Death of six sibling children in May 2012, as the result of a fire at their home where they lived with their father and mother (mother (a)). Father and mother (a) and another adult were convicted of the manslaughter of all six children. Father lived simultaneously with his wife (mother (a)) and their six children and another partner (mother (b)) and their five children until February 2012. Family had appeared on television and had, at times, a high profile in the media. History of: paternal conviction for attempted murder and wounding with intent in 1978; domestic abuse in mother (a)'s previous relationship; and father and mother (a)'s suicide attempts within 2-weeks of each other in February 2012. Key themes include: overcrowding, with periods where up to 15 people were living in the household at the same time; the adults' relationships; father's history of violence; father's controlling and manipulative manner and his hostile and aggressive behaviour toward social workers; and the impact of media coverage on the family. Makes recommendations covering: children's services, police, education, health, fire and rescue services and housing services.
      
 Title:  Serious case review overview report: ED12 LSCB: Derby Safeguarding Children Board Author: Glenys Johnston Date of publication: 2014  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                        1            Derby Safeguarding Children Board       Serious Case Review Overview Report  ED12   Date: 15 January 2014    Independent Overview Report Author  Glenys Johnston OBE  2    Contents   Page  1 Introduction  3 2 The format of the Overview Report  4 3 The Decision to hold a Serious Case Review  4 4 Key Issues to be addressed by the SCR  7 5 The circumstances that led to this Serious Case Review  9 6 The Facts  9 7 Family History  10 8 Summary of Significant Events and Agency Involvement Prior to 2006 11 9 Consideration of the key themes  12 10 Conclusion  24 11 Recommendations  27  Appendix 1: The Review Process: Terms of Reference  29  Appendix 2 Agency Action Plans  33    3  1.0 Introduction  1.1 This Serious Case Review (SCR) overview report brings together, in a thematic format, the overall conclusions from information and analysis contained in the Independent Management Reviews (IMR), the Health Overview Report and supplementary information from the criminal prosecution of the parents. It does not seek to repeat the detailed contents of the IMRs or the recommendations they made.  1.2 The report has been written to comply with a Reporting Restriction Order and balances what can be published with information that cannot be disclosed, to avoid breaching the human rights of family members.   1.3 The delay in publishing the report is due to ensuring that all learning was obtained in respect of the large number of children and relevant family members involved. Delays were also incurred due to the necessity to obtain specialist legal advice and complying with above.   1.4 The father and mother(a) and their six children, and the same father and female partner (mother (b)) and five children lived at a house together in Derby. In February 2012 the relationship between the father and mother(b) broke down and she and her five children left the family home.  1.5 On 11th May 2012 a fire occurred at the home address where the father and mother(a) continued to live with their six children. All six children died, five on the night of the fire, and the oldest, later in hospital.   1.6 On 2nd April 2013 the father and mother(a) and another adult (adult (c)) were convicted of the manslaughter of the six children.   1.7 This has been a comprehensive review with full co-operation from all agencies the outcome is that despite the horrific deaths of these children there are few areas for learning for professionals.    4  2.0  The format of the Overview Report  2.1 As previously stated, the Overview Report will be published in a way that complies with the Reporting Restriction Order, upholds the human rights of the surviving siblings and ensures that their welfare is not adversely affected by publication.  2.2 To achieve this, the Overview Report sets out the narrative of the events thematically. This includes a brief overview of the circumstances, prior to a robust analysis of lessons learned in seeking to answer questions about multi-agency practice.  2.3 This thematic approach recognises the complex circumstances in which professionals work together to safeguard children and seeks to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight. Relevant research and case evidence has been used to inform the findings.  2.4 The thematic approach of the Overview Report includes analysis of the key issues set out in section 4 below. It summarises the relevant information that was known at the time to the agencies and professionals involved, about the parents/carers, any perpetrator and the home circumstances of the children.  2.5 The Overview Report seeks to analyse how and why events occurred, decisions were made and actions taken or not taken. The report considers whether different decisions or actions may have led to an alternative course of events.  3.0  The Decision to hold a Serious Case Review  3.1 At an extraordinary SCR Panel meeting on the 15th May 2012 the tragic deaths of the six children was discussed and it was noted that there were ongoing police investigations being carried out into the cause and person(s) responsible for the fire. There was no evidence at that time that the case should be considered as meeting the criteria set out in Working Together 2010 for a SCR.  3.2 Following the decision that the mother and father had been charged with killing their six children; notification was made to Ofsted of a serious childcare incident on 31st May 2012.  3.3 The SCR Panel considered the details known about the case on 11th June 2012. The Panel recommended that, from the evidence available at the time, 5  a SCR should be conducted. The rationale for this decision was that evidence indicated that the fire had been started deliberately and that the parents had been charged with murder.  3.4 The Panel noted however, that there would be difficulties in carrying out a SCR at this stage given the continuing and complex police investigation and the complexities around identifying and safeguarding other associated children and vulnerable adults, and recommended a pause in the process. Ms Christine Cassell, the Independent Chair of Derby City Local Safeguarding Children Board (DSCB) endorsed the recommendation of the Panel to review this incident, with the proviso that the timing of the review should take account of the ongoing investigation and related judicial processes, as well as the immediate safeguarding needs of the wider family.  3.5 On 26th June 2012 Ms Cassell wrote to the Department for Education (DfE) advising them of the complexities of the case and that as a result, a multi agency Gold Group had been convened. This group was responsible for co-ordinating the investigation and work with the family and were sufficiently concerned to have set up two specialist Silver Groups – one to ensure that the children within the family were identified and safeguarded and the second with a similar remit in relation to any vulnerable adults within the family.   3.6 It was noted that although the parents had been charged with murder, the evidence gathering was continuing and the DSCB was concerned not to prejudice the outcome of any criminal proceedings by commencing the SCR process at that stage.   3.7 There was a shared concern amongst all agencies that the information available at the time was not sufficient to enable a meaningful SCR to be commenced in relation to such complex circumstances. The DSCB wished to ensure the potential for identifying any learning was maximised and it was noted that this was not possible when new information continued to emerge on a daily basis.   3.8 The DfE wrote to the Ms Cassell on 13th July 2012 acknowledging the complexities of the case and accepting the reasons for delay.  3.9 At the SCR Panel on 3rd September 2012 it was agreed that the SCR review could proceed without potential adverse impact on the police investigation or the court case. It was also established that the immediate safeguarding of family members had been achieved and their future needs understood.   6  3.10 It was confirmed on the 12th October 2012 that:  Ian Johnson, Assistant Director, Safeguarding and Specialist Services, Derbyshire County Council would be the Independent Chair.  Glenys Johnston OBE would be the Independent Overview Author.   Ray McMorrow, Designated Nurse, would be the Health Overview Author  3.11 It was agreed that the question of whether the deaths of the children could have been predicted and prevented would remain key to the learning arising from the review.  3.12 The SCR focuses on the deceased children known for the purposes of this report as:  CH1   CH2   CH3   CH4   CH5   CH6   3.13 It was agreed that consideration would be given to any relevant information in relation to other family members who had lived at the address and, to a more limited extent, extended family members.   3.14 Following the conclusion of the Criminal Trial, a Reporting Restriction Order was made in respect of other family members who had lived at the address. In order to comply with this order the Overview Report was reviewed and appropriate redaction undertaken, following the advice of legal counsel. Mr Wise, QC, reviewed the draft report and consideration was given to the human rights and future short, medium and long term welfare interests of the surviving siblings and family members and the requirements of Working Together for LSCB’s to publish as much detail as possible.  3.15 In order to comply with the terms of the Reporting Restriction Order and also respect the ongoing human rights and welfare needs of the children it is appropriate to acknowledge that five other children were part of the household prior to the fire occurring. Their welfare and safeguarding interests are of paramount concern to the DSCB.  3.16 In order to ensure that the human rights of these children are upheld and prevent any potential adverse consequences of publishing details of their lives in the public domain, the Terms of Reference were subsequently amended to 7  reflect these circumstances and the SCR does not include additional information in relation to them.  4.0  Key Issues to be addressed by the SCR  4.1 What specific issues or questions does this case raise? Discussion at the SCR Panel on 3rd September 2012 and subsequently on 12th October 2012 and 3rd December 2012 identified the following key issues.  1. Overcrowding: It appears that there had been overcrowding issues at the home of the deceased children, but not at the time of their deaths. It needs to be determined whether or not the overcrowding constituted an issue that should have raised a safeguarding concern and how the impact of overcrowding on all the 11, and at times 12, children was understood. It needs to be determined whether or not at the time of re-housing requests from the father, safeguarding concerns should have been raised, and/or whether there were systems or processes in place for this to take place.  2. Adult relationships: What was known by agencies about the adult relationships at the home address? It needs to be determined whether there was any consideration of the impact of this on the emotional and psychological well being of the children living in the home.  3. Previous convictions and domestic abuse: What was known about the conviction of a domestic violence offence by the father in 1978 and any other subsequent concerns about domestic abuse or violence in relation to adult family members? It needs to be determined whether complaints about domestic abuse arising from the mother, or father's partner during the period they were all living together in the family home, or elsewhere, were acted upon appropriately and whether the safety of the children was considered in line with the safeguarding policies relevant and in place at the time.  4. Adult behaviour and manner: It needs to be determined whether or not the manner, presentation or behaviour of the father or adult members in the household impacted on the services provided by practitioners.   5. The impact of media coverage:  The family had appeared on television and at times had a high profile in the media. It needs to be determined whether the agencies were aware of this and whether or not this had an impact on their assessment or the assumptions staff 8  may have had about their own roles, and that of their and other agencies.  4.2 Footage in respect of family involvement in TV programmes has been collated by the Police as part of their ongoing investigation. This has been made available to me, as part of the review.  4.3 Are there any unusual factors in this case and if so what are they? The father lived simultaneously with his wife (mother(a)) and their six children and another partner(mother(b)) and five children until February 2012. This is not a frequently occurring family arrangement and it needs to be determined whether there is any indication that these arrangements were having a detrimental effect on the welfare of the children and whether appropriate consideration was given to their needs?  4.4 Are there similarities with previous IMRs or SCRs, if so, what are they? The Overview Author and Independent Chair both have experience of a SCR in which children died as a result of fire caused by a parent. Learning arising from this review and any other similar reviews has been considered.   4.5 Were there any failings or gaps in multi agency working? Early analysis by the SCR Panel does not identify obvious failings or gaps in multi -agency working but this has been considered by the review and action taken as required.  4.6 Are there any issues which relate to ethnicity, disability or faith which may have a bearing on this review? The initial scoping of the SCR did not identify specific issues relating to ethnicity, disability or faith that presented a significant dimension to the involvement of agencies with the family.  4.7 It needs to be determined whether or not the background and culture of the family were issues about which professionals and agencies could and should have been aware and whether or not this had an impact in respect of the safety of the deceased children.   4.8 Further details of the review process are attached at Appendix 1     9  5.0  The circumstances that led to this Serious Case Review  5.1 This SCR concerns the deaths of six sibling children caused by a deliberately set house fire. The children lived at the property with their father and mother(a).  The fire was reported at 03.46hrs on Friday 11th May 2012. Five of the children died on the night of the fire. The eldest child was taken to Birmingham Children’s Hospital and placed on a life support machine. It was turned off on 13th May 2012.  5.2 On 2nd April 2013, the father, the mother and their associate adult(c) were all convicted at Nottingham Crown Court of the manslaughter of the six children.  5.3 The father was later sentenced to life imprisonment with a minimum of 15 years. The mother(a) and adult(c) were each sentenced to 17 years imprisonment.   6.0  The Facts  6.1 At the time of the children’s deaths there were eight people living in the household, the father, mother(a) and their six children. The house was a three bed roomed semi –detached property with a large kitchen and a living room. The children all slept in two bedrooms, on bunk beds. The property was extended by a conservatory and additional sleeping accommodation was provided by a caravan parked at the front of the house. Before the fire, there were up to 13 children living in the household with their parents at different times.  6.2 Prior to the fire the number of people living in the household had increased over time.  6.3 The family structure was effectively polygamous, with two concurrent female partners living together with a male partner in one household. This type of arrangement is unorthodox and not one that professionals often come across.   6.4 The children were all of white British origin. There are some indications of connections with the travelling community but no evidence that these were strong links, or significant to the family's identity. They were geographically stable: these children were born and grew up in Derby and the three adults mostly live in Derby. The parent’s religion is Roman Catholic though not all the children have been baptized in this faith.  Although the family did not follow their faith’s religious requirements in many respects, they did have connections with the church and the children attended faith schools.  10   6.5 They lived in an area of traditional social housing where levels of deprivation are relatively high, although mixed with traditional working class households and some where incomes can be significant.   6.6 Housing Departments often deal with applications from large families including, different families living in one property together. However, it is unusual for a housing application to include a husband, wife, partner and all of their children together.  6.7 Although other communities in Derby, especially amongst new migrants, often include large families and multiple or extended family households, this is less common in this family's community and they did attract local attention. This was something that the father seemed to enjoy and he courted media attention on the TV and in the local press. There were no reports of the children being subjected to bullying or teasing as a result of the way their family lived.  6.8 There has been no information that suggests that any parent has a disability.  7.0  Family History  Mother (a)  7.1 There is little known about mother(a)’s history other than that she is believed, by some professionals, to be of Irish gypsy/traveller origin and has two sisters. The relationship with her family is unknown, apart from one comment in one of the IMRs that at one point she had stopped speaking to her mother.  Father  7.2 See para 9.42  Extended Family 7.3 The IMRs contain no information about other family members.  11  8.0  Summary of Significant Events and Agency Involvement Prior to 2006  8.1 The SCR Panel agreed that events prior to the first period, from 6th February 2006 to the events that caused the deaths of the children on 11th May 2012, would only be considered if appropriate. Information from the detailed IMRs has led me to conclude that some of the information gathered through the review, about issues before the 6th February 2006, are worthy of inclusion by way of background information, they are included here in summary.   8.2 On the 19th December 1978 the father was convicted at Nottingham Crown Court for the offences of attempted murder and wounding with intent. He received a sentence of seven years imprisonment and five years imprisonment, to run concurrently. Records show that the circumstances were that he visited the house of a recent girlfriend and that during an argument he repeatedly stabbed her and her mother, causing permanent damage.  8.3 The earliest contact with health agencies is in connection with the birth of CH1 on 30th December 1998.  Mother(a) was 17 years, 9 months at the time of his conception.  The child was of a previous relationship and domestic violence within this relationship was evident, as she was living in a refuge in the county.  8.4 On the 28th May 2000 police officers spoke to former partner(d) who reported a difficult split with the father. She stated that they had been together since she was 15 years old. There was mention of two children at the time of this separation and a three year custody battle followed the separation.   8.5 CH2 was born on 26th August 2001 to the father and mother(a), it is documented by the Health Visitor that two of the father’s older children by former partner(d) had been living with them but that he had lost a custody settlement.  8.6 In May 2003 the father and mother(a) were married.  8.7 On the 1st March 2005 the father reported to the police that he had argued with his former partner(f) over child access. She was pregnant and was offered advice by the police. Later the same year (in December) she reported that she was receiving abusive text messages from the father during the time she was in a hostel. Police officers visited the hostel however, former partner(f) had left without leaving any contact details.    12  8.8 Throughout the period between 1998 and 2007 12 children were born to the father and the number of people in the household increased, this was particularly so in 2006, when mother(b) and her children joined the family of the father and mother(a).  9.0 Consideration of the key themes  This section is linked to the terms of reference which identified the key issues that would best inform any learning in relation to what was understood about the family and circumstances relevant to the review.  9.1 Overcrowding   Background 9.2 It was well known to professionals and the public, over several years, that a considerable number of children lived with the father, mother(a) and mother(b) and that the number of children had increased over time.  a. In January 2006, Derby Homes (Housing) received an application from the father and mother(a) requesting re-housing, due to overcrowding. At the time of their application, the father and mother(a) occupied the property with five children, and the father advised that he had access to five other children who did not routinely live with him. He also stated that another partner(mother(b)) wished to move into the property with her three children and that she was expecting a baby. Shortly afterwards mother(b) ended her own tenancy and, against advice from Housing, she and her children moved in with the father, mother(a) and their children.  b. In March 2006 Royal Derby Hospital contacted Derby City Council Children’s Social Care (CSC) at the request of mother(b) and mother(a) for assistance with housing in respect of Child 10.   c. In May 2006 the Health Visitors described the home circumstances as housing nine children with the boys sharing one bedroom and the girls another.   d. In 2006/7 there was considerable media attention paid to the father. The Derby Evening Telegraph interviewed him in 2006, and subsequently produced articles relating to the size of his house, and the size of the family. These were quickly followed up by national press articles in the Daily Express, Daily Star the Sun newspapers and others. The father was seen as using the media to put pressure on Housing for a larger property. The articles and the television 13  programmes all described the living arrangements of the family, and their frustrations with the Council for not providing a bigger house.    e. On 26 March 2007 an overcrowding assessment was carried out by the Housing Department. This assessment determined that the property could cater for seven people, and was overcrowded by half a person. Increased priority was awarded to the household, in recognition of this.  f. In April 2007 two further children were added to the household.  g. In June 2007 the father applied to buy the property under the ‘Right to Buy’ scheme, which indicates that he thought the property was suitable for his family.  h. In December 2007 the father requested permission from Derby Homes to erect a conservatory at the rear of the property.   i. In June 2008 the father withdrew his ‘Right to Buy’ application.  j. There were two further contacts with CSC by the father in March 2011 regarding overcrowding and he was again advised to contact Housing.   k. In September 2011 the father discussed with his GP, the over-crowding at home, as there were now 15 people in the household.  The GP was already aware of the over-crowding but as there were no other indicators of distress amongst the children in the family, no concerns were raised with other professionals.    Analysis 9.3 Currently in Derby, demand for housing outstrips supply. There are approximately 4,000 people on the housing register, who are in some form of housing need, and are requesting housing. Housing let approximately 1200 properties each year, through the Council’s housing stock and housing association partners. These include all types of accommodation ranging from single person properties, to family homes and age restricted living accommodation such as retirement living.   9.4 The type of arrangement in this family is unorthodox and not one that housing professionals often come across. Housing often deal with applications from large families including, different families living in one property together. However, it is an unusual occurrence for a housing application to include a husband, wife, partner and all of their children, and for them to request housing together.  14   9.5 The limited supply of affordable housing and lack of larger housing units in the city is a major factor when considering overcrowding cases. Derby City Council’s Allocations Policy recognises overcrowding/cramped conditions as a reason for some priority to be awarded to applicants requesting housing through the joint housing register. However, this level of priority is no greater than is awarded, for example, to applicants who have a medical or welfare need to move. The Housing Health and Safety Rating System (HHSRS) guidance issued in April 2009 advised local authorities, as a first step to assessing the health and safety implications of overcrowding to enforce part 1 of the Housing Act 2004 as to continue to use part 10 of the Housing Act 1985 would maintain the use of an outdated legislative system which does not reflect modern day standards. Health and safety were therefore considered and assessed not to be a factor in this family.   9.6 Housing Options and Derby Homes staff have received training in relation to safeguarding of vulnerable adults and children. They have also received training on the Common Assessment Framework (CAF). There are policies in place on how to make a safeguarding referral should staff have concerns.  9.7 There was no evidence that at any time there were health and safety issues that related to the children in the household and should have triggered a referral to CSC by Housing.  9.8 Following the fire the fire investigation carried out by Derbyshire Fire and Rescue Service identified that no concerns had ever been reported about fire safety in the home and the property was fitted with working smoke alarms at the time of the fire.  9.9 Although other agencies did not formally consider the information that emerged in the press, in terms of the impact on the children of overcrowding, there was no indication that the situation included safeguarding issues caused by the housing situation.  Agencies that visited the house described it as having adequate amenities (given the use of a caravan that provided sleeping accommodation for the father and his partners and a large conservatory) and that the atmosphere during their visits was observed to be consistently warm, comfortable and loving.    Learning 9.10 The information reviewed evidences that the way the overcrowding was dealt with by Housing professionals, using the legislation followed at the time, was correct however, this review has also identified that, although it was not required practice at the time covered by this review, it would be good practice for senior managers to undertake periodic reviews of overcrowded situations, 15  whether there is or is not a trigger to consider this and that this will improve practice. However, in relation to this case it is unlikely that this would have changed the decisions made, which were appropriate.   9.11 Adult relationships  9.12 The relationships between the adult members of the household were not kept secret and were known to a number of agencies including Housing, CSC, Health Visitors and the family GP and to the public through the press and media including the television appearance of all three.   9.13 The records reviewed and interviews undertaken as part of this review include several references to the relationships but none indicate any concerns, even when considered:  a. There were several difficulties between the father and his previous partners but these related to custody and access. b. In 2005 and 2006 Sure Start staff commented positively on the family atmosphere and the father’s engagement with his children. c. The CSC assessment of 2006 noted that the relationships looked positive. d. There was a contact by school in September 2011 relating to one child who said she had been slapped at home that may, but not necessarily, have been indicative of some tensions within familiar relationships. There were no visible marks or injuries when the concern was raised and when it was discussed with CSC by the school head, it was concluded that what was described was within normal styles of parenting and was not felt to be a significant concern. It was agreed however, that the school would discuss the reported incident with the parents and report back to CSC if there were ongoing concerns. The child concerned and all the other children in the family continued to appear well adjusted and happy.  e. In January 2012 a Social Worker visited the family with the Police and a Student Social Worker, following a referral from the Police to Derby Social Care ‘Out of Hours’ Team, in connection with a related family member. The Social Worker recalls observing mother(b) and mother(a) chatting cheerfully and the children seen in the home being well behaved.   9.14 Relationships in the UK are predominantly monogamous and the arrangements in the family under review are unusual, the father was only married to mother(a) and therefore he had not committed bigamy which is illegal. Whilst professionals may have had personal views about the nature of the relationships they acted in a professionally non-judgemental manner; the 16  records reviewed and the interviews conducted as part of this review indicate that although professional recognised the arrangements as unusual, they did not appear to affect the children and there was no evidence of difficulties between the adults.   9.15 Information that has emerged after the deaths of the children have described some tensions between the father and the women who lived in the house, due to his controlling manner but this was not apparent at the time. The relationship between the two mothers was always viewed as supportive and caring with neither of them having any difficulty with the partnership arrangements or any jealousy. Indeed mother(a) described mother(b) as her “sister”.  9.16 There is no information that indicates that the arrangements had a detrimental impact on the children and between 2006 and July 2011, no agency expressed concerns about any of the children to CSC, other than the incident covered in 9.13(d) above.  9.17 Previous convictions and domestic abuse:   9.18 The father has a history of violence which preceded his relationship with mother(a):  a. On the 19th December 1978 he was convicted at Nottingham Crown Court for the offences of attempted murder and wounding with intent. He received a custodial sentence of seven years and five years to run concurrently. Records show that the circumstances were that he visited the house of a recent girlfriend, and, during an argument he repeatedly stabbed her and her mother.  b. There are indications that the father has frequently found separation from partners and his children particularly difficult: I. The stabbing of his girlfriend in 1978 was prompted by his inability to cope with her leaving him. II. In May 2000 another former partner(d) reported a difficult split with him. She stated that they had been together since she was 15 years old. Their two children were involved at the time of the separation and a three year custody battle had followed the separation.  III. In March 2005 the father reported that he had argued with another former partner(f) over child access. At the time she was pregnant. Later on the same year she reported that she was receiving abusive text messages from him during the time she was staying in a women’s refuge.  17  9.19 During the period that the father, mother(a) and mother(b) lived together there were few reports of domestic abuse, those that were made included the following:  a. In 2006, following the father’s appearance in the media, a Midwife queried with the GP whether domestic violence may have occurred, after she noted a bruise on mother(a). The GP was reported to have stated that mother(a) had attended with bruising in the past, but there is no date for this and it may have pre-dated her relationship with the father.  The Midwife passed this information and that she had seen in the newspaper that the father had a previous conviction for murder, to CSC. This concern was appropriately followed up by CSC who contacted Probation and the Police Domestic Violence Unit. Probation reported that they had no information about the incident and the Police said they only had a record of one incident relating to a previous partner, amounting to unwanted text messages.  A written Police check was requested, but there is no copy on file and no recorded consideration of the result.  b. In May 2009 mother(b) reported to the Police, by telephone, that during an argument with the father he had thrown a cup of coffee over her. The operator checked whether she was injured or whether the children were in danger, she replied “No” to both questions. Police officers attended the home address later the same day and found that mother(b) and the father had resolved their differences. Mother(b) had not sustained any injuries and declined to make a formal complaint.   c. A record was completed with reference made to the children but as there was no evidence that any of the children witnessed the incident, it was assessed as being of standard risk i.e. a minor incident with no evidence that any of the children were a witness to this incident. As a result, no referral was made to CSC.   d. In March 2010 a report was received by the Police from the father who expressed concern about his wife mother(a). He stated he had hit her and that she had left the house and not returned. He stated that she had been drinking.  e. Police officers attended and found mother(a) had returned home and was in bed with the father. She had sustained a minor injury and refused to give an account of what had happened and declined to make a complaint. Nevertheless, the father was arrested and later cautioned for committing a common assault on mother(a).   18  f. In November 2011 Nottinghamshire CSC shared an assessment that includes a reference to the father’s historical violence against a previous partner.  g. In February 2012 a non emergency call was received by the Police, from the father reporting that mother(b) was at his house trying to kick the door in. By this time mother(b) had separated from the father and had left the house together with her children.  Police officers attended the address where no offences were disclosed but it was recorded that the dispute was about child access and the financial issues.  h. The father took an over-dose on 12th February, 2012 and attended AED and was noted to have family problems, but no additional information was available.   i. On 21st February mother(a) attended AED following an overdose  A clear intention to die was evidenced in three suicide letters in which she noted that the children wanted mother(b) to return, that she (mother(a)) has mistreated the children and that she wanted mother(b) and the father to be happy together.  j. The hospital referred the incident to CSC regarding the children remaining at the family home. It is noted under the section of the assessment entitled ‘parenting capacity’ that “Mother of children took intentional overdose with a view to end her life, tablets taken whilst some of the children in the house”.    k. In March 2012 a number of calls were made to the Police reporting a disturbance in the street between mother(b) and the father in relation to access to the children and financial matters.  l. On the 1st May 2012 a Multi Agency Risk Assessment Conference (MARAC), which brings together a range of agencies to consider the potential risk to victims of domestic abuse, was held in respect of mother(b) who was concerned that she was at risk from the father. The request for the MARAC meeting was made by Derwent Living and the names of all the children were contained in the agenda.  The meeting was well attended by a wide range of appropriate agencies.  19  Analysis 9.20 In 1978 the methods for recording convictions were very different from today. A paper system was used to record the detail, with a brief record kept on the Police National Computer. As a consequence, historic cases were stored on a microfiche, and the papers were destroyed. This made searching for previous information very time consuming and difficult; it created challenges in sharing the information when it was requested.   9.21 Furthermore, at the time of the offence and his discharge from prison, the father did not have any children and did not join a household with children. His offence was not against a child (formerly known as a Schedule 1 Offence). Thus on neither count would there have been a requirement for the Probation or Prison Service to notify the Local Authority (which at this time was Nottinghamshire). From 2005 his offence would have met the criteria1 for notification to the Local Authority as a potential risk to children, but the Government of the day did not apply this retrospectively.  9.22 When CSC sought information from the Police, following the information being received in 2006, no information was therefore provided. In addition, due to concerns at the time about Data Protection compliance in relation to adults it was practice not to keep a copy of any Police check and not to record any information on CSC’s adult files. A file alert could have been created on the father’s file but practice was that this would only be done where there was corroboration in writing of a conviction of an offence against a child which was not received.  9.23 There is some evidence that a previous partner of the father was aware of the convictions and circumstances of the 1978 offences, but it is unclear whether mother(a) and mother(b) had the same degree of knowledge.  9.24 During the 2006 assessment, concerns were raised about domestic violence against mother(a), but were explained away as insignificant by the family. Because it was a minor incident, caused during an assault on the street, by a previous partner who was known to be violent, the GP, Health Visitor and Midwife were consulted by the Social Worker but as they had no records of other incidents and the incident was minor it was understandable why the Social Worker asked the Health Visitor, who knew the family, to speak to mother(a) and mother(b) and refer back to CSC, if there were concerns. There was no further contact from the Health Visitor and the case was closed by CSC. However, if Health Staff had been aware at the time of                                                  o 1 PC32/2005 Identification of individuals who present a Risk to Children interim guidance   20  the father’s earlier conviction, it is likely that this incident would have been cause for greater concern and investigation.  Verbal reports from the Police did not reveal all the instances of domestic abuse  which it subsequently emerged  were known, and there is no indication that the CAFCASS report, which would have been on the half-siblings' case files at the time, was referred to, although this too makes no reference to the father’s conviction. There is no record of a written Police check being received or considered by CSC.  9.25 CSC practice at this point here could and should have been more thorough , with checks being made on all the children’s files, the Police being contacted again for any information and further contact made with  the Health Visitor to ask whether she had seen the two mothers. It would however, have been difficult to review all the sibling’s files as records were kept on paper and would have had to have been manually retrieved.  It is not known why this did not happen but there were pressures to maintain the throughput of work and as information had been obtained verbally before, it may have been considered that the Social Worker should move on to other more urgent cases.  9.26 Best practice would also have been for the Social Worker to have seen mother(a) and mother(b) alone. However, there was no confirmed report of a domestic violence incident and mother(a) was not making an allegation or complaint about the father’s abuse of her and there was no corroborating evidence. The lack of a clearly recorded consideration of risk of domestic abuse is an omission, but given the information which appeared to be available at the time to the Social Worker and his manager, any assessment would likely have been one of ‘low risk’. However this judgement is made with the benefit of what information subsequently became known but was not known to everyone at the time.  9.27 The domestic abuse incident of 2009 was appropriately managed by the Police.  9.28 The Police acted appropriately by responding to the incident of March 2010 although some aspects were missed. Records of the incident note that the children were asleep in the house at the time the incident took place however, officers did not ascertain their names and dates of birth, nor add their details to their records. They were therefore not aware that the youngest child was three years old which would have resulted in an automatic referral to CSC.  9.29 The management of the non-emergency incident in February 2012 was partly acceptable in that officers attended and information was taken about 21  the children who no longer lived in the father’s household, but not about mother(a)’s children who continued to live there. As a result the incident was not referred to CSC which should have happened.  9.30 The outcome of the hospital referral to CSC, in respect of the suicide attempts of February 2012, is unknown to the hospital but it appears that the Social Worker did not see mother(a), as it was considered that when she had been seen by a mental health worker, following her overdose, she had not disclosed any violence or abuse towards herself. It is therefore unlikely mother(a) would have disclosed anything to a Social Worker. Any agency checks would also have revealed happy, well-adjusted children. Available information at that time would certainly have confirmed that the father was manipulative and controlling, but there was little known at this point about recent violence, and there were no grounds for statutory intervention.   9.31 On 19th March 2012, the GP Practice received a domestic violence alert from Nottinghamshire Police about the father sending abusive texts and a copy was forwarded to the School Nursing records. The GP Practice placed an alert on the father’s record – however, there is no record of any conversation with other Health Professionals, in particular Health Visitors and School Nursing.    9.32 Information gathered for the MARAC meeting of May 2012 did identify the father’s previous conviction for attempt murder in 1978, but not that it was linked to domestic violence. The information researched for the MARAC had been completed before information had been received from Nottinghamshire about other matters involving the father and a previous partner.  This subsequent information did include the domestic abuse related conviction. It is possible that if the inclusion of the domestic abuse element of the historic attempted murder had been discussed at the MARAC, it would have changed the final risk assessment and agreed actions.  9.33 The MARAC concluded that there were no incidents, intelligence or information to suggest that any of the children they were ‘at risk’. The children were described as well nourished, clean, well presented and happy. During those discussions the suicide attempts by the father and mother(a) were also revealed, although there is no record of the Police being made aware of these incidents at the time that they occurred.  Analysis 9.34 The MARAC meeting of 1st May 2012 could have been convened a little earlier, following the difficulties caused by the father’s behaviour after mother(b) and the children left the father and mother(a) in February 2012. CSC had had the historical information about the father’s violent past since 22  2011 and could have contributed this to a consideration of any potential risks to mother(a) and her children who continued to live with the father.   9.35 There was insufficient consideration of the risks to the children who remained with the father and mother(a), the focus was on potential risks to the victim mother(b) and her children.  9.36 The incident of March 2012 shortly before the fire was responded to appropriately; however, although no offences had been committed, there was no referral to CSC, which would have been appropriate action in the circumstances.   9.37 The information that has emerged during this review evidences that the father is a man with a violent past. He also has a history of finding challenges to his authority difficult, particularly where this involved the ending of relationships with former partners and access to their children. However, this was not known or observed, over time as a pattern, by professionals during the period covered by this review.   9.38 There were relatively few incidents of domestic abuse that were reported or became known, during the period covered by the review. The significantly violent offence of 1978 was not known until 2011 due to the way records were previously held and because the incident did not involve a child.  Learning 9.39 There were however a small number of incidents, albeit minor in nature that should have resulted in referrals being made to relevant partner agencies by the Police. However, the failure to make these referrals is unlikely to have influenced a change in how the family were managed by other agencies.  9.40 There could have been more consideration by MARAC of the risks to the children who remained living with the father and mother(a), given the information shared at the meeting.  9.41 Adult behaviour and manner  9.42 The father is a very confident, arrogant, manipulative man and there is evidence from information gathered during this review that professionals were aware of this and at times experienced it: a. He made sexual advances towards a Midwife, and hugged her in the presence of her husband.   b. There are examples where he appears to attempt to take the initiative and report incidents to the Police where he has committed a criminal offence for example his assault of mother(a). 23  c. He had a reputation for being hostile and verbally aggressive which did act as a deterrent to some staff, although in fact it appears that it was only Social Workers who directly experienced his aggressive and controlling manner.  9.43 However, he is described by school as co-operative and reliable. When he became angry about the disciplining of one of his children, he apologised the following day.  9.44 There is no evidence that his manner affected the services provided by practitioners and agencies took appropriate steps to ensure this by supporting and protecting their staff, for example by ensuring that senior practitioners or managers either accompanied more junior staff or dealt directly with him.  Learning 9.45 However, whilst he was known to be challenging to some professionals and in the media, there does not appear to have been any reflection or professional curiosity as to what he might be like at home and the impact of this on his family. There is also no information on the father’s history or any exploration of his experience of childhood. Several agencies did not know of his violent past; had they, they may have considered their assessment of him differently at the time of their involvement.  9.46 The impact of media coverage:    9.47 The father and his family appeared in the press and media on a number of occasions: a. In March 2006 the Daily Mail published an article headlined Dad of 14 - “I want a bigger house”. The article describes how the father was living in a house with his wife and his “mistress” along with several of his 14 children. The father claimed that at the time that he was living in a tent because the house was too small. Comment was made that the father had applied for a larger house but none was available. The article stated that he was expecting a fifteenth child.  b. In August 2006 the Sun newspaper published an article headlined “Dad of 14, sick of Britain”. This article features the family and how their application for a larger house had been turned down by Derby City Council.  c. In November 2006 The Daily Telegraph published an article headlined “Shameless (naming father)”. This article was very similar in content to the Daily Mail and The Sun newspaper articles and it described the family and how they were seeking a larger house.  It also stated that both his partners were pregnant. The article quotes an unnamed 24  Council spokesman who stated that the house was large enough to accommodate sixteen people. d. In 2007 the father, along with mother(a) and mother(b), appeared on the Jeremy Kyle show. The father described how he slept in a caravan adjacent to the house and his two partners alternated sleeping with him on a nightly basis. Though unprovoked, the father became aggressive with the show host without justification, resulting in a member of the security staff being called to stand on the stage.  The father appeared to be very defensive of his children and challenged any criticism despite none being made of them during the show.   e. In 2007 the father featured on a programme entitled “Ann Widdecombe Versus the Benefit Culture”. The theme was to challenge the benefit culture and engaged a number of individuals who were unemployed and claiming benefit and get them into employment.  The father was one such individual, the programme found him a job but he failed to turn up, claiming that he had an injured wrist.  Analysis 9.48 Most agencies were aware of the father’s notoriety, the media appearances and the hostility to him by neighbours and the public but there is no evidence that this had a detrimental impact on the way they dealt with the family. However, there is also no evidence that his media appearances, what he reported and the way he appeared was reflected on  in relation to what sort of father he was by individual agencies or through a multi-agency meeting when there was particular involvement with the family in 2006 and 2012.  10.0 Conclusion  10.1 The death of any child is a profound tragedy and creates distress for the family, the community and the professionals involved. This Serious Case Review concerns the deaths of six children and has created national concern and a wish to understand why the events that took place occurred. There is, quite naturally, some interest in the fact that the children lived in the circumstances in which they did, the extent to which this was challenged by agencies and that they remained with parents who were capable of such atrocious behaviour.  10.2 The aim of this Serious Case Review is not to investigate the incidents that occurred on 11th May 2012, as this has been concluded by legal process, but it is to examine closely the work of individual agencies and their inter-agency practice, to identify any learning and to answer the key question ‘Could the deaths of the children have been predicted and/or prevented?’  25  10.3 There are a number of factors that I have born in mind when reaching a conclusion: a. The parents have been convicted of manslaughter, not murder which would indicate deliberate intent. b. The living arrangements of the children were well known to agencies and the public, indeed the father boasted about them on television in 2006. This was not a secret arrangement and though morally unpalatable to some, it was not bigamous and therefore not illegal. c. Agencies took the view that the arrangement, though unusual, was not apparently harmful to the children. d. No member of the family, immediate or extended, the community or any agency raised concerns about the care of the children, during their lives before the fire.  e. Before the fire, the children were not hidden from or invisible to universal services. Their voices were well heard: o They were well known to their school teachers who described them as happy, well adjusted, caring children who had good relationships with each other and with children from other families. They did not appear cowed, malnourished or uncared for and attended school regularly. Although they did not join in school outings, this is not uncommon in large families where resources can be stretched. o The children’s contact with health services was unremarkable. Their contacts with the Primary Care Health Team were appropriate and would not have alerted the team to any safe guarding issues. The illnesses that the children presented with at the surgery did not indicate that these were related to overcrowding issues. The parents did not make any excessive or inappropriate demands from the health professionals. The frequency of attendance at the GP practice was not excessive. There is no evidence of persistent ill-health. The children did not have any excessive or inappropriate contacts with the out-of-hours health services and they were not taken to different hospitals, in an attempt to avoid detection of abuse. o None of the children were involved in criminal behaviour.  10.4 The parents of the children, particularly the father, engaged well with the children’s schools. He also made contact with Children’s Social Care, Health professionals and Housing, to support him with his request for a larger house.  10.5 There were some challenging aspects for all professionals which are identified in this report.  10.6 When reviewing practice over several years it is important to consider what was expected of professionals at the time and what research and professional knowledge guided their practice. As could be expected, when 26  reviewing the practice of a number of agencies who had contact with the family, the quality of practice has been found to be variable with some good professional practice and some that could have been better. However, in the months before the deaths of the children it is apparent that, with hindsight and the wealth of information provided by the IMRs, the situation within the household was increasingly difficult, particularly after mother(b) left with her children and as the father began to be less able to exert control, there were also increasing difficulties without information being gathered together about the whole family and a lack of consideration about the father and his adult relationships. This would have ensured that the father’s violent history was made known to all agencies and it may have resulted in closer involvement in the family and some additional support however, given the reluctance of the mothers to describe what life in the family was really like, indeed a former partner has said she would not have confided in anyone, due to her fear of the father, it is unlikely that a true picture would have been obtained; it is also unlikely that the family would have accepted any intrusion into their family  and given the lack of any verbal or behavioural concerns from the children there were no grounds for statutory intervention, or the removal of the children.  10.7 There is no evidence whatsoever that the intention to start the fire that killed the children was known to any agency and I am of the view that the intention could not have become known prior to the event.  10.8 Given the notoriety of the father, the incidents of domestic abuse and visibility of the children there were some opportunities to get to know the family better. However, this would not have led to professionals becoming aware that there were plans to deliberately set fire to the house when the children were sleeping.  10.9 I am therefore of the opinion that the tragic deaths of the children could not have been predicted or prevented.  27  11.0  Recommendations  11.1 The agencies involved in this SCR have made a number of recommendations, which are attached below, some of these have already been implemented and the DSCB will monitor the implementation of the remainder.   Overview Recommendation   1 Ensure Multi Agency Risk Assessment Conferences (MARACS) consider not just the victim, but all children who possibly remain at risk from the perpetrator.   Agency Recommendations  Recommendations: Children’s Social Care 1 For all referrals, explicit consideration should be given to any needs which may arise for siblings or half-siblings. The decision whether to include other children in a referral, and the rationale for this, should be clearly recorded on the case file.  Recommendations: Derbyshire Police 2 All front line police officers will be reminded of the necessity to document the details all children at an address when attending incidents of domestic violence and to fully consider their welfare, making physical checks whilst they are asleep in bed where necessary.  Recommendations: Education Service  3 Improve security of use of E1 Database and text messaging by schools, particularly in relation to safeguarding and domestic violence.  4 All head teachers aware of potential for breaches of confidentiality that E1 Database and texting poses, particularly with regard to schools with a Women’s Refuge in their catchment area.  Recommendations: Derbyshire Healthcare Foundation Trust 5 Consider through a review of this case if toxicology reports should be considered as a more significant element of risk assessment where there is contradictory information to the reported overdose.   Recommendations: Derby Hospitals NHS Foundation Trust 6 That the impact of parental mental ill health on children should be identified when adults attend emergency departments with overdose/self-harming behaviour.  Recommendations: Derbyshire Fire and Rescue Service (DFRS) 7 To firmly connect and communicate the National Fire Safety messages of having fitted, working tested smoke alarms on each level of a domestic property with the recommendation for a practised, familiar escape plan that is 28  familiar to anyone in the property (family, friends and visitors) and that smoke detectors are additionally located in bedrooms and that they are easily heard throughout the property.  8 DFRS will continue to work in partnership with developers, the residents of Derbyshire and social housing landlords to encourage the installation of sprinklers in new builds and homes occupied by the most vulnerable people.  9 Local and national attention continues to be drawn to the publication of the current and future research into the effectiveness of domestic smoke alarms in waking children under the age of 13 years.   Recommendations: Derby Homes 10 Completion of overcrowding assessment to be reviewed and countersigned by senior manager.   29  Appendix 1  The Review Process: Terms of Reference  1.0 Expert Opinion  1.1 The need for expert opinion was reviewed during the SCR and was obtained about the publication of the report and compliance with both the Reporting Restriction Order and the human rights of surviving relatives.  2.0 The period over which it was agreed events should be reviewed and the framework for the Independent Management Reports (IMR)  2.1 The period of time which has been focussed on has been February 2006 until May 2012 but this period has been flexible and extended to cover any additional key issues that emerged during the SCR.  An outline of key events during the above period was provided for IMR authors and their chronologies have concentrated on these key events. Additional events may subsequently have been included if relevant, as judged by the IMR Authors, the SCR Panel, Overview Author, Health Overview Author and/or Independent Chair. ‘Key events’ mean those events where agencies had opportunities or duties to assess the needs of the children and those events over the preceding year that appear to be linked to the tragic outcome for the children.  Routine events have not been included.  3.0 Chronologies  3.1 One chronology has been completed by each agency and covers all the six children who died, providing a short and succinct illustration of relevant events for each child. An explanation of the significance of the events has been highlighted. The chronologies cover the period from February 2006 until May 2012. The IMR authors have exercised judgement about what is relevant and significant and whether additional information should be included that predates the timeframe. Specific IMRs address issues outside this timeframe and the details are set out below.  4.0 The key issues addressed by all IMRs  4.1 The following questions were considered by each agency in reviewing their practice for this SCR: a. Were practitioners aware of and sensitive to the needs of the children in their work, and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare? Had they appropriate training and supervision?  30  b. When, and in what way, were the individual child’s wishes and feelings ascertained and taken account of when making decisions about the provision of children’s services? Was this information recorded?  c. What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family? Do assessments and decisions appear to have been reached in an informed and professional way? Did actions accord with assessments and decisions made? Were appropriate services offered/provided or relevant enquiries made, in the light of assessments?  d. Were there any issues, in communication, information sharing or service delivery, between those with responsibilities for work during normal office hours and others providing out of hours services?  e. Where relevant, were appropriate child protection or care plans in place, and child protection and/or looked after reviewing processes complied with?  f. Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family, and were they explored and recorded?  g. Were senior managers or other organisations and professionals involved at points in the case where they should have been?  h. Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare? Was the work in this case consistent with each organisation’s and the DSCB’s policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards?  I. Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff being absent on sick leave or subject to disciplinary procedures have an impact on the case? Was there sufficient management oversight and accountability for decision making?  5.0 Organisations involved in this SCR  5.1 Individual Management Reviews have been provided by: 31  a. Derby City Council Children and Young People’s Department (covering Children Social Care and Early Intervention Services) b. Derbyshire Constabulary c. Derbyshire Healthcare Foundation Trust (Universal Services and Mental Health Services) d. Derby Hospitals NHS Foundation Trust (Midwifery and Royal Derby Hospital)  e. NHS Derby City (CCG) (GP services) f. Derby City Council Learning and Inclusion Service (covering schools’ involvement) g. Derby City Council Housing Services h. CAFCASS i. Derbyshire Probation  5.2 Summary Reports have been provided by: a. Derbyshire Fire and Rescue Service b. East Midlands Ambulance Service  6.00 The Involvement of Family Members  6.1 The principle of involving family members has underpinned this SCR.  6.2 The father and mother were invited to participate in the review and to share their views with the Overview Author. Both declined to have any involvement.  6.3 Father's former partner has participated in the review and her invaluable contribution is included in a way that is consistent with the Reporting Restriction Order.  7.0 Other Parallel reviews (e.g. PPO/ homicide or suicide reviews)  7.1 There were no parallel reviews.  8.0 Involvement of organisations in other LSCB areas  8.1 LSCBs, where children lived in the area, were notified of the SCR  9.0 Coroner’s Inquiries/Criminal Investigations  9.1 The conclusion of the criminal trial and conviction of manslaughter of the father, mother and third adult means that a Coroner’s Inquiry will not be required  32  10.0 SCR Review Timescales  The commencement of the SCR was delayed, due to the complexities set out above and therefore it has been completed outside the expected six month timescale.   11.0 Independent Overview Author  11.1 Glenys Johnston OBE has been commissioned as the Independent Overview Author. She has previously been the Independent Author of a SCR in which children died as a result of a fire caused by their parent and several other SCRs. She has extensive safeguarding experience as an Assistant Director for Children and Families Services; she is the former Independent Chair of a tri-partite LSCB and the current Independent Chair of an LSCB and SAB. She has undertaken a considerable number of inspections and reviews and a domestic homicide review.   11.2 Mrs Johnston has never been employed by any of the organisations involved in the SCR and has no personal connection with any of the professionals involved in the case. She is therefore considered to be independent Derby City Council.  33  Appendix 2  Agency Action Plans  Derby Safeguarding Children Board Action Plan   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 Ensure Multi Agency Risk Assessment Conferences (MARACS) consider not just the victim, but all children who possibly remain at risk from the perpetrator. Issue guidance to attendees at MARAC to require consideration on all relevant children  Risks to all children in contact with the perpetrator have been assessed and action taken to ensure the children are safe Chair of MARAC Jan 14 MARAC minutes record confirmation of the consideration of all relevant children An audit report will be provided to the Board to demonstrate compliance in March 2014   Children’s Social Care Action Plan   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 For all referrals, explicit consideration should be given to any needs which may arise for siblings or half-siblings. The decision whether to include other children in a referral, and the rationale for this, should be clearly Review protocol for file alerts and ensure any individual who is assessed as posing a risk to child is tagged in future Staff can readily identify any adult who may present a risk to children Service Director – Specialist services March2014 Robust alert process is in place enabling individuals who present a risk to be identified Data cleansing process of current records to take place before migration to new recording system (April 2015)  In the commissioning of a new CYPD recording system, address how to provide easy access to Staff can readily identify related or linked children to check their As above As above Staff guidance has been re-issued for use of current recording system Current procurement process for new recording system  34  recorded on the case file  historical and sibling records  records, and will easily see relevant historical info will ensure this requirement is an integral part of system. New system to be in place for April 2015. Issue guidance to explicitly consider related children, to all current Social Workers and managers, with particular focus on Reception. Include in assessment checklist. Ensure this is addressed in training Related children are considered with all referrals accepted by social care Service Director EISS Jan 2014 Revised flow chart developed for First Contact Team- staff briefed week commencing 13/1/14  Assessment check list developed for Reception workers- currently in draft for consultation- staff briefed on draft week commencing 13/1/14  To ensure action is reflected in guidance for new Single Assessment Guidance (joint with Derbyshire County Council). Implementation of new assessment scheduled for April 14 Baseline audit of files of sibling groups completed Nov/Dec 2013   Further audit of files of sibling groups completed Nov/Dec 2014  Clarify use of linked referrals for related children and how Guidance in place and staff are clear Service Director – March 2014 Current system specification allows File auditing tool and monthly  35  the required response or management action can be assured.  Specialist services for the linking of referrals of related children. Staff memo to be issued January 2014 reminding staff of process. Also an integral part of training and induction on the system process provides opportunity for regular monitoring including at first contact point Clarify practice with regard to "sign-off" function on referrals, assessments, etc on sibling records to ensure decisions are recorded on all siblings Guidance in place and staff are clear Service Director – Specialist services March 2014 Required practice has been confirmed with managers and staff and streamlined process will be built into new recording system   Audit of files of sibling groups completed Nov/Dec 2013   36  Derbyshire Police Action Plan    Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 All front line police officers will be reminded of the necessity to document the details all children at an address when attending incidents of domestic violence and to fully consider their welfare, making physical checks whilst they are asleep in bed where necessary As part of the ongoing awareness raising in Safeguarding issues across the Force, a message will be sent out to all officers and staff utilising ‘Chief’s Orders’ and there will be a periodic reminder in one of the Public Protection bulletins highlighting SCR lessons Action has been completed Head of Public Protection Sept 2013 July 2013  Bulletin has been circulated There will be a periodic reminder in one of the Public Protection bulletins highlighting SCR lessons Dec 2013    37  Education Service Action Plan   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 Improve security of use of E1 Database and text messaging by schools, particularly in relation to safeguarding and domestic violence.  Review E1 Database current custom and practice  so that safeguarding practice is improved  Estranged parents who no longer have access to children do not learn of children’s new school via text message circulars from new school using out of date contact details. Information Manager   Information and Performance Analyst  Head of Inclusion and Intervention Sept 2013 Guidance forms part of routine safeguarding training for school heads and schools’ data protection officers Guidance delivered to all schools Summer 2013 and will be repeated Spring 2014   2 All head teachers aware of potential for breaches of confidentiality that E1 Database and texting poses, particularly with regard to schools with a Women’s Refuge in their catchment area Head teacher’s to be made aware through briefing meeting and through School Circular. Head teachers and school staff aware that contact details of children transferring to a new school following parents move to a Women’s Refuge do not include contact details for estranged partner.  Records from previous schools should not be copied into the receiving schools records.  Head of Inclusion and Intervention  July Term 2013 LSCB provided with copy of agenda and briefing Guidance forms part of routine safeguarding training for school heads and schools’ data protection officers Dec 13  38  Derby City Health Providers Action Plan   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken On-going monitoring Date signed off by LSCB Derbyshire Healthcare Foundation Trust 1 Consider through a review of this case if toxicology reports should be considered as a more significant element of risk assessment where there is contradictory information to the reported overdose Trust to adopt this recommendation with toxicology report forming part of all deliberate self-harm assessment. Adoption of recommendation by September 2013. Deputy Chief Nurse/ Head of Effectiveness Sept 2013 Emergency Dept. Liaison Services compliant with recommendation Subject to random audits March 2014 and reported when completed to the Health Quality Assurance hub  Derby Hospitals NHS Foundation Trust 2 That the impact of parental mental ill health on children should be identified when adults attend emergency departments with overdose/self-harming behaviour That all staff are reminded of the importance of asking all adults about their care of children and the necessity of referral That staff “Think Family” when adults attend emergency departments with self-harming behaviour and refer relevant children to Children’s Social Care for assessment Trust Lead for Safeguarding Completed E-mail and training notes Audit of referrals to be started by June 2014 and reported when completed to the Health Quality Assurance hub  39  Derbyshire Fire and Rescue Service (DFRS) Action Plan   Recommendation Actions required Outcome required Responsible person Time scale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 To firmly connect and communicate the National Fire Safety messages of having fitted, working tested smoke alarms on each level of a domestic property with the recommendation for a practised, familiar escape plan that is familiar to anyone in the property (family, friends and visitors) and that smoke detectors are additionally located in bedrooms and that they are easily heard throughout the property.  All press releases and media communication to contain these messages. Communication of this across the Service via its internal Organisational Assurance Bulletin. Increased number of fitted smoke alarms in domestic properties Corporate Communications Officer Immediate effect Press releases and corporate communication.  Entry on DFRS website This to be monitored by the Service’s Corporate Communications Department Dec 2013 2 DFRS will continue to work in partnership with developers, the residents of Derbyshire and social housing landlords to encourage the installation of sprinklers in new builds and homes occupied by Where appropriate produce memoranda of understanding with partners to encourage the installation of domestic sprinkler systems MoUs produced and signed off between partner agencies. Installation of domestic sprinkler systems in homes occupied Chief Fire Officer Continuing MoUs signed off between partner agencies Prevention & Inclusion Department to monitor progress and report to Service via its Strategic Leadership Team Dec 2013 40  the most vulnerable people. by vulnerable people. 3 Local and national attention continues to be drawn to the publication of the current and future research into the effectiveness of domestic smoke alarms in waking children under the age of 13 years.   On completion, the research should be published as soon as possible. That the research be disseminated as widely as possible and the results used to encourage smoke alarm manufacturers to develop systems to address this problem. Corporate Communications to disseminate the message Research completed June 2013 Press release produced and disseminated June 2013 Continuing close liaison with manufacturers to ensure this is achieved Dec 2013  Derby Homes Action Plan    Recommendation Actions required Outcome required Responsible person Timescale Evidence of action taken Ongoing monitoring Date signed off by LSCB 1 Completion of overcrowding assessment to be reviewed and countersigned by senior manager. Discussions for Service Level Agreement with Housing Standards for completion of overcrowding assessments. Independent review and countersignature by senior manager Overcrowding Assessments with be independently assessed to ensure decisions are quality assured   Head of Housing Management.   Head of Housing Options Oct 13 New standard forms produced for overcrowding assessment and counter signature by a senior officer.   Audit of compliance with procedures as part of wider housing management audits reported to Board at the end of March 14   