonable adjustment does not require meeting a diagnostic threshold. How did this finding manifest in this case? 3.5.8. Andrea had contact with multiple professionals (community midwife, a specialist midwife, hospital midwives, a health visitor and nursery nurse, GP, practice nurses, early help social worker, tenancy support officer, children’s centre manager and children’s centre worker) and all of them queried whether Andrea had a learning difficulty. They recognised and described Andrea as seeming much younger than her age and identified the ideal support as one which is not available to her age group (e.g. Family Nurse Partnership). The GP recognised this could be important from previous experience and looked up Andrea’s personal records. She confirmed that Andrea did not have a diagnosis of any learning difficulty. Andrea never suggested to any professionals that she had a learning difficulty and no professional ever raised this with her, although it was accepted by all and was not challenged. 3.5.9. In the absence of a diagnosis the professionals were at a loss to clearly understand the impact of Andrea’s ability to consistently follow professional advice; they did not consider  30                                                    SCR: Emily Final Report whether Andrea needed reasonable adjustments for advice and guidance different to that which they usually offer. It isn’t clear why Andrea never had a learning difficulty assessment, we can only presume that her needs were not considered “significant enough” to trigger such an assessment and so none was undertaken.  3.5.10. It is also relevant to consider the amount of caring that Charlotte was undertaking for the twins. Charlotte routinely cared for Emily, which one case team member estimated as taking place more than 50% of the time, and a significant number of case recordings show that Emily was not available as she was with Charlotte. Charlotte did have a diagnosis of a learning difficulty and indeed told health professionals that she had a mental age of 7 years. Despite these concerns, the impact on the twins was not considered and no reasonable adjustments were made by services.   How do we know this issue is underlying and not unique to this case? 3.5.11. As a result of the commonality of this issue, the Review Team requested that the use of the term ‘learning difficulty’ and impact on service response was specifically explored during this SCR (Ref: Research Questions P.6). 3.5.12. The Lead Reviewers learnt that the use of the term learning difficulties was quite often seen within case recordings across the agencies, even when there had been no previous diagnosis. It was reported as being commonly used as  a phrase that indicated professionals were concerned about parental levels of understanding but without a diagnosis, professionals struggled to identify how services needed to be adapted or what reasonable adjustments needed to be made.      What is known about how widespread this issue is?  3.5.13. There are recent cases reported in Family Law courts where parents with diagnosed learning difficulties have launched defences based on the Equality Act, where they feel professionals have not taken into account reasonable adjustments. However, no research could be found on how reasonable adjustments, and the consideration of them, are used for those who do not meet diagnostic thresholds as applied for medical and legal purposes. 3.5.14. This issue is seen in a recent City and Hackney 2016 SCR27.  In this SCR the reviewer concludes that whether or not the criteria for learning difficulties or mental health is met, existing risk factors (arising from the fact that some level of learning difficulty or mental health difficulties are identified) should be assessed and considered as such. It is suggested it may be helpful to produce a tool for assisting professionals to assess levels of learning difficulties, and the potential impact upon parenting, and that a greater level of understanding of adult learning difficulties should be promoted across all agencies.                                                            27 Harrington, Kevin (2016). Serious case review: Child H: overview report. Hackney: City and Hackney Safeguarding Children Board.  31                                                    SCR: Emily Final Report 3.5.15. This SCR reported that the relevance of a diagnosis for the parent was not the most important factor and indeed could mask the true focus of services which should be about identifying other risk factors potentially arising from a parent with some level of learning difficulty, including the potential impact of neglect on the baby and the ability of that parent to meet the basic needs of a baby.  What are the implications for the reliability of the multi-agency child protection system? 3.5.16. Where there is a shared understanding of a parent’s needs, and a clear framework in place to address these needs, professionals are enabled to make an informed assessment of risk, assess parenting skills, and make a judgement on parental capacity to change.  This approach results in effective multi- agency assessment and planning to address risks and the provision of effective support for parents where needed.  3.5.17. In the absence of a diagnosis or a shared understanding of parental needs, the impact of any learning difficulty (perceived or actual) on parental capacity will be unknown. Professionals may hold false expectations of parental capacity and overly rely upon parents to keep their children safe. Such false optimism can lead to the risks being missed, and a failure to identify what services a parent may need (or what adjustments should be made to services) to enable a child’s needs to be met. The consequences are that children may be left too long in situations of harm, or conversely, ill thought out services provided that fail to give parents sufficient opportunity to effectively care for their children.  Finding 4: Professionals overreliance on diagnosis fails to recognise the continuum of needs of parents who have learning (or mental health) difficulties and the potential impact on children.    Summary The use of the term learning difficulty is commonly seen in multi-agency case recordings but when there is no formal diagnosis, professionals struggle to understand the needs of parents and the impact on parental capacity. When safeguarding children, locally agreed thresholds and guidance can provide a level of support, but more importantly, recognising the needs of parents with a perceived learning difficulty and making suitable adjustments to the way services are provided is critical in preventing harm to children and giving parents the best possible opportunity to parent their children and protect them from harm. Questions for the Board  How do professionals across all agencies understand the terminology of learning difficulties and consider how services will be provided to support those that have learning difficulties, with diagnosis or not?  32                                                    SCR: Emily Final Report  What changes in service provision may need to be made?   3.6. Additional Learning  Early Help  3.6.1. In line with the area’s commitment to intervening early in a child’s life to prevent problems developing or escalating and to enable a child to reach their full potential, Early Help Services are provided across the city to children with additional or complex needs. These children are supported by Early Help teams who are responsible for assessing need using a Single Assessment Framework (SAF) and planning for a child’s needs through multi agency meetings known as a Team Around a Family (TAF). 3.6.2. These children meet the threshold for intervention by statutory services. This group includes those children who require an assessment undertaken by a social worker to determine whether or not they are ‘children in need’. This is defined under section 17 of the Children Act 1989 and includes those who have already been assessed as children in need, and those who have suffered or who are at risk of suffering significant harm as defined under section 47 of the Children Act 1989.  3.6.3. The local area Front Door Team is the first access point to these services, receiving referrals from other agencies or from members of the community and making threshold decisions about levels of need and passing referrals to the service that would best meet these needs. Using a definition of urgent need, children’s cases are passed to Children’s Services. Alternatively, if it is concluded that on the information available a child has emergent, complex or additional needs, referrals are passed to the Early Help Service. This approach both meets the needs of children and families in providing a service to children which is led by their needs, and ensures that Children’s services have the capacity to provide an immediate response to children at risk of harm.  3.6.4. For this to work well, there needs to be a clear and dynamic interface between the Early Help and Children’s services, suitably well-trained professionals employed in these services, consistency in how risk is understood, how assessments are completed, and how plans are made, delivered, reviewed and monitored. The local authority acknowledges that a child and family’s needs are dynamic and therefore supports a fluid approach to the question of need and risk, it is an approach that underpins the reality of children and families lives; need is not static and therefore the service response must be subject to review and change. 3.6.5. In this case, the nature of the services provided by Early Help and the absence of any meaningful interface with children’s social care teams seemed to contradict this approach. It was understood that the reason for this was due to several factors. A significant remodelling of social work and Early Help had taken place in November 2014, family  33                                                    SCR: Emily Final Report intervention social work support had been moved into Early Help and Social Work Units were formed to work with child protection cases. Front Door focussed on determining immediate danger and providing a swift response, and Early Help on parenting support and longer-term work (with higher risk being stepped up to the new social work units).  3.6.6. The professionals within this case were unclear about how these changes (and the changes in services provided by children’s centres) interacted with service delivery. The response was therefore one of confusion, with significant delays and missed opportunities for a step up and the focus of intervention centred on support to Andrea, rather than on the lived experiences of the children.  3.6.7. No finding has been made about the Early Help Services, as it was understood that there have been some significant changes to the way Early Help and Front Door now operate. These changes include a far clearer and more robust interface between Early Help and the specialist teams, routine involvement of experienced social workers (who are more actively involved in decision making within both service areas), improved step up processes, strengthened policy and procedure in relation to the work of the teams and better management supervision oversight and review.   Summary In light of further changes currently taking place within the Early Help Service, the Board is recommended to consider the learning that has emerged from this serious case review (and others) and consider what more may be needed, if anything, to improve service delivery going forward.    Questions to the Board   How is the Board reassured that actions identified from previous Serious Case Reviews are evident in ongoing service delivery?      34                                                    SCR: Emily Final Report Appendix 1: References Bilgin, A. and Wolke, Dieter. (2015) Maternal sensitivity in parenting preterm children: a meta-analysis. Pediatrics, 136 (1). e177-e193. ISSN 0031-4005  Brandon. M, Danya Glaser, Sabine Maguire, Eamon McCrory, Clare Lushey & Harriet Ward Missed opportunities: indicators of neglect – what is ignored, why, and what can be done? Research report November 2014– Childhood Wellbeing Research Centre Cuthbert, et al (2011) All babies count: prevention and protection for vulnerable babies: a review of evidence (NSPCC)   Evans GW, Gonnella C, Marcynyszyn LA, Gentile L, Salpekar (1987). The role of chaos in poverty and children's socioemotional adjustment.   Farmer and Callan 2012 Domestic Violence, Breaking the Cycle a Report for the Centre for social Justice.   Fish, Munro & Bairstow: Learning Together SCIE 2010  Guy. J, with Leon Feinstein and Ann Griffiths Early intervention in domestic violence and abuse   Hanscombe KB, Haworth CM, Davis OS, Jaffee SR, Plomin R J National Scientific Council on the Developing Child, 2005, 2007, 2010) Chaotic homes and school achievement: a twin study. Child Psychiatry. 2011.   Johnson, M.P. (2008) A Typology of Domestic Violence: Intimate Terrorism, Violent Resistance, and Situational Couple Violence. The North-eastern series on gender, crime, and law. Lebanon, New Hampshire, US: UPNE  Office for National Statistics: http://www.ons.gov.uk/ons/rel/child-health/gestation-specific-infant-mortality-in-englandand-wales/2012/index.html  Office of National Statistics: Sudden Infant Death Statistics 2015.  Radford, L, Ruth Aitken, Pam Miller, Jane Ellis, Jill Roberts and Ana Firkic Early intervention foundation. Meeting the needs of children living with domestic violence in London Research Report Refuge/NSPCC (research project funded by the city bridge trust November 2011)  Robyn Johnson and Richard Cotmore. National Evaluation of the Graded Care Profile. NSPCC Evaluation department. Oct 2015  Sidebotham. P, Brandon, Sue Bailey, Pippa Belderson, Jane Dodsworth, Jo Garstang*, Elizabeth Harrison, Ameeta Retzer and Penny Sorensen. Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 Final report May 2016 University of Warwick University of East Anglia  The physical environment and development of children. Handbook of environmental psychology (pp. 281–328). New York, NY: Plenum Press  Working relationally with couples where there is situational violence’. A policy briefing paper from: The Tavistock Centre for Couple Relationships www.tavistockrelationships.ac.uk/policy.  