Death of a 6-day-old baby girl in July 2017. Father was sentenced to life imprisonment for murder. On the third day after birth father contacted emergency services reporting that Baby Madison had breathing difficulties after falling off the sofa. Madison was transported to hospital and was found to have a brain injury considered to be non-accidental, and extensive bruising and injuries. She died in hospital three days later. Family had been known to Children's Social Care since September 2015 due to concerns about poor home conditions and neglect in relation to Madison's sibling. Evidence of domestic abuse but no indicators of either parents presented a risk of harm. Death of maternal grandmother two months before the birth of Madison had a significant impact on the parents. Ethnicity or nationality of family not stated. Learning includes: in cases of concerns about long-term neglect it is important to understand the child's lived experience, and assess the totality of the child's care; importance of reflective and challenging supervision in cases where there are concerns about long- term neglect to guard against the rule of optimism; importance of recognising a lack of engagement/disguised compliance. Good practice identified includes: early recognition of the family's need for enhance support by the health visitor. Uses the Significant Incident Learning Process (SILP) methodology. Recommendations include: use a standardised, objective approach to the assessment of neglect; need for a shared understanding and common language of levels of needs/thresholds, particularly following a referral to Children's Social care.
      
 Title:  Serious case review: overview report: ‘Madison’. LSCB: Wakefield District Safeguarding Children Board Author: Adrienne Plunkett Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1             Serious Case Review  Overview Report                                            ‘MADISON’       Author: Adrienne Plunkett  SILP Lead Reviewer June 2018      2  CONTENTS:         Page No.  1. Statutory framework        3  2. Significant Incident Learning Process (SILP)    3   3. Process for the Serious Case Review     4  4. Introduction to the case under review     4  5. Family engagement in the Review     4    6. Pre-Scoping                    5  7. Scoping Period: Key Episodes      5  8. Themed Analysis: Terms of Reference              12  9. Examples of good practice                                                                     27  10. Recent developments                           27  11.  Key learning                            27         12.  Conclusion                             29                        13. Recommendations for LSCB                30           Appendices:   Appendix A:  Agency Report Template/Terms of Reference  Appendix B:  Key Single Agency Recommendations  Appendix C:  References3  1. Statutory Framework: 1.1. The Local Safeguarding Children Boards Regulations 2006 outline that LSCBs should undertake reviews in specified circumstances as below. 5 (1)(e) Undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. 5 (2)     For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. 1.2. Working Together to Safeguard Children 20151 contains the guidance for undertaking Serious Case Reviews (SCRs) and emphasises the importance of each LSCB developing a Learning and Improvement Framework. It outlines that reviews should be completed in a way which:  Recognises the complex circumstances in which professionals work together to safeguard children;  Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight;  Is transparent about the way data is collected and analysed;   Makes use of relevant research and case evidence to inform the findings. 1.3. Working Together 2015 encourages LSCBs to use a variety of models for undertaking SCRs, including the systems approach.  The Significant Incident Learning Process (SILP) is one such model. 2. Significant Incident Learning Process (SILP) 2.1. The SILP methodology reflects on multi-agency work systemically.  It engages frontline staff and their managers in the review, focussing on why those involved acted in a certain way at that time. The SILP methodology adheres to the principles of:  Involvement of families  Active engagement of practitioners and frontline managers  Systems methodology  Proportionality                                                            1 Working Together to Safeguard Children:  A guide to inter-agency working to safeguard and promote the welfare of children, Department for Children, HM Government 2015. 4   Learning from good practice  2.3. SILPs are characterised by practitioners, managers and Agency Report Authors coming together for a Learning Event. Agency Reports are shared in advance and the perspectives of all those involved are discussed and valued. The same group then comes together to consider the draft Overview Report at a Recall Event. 3. Process for this Serious Case Review:   3.1. On 11 August 2017 the Safeguarding Children Board’s Independent Chair made the decision to undertake a Serious Case Review in respect of Baby Madison.   Furthermore, a decision was taken that the SCR would be undertaken using the SILP methodology.  A Scoping Meeting to discuss the Terms of Reference (Appendix A) was held on 4 October 2017 and the Agency Report Authors’ Briefing on 19 October 2017. An integrated chronology of agencies involvement was produced.  3.2. The Scoping Period for the Review is from February 2015, when Mother attended the booking-in ante-natal appointment for her first child, to July 2017, when Baby Madison sustained serious non-accidental injuries.  However, agencies were also asked to provide brief details of any significant events in respect of the family prior to the Scoping Period.   3.3. The SILP Learning Event was held in January 2018 and the Recall Event in February 2018. The Events were attended by practitioners, managers and Agency Report Authors from the Police, NHS Foundation Trusts, Clinical Commissioning Group (CCG), GP Practice, Children’s Social Care, Early Help and a Voluntary Sector Organisation (VCS).  The District Housing provider was invited, but did not attend.  3.4. The SILP Lead Reviewer was Adrienne Plunkett, who has substantial experience working in Children’s Social Care, including as a Senior Manager, managing an Independent Reviewing Service and a Local Safeguarding Children Board.    3.5. In the Overview Report the names of family members have been anonymised. 4. Introduction to the case under review 4.1. Baby Madison sustained life-threatening, non-accidental, injuries as a very young baby. Tragically, the injuries were not compatible with life.  The baby’s Father was convicted of the murder.   4.2. At the time of the injuries the family were receiving support through the Health Visiting Universal Plus Care Pathway and from the Early Help service.     5. Family Engagement in the Serious Case Review:  5.1. The Lead Reviewer has met twice with Madison’s Mother, who was supported by her Aunt and Cousin, and with Father’s Mother and Step-Father. It has not been possible to gain Father’s views. 5   5.2. All the family members have been shocked by what happened to Baby Madison.  Father did not have a history of criminality or violence and there were no indications that he would be capable of inflicting such injuries to a baby. They all talk positively about his relationship with child one.  5.3. Information provided by the family has been included as relevant through the Report.  6. Pre-Scoping:  6.1. It is understood that the Maternal Grandmother (MGM) suffered with poor health for many years.  From the age of 14 years Mother had been the MGM’s carer and her school attendance was limited, restricting her friendships and social activities.   She had been offered support through the VCS Young Carers service but had not fully engaged with this.  The MGM died during the Scoping Period.  6.2. It is understood the MGM had an older child who for a period had been in the care of the local authority.  6.3. Neither parent had a criminal record at the time of the injury to Madison.  7. Scoping Period  7.1. Mother attended the booking-in ante-natal appointment for her first child early in February 2015.  This was a late booking, at 17 weeks, but she and her partner, the baby’s Father, regularly attended subsequent appointments.  As is required, a Pregnancy Vulnerability Risk Assessment was undertaken and no concerns were noted, including in respect of domestic abuse, substance misuse and mental health, although Mother was referred to the Smoking Cessation Clinic. This was therefore assessed as a low risk pregnancy from both a social and obstetric perspective. Mother was living with, and caring for, the MGM and the Father was a regular visitor to the home.   7.2. The Health Visitor received notification of the pregnancy, established contact with the family two months prior to child one’s birth and visited fortnightly. From the first visit, the family were placed on the Universal Plus Care Pathway, which led to an enhanced programme of home visiting.  The Health Visitor was concerned about potential neglect, due to the poor condition of the home, which was cluttered, untidy, dirty and smelt heavily of cigarette smoke, and liaised with District Housing and the Midwife.  Referrals to the Children’s Centre and Home-start were suggested, but the family declined.  Over the next two months, there was little improvement in the home conditions and the Health Visitor had considered making a referral to CSC prior to child one’s birth.   6  7.3. The Mother and Father were 19 and 20 years respectively at the time of child one’s birth.   The late booking meant that Mother was not eligible for the Family Nurse Partnership (FNP) service 2.  Key Episode One: July 2015 Birth of child one. 7.4. Child one was born in July 2015 and, at Mother’s request, she and the baby were discharged after 11 hours. The Hospital NHS Truct Report Author notes that due to several factors, e.g. a complicated labour, a first baby and the home circumstances, consideration should have been given to discharge being delayed for 24 hours after birth.  7.5. There were eight visits by Midwifery, handing over to the Health Visiting service in mid-August. Mother coped well with the new baby and received good family support.  The baby’s Father was living with the family and helping to care for the child.  The Midwife provided advice about safe sleeping, sterilising bottles and the risks of smoking.  There were concerns that the baby was slow to regain its birth weight and possibly not being fed on demand, which led to increased visits by the Midwife and a delayed hand-over to the Health Visitor.  The baby presented as clean and appropriately dressed.  7.6. The family continued on the Universal Plus Programme by the Health Visiting service and the Health Visitor and Student Health Visitor maintained regular contact.  The baby was feeding well and gaining weight satisfactorily. The Whooley questionnaire was used to ascertain if Mother had any post-natal mental health needs and none were identified.  However, concerns continued about the home conditions.  There was some uncertainty about where the baby was sleeping as the bedroom, including the Moses basket, contained piles of washing.  Guidance was given about safe sleeping for the baby.  The Health Visiting records note observations that Mother’s responses to child one demonstrated some ambivalence and inconsistency and were likely to be dependent on how she was feeling.  The Health Visitor liaised with the GP. 7.7. From early on, it appears that the MGM took a substantial role in supporting the parents and helping to care for the baby. When the Health Visitor visited in the morning, the parents were often still in bed and the MGM was caring for child one.   However, she was not happy at the frequency of health visiting contact and on one occasion became angry and distressed about this.  Key Episode Two: September 2015 Referral to Children’s Social Care by Health Visitor 7.8. In September 2015, the baby was taken to the GP with a rash, diagnosed as infected eczema.  The GP was concerned that the baby should have received earlier medical attention. The family attended a follow-up GP appointment, but then missed the next review.  Following discussion between the GP and Health Visitor, when concerns were discussed about medical neglect as well as wider                                                            2 Family Nurse Partnership. A targeted service for pregnant women aged 19 years or under at the time of the conception of their first child.  The FNP offer should usually be made before 16 weeks of pregnancy, preferably at 10 or 12 weeks. 7  neglect, a written referral was made by the Health Visitor to Children’s Social Care’s.  Concerns reported included the delay in seeking medical attention and the poor home conditions, which had shown little improvement in four months. There was no reference to the concerns about mother’s interaction with the baby.  When the Health Visitor informed the family of her intention to make the referral to CSC, Mother became distressed and the MGM again became extremely agitated and a neighbour was called to calm her. 7.9. The referral to CSC was triaged, and the initial decision was that it would be stepped down to Early Help.  However, the presence of the maternal uncle in the household raised the level of concern, the referral was stepped up from Early Help, MASH checks were undertaken and it was passed to the Joint Investigation Team (JIT) for Section 47 child protection enquiries.3 An assessment was undertaken which focussed on whether the presence of the uncle in the household presented a risk.  Concerns related to an historic allegation of sexual assault, drug-use and his associates. The assessment concluded that, whilst not accepting the validity of the allegation, the MGM and Mother would safeguard child one.  There was less attention to the home conditions and concerns about neglect. 7.10. Two months later in November 2015, the JIT referred the family to VCS for support with housing, budgeting and developing parenting skills and the case was closed to CSC. Father did not want this referral made. 7.11. The VCS undertook an initial assessment with Mother early in January 2016.  Father was not present.  Mother signed consent for the VCS to liaise with other agencies. The plan was to support the family with parenting skills, improving the property, home safety and finance. The VCS worker noted concerns about the cleanliness of the home, the full ashtrays and amount of clutter, which could potentially impact on the baby’s development due to the lack of space to sit and crawl.  The baby was smiley, but pale, and the hair at the back of the head was matted.  The VCS worker informed the Health Visitor of these concerns.  7.12. In February 2016 the MGM was diagnosed with a terminal illness. The GP made a home visit and following this contacted the Health Visitor due to concern about the home conditions.  The MGM received support and nursing care from the MacMillan and District Nurses.  Adult Services were not involved with the family. 7.13. There was some difficulty for the VCS service provider in arranging appointments, but the worker saw the family again towards the end of March and again in mid-May. The Initial Assessment was shared, and Mother informed the worker that Father did not live with the family but stayed a few nights per week.   In May, the worker was concerned about the condition of the home; it was messy and smoky, with full ashtrays. The baby again had matted hair and a sore ear, and the worker arranged appointments with the GP and the Children’s Centre.  The VCS worker again informed the Health Visitor of their concerns.  The next day mother                                                            3 Section 47, Children Act 1989. Where a child is suspected to be suffering, or likely to suffer, significant harm, the local authority is required to make enquiries, to enable it to decide whether it should take any action to safeguard and promote the welfare of the child. The enquiry will involve an assessment of the child’s needs and the ability of those caring for the child to meet them. 8  cancelled the visit to the Children’s Centre as she was unwell.  She had also not taken child one to the appointment with the GP.   7.14. During this time, September 2015 to May 2016, the Health Visitor maintained contact with the family and remained concerned about the home conditions. The baby’s 8/10-month developmental review was undertaken, and weight and development were noted to be satisfactory. The family had not attended an appointment with the Dermatologist in April but were using the cream prescribed by the GP and the skin condition had improved.   There was a delay in the baby being brought for immunisations but, with prompting by the Health Visitor, these were completed in April.  There was concern about the accessibility of MGM’s medication, with a young child in the household, and advice was given regarding safe storage.  7.15. Towards the end of this period, there were increased difficulties for both the Health Visitor and VCS worker in gaining access to the family and a number of visits were undertaken when the MGM was seen briefly on the doorstep and the parents was reported to be in bed.  Key Episode Three:  June 2016 Referral to CSC by VCS Service provider. 7.16. The VCS service made a referral to CSC’s in June 2016, due to concerns about the presence of the maternal uncle in the household and him taking out child one unaccompanied.  The VCS service was informed by CSC that an assessment had been undertaken in 2015, which concluded it was safe for him to be having contact with the child.  On the next two visits the worker was informed by MGM and Mother that the VCS support was not required. The MGM was hostile and angry that the referral had been made to CSC.  The baby’s progress was satisfactory, although lack of stimulation was a concern. Due to continued concerns about the deteriorating home conditions, e.g. unclean, untidy, cluttered, smelling of cigarette smoke, and potential risks to child one, following discussion with the Senior Practitioner, a further referral was made to CSC for an assessment. District Housing was notified of the deterioration in the conditions in the house.  7.17. The referral was triaged at Level 4, and a decision taken that the case should be allocated to the Early Help Hub for support with improving the home conditions, budgeting, supporting child one’s development and attending the Children’s Centre.  At this point the VCS service agreed no further action. 7.18. The first visit by the Early Help worker was in mid-July 2016 when Mother agreed to engage and to liaison with other agencies.  The living room was noted to be clean, but cluttered, and the family were advised regarding safety.  A few days later the worker took mother to the Children’s Centre to register. It was noted that the interaction between mother and child one was appropriate.   7.19. In Early Help supervision in July weekly contact was agreed until the home conditions improved.  This continued until early September when the case was reallocated due to the worker’s ill health.  Engagement was spasmodic, with some visits unsuccessful. It was noted that the home was clean, with varying degrees of mess and clutter.   Child one shared a bedroom with her parents, but there is no 9  record that this was seen. It is normal practice for a Home Safety Check to be undertaken but again there is no record of this.  Child one’s development was age appropriate, e.g. smiling and crawling, with suitable toys in the home.  Her hair was still matted.  The parents declined involvement in the Children’s Centre, which was close by.  It appeared that they did not want outside help and thought they would be ‘judged’ negatively if they attended the Centre. Father was referred to DWP for advice with employment and training.  The paternal grandparents noted that the family was insular, and Mother did not go out very much.  7.20. An Early Help Plan had been agreed with the family.  The three goals included:  To improve home conditions and make sure there are no risks to child one.   MGM to be aware of how her illness impacts on the family  To build Mother’s confidence and self-esteem, so that she can access local support groups.  7.21. Liaison took place with other agencies working with the family, e.g. Health Visitor, GP.  However, the plan was not shared, and neither was a multi-agency meeting, e.g. Team Around the Family, held.  Early Help involvement ended in November 2016. 7.22. The Health Visitor continued to have some difficulty gaining access to the family home.  In July the MGM was seen on the doorstep, mother was in bed, in August the family was seen, the baby was noted to be sociable with age appropriate development, and in October the MGM was again seen on the doorstep. 7.23. In October 2016 the District Housing provider received an anonymous telephone call, reporting overcrowding in the family home.  The property was visited by a Housing Officer and there were no concerns.   Key Episode Four:  November 2016 Anonymous referral to CSC 7.24. CSC’s received an anonymous referral In November 2016 about the care of child one, including being unkempt, the presence of the uncle in the household, substance misuse and the family not opening the door to professionals.  A MASH Meeting was held, and a decision made to pass for a single assessment due to concerns raised about neglect.  Police information supported concerns about drug use in relation to the maternal uncle.  Further enquiries were undertaken by Police with neighbours who reported no concerns about the care of the child 7.25. Following the referral to CSC, the Police also received an anonymous report containing concerns about the welfare of child one; being neglected, not bathed or changed frequently enough, physically chastised, spoken to inappropriately, having access to sharp objects and family members were using drugs. A Police Officer visited the same day to ascertain whether there were immediate safeguarding concerns and was satisfied that there were not. The child appeared healthy and clean, the cot had clean bedding, though the house was untidy, and the MGM was smoking. Mother informed the Officer of CSC’s involvement; her view was that the report was malicious.  This information was not shared with CSC. 10  7.26. The single assessment was commenced early in December and three home visits were undertaken. The Health Visitor was approached for information, but the GP was not, nor the Early Help service, despite their recent involvement with the family. By chance the Social Worker undertaking the assessment and the Health Visitor visited the home together.  It was reported that child one’s height, weight and development were age appropriate and the baby had grown from 9th to 50th centile.  The home was messy but not unclean and the Health Visitor noted an improvement from her last contact.   7.27. The assessment by CSC was completed later in December 2016, but not progressed until mid-March 2017, over three months later.  The decision was to ‘step down’ to the Early Help service, which had been requested by the family.  No additional services had been offered since the referral in November. 7.28. The Health Visitor had been contacted for information as part of the MASH enquiries and assessment and was informed by the Social Worker early in March that the decision had been taken to ‘step down’ to the Early Help service.  Key Episode Five:  Ante-natal booking in appointment. 7.29. At the end of March 2017 Mother attended the booking-in ante-natal appointment at the GP Surgery.  This was another late presentation, at over 21 weeks, possibly due to the serious illness of the MGM.   A risk assessment was completed by Midwifery and the parents denied any involvement with CSC or Early Help or any financial difficulties. No concerns were expressed about domestic abuse, substance misuse or mental health.  Five ante-natal appointments were attended, three of these with Father.  Two home visits were undertaken, as mother had not attended clinic appointments, and the home conditions were noted to be similar to those at the time of the previous birth; untidy and cluttered but clean. Midwifery sent antenatal booking information to the Health Visitor but were not made aware of the concerns about the home conditions and the involvement of Early Help.  7.30. The Early Help Hub worker was introduced to the family in April.  The parents appeared to be reluctant to engage and again declined support from the Children’s Centre. There were positive observations of the interaction between child one and the parents.  Early Help were concerned about the impact of the MGM’s illness on the family and informed the Health Visitor.    On the return from sick leave of the original Early Help Hub worker towards the end of April, the family were reallocated, as it was known that she had a positive working relationship with the family.   7.31. The MGM died in April 2017.  She had been cared for at home until a few days before her death by Mother and Father.  Following this, it was reported that there appeared to be an improvement both in the mood and conditions in the family home. It was noted that Father was now living with the family.  Mother declined bereavement counselling. There was positive interaction between parents and child one, who was clean and well dressed.  The parents were experiencing financial difficulties and the Early Help worker supported them with their benefits claim and provided food parcels.  Dirty washing was piling up due to lack of money, the Early 11  Help worker offered to take this to the Children’s Centre, but the parents declined.  It is understood that the paternal grandparents helped with this. 7.32. When the Health Visitor and Early Help worker undertook a joint visit in May 2017 the home conditions were noted to have improved and the washing was done.  Child one was playing and smiling.  In July the worker liaised with the Health Visitor expressing concern about the family’s need for support to prevent a deterioration in the home conditions.   7.33. Housing received a further anonymous call in mid-April, alleging overcrowding, with six people living in the home.   The Housing Officer visited and was informed that the MGM had recently died.  A subsequent inspection noted that a substantial amount of redecorating was required to bring the house up to an acceptable standard, in addition to clutter needing to be cleared from the downstairs exits and rubbish from the garden.  Following the death of the MGM, Mother applied for a change of tenancy, which was complicated by not having any ID or a bank account.   7.34. The Health Visitor undertook the antenatal appointment, where Perinatal Mental Health Screening occurred, in mid-June.  This was the first time the Health Visitor had seen Mother on her own and she appeared more open.  She was well and appeared to be coping with her bereavement.  The home was untidy and a Moses basket for the baby to sleep in had not been obtained.  On a visit later in June, the family were in bed.  The home was cluttered and there was still no Moses basket.  The Health Visitor informed the Midwife, who subsequently confirmed that the necessary items were prepared, e.g. Moses basket and steriliser.    Key Episode Six: Birth of child two. 7.35. Madison was born in July 2017.  Midwives reported that mother was extremely distressed during labour and needed considerable reassurance.  Father was present at the birth.  7.36. Following the birth, mother’s emotional state stabilised, and the baby presented as well. The Paternal Grandmother visited at the hospital and Mother and baby were discharged 6 hours post birth, as is normal with a second birth without complications.  They had everything needed for the baby, e.g. clothes, blanket.   7.37. The Midwife visited on day two. The baby was examined and was clinically well and alert.  Parents were concerned that the baby had not passed urine and advice was provided.  The baby had been unsettled during the previous night and parents were advised regarding the care of crying babies and alerted to the contact numbers for advice.  Parents were quiet and somewhat unresponsive, although Mother was reported to be well.  Father had provided the care for the baby during the night.  The older child was happy and wanting to play. The home was untidy, but not unusually so.  The next midwifery visit was arranged on day five, which is normal practice, and in line with the NICE guidelines, when there are no concerns. 7.38. Father contacted the Paternal Grandmother on day three concerned about the baby who had been crying constantly, was very difficult to settle and was having some breathing difficulties.  She advised him to seek medical advice.    12  7.39. At lunch time, Father made a call to emergency services.  He reported that the baby had fallen off the sofa earlier in the morning and was having difficulty breathing.  Two rapid response vehicles were dispatched and arrived in 6 minutes.  Practitioners found injuries to the baby that were inconsistent with the explanation given by Father.  Police and CSC were alerted.   7.40. The baby was transported to the hospital with Father in attendance, Mother followed. The baby’s condition deteriorated, the Specialist Infant and Child Transport Service Team took over care and arranged transfer to a Paediatric Intensive Care Unit.  The baby was critically ill as a consequence of a global brain insult and died 3 days later. 7.41. The parents were interviewed by the Police and Father admitted causing the injuries to the baby.  He had been sleeping downstairs with the baby who was crying constantly and very difficult to settle.  Mother was sleeping upstairs.  There were concerns about the delay in contacting emergency services.  Father was tested for drug and alcohol consumption; there were no indications of their use at the point of arrest.  Father was subsequently convicted of the baby’s murder.   8. Analysis: Terms of Reference: 8.1. Review the responses to referrals to CSC from 2015 to 2017.   Were there any patterns identified in the referrals and information gained?  8.1.1. There were four referrals to CSC during the Scoping Period.  These included referrals from the Health Visitor, the VCS service and one anonymous referral.  There were two themes to the referrals; firstly, the potential risk posed to child one from the maternal uncle and, secondly, concerns about neglect in view of the poor home conditions, with fluctuating engagement by the family and progress in dealing with the concerns.  No concerns were expressed about domestic abuse within the family. 8.1.2. The first referral in September 2015, from the Health Visitor, was triggered by the delay in the parents taking child one for medical attention in relation to a skin rash. There were also concerns about the poor condition of the family home and the MGM’s possible mental health needs. The referral was triaged, and the initial decision was to pass to the Early Help service. However, this decision was re-evaluated due to concerns about Mother’s brother being in the household, checks were undertaken by MASH and the case was passed to the Joint Investigation Team for child protection enquiries, which were undertaken by a Student Social Worker.  These concluded that the family were aware of their responsibility to safeguard child one.  The case was closed, and the family were referred to the VCS for support with developing parenting skills. In addition, support would continue to be offered by the Health Visitor.  This appears to be an appropriate response given that this was the first referral to CSC. 8.1.3. There were two referrals by the VCS worker in June 2016.  The initial concern was in relation to the maternal uncle moving back into the family home and the potential risk he posed to child one.  The previous referral and social work assessment were reviewed, and it was noted that the decision was that Mother was able to safeguard child one. Therefore, no further action was taken.  Following this referral, VCS worker’s relationship with the family was damaged and engagement became difficult. A further referral was made in relation to the poor home conditions 13  and concern about the delay in seeking medical attention for child one’s sore ear.  The VCS service requested that an assessment with a view to providing support was undertaken.  The referral was triaged, and the decision made to refer the family to the Early Help Hub for support and advice.  An Early Help Plan was developed, the family engaged with this and the work was completed in October 2016. 8.1.4. The last referral was made by an anonymous caller in November 2016.  The referral raised concerns about child one being underweight, unkempt and unwashed, substance misuse in the family home, people coming to the house demanding money and Mother not allowing professionals, e.g. Health Visitor, access.  The referral was passed to MASH for agency checks and the decision taken that a single assessment would be undertaken by a social worker.   8.1.5. This was the appropriate course of action given that this was the third referral in just over a year raising concerns about the home conditions and neglect of child one, as well as concern about substance misuse in the family home.   8.1.6. The Health Visitor and GP were approached for information on both occasions when MASH undertook enquiries.  The Health Visitor shared concerns about the poor home conditions, but not about her observations of the mother and child interaction which would have been valuable information for the social worker undertaking the single assessment.  Midwifery were unaware of the referrals and concerns raised about the family.  8.1.7. All the referrals made to CSC eventually resulted in closure or ‘stepping down’ to Early Help.  It appears that the only agency that challenged this was the Early Help service which questioned whether the identified level of need was appropriate in March 2017, following the completion of the single assessment.   8.1.8. The Health Visiting Report Author has highlighted that the Health Visitor did not fully understand the level at which the case was managed by CSC and at one stage believed that it was being managed within the child protection system which would have addressed her concerns.  This is of concern as, if the Health Visitor was of this view, then she should have been expecting, and concerned that she had not received, an invitation to a Child Protection Conference.  Therefore, it is difficult to understand how this view could have been maintained for any length of time. However, this meant that the Health Visitor did not recognise there may be a need to challenge CSC’s decision to step down to Early Help or to escalate the concern to a manager.   The LIPP Briefing: Disagreement about the use of early help assessments 4 highlights that professionals felt unable to challenge the decisions of another agency and could be unsure about trusting their own judgement.  This may be reflected here. 8.2. Analyse the quality of the single assessment undertaken in March 2017. What was the understanding of the family history and its implications for risk?  To what extent were males incorporated into the assessment processes? Was the composition of the household fully understood?  8.2.1. As stated above, the single assessment commenced early in December 2016, in response to the anonymous referral received by CSC.  Three home visits were undertaken, and the assessment was completed in mid-December 2016.  However,                                                            4 Practice issues from Serious Case Reviews: Disagreement about use of early help assessment. Learning into practice project: Improving the quality and use of Serious Case Reviews, SCIE/NSPCC, 2017. 14  it was not written up and ‘signed off’ for a further 59 days, and the actions were not progressed until March 2017.  Parents requested support from the Early Help service and this was recommended as the outcome. 8.2.2. The referral raised concerns about child one being underweight and unkempt, the presence of the maternal uncle in the home, substance misuse and the family not allowing professionals, e.g. Health Visitor, access.   Information about the anonymous report to the Police (7.25), which raised additional concerns about child one’s welfare, had not been shared with CSC. 8.2.3. The single assessment focused on three areas:  the risk from the maternal uncle, the alleged drug use in the family and the home conditions and care of child one.  The Health Visitor was consulted for information, but not the GP or District Housing, which had had concerns for some time about the condition of the family home.  The Early Help service was also not approached for information, even though the service had only recently ceased involvement with the family. The social worker undertaking the assessment could have accessed the Early Help records but did not do so.   Therefore, full background information was not gained.   8.2.4. During the assessment a joint visit (not prearranged) was undertaken with the Health Visitor, who observed that child one’s development and weight were satisfactory.  However, there were concerns about the lack of opportunities for social and emotional development and the parents had declined to engage with the Children’s Centre. The Paternal Grandparents have expressed concern about child one’s development. Parents stated that the only drugs in the household were those prescribed to the MGM and this was accepted.  Regarding the concerns about the maternal uncle and the allegation of a serious sexual assault some years ago, the Police had taken NFA and the assessment in 2015 had concluded that mother and MGM were protective of child one, so this was not explored further. 8.2.5. The assessment noted that the parents and MGM responded to child one appropriately and demonstrated warmth.  There were no concerns about child one’s physical and emotional development, behaviour or presentation. Child one was dressed appropriately, although on one occasion looked unkempt and on another clothes were noted to be stained with food.  Concerns identified about child one’s care were twofold.  Firstly, the amount of time spent at home with adults and the lack of opportunities to go out, e.g. to the park, shopping, or to socialise with other children, and secondly, the risk to health and safety from the amount of clutter in the home.  8.2.6. Regarding the home conditions, it was noted at the beginning of the assessment that the lounge and kitchen had been very cluttered and that the parents had improved this by throwing away some of the clutter and rearranging furniture.  This meant that child one now had ‘more room to play and the kitchen can be entered safely, and meals prepared on the work surfaces which are free from clutter, dirty washing and dirty crockery.’  This presents a picture of long-standing neglect of the family home and potential risks to child one.   8.2.7. There is no reference in the assessment to the condition of the bathroom, toilet or the bedrooms and it was not noted where child one was sleeping.  Harry Ferguson 5 highlights the challenges for practitioners in gaining access to the whole home due to ‘feelings of discomfort around boundaries and privacy’, but also the importance                                                            5 Child Protection Practice, Harry Ferguson, Palgrave Macmillan, 2011. 15  of doing so.  He argues that the ‘primary rationale for seeing around the entire home is to be able to examine the standard of care being provided and to gain an appreciation of the child’s world through the space they inhabit.’   From reading agency reports and discussions, it appears that the multi-agency network did not achieve a shared understanding of what day to day life was like for child one and of the child’s world.   8.2.8. The single assessment concluded that ‘there was nothing to suggest that the parents were not able to attend to meeting child one’s basic care needs – talking, encouraging play. However, at times they may lack motivation to complete general daily tasks, like up keep of the family home and ensuring child one has lots of stimulation and development opportunities. Further concerns were noted about whether the parents could ‘keep on top of the family home conditions, clearing rubbish, keeping the floors clean and free from items that child one could trip over and ensuring that any medications are kept locked away’, which reflects the view of the Paternal Grandparents. 8.2.9. It also noted that the worries from CYPS for the family were:  Risk of home conditions deteriorating, which tended to be in sequence with Mother and Father’s mood and level of motivation.  Mother being the main carer for her mother and child, whilst presenting as low in mood/on the verge of depression.  Child one may not have opportunities for social and emotional development, due to the mood and motivation of parents.  If things continued to deteriorate, Mother could become more depressed and lose motivation to meet her own and her child’s needs.  8.2.10. The assessment recommended further exploration around Mother’s emotional health and understanding of how her mood and motivation may impact on her child.  Thus, the assessment appropriately identified concerns about the parents’ apparent lack of motivation to maintain the improved home conditions and about Mother’s emotional wellbeing. However, it appears that the full impact of this on their parenting capacity was not recognised in the conclusion and outcome of the assessment. 8.2.11. Reviewing the Agency Reports, there are a number of comments which indicate concerns about mother’s emotional presentation and wellbeing and the impact of this on her parenting.  The Health Visiting Report suggests that Mother showed some ambivalence in her parenting role, with the MGM spending long periods caring for the child.  Mother’s ‘responses to child one appeared unpredictable and were likely to be dependent on how she is feeling’.  This may imply that there were emerging concerns regarding the emotional care of child one.  In addition, the Early Help plan included a goal to boast Mother’s self-esteem and confidence to enable her to attend local groups for parents and children.   8.2.12. Father was the father of both children.  He was incorporated into the assessment, being included in the meetings with the family and the process as a whole. Both parents were encouraged to improve the home conditions and support was offered to Father with employment.  He was regularly present for meetings with practitioners, e.g. Midwives, Early Help, although he was not in agreement with the referral to the VCS service and did not engage with the plan.   16  8.2.13. Observations of father’s interaction with child one were positive and he supported Mother well in caring for the MGM.  He did not have a history of criminality or violence and there were no concerns about domestic abuse or substance misuse. Mother spoke of father as a ‘really good dad’ and of child one being close to him.  The Paternal Grandparents talked of them having a ‘super’ relationship’.  Therefore, what happened to the baby came ‘out of the blue’ and was a complete shock to the family.  Father had been tired and stressed about improving the home and finances, but it is hard for them all to make sense of what happened. 8.2.14. It is apparent from reading the Agency Reports that there was a lack of shared understanding amongst practitioners about Father’s role and how much time he spent in the family home.  It is recorded at various times that he was living with the family or was spending two or three days a week there.  The paternal family are clear that he was living with the family from before child one’s birth. It should be recognised that families may not be honest about the amount of time a partner is spending in a household due to the implications for benefits.  The Health Visiting Report Author has commented that the family functioning was not fully understood, and this would appear to be so.  8.2.15. Discussions with the Paternal Grandparents present a similar picture to that contained in the assessment. They were in regular contact with the family and would take child one to their house weekly or fortnightly. The home was very cluttered, and the garden was full of discarded objects.  Child one had little routine and on occasions appeared dirty and unkempt, with matted hair. In their view child one spent too long in the cot and some areas of development were delayed, e.g. speech.   They helped financially and with washing and kept clean clothes at their house.  They described the couple as ‘okay parents’ but lacking in motivation.  In addition, they were worried about people coming into the house late at night. They knew that CSC had been involved and were surprised that they appeared to ‘back off’.  Whilst they had serious concerns, they felt conflicted about raising these concerns formally, although came close to this at times.  They were not spoken to by the social worker during the assessment and hence this information was not gained. 8.2.16. There must be a question about whether the recommendation to step down to Early Help involvement flowed appropriately from the findings and conclusion. Referring to the definition of neglect may help with this question. It states that neglect is: The persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:  provide adequate food, clothing and shelter (including exclusion from home or abandonment);  protect a child from physical and emotional harm or danger;  ensure adequate supervision (including the use of inadequate care-givers); or  ensure access to appropriate medical care or treatment. 17  It may also include neglect of, or unresponsiveness to, a child's basic emotional needs.6 8.2.17. It could be argued that there had been a persistent failure to provide a safe home environment for child one, as well as appropriate opportunities for intellectual and social development. This was the third referral in respect of the poor home conditions and neglect of child one and the Health Visitor had been concerned for 18 months.  Given the social worker’s clearly articulated concerns about whether the family could maintain the improvement in the home conditions there has to be a question as to whether immediately ‘stepping down’ to Early Help was the correct outcome.  It was noted that the parents were aware that any future safeguarding concerns could mean further statutory involvement from CYPS.  8.2.18. There is a danger in making judgements about neglect based on a snapshot over a short period of time, as appears to have happened with this assessment.  Where there are concerns about long term neglect, it is important to assess whether any improvements can be maintained, and the timing of this assessment did not allow for this.  A more appropriate and safer course of action would have been for child one to be considered a child in need 7 for a six-month period and for services to be coordinated through a child in need plan.  If there was evidence of improvements being maintained, the service could then be stepped down to Early Help, or if there was not, then stepped up to child protection.  The decision to step down may well have been influenced by the parents’ request for support from the Early Help service and the social worker’s sense of optimism. 8 8.2.19. The CSC Report Author noted that the ‘level of concern around neglect in relation to child one could potentially have been more fully assessed’ but that there was ‘no specific framework in place at that time to enable neglect issues to be fully considered’.   This has recently been addressed by the LSCB with the launch of The Multi-Agency Toolkit, supporting families, preventing neglect. 9  8.2.20. The CSC Report Author has also drawn attention to the delay in progressing the single assessment and has highlighted two concerns.  Firstly, where an assessment has been completed and the case passed to Early Help, the plan of work is based on that assessment.  However, after three months the level of need may have changed and in this case, it was likely that it had.  It was known mother was pregnant with the second child and the MGM was becoming increasingly unwell and reliant on the parents.  Given the delay, the Author notes that an initial multi-agency planning meeting at the point the case was opened by the Early Help Team would have been beneficial to ensure that the assessment and plan remained appropriate to the level of need.   Secondly, from the referral in November 2016 to Early Help making contact in March 2017, no additional services were offered to the family to address the concerns raised, one of which was the family’s capacity to maintain satisfactory home conditions.                                                              6 Working Together to Safeguard Children:  A guide to inter-agency working to safeguard and promote the welfare of children, HMG, 2015. 7 Section 17, The Children Act 1989, Definition of need: A child is in need if s/he is unlikely to achieve or maintain, or have the opportunity to so do, a reasonable standard of health or development without provision of services by a local authority, or if her/his health or development is likely t be significantly further impaired, without such services, or s/he is disabled. 8 Dingwall et al, Monograph: The Protection of Children: State Intervention in Family Life. 1983. 9 The Multi-Agency Toolkit, supporting families, preventing neglect, Local Safeguarding Children Board, 2017. 18  8.2.21. In summary, the assessment did address the concerns that had triggered it and there was evidence of thought and reflection. However, it lacked a thorough assessment of the nature of the home conditions and the impact of these on child one’s safety and development and fails to address fully other areas of potential neglect, e.g. lack of opportunities for social and intellectual development. Also, the functioning of the wider family network, including the paternal family and the role of the Maternal Grandmother, were not fully explored and understood.  The Paternal Grandparents were not contacted during the assessment and from their discussions with the Independent Reviewer it is apparent that they were in regular contact with the family and had concerns about child one’s care. Concerns about Mother’s emotional presentation, and possible depression, together with the both parents’ lack of motivation, and the impact of this on their parenting capacity were appropriately highlighted, but insufficient attention was paid to these factors.  The family’s explanations in respect of the concerns about drug use in the home were accepted without challenge.   8.2.22. Given the long-standing concerns and the information presented in the assessment there has to be a concern that the conclusion was over-optimistic10 and lacked a focus on the child’s needs, as well as a question about the appropriateness of the recommendation and decision to again step down to early help, rather than pursue a child in need plan11, under Section 17 of the Children Act 1989, with the early help service being part of the package. The view of the CSC Report Author is that the social worker was unduly influenced by the parents’ willingness to work with early help again.   8.2.23. This decision was discussed in some depth at the Recall Event and it was highlighted that in the past there has been concern that the district had a higher than average number of Child in Need plans and that in response to this CiN plans significantly reduced and early help became a ‘catch all’ service when concerns had not reached the level of child protection.   The view of practitioners is that there has now been a shift, with CSC maintaining lead responsibility and working alongside early help services until it becomes clear that the family are motivated and engaging with the plan.  8.3. Comment on the application of thresholds/different perceptions of the level of concern within the agencies involved. To what extent did subjective judgements about home conditions feature in this case?  8.3.1. Since January 2016 the Safeguarding Children Board has had guidance, in place to assist practitioners in understanding levels of need, The Multi-Agency Continuum of Need: Supporting Children, Young People and Families 12.  This identifies four levels; Universal, Universal Plus, Co-ordinated and Specialist and states that:   Support should be delivered by the whole partnership to ensure children and families receive the right help at the right time.  A family’s need for support will change with time and circumstances. For this reason, it is crucial that we work                                                            10 Dingwall et all, 1983. 11 Section 17, The Children Act 1989, Child In Need. 12 The Multi-Agency Continuum of Need: Supporting Children, Young People and Families, Local Safeguarding Child Board, January 2016. 19  together to ensure we respond appropriately and in a prompt and timely way when need either increases or reduces.   (2.7. Multi-Agency Continuum of Need) 8.3.2. In discussions at the Learning and Recall Events it was apparent that there has been a lack of understanding, and considerable confusion, amongst practitioners about the levels of need as operated in the district.  (Learning point and recommendation).    There appears to be a number of reasons for this:  There was a period when the area guidance had included five levels of need, rather than the four which is used more widely.   There was insufficient communication, training and awareness raising when the levels reduced to four.   Levels tend to be referred to numerically, e.g. Level 3, rather than using a descriptor. 8.3.3. In addition, there was a lack of understanding about the process when a referral is made to CSC and it was suggested that CSC may make the assumption that practitioners understand what will happen, when in fact they do not.  The Health Visitor understood that the case was being managed at Level Four and that this meant child protection.   It was true that at one point it had been passed to the JIT for child protection (Section 47) enquiries, but then stepped down and referred to the VCS service for young families for support.  8.3.4. The Health Visiting Agency Report Author notes that the records demonstrate ‘a clear picture of chronic neglect within the family’, with the following factors identified:  Chronic ill health of MGM  Poor home conditions  Young parents  History of CSC involvement  Parental ambivalence, including late bookings for each pregnancy  Lack of clarity regarding the parental roles and that of MGM   Child not brought to appointments, e.g. Dermatologist, immunisations.  Distrust of professionals   8.3.5. The Agency Report Author’s view is that these factors were not explicitly identified or analysed for their potentially cumulative risks of harm.  It was the Health Visitor’s perception that the home conditions were poor and inadequate suggesting an unsuitable environment for a very young child.   However, there was no analysis of how the neglect might impact on children in the home.  The Health Visitor had clearly considered making a referral to CSC from early on in her involvement with the family, and prior to the birth of child one, but delayed doing so in part because she wanted to give parents the opportunity to engage with services, but also because of a ‘lack of confidence in the wider agency response’, believing that the situation needed to be much worse before CSC would take any action.   Thus, the Health Visitor had pre-empted the response of CSC and allowed this to deter her from being ‘authoritative in her own assessment’ and making an early referral.  Once the Health Visitor had made the referral, it appears she then ‘stepped back’.   20  In addition, at times it appears that the Health Visitor believed the case was being managed as child protection, which is difficult to understand as there would have been an expectation of invitations to Child Protection Conferences and Core Groups.  8.3.6. The VCS staff described the home conditions in a factual manner and made judgements about the impact of these on the child one’s safety and well-being.  They were clearly concerned that these were worsening, hence, the referral for assessment in June 2016.  This approach was less subjective, staff were not making judgements about the home conditions but assessing the impact on child one’s safety and development. 8.3.7. The Police Agency Report Author is of the view that a Strategy Meeting should have been held in November 2016 as child protection concerns had been reported to CSC and the Police.  The Author also raises wider concerns about how referrals of child protection concerns are dealt with and whether there is ‘a disconnect between police and social care colleagues about their mutual understanding of ‘significant harm’ and also what is appropriate for a joint strategy discussion and police action, resulting in matters which may amount to a criminal offence not being passed to them.’  A review of these cases is currently being undertaken by senior police managers.  (Recommendation) 8.3.8. Making assessments about poor conditions and neglect can be challenging for practitioners and a number of factors can come into play.  Firstly, workers can be reluctant to make judgements for fear of oppressive practice, and secondly, workers can lower their expectations according to the area in which the family live. There were discussions at the Learning and Recall Events about whether there was an acceptance that the home conditions were not untypical for the area and whether practitioners’ thresholds had been raised.  The view was that this was not considered to be a factor in this case, but practitioners should be mindful of this lowering of thresholds.   8.3.9. Whatever the reasons it does appear in this case that concerns about home conditions were not pursued robustly.  Despite concerns about long-term neglect, practitioners did not routinely ask to view the bathroom and bedroom, where the parents and child one slept.  Hence, there was a lack of awareness of the condition of these rooms and where child one was sleeping.   (Learning point and Recommendation). 8.3.10. Research undertaken by the University of East Anglia, Neglect and Serious Case Reviews 13, found that professionals were tolerant of dangerous conditions and poor care when a safe living environment is a basic precondition for a safe relationship between children and their caregivers.    It is a right that all children should have decent living conditions and those caring for the child have a responsibility to maintain a child friendly environment.  Professionals need to make a judgement about whether parents can maintain a safe and healthy environment if they are given reasonable support.  If parents have a good relationship with children but their living conditions are not safe, then the chid is not safe.                                                              13 Neglect and Serious Case Reviews: A Report from the University of East Anglia commissioned by NSPCC, UEA/NSPCC, Jan 2013. 21  8.3.11. The LSCB has recently launched a toolkit for practitioners in dealing with neglect, The Multi-Agency Toolkit, supporting families, preventing neglect14.  This is based on the Signs of Safety approach and supports workers in identifying the level of concern.  Feedback during the SCR was positive about the Toolkit, as it provides a frame of reference and helps practitioners to ‘pinpoint particular issues’.  It can be used in a multi-agency setting.  The Midwifery Agency Report Author considers that this will provide a ‘standardised approach’ to dealing with concerns about neglect and should help to reduce ‘the subjective judgements which featured in this case’.   It is important that this guidance is consistent with the Multi-Agency Continuum of need.15 (Recommendations) 8.4. What impact did the family’s poor engagement with services have on service delivery? 8.4.1. The Biennial Analysis of Serious Case Reviews 2005 – 07 16 identified five levels of family’s co-operation, from highly co-operative and persistently seeking help to not co-operative, actively avoiding involvement and hostile.  However, it suggests that putting families into one category or another is not helpful as parents’ behaviour tends to be changeable and to display different levels of cooperation at different times and with different agencies.  There is evidence of this changeable parental behavior, also known as disguised compliance 17 , which can lead to a downgrading in concern by professionals and allow cases to drift, so losing the opportunity to make timely interventions.  The paternal grandparents were aware that on occasions the door was not opened to professionals. 8.4.2. The Biennial Analysis highlights that it is important to recognise that there are a range of factors that influence the way in which families engage with services and why they might lose the motivation to engage and suggests that hostility can be ‘modified by positive engagement skills of staff and should not be considered an inherent or unchangeable attribute.’ Certainly, there is evidence that the Early Help worker was able to establish a positive relationship with the family.  The Agency Report Author had discussed this with the worker and it is apparent that she was able to balance honesty regarding the concerns about the home conditions and what needed to be changed, with practical support for the family.  Mother has spoken positively of the support offered and commented that the worker had time to sit and talk with them about the difficulties they were facing.   8.4.3. It is apparent that the family did not easily accept practitioners’ decisions to refer to CSC and this impacted on future relationships and the work undertaken.  This may have been strongly influenced by the attitude of the MGM, who it is noted was resistant to agency involvement, being particularly evident in her response to the frequency of visiting by the Health Visitor and to the VCS making a referral to CSC. Mother has confirmed that the MGM did not like people coming into the home nor what was said about the family, which may relate to her experience of having a child in the care of the local authority.  The Health Visitor struggled to gain access to the family home for several months early in 2017 and the family declined the support being offered by the VCS project for young families.  The VCS found the family could                                                            14 Neglect Toolkit, LSCB 2017. 15 Continuum of need, LSCB. 16 Understanding Serious Case Reviews and their impact.  A Biennial Analysis of Serious Case Reviews, 2005 - 07.  DCSF, 2009. 17 Disguised compliance: Learning from case reviews.  NSPCC Briefing March 2014. 22  be ‘intimidating’ and felt that the MGM was controlling in respect of mother. It is therefore open to conjecture whether the decisions about involvement with agencies were made by the parents or MGM.  8.4.4. There were a number of home visits when practitioners were spoken to on the doorstep by the MGM and not allowed access to the family home. It is suggested that the MGM was the ‘door keeper’ and controlled who went in and out of house.  She managed the family’s relationship with professionals, kept them at bay, prevented child one being seen on occasions and blocked the couple receiving the support that was being offered. There is a suggestion that workers may have ‘backed off’ from putting any pressure on the family for fear that their engagement might stop altogether, leading to a failure to provide sufficient challenge to the parents.18  In addition, there would have been added concern about this in view of the MGM’s terminal illness.  As highlighted earlier, this may have influenced the decision to step down to the early help service in March 2017. 8.4.5. In Child Protection Practice, 19 Harry Ferguson, discusses the challenge of doorstop visits.  He suggests that the doorstep is a ‘transitional space’, the threshold between the worker’s public world and the family’s private life and it is significant how parents, and carers, can use the physical structure of the home to prevent practitioners gaining access to and properly seeing children and the home.  The danger of doorstep encounters is that even if the child is seen only briefly, and may be at a distance, this can satisfy practitioners and managers that the child has been seen.  Ferguson argues that seeing a child from a distance is ‘not good enough’. 8.4.6. Whilst mother’s presentation for ante-natal care in both pregnancies was late, she, usually with the father, attended all subsequent appointments.  An issue has been identified in terms of the information shared with midwifery in the second pregnancy, with the couple denying the involvement of CSC and Early Help.  This meant that Midwifery were not fully aware of the concerns about the home circumstances when deciding how long mother and baby would remain on the post-natal ward 8.4.7. Therefore, the poor engagement did impact adversely on services being offered to the family. The Health Visitor had difficulty gaining access consistently. The VCS had undertaken an assessment and had a clear plan of work with the family in mind.   It should be noted that this plan was mirrored in the work subsequently undertaken by Early Help, where the parents did engage with one worker, although less so with the replacement when that worker was away on extended sick leave.  A consistent approach is essential when working with families where there are concerns about long standing neglect in order to lessen the likelihood of ‘start again syndrome’, which prevents practitioners thinking and acting systematically.20 8.5. What was the impact of the illness and death of the maternal grandmother on the family, particularly emotionally and financially? 8.5.1. The MGM suffered long term ill health due to a number of chronic medical conditions and became terminally ill during the Scoping Period for this SCR. She is also described as being a ‘hoarder’, which led to the home being extremely                                                            18 In the child’s time: Professional responses to neglect.  Ofsted, March 2014. 19  Harry Ferguson, Child Protection Practice, Palgrave, Macmillan, 2011. 20 Analysing child deaths and serious injury through abuse and neglect: what can we learn?  A biennial analysis of serious case reviews 2003 – 2005. DCSF, 2008. 23  cluttered, to the point that District Housing were concerned about the fire risk and provided skips to clear rubbish.  The Maternal Aunt noted that it was very difficult for the parents to deal with the clutter as the MGM would constantly undermine their attempts and Mother confirmed that it was only after her death that they could clear and clean the house.  From the age of 14 years, Mother was the MGM’s carer, her school attendance was limited and her social activities as a young person were severely restricted.  The family was insular. 8.5.2. Reflecting on Mother’s presentation (See paragraphs 8.2.13/14.) it appears that her experiences during adolescence may have impacted on her emotional development and opportunities to acquire the skills required for adulthood.   8.5.3. The MGM was cared for at home by the parents until she was admitted to hospital just a few days before her death in April 2017.  The parents took the responsibility of their caring role very seriously.  Mother was pregnant, so Father became heavily involved in the day to day care and the wider family have commented on how patient and caring he was. 8.5.4. Both the VCS and CSC Report Authors view the impact of the MGM’s death as considerable.  The MGM was the dominant person in the family, the Head of the Household, and offered support and protection to Mother, managing the relationships with professionals.  Neither parent had lived independently before, so this was a major change for them. 8.5.5. The MGM’s death had definite practical implications for the family. The tenancy of the home was in her name, so the parents had to apply to have the tenancy transferred and District Housing stipulated that a considerable about of redecoration was required, as well as the house being cleared of clutter and the garden of rubbish.  It is understood that Father was working hard, into the night, to complete this work. Mother had been in receipt of a Carer’s Allowance, which would have ceased when the MGM died, and the parents were experiencing difficulties claiming benefits and were receiving support with managing this from Early Help. Therefore, housing and finance were creating considerable stress for this young couple, who were living independently for the first time.  8.5.6. Despite the demands on the parents, practitioners have also spoken about the atmosphere being lighter in the household and home conditions beginning to improve.  8.5.7. In spite of the MGM’s poor health, it is apparent, from Agency Reports and discussions with the maternal and paternal families, that she provided considerable support to the parents and took a significant role in caring for child one, particularly as a young baby, including sharing the night time feeds.   There was discussion at the Learning Event about the impact of MGM’s death on the care provided to the children, particularly to the new baby.  It was suggested that the parents would be viewed as ‘second time parents’ when in fact, given their circumstances, they were young ‘first time parents’, caring for a baby on their own for the first time.    8.5.8. The Paternal Grandmother had recognised this and had spoken to the parents about the fact that caring for their second child would be much harder.  Not only did they not have the support of the Maternal Grandmother, but they also had a toddler to care for.  8.5.9. Therefore, overall, the death of the MGM, just over two months before the birth of Madison, had a significant impact on the family, and the fact that things would 24  be very different was commented on to the parents by the PGM when Madison was born.   The CSC Author notes that her death would have had ‘a significant impact on a practical as well as emotional and financial basis.’.  This was particularly significant as the parents were still young and not fully independent.  The report ‘New learning from serious case reviews’ 21 found that ‘almost 60% of the mothers were under 21 years of age when they had their first child.  Although the vulnerability of many of these young mothers has been recognised, we need to acknowledge that this vulnerability can be lasting and that there may be cumulative stresses and risks of harm when these young first-time mothers go on to have more children.  This highlights that the family was in a vulnerable position when their second child was born. 8.6. Were interventions and support well co-ordinated between agencies? Was there a sense of one lead agency or professional?  8.6.1. There was considerable agency involvement with the family during the Scoping Period by the Health Visitor, GP, Midwives, VCS, Early Help and District Housing.  There is evidence that practitioners were tenacious in their efforts to engage with the family and there are examples of positive joint working between practitioners.  However, overall the work was poorly coordinated, and a Lead Professional and Agency were not identified. 8.6.2. From an early stage the Health Visitor identified concerns about the home conditions and liaised with Midwifery and the GP.  The GP and Health Visitor discussed the family at Link Meetings, however, Midwives were not invited to these meetings.   Similarly, the VCS liaised with the Health Visitor, Housing and the DWP.  8.6.3. In August 2016, the Early Help service developed a plan of work with the family, which was based on the signs of safety model. However, the plan was not fully completed. Three ‘worry/harm statements’ were identified, and these should be graded on a ‘scale of safety’ from 0 (no safety) to 10 (very safe), but none of the three statements were rated.  In addition, the section for Parent’s Views was not completed, which suggests that the plan was either not discussed with the family or it was, but their views were not recorded.  Nor was the plan agreed by the manager.   8.6.4. The Early Help Plan was not shared with other agencies, a multi-agency meeting was not convened and the Lead Agency and Professional were not identified.  Despite this, the CSC Author notes that Early Help ‘understood their role to be that of Lead Professional and believed that others shared this view.’ 8.6.5. Good practice would indicate that a Team Around the Family meeting should be convened in such circumstances and the plan agreed, with clear goals and timescales, as well as the roles and responsibilities of agencies defined.  This would have been particularly helpful for this family, where long term neglect was a concern, in identifying which aspects of the home conditions needed to be prioritised and how the improvements would then be maintained. The Report Author for CSC noted that a multi-agency planning meeting ‘may have brought a better shared understanding of the family situation and level of concern, which would determine whether the case was being managed at the right level according to the continuum of need’.                                                            21 New learning from serious case reviews: a two-year report for 2009-2011, University of East Anglia and University of Warwick. DoE, 2012. 25  8.6.6. At the Learning Event, there was a discussion about the fact that the parents were unlikely to attend a multi-agency meeting and whether the meeting should then go-ahead as Early Help involvement is based on parental agreement.  The view was that if this was routine practice, then the family would be informed of the meeting at the commencement of the work, with the option to attend the meeting.  If they choose not to do so, then their views could be sought and presented, and the outcome of the meeting shared with them. (Learning Point) 8.6.7. The Police Agency Report Author notes that there was a lack of co-ordination both within the Police and with CSC following the anonymous reports to the agencies in November and December 2016 and that, given the child protection concerns, consideration should have been given to convening a Strategy Meeting.  Information about the anonymous report was not shared with CSC so was not available to the social undertaking the assessment.   The Author notes that the offices of MASH and the Police Child Protection Officers are next door to each other, but this proximity may not have promoted closer working.  The Report Author raises concerns about how referrals raising child protection concerns are dealt with and whether there is ‘a disconnect between police and social care colleagues about their mutual understanding of ‘significant harm’ and also what is appropriate for a joint strategy discussion and police action, resulting in matters which may amount to a criminal offence not being passed to them.’  A review of these cases is currently being undertaken by senior police managers.  (Recommendation) 8.6.8. At the booking in ante-natal appointment in March 2017, the Midwife undertook the Vulnerabilities Risk Assessment and, although questioned, the parents did not inform the Midwife that they were receiving support from the Early Help service.  This was compounded by the fact that the Health Visitor did not inform Midwifery either.   There was a discussion at the Learning Event that if Midwifery had been more fully aware of the family circumstances then consideration could have been given to encouraging mother and baby to remain in hospital for longer than 6 hours post birth.  (Learning point and recommendation).  8.6.9. The Health Visitor and GP held Link Meetings, which were a valuable mechanism in discussing families of concern.  Midwives were not included in these meetings at the time of the Scoping Period, but there is a move to do so.  (Learning point and recommendation) 8.6.10. At the Recall Event there was discussion about the fact that there are two assessments used at the early help level of intervention.  The Local Authority’s early help service has an assessment tool and other agencies use the electronic Child Wellbeing CAF.  The later appears to be ‘unpopular’/’not user friendly’ with practitioners.  This may be a barrier to practitioners undertaking CAFs, reducing the number undertaken, and the Board may well be advised to look in this. 8.6.11. In summary, the SCR has identified a need for improved multi-agency coordination when an Early Help Plan is in place for a family.   The Triennial Analysis of Serious Case Reviews 22 highlights that a failure to meet a threshold for specialist (CSC) services should not result in a less rigorous process of assessment and service provision.  There should be an appraisal of risk and vulnerability and multi-agency                                                            22 Triennial Analysis of Serious Case Reviews (2011 – 2014).  Practice briefing for LSCBs, Research in Practice, June 2016.  26  meetings should have a clear structure and format, together with a clear plan, with assigned accountability and measurable outcomes.  (Learning point) 8.7. Explore the role of managers and Safeguarding Leads. Did supervision or management oversight contribute positively to practice? Were there missed opportunities for escalation? 8.7.1. There is a mixed picture in relation to supervision and the role of Safeguarding Leads. 8.7.2. There is clear evidence of regular supervision in the VCS records, the assessment and action plan were signed off by the Senior Practitioner, who also accompanied the worker on a home visit to offer support.  The worker acted on the manager’s advice to inform CSC of concerns about the home conditions.  It is positive that the VCS made a referral for assessment to CSC when it was apparent that they were unable to engage with the family and that the case was not closed until confirmation was received that the case had been passed to the Early Help Hub.  A SCR in 2012 had highlighted the need for an improvement in the arrangements for supervision and this has clearly been actioned.   8.7.3. Following the anonymous referral to CSC, it was recommended that checks should be undertaken with neighbours, but these were not carried out.  This was identified when the case was reviewed by a Detective Sergeant and the outstanding task was completed. 8.7.4. The Health Visitor recognised concerns about the poor home conditions and potential neglect prior to child one’s birth and made the first referral to CSC in September 2015.  These concerns continued and there was a period of several months when the Health Visitor was unable to gain access to the family home.  In addition, there was concern about the delay in seeking medical attention for child one’s skin rash and immunisations were delayed.  In line with procedures, the Health Visitor did have safeguarding supervision on a three-monthly basis, but did not raise this case for discussion in supervision until March 2017, when she discussed her concern that child one had not been seen for a few months.  Clear actions were agreed. 8.7.5. The Health Visitor did not consider escalating concerns about the response of CSC to the referrals and the Report Author suggests two reasons for this. Firstly, that there were other cases which were of more concern and secondly, the Health Visitor’s lack of understanding about the level at which the case was being managed by CSC, believing that the family were receiving supportive services after the referral made in September 2015.  Also, at one stage the Health Visitor believed that child protection procedures had been instigated and was awaiting an invitation to an Initial Child Protection Conference but did not pursue this when it did not arrive.  More regular supervision would clearly have supported the Health Visitor, who found work with the family challenging, and provided an objective overview.  It may also have helped to clarify the level of CSC’s involvement and consider whether there was a need for escalation.   8.7.6. In October 2016, the Team Manager did review the case, which took 7 minutes.  The Health Visiting Report Author suggests that this was a missed opportunity to provide in-depth management oversight.   However, each Health Visitor holds such a large number of cases that the only meaningful way to review a 27  case is if the Health Visitor raises the matter in safeguarding supervision or directly with a manager.   8.7.6. There is evidence that management oversight and supervision provided in Early Help was regular, with opportunities for reflection. 8.7.7. In CSC supervision was undertaken in line with the required timescales and actions and decisions were recorded.  There was management oversight of the assessment process and agreement to the recommendations.  However, there are questions about the robustness of this.  Firstly, the manager did not identify the delay in writing up the assessment, which was allowed to drift for two months.  Secondly, concerns have been identified about the robustness of the single assessment and the resulting recommendation. The CSC Report Author has reflected that the focus of management oversight may well have been procedural, to ensure that the assessment was written up and signed off, rather than providing the opportunity for reflection and challenge and careful consideration of the analysis and recommendations.   The national analysis of SCRs 2009 - 2011 highlighted ‘the importance of challenging and reflective supervision’ which goes beyond procedures and processes.23 (Learning Point) 9. Examples of good practice:   Early recognition of the family’s need for enhanced support by the Health Visitor and her tenacity in visiting the family, despite their resistance to her involvement.   The Early Help worker established a positive working relationship with the family, who viewed her as very supportive and easy to talk to.   Evidence of the impact of management oversight by the Senior Practitioner in the VCS   Police management oversight identified that the required checks with neighbours had not been undertaken and this was rectified.   In the second pregnancy the Midwife undertook additional home visits in view of the recent bereavement in the family.    Good communication between the Health Visitor and GP, including the link meetings when families of concern could be discussed. The need for improved communication between GPs and Health Visitors had been highlighted in a number of local SCRs and this is evidence that positive action has been taken in this regard.    10. Recent Developments:                                                             23 New learning from serious case reviews. DoE, 2012. 28   Launch of the LSCB’s Multi-Agency Toolkit: Supporting families, preventing neglect.   Midwives are beginning to be involved in link meetings between GPs and Health Visitors when families of concern are discussed.  11.  Key Learning:  In cases where there are concerns about long term neglect, it is important to:   Understand the child’s lived experience.  What is life like for them day-to-day?  What is their routine?   Routinely view all the accommodation, including the kitchen, bathroom, bedrooms, and where the child is sleeping, in order to gain an overview of the child’s world.     Assess the totality of the child’s care, not just the home conditions and physical care, but also the emotional care, stimulation and opportunities for social interaction offered to the chid.     Assess the impact of the neglect on the child’s safety and development e.g. when the home is too cluttered to move around safely, when opportunities for play and social interaction are not accessed.    Maintain chronologies, which can help to identify patterns.     Gain an understanding of significant people in the child’s life and involve them in assessments.  They may be able to offer support to the family and protection to the chid, e.g. grandparents.   Use a standardised, objective, approach to the assessment of neglect, reducing the tendency for subjective judgements about whether the level of cleanliness and clutter in the home is ‘good enough’.  This can be achieved by using the LSCB’s Neglect Toolkit, launched in 2017, which provides practitioners with an objective framework for assessing and monitoring long term neglect.  (Recommendation)   Importance of reflective and challenging supervision in cases where there are concerns about long term neglect, in order to guard against the rule of optimism and to recognise a practitioner’s sense of helplessness.    Importance of effective co-ordination between agencies.  At whatever level of intervention, i.e. Early Help, Child in Need, Child Protection, there should be multi-agency meetings to pull together information and achieve a shared understanding of the family functioning and concerns about the care of the 29  child. Multi-agency plans should be developed with clear goals and timescales, as well as the roles and responsibilities of parents and agencies defined.  This is particularly helpful in cases where long term neglect is a concern to identify which aspects of the home conditions should be prioritised and how the improvements would then be maintained.     (Recommendation)   The belief that a family will not engage in multi-agency meetings should not be a barrier to convening these.  There are ways in which the family’s views can be sought and presented to a meeting and feedback can be given to them after the meeting.   There is a danger that a family’s lack of engagement weakens the co-ordination and effectiveness of the multi-agency working.    Importance of recognising a lack of engagement/disguised compliance, but also of the need for consistent support over time to gain a family’s trust.   Need to consider the impact of this on the co-ordination and efficacy of services.  (LSCB’s non-engagement pathway.)  (Recommendation)   Need for a shared understanding, and common language, of levels of need/thresholds, particularly following a referral to CSC.  Numbering levels of need are not helpful.  Early Help, Child in Need, Child Protection etc are more helpful descriptors for agencies. (Recommendation)   Importance of the outcome of referrals being clearly communicated to referring agencies.   Importance of Midwifery being informed when there are concerns about parenting and knowing which agencies are working with the family and if there is a multi-agency plan in place, i.e. early help, CiN, child protection.  Need to guard against seeing health as one agency where records are shared, when in fact it is many agencies and records are not routinely shared.     Value of including midwifery in the link meetings between GPs and HVs.  12. Conclusion:  12.1. This serious case review concerns the tragic death of a very young baby due to physical abuse.  Whilst the review has identified weaknesses in the assessment and intervention in relation to the long-term neglect of the older child in the family, there is no evidence in the Father’s background, or in what was known about the family 30  functioning, that would indicate that he would inflict such injuries. There had been no concerns expressed about his relationship with the older child, which was seen as positive, and no evidence of criminality or domestic abuse within the household.  12.2. There were long standing concerns about neglect in relation to child one, notably in respect of the unsafe, cluttered, home conditions, but also concerning the lack of opportunities for stimulation and socialisation. There were no concerns regarding the child’s health and basic development, which was assessed as age appropriate, although this is challenged by the Paternal Grandparents. 12.3. The parents and child one lived with the Maternal Grandmother, who suffered chronic ill health.  The parents were both young, Mother had assumed a caring role for the Maternal Grandmother from the age of 14 years and from then had limited access to education and social activities.   Despite her poor health, the MGM had been very supportive to the parents, particularly in caring for child one.  However, the review has identified that, as Head of the Household, she may also have disempowered and prevented them accessing the support that was available from services, e.g. Health Visitor, VCS, seeing this as intrusive.   12.4. From Mother’s first pregnancy there was recognition of the family’s need for additional support.  The Health Visitor appropriately placed the family on the Universal Plus Care Pathway, which led to enhanced visiting, and the family were referred to the VCS and Early Help services.  Their engagement was variable, with some signs of disguised compliance. 12.5. In response to the number of referrals, Children’s Social Care undertook a single assessment, which was completed in March 2017.  This assessment did not fully address the entrenched nature of the family’s difficulties, nor achieve an understanding of the family functioning, of Father’s role or of Mother’s emotional wellbeing and how this impacted on her parenting capacity.  There was a lack of consideration of the impact of the neglect on the child’s wellbeing and development and an understanding of the child’s routine and lived experience was not developed.  This was reflected in the decision to ‘step down’ to Early Help, rather than offer support to the family through a statutory Child in Need Plan.   12.6. The MGM died just over two months before the birth of the second child, which the review has concluded had a significant impact on the parents.  They were facing challenges with finances and housing. as well as dealing with the grief of their loss.  Therefore, they were vulnerable parents.  It is likely that they were viewed by practitioners as second time parents, but in reality, without the support of the MGM, they were first time parents.   12.7. Whilst this review has identified important lessons to be learnt for single and multi-agency working, there is no evidence in the father’s background to suggest that he would harm the baby physically.   Even it there had been statutory involvement at the time of the baby’s birth, it is highly likely that the focus of engagement with the family would have been in relation to neglect, rather than the risk of physical abuse.  Recommendations for the Local Safeguarding Children Board: 31  Below are the recommendations for the LSCB.  These, together with the recommendation made by individual agencies, will be closely monitored by the LSCB’s Serious Case Review Sub-Group. 1. LSCB should evaluate the impact of the Neglect Toolkit through the mechanisms below and develop this as necessary.   Feedback gained from the event ‘Neglect Toolkit One Year On’ to be held in June 2018.  Data gained from the questions added to Children Social Care’s point of contact script and to School Nursing and Health Visiting records (SystemOne).  Information about the quality of referrals to CSC’s in respect of neglect.  Findings from multi-agency and single agency audits, SCRs and Case Reviews. 2. LSCB should receive a report outlining the findings of the Police’s review of the multi-agency action taken in respect of child protection referrals and agree an action plan as necessary.      3. LSCB should review the Continuum of Need to ensure that it reflects the learning of recent SCRs and that it is a meaningful document for use by a range of practitioners and agencies.  Consideration should be given to producing a simplified and accessible version of the guidance for practitioners.  4. LSCB should seek assurance from the Children and Young People Partnership that the review of the Early Help Strategy has strengthened the co-ordination of early help services.  This should include a clear proposal in relation to the arrangements for the early help hubs when offering a service to a family alongside universal services.  In addition, there needs to be clarity with regard to multi-agency plans and the identification of a Lead Professional and the roles and responsibilities of all practitioners.     5. LSCB should seek assurance that the processes for the dissemination of key information from the Board to practitioners are robust and ensures that information about significant changes is disseminated widely and promptly.  6. LSCB should seek assurance from health partners, including CCG, 0-19 Service provider, and Hospital NHS Trust that relevant information is shared between Trusts and partner agencies (notably midwives) working with children and families.   32    33   APPENDIX A      CASE REVIEW TERMS OF REFERENCE & PROJECT PLAN  SUBJECT: Madison  Date of birth: 2017 Date of death: 2017      Version 3: 09.10. 2017  34  1. Introduction: 1.1 This Serious Case Review is commissioned by the Local Safeguarding Children Board following Madison’s death in 2017. Madison had arrived at hospital by ambulance with her father with a brain injury considered to be non-accidental. She had extensive bruising and injuries. 1.2  Madison had been in the care of her parents at the time she was injured. The family had been known to Children’s Social Care since September 2015, initially referred by the health visitor who had concerns about poor home conditions and neglect in relation to Madison’s sibling.  1.3 Whilst there is recorded evidence of domestic incidents, a multi-agency strategy meeting did not identify any indicators that either parent presented a risk of harm to Madison in response to one serious incident. Madison had been admitted to hospital, which alerted Police and Children’s Social Care. 1.4    Madison’s father has pleaded guilty to murder. He has been sentenced to life imprisonment, with a recommendation to serve at least 10 years.  2. Legal Framework: 2.1 Serious Case Reviews and other case reviews should be conducted in a way in which:  recognises the complex circumstances in which professionals work together to safeguard children;   seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   is transparent about the way data is collected and analysed; and   makes use of relevant research and case evidence to inform the findings.    (Working Together Chapter 4 para 11, March 2015) 3. Methodology:  3.1 This Case Review will be conducted using the Significant Incident Learning Process (SILP) methodology, which reflects on multi-agency work systemically and aims to answer the question why things happened.  Importantly it recognises good practice and strengths that can be built on, as well as things that need to be done differently to encourage improvements.  The SILP learning model engages frontline practitioners and their managers in the review of the case, focussing on why those involved acted in a certain way at that time. It is a collaborative and analytical process which combines written Agency Reports with Learning Events. 35  3.2 This model is based on the expectation that Case Reviews are conducted in a way that recognises the complex circumstances in which professionals work together and seeks to understand practice from the viewpoint of the individuals and organisations involved at the time, rather than using hindsight.  3.3 The SILP model of review adheres to the principles of;  • Proportionality • Learning from good practice • Active engagement of practitioners • Engagement with families • Systems methodology  4. Scope of Case Review: 4.1 Subject Madison:    Date of Birth:  2017 4.2 Scoping period:   May 2015:   (Failed antenatal visit by health visitor)   to July 2017:  (Date father was charged) 4.3 In addition agencies are asked to provide a brief background of any significant events and safeguarding issues in respect of Madison and her immediate family.  This will include any significant event that falls outside the timeframe if agencies consider that it would add value and learning to the review.  5. Agency Reports:  6.1 Agency Reports will be requested from:    Children’s Services (Social Care & Early Help)  GP   Police  NHS Care Foundation Trust – 0-19 Service  Hospital NHS Trust  Ambulance Service  Specialist Infant and Child Transport Service   The Voluntary Sector Organisation (VCS)  District Housing   36  5.2 Agencies are requested to use the attached Report Template. 6. Areas for consideration: 6.1 Please review the responses to the referrals to CSC in respect of the family from 2015 to 2017.   Were there any patterns identified in the referrals/information gained?  6.2 Please analyse the robustness and quality of the assessment undertaken in March 2017. What was the understanding within your agency of the family history and its implications for risk?    6.3 To what extent were males incorporated into assessment processes? Was the composition of the household fully understood? Did agencies Think Fathers?  6.4 Please comment on the application of thresholds / different perceptions of the level of concern within the agencies involved. To what extent did subjective judgements about home conditions feature in this case?  6.5 What impact did the family’s poor engagement with services have on service delivery?  6.6 What was the impact of the illness and death of the maternal grandmother on the family, particularly emotionally and financially.  6.7 Were interventions and support well-coordinated between agencies? Was there a sense of one lead agency or professional?   6.8 Please explore the role of managers. Did supervision or management oversight contribute positively to practice? Were there missed opportunities for escalation, and if so was this pursued in line with local procedures?  6.9 Please identify examples of good practice, both single and multi-agency.  7. Engagement with the family 7.1 A key element of SILP is engagement with family members, in order that their views can be sought and integrated into the Review and the learning.  LSCB will inform the family that this Review is being undertaken.  The independent lead reviewers will follow up by contacting Madison’s parents and paternal 37  grandmother. The scope for and relevance of inviting a conversation with her maternal aunt and paternal uncle will be further explored, 7.2 Their contributions will be woven into the text of the Overview Report and they will be offered feedback at the end of the process. 8. Timetable for Serious Case Review: Scoping Meeting  4 October 2017 Letters to Agencies 11 October 2017 Agency Report Authors' Briefing   19 October 2017 at 11am Engagement with family Begin October 2017 once authorized Agency Reports submitted to LSCB   16 December 2017 Agency Reports quality assured by chair 18-19 December 2017 Agency Reports distributed  8 January 2018 Learning Event  16 January 2018, 9.30am to 4.30pm First draft of Overview Report to LSCB  13 February 2018 Recall Event  27 February 2018, 11am to 4pm  Second draft of Overview Report to LSCB  Wednesday, 7 March Presentation to LSCB Sub Group   March 2018                                    Version 3:  09.10.2017   38  Key single agency recommendations:                  Appendix B  Midwifery:  Consider the development of a process of a read/receipt from the Health Visiting service to enable a two-way process of information sharing from the antenatal booking summary.   Use of a standardised approach to identify the multi-faceted aspects of neglect, which will assist a co-ordinated multi-agency approach and plan when there is a disparity in value judgements.   Ensure there is formal documentation that safe management for crying babies has been discussed with parents. Voluntary Sector Organisation:  Case records should be clear about the reasons for gaps in service provision.   Consider what action should be taken when a service user does not engage with the service.   Fathers (or other partners) should be encouraged to engage with services being offered.   Manager should be aware of the impact of intimidating families on workers and allow workers to be honest about this.  Clinical Commissioning Group (GPs)  GP Practices will record all safeguarding concerns for a child on the safeguarding notes and should also consider an entry on the parent/carer’s record.    GP Practices will obtain the names and relationships of adults attending appointments with a child and who is present during home visits.   Health practitioners in MASH should inform GPs and the 0 – 19 service that a child on their practice list/caseload will be subject to an assessment by Children’s Social Care following a MASH enquiry. Children’s Social Care:  Ensure all assessments are completed within statutory timescales.   Ensure multi-agency planning and review meetings are held as part of CIN and early help case management. 39    Ensure neglect issues are fully assessed and understood in relation to previous, current and potential risk.  Foundation NHS Trust 0 – 19 Service (Health Visiting):  Children who meet the Continuum of Need (Level 3) should be assess using the appropriate documentation to reflect the level of intervention they require, and this should be regularly reviewed.    Practitioners are able to understand the process following a referral to Children’s Social Care.   Practitioners receive strength-based assessment training in line with the Signs of Safety Model and the Neglect Toolkit.   Practitioners should consider the use of chronologies and seek safeguarding advice where there are emerging safeguarding concerns.       40  References                                                                                         APPENDIX C   Working Together to Safeguard Children:  A guide to inter-agency working to safeguard and promote the welfare of children, Department for Children, HM Government 2015.   Practice issues from Serious Case Reviews: Disagreement about use of early help assessment. Learning into practice project: Improving the quality and use of Serious Case Reviews, SCIE/NSPCC, 2017.   Ferguson, Harry.  Child Protection Practice. Palgrave Macmillan, 2011.  Dingwall et al, Monograph: The Protection of Children: State Intervention in Family Life. 1983.   Neglect and Serious Case Reviews: A Report from the University of East Anglia commissioned by NSPCC, UEA/NSPCC, Jan 2013.   Understanding Serious Case Reviews and their impact.  A Biennial Analysis of Serious Case Reviews, 2005 - 07.  DCSF, 2009.   Disguised compliance: Learning from case reviews.  NSPCC Briefing March 2014.   In the child’s time: Professional responses to neglect.  Ofsted, March 2014.   Analysing child deaths and serious injury through abuse and neglect: what can we learn?  A biennial analysis of serious case reviews 2003 – 2005. DCSF, 2008.   New learning from serious case reviews: a two-year report for 2009-2011, University of East Anglia and University of Warwick. DoE, 2012.   Triennial Analysis of Serious Case Reviews (2011 – 2014).  Practice briefing for LSCBs, Research in Practice, June 2016.   The Multi-Agency Continuum of Need: Supporting Children, Young People and Families, Safeguarding Child Board, January 2016.   The Multi-Agency Toolkit, supporting families, preventing neglect, Safeguarding Children Board, 2017.  