Death of Sama, a baby girl under 2 months old of white British/Pakistan origin, in October 2015 as a result of fatal injuries received after falling from her car seat. Mother and father were involved in an altercation just before the event. The Coroner's Inquiry found her death was a tragic accident that could not have been predicted. Mother was 20 and father 28 when Sama was born. Mother spent time in foster care and had had witnessed domestic abuse against her mother when she was a child. Mother was looked after for 4 months when she was 15 when concerns were raised that she was involved with a 23 year old male (Sama's father) who was known to be violent. Mother convicted of causing unnecessary suffering to an animal. Evidence of domestic abuse by father against mother. Father had convictions for domestic violence and assault and drug dealing and breeding dogs for fighting. Concerns identified about father being involved in the sexual exploitation of two looked after children. Father found to be married. In July 2015 Sama was made subject to a Child Protection Plan under the category of neglect. Following her birth no professional concerns were raised concerning her physical care. Issues identified include: recognising and addressing the impact of child sexual exploitation (CSE) in assessments and plans to safeguard children; understanding the dynamics of domestic abuse including perpetrator behaviour; information about an individual's criminal background should be accessible on the child's file and shared appropriately; minutes of strategy meetings, Child Protection Conferences and core groups should be included in the records of all agencies involved or invited to attend; recognising the links between animal abuse and child abuse/domestic abuse. Makes recommendations relating to the safeguarding of babies from domestic abuse.
      
 Title:  Serious case review overview report relating to Baby Sama. LSCB: Bedford Borough Safeguarding Children Board Author: Liz Murphy  Date of publication: 2017  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.                              Serious Case Review Overview Report relating to Baby Sama                       Publication April 2017    1  Foreword to the Serious Case Review (SCR) Baby Sama. This SCR was commissioned by the Independent Chair of Bedford Borough Safeguarding Children Board (BBSCB) following the death of Sama who was a 7 week old baby in October 2015.  Jenny Myers, Independent Chair of the BBSCB, said: “There is no greater responsibility than the welfare and safety of children. Sama died in tragic circumstances and was the subject of a Child Protection Plan which is why we felt it necessary to conduct a Serious Case Review into this incident.” “As with all Serious Case Reviews there is learning for us yet the overriding circumstances of this case as highlighted by the findings within the Coroner’s Inquiry was that it was a tragic accident that could not have been predicted.”  The SCR has been carried out to explore the strengths and gaps in the multi-agency response to safeguarding infants from domestic abuse.  A summary of the learning points is set out below and it is hoped they will be used to inform the ongoing development of safeguarding systems and practice in Bedford Borough.  Staff who attended the learning event held as part of this review identified a number of ways that safeguarding systems and practice in Bedford Borough can be improved and these have been used to inform the learning from this review.   A number of strengths have been identified in the multi-agency response to safeguarding babies from domestic abuse and include: • Contribution of named/lead professionals in health to the identification of safeguarding risks; • More timely completion of social work assessments and reduced caseloads in the  assessment team; • Introduction of systems for children’s social care and professionals within health to track progress of pre-birth assessments.  A number of gaps have also been identified some of which relate to the generic safeguarding systems and practice and others which relate specifically to the safeguarding of infants from domestic abuse.  Those that relate specifically to the safeguarding of babies from domestic abuse are:  • Embedding the pre-birth protocol and practice guidance; • Using knowledge of the dynamics of domestic abuse, including perpetrator behaviour, to inform practice; • Understanding, recording and using criminal history and background to inform assessment,  planning and service provision; • Disseminating minutes of safeguarding meetings in a timely and consistent way; • Recognising the links between child abuse and animal abuse.  This SCR also identified some additional learning around the importance of early identification and response to risk around child sexual exploitation (CSE).  These learning points are relevant to individual agencies as well as the BBSCB.  BBSCB will coordinate how the learning points are used to further develop safeguarding arrangements and practice in Bedford.    Jenny Myers Independent Chair of BBSCB  2  Contents   Page 1.  Introduction 3  2. The Findings 9  3. In what ways does this case provide a useful window on safeguarding systems process and procedures in Bedford Borough? 23   4. Conclusion 29  5. Appendices  30     3  1. Introduction   1.2 Why this case was chosen to be reviewed  1.3 In October 2015 the mother and father of Sama (not their real name) were involved in an altercation outside Sama’s home address.  Her father was the driver of a vehicle, and her mother was standing outside of the vehicle holding Sama in a car seat. Somehow, as father was driving away, Sama fell from her car seat and was fatally injured.  1.4 Sama was aged nearly 2 months old at the time of her death and had been made subject to a Child Protection Plan since her birth.  1.5 The Independent Chair of Bedford Borough Safeguarding Children Board (BBSCB) agreed  on 22nd October 2015 that the case met the criteria for a Serious Case Review (SCR). The  SCR Panel asked that the focus of the review might help to identify the strengths and gaps  in the multi-agency response to safeguarding babies from domestic abuse.    1.6 Family composition  1.7 Sama was a female child of White British and Pakistani heritage.  Her parents had chosen to bring her up in the Muslim faith and mother had also decided to practice the Muslim religion.  1.8 Sama was the only child of her parents.   1.9 Sama’s mother is white British origin and was aged 20 at the time of her birth.  Her father is of Pakistan origin and was 28 at the time of her birth.  As set out above, mother met father when she was 14 years of age.  1.10 Neither parents are known to have any disabilities and both parents speak English.  1.11 Timeframe  1.12 BBSCB agreed that the time period to be covered by the review should commence at the point mother’s pregnancy was known by professionals and end with the date Sama died.  This means the timeframe for the review is January – October 2015.  1.13 Organisational learning and improvement  1.14 Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including Serious Case Reviews states that:   Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. (Working Together 2015)  1.15 Bedford Borough Safeguarding Children Board (BBSCB) identified that the SCR of this case should address the following questions:   a. How did the Local Authority and partners share information and undertake the pre-birth assessment to identify/understand risk and why was this the case?  b. How did the Local Authority and partners work together at the Strategy Meeting to understand risk and why was this the case?  c. How did the Local Authority and partners work together at the Initial Child Protection Conference to devise a child centred protection plan and why was this the case?   4  d. How did the Local Authority use the PLO framework to safeguard Sama and why was this the case?  e. How did the Local Authority and partners work together to safeguard Sama during the post birth period and why was this the case?  1.16 The following agencies contributed to the Serious Case Review because they had contact with Sama and her family during the period under review:  • Bedford Borough Council Children’s Services • Bedford Borough Council Legal Services • Bedford Borough Council Housing • National Probation Service  • General Practitioner • Bedfordshire Police • South Essex Partnership Trust (SEPT) • Bedford Hospital NHS Trust • Families First Bedfordshire  1.17 BeNCH (Community Rehabilitation Company) were invited to contribute to the SCR however, they advised that the National Probation Service were best placed to contribute as they had responsibility for the Community Order that father had been made subject to in February 2014.   1.18 Methodology  1.19 BBSCB determined that the review would use a ‘hybrid methodology’ drawing from a number of theoretical approaches and techniques.  This meant that all involved agencies provided a chronology of involvement as well as a summary report.  A number of professionals were interviewed and a practitioner and manager learning event was held to explore emerging findings. A fundamental part of the approach was to talk with staff to understand what they thought and felt at the time they were involved in the case; the aim being to mitigate against the hindsight bias as much as possible.  The review has been carried out in keeping with the underlying principles set out in Working Together 2015.  The review:  • 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.    1.20 The government normally requires the publication in full of Overview Reports from Serious Case Reviews and care has been taken to ensure that the information in the report: -  • Is appropriately anonymised • Protects the right to an appropriate degree of privacy of family members.  1.21 Reviewing expertise and independence  1.22 The SCR has been led by two people independent of the case that is being reviewed and of the organisations whose actions are being reviewed.  Liz Murphy, Independent Safeguarding Consultant, has had lead responsibility for authoring this report and Carol Pennington, Senior Service Manager, Cafcass has chaired the Serious Case Review Panel.  Neither has 5  any previous involvement in this case and Liz Murphy is independent of all agencies that work to safeguard children and young people in Bedford Borough.  1.23 Acronyms used and terminology explained  1.24 Statutory guidance requires that SCR reports be written in plain English and in a way that can be easily understood by professionals and the public alike.   1.25 Writing for multiple audiences is always challenging. In Appendix 1, we provide a glossary on professional terms used within the report to increase accessibility of the report to readers who are not familiar with the processes and language of safeguarding and child protection work.   1.26 Specialist advice  1.27 The Serious Case Review Panel agreed to invite a domestic abuse specialist to join the Panel with the aim of understanding wider issues in relation to domestic abuse in Bedford Borough.  Unfortunately, the individual approached was unable to join the Panel. Their unavailability is not considered to have impeded the quality of this review as the lead reviewers, along with the Serious Case Review Panel members, have a well-developed knowledge of domestic abuse.  A representative from a Domestic Abuse specialist service contributed to the practitioner and manager learning event.  1.28 Methodological comment and limitations  1.29 Any SCR has to be managed well so that it is proportionate in terms of both the time period covered and data reviewed.  This review focused on Sama rather than any contact agencies had with her mother when she was a child.  This means that the strengths and gaps in the multi-agency response provided to Sama’s mother when she was a child have not been considered.  1.30 In terms of the time period that was reviewed some key staff from Children’s Services, Police and the National Probation Service were unavailable either because they were away from work or because they had left the organisation.  Their employing agencies made efforts to provide information about their involvement to the review which has significantly helped to manage the potential limitations of their direct input to the review.  1.31 Participation of the parents’/family members 1.32 The SCR Panel agreed that both parents, as well as maternal grandmother, should be  invited to contribute their views to the review.  One family member contributed their views to  the Serious Case Review. They shared that what happened to Sama was a tragic accident  and that she was loved by both of her parents. They did not identify anything else that  professionals could have done that would have helped Sama. The ongoing emotional impact  of Sama's tragic death was evident from their contribution to the review.  1.33 Case summary  1.34 On 13th January 2015, mother aged 19 years old, was seen by the community midwife at her GP surgery; mother was approximately 8 weeks pregnant. At this time, mother lived with her 4 younger siblings and her mother (Sama’s maternal grandmother).  1.35 Records indicate that mother spent time in foster care when aged 7 years old due to abusive behaviour by her father; she also witnessed the domestic abuse her mother was subjected to.  Mother was also looked after for a 4-month period when she was 15 years old.  Sama’s maternal grandmother was struggling to manage mother’s behaviour which included mother drinking and returning home late.  Shortly after becoming ‘looked after’, there were concerns that mother, then aged 15 years, was having a “relationship” with a 23-year-old male who was known to be violent.  This male is Sama’s father.  On one occasion when mother was missing overnight from her foster placement, she was found at father’s address and discovered to have physical injuries; she declined to disclose how they were caused.  On two occasions during this period, Sama’s maternal grandmother also reported to the Police 6  and Children’s Services that mother returned home with injuries following contact with father; she also stated that father had made threats and on one occasion caused damage to property.   1.36 Days after turning 18 years of age mother reported domestic abuse to the Police in August 2013.  Father was arrested and bailed.  Mother subsequently stated that the allegations were not true and although no further action was taken against father, mother was discussed at MARAC (Multi Agency Risk Assessment Conference) because she had been assessed as a high risk victim of domestic abuse.  1.37 In January 2015, Children’s Services were aware that mother’s siblings, aged 8 and 7 years old, were struggling with mother’s relationship with her ‘boyfriend’.  The ‘boyfriend’ (Sama’s father) was described as ‘abusive and controlling’ and maternal grandmother shared that she had tried banning him unsuccessfully from the house. Maternal grandmother also shared that she has no authority over mother and that mother asserted authority over the household.   1.38 Background checks by Children’s Services identified information about father’s criminal and violent background.  Information was sought from the Police.  1.39 Contact was made by Children’s Services with Bedfordshire Police’s Child Sexual Exploitation (CSE) team to establish if father was known to them which established that father was not known to them at this time.  1.40 In light of concerns about father which, along with his criminal and violent history, included concerns about drug dealing and breeding dogs for fighting, the case was reviewed by a Children’s Services manager and a request was made that a pre-birth assessment was carried out on the unborn baby. A separate assessment of mother’s younger siblings was also requested.  The assessments were requested because of ‘significant concerns’ relating to Sama’s father who was identified as living at maternal grandmother’s home address.  1.41 The case was allocated to a social worker on 2nd February 2015 for a pre-birth assessment to be completed.  This assessment was completed on 16th June 2015.    1.42 On 18th March 2015 a referral was made by the community midwife to the Family Nurse Partnership for mother as she met their referral criteria in that she was under the age of 20 years and having her first baby.  Mother was enrolled to the Family Nurse Partnership on 5th May 2015 and contact between the Family Nurse Partnership and mother took place from this point onwards.  1.43 Father had been made subject to an 18-month Community Order with a requirement for 150 hours’ unpaid work and supervision on 4th February 2014 for an offence of assault against a male who he believed to be having a relationship with mother.  The offence was committed in August 2013.  At this time parents were not in a relationship.  Father was initially assessed by his Probation Officer to pose a high risk of harm through violence towards “known adults”.  Mother and the care leaver referred to above were identified as the “known adults”.  In July 2014, a review risk assessment was undertaken which identified father posed a medium risk of harm to the “known adults”.  The rationale for the revised assessment was that there has been no new intelligence, convictions or call outs reported.  A risk review termination was completed in July 2015, and prior to father’s supervision requirement ending in August 2015.  The risk level was re-assessed as high due to the current circumstances i.e. Sama’s pending birth.  1.44 Father had previously been known to Probation following a domestic violence related conviction in 2013.  The victim was the care leaver.  In November 2013, father was convicted of common assault and received a suspended sentence order with requirements to 7  undertake 10 days’ alcohol intervention and 12 months supervision.  A Restraining Order was also made on this date requiring father not to contact the care leaver.    1.45 The care leaver had made numerous previous complaints to the Police of domestic abuse prior to father’s conviction in November 2013 and both she and mother were discussed at MARAC in September 2013.  Information available to this review indicates that significant concerns in relation to sexual exploitation and domestic abuse were identified for both mother and the care leaver at this time.  1.46 In her contact with the Family Nurse Partnership, mother shared that she was about to be made homeless as her mother was about to be evicted and she would not be able to live with her in the future.  1.47 In June 2015, Children’s Services convened a Strategy Meeting.  The meeting was called because the pre-birth assessment identified concerns for Sama’s safety because of her father’s violent and criminal history and mother’s perception that father did not present a risk to her or her unborn baby.  Concerns were also identified regarding the impact of mother’s own childhood experiences on her parenting capacity and the difficult, and at times aggressive behaviours, she had displayed as a teenager.  1.48 The Strategy Meeting concluded that an Initial Child Protection Conference should be convened and a Legal Planning Meeting arranged. An Initial Child Protection Conference was held on 7th July 2015 and Sama was made Subject to a Child Protection Plan under the category of neglect.  Shortly after the Initial Child Protection Conference, a different social worker took over responsibility for the case.  1.49 A Legal Planning Meeting was held on 28th July 2015.  The legal advice was that the threshold to instigate the Public Law Outline (PLO) process and also to issue proceedings was met.  A decision was made by Children’s Services to manage the case at the pre-proceedings stage and two Legal Gateway Meetings involving Sama’s parents were subsequently held.  Parents signed written agreements that were drawn up as part of the PLO pre-proceedings stage.  1.50 Prior to the conference, mother and father advised Children’s Services and Family Nurse Partnership that they had been contacted by/received abusive messages from the care leaver.  Mother and father were advised to report this to the Police and in mid-September 2015, both parents made a statement to the Police regarding ongoing contact/threats made to them by the care leaver.  1.51 Shortly after the Initial Child Protection Conference, mother became homeless and was placed in temporary accommodation.  The plan was for mother to live in supported accommodation and in early August 2015 she was offered accommodation with a local supported housing provider although she failed to take up this accommodation and therefore made herself intentionally homeless.  Three days prior to Sama’s birth, mother was offered a 2-bedroom flat.  1.52 Sama and her mother were discharged from hospital to maternal grandmother’s home and shortly afterwards they moved to their new home.  At the Legal Gateway Meeting held in September, parents confirmed that father visited most days and stayed over a couple of nights a week at mother’s home.  Post her birth; no professional concerns were raised regarding the physical care provided to Sama.  1.53 Referrals were made for mother to attend a programme aimed at women at risk of/experiencing domestic abuse and for father to attend a programme aimed at perpetrators of domestic abuse.  Early in August 2015, and just after his involvement with National Probation Service ended, father was arrested for Actual Body Harm against the care leaver.  In response to this allegation, father was arrested and the care leaver was again discussed 8  at MARAC in September 2015.  In August 2015, maternal grandmother reported to the Family Nurse Partnership that she had been assaulted by the care leaver.  1.54 Two anonymous calls were made to Children’s Services, one just before Sama’s birth and one shortly before her death.  The first call was to report concerns that mother had been seen getting into a car with father who was driving around Bedford drug dealing.  The caller reported their concerns for mother and the unborn baby due to father’s violent behaviour.  The second call was made shortly after the Review Child Protection Conference held in October 2015 where it was decided that Sama would remain subject to a Child Protection Plan.  This caller was identified as a different caller and again expressed concerns about father’s violent behaviour and their concerns that mother would suffer abuse in silence.  The caller stated that father had introduced mother to drug dealing and this activity was happening at the new flat.  At this time, Children’s Services also identified that father lived with his wife in Bedford.  Up until this point, and based on information provided by father, professionals involved thought that father’s wife lived in Pakistan. Their understanding that father was married and the perceived cultural sensitivities associated with him fathering a child with another woman, along with father not providing information or permission for contact to be made with his family, resulted in professionals having little or no understanding of Sama’s paternal family circumstances.  1.55 In the month Sama died, mother was convicted of causing unnecessary suffering to an animal and a Disqualification Order was imposed. Concerns were also identified about father being involved in the sexual exploitation of two looked after children who had been missing from their care placement.  1.56 Sama died approximately 2 weeks after the Review Child Protection Conference. No charges have been brought against any individual and the coroner concluded that this was a tragic accident.   9  2.  The findings  2.1 Statutory guidance requires that SCR reports provide a sound analysis of what happened in the case, and why, and what needs to happen in order to reduce the risk of recurrence.  2.2 These processes should be transparent, with findings of reviews shared publicly. The findings are not only important for the professionals involved locally in cases, everyone across the country has an interest in understanding both what works well and also why things can go wrong.   2.3 An overview is provided of what happened in this case. This clarifies the view of the SCR Author and Panel about how timely and effective the help that was given to Sama and their family was, including where practice was below expected standards. The review considers why professional practice was not more effective in protecting Sama and then goes on to consider the priority learning that has emerged from the review. Priority learning is identified because these issues create risks to other children, young people and families in future cases because they undermine the reliability with which professionals can do their jobs.  Priority learning provides useful organisational learning to underpin improvement.    2.4 Appraisal of professional practice in this case 2.5 The SCR Panel agreed 5 key practice episodes to be used as a framework in which to appraise professional practice   However, the appraisal begins with exploring an issue that cuts across all 5 practice episodes and that is the impact of mother’s experiences of child sexual exploitation (CSE).  2.6 Mother and father began their “relationship” when mother was aged 14 years old and there is an eight-year age difference between them.  The age differential in the parent’s relationship was known by all professionals involved in working with Sama and her parents.  However, at the pre-birth stage, no professional identified mother’s experience of child sexual exploitation as a risk factor.  In terms of information shared, the Police shared intelligence about CSE concerns with Children’s Services although this was not thoroughly considered or addressed at the Strategy Meeting.   2.7 The assessment made by Bedfordshire Police at the time mother made allegations of domestic abuse to the Police in August 2013 was that “it would appear to be more than a domestic, and is a history of yearly systematic abuse by the offender on the victim under the pretext of girlfriend boyfriend when following him grooming the victim since 14, he has subjected her to years of physical sexual and psychological abuse”.  A summary of this assessment was included in the Police report prepared for the Initial Child Protection Conference however insufficient weight was given to this by the attendees at the Initial Child Protection Conference.  2.8 Just prior to Sama’s birth, a senior manager in SEPT reviewed the case and raised the issue of CSE needing to be considered including whether there was evidence of any prior grooming.  This was communicated to Children’s Services with a suggestion there should be a consideration of the vulnerability of mother and the care leaver.  Children’s Services response to the suggestion that CSE should be explored was that mother was an adult and had stated that she was in a consenting relationship.  They did not share the same view as SEPT that mother was “over investing in an unhealthy relationship with the punitive father”.   2.9 The shortfall in exploring and understanding the psychological impact of mother’s experiences of child sexual exploitation impaired the quality of the assessment and subsequent planning in this case.        10  2.10 Factors that influenced why this happened • Much of the recent activity in relation to child sexual exploitation at a national, as well as, local level has focused on identifying those children who are currently at risk of or being sexually exploited. The result is that the needs of victims who are now adults do not receive the same degree of attention.   • A compounding factor is that the statutory definition of CSE covers children up to the age of 18 years of age which means that for those individuals who continue to be abused beyond their 18th birthday, there is often no clear pathway for them to receive support. Most will not be classed as an adult at risk and so be ineligible for adult protection services provided and coordinated by the Local Authority.  2.11 Information sharing and pre-birth assessment. 2.12 A social work assessment was carried out between 2nd February 2015 and 11th June 2015; the assessment was completed as a single rather than pre-birth assessment and the review has learnt that this is the way that pre-birth assessments are carried out in Bedford Borough. The review has established that staff working in the assessment team had excessive caseloads at this time.  The reviewers were advised that the average caseload was approximately 30 plus and this was a significant causal factor in the delay in completing the assessment.  The review received information to indicate that additional interim social work and management capacity was secured from April/May 2015 onwards and coupled with more effective application of thresholds, the volume of work in the team is now more manageable. Evidence of impact includes that 79% of assessments were completed within 45 days in April 2016 compared to 50% in February 2015. Caseloads are lower and considered manageable with the review being informed that the average caseload, as of March 2016, is 22.  2.13 The social work assessment that was completed sets out the risk factors to the unborn child except for the impact of mother’s experiences as a victim of child sexual exploitation.  The fact that father’s family did not know about the baby was also identified as a risk factor. The assessment reports that father intends to live with mother once she is allocated a property by the council and concludes that this is likely to place mother and the unborn baby at a high risk given father’s history of conducting criminal activity in the property he lives in.  2.14 The assessment appears to have been largely completed as a single agency assessment and would have been significantly enhanced if the following agencies had contributed to it: • Police • GP • National Probation Service  2.15 In particular, this would have provided an opportunity for the GP to share information from their records on the domestic abuse mother had experienced by father.  This information was ‘flagged’ on the GP records however was not shared at any stage with professionals, including the hospital who provided ante natal care to mother. This resulted in the professional network not knowing that mother was a victim of domestic abuse.  In the absence of this information, the assessment identified domestic violence as a risk factor to the unborn child because of father’s violence in a previous relationship.    2.16 There were several research evidence1 indicators of domestic abuse present in this case e.g. past violence, presence of unborn child, breach of civil order and alcohol abuse by the perpetrator which indicated that father’s contact with the child should have been assessed and managed, particularly given that mother’s own vulnerabilities were impeding her ability to recognise and so manage the risks.                                                             1 Campbell, J (ed) (2007) Assessing Dangerousness! Violence by Batterers and Child Abusers. New York. Springer 11  2.17 The delay in finalising the pre-birth assessment left little time for intervention and other assessments prior to Sama’s birth.  2.18 Factors that influenced ‘why’ this happened. a) At the time BBSCB did not have any formal pre-birth Child Protection Procedures in place which would have provided a framework for social workers to complete pre-birth assessments.  Such procedures were launched at the end of August 2015. b) Analysis of risk in assessments is a common shortfall with workers focusing on describing the child’s story rather than analysing the risks to the child. c) High caseloads and volume of work at that time impacted on the time taken to complete the assessment. d) Potential lack of clarity regarding ‘flagging’ system for domestic abuse used in GP records.  2.19 Strategy Meeting 2.20 A Strategy Meeting was held in June 2015 approximately 2 weeks after the Children’s Services management decision to convene such a meeting. Relevant professionals attended this meeting. However, it does not appear that GP information was gathered to inform the discussions. The Strategy Meeting notes record “high concerns re mother’s and baby’s safety – due to the father’s violent background and criminal record; mother’s lack of understanding of any risks that he is posing to herself and to the baby. There are concerns regarding her capacity to protect the baby and prioritise the baby’s needs, as she does not recognise any risks, denied domestic abuse and does not understand the risks he may pose to her and to the baby”.  2.21 A robust set of actions were agreed including a decision to arrange an Initial Child Protection Conference and request a Legal Planning Meeting.  The Strategy Meeting effectively identified the risks, except for the impact of mother’s experiences of CSE and a robust child centred plan was developed.  2.22 Prior to the Strategy Meeting, Bedfordshire Police had sent extensive information regarding father’s criminal background by email to a Children’s Services colleague in the MASH.  The day after the Strategy Meeting, and as agreed at the meeting, the same information was re-sent by email to Children’s Services.  Information received by email does not always get added to the child’s social care record and this review has established that neither of these emails was added to the child’s social care record.  The information that was sent included summary information in respect of mother’s allegations of domestic abuse made in August 2013.  This was recorded under the heading “the following relates to father and other parties”.  It is therefore not immediately clear that this information related to mother.  The fact that mother and the care leaver had been discussed at MARAC due to concerns about the risk posed by father was not shared and nor was the risk assessment completed by the Police in respect of mother in 2013 following her reports of domestic abuse i.e. systematic abuse of the victim following him grooming her since 14 years of age.  2.23 In relation to the Strategy Meeting, the Police, National Probation Service and SEPT have never received a copy of the minutes although the Local Authority understood they had been distributed.  2.24 BBSCB procedures states that “all agencies attending should take note of the actions agreed at the time” and “a copy of the record should be made available for all those who attended, who had been invited or involved, as soon as practicable by Children’s Social Care”.  The requirement for each attendee to take notes of the actions agreed creates the potential for more than one interpretation of the actions ‘agreed’ and in addition could result in confusion as to who is responsible for completing actions.  In this case, whist the summary of risks is comprehensive, the record of the meeting does not specify who is responsible for any of the agreed actions and whilst it is implied for some actions e.g. referral for Initial Child Protection Conference it is not clear for others e.g. referral to MARAC.  Practitioners who contributed to 12  the review process shared information to indicate that gaps in dissemination of minutes are not unique to Strategy Meetings or this case.  2.25 Factors that influenced why this happened. a) The IT system used by Children’s Social Care does not readily support information received by email being uploaded onto the child’s social care record.  A worker would be required to save and upload the email to the child’s social care file and also to add a case note to flag that the email had been received.  The review has been advised that an IT solution is currently being piloted whereby Children’s Social Care staff will have a tool available in their email system to automatically upload emails to the child’s social care record. b)  Family Nurses do not routinely have full access to SystmOne (GP recording system) and so cannot be relied upon to provide relevant information from GP records to pre-birth Strategy Meetings/other safeguarding forums.  The review has established that the GP had in 2013 added a flag to mother’s records due to her experiences of domestic abuse.  To view this flag would require the user to have full access to the SystmOne records which the Family Nurse did not have at the point of the Strategy Meeting.   c) Potential lack of clarity regarding ‘flagging’ system for domestic abuse used in GP records as neither the midwife nor the Family Nurse, once granted access, identified via the ‘flagging’ system that mother was a victim of domestic abuse. d) Information about an individual who has previously been discussed at MARAC; either as a victim or perpetrator is held on a different system (MODUS) to the one that other Police information is held (CATS).  Those who compile the Police information for strategy discussions do not have access to MODUS.  That said, DASH risk assessments in relation to victims of domestic abuse are held on CATS.  2.26 Initial Child Protection Conference 2.27 An Initial Child Protection Conference (ICPC) was arranged within 15 working days of the Strategy Meeting.  Written invitations were sent 6 days in advance of the conference to: -  • Community Midwife • Family Nurse • Bedfordshire Police • Health Visitor • National Probation Service • GP • Mother • Father • Maternal Grandmother  2.28 The GP and National Probation Service sent their apologies.  The National Probation Service decided not to attend the ICPC because father only had 4 weeks remaining on his community order and so probation staff would not be involved with the implementation of the plan which was to be devised.  All other attendees, along with the allocated social worker attended the ICPC.  The National Probation Service prepared and submitted a report and the GP also prepared a report; however, this review has established that the report prepared by the GP was never submitted as intended.  It is not known how this happened as the GP understood their report had been submitted.  2.29 The minutes of the ICPC appropriately identify the risks to the unborn baby except for the impact of mother’s experiences of CSE.  The six professionals in attendance decided that the unborn baby should be made subject to a Child Protection Plan; the Family Nurse Partnership considered the decision to be a “tough” one because if they “went with what the family have said and if what the family have said was not disputed it would be child in need”. They decided that given lack of “unknowns” or “fact”, a Child Protection Plan was required. 13  2.30 The issue that appears to have been “unknown” for the Family Nurse Partnership was whether the ‘accusations’ made by the care leaver against father were to be believed. This professional mind-set illustrates the importance of professionals having an increased understanding of the nature of domestic abuse i.e. domestic abuse is not usually a one off event. If the information about mother’s experiences of domestic abuse, as recorded in the GP records, had been available to the professional network, the assessment of the level of risk to Sama and her mother may have been more decisive.  2.31 Both Police and the National Probation Service had prepared written reports for the Conference.  The Police use internal pro-forma to provide this information which helpfully includes current involvement/investigation, previous history, previous convictions and other relevant information. Information was provided about the child protection and domestic abuse related incidents between mother and father; however, the nature of the 12 reports made by the care leaver against father between 2013-14 were not included and no reference was made to the fact that she had been discussed on more than one occasion at MARAC.   2.32 The minutes of the ICPC indicate that the allegations of physical, sexual and psychological abuse made by mother in 2013 were not considered in full by the Conference in that it is recorded that “mother made an allegation where father had harassed her, it was not physical violence.” This is very different to what is set out in the Police report. Police reports to ICPCs are not shared with all professionals in attendance and so whilst the Police report did contain this information, the details of the domestic abuse reported by mother and the subsequent assessment that she was a high risk victim was never shared with professionals.  The information that mother had been discussed at MARAC was not known by Conference attendees either.  2.33 To compound information about mother’s report of domestic abuse made in August 2013 not being effectively considered by the ICPC, the minutes of the ICPC do not indicate that the National Probation Service report was considered by the Conference.  This report identified concerns about a pattern of Police call outs in relation to three women although it did not state the level of risk father was considered to present or that father had, on two previous occasions, been assessed as unsuitable for a domestic abuse programme due to his lack of acceptance about his pattern of abusive behaviour. In the context of the concerns for Sama, this was highly relevant information.  2.34 Both the Conference and Review Service and the National Probation Service, with the benefit of hindsight, recognise that the absence of the National Probation Service at the ICPC impacted on the understanding and so assessment of risk.  The Child Protection Plan contained an action to clarify with the National Probation Service whether father had attended anger management counselling.  Anger management is not a suitable intervention in cases of domestic abuse. Researchers2 attribute domestic abuse to a sense of entitlement to power and control over their partner/family member.  It is a dangerous misconception that abusers should attend anger management classes. This is because domestic abuse is not about an abuser’s inability to contain their anger but rather their deliberate use of anger to control their victim.  Abusers instead should be referred to specific domestic violence perpetrator programmes which address an abusers misplaced entitlement to power and control.  The action contained in the Child Protection Plan with regard to anger management indicates a need for an increased understanding of the nature of domestic abuse amongst the children’s workforce.  2.35 Despite the information about mother’s reported domestic abuse and the National Probation Service report not being considered, there was sufficient information about father’s criminal background available to professionals at the ICPC to inform their assessment of the level of risk and potential harm to the unborn child. If the assessment had been fully informed by an                                                            2 Barnish, M; Domestic Violence: A Literature Review, HM Inspectorate of Probation, 2004 14  understanding of the risk factors associated with domestic abuse, it is likely a more accurate assessment of the risk of harm to Sama would have been made  2.36 At the Conference, both parents stated that they wished to be given a chance to demonstrate to professionals that they could care for their baby whilst maternal grandmother advised that she had not always got along with father however, since mother became pregnant he had changed and she shared her view that if the care leaver had not made the allegations against father then professionals would not be involved.  2.37 In terms of the Child Protection Plan, a recommendation was made that a Legal Planning Meeting should be convened to discuss whether the threshold for initiating care proceedings was met and to determine what additional assessments were required to inform future care planning. Sama was made subject to a Child Protection Plan under the category of neglect and professionals who attended the learning event shared that it was common practice for the category of neglect to be used in such cases because neglect is considered a category of abuse that reflects the range of concerns for the child. Professionals were asked what thoughts they would have about a case they were allocated to work with where the child was subject to a Child Protection Plan for neglect. Responses included “a dirty house”, “unkempt appearance”, “poor school attendance”, “missed appointments” and “unsafe home conditions”. The use of neglect as a category of Child Protection Plans therefore potentially shifts the focus of professional attention.  2.38 The Child Protection Plan did not address the issue of contact and no professional raised this issue.  The thinking at the time was that further assessments were required to inform a decision about whether the baby should live with mother.  This provides some insight into why contact was not specifically addressed in the Child Protection Plan.  More widely, the review has identified that Child Protection Plans do not necessarily make recommendations about the nature of contact but instead identify contact as an issue for the Local Authority to consider.  2.39 This review has been advised that it is common for written agreements to address contact.  The written agreement in this case did not address contact and the professional mind-set of Children’s Services staff involved post the ICPC provides an understanding as to why contact between Sama and her father was not addressed.  This will be explained in the next key practice episode.  2.40 Factors that influenced ‘why’ this happened a) Problematic information sharing - the absence of the National Probation Service, gaps in the information contained in the Probation report and the lack of consideration of the Probation report meant that the assessed level of risk posed by father was not shared and nor was the fact that father had on 2 occasions been assessed as unsuitable for a domestic violence perpetrator programme due to his lack of acceptance of his pattern of behaviour.  Gaps in the Police report and a lack of analysis of the information provided further compounded the Conference’s understanding of the domestic violence risk as did the way mother’s allegations of domestic abuse were considered by the ICPC. b) Workforce capacity to work with domestic abuse – Specialist domestic abuse knowledge and expertise exists in Bedford Borough however this appears confined to services providing domestic abuse services. There is a need for all staff involved in working with vulnerable children and families to have an understanding of the nature and dynamics of domestic abuse and to use this to inform their practice.  2.41 Public Law Outline/Pre-proceedings work 2.42 A referral was made for a Legal Planning Meeting by the social work team who completed the pre-birth assessment and the meeting was held 3 weeks after the ICPC and approximately one month prior to Sama’s birth. 15  2.43 By this date, the case had been transferred to a different social work team in accordance with internal transfer protocols within Children’s Services.  Representatives from this team, the team who had completed the pre-birth assessment and the Local Authority’s legal team were in attendance at the meeting.  2.44 The referral that was made to request a Legal Planning Meeting stated that the risk of harm was: - • Physical and emotional harm • Domestic Violence • Neglect  2.45 With regard to the likelihood of harm the referral stated “as soon as mother moves into a property of her own she will be vulnerable due to father having on-going access to the property”.  2.46 The Local Authority’s legal team received a copy of the single assessment, minutes of the strategy discussion and a genogram.  They did not receive the information provided by the Police in respect of father’s criminal background and nor did they receive the minutes of the ICPC or the Child Protection Plan.  2.47 The legal advice provided at the Legal Planning Meeting was that the threshold to instigate the Public Law Outline (PLO) process and also to issue proceedings was met.  The legal team advised that they considered it unlikely that the Court would agree to immediately remove the baby from mother’s care as the Local Authority would need to evidence that the baby was at risk of imminent harm to be granted an Interim Care Order.  The legal team advised that the assessment could be completed within the Court process and that this would avoid delay.  2.48 Children’s Services decided that the Local Authority should manage the assessment and the PLO process should be commenced.  A number of actions were agreed including: • A parenting assessment would be undertaken • A risk assessment of father would be undertaken • A Domestic Abuse perpetrator programme would be identified for father • A support programme about positive and healthy relationships would be identified for mother • Consent from Head of Service would be sought to disclose the Police report presented to ICPC to legal services (The review has been advised that the social worker who undertook the pre-birth assessment advised that Head of Service permission was required to share the information).  2.49 Children’s Services have advised that it was their understanding that the legal advice provided was that the threshold for managing the case via the PLO process was met rather than the threshold for initiating proceedings. This potential misunderstanding of the legal advice, coupled with the view that the Local Authority had not provided the family with the opportunity to work with them outside of the Court process, led Children’s Services to decide to manage the case via the PLO process as opposed to initiating care proceedings.  Their thinking and decision-making was also informed by the fact that there was no information to indicate domestic abuse between the parents and furthermore the parents had stated they wished to be a couple and co-parent their child and this needed to be “tested out”.  The Local Authority considered that any risk of harm to Sama from domestic abuse would be managed by referring mother to a support programme and father to a perpetrator programme.  What was not known was that father by this time had already been assessed on two occasions (2013 and 2014) as unsuitable for a perpetrators programme due to his lack of acceptance about his abusive behaviour?  16  2.50 In making this decision, Children’s Services had not considered the Police information on father’s criminal background provided before, at and after the Strategy Meeting because as explained earlier the emails that contained this information had not been added to the child’s social care record.  Neither did they have access to the National Probation Service report prepared for the ICPC although the Legal Planning Meeting agreed the National Probation Service would be contacted as soon as possible for a risk assessment.    2.51 The review has explored where the reports provided by the National Probation Service and Police to the ICPC were stored on the child’s social care file with a view to establishing if the relevant Children’s Services staff had access to them. Children’s Services staff have advised that they tried to find them but they were not saved in the relevant part of the child’s file however, the review has been advised that the reports were saved in the ‘reports’ section of the child’s social care record. Children’s Services staff did not take any further action to obtain the Police report.  One email was sent to Probation to request a risk assessment however; this was not pursued including when Children’s Services and National Probation Service staff spoke the day after the first Legal Gateway Meeting. The National Probation Service did not share the outcome of their updated assessment with Children’s Services or the Core Group i.e. father had been re assessed as posing a high risk.   For Children’s Services to make a case management decision without accessing such significant information and the lack of action to obtain this information to inform case planning and decision making is considered by the lead reviewers to fall below the expected standard of social work practice required.    2.52  The legal team advised the review that they do not routinely receive copies of Police reports prepared for ICPC’s.  A formal request known as an Annex D is made to the Police for them to disclose information they hold.  Such a request was made by the legal team in mid-August 2015 and acknowledged the next day.  The first part of the information was provided to the Local Authority legal team the day before Sama’s death i.e. nine weeks later and the remainder was provided 3 days after her death and so it was not until after Sama’s death that the legal team was aware of the full extent of the information held by Police in respect of father.  2.53 A revised written agreement was signed by parents after the first Legal Gateway Meeting.  The written agreement states “that there is concern mother and father plan to live together once she is awarded accommodation”.  At the first Legal Gateway Meeting, when asked, parents advised they would not be living together and that father would remain living at his mother’s home.  2.54 One of the actions agreed at the first Legal Gateway Meeting was that mother would move to supported housing provision once the baby was born.  Mother was offered such accommodation and the Legal Gateway Meeting understood she would move in later that day.  Mother never moved into the supported housing provision and less than one week after the Legal Gateway Meeting, mother declined the placement.  2.55 This review has established that the legal team understood that the requirement for mother to live in supported accommodation had been determined as required by Children’s Services because the supervision available at the provision would mitigate some of the risks posed to Sama.  Children’s Services staff have reported that their thinking was that mother required accommodation as she was about to be made homeless rather than supported accommodation to manage the risks to Sama. As a result, mother’s decision not to accept the placement at the supported housing provision was not interpreted by Children’s Services as non-compliance with the plan agreed at the Legal Gateway Meeting. In addition, concerns had been raised by the Family Nurse Partnership that the location of the supported housing provision was not suitable as it was close to father’s family and to areas frequented by the care leaver. Parents had reported that the care leaver was contacting them and intimidating mother.  The concerns about the location of supported housing provision added to Children’s Services thinking that a property in a different location would be more suitable.  The legal 17  team were never informed that mother had declined the placement at the supported housing provision.  2.56 The minutes of the Legal Planning Meeting indicate that subject to an assessment by the supported housing provider, father would be able to stay up to 3 nights a week at the accommodation.  The number of nights he was able to stay was determined by Housing Benefit rules. This means that the risks identified in the referral to mother and the unborn baby through father having access to the mother’s property were not addressed and in fact contact between the parents was sanctioned by the Local Authority. By the second Legal Planning Meeting which was held 7 weeks later and just over 2 weeks prior to Sama's death, parents reported that father “comes over most days after work and stays a couple of nights a week”.  The degree of contact between parents was therefore used to determine the decision as to whether a risk assessment was required to assess the potential risk of harm to Sama from domestic abuse.  Contact per se created the potential of harm to Sama although this was never recognised in the planning and decision-making.   2.57 The Family Nurse Partnership emailed Children’s Services approximately 2 weeks after Sama’s birth to advise that a senior manager had raised that, in accordance with the written agreement, a risk assessment should be carried out given the parents were spending a significant amount of time together at mother’s home. This email correspondence was sent 3 days after a Professionals Meeting held to discuss concerns raised by SEPT in this case and this matter was not raised or discussed at the Professionals Meeting and instead the discussion focused on the potential risk of harm posed by the care leaver. The review has found that the professional network directly involved with Sama had not recognised the degree of risk to Sama from contact with her father.  2.58 It is positive and evidence of the value of management oversight that those with management responsibility for this case in SEPT picked up on this matter.  Children’s Services did not respond to the email nor to a further email asking for a response and no further action was taken by SEPT in relation to whether a risk assessment would be completed. The lack of satisfactory response by Children’s Services to this matter should have resulted in SEPT escalating their concerns as per the BBSCB Escalation Policy.  Analysis about the use of the BBSCB Escalation Policy is contained in the following section.  2.59 There was a delay in the minutes of the Legal Gateway Meeting being produced and it is understood that a back log of administrative work in the social work team led to delay in distributing the minutes.  One month after Sama’s birth, the legal team emailed the social work team to discuss the ‘goal’ in the case and raised the need for timescales for actions agreed under the PLO framework.  The social work team advised the solicitor that there were no concerns with regard to the basic care of the baby although there was an issue with regard to the care leaver and father had been advised to apply for a Restraining Order. The shift of professional focus in this case to the potential risk posed by the care leaver is explored in the next section of this report.  2.60 Children’s Services hold monthly meetings to track the progress of actions on all cases managed under the PLO process.  Whilst the written agreement identified the assessments that should be carried out as a risk assessment, parenting assessment, updated single assessment and hair strand tests for drugs (father), the details of the types of assessments needed was not stipulated in the actions agreed at the first Legal Gateway Meeting and instead the action is recorded as “mother and father to work with the Local Authority in all assessments”.  No timescales were identified for any of the actions.  The wording of this action was vague and the lack of clear times scales would have reduced the likelihood of lack of progress or drift being identified at the monthly tracking meeting.  2.61 The Child Protection Plan equally did not have clear timescales for 5 of the 12 actions and so could not be used as a tool by the Core Group to effectively gauge progress/measure drift.  Furthermore, the Child Protection Plan was not updated to reflect actions agreed under 18  the PLO Framework e.g. father to complete a hair strand test and so the Core Group could not monitor all of the actions required to reduce the likelihood of harm to Sama.  2.62 Factors that influenced ‘why’ this happened a) Drift and delay – the delay in holding the Legal Planning Meeting meant that the opportunity to carry out further assessments prior to Sama’s birth was not possible. Such assessments may have led to the better protection of the baby once born.   b) Problematic practice and decision making – The plans that were developed were created without a risk assessment of father and the full information on his criminal background and so they were significantly impaired because they were not informed by all of the available information.   c) Problematic information sharing and record keeping – the emails sent by the Police were not uploaded to the child’s social care record and so information on father’s criminal background was not readily available to Children’s Services staff. The National Probation Service did not include all relevant information in the report they provided for the ICPC and this report was not considered by the Conference. The legal team did not receive all relevant information at the point of referral and the delay in the Police responding to the formal request for information (Annex D) resulted in the legal team not having access to the relevant information which reduced their ability to influence the plans devised.  d) Workforce capacity to work with domestic abuse – Specialist domestic abuse knowledge and expertise exists in Bedford Borough however this appears confined to services providing domestic abuse services. There is a need for all staff involved in working with vulnerable children and families to have an understanding of the nature and dynamics of domestic abuse and to use this to inform their practice. Practice should also include addressing contact between children and perpetrators of domestic abuse.  e) Culture of inter - agency work and problematic use of BBSCB Escalation Policy -Openness and mutual respect were not always features of professional working relationships in this case and processes were not followed in accordance with BBSCB Escalation Policy.  f) Lack of outcome focused planning – the lack of clearly defined timescales in the plans that were developed meant that the tracking of progress was significantly impaired.  2.63 Post birth period 2.64 Sama was born at the end of August 2015 and just over seven weeks after the ICPC.  A discharge planning meeting was held at Bedford Hospital prior to Sama being discharged.  The minutes state that the baby “is not at risk of significant harm”. There had been a shift in professional focus away from the risk father posed to Sama to the perceived risk the care leaver presented to mother and Sama.  2.65 Prior to Sama’s birth, the Family Nurse Partnership had on several occasions raised concerns about information shared by parents that they were being contacted, harassed and eventually threatened by the care leaver.  The Family Nurse Partnership requested a Strategy Meeting to share information and consider the potential risks to the unborn child.  Bedford Hospital also raised similar concerns by email immediately after the discharge meeting. In addition, and having reviewed the Child Protection Plan they also raised the following issues because they had not been confirmed at the Discharge Planning Meeting: - • Confirmation as to whether father had attended anger management counselling • Confirmation that protective work with mother had commenced/taken place • Confirmation that viability assessments had been completed on family members 19   2.66 Bedford Hospital expressed their concern that without the above being explored or clarified Sama and her mother were placed at risk of harm. Bedford Hospital were aware that the Family Nurse Partnership had requested a ‘professionals meeting’ and asked to be informed of the date of the meeting.  This correspondence is again evidence of the value and contribution safeguarding professionals in health can make to the safeguarding of individual children.  Community midwifery services remained involved for the first month of Sama’s life however, they were not invited to the Professionals Meeting that was eventually called and no supervision of the professionals from the community midwifery service took place either.  The lack of supervision and follow up by Bedford Hospital of the issues raised either with Children’s Services or via supervision meant that the legitimate risk issues that had been raised regarding domestic abuse were never addressed.  2.67 The Family Nurse Partnership made a total of 10 requests for a strategy discussion to be convened to discuss the threat and risk posed by the care leaver.  The Conference and Review Service was copied into some of the requests and discussed the case with the social work team and were advised that the Local Authority did not consider a Strategy Meeting was required and instead they advised that the issues would be discussed at the next Core Group however that meeting did not go ahead as planned as both parents and professionals had different meeting times.  2.68 Children’s Services decided on two occasions that a Strategy Meeting was not required because the potential risk was from a 3rd party i.e. the care leaver and the parents needed to report any threats or harassment to the Police as per the Child Protection Plan.  After the first decision was made not to hold a Strategy Meeting, SEPT contacted the Police to ask if they would attend a strategy discussion convened by SEPT.  The Police declined to attend and similarly advised that any threats or harassment should be reported to the Police.  After the second decision not to hold a Strategy Meeting, managers from Children’s Services and Family Nurse Partnership met and agreed a professionals meeting should be convened within a week and that the Police should be in attendance.  The following day and after a review of the case by a senior manager in SEPT, the Family Nurse Partnership also raised concerns about the need to consider CSE and any resulting vulnerability of mother and the care leaver.  Just over one week after the Family Nurse Partnership and Children’s Services managers met, and in response to further information received, the Family Nurse Partnership sent out an invitation to the social worker, social work team manager, conference chairperson and community midwife to attend a professionals meeting.  The Police and other colleagues in SEPT were copied into the email.    2.69 The meeting that had been convened by the Family Nurse Partnership did not go ahead because two days after the invitations were sent mother gave birth and Children’s Services advised that the Discharge Planning Meeting would take precedence for Children’s Services. A Discharge Planning Meeting was held and at this meeting the Family Nurse Partnership made another request for a Strategy Meeting to be convened.  2.70 On 2 occasions, a senior manager in the Local Authority was copied into email correspondence sent by a senior manager in SEPT.  One of these emails asked for consideration to be given to reviewing the situation whilst the other asked for their view on the current case management.  In response the senior manager in Children’s Services discussed the case by email with the social work team.  The response provided by the social work team confirms that they did not consider there was a risk of harm to Sama from domestic abuse or that CSE was a factor in this case.  The response provided by the social work team also detailed that the child was subject to a Child Protection Plan and the case was being managed via the PLO.  The response provided resulted in the senior manager in Children’s Services not making any further enquiries; equally SEPT did not pursue the lack of resolution to the professional concerns being raised.  20  2.71 A professionals meeting was eventually held just over one week after Sama’s birth and whilst an invitation was sent to the community midwifery service, the safeguarding professional at Bedford Hospital was not invited as they had requested. The Police were not invited either. A practitioner from the Family Nurse Partnership, social worker and social work team manager attended the meeting.  The notes from this meeting indicate that the meeting focused on explaining thresholds and the remit of social care.  The remit of social care is recorded as ‘deals with safeguarding issues where there are familial relationships’.  The care leaver was identified to be an ex-partner of father and not a family member and so it was not considered by Children’s Services that a Strategy Meeting was required.  The professionals meeting did not therefore address the risks that had been identified by SEPT and Bedford Hospital in relation to the care leaver however; there was no further action taken by SEPT or Bedford Hospital as per the BBSCB Escalation Policy. Similarly, there was no further action taken regarding the concerns raised about the risks father may present.  2.72 The BBSCB Escalation Policy stipulates that if Senior Managers are unable to resolve the issue then consideration must be given to referring the case to the Director or Assistant Director of the relevant agency who will make the final decision.  The lack of escalation by SEPT to more senior officers in the Local Authority reduced the likelihood of securing a child centred resolution to the matters being raised as did the fact that the matters of concern, including the risk posed by the care leaver were not thoroughly considered by all relevant agencies at a multi-agency meeting.  If the escalations had been managed in accordance with the practice guidance and principles set out in the BBSCB Escalation Policy, the likelihood of a more child centred resolution would have been increased.  Instead what resulted was a deep sense of frustration and discord between the social work team and the Family Nurse Partnership with the social work team viewing the Family Nurse Partnership as somewhat of an agitate; partly due to the volume of email correspondence they received.  2.73 Alongside the shift in professional focus away from the risk father presented and the lack of effective resolution of professional concerns, the professionals involved deemed the parents to be engaging well in services when in fact there was evidence of disguised compliance.  Disguised compliance is a term defined by the NSPCC3 as involving “a parent or carer giving the appearance of co-operating with child welfare agencies to avoid raising suspicions, to allay professional concerns and ultimately to diffuse professional intervention.  In their biennial analysis of Serious Case Reviews Brandon et al4 state “apparent or disguised cooperation from parents often prevented or delayed understanding of the severity of harm to the child and cases drifted.  Where parents engineered the focus away from allegations of harm, children went unseen and unheard”. Families who fear negative consequences may well try to deflect professional attention and the task for professionals is to look at the facts and evidence rather than rely on what is said.  Relying on parents presenting behaviour and assertions can result in professionals becoming over-optimistic about the progress being achieved.  In this case, there was evidence of disguised compliance both before and after Sama’s birth and it manifested itself in the following ways: - a) Parents deflecting attention by continuously talking about contact, harassment and threats from care leaver b) Parents minimising the concerns by stating that the care leaver’s “allegations” were the reason for professional involvement c) Mother’s failure to engage with services.  Mother failed to take up the placement at the supported housing provision and to attend appointments with the provider of a support programme for victims of domestic abuse d) Parents avoiding contact with professionals – the Family Nurse Partnership, Children’s Services and specialist domestic abuse services were all unable to make contact/visit mother on various occasions after Sama was born.                                                             3 NSPCC Information Service, 2010 4 Analysing child deaths and serious injury through abuse and neglect what can we learn.  A biennial analysis of Serious Case reviews 2003-2005.  Brandon, M et al (2008) 21  2.74 The lack of parental engagement was not recognised by professionals and the lack of clear timescales for actions to be achieved contributed to this lack of recognition as did the absence of a multi-agency chronology.  The social worker responsible for the Child Protection Plan did not receive any formal supervision on this case which means that they were not provided with opportunity to reflect on whether the progress that they were assessing had taken place.  2.75 New information was received via two anonymous referrals.  One of these referrals included information that father and mother were involved in drug dealing whilst the other contained information about father’s violent behaviour.  In addition, and shortly before Sama’s death, Children’s Services received reliable information that father lived with his wife in Bedford; prior to this, the professional network had understood father’s wife lived in Pakistan.  This information was not shared at the Core Group meeting that was held a few days later or with the professional network.  One of the referrals was deemed by the social work team to be malicious and the information was effectively discounted whilst the information provided in the other was not used to re-evaluate the professional judgements that had been reached by the Local Authority.  Failure to review judgements and plans is a predictable and persistent error in human reasoning in that once we have formed a view on what is going on, there is a surprising tendency to fail to notice, or to dismiss, evidence that challenges that picture.  An example of how this manifested in this case is that care leaver was discussed at MARAC following the allegation of domestic abuse she made against father after Sama was born.  This would indicate that the Police had assessed she was at high risk of harm from father however despite this information being shared raised at the professionals meeting it did not result in a review of the level of risk of harm to Sama from domestic abuse.  This is also a further illustration of the lack of awareness of domestic abuse perpetrator behaviour amongst professionals.  2.76 On two occasions, father gave cultural norms as an explanation for events that had or had not happened, including why parental grandmother did not see or discuss Sama with him.  These explanations were not challenged by professions yet both of the matters that were under discussion were significant to Sama’s needs and well-being.  2.77 A Review Child Protection Conference (RCPC) was held approximately 2 weeks before Sama died and an updated social work assessment was considered at the conference. Sama was described by Children’s Services as a quiet, calm and content child. It was reported that she only cries when she is hungry or uncomfortable and her mother was assessed as meeting all of her care needs, with father also involved in the provision of some basic care. The Family Nurse Partnership reported the parenting provided by mother and father as fantastic. The updated social work assessment states “the father may not prove a direct risk to mother and child but the risk is indirect and in association to the care leaver”.  The minutes of the meeting identify that “the impact of the care leavers activities is the most concern” and both of these statements reflect the shift in professional focus in this case.  As per local agreement, the Police did not attend the RCPC and a report was not requested.  This means that reliable information about the allegation made against father by the care leaver in August 2015 and the subsequent risk assessment of her safety was not considered and nor was the fact that care leaver was arrested in September 2015 for harassment offences following reports made by the parents. No charges were subsequently made against the care leaver in respect of these allegations.   2.78 Children’s Services and Family Nurse Partnership were the only agencies in attendance at the RCPC because neither Housing nor the specialist domestic abuse service had been invited to join the Core Group. Housing or the specialist domestic abuse service also did not receive any relevant information about the child’s circumstances e.g. Child Protection Plan. The lack of involvement of other relevant agencies in the Core Group and RCPC limited the quality of information sharing and analysis of the risks to Sama including mother’s lack of engagement with the specialist domestic abuse service.  22  2.79 Three days after the RCPC, mother was convicted of causing unnecessary suffering to an animal and a five-year Disqualification Order was imposed. This information has only come to light during the course of the review and was not known by professionals at the time.  2.80 Shortly before Sama’s death father was discussed at the Child Sexual Exploitation Panel (CSEP) because of significant concerns that he was involved in the sexual exploitation of two children. Both of these children were looked after and one was in care of Bedford Borough.  Although representatives of Bedford Borough Council and the Police were in attendance at the CSEP, the information about father being currently involved in the sexual exploitation of children was never shared with professionals involved with Sama and her parents.  This was a significant breakdown in information sharing arrangements.  2.81 The Family Nurse Partnership on several occasions contacted Children’s Services to chase minutes of meetings including Core Group minutes, child protection conference minutes, professionals meeting minutes and the discharge planning meeting minutes. Staff, both internal and external to the Local Authority, have raised issues of delay with receiving the minutes of relevant meetings. There is dedicated administrative capacity in the Assessment Team and Conference and Review Service to produce these minutes and so it is unclear why there is ad hoc distribution of the minutes from strategy discussions and Child Protection Conferences.    2.82 Factors that influenced ‘why’ this happened a) Problematic information sharing and in particular the sharing of information from MARAC and CSEP regarding risky individuals with those responsible for safeguarding children they are in contact with. The lack of information sharing between the RSPCA, Police and Children’s Social Care Services was also problematic. b) Culture of inter - agency work and problematic use of BBSCB Escalation Policy -Openness and mutual respect were not always features of professional working relationships and processes were not followed in accordance with BBSCB Escalation Policy. This meant concerns remained unresolved. c) Gap in reflective supervision – the community midwife and social worker were not afforded the opportunity to reflect via formal supervision on the risks to Sama including new information that emerged. d) Workforce capacity to work with domestic abuse – Specialist domestic abuse knowledge and expertise exists in Bedford Borough however this appears confined to services providing domestic abuse services. There is a need for all staff involved in working with vulnerable children and families to have an understanding of the nature and dynamics of domestic abuse and to use this to inform their practice.  The professional network was distracted from the risks posed to Sama from domestic abuse; if practice and planning had been informed by knowledge and research about perpetrator behaviour the likelihood of this occurring would have been less.  e) Gap in multi-agency chronology – a chronology could have supported professionals to identify risk and patterns of non-engagement. f) Cultural competence5 - the need to equip the children’s workforce in Bedford Borough to work with families from diverse background and practice in a culturally competent way was identified at the practitioner and manager event held during this review.                                                               5 Cultural competence is a set of congruent behaviours, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations 23  3. In what ways does this case provide a useful window on safeguarding systems process and procedures in Bedford Borough? 3.1 This report has thus far focused on exploring what happened and why in this case.  The purpose of Serious Case Reviews is to identify learning to improve safeguarding systems, processes and procedures in the local area so as to reduce the likelihood of similar reoccurrence in the future.   This is achieved by using the case that is being reviewed as a “window” on the system which in turn creates the opportunity to consider wider learning rather than case specific practice.  3.2 Six key learning points have been identified that have wider relevance for the multi-agency response to safeguarding of unborn/baby children from domestic abuse.  The review has also identified seven other learning themes of wider relevance for the safeguarding system in Bedford Borough.  These seven themes are not specific to the area of practice under review.  The preceding text explains how these seven themes featured in this case. Research and learning from other Serious Case Reviews6, indicates they are common ‘problems’ in the safeguarding system. To support individual agencies and BBSCB to continuously focus their attention on relevant issues they are set out below: i. Quality of assessments including analysis of all available information/risk factors ii. Outcome focused planning including specifying timescales for the completion of actions iii. Contribution of GPs to safeguarding arrangements including information sharing iv. Supervision of front line staff to support them to reflect on new information and level of parental engagement v. Parental disguised compliance vi. Escalation and resolution of professional concerns and disagreements vii. Use of chronologies  3.3 This report will now consider in turn the six key learning points related to the safeguarding of unborn children/babies from domestic abuse.  3.4 Learning Point 1: CSE: Recognising and addressing the impact of child sexual exploitation in assessment and planning  3.5  This review has established that mother was a victim of child sexual exploitation and the impact of her experiences of being a victim of sexual exploitation was highly relevant to any assessment of her parenting and in particular her capacity to safeguard a child whose father was the person who had been sexually exploiting her.   There was relevant information available on agency records e.g. Children’s Services, Police and GP to evidence the controlling and abusive nature of father’s involvement with mother when she was a child however this did not result in professionals recognising that mother had been a victim of sexual exploitation. The 8-year age gap between the parents was also an indicator of child sexual exploitation and again this did not result in professionals identifying mother as a victim of child sexual exploitation.  Contributing factors to the lack of recognition of mother’s experiences of child sexual exploitation include the national focus on the group/gang model of sexual exploitation and the focus on under 18 years old as victims of sexual exploitation.  This review has identified that professionals need to be able to recognise all forms of child sexual exploitation. Barnardo’s has identified three different models of child sexual exploitation as set in Appendix 2, and whilst not exhaustive, they show a spectrum of exploitation including “inappropriate relationships” that professionals need to be equipped to recognise. Professionals also need to be able to recognise that young people can require support as a victim of child sexual exploitation beyond the age of 18 years old and this needs to be supported by a locally agreed pathway and service provision.                                                             6 Analysing child deaths and serious injury through abuse and neglect what can we learn.  A biennial analysis of Serious Case reviews 2003-2005.  Brandon, M et al (2008) 24  3.6  Mother advised professionals that she was not in an abusive or controlling relationship with father and this was accepted by professionals. Victims of child sexual exploitation can defend the abuser and/or deny that the relationship with the perpetrator is abusive. There are two accepted explanations of why a child or young person may defend the abuser and/or deny their relationship with the perpetrator is abusive: The Stockholm Syndrome and the Betrayed trauma theory.  Both are explained at Appendix 3 and illustrate the impact of CSE on victims. These evidence based explanations provide a framework for front line practitioners and their managers to understand the victim’s response to their abuser and should be used to inform assessments, planning and decision making. The victim’s survival response will mean they will require intensive support in their own right to resolve the ‘trauma bond’ that can develop with the perpetrator before they are able to meaningfully engage in plans to safeguard themselves or their child/ren from the perpetrator. Whilst this work is happening, there needs to be robust information sharing arrangements as well as coordination of activity to disrupt perpetrator behaviour. Information about suspected perpetrators also needs to be shared with all relevant practitioners. This did not happen in this case as information about father’s involvement in child sexual exploitation that was discussed at the CSEP Panel in October 2015 was not shared with relevant professionals involved with Sama and her family.   3.7  Areas for consideration by BBSCB  • How effective is the Pan Bedfordshire CSE strategy in supporting front line staff to recognise and respond to all forms of CSE? What support is available for victims of CSE who have reached 18 years of age and is there a clear pathway? • How well do arrangements to share information about CSE perpetrators with all relevant practitioners operate in practice? • How well is background history and all forms of vulnerability addressed in assessment, planning and service provision?  3.8 Learning Point 2: Embedding pre-birth assessment procedures and practice guidance   3.9 The vulnerability of children under one year of age is well evidenced in research. 45% of Serious Case Reviews in England relate to babies under the age of one year and babies are eight times more likely to be killed than older children7. Timely assessment of the safety of unborn children on a multi-agency basis is critical to the development of effective plans to meet the child’s needs. The delay in completing the pre-birth assessment in this case meant that there was no time to commission a specialist assessment to develop plans that would have more effectively managed the risks prior to Sama’s birth and the lack of involvement from key partners e.g. GP resulted in critical information not being considered as part of the assessment.  3.10 BBSCB launched pre-birth procedures and practice guidance in August 2015 that are designed to ensure that pre-birth assessments are carried out on a multi-agency basis and in a timely manner, however this review has established that they are not commonly known about or embedded across the professional network. Pre-birth assessments continue to be completed as single assessments rather than using the bespoke pre-birth assessment template and the pre-birth planning meetings designed to support a multi-agency pre-birth assessment that should take place in every case have only recently started to happen.  At the point of the practitioner event, the Police were unaware of these meetings and unclear if they were required to attend.  3.11 Pre-birth procedures that set out a timeframe for managing, when required, the pre-birth assessment process alongside the Public Law Outline Framework could support more timely consideration of cases at a Legal Planning Meeting. Outcome focused plans that set out                                                            7 Cuthbert,C. Rayns, G and Stanley All Babies Count: prevention and protection for vulnerable babies, NSPCC, 2011 25  clear timeframes for actions to be completed will also support more effective management of risks to baby children as will addressing the issue of contact in these plans.  3.12 Significant information may be held on GP records and this review has identified that there may be a potential lack of clarity regarding the ‘flagging’ system used on GP records amongst some health professionals. A commonly understood ‘flagging’ system is required and in this case, the Family Nurse Partnership did not have access to the GP records at the start of their involvement. Systems need to support all relevant professionals to have access to the information they need.   3.13 Key professionals involved in this case did not receive formal supervision and this meant they were not provided with the opportunity to reflect on the strengths and risks in this case. In addition, there was no opportunity to reflect on the degree that they were practicing in a culturally competent way and in particular whether they were accepting or using “culture” as an explanation for risk factors in the case.  3.14 Areas for consideration for BBSCB:  • How effectively are the pre-birth procedures and guidance used?  • To what degree does the children’s workforce practice in a culturally competent way? How do you know they do? • What arrangements are in place to oversee the quality of planning and decision making for unborn children and how well are staff who work with vulnerable groups of children, including unborn children, supervised?   3.15  Learning Point 3: Domestic Abuse: Using knowledge of the dynamics of domestic abuse including perpetrator behaviour to inform practice.    3.16 Domestic abuse was a feature in this case and being harmed as a result of domestic abuse between her parents was a significant risk to Sama. The information available to professionals was that father had been abusive in a previous relationship; however, he and mother maintained that their relationship was not abusive.  This assertion contributed to the professional network’s view about the nature and degree of risk to Sama. If knowledge about the dynamics of domestic abuse and perpetrator behaviour had been used to inform professional practice, then the risk of harm to Sama from domestic abuse would have been more likely to be identified. If the degree of risk to Sama from domestic abuse had been recognised, then there is a strong likelihood that there would have been consideration as to whether contact between Sama and her parents was safe for her. Appendix 4 sets out the core aspects of domestic abuse and perpetrator behaviour that front line professionals should be supported to use to inform their practice.  3.17 The local practice to use neglect as the category for child protection plans in cases of domestic abuse could be interpreted, particularly by the victim, as making them jointly responsible for the risk of harm to their child/ren rather than placing the responsibility with the perpetrator.   It could also serve to divert professional attention away from the physical and emotional harm that the child is exposed to from the perpetrator.  3.18 A feature of domestic abuse perpetrator behaviour can be to attempt to divert professional attention away from the risk that they pose by for example minimising or deflecting the professional concerns. There is evidence that this happened in this case in that the focus of professional concern became about the risk posed by the care leaver however this shift away from the risk posed by father was not recognised by the professionals involved. Again, if knowledge of domestic abuse and perpetrator behaviour had better informed practice, this would have been less likely to occur as would the decision to refer father for “anger management”.     26  3.19 The Police were involved in investigating a further incident of domestic abuse reported by the care leaver shortly before Sama’s birth however, and in accordance with the locally agreed protocol, the Police do not attend Review Child Protection Conferences and so the nature of the complaint, assessment and progress of the investigation nor that into the allegations made by parents against the care leaver were not considered by the Review Child Protection Conference. It is considered that information about further incidents of domestic abuse or harassment are relevant to the decision making of subsequent Child Protection Conferences. Similarly, information about the nature of domestic abuse is relevant to any specialist domestic abuse service and they should be invited to formally join the Core Group. In this case, this did not happen and the specialist domestic abuse service commissioned to provide a service to mother were not members of the Core Group and equally, they did not receive all relevant information at the point the referral was made.  3.20 Multi-Agency Risk Assessment Conferences (MARACs) are held in respect of high risk victims of domestic abuse to design plans to promote their safety. Both mother and the care leaver were discussed at MARAC and in fact the care leaver was discussed on several occasions; including shortly after Sama’s birth. Relevant agencies were in attendance at the MARAC that was held shortly after Sama’s birth however, there was no effective join up between the risks being identified about father in relation to the care leaver and the safety and well-being of Sama.  Similar, to the management of CSE perpetrators, there needs to be effective information sharing with relevant professionals regarding domestic abuse perpetrators discussed at MARAC and this may require the sharing of information across Local Authority boundaries.  3.21 Areas for consideration by BBSCB:  • How does BBSCB and the Community Safety Partnership work together to address the needs of children affected by domestic abuse? • How well equipped are front line staff and managers to assess and manage the risk of harm to children from domestic abuse? What else would support them to effectively exercise professional judgement? • How well do arrangements to share information about domestic abuse perpetrators with all relevant practitioners operate in practice?   3.22 Learning Point 4: Understanding, recording and using criminal history and background information  3.23 This review has identified that whilst information regarding father’s criminal history was available to professionals working with the family there is learning about how such information is shared, stored, analysed and used.  3.24 An individual’s criminal history and background is relevant to the assessment of a child’s safety.  In general, the more the risk marker resembles the behaviour in question, the stronger the risk indication.  Research8 points to past assaults on the same victim or another partner as one of the strongest and simplest predictors of further domestic violence.    3.25 Bedfordshire Police provided criminal history and background information by email for the strategy discussion in this case however this information was not recorded in or appended to the Strategy Meeting minutes, added to the child’s file or shared with the Children’s Services Legal Team in advance of the Legal Planning Meeting. All of these actions were required to promote the safety of Sama from domestic abuse. The need to record information about an individual’s criminal history/background on the child’s social care file is essential particularly as cases will move between social work teams and the information needs to be available to the social work team following any such transition.                                                            8 Barnish, M., Domestic Violence: A Literature Review, HM Inspectorate of Probation, 2004 27   3.26 Bedfordshire Police helpfully use a standard template to provide information to ICPCs however, there is no section in the report template that requires an analysis of the information provided in relation to the children who are being considered by the Conference.  Currently, Police reports to ICPCs are shared with the Conference Chairperson rather than all professionals in attendance and a brief analysis of the information provided that could be shared with professionals would assist professional understanding of the impact of criminal history/background information on the child’s safety.  3.27 The National Probation Service do not use a standard report template to provide information to Child Protection Conferences and in this case information about the assessed level of risk of harm father posed to others and suitability for engaging in a domestic abuse perpetrator programme was not included in the report provided to the ICPC. This information could have helpfully informed the assessment of risk and plans made by the Conference.  3.28 Areas for consideration by BBSCB: -  • How well is information about an individual’s criminal background shared, analysed and stored? Do all agencies who provide services as part of the child’s plan receive the necessary information? • How well is an analysis of an individual’s criminal background reported to and considered by Strategy Meetings, Child Protection Conferences and Legal Planning Meetings?   3.29 Learning Point 5: Disseminating minutes of meetings in a timely and consistent way  3.30 This review has identified that minutes from meetings were not consistently issued to all agencies in this case; whilst in some cases the minutes were not circulated at all. Statutory guidance9 requires that the Local Authority records Strategy Meeting and Child Protection Conference decisions and recommendations. BBSCB procedures state that a copy of the record should be made available to all those who had been invited or involved. For Child Protection Conferences, BBSCB procedures state full minutes will be distributed within 15 working days and for strategy discussions, they state “as soon as practicable”.  BBSCB procedures require Core Group minutes to be circulated within 5 working days.  3.31 The review has identified that the gaps in the distribution of minutes from a range of meetings including Strategy Meetings, Child Protection Conferences and Core Groups is wider than the case under review. This shortfall in practice will reduce the effectiveness of safeguarding arrangements for individual children in Bedford Borough as all agencies will not have the relevant information and be clear about the precise details of the plans agreed and the actions they need to take and the timescale for completing these actions.  3.32 Areas for consideration by BBSCB: -  • How effective are arrangements for recording and distributing minutes of safeguarding meetings within Bedford Borough? How are they monitored and what, if any, are the barriers to timely dissemination?  3.33 Learning Point 6: Recognising the links between animal abuse and child abuse/domestic abuse                                                             9 Working together to safeguard children. An inter-agency guide to working together to safeguard and promote the welfare of children. HM Government. 2015 28  3.34 In October 2015, mother was convicted of causing unnecessary suffering to an animal. The prosecution was brought by the RSPCA and any subsequent conviction that arises from a prosecution brought by the RSPCA is added to the Police National Computer (PNC) by the Court. No alert is generated to local Police at the point the conviction is added to the PNC and so this raises the important issue of how the RSPCA and partner agencies work in partnership.  BBSCB has a RSPCA, Social Care and Police Referral Protocol in its inter-agency procedures and this was updated in December 2015.  The protocol states “research suggests that animal abuse can be part of a constellation of family violence, which can include child abuse and domestic abuse”  3.35 The protocol sets out that Social Care and the Police will notify the RSPCA of any concerns relating to abuse and neglect of animals.  Conversely, the protocol states that the RSPCA will notify Children’s Social Care and/or the Police where there is: • Deliberate harm of animals and children are in the household; or • Neglect of animals through deprivation of food, water, shelter or veterinary care and children are part of the household.  3.36 It is not known who made the referral to the RSPCA that resulted in mother being convicted of causing unnecessary suffering to an animal, however there is no information available to this review to suggest that there was any liaison between the RSPCA, Social Care and the Police. This is despite multiple references to intelligence that father was breeding dogs for fighting and that these were kept at maternal grandmother’s home.   3.37 There is increasing research and clinical evidence which suggests that there are sometimes inter-relationships, commonly referred to as ‘links’ between the abuse of children, vulnerable adults and animals including where serious animal abuse has occurred in a household there may be an increased likelihood that some other form of family violence is also occurring and that any children present may also be at increased risk of abuse.10 Acts of animal abuse may in some circumstances also be used to coerce, control and intimidate victims of domestic abuse and their children to remain, in, or be silent about their abusive situation.  3.38 This review has identified the need for systems and practices to operate so that the potential inter-relationships between child abuse, domestic abuse and animal abuse are recognised.  3.39 Area’s for consideration by BBSCB:  • What arrangements are in place to secure the engagement of the RSPCA in the work of BBSCB? • How widely understood and applied is the BBSCB RSPCA, Social Care and Police Referral protocol?                                                                10 Deviney, E. Dickert, J and Lockwood, R (1983) ‘The care of pets within child abusing families’ International Journal for the Study of Animal Problems, 4, Pp 321-9 29  4. Conclusion  4.1 This Serious Case Review was commissioned by BBSCB in response to the death of Sama in October 2015.    4.2 The review has been carried out to explore the strengths and gaps in the multi-agency response to safeguarding babies from domestic abuse.  A summary of the findings is set out below and it is hoped they will be used to inform the ongoing development of safeguarding systems and practice in Bedford Borough.  Staff who attended the learning event held as part of this review identified a number of ways that safeguarding systems and practice in Bedford Borough can be improved and these have been used to inform the learning from this review.    4.3  A number of strengths have been identified in the multi-agency response to safeguarding babies from domestic abuse and include: • Contribution of named/lead professionals in health to the identification of safeguarding risks; • More timely completion of social work assessments and reduced caseloads in the assessment team; • Introduction of systems for social care and health professionals to track progress of pre-birth assessments.  4.4  A number of gaps have also been identified some of which relate to the generic safeguarding systems and practice and others which relate specifically to the safeguarding of babies from domestic abuse.  Those that relate specifically to the safeguarding of babies from domestic abuse are: - • Recognising and addressing the impact of CSE in assessments and plans to safeguard children; • Embedding the pre-birth protocol and practice guidance; • Using knowledge of the dynamics of domestic abuse, including perpetrator behaviour, to inform practice; • Understanding, recording and using criminal history and background to inform assessment, planning and service provision; • Disseminating minutes of safeguarding meetings in a timely and consistent way; • Recognising the links between child abuse and animal abuse  4.5 These findings are relevant to individual agencies as well as the BBSCB.  BBSCB will coordinate how the findings are used to further develop safeguarding arrangements and practice in Bedford.   30  Appendix 1 - Glossary BBSCB Bedford Borough Safeguarding Children Board – a statutory partnership whose functions are to coordinate how agencies work together to safeguard children and young people in the local area and to ensure the effectiveness of those arrangements. Cafcass Cafcass stands for Children and family court advisory and support service. Cafcass represents children in family court cases and their role is to make sure that children's voices are heard and decisions are taken in their best interests. Cafcass are independent of the courts, children’s services, education and health authorities and all similar agencies. CSE Child Sexual Exploitation -  Sexual exploitation of children and young people under 18 involves exploitative situations context and relationships were young people, (or a third person or persons) receive ‘something’ (e.g. food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of them performing and/or another or others performing and/or another or others performing on them, sexual activities.  In all cases, those exploiting the child or young person have power over them by virtue of their age, gender, intellect, physical strength and/or economic and other resources. Violence, coercion and intimidation are common, involvement in exploitative relationships being characterised in the main by the child or young person’s limited availability of choice resulting from their social, economic and/or emotional vulnerability. DASH risk assessment Domestic Abuse, Stalking and Honour Based Violence Risk Assessment tool that is completed in cases of domestic abuse to identify the level of risk to the victim Family Nurse Partnership A structured and intensive programme to teenagers under the age of 20 years, having their first baby and less than 28 weeks pregnant. The service is structured to cover all aspects of pregnancy, health and parenting over the course of the pregnancy and up until the child is aged 2 years. Grooming Grooming is when someone builds an emotional connection with a child to gain their trust for the purposes of sexual abuse or sexual exploitation. Children and young people can be groomed online or in the real world, by a stranger or by someone they know - for example a family member, friend or professional. Groomers may be male or female. They could be any age. Many children and young people don't understand that they have been groomed, or that what has happened is abuse. Genogram A genogram is a pictorial display of a person's family relationships. It can be used to identify repetitive patterns of behavior and to recognize hereditary tendencies MARAC Multi-Agency Risk Assessment Conference - A MARAC, or multi-agency risk assessment conference, is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local Police, probation, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other specialists from the statutory and voluntary sectors. After sharing all relevant information about a victim, representatives discuss options for increasing safety for the victim and turn these options into a co-ordinated action plan. The primary focus of the MARAC is to safeguard the adult victim. MASH Multi-Agency Safeguarding Hub - A MASH is a multi-agency team which co-locates key safeguarding agencies with a view to better identifying risks to children, and improving decision-making, interventions, and outcomes. PLO Public Law Outline – Protocol for managing cases designed to reduce unnecessary drift and put the child at the heart of care proceedings by promoting better co-operation between all of the parties involved. SEPT South Essex Partnership Trust - a provider of health services to children and families in Bedford Borough including the Family Nurse Partnership. Viability Assessments Viability assessments are a way to quickly and effectively gather all the necessary information that determines whether an adult is deemed appropriate to be an alternative carer for a child who may be unable to stay with their parent. 31  Appendix 2 - Models of Child Sexual Exploitation Barnardo’s11 identified three different models of child sexual exploitation as set out in the table below, and whilst not exhaustive, they show a spectrum of exploitation.                                                                 11 Barnardo’s, Puppet on a string: the urgent need to cut children free from sexual exploitation, 2011 Model 1: Inappropriate relationships  Usually involving one perpetrator who has inappropriate power or control over a young person (physical, emotional or financial). One indicator may be a significant age gap. The young person may believe they are in a loving relationship. Model 2: ‘Boyfriend’ model of exploitation and peer exploitation The perpetrator befriends and grooms a young person into a ‘relationship’ and then coerces or forces them to have sex with friends or associates. Young people can be forced or coerced into sexual activity by peers and associates. Sometimes this can be associated with gang activity but not always. Model 3: Organised/networked sexual exploitation or trafficking Young people (often connected) are passed through networks, possibly over geographical distances, between towns and cities where they may be forced / coerced into sexual activity with multiple men. Often this occurs at ‘sex parties’, and young people who are involved may be used as agents to recruit others into the network. Some of this activity is described as serious organised crime and can involve the organised ‘buying and selling’ of young people by perpetrators.  32  Appendix 3 – Stockholm Theory and Betrayed Trauma theory Stockholm Syndrome12 According to the Stockholm Syndrome children who experience a perceived or real threat to their physical or psychological survival and believe that the abuser will carry out the threat - as is the case when they are being or have been sexually exploited, can develop and retain an emotional ‘bonding’ with their abuser1. The positive feelings the child has for the abuser lead to the child supporting or helping the abuser.  At the same time the child develops negative feelings toward family, friends, or authorities which creates isolation from other perspectives.  This exacerbates the child’s perception or real inability to escape from the situation.  Stockholm Syndrome develops subconsciously and on an involuntary basis, through several stages:   • The victim dissociates from his or her pain, helplessness or terror by subconsciously beginning to see the situation / world from the abuser’s perspective. The victim begins to agree with the abuser and certain aspects of his or her own personality, opinions, and views will fade into the background.   • By doing this, the victim begins to learn how to appease and please the abuser, which may keep him or her from being hurt or worse. Similarly, this tactic can be used to manipulate the abuser into being less dangerous, at least for a little while.  • After a while the victim begins to realise that his or her abuser portrays the same human characteristics as anyone else.  At this point he or she will begin to see the abuser as less of a threat.  Some abusers may even share personal information in an effort to bond with the victim and to promote pity rather than anger.   • This bonding, in turn, leads to conflicting feelings (e.g., rage and pity) and illogical concern for the abuser.  The victim ignores his or her own needs.   • Once the traumatic event has ended, however, the victim must again learn not to dissociate from his or her emotions and not focus on the abuser.  This can be a very difficult transition.   The Stockholm Syndrome reaction may possibly be understood as a special kind of betrayal trauma.  Betrayed Trauma Theory13 Betrayal Trauma Theory posits that whilst humans have evolved to be excellent self-protective detectors of potential or actual betrayal, under some circumstances detecting betrayal may be counter-productive to survival goals.  Thus in cases where the victim is, or perceives themselves to be, dependent on the abuser, the victim remains ‘unaware’ of the abuse in order to maintain the relationship which s/he perceives as key to survival1.  The theory accepts that the knowledge/memory of the abuse enters the ‘system’, but that the victim isolates or dissociates awareness from consciousness.   Betrayal theory gives three explanations for how the victim can be unaware of the abuse:   • The neurobiological impact of fear, and the stress it causes, impairs the hippocampus and related structures responsible for memory consolidation.                                                             12 Love and Stockholm Syndrome: The Mystery of Loving an Abuser. Counselling Resource. Dr. Joseph M Carver, PhD. January 2004 13 J. Freyd, What is a Betrayal Trauma? What is Betrayal Trauma Theory? 2012 http://pages.uoregon.edu/dynamic/jjf/defineBT.html 33  Hippocampus dysfunction in an individual with Post Traumatic Stress Syndrome is likely to explain impaired ability to integrate memories for trauma at the point of retrieval.   • Dual-representation theory recognises verbally accessible memories (VAM) and situationally accessible memories (SAM).   VAMs are linked to a particular point in time, can be updated and are verbally accessible.  SAMs on the other hand, remain current and give rise to intrusive memories (flashbacks) in which ‘one doesn’t know what happened in a verbally accessible way’.   • Avoidance.  To the extent that fear-related memories are painful and aversive, anxiety models suggest that a sexually exploited child will increasingly avoid both external and internal reminders of the trauma. Particularly when these memories are prematurely inhibited, they may not be processed in ways that integrate them into other autobiographical memories, increasing the likelihood of unawareness.                        34  Appendix 4 –Knowledge requirements about Domestic Abuse and perpetrator behaviour  To effectively intervene and manage the risks, practitioners need a good understanding of domestic abuse and perpetrator behaviour including that: • Previous violence in one relationship is a reliable indicator of violence in a future relationship; • Domestic abuse is about power and control rather than a momentary loss of self-control; • Domestic abuse is likely to be a pattern of behaviour rather than a one off event; • Domestic violence treatment programmes can help perpetrators to change their behaviour however, the perpetrator needs to accept responsibility for their abusive behaviour; without engaging in a treatment programme the level of risk will remain; • Child contact is used by perpetrators to further abuse their victims.   