Death of 3-month old child in 2015 due to medical causes. A child protection plan had been in place one year before the death for child BW and siblings, who lived with their mother, due to concerns of neglect. In 2013 there had been concerns about neglect when family lived in a different area, which resulted in a common assessment framework process being started to support the family. A 'Getting it Right Assessment' was completed in 2014 due to increasing concerns about the family. Issues identified include: views on a good enough home environment can be subjective and is complicated by working in a deprived area; safe sleep advice had been provided but was not followed; mother's disguised compliance may have added to the optimistic view of her intentions and capacity to change. Good practice identified: robust information sharing processes and good local professional relationships. Recommendations include: wider promotion and clarification for staff of the Graded Care Profile 2, and any other agreed neglect assessment tool for the multi-agency partnership; audit on how expected outcomes are recorded on Children's Services' documentation particularly Child Protection Plans, to clearly highlight what difference is expected to be made, and the consequences should positive change not occur; audit of pre-birth child protection processes to ensure that when siblings are on a child protection plan the needs of an unborn baby in the family are considered separately; review the Multi-Agency Pre-birth protocol; review of position of progress of the recommendation regarding safe sleep assessment from an earlier serious case review ; develop training on non- engagement and disguised compliance.
      
 Title:  Serious case review: Child BW. LSCB: Blackpool Safeguarding Children Board Author: Amanda Clarke and Kathy Webster 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.                           1 BSCB Child BW SCR FINAL 02.02.2017     Blackpool Safeguarding Children Board  Serious Case Review  CHILD BW   Review Process  This serious case review (SCR) was commissioned by the Independent Chair of Blackpool Safeguarding Children Board (BSCB) after a referral from the Pan-Lancashire Child Death Overview Panel (CDOP). It was agreed after consideration of the recommendation from the BSCB Case Review Sub Group that the circumstances surrounding the death of a child met the criteria for a serious case review.  Subject of the review:   Child BW  aged 3 months (deceased)  Child BW was aged three months at the time of death. BW was born in the local area and had lived with Mother and two siblings. Other close family members involved in BW’s life included BW’s Father, maternal Grandmother and maternal Grandmother’s Partner.   Circumstances resulting in the review  Child BW had lived locally with birth Mother (Mother) and two older primary school aged half-siblings prior to the death. Within the report the eldest sibling will be referred to as Sibling 1 and the youngest as Sibling 2. The family had recently moved into a different property within the area at the time of the death and were settling into their new home. There were issues at the previous address around the state of the property, including cleanliness, tidiness and household risks. Due to the home environment and other circumstances, the two Siblings and the unborn Child BW had been placed on Child Protection Plans in the autumn of 2014 under the category of neglect. The process around the Child Protection Plans will be explored in detail later in the report.   BW’s birth Father (Father) had had some contact with the child but had not been involved in the daily care. He was not the father of BW’s siblings but had been involved briefly in their lives during the short relationship with the children’s Mother. Mother and children were regularly supported by maternal Grandmother (Grandmother) and her partner (Grandmother’s Partner) who lived in the same area. Mother was known to have a number of friends locally who she would visit with the children.   BW was seen by a number of professionals on different occasions during the child’s short life, and was described as a happy looking baby, appropriately dressed and warm. Sadly, BW was found at home, unresponsive by Mother during a morning in early 2015. Mother reported feeding BW at 5am then both slept downstairs, Mother on the sofa and BW in a baby swing chair in the same room. The Siblings were at Grandmother’s overnight. Mother awoke at 11am and on seeing BW an ambulance was called. Unfortunately despite everyone’s best efforts BW was pronounced dead at hospital.  The cause of death was considered as natural causes due to infection. The Police have conducted enquiries regarding the sudden death and there are no criminal proceedings as a result.    2 BSCB Child BW SCR FINAL 02.02.2017   History and significant events leading to the review   Mother and the two Siblings had previously lived with the Siblings’ birth father (Siblings’ Father) in another part of the country. Mother and the Siblings moved in the autumn of 2013 to Blackpool to be closer to Mother’s own family, and in particular Grandmother. The relationship between Mother and Siblings’ Father had ended around two years prior to the move and Mother became the main carer for the Siblings after the separation. Local services in the area had had some involvement with Mother and the children after the break-up, and Children’s Social Care from the previous area have contributed information to the review.  Children’s Social Care in the previous area, were involved in early 2013 regarding the poor state of the family home, and an initial assessment led to a Common Assessment Framework process (CAF) being commenced to support the family.   The Common Assessment Framework (CAF) is a shared assessment tool used across agencies in England. It can help professionals develop a shared understanding of a child's needs, so they can be met more effectively through a multiagency plan. CAF is an important tool for early intervention which requires the engagement of parents and carers, Pan Lancashire Safeguarding Children Procedures, 1.5.  Soon after the initial assessment took place, unexplained bruising to Sibling 1 was noted at school where the child was also known to have had poor attendance. Mother had not engaged fully with the CAF process and was described as “low in mood”. The bruising was unexplained with no perpetrator identified by Sibling 1. A core assessment by a social worker resulted in an agreement to support the family by universal services and a continuing CAF plan. Later that year (2013) the family moved to Blackpool.   Sibling 1 was admitted to a Blackpool school in Autumn 2013 and information was shared verbally with the school by the previous Local Authority. School health records were also transferred and reviewed in line with cross border transfer arrangements. Sibling 2 joined the nursery provision in the same school setting in early 2014.  The family were living in a rented house but conditions were poor with no cooker connected, no carpets and the property was mostly undecorated. The children were often brought to school late, looking unkempt and in early 2014 Sibling 1 told a teaching assistant they had not washed, showered or cleaned teeth for three days. The family were known to be staying at other properties with friends due to the condition of their own home, and school and health professionals visited various local addresses to try to engage and offer support to the family. Many pre-arranged visits made by professionals were unsuccessful and Mother and the children were not always seen.     During early 2014 school health and education professionals met and decided to complete a Getting it Right (GIR) assessment due to the accumulation of concerns for the family. GIR was a new process implemented in the local area in October 2013.  The early intervention strategy, the ‘Getting It Right’ (GIR) framework, is designed to support partner agencies in helping families with more complex needs, thus reducing the likelihood that they will require support from statutory services.  The professionals involved categorised the concerns as Level 3: complex: this category identifies children whose vulnerability is such that they are unlikely to reach or maintain a satisfactory level of health or development, Blackpool Thresholds for Intervention, November 2013.    The health visitor visited the family home soon after the GIR assessment had commenced and conditions had not improved; all rooms were described as dirty with food on the floor, toilet facilities were unclean and the children had no bedding on mattresses which had been placed on bare floorboards. Mother said she had been prescribed anti-depressants by the GP. The health visitor shared her additional concerns with the school and it was agreed that the new information would be added to the GIR assessment tool. As the 3 BSCB Child BW SCR FINAL 02.02.2017  GIR process was quite new checks were required about the process to complete the task of adding additional concerns to the assessment, but the extra concerns and information was submitted. After three weeks, and several requests for updates by the school, they were informed that the case had been sent by the Early Assessment Team to the Families in Need Team (FIN) for allocation. The FIN team is a family intervention service operated through a multi- disciplinary team providing intensive support in homes. FIN was previously known locally as ‘Springboard’ and is often still referred to as ‘Springboard’ by families.  In Spring 2014 less than a month after the initial concerns were raised, the health visitor, being so worried about the continuing poor home conditions, made a child protection referral to Children’s Social Care (CSC). The concerns in her professional opinion had now escalated to Level 4: acute: children at risk of significant harm / or has suffered abuse and for whom there is continued risk, Blackpool Thresholds for Intervention, November 2013.   As a result a CSC and Police Public Protection joint visit was made and the children were placed in the care of Grandmother whilst Mother was required to attend to the poor home conditions. The children returned two days later and at this time a Child in Need plan was developed.   A child is defined as a child in need in law, if he or she is unlikely to achieve or maintain or to have the opportunity to achieve or maintain a reasonable standard of health or development without provision of services from the local authority; his or her health is likely to be significantly impaired, or further impaired, without the provision of services from the local authority; he or she has a disability, Section 17 Children Act 1989.  Mother was informed that should standards fail to improve an Initial Child Protection Conference would be initiated.   The purpose of an Initial Child Protection Conference is to bring together family members, the child (where appropriate), supporters/ advocates and those professionals most involved with the child and family to share information, assess risks and to formulate an agreed plan of management and services, with the child's safety and welfare as its paramount aim; Pan Lancashire Safeguarding Children Procedures, 3.5.    During this period BW’s Father and Mother had commenced their relationship. Father was subject to a Suspended Sentence Order at the time (for an offence unconnected to the family) and there was some liaison about the relationship between professionals from the Probation Trust and CSC. There were concerns historically about Father’s behaviour, including domestic abuse, and his use of alcohol and drugs. At the first Child in Need meeting Mother confirmed the relationship and that she was in the early stages of pregnancy with Father’s child. The unborn child was BW.  Throughout the Spring and Summer of 2014 there was regular involvement by professionals with the family. Concerns noted in agency records included the children described as dirty and unkempt at school, at times smelling of urine. Both Siblings had head lice, which was not immediately treated. The Pupil Welfare Service was involved regarding school non-attendance. The home conditions were regularly described as poor with only occasional improvement, the house was recorded to be dirty and cluttered, particularly the kitchen, and the toilet was unclean. Sometimes the home smelt heavily of cigarettes and occasionally of cannabis. There were concerns that the children were often caring for themselves, there were no routines, and they were sometimes out late into the evening with Mother at other addresses.   Engagement with Mother was regularly un-successful, there were no access visits when Mother and the children were not seen, and the home was not entered. However Mother did regularly attend the Child in Need meetings which took place monthly. As there was no significant improvement in the living conditions and lifestyle of the family they were referred to FIN for additional support. This was towards the middle of the Summer 2014 and at that time there were difficulties with Mother and Father’s relationship and a possible break-up.  4 BSCB Child BW SCR FINAL 02.02.2017  FIN commenced involvement mid to late Summer 2014 with home visits made at all times of the day and evening to try to better engage the family. However, records show in the first month of FIN involvement there were 14 no access visits. On 10 occasions the family were seen (either at home or when found to be at Grandmother’s address). At the Child in Need review it was agreed that, overall, circumstances had not improved and there were concerns for the unborn child (BW). A strategy meeting took place immediately which led to a decision in early Autumn to step up the case to an Initial Child Protection Conference (ICPC). At this time Mother was 24 weeks pregnant.   At the ICPC Sibling 1 and Sibling 2, and the unborn child (BW) were placed on Child Protection Plans under the category of neglect. A number of concerns were explored at the conference including Father of unborn BW’s involvement in the family and associated risks. Consequently a written agreement was signed by Mother for there to be no contact between unborn BW’s Father and her children, Sibling 1 and 2, until a risk assessment was completed.   FIN continued their intensive involvement but there was little change to the home conditions and limited improvement in terms of access to the premises, with 11 no access visits across the month after the children had been made subject to Child Protection Plans. The family were seen 10 times but half of these were at Grandmother’s home.    The view of FIN professionals at this time was that the home conditions were scoring very high on the FIN neglect tool, which was a tool internally developed in FIN to provide some consistency to workers when managing neglect. The home was scored at 9 out of 10, with a score of 10 categorised as requiring immediate action to be taken. On one visit the conditions were recorded as “uninhabitable” with rubbish and dog faeces on the floor, and the children’s beds were wet with urine. On that occasion the children were placed with Grandmother by the Social Worker, being able to return home after four days once improvements had been made.  In late Autumn 2014 a new Social Worker was allocated due to maternity leave. There had been a slight improvement to the home setting but leading up to the Review Child Protection Conference other concerns were noted. These included the children and Mother being located at the home of Mother’s friend one evening which smelt strongly of cannabis, an unexplained bruise to Sibling 1’s arm, and untreated head lice for Sibling 1. There was also a lack of preparation for the new baby (BW). The new Social Worker discussed obtaining legal advice with her Manager.     At the Review Child Protection Conference, which took place one week before the birth of BW, the decision was made that the two Siblings and the unborn Child BW were to remain on Child Protection Plans. After BW was born a discharge planning meeting was held at the hospital with discharge of Mother and BW delayed due to lack of preparation of baby equipment by Mother at home. BW was seen by FIN professionals in the first week after the birth but the Midwife was unable to gain access and was therefore unable to monitor the health of the new baby. BW was finally seen by the Midwife for the first time at school as this was a place that Mother was expected to visit to collect Siblings 1 and 2, therefore access to Mother and BW could be reasonably guaranteed.   There were concerns once BW was born that Mother was allowing Father to have contact with the baby, which was against the agreement made with CSC until a full assessment of Father had been completed. Other concerns at the home related to safety hazards including insufficient lighting upstairs, no loft door and a dog which was considered as a possible risk if left alone with Child BW and the Siblings. A strong smell of smoke and cannabis had also been recorded as noticed in the house. On a positive note the property was said to be warm on visits, BW was appropriately dressed and there was good attachment seen between BW and Mother. Professionals did see the family on 15 occasions, but there were 12 no access visits. Safe sleep advice is recorded as having been provided by the Health Visitor, and records show this was also given to Mother before the birth.   5 BSCB Child BW SCR FINAL 02.02.2017  Early in the new year 2015 Police were called to an argument outside Mother’s address which involved Mother and Father of BW. Mother said Father was upset at not being allowed to see BW but no offences were reported in the incident. The Police took no further action other than to remove Father to a different location. Soon after Mother reported to the Health Visitor that the relationship between the two had ended.   When BW was nearly two months old the family (Mother, BW and the Siblings) moved house to a different property in the local area. Home conditions at the first address had been noted as poor by the Social Worker just prior to the move. Unfortunately during this period Sibling 1 was required to have 5 teeth removed due to dental decay following poor dental hygiene.   In the first month at the new property Mother acted appropriately by taking BW to the GP for routine appointments. There were a further three appointments with the GP for BW for treatment of a viral upper respiratory tract infection. Home conditions were described as better, the children were all seen by the Social Worker and appeared well, and Mother’s emotional state seemed to have improved. On occasion BW was felt to be too warm and professionals advised a coat and blanket should be removed.   After one month in their new home, as described earlier in the report, BW was found unresponsive at home and was later pronounced dead at hospital.   Following BW’s death Sibling 1 and 2 moved out of the area and into the care of their own father (Sibling’s Father) who had become involved formally as the child protection process evolved in the autumn of 2014. Siblings have subsequently returned to live with Mother, following an assessment by Children’s Social Care.  Legal Context:  A serious case review was commissioned by Blackpool Safeguarding Children Board, following agreement at Blackpool Case Review Sub Group in accordance with Working Together to Safeguard Children (Department for Education 2013).  Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulation 2006 sets out the functions for LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB's function in relation to serious case reviews, namely:  5. (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.  (2)  For the purposes of paragraph (1)(e) a serious case is one where:   (a) abuse or neglect of a child is known or suspected; and   (b) either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.  The methodology used was based on the Child Practice Review process (Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012). This is a formal process that allows practitioners to reflect on cases in an informed and supportive way. Documenting the history of the child and family is not the primary purpose of the review. Instead it is an effective learning tool for Local Safeguarding Children Boards to use where it is more important to consider how agencies worked together. The detail of the analysis undertaken of the case is not the focus of the reports which are succinct and centre on learning and improving practice. However, because a review has been held, it does not mean that practice has been wrong and it may be concluded that there is no need for change in either operational policy or practice. The role of Safeguarding Children Boards is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the 6 BSCB Child BW SCR FINAL 02.02.2017  learning from the review can be used to inform systems and practice development. In so doing the Board may identify additional learning issues or actions of strategic importance. These may be included in the final report or in the action plan as appropriate.  The decision to conduct the serious case review in this way was considered and agreed by the Blackpool Safeguarding Children Board after the change in statutory guidance following The Munro Review of Child Protection: Final Report: A Child Centred System, May 2011. Munro suggests that Local Safeguarding Children Boards should use any learning model which is consistent with the principles in the Working Together to Safeguarded Children Guidance: Learning and Improving, HM Government 2015.     Methodology:  Following notification of the tragic death of Child BW in this case, and agreement by the chair of the Blackpool Safeguarding Children Board to undertake a serious case review, a review panel was established in accordance with guidance. This was chaired by Dr Rob Wheatley, the Designated Doctor and Consultant Paediatrician, Blackpool Teaching Hospitals NHS Foundation Trust and included representation from relevant organisations within Health, Education, the Police, Probation and Social Care.  Amanda Clarke, an independent reviewer from Derbyshire was commissioned to work with the panel and to undertake the review. Kathy Webster, Consultant/Designated Nurse for Safeguarding Children in Derbyshire was commissioned as a second reviewer due to the children being on child protection plans at the time of the death, to provide additional scrutiny regarding the child protection processes.  Review timeframe  The timeframe for this review was from 19th November 2013 until 1st March 2015. However, any significant events relevant to the case but prior to the start date of the timeframe were reflected in the information submission and analysis completed by each agency.  The timeframe starting point was to reflect the time at which Mother and the Siblings were known to have moved to Blackpool from another part of the country to live permanently. Information provided by services in the previous area has provided some historical context for the review but the interventions in the other area have not been analysed in detail as they were outside the review’s timeframe. This was the joint decision of the review panel. There is evidence of information sharing and follow up between professionals across borders.  The end date of the review reflects the time around the death of BW. Full terms of reference for the review are included in Annex 1.  All relevant agencies reviewed their records and provided timelines of significant events and analysis of their involvement. These were considered by the panel and provided opportunity for panel members to raise questions and clarify understanding of the circumstances of the case and of the separate services provided. The agency timelines were merged and used to produce an interagency timeline. This was carefully analysed by the Reviewer and second Reviewer with the panel and informed of the areas of interest that required further exploration and consideration. The process also allowed for the identification of the key practitioners required to attend a learning event in order to understand the detail of the single and interagency practice in this case.   Family involvement  The Reviewer attempted to meet with the Mother of Child BW in July 2016 but initially Mother decided that she did not wish to contribute to the review process. Fortunately in October 2016 Mother agreed to speak to the Reviewer by telephone. Father was seen in person by the Reviewer in July 2016 and was able to participate in brief to the review. The Siblings’ Father (Siblings’ Father), who resides away from the local area, was spoken to by telephone in September 2016. Grandmother was also spoken to by telephone in October 2016.    7 BSCB Child BW SCR FINAL 02.02.2017  The involvement of family members in the review has provided valuable insight into their own experiences, knowledge of the services offered to the family and overall some useful context. The thoughts of the family are included where appropriate and account was taken of the views of the different family members when writing the report and recommendations. The Reviewer is grateful for their contribution.   The learning event  The learning event was held in September 2016 and was attended by 6 professionals who had had direct involvement with Child BW and/or significant family members, in addition to the Reviewer who facilitated the session, the Second Reviewer, the Chair of the panel and the Board Manager of BSCB. The learning event was organised in line with Welsh Government guidance (Child Practice Reviews: Organising and Facilitating Learning Events, December 2012) and notes were recorded of the event. With the support of panel members and the Blackpool Safeguarding Children Board team, further enquiries were made with professionals who were unable to attend the learning event, and this information is included in the report.    Following the learning event, the Reviewer collated and analysed the learning to date for discussion with the panel. Practice issues originally identified by the panel were re-examined in the light of the findings of the review. This provided opportunity to identify issues requiring further clarification with practitioners or managers. In reviewing the findings, the panel gave consideration to what could be done differently to further improve future practice. A draft report was provided to the panel in advance of the panel meeting in November 2016. Learning from the full report will be made publically available after consideration by the Blackpool Safeguarding Children Board Case Review Sub Group and the Board.  ANALYSIS: Practice & Organisational Issues Identified  Child BW and the identified significant family members, were engaged with a number of services during the timeframe of this review, including Midwifery and Health Visiting Services, Education, the GP, Children’s Social Care, Families in Need, the Police, the local Probation Trust and it’s successor Community Rehabilitation Company and Pupil Welfare Service . Scrutiny of the timeline, information shared and reflections at the panel meetings and the learning event have highlighted areas of good practice and also provided an opportunity for wider learning to emerge about the ways in which services work together. The following is an analysis of the issues identified:  1. Management of Neglect  1(a) Thresholds for neglect  “The extent and significance of neglect in children’s lives has been a key and recurring theme throughout the previous biennial reviews of serious case reviews”. In the latest review for 2011-2014 from the 175 SCR final reports available, neglect was apparent in the lives of over half (52%) of the children who died, and nearly two thirds (62%) of the children who suffered non-fatal harm, Triennial Analysis of Serious Case Reviews 2011 to 2014, Pathways to Harm, Pathways to Protection:  Final Report May 2016, Peter Sidebotham, Marian Brandon et al.   There is evidence in this case to suggest that Sibling 1 and Sibling 2 suffered neglect during the timeframe of the review, as did the unborn child, BW. Descriptions in case recording by a number of different professionals, which are only summarised above, help to illustrate what living conditions were like for the two young children (the siblings of BW), their Mother, and for BW both pre and post-natal. Furthermore there is some information of the lived experience of Siblings 1 and 2, including how they presented; dirty, with head lice and tooth decay, and how they felt: frightened having no upstairs lighting or loft hatch door, and unclean by not brushing teeth for 3 days. There is considerable information on record to suggest that the children were often seen caring for themselves and that they were not having their basic needs met.  8 BSCB Child BW SCR FINAL 02.02.2017  Professionals visited the home frequently, recorded their concerns and regularly challenged Mother. However it appears that a sense of acceptance on the behalf of professionals was prevalent regarding the conditions in which Sibling 1 and 2, and the unborn BW lived. For a period of at least 5 months in 2014, the siblings were viewed as Child in Need but it appears limited action was taken during this time other than advice and support given to Mother to make improvements.   Records, particularly of the Initial Child Protection Conference and Review Conference show some professionals were optimistic about Mother’s capacity to change especially in terms of the state of the house. There appeared to be some acceptance that no change to, or slight improvement of, the conditions was satisfactory.   No change to very poor home conditions (therefore no improvement) means conditions remain very poor. Slight improvement to very poor home conditions means they are still poor. Neither is acceptable when this is the home where young children and an unborn child are expected to live.    The understanding of ‘what is good enough’ in terms of home environment is subjective in that what is good enough for one group of professionals or a family, is not for another. Subjectivity can also affect judgements of the type of area and housing where people live. In areas where there is known deprivation the threshold for intervention for neglect can be higher. When Mother and the Siblings moved to the area Blackpool ranked 12th highest in England for the proportion of children in low income families, compared to all authorities in the country and to the English average, Department for Education 2013. Furthermore Blackpool has a high level of child poverty, at 29.5%, a level which varies across the area rising to over 50% in some wards, Together on Poverty: Blackpool’s Child Poverty Framework 2012-2015. Professionals at the learning event working in the area where BW and family lived were in agreement that there were other families with children, in the same local area, living in similar circumstances.  The definition for neglect includes the phrase “persistent and severe failure to meet a child needs”. This does not mean circumstances and the environment have to get progressively worse; the threshold for neglect can be met by the concerns not getting any better, despite as in this case extensive professional intervention. The environment in which BW’s family lived and level of basic care to the children did not show any sustained improvement until the family moved house in the last weeks of BW’s life. Supervision of the professionals involved is explored later but supervision is a key place for the beliefs of professionals to be challenged about apparent changes, good or bad, within families and for managers to seek evidence of actual progress through management oversight of cases.   The impact of neglect on children should not be underestimated. In Children’s Social Care supervision records for the case the Siblings were described as “resilient, developing independence and the ability to self-care”. The Siblings were nursery and early primary school age at the time therefore such life skills should not be reasonably expected. Furthermore, no child should be expected to be resilient to neglect. This professional view could again be linked to the subjectivity of identifying levels of neglect or working routinely in circumstances where neglect is common and children “learn to live with it”.  It is positive that Blackpool Safeguarding Children Board has adopted a suite of neglect assessment tools to help support professionals facing the challenges associated with the subjective nature in agreeing the severity of neglect in families. One example is the neglect assessment tool known as the Graded Care Profile 2 (GCP2).   The Graded Care Profile (GCP) scale was developed in 1995 as a practical tool to give an objective measure of the care of children across all areas of need where there are concerns about neglect. The second version of the tool, known as ‘GCP2’ was developed to improve on GCP with the core principles of GCP remaining the same. GCP2 is a reliable and valid assessment tool in aiding practitioners in the assessment of child neglect: Testing the Reliability and Validity of the Graded Care Profile version 2. National Evaluation of the Graded Care Profile: NSPCC, Robyn Johnson, Emma Smith and Helen Fisher, NSPCC October 2015 9 BSCB Child BW SCR FINAL 02.02.2017   Full implementation of GCP2 in Blackpool is said to be planned to occur during the Winter of 2016/ 2017 and should allow the threshold for neglect and emotional abuse to be promoted and used consistently. Professionals at the learning event were at times confused about which neglect tool had been formally agreed for use across the area, particularly during the timeframe of the review. This may have been due to the different tools and initiatives regarding responses to neglect which have been introduced and tested over a period of time. The Blackpool Safeguarding Children Board multi agency training programme includes a course on Neglect Tool Training with objectives which include to become licensed to use the GCP2 and to consolidate knowledge in relation to neglect. The Board should consider wider promotion and clarification for staff of the GCP2 and any other agreed neglect assessment tool for the multi- agency partnership, to ensure all staff are aware of its implementation and how to use it effectively.   1(b) The Toxic Trio  The term “toxic trio” is often used to describe the issues of domestic abuse, mental ill-health and substance misuse which have been identified as common features of families where harm to children can occur.   Issues highlighted during the timeframe of the review include the mental health of Mother, her concerning relationship with Father who had some history of domestic abuse in a previous relationship, and the use of cannabis by adults in the environments in which the children lived and visited.   Mother at times presented as low in mood, and sought support from the GP regarding this. Historical information shared regarding Mother indicates she had showed signs of similar low level mental health issues previously whilst residing in the other area of the country. Mother herself, in conversations with the Reviewer, confirmed she had sometimes thought that she “felt depressed” and had taken prescribed medication for how she felt, prior to the pregnancy with BW. She praised FIN workers who she said would ask her about how she was feeling at different times. In contrast she said she felt the Social Workers involved asked how she felt, wrote down her response but didn’t support her to find solutions.  The relationship between Mother and Father (of BW) was relatively short but Father was identified as a risk to the children due to previous offending. It was positive that professionals from the Probation Trust/ Community Rehabilitation Company (there was no change of staff despite organisational changes) maintained good lines of communication with others involved with the family to share information and consider risks. Action was taken in that an agreement was required regarding Father’s involvement with Mother’s children and with BW, and an assessment was planned. When Father was seen as part of the serious case review process he shared that he felt unfairly treated by some professionals who he said viewed him as the only problem in the children’s lives because of one prior incident from his past. The Police did attend a dispute between Father and Mother early in 2015 and this indicates there was some hostility and aggression within that relationship. The incident was not recorded by Police as domestic abuse and therefore no Protecting Vulnerable Persons (PVP) form was submitted.   Lancashire Constabulary has a Protecting Vulnerable Persons (PVP) form that is used for the submission of a referral around vulnerability. The PVP has three vulnerability categories of vulnerable child, vulnerable adult or domestic abuse. In addition the referral form also allows officers to risk assess the particular referral using the following classification of risk – standard, medium and high.   Lancashire Constabulary was inspected in 2015 as part of Her Majesty’s Inspectorate of Constabulary’s (HMIC) effectiveness programme. The programme was to assess how well police forces keep people safe and reduce crime. Within the programme, HMIC’s vulnerability inspection examined the overall question, ‘How effective are forces at protecting from harm those who are vulnerable, and supporting victims?’  Overall Lancashire Constabulary’s operational procedures to protect vulnerable people and support victims were judged as good. In addition it was noted the quality of risk assessments was seen as improved since domestic abuse was inspected in 2014, Police effectiveness (HMIC) 2015 (Vulnerability): 10 BSCB Child BW SCR FINAL 02.02.2017  An inspection of Lancashire Constabulary, December 2015   The incident above, between BW’s parents, which occurred in early 2015, highlights a possible domestic abuse episode where appropriate risk assessment of vulnerability did not take place. In view of the judgement from the HMIC Vulnerability Inspection in the same year this was hopefully an individual oversight which fortunately had no serious related consequences. Lancashire Constabulary may wish to reassure itself that all frontline staff, officers or civilians, coming into contact with vulnerable children and adults are aware, and fully understand the requirements of the PVP process and the importance of sharing information about risk.  It was suggested by some professionals at the learning event and by Grandmother in her contribution to the review, that there was suspected controlling behaviour by Father against Mother during the review timeframe. On speaking to the Reviewer Mother said, in her opinion, that no domestic abuse took place. She was aware of the incident in Father’s previous relationship, but claimed she had felt at no risk from him whilst they were together and that her children were safe, in her view, when in BW’s Father’s presence.   Records in the timeframe suggest Father was a regular user of cannabis, and in the summer of 2014 he received a police cannabis warning after being found in possession of the drug. Mother was regularly challenged about her acceptance of cannabis use by her friends and Father, particularly when Siblings 1 and 2, and unborn BW were with her in environments where cannabis was obviously being used. It is noted that 3 weeks prior to BW’s birth, Mother and the children were located at a friend’s address where cannabis was openly being used.  There is no record of Mother using cannabis or other controlled substances in Blackpool, and she denies any drug use herself. However her lifestyle choices are known to have brought her and the children into regular close contact with adults using cannabis. Risks from this lifestyle are recorded as being discussed frequently at professionals meetings including core groups and the Initial Child Protection Conference.  In the Triennial Analysis of Serious Case Reviews 2011 to 2014, Pathways to Harm, Pathways to Protection:  Final Report May 2016, Peter Sidebotham, Marian Brandon et al, a  wide range of factors in the parents’ backgrounds were highlighted as raising potential risks to children. These include domestic abuse, parental mental health problems, and drug and alcohol misuse. The timeframe for the review regarding BW’s death contains numerous entries of concerns relating to these issues, commonly referred to as the “toxic trio”. Others factors identified in the Triennial Analysis of Serious Case Reviews are a history of criminality (particularly violent crime) and acrimonious separation. These were also features in the lives of Father and Mother, and therefore in the lives of BW and the Siblings.  In March 2015 BSCB identified the “toxic trio” as a priority theme for the Board, as well as neglect and early help. The toxic trio has also been a common priority for the Blackpool Safeguarding Adults Board. A course is currently available through the BSCB multi agency training programme titled “Hidden Harm-Toxic Trio”, with further training available on each individual element of the toxic trio. Half-day neglect briefings have also been externally commissioned by the BSCB since the start of 2016. Due to the highlighting of these risks and their potential links to children known to be subjects of serious case reviews nationally through the Triennial Analysis, BSCB should lead an evaluation of the Hidden Harm-Toxic Trio training. The evaluation should focus on overall attendees, which professional staff groups and agencies have attended, and whether from a Safeguarding Adult or Children background. What difference the training has made to those professionals, regarding their approach to neglect and identification of risk factors since attending, should be examined.     1(c) Making a difference for children  Families in Need (FIN) had considerable involvement in the lives of BW’s family. FIN is currently positioned within the early help section of Children’s Social Care and is co-located in a Blackpool Police Station 11 BSCB Child BW SCR FINAL 02.02.2017  setting. Extensive visiting and intervention took place by FIN particularly in the period when Mother was pregnant with BW, but the question could be asked as to what difference this intensive service provision made to BW and the Siblings. Unfortunately FIN representatives were unable to attend the learning event but the Service Manager of FIN has provided valuable context of the service then, and now.  The FIN Service Manager explained in March 2016 a decision was taken to audit cases that had been open to FIN for over 12 months. The audit was expected to show clear evidence of direct work with children and adults to address the needs that had already been identified. However some case audits showed a clear pattern of multiple visits (largely ‘welfare check-type visits’) but little evidence of direct work. There was limited evidence of any change in risk for the children, particularly in the cases involving the most complex and chaotic families.   It appeared that increasing the frequency of visits to a family had become the default option when FIN  were attempting to support a family in chaos or crisis, with some families receiving numerous visits, but this was not effecting real change.  After consultation across FIN the approach of increased welfare check visiting was discouraged. Instead all practitioners were tasked to reflect and consider “So what?” in every aspect of their work, the main focus being to ask themselves to consider what they could do to make the most difference for children at each contact. This immediately led to a reduction in welfare visits and an increase in productive and effective direct work with children and their families. The FIN Service Manager reported ‘So what?’ is now a commonly used phrase across the team and hoped this change helped to demonstrate ongoing improvement in practice across FIN in relation to achieving better outcomes for children and families.  The proactive approach to try to affect change in services for children is encouraging. Blackpool Safeguarding Children Board should request FIN undertake a further audit of complex cases and report findings to the Board. The audit should focus on cases open for over 9 months, as was the position in the family of BW, with particular scrutiny of frequency and reason for visits undertaken, and to explore specific outcomes for children as a result of FIN intervention.   In the Children’s Social Care interventions with the family there was limited evidence of the outcomes for the children being explored or scrutinised in any depth. The case was discussed regularly in supervision once the Siblings had been identified and categorised as Child In Need for three months. Unfortunately there was no recorded supervision in the early stages of Children’s Social Care involvement. This is the time when expected outcomes should have been explored, what the expected outcomes were specifically and what early progress was being made. Supervision is explored later. Multi-disciplinary conversations did take place during the Child in Need and Child Protection processes. However, the “So what?” question does not always appear to have been clearly answered, in that there is no obvious outcome or improvement for the children to demonstrate what difference a specific intervention or action had made.   On the Conference Outline Plan, which is a document with details of an Initial Child Protection or Child in Need Plan, there is a column with the heading “desired outcome”. In this case the Outline Child Protection Plan agreed in early Autumn 2014 includes some generic outcomes but these are brief and non- specific to the actual circumstances of unborn BW and the Siblings. Therefore professionals working with the plan may not have had complete clarity of exactly what was trying to be achieved and what difference this would make to the children. Furthermore the first core group notes and actions, from a week after the Child Protection Plan was instigated, has no reference or reminder to the desired outcomes as agreed on the plan.  Detailed plans were completed after the initial outline plans, and these do focus more clearly on what is expected to change for BW and the Siblings. However the circumstances for the family and the unfounded optimism that change would happen demonstrate that whatever the detail in records of outcomes and what difference these would make, in this case little or no positive change occurred.    12 BSCB Child BW SCR FINAL 02.02.2017  Finally a further gap regarding outcomes in this case was an agreed plan, or consequences, for professionals to put in place should outcomes not be achieved and no positive difference be identified. This would have helped to avoid drift in the case creating focus on the expected outcomes for the children.   Blackpool Safeguarding Children Board conducted a multi-agency ‘deep dive’ case audit in the Autumn of 2014 with a specific focus on neglect. A conclusion from the audit was despite high levels of agency involvement and resources being in place, there appeared to be no positive impact on the children. The BSCB should consider a further audit focussed simply on how expected outcomes are recorded on Children’s Services’ documentation particularly Child Protection Plans, to ensure detail is specific to an individual child and/or family’s circumstances and clearly highlights what difference is expected to be made, and what consequences are planned should no positive change occur.           2. Voice of the Child  BW at 3 months old did not yet have a voice but records demonstrate there was some focus on the child, once born, in terms of observation of BW’s presentation by professionals working with the family. As stated earlier how the child was dressed, positioned and attachment with Mother was noted.   Before BW was born but whilst the pregnancy was known to services there was only intermittent focus on BW as a child in their own right. The majority of case discussion and activity focussed on Sibling 1 and 2 and Mother, and this is evidenced by the lack of a pre-birth assessment of BW’s needs. Pre-birth protocols are examined later.   There were a number of occasions during the review period when the Siblings would speak about their concerns to a member of staff in school. Sibling 1 reported there was no heating in the home during the winter and that they (Sibling 1) had been sleeping in a “baby cot”. Sibling 1 was also concerned that their hygiene needs were not being met including not being able to clean teeth. Unfortunately despite these concerns being raised eventually Sibling 1 had five teeth removed as a result of tooth decay. Records at school evidence that Sibling 1 and 2 were listened to by members of staff and this resulted in the concerns being raised more formally by the school, jointly with Health professionals.  However there was limited evidence that the voices of the siblings of BW were properly listened to by all professionals, or that they were given every opportunity for their wishes and feelings to be fully heard. The poor, and at times shocking, state of the property where the family lived resulted in some professionals focussing more attention on Mother in trying to find ways to support her to improve the home. If such efforts had been effective, and conditions had got better, the outcome for Siblings 1 and 2, and subsequently BW, would have been positive. Unfortunately, despite the best efforts of professionals, who made numerous daily visits and revisits to the home, improvement was minimal. Therefore what could be described as the ‘indirect focus on the children via their Mother’ was of no benefit to them.  It is positive that the bedroom where Sibling 1 and 2 slept was examined by those involved on a number of occasions, what they wore was noted and professionals obviously attempted to build a rapport with the children. Unfortunately acknowledging the presence of children and noting how they are dressed does not equate to giving them a real opportunity, and safe space, to share what their life is really like.    Messages from children on their experience of the child protection system were submitted to the Munro review. Children voiced the importance of being heard separately from their parents and being listened to…. They made a plea for better information, honesty and emotional support throughout the process: The Munro Review of Child Protection: Final Report: A Child Centred System, May 2011, Chapter 2.9.  Professionals visiting families known or suspected to be living in neglectful environments should ensure children are regularly spoken to alone, and for this to occur away from the home setting when practicable. It is known that the Siblings were occasionally spoken to by the Social Worker within school, but what was discussed and how this information was used is not clear. Interventions with children in a safe, neutral environment will enable them to speak of their lived experience and more importantly how they feel, which can inform assessments and service provision.  13 BSCB Child BW SCR FINAL 02.02.2017  From early Autumn 2014 Sibling 1 and 2, and the unborn BW were all made subject to Child Protection Plans. The children did contribute to the Social Worker’s report to Conference by completing the standard children’s questionnaires which is the norm for the Blackpool area. The Siblings did not attend the conference and this is acceptable due to their young age. Their contribution to the process was therefore very brief and it is not clear, for example, what their thoughts were on Mother having another child and how this might affect their daily lives.  Once the Child Protection Plans were in place the Siblings were seen by the Social Worker on statutory visits, but it is unclear if they were seen alone and for how long, or what type of intervention took place with them other than observation. The experiences of the Siblings, if explored in depth throughout the whole Children’s Social Care involvement, would have provided valuable insight into both the pre-birth experience of BW and how life was for the family once BW was born. It is known from Education professionals attending the learning event, and from records, that the Siblings were capable of sharing some information about their lives and home conditions.  Blackpool Safeguarding Children Board reported it is standard practice in all case audits to examine whether the voice of the child was evident. This was part of the neglect case audit which took place in late 2014, see above. BSCB may wish to consider undertaking a specific audit regarding focus on all children, including unborns, and what this actually involves for the child being heard. Such an audit would be in in addition to child focus being an area considered in all multi agency audits as happens now.   3. Pre-birth protocols  Research and experience indicate that very young babies are extremely vulnerable. According to The Triennial Analysis of Serious Case Reviews 2011 to 2014, Pathways to Harm, Pathways to Protection the largest proportion of cases leading to serious case reviews related to children who were aged under one year. 120 of the 293 children (41%) were aged under one year at the time of their death, or incident of serious harm; and nearly half of these babies (43%) were under three months. “The high number of serious case reviews conducted with regard to babies under one year of age reflects the intrinsic vulnerability of the youngest babies who are dependent on their parents for care and survival”. Work carried out in the antenatal period to assess risk and to plan intervention will help to minimise harm.  A Multi-Agency Pre-birth Protocol exists in the Pan Lancashire Safeguarding Children Procedures, October 2012. The protocol is to ensure that a clear system is in place to develop robust plans addressing the need for early support and services and to identify any risks to unborn children.  A pre-birth assessment for BW was not considered or undertaken but several concerns relating to the Mother and Father of unborn BW and their parenting capacity indicate that, according to the Protocol, an assessment of identified risk factors should have taken place.  It is obvious that considerable multi-disciplinary involvement was taking place with unborn BW’s immediate family and that statutory child protection processes were ongoing. A birth plan was developed by the Social Worker which included conditions regarding Father’s presence at hospital and contact after BW’s birth. This was discussed in supervision. However the lack of completion of a pre-birth assessment for BW meant that the risks to BW were not considered exclusively even though a number of concerns were known.   Although it is widely accepted that BW, whilst unborn, was placed on a Child Protection Plan in early Autumn at the same time as the Siblings, there is no formal record of this, as the outline plan names the Siblings only. Subsequent records relating to the Child Protection Plan, including the Review Conference continue to exclude unborn BW as a subject in their own right.   This may be a recording error or oversight as BW is certainly mentioned and considered in the body of documents relating to the Child Protection Plans for the Siblings. However if a pre-birth assessment had 14 BSCB Child BW SCR FINAL 02.02.2017  taken place this may have resulted in a continued focus on unborn BW’s own needs rather than these being added to, and possibly being overtaken by the needs of the Siblings and Mother. The Reviewer raised an additional concern that if BW was not recorded individually on some Child Protection Plan documentation would BW have been traced on any records search or management information data collection, and have been formally identified, and counted, as a child on a Child Protection Plan, whether unborn or not.   Blackpool Safeguarding Children Board should audit pre-birth child protection processes, including the effectiveness of assessments completed, to ensure that when siblings are on a child protection plan the needs of an unborn baby in the family are considered separately, and the impact of the new baby on the mother’s/care giver’s ability to meet the needs of the other children is understood.   The Multi-Agency Pre-birth Protocol in the Pan Lancashire Safeguarding Children Procedures should be reviewed by the relevant sub group with oversight of the Pan Lancashire Procedures. The version available for use currently states due for review in 2014, but this review has not yet been completed. Once reviewed and re-issued the new Protocol should be promoted and highlighted to all relevant professionals.   4. Embedding new processes  Working Together 2015 is very clear that local agencies should work closely to provide early help assessment and effective services for children who may benefit from them. Blackpool’s strategy of support for children and families is called the “Getting it Right” (GIR) framework, as mentioned earlier. The strategy is designed to assist everyone who works with children and families in Blackpool in their work, and to ensure families get the right support at the right time. The key principle is to offer help to children and families who need it at the earliest possible stage.   GIR processes were launched in Blackpool in October 2013. This was a few months prior to the GIR assessment which commenced as a result of school and Health Level 3 concerns for Siblings 1 and 2. When the concerns were first raised Mother was not yet pregnant with BW. Professionals at the learning event who were involved in the initial GIR assessment spoke of confusion at that time regarding the new process, including completion of required GIR documentation. There was acceptance that training had been provided regarding the GIR framework but using the new process was described as challenging and time consuming. It was fortunate that the professionals persevered with the process and eventually the case was allocated in FIN.   Blackpool Safeguarding Children Board reported that there was a considerable amount of support available for the launch of the new GIR process including practitioner training and a GIR champions’ network established for help in individual agencies. Literature including leaflets was and still is available across the partnership.  The experience of professionals in using new systems and processes should not be ignored. Introducing and embedding new frameworks, processes and assessment tools, across a workforce takes time, see management of neglect section above. For implementation to be a success key messages for the new system need to be widespread and consistent, with support available when difficulties arise. Despite all the best efforts of Blackpool Safeguarding Children Board and Blackpool Council regarding the smooth introduction of GIR, experienced members of staff struggled with its implementation.      The Triennial Analysis of Serious Case Reviews 2011 to 2014, Pathways to Harm, Pathways to Protection:  Final Report May 2016, Peter Sidebotham, Marian Brandon et al, 8.3.2 explored the lack of clarity of processes concluding that “professionals’ familiarity and comfort using processes is integral to their effectiveness”.  Whilst no recommendation is made regarding the testing of GIR’s continued implementation and use across Blackpool, the Safeguarding Children Board and the Early Help Steering Group should note the 15 BSCB Child BW SCR FINAL 02.02.2017  views and experience of practitioners in this case, and the learning from the Triennial Analysis of Serious Case Reviews (above), to inform plans for successful implementation of new processes and pathways.     5. Safe sleep support   Due to the circumstances of how BW was found immediately prior to being taken to hospital safe sleep processes have been scrutinised by the Panel and by professionals at the learning event. Safe sleep materials are shared by the three Pan-Lancashire Local Safeguarding Children Boards and were re-launched in late August 2015. The Pan-Lancashire Child Death Overview Panel commissioned the Lullaby Trust to facilitate training to raise awareness of the need to promote safe sleeping arrangements for infants and toddlers. The multi-agency training has been ongoing and is complimented by local safe sleeping awareness campaigns.  It is clear that Health professionals involved with the Mother of BW provided appropriate safe sleep advice and guidance to Mother both pre and post-natally. The Pan-Lancashire Safer Sleeping Guidance for Children, updated July 2015, gives clear information to the multi-disciplinary workforce who have contact with parents and carers of babies, “to discuss baby sleeping arrangements, in order to support parents to make informed choices regarding safer sleep”. Within Lancashire it is recommended that the safest place for a baby to sleep is in a cot in a room with the baby's carer for the first six months, and this refers to any time the baby is asleep, during the day or night. The guidance includes information on car seats, pushchairs, and other baby sleep and carrying devices where babies should not spend longer than is necessary.   Mother did confirm that she received safe sleep advice from the Midwife, as well as other advice for new babies, but it is not known what she had retained regarding the safe sleep information that was given. Professionals visiting the home had recorded that BW had been seen on the sofa and in the baby swing chair. It is not clear how much challenge was made around this observation. There were also two occasions, as mentioned earlier when BW was found to be too warm and the baby’s coat and blanket was required to be removed.  Sadly on the morning of the death BW was found to have been sleeping overnight in a baby swing chair, not a cot or moses basket. There is no evidence in this specific case that the sleeping position and equipment used contributed to the death but the safe sleep advice provided consistently by professionals to Mother of BW was not being followed.  In a serious case review in the local area in 2015, BSCB Case BV, a recommendation was made that BSCB should explore the introduction of a safe sleep assessment process for all new babies in the Pan Lancashire area. The process is designed to promote more robust safe sleep practices in gathering as much information about a baby’s sleeping situation, including location and equipment available, in order that appropriate advice is given. There is additional scrutiny as part of the assessment in that the Health professional actually sees where the baby is sleeping in order to promote safer sleeping routines and give appropriate advice which is relevant to the circumstances of each family.   The timing of BW’s death was prior to the recommendation regarding the introduction of the safe sleep assessment being agreed, which means Mother of BW would not have been subject to the new assessment. Furthermore the provision of safe sleep support and an assessment of parents and carers will only result in positive outcomes for babies and infants if those responsible for settling them to sleep remember and act on the advice provided.     It is evident that safe sleep information for parents was, and is still being provided consistently in the area, and the issue is whether parents and carers choose to act on the information and support. BSCB should request the current position in terms of progress of the recommendation from the serious case review BV, including data of how many assessments have been completed compared to numbers of local births, as the intended outcome was that use of the new assessment could assist in embedding safe sleep 16 BSCB Child BW SCR FINAL 02.02.2017  messages in families.  Professionals at the learning event noted that colleagues other than Health professionals were also well placed to highlight and reinforce safe sleep messages due to the high frequency of contact with some families as in BW’s case. BSCB should continue to ensure that the safe sleep awareness materials through local initiatives such as the Safer Sleep for Baby Campaign are available, accessible and embedded across relevant partner agencies in order that consistent advice can be shared with families at every opportunity.    6. Non engagement  Records demonstrate that non engagement was a feature in this case with extensive efforts and resources required by many professionals to maintain contact with the children and Mother. Examples include the numerous visits undertake by FIN staff to gain access to the home, and after BW was born, the Midwife having to pursue Mother and BW to the Siblings’ school as all other attempts to see the new baby had failed.  However, there is also evidence of Mother’s attendance and participation at core groups and other multi-disciplinary meetings which would indicate some compliance with safeguarding processes. Disguised compliance involves parents giving the appearance of co-operating with agencies to avoid raising suspicions and allay concerns. Although there were many instances of professionals not gaining access to the home of BW and the Siblings, by complying on some occasions when visits took place and by attending formal safeguarding meetings Mother gave an impression of cooperating with agencies, therefore showing disguised compliance. This appears to have added to the optimistic view of Mother’s intention and capacity to change and thus to improve the lives of the children. Furthermore disguised compliance can lead to a focus on adults, in this case Mother, and their engagement with services, rather than on achieving safer outcomes for children.   Issues relating to engagement or lack of it, and disguised compliance, by parents and carers must be a standard area for discussion in supervision of professionals. For all professionals, disengagement, resistance and disguised compliance should be included as a key area of concern when assessing risk to a child, and therefore be included in supervision discussions about decisions and risk analysis. If issues of non- engagement and hostility in families are not brought to the attention of Managers or if Managers do not include engagement as a supervision agenda item, then the impact of non- engagement and subsequent risks will not be addressed. A learning point from a Serious Case Review January 2016 into the Death of Child A in Milton Keynes highlighted a similar theme that “supervision needs to be available and sought to help professionals challenge themselves, each other and family members when there are concerns about lack of engagement”. Supervision is discussed later in the report.  Professionals attending the learning event spoke generally about the challenges of dealing with non- engagement by families. In some Local Safeguarding Children Boards multi agency training programmes include specific training courses on dealing with hostile and uncooperative families. It was shared that BSCB do incorporate non engagement and resistance as a theme running through much of their safeguarding training. The Board should explore the development of training focussed on the issue of non- engagement and the impact on children, particularly in cases of chronic neglect, to better equip professionals to respond to such behaviour and the associated risks.  In BW’s case non engagement of Mother and gaining access to the family home was a routine problem for all those involved. In these cases particularly when Child Protection Plans are in place and there are known risks to an unborn child and/or young children the content of the Plan should include clear consequences for parents and carers should engagement remain an issue. Quick and robust action must be taken if improvements regarding access and contact with the children are not made.     17 BSCB Child BW SCR FINAL 02.02.2017   7. Concerns Resolution  At Panel meetings and at the learning event for this review the overall view of partnership working in the area is positive. Strong links are said to exist between agencies, there is some co-location of professionals and there are multi-disciplinary teams. Meaningful information sharing is said to take place. Professionals at the learning event held the view that much of this is due to longstanding working relationships and a small geographical area which assists in sound professional relationships being developed.  Even in areas where good working relationships exist, professionals across all safeguarding organisations must be aware of, and have the confidence to use, the local Resolving Professional Disagreements Guidance 8.1 Pan Lancashire Safeguarding Children Procedures 8.1 in conjunction with the Blackpool Children’s Services Concerns Resolution Protocol which covers all services that operate within Blackpool Children’s Services Department.   In this case there were apparent delays in the initial referral after the GIR assessment was actioned and records show professionals were proactively requesting updates on progress. The use of the Resolving Professional Disagreements Guidance was not required at this stage but there was no common knowledge amongst professionals at the learning event of the guidance should circumstances have developed differently. Managing expectations and differing viewpoints of professionals in complex cases such as BW and family is difficult. Raising awareness of the guidance to resolve disagreements will enable problem solving between professionals which is transparent and non-confrontational, and which retains a focus on the needs of the child.   As guidance is already in place in the local area the Blackpool Safeguarding Children Board should ensure, as a practice issue, that the Resolving Professional Disagreements Guidance is highlighted and re-promoted as necessary across all partner agencies.  8. Supervision and management oversight  In referring to reflective practice and the role of social workers and managers Lord Laming stated “supervision should be open and supportive, focusing on the quality of decisions, good risk analysis, and improving outcomes for children”, The Protection of Children in England: A Progress Report, March 2009 3.15.  In the Ofsted Inspection of Blackpool Services for Children in Need of Help and Protection, Children Looked After and Care Leavers, July 2014 inspectors highlighted that social workers did not consistently receive regular reflective supervision to support and challenge their practice. There is no record of supervision taking place for the first three months when the Siblings were categorised as Child in Need with social work involvement. This period was just prior to the Ofsted inspection.  Supervision of the Social Workers involved did take place regularly over the nine month period leading up to BW’s death.  There was consistent case management for that period of the serious case review timeframe with just two Social Worker/Manager partnerships involved. Recording of these supervision discussions was detailed. However the period of social care intervention where there was no recorded formal supervision is a missed opportunity for informed and specific management oversight, which is especially pertinent in the early stages of any case.   Furthermore as mentioned above there was limited focus throughout interventions on the needs of BW as an individual before BW was born. This was a similar position in case supervision where unborn BW was not a focus.  There was an element of optimism of Managers that Mother was capable of change without an assessment to evidence this was actually happening, but eventually legal advice was sought by the local 18 BSCB Child BW SCR FINAL 02.02.2017  authority in late 2014. This was as a result of supervision discussions. At one point a joint visit of the Social Worker accompanied by the Manager was discussed in supervision but there is no record of this taking place. Whilst accepted that Managers are supervising high numbers of staff and demands on time are challenging, joint visits to families and homes can provide an opportunity for supervision “on the ground”. Furthermore, joint visits can help with illustration of family circumstances particularly when neglect is suspected, to enable effective and joined up analysis of risk and to better effect change. The review panel was told that ‘live supervision’ when managers and workers are able to discuss cases whilst being operational is being considered within the authority.   The Service manager of Families in Need (FIN) reported that managers across FIN are trained in safeguarding supervision and provided reassurance that supervision of FIN staff is taken seriously and does regularly take place. FIN Managers should also consider undertaking joint visits with their staff where practicable and particularly in cases open to the service for longer than 9 months. Recording of FIN supervision is now on the same recording system as used by Children’s Social Care. Joint supervision between FIN and Children’s Social Care for cases with both departments’ involvement does not routinely take place, but resource panels attended by both FIN and Children’s Social Care regularly occur. The panels provide a good opportunity for progress, any challenges and forward plans in open cases to be discussed.  9. Involvement of fathers   A number of local and national reviews have highlighted the importance of professional communication with both parents even when they become estranged. In Blackpool the serious case review regarding Child BT (BSCB May 2015) considered this issue, and the NSPCC have produced a summary (March 2015) of the learning from national reviews with regard to “Hidden” Men (see below). In this case BW’s Father was not hidden but as he was required to have no contact with the Siblings, and BW once born, due to identified risks, this meant that some professionals did not see or involve him.   Father did attend some health appointments with Mother early in the pregnancy and in his brief contribution to the review he spoke warmly of the midwives who took time to ask him how he felt about becoming a parent.  On the other hand, Father said he felt excluded by some professionals, particularly towards the end of the pregnancy, and he was aggrieved by the perception, which he felt, professionals had formed of him.    Officers from the Probation Trust/ Community Rehabilitation Company were closely involved with Father throughout the timeframe of the review due to his offending and were proactive in sharing safeguarding information with others. Licence conditions for Father, after prison release for an unconnected matter in the Autumn of 2014, included non- contact with the Siblings and a condition of residence to live at an address other than with Mother. Records show contact issues and identified risks, including the impending birth of BW, were regularly discussed by Probation staff with other professionals. There is also some evidence that the concerns and rationale for restrictions were discussed with Father which shows transparency and involvement of fathers, even though Father disagreed with the professional judgements formed of him.   Learning from Case Reviews: Summary of Risk Factors and Learning for Improved Practice Around ‘Hidden’ Men - NSPCC March 2015 highlights that professionals do not always talk enough to other people involved in a child’s life, such as the mother’s estranged partner, or other extended family. This can result in important information being missed and sometimes failure to examine another perspective or realise inconsistencies in a mother’s account. In the Reviewer’s brief contact with Father, and through the contact subsequently with Mother and Grandmother differing viewpoints were shared about the family. Whereas this is normal particularly when relationships have ended, opportunities for involved professionals to gather as much information from significant adults must not be overlooked to build a more rounded picture of what life is said to be like for the children concerned.  The pre-birth plan for BW, which was agreed one month before the birth, shows a risk assessment was 19 BSCB Child BW SCR FINAL 02.02.2017  required for Father before his contact with BW could occur. Unfortunately the process was not completed due to Father’s lack of engagement with the assessment and then the death of BW. This meant the support which could have been provided to Father by professionals, and the window this could have given on the family from another perspective (Father’s) was never developed. Father was described as difficult and challenging to manage by a number of professionals particularly towards the end of the pregnancy. The Social Worker was subject of an aggressive episode by Father against her. Whilst aggression and threatening behaviour should not be tolerated, and the Social Worker rightly reported this to a Manager, there are many reasons why this type of behaviour may be displayed. A lack of rapport and feeling of not being listened to are just two reasons given by Father of BW as to why he failed to engage with services, which may reinforce the research regarding fathers above.  Siblings’ Father contributed to the review to provide some useful context, albeit he had no involvement with Child BW. He said his relationship with Mother ended soon after Sibling 2 was born and there was limited contact after that, and once Mother and Sibling 1 and 2 moved areas to Blackpool. Father did look after the Siblings overnight in the summer of 2014 whilst he was visiting Blackpool, which is when, as he recalls, for the first time he was informed of the Children’s Social Care involvement with the Siblings (his children). At this point they were categorised as Child in Need (see above) and Child in Need meetings had been taking place regularly throughout the spring/summer of 2014, which Mother attended. He recalls he was involved by services after that overnight stay and he was able to attend the Review Child Protection Conference for all the children, just before BW was born.  In Learning from Case Reviews: Summary of Risk Factors and Learning for Improved Practice Around ‘Hidden’ Men - NSPCC March 2015 it is noted that “failing to identify and/or engage with fathers ignores their fundamental importance in a child’s emotional and psychological development. When a vulnerable child’s needs are not being met by their mother, an estranged father may be able to provide the protection and stability that the child needs”. For BW’s Siblings there had been intermittent contact with their Father (Siblings’ Father), however this was not explored as an option on the occasions when the Siblings were required to spend time away from their home due to worsening conditions. Whilst accepted that the Siblings’ Father did not live locally there were concerns which developed over time regarding Grandmother’s home including sleeping arrangements and other environmental factors, but still the Grandmother was the first and only option considered. In contrast almost immediately after the death of BW the Siblings were returned to the Siblings’ Father’s care.   How fathers can be better engaged, and therefore also used as a source of information, whatever their current position is within a family, can be a challenge. Those involved need to remain professionally inquisitive with fathers, and to identify any additional support and guidance which may be required to get the best from them.   A recommendation was made regarding the death in Blackpool of Child BV (published by BSCB January 2016) to explore new opportunities of better engaging all expectant and new fathers and work is continuing to complete that action.     Practice issues  Practice issues were highlighted for individual organisations as a result of the learning review. These issues are not subject to separate recommendations as practice improvement is already in place, or relevant policy and procedures exist. The organisation’s own governance arrangements will need to monitor that issues continue to be resolved;   Lancashire Constabulary should continue to ensure that all frontline staff, officers or civilians, coming into contact with vulnerable children and adults are aware, and fully understand the requirements of the PVP process and the importance of sharing information about risk.  20 BSCB Child BW SCR FINAL 02.02.2017   Safe sleep awareness materials through the local Safer Sleep for Baby Campaign continue to be available and are embedded across relevant partner agencies in order that consistent advice can be shared with families at every opportunity.   Blackpool Safeguarding Children Board should ensure that the Resolving Professional Disagreements Guidance within the Pan-Lancashire Safeguarding Children Procedures is highlighted and re-promoted as necessary across all partner agencies.   Supervision for all safeguarding professionals must take place to the prescribed individual agency frequency and be recorded accordingly.    Good Practice Identified  Good practice was identified during the review, by the panel and by professionals at the learning event as follows:   Robust information sharing processes and the existence of good professional relationships locally between all partners were highlighted, including agencies where safeguarding is not seen as the core daily business such as within the Community Rehabilitation Company.   Conclusion  The outcomes for all three children in this family before the sad death of BW could have been improved more promptly. There was some lack of understanding around Mother’s parenting capacity and ability to change which resulted in prolonged inadequate parenting of the children. All professionals should have challenged Mother more consistently and effectively using prescribed thresholds for neglect whilst working to detailed and specific outcomes for BW and the Siblings.  However the findings of this serious case review do not indicate that inter-agency practice or the practice of any individual or organisation could have altered the outcome of this case. The death of Child BW, which was due to natural causes, could not have been predicted or prevented.   Within the review good practice was noted. Scrutiny of practice, however, always provides an opportunity to consider ways in which services may be improved and therefore the following recommendations, based on the learning from this case, have been made:  Recommendations In order to promote the learning from this case the review identified the following actions for Blackpool Safeguarding Children Board and its member agencies:  1. Blackpool Safeguarding Children Board should consider wider promotion and clarification for staff of the Graded Care Profile 2, and any other agreed neglect assessment tool for the multi- agency partnership, to ensure all staff are aware of its implementation and how to use it effectively. Intended outcome: Thresholds and criteria for neglect are consistently applied and understood by all professionals ensuring children living with neglect are identified and supported at the earliest opportunity.  2. Blackpool Safeguarding Children Board should lead an evaluation of the Hidden Harm-Toxic Trio training. The evaluation should focus on which professionals and agencies have attended, including which professionals from an Adult Safeguarding background as responding to Hidden Harm-Toxic Trio has been a common priority across both the Safeguarding Children and Adult Boards in 21 BSCB Child BW SCR FINAL 02.02.2017  Blackpool. What difference the training has made to the professionals who attended, regarding their approach to neglect and identification of risk factors since the training, should be examined.    Intended outcome: The current training programme is evaluated and as a result may be developed or amended as necessary to capture the findings of this serious case review. The evaluation should provide evidence of which relevant professionals are attending, from both Adult and Children Safeguarding backgrounds, and whether training has transferred into practice which will provide improved outcomes for children affected by neglect.  3. Blackpool Safeguarding Children Board should consider an audit focussed simply on how expected outcomes are recorded on Children’s Services’ documentation particularly Child Protection Plans, to ensure detail is specific to an individual child and/or family’s circumstances and clearly highlights what difference is expected to be made, and the consequences should positive change not occur.     Intended outcome: All professionals working with children subject to Child Protection Plans are clear about the specific outcomes and expectations for individual children, enabling focussed intervention on the needs of each child.   4. Blackpool Safeguarding Children Board should audit pre-birth child protection processes, including the effectiveness of assessments completed, to ensure that when siblings are on a child protection plan the needs of an unborn baby in the family are considered separately, and the impact of a new baby on the mother’s/care giver’s ability to meet the needs of the other children is understood. Intended outcome: Unborn children are afforded the focus and protection required when concerns have been identified either for the unborn child or any siblings.  5. The Multi-Agency Pre-birth Protocol in the Pan Lancashire Safeguarding Children Procedures should be reviewed by the relevant sub group with oversight of the Pan Lancashire Procedures.  Once reviewed and re-issued the new Protocol should be highlighted to all relevant professionals.  Intended outcome: The Multi-Agency Pre-birth Protocol is updated and its use promoted, to provide robust and up to date guidance to professionals involved in offering support and managing risk to unborn children, improving the focus on and protection of these vulnerable subjects.  6. Blackpool Safeguarding Children Board should request the current position of progress of the recommendation regarding safe sleep assessment from the serious case review BV. The progress report should include data of how many assessments have been completed compared to numbers of local births, as the intended outcome was that use of the new assessment could assist in embedding safe sleep messages in families. Intended outcome: The use of the safe sleep assessment is confirmed as being routinely used by professionals in order to assist in embedding safe sleep messages in families. If data suggests the assessment is not frequently used this position can be addressed. 7. Blackpool Safeguarding Children Board should explore the development of training focussed on the issue of non- engagement and disguised compliance, and the impact on children, particularly in cases of chronic neglect, to better equip professionals to respond to such behaviour and the associated risks. Intended outcome: Professionals are provided with an opportunity to improve their knowledge and practical skills in managing families where persistent non-engagement and disguised compliance is a concern, to ensure the issues are confronted, access to children and homes is increased, and meaningful engagement with families takes place.  References   Working Together to Safeguard Children H M Government March 2013 and 2015  Pan Lancashire Safeguarding Children Procedures  The Munro Review of Child Protection: Final Report: A Child Centred System, May 2011 22 BSCB Child BW SCR FINAL 02.02.2017   Triennial Analysis of Serious Case Reviews 2011 to 2014, Pathways to Harm, Pathways to Protection:  Final Report May 2016, Peter Sidebotham, Marian Brandon et al  Together on Poverty: Blackpool’s Child Poverty Framework 2012-2015  Testing the Reliability and Validity of the Graded Care Profile version 2. National Evaluation of the Graded Care Profile: NSPCC, Robyn Johnson, Emma Smith and Helen Fisher, NSPCC October 2015  Police effectiveness (HMIC) 2015 (Vulnerability): An inspection of Lancashire Constabulary, December 2011  Multi-Agency Pre-birth Protocol, Pan Lancashire Safeguarding Children Procedures, October 2012  Pan-Lancashire Safer Sleeping Guidance for Children, updated July 2015  Serious Case Review into the death of Child BV 2015 in Blackpool, BSCB  Serious Case Review into the death of Child A 2016 in Milton Keynes, MKSCB  Resolving Professional Disagreements Guidance, Pan Lancashire Safeguarding Children Procedures  Blackpool Children’s Services Concerns Resolution Protocol  The Protection of Children in England: A Progress Report, Lord Laming, March 2009  Ofsted Inspection of Blackpool Services for Children in Need of Help and Protection, Children Looked After and Care Leavers, July 2014  Serious Case Review into the death of Child BT 2015 in Blackpool, BSCB  Learning from Case Reviews: Summary of Risk Factors and Learning for Improved Practice Around ‘Hidden’ Men - NSPCC March 2015.                                23 BSCB Child BW SCR FINAL 02.02.2017  Statement by Reviewer REVIEWER  Amanda Clarke (Independent)  Statement of independence from the case Quality Assurance statement of qualification  I make the following statement that  prior to my involvement with this learning review:-    I have not been directly concerned with the child or family, or have given professional advice on the case.  I have had no immediate line management of the practitioner(s) involved.   I have the appropriate recognised qualifications, knowledge and experience and training to undertake the review.  The review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as set out in the Terms of Reference. Reviewer (Signature) Amanda Clarke  Date 20th December 2016  Second Reviewer (Signature) Kathy Webster  Date 5th January 2017  Chair of Review Panel   (Signature) Rob Wheatley                     Date 2nd February 2017                 