Non-accidental injuries to a six-month-old baby girl in August 2013 who was admitted to hospital a fractured femur and bruises. Mother became seriously ill following the birth and parents struggled to care for Baby O. History of: missed health appointments and poor home conditions. Baby O and her older sister were removed to the care of their paternal grandmother in May 2013. Grandmother already cared for two children under four years and struggled to look after the two siblings. Following her hospital admission in August 2013, Baby O and her sister became subject of care proceedings. Paternal grandmother was convicted of child cruelty and neglect in 2015. Mother died in 2014 from complex medical condition. Maternal history of: domestic violence; depression, non-engagement with services; and missing own health appointments. Father had history of anxiety and depression. There was a delay in the initiation and completion of the serious case review. Issues identified include: pattern of neglectful parenting not consistently monitored; threshold for Children's Services intervention was high; some positive examples of escalation but also failure to escalate and challenge inaction by Children's Services; lack of clarity about legal and safeguarding issues related to placement with grandmother; mother's vulnerability and health condition and father's involvement not sufficiently shared or considered. Uses a systems methodology. Recommendations include: implementation of Graded Care Profile (GCP) for interagency use in cases of neglect; regular multi-agency workshops; audit of Section 47 enquiries. Highlights some examples of good practice by professionals, in keeping the children as the central focus.
      
 Title:  Serious case review: Baby O: overview. LSCB: Sunderland Safeguarding Children Board Author: Amy Weir Date of publication: 2016  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1          Serious Case Review    Baby O (The SSCB has used a pseudonym to protect the identity of the child and family)         Publication Date:  6 September 2016           2  Contents  1.  Decision to hold a Serious Case Review  (SCR)       3  2. Serious Case Review approach         3  3. Scope and Terms of Reference         5  4. Child’s voice and the Family’s Perspective        5  5. The family as known to agencies         7  6. Areas of Significant Practice (ASP)         10  ASP 1:  Children’s Services: Response to Referrals from other Agencies ASP 2:  Managerial Oversight and Supervision - Timeliness of completion,                 endorsement and sharing of assessments ASP 3:  Lack of full consideration of history and the consideration of /    role of fathers ASP 4:  Context in which professionals were working ASP 5:  Failure to challenge and escalate concerns ASP 6:  Managerial Oversight and Supervision  7.   Agency learning and actions taken        13  8.   Findings           14 9.   Summary            18   10.   Recommendations           18  11.   Appendices  Appendix 1   The SCR Review Team including Reviewer biography   20 Appendix 2 Single Agency Learning       21 Appendix 3 How has the learning from this SCR improved practice?   25 Appendix 4 References         30 Appendix 5  Learning and Improvement Workshops – Impact    31    as described by staff attending     3  1 Decision to hold a Serious Case Review (SCR)  1.1 Baby O was born in February 2013. In August 2013, when she was 6 months old, she was taken to hospital where she was found to have bruising to her body and a transverse fracture of her left femur; these injuries were considered to be non-accidental and the Police and Children’s Services were informed.  1.2 The Case Review Sub-committee of Sunderland Safeguarding Children Board (SSCB) held a scoping meeting on 29th July 2014 and agreed that the circumstances surrounding the injuries to Baby O met the criteria for holding a Serious Case Review (SCR).1  The Independent Chair of SSCB endorsed the recommendation in August 2014.  The reason for the delay in the initiation and completion of this SCR is an issue, which is being addressed by SSCB. The SSCB was not notified for some time of the injury to Baby O or of the circumstances in which this occurred.  The completion of the review has been delayed by the significant volume of work in respect of other SCRs being undertaken by the Board. In addition, the review has had to wait on the conclusion of criminal proceedings in relation to Grandmother and which concluded in June 2015 and the inquest in respect of Mother.   1.3 Several other reviews relating to the death and injury of babies under the age of one year have occurred in Sunderland in recent years.  The SSCB Chair therefore directed that this review should not only consider the learning and recommendation from previous SCRs but also should build on the findings and recommendations from other recent reviews. A major focus for the Board is to identify any improvements in service delivery which will prevent future such injuries and deaths.   2 The approach we used  2.1 It was agreed that the review should be undertaken using a ‘systems methodology’, an approach that recognises that the actions and decisions of practitioners occur through a chain of events and the interaction of a number of factors, many of which are beyond the control of the individuals involved. This is the method recommended in Working Together 2013 and 2015.  2.2 This review therefore was undertaken using an approach that provides a theory and method for better understanding why good and poor practice occurs, so effective supports and solutions can be more easily identified.  2.3 Senior managers from key agencies who had worked with the family or were working with the family at the time of Baby O’s injuries were asked to join a Review Team which met on four occasions during the SCR process.                                                    1Regulation 5 of the Local Safeguarding Children Boards (SSCB) Regulations 2006 requires SSCBs to undertake reviews of serious cases in specified circumstances and to ‘advise the Authority and their Board partners on lessons to be learned’.   A SCR 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.’  4  2.4 Agencies represented on the Review Team were as follows:  Amy Weir  Lead Reviewer Jan Grey   Chair of SCR Panel/Second Reviewer  Lynne Thomas  SSCB Business Manager Head of Safeguarding  Sunderland CCG Lead Nurse Safeguarding  South Tyneside NHS Foundation Trust Education Safeguarding Team Manager Sunderland City Council SSCB Legal Representative  Sunderland City Council Acting Detective Inspector  Northumbria Police Named Nurse  City Hospitals Sunderland Head of Safeguarding  Sunderland People Directorate2  2.5 Each member of that team was asked to identify the frontline practitioners from their agency who were known to, or had worked with, the family of Baby O.  These practitioners met to discuss their experience of the case.   2.6 The Practitioner’s Group consisted of managers and practitioners who had been directly involved with the case.  2.7 The Lead Reviewer was commissioned to carry out this review in October 2014. Within the first few months of the review, the SCR process, the role of the Lead Reviewer and Review Chair and the functions of the Review Team and Practitioner Group were shared and clarified.    2.8 The methodology adopted for the review and the opportunity to be an integral part of a multi-agency review process was still fairly new to some of the professionals involved. Whilst some reservations were apparent at the outset of the review, there was general enthusiasm about the opportunity it afforded for identifying and understanding factors that influenced the nature and quality of their work with this and other families. It is clear from subsequent reporting that all those who participated did regard the opportunity to contribute more directly as beneficial; it provided them with good learning about their own part as well as that of others in the case.   2.9 In this review, there were no individual conversations with practitioners. However, two meetings were held jointly with the practitioners who had been involved. The notes from these conversations together with key documents were the key documents for consideration within the review.   2.10 Further information about the function of the SCR Review Team and the roles and responsibilities of key groups can be found in Appendix 1 and Appendix 2. Comments on the methodological limitations of the SCR model used are attached in Appendix 3.  2.11 The formatting designed by a colleague, Linda Richardson, for previous Sunderland SCB SCRs has been customised to report this review.                                                   2 Previously Children’s Services and remains the term used in this report. 5  3 Scope and Terms of Reference  3.1 Taking a systems approach encourages reviewers to begin with an open enquiry rather than a pre-determined set of questions from terms of reference. This helps the issues which arise to drive the key issues to be explored as opposed to the preconceptions of managers or a review team. Key lines of inquiry for this review quickly emerged around: • Quality and consistency of multi-agency working   • Management of concerns about neglect • Impact of organisational change – particularly in Children’s Services • Non-compliance, avoidance and lack of parental engagement • Mother’s neglect of her own health and failure to take medical advice • Involvement of Father and his relationship with Mother  3.2 There have been other parallel processes underway during the course of this review. Paternal Grandmother in whose care Baby O was at the time of the injuries was convicted of child cruelty/neglect in 2015.  3.3 The Local Authority instigated care proceedings in relation to Baby O and her sister. They have subsequently been the subject of care orders and plans have been made for them to live in a new family.  3.4 This review looks at events that took place between 1st April 2011 – following an initial assessment which led to Early Help intervention and 30th September 2013 concluding with Baby O’s serious injury.  4 Child’s Voice and The Family’s Perspective  The Child 4.1 Baby O was the second child of her Parents. Her Parents struggled to care for her during the three months she was living with them. Baby O’s early experience was difficult. Although they made an effort at times they were not providing consistent safe care. Her Mother became seriously ill a few weeks after Baby O’s birth and this affected her ability to care for her children not least because she required regular lifesaving medical treatment. In March 2013, Baby O’s Mother had to be admitted to hospital as an emergency and the children spent a brief period with their Paternal Grandmother.   4.2 Most of the child health appointments for Baby O were missed or cancelled by the family, her immunisations were not up to date and Baby O was living in poor home conditions for much of the time. After Baby O was left at home alone in May 2013, she and her elder Sister were removed to the care of their Paternal Grandmother.   4.3 The children were living with Paternal Grandmother from May to August 2013. Grandmother struggled to look after the children – not least because there were already two other grand-children under four years in the household for whom she was responsible 6  as a Special Guardian3. Grandmother seemed to have found Baby O particularly difficult. Baby O was described as crying all the time both day and night. The Health Visitor recorded that Baby O was not smiling and not happy or content.   4.4 In mid-August 2013, Baby O, aged 6 months, suffered a severe transverse fracture to her leg.  Paternal Grandmother was prosecuted in relation to this injury. At hospital, Baby O was also found to have bruising on her face, lower back and legs. Clearly, Baby O’s experience was stressful and difficult during these few months.  4.5 Baby O and her Sister moved to foster carers after this. When seen a month later by the Health Visitor, Baby O was described as flourishing, interactive and smiling and she was playing happily with her Sister.  With consistent, good care, Baby O was clearly settled and developing well. After her neglected early start and experience of physical abuse, Baby O’s experience has become more positive and her needs are being met.   The Family 4.6 Mother seems to have had a series of difficult experiences in her life, including being subjected to domestic violence and suffering depression. Her own Mother died in 2009 but she kept in contact with her Father. Her relationship with Baby O’s Father included a period of separation for over a year when he asked her to leave their home.    4.7 Mother did not engage with much of the professional help and support which was offered to her for the children.  She smoked throughout her pregnancies.   She was largely unsupported and her care of the children was inconsistent and did not meet their needs fully.  4.8 A few months after Baby O’s birth, Mother had two black eyes which she explained away as having been caused by the baby.   After Baby O’s birth, Mother was diagnosed with a life threatening health issue which undoubtedly affected her capacity to look after the children.  She did not always accept treatment and missed essential medical treatment and several other appointments.   4.9 In September 2013, she was rushed to hospital with very serious injuries which required emergency surgery. She denied that these had been inflicted on her and she and her partner advised that she had fallen down the stairs. A medical expert reported shortly after her death that the injuries were not compatible with the explanation given and were more likely to have been as a result of a serious assault. Her condition remained serious and she continued not to follow medical advice consistently or accept the treatment which she needed. After further complications arising from her medical condition Mother died in 2014 eight months later.  The subsequent Inquest found nothing untoward.  4.10 She appears not to have been able to confide in professionals and is likely to have been isolated. Mother had some contact with family in London but remained in Sunderland. When Baby O’s Sister was born, Mother initially responded to the support provided by                                                  3 A special guardianship order is an order appointing one or more individuals to be a child's 'special guardian'. It is a private law order made under the Children Act 1989 and is intended for those children who cannot live with their birth parents and who would benefit from a legally secure placement. 7  professionals. However, after her separation from the Father, mother became increasingly difficult to engage which resulted in the children not receiving the health care they needed. Professionals sought to gain her confidence and to provide her with support but she avoided health appointments and did not fully engage with professionals. When spoken to she seemed to be coherent, cooperative and stated she was coping – even when she was really ill.  4.11 Unfortunately, it has not been possible to speak to Mother for this Serious Case Review.   4.12 Father saw his GP regularly and is known to have experienced anxiety and depression following the death of a close family member.  He received medical support during this time.   4.13 Father attended the antenatal booking appointment for Victoria but not for Baby O. He had very little contact with the professionals who were involved with Baby O.   Father and Mother both took Victoria to nursery school and he was involved to some degree with the care of the children.   4.14 It is difficult to understand what Father’s views and experience are from the records as he was not seen very often. Father has declined to be part of this review and without his involvement it has been difficult to understand the wider picture.  There are many aspects of what was happening within the family which remain unclear.   4.15 Paternal Grandmother was increasingly involved with the family after the birth of Baby O and after Mother became so ill. There was a brief period of her caring for the children and then the longer period from May to August 2013.    4.16 The basic care provided to the children by Paternal Grandmother was good but it is clear – as Grandmother indicated to some professionals – that she struggled to cope with looking after four children under four years. There were two other grandchildren under five years also living in the household. If more effective, accurate background checks had been completed, the children may not have been placed with her. She was convicted of child cruelty/neglect in June 2015. Paternal Grandmother has also not been part of this review.  5 The Family as known to Agencies  5.1 The Family4   Mother - LO     24 years  (died in 2014)    Father - MO                25 years      Sibling - Victoria   6 years          Paternal Grandmother 44 years     Baby O      2 years                                                   4Names and some family details have been changed to preserve anonymity. The ages given are the ages at the time of Baby O’s injuries.  8  The SCR covers the period 1st April 2011 to 30th September 2013.   April 2011 to Birth of Baby O in February 2013  5.2 LO and MO appear to have been in a relationship since 2008. Early in their relationship LO had a miscarriage at 20 weeks – both she and MO were clearly distressed about this. In 2009, they had Victoria and initially managed well with her care.  5.3 Victoria missed her nine-month development check and her immunisations. At the beginning of 2011, the Health Visitor was having difficulty in seeing Victoria and there was a concern that she had some developmental delay; there were fifteen missed appointments. When Victoria was seen, the house was damp and smelt of smoke; Victoria had nappy rash and was not able to walk unaided. A referral was made to Children’s Services in March 2011, which resulted in an initial assessment being completed by a Social Worker and a CAF5 was recommended.   5.4 Father decided that the couple should separate and LO left with the baby in April 2011.  Mother and Victoria were found temporary housing LO was rehoused in May 2011. The Health Visitor made a referral to the Paediatrician as there were some concerns about Victoria’s development. A Family Support Worker started working with the family and a CAF was completed. Several Team around the Child/Family meetings were held from May to December 2011. Despite efforts to engage LO she did not respond and missed many appointments. The Paediatrician saw Victoria in Summer 2011 when she found her to be developmentally delayed and under-stimulated; Victoria was also not registered with a GP.  5.5 LO was now in a new home but there were no carpets and there was a great deal of rubbish around. Due to concerns around the home conditions, Victoria’s development and Mother not working with the plan, the Health Visitor made another referral to Children’s Services in November 2011. An Initial Assessment was completed with some delay because of difficulties in seeing Mother and Victoria. In early January 2012, the Health Visitor raised more concerns and it was agreed this should be a Child in Need6 (CIN) case.  The case was not allocated till February and a multi-agency CIN meeting took place in March 2012. The Social Worker was then off sick and limited work was done. The Health Visitor was unable to get access to the family until May 2012 when Mother said she was thinking of getting back together with Father.   5.6 There was no CIN meeting as planned in August 2012. Victoria was not taken to  a speech and language appointment. A new Social Worker was allocated in September 2012. By this point, LO and MO were reconciled, but living apart and LO was 20 weeks pregnant with Baby O. The Social Worker visited in October 2012 and the Health Visitor saw some improvement in November 2012 although Mother had missed a Midwife appointment.                                                   5 The Common Assessment Framework (CAF) is a process for gathering and recording information about a child for whom a practitioner has concerns in a standard format, identifying the needs of the child and how the needs can be met. 6 A child in need is defined under the Children Act 1989 as a child who is unlikely to reach. or maintain a satisfactory level of health or development, or their health or development. will be significantly impaired, without the provision of services, or the child is disabled. 9  5.7 In January 2013, the family moved and LO and MO were living together again.  Baby O was born in February 2013.  Birth of Baby O in February 2013 to 30th September 2013.   5.8 Both the Midwives and the Health Visitor struggled to get access to Mother and Baby O. In mid-March 2013, LO was rushed to hospital in a serious condition. The Health Visitor was very concerned about the family and made a referral to Children’s Services. Paternal Grandmother then looked after the children until early April.  5.9 During April 2013, the family continued to miss appointments. The Health Visitor made a further referral to Children’s Services. Towards the end of April, the school for Victoria reported that Mother, had black eyes. The Social Worker visited and accepted Mother’s explanation that this injury had been caused by the baby flipping her head forward; no examination of the baby was undertaken and this explanation was not sufficiently challenged.  5.10 At the beginning of May 2013 the Health Visitor asked for a Strategy Meeting; and this was held two days later. It was agreed that a Section 47 child protection enquiry should be undertaken with a view to holding an Initial Child Protection Conference.  Victoria’s school became concerned that both Parents were bringing Victoria to school but without Baby O. They contacted Children’s Services. In late May, an unannounced social work visit was carried out and when entry could not be achieved, the Police were called. Baby O was found at home alone strapped in her buggy. Police Protection was taken and the Parents were arrested and cautioned.   5.11 The Parents agreed to Section 20 Accommodation and to the children going to stay with Paternal Grandmother. Thereafter the legal status of the children was unclear. In June, a Placement Panel 7  did not agree to an assessment being undertaken of Paternal Grandmother as a connected person and deferred making a decision. This left the practitioners and their manager in an unclear position. The LAC Review8 which had been organised was cancelled because it was now being said that the children were not in care. Between May and August 2013, this remained the position. A few days before Baby O’s injury a Social Worker visited Grandmother and it was agreed the children would stay there until October and Paternal Grandmother would continue to be paid for caring for them through Section 179 money.  5.12 From the first week the children were placed, Paternal Grandmother repeatedly told health professionals and the school that she could not cope with caring for four children. Health professionals and the school informed Children’s Services. Social Workers were not visiting regularly but there were telephone calls with Paternal Grandmother when she said she                                                  7 It is the responsibility of Placement Panels to make timely decisions about the contracting and finance of the placements of children and young people who need to become looked after, and once they are looked after, at key transition stages. 8 A looked-after child (LAC) review is a regular meeting to review the child’s care plan. 9 Children's Services use Section 17 (Children Act 1989) money in order to provide urgent assistance to families, where the child is deemed to be a Child in Need.  10  could cope. There is evidence from Paternal Grandmother stating that she struggled to care for Baby O.  5.13 In August 2013, Paternal Grandmother called the Ambulance Service on 111 saying that Baby O had a floppy leg. She was taken to hospital where a severe transverse fracture and multiple bruising on her body were found. Grandmother denied causing these injuries but she was convicted in May 2015 of child cruelty and neglect as a result of these injuries.   5.14 Baby O and her Sister plus the two other grandchildren living there were taken into care and moved to foster carers. Within weeks Baby O was settled and doing well.   5.15 In September 2013, LO was admitted to hospital with multiple serious injuries. She and her Partner stated that she had fallen down the stairs and denied any violence. She never fully recovered from her condition and failed to accept medical advice or take up the treatment recommended. She died in 2014 from her complex serious medical condition.  6 Areas of Significant Practice (ASP)   6.1 This section looks back at the actions and decisions of professionals working with Baby O’s family and explores why these professionals acted as they did.  The ‘why’ questions are important as they helped the Review Team understand what systems were in place at that time to promote good practice and what should have been happening. In this case, there are several examples of shortcomings and gaps in practice. A key factor of a systems review is also to consider whether any system vulnerabilities are still present and how these can be changed.    6.2 From studying key documents and listening to the views and experiences of front line practitioners involved in this SCR process, the Review Team identified five areas of significant practice. These are listed below and are explained in more detail in later section  • ASP 1: The pattern of neglectful parenting was not tracked or consistently monitored. • ASP 2: The threshold for Children’s Services intervention was high and, when there was intervention, the practice with the family lacked effective reflection and management oversight. • ASP 3: Context in which professionals were working – There was a failure to escalate and challenge effectively inaction by Children’s Services: Multi-agency working and communication did not effectively protect Baby O.  • ASP 4: Children’s Services response from May 2013 to August 2013 was not clear and incoherent and left Baby O and her Sister unprotected.  • ASP 5: Mother’s vulnerability and life-threatening chronic ill-health and Father’s involvement was not sufficiently shared or considered in relation to her capacity to care for her children.    11   6.3 ASP 1: The pattern of neglectful parenting was not tracked or consistently monitored  Baby O’s Parents clearly wanted their children but they struggled to provide consistent physical and emotional care to their children. This manifested itself in their avoidance of interactions with health professionals and others and the failure to ensure that Victoria, in particular, attended the health appointments which had been made for her. Even when action was promised, it did not follow and Victoria’s development suffered as a result. Baby O was left alone at home though it is clear that both Father and Mother knew that this was not appropriate.   6.3.1  At times the Parents were more cooperative and there were slight improvements. This partial compliance made it more difficult to see the whole pattern. There was no tool in place to help all practitioners track and monitor the patterns of behaviour and actions over time and the impact of what occurred on the children.   6.3.2  Brandon et al10 consider the importance of analysing rather than simply identifying what is known about a family’s history and warns without such an analysis there is a risk of falling into the trap of what is referred to as the ‘start again syndrome’.   6.3.3  Each time there was a difficulty or relapse this was seen as something additional by Children’s Services rather than as a pattern. As the Health Visitor did not have a tool to record the pattern it was not easy to evidence what had been happening over years and months. There is evidence that each report/referral to Children’s Services was seen in isolation from past concerns.  6.4 ASP 2: The threshold for Children’s Services intervention was very high and, when there was intervention, the practice with the family lacked effective reflection and management oversight.  As has been identified in previous SCRs, practitioners in the area were clearly working under a great deal of pressure, both in respect of competing demands for time, and the fact that thresholds for intervention were high. This pressure was particularly felt in Children’s Services. The practitioners and managers involved in this review process spoke about the impact of both, commenting that high caseloads could easily encourage professionals to focus more on their own individual responsibilities because multi-agency working can appear to take more time and maintenance.   6.4.1  When concerns first arose in 2011 about the parenting being provided to Victoria, Baby O’s Sister, it was suggested that early help and referral to the family support service with a CAF and regular meetings should be put in place. This was a reasonable response given that Mother appeared to be willing to cooperate and that she seemed to have the capacity to understand the gaps in her parenting. Unfortunately, she did not genuinely cooperate and there was no marked improvement.                                                  10  Understanding Serious Case Reviews and their Impact – A biennial Analysis of Serious Case Reviews 2005-2007. 12  6.4.2  The second referral to Children’s Services in November 2011 eventually resulted in a Child in Need response but only after the Health Visitor continued to chase concerns. Initially, it seemed that the case might be closed. There was delay partly caused by Mother but also because of staff shortages in Children’s Services. Practitioners, who contributed to this review and especially colleagues in health settings, shared this view and concerns about thresholds. It appears that the neglect concerns especially about the failed uptake of health checks may not have been seen as such an urgent concern by Children’s Services.  6.5 ASP 3: Context in which professionals were working - There was a failure to escalate and challenge effectively inaction by Children’s Services: Multi-agency working and communication did not effectively protect Baby O.   There were many positive examples of escalation in this case. For example the Health Visitor requested a Strategy Meeting in May 2013. However, there were long periods of inaction and delay without sufficient challenge from partner agencies.   When Baby O’s Mother became acutely ill in 2013, there was some communication with the GP about her condition but not all of the professionals involved seemed aware of the need to consider and support her parenting and to safeguard the children.   6.6 ASP 4: Children’s Services response from May 2013 to August 2013 was not clear and incoherent and left Baby O and her Sister unprotected.  After the decision was made in May 2013 to follow up the Police Protection by placing Baby O and her Sister with Paternal Grandmother, there was a lack of clarity about the legal underpinning of this arrangement. There was no formal plan in place for the children to ensure that they were formally safeguarded.   Although a strategy meeting had been held in May 2013 and a Section 47 enquiry commenced with a view to holding an Initial Child Protection Conference (ICPC)11, there is no further mention of this after the children left their parents’ care.   6.6.1  Several professionals including the Social Worker and his Manager assumed that the children were accommodated under Section 20 Children Act 1989 and placed with Paternal Grandmother as a Connected Person12. However, at a Panel in June this was not confirmed and the decision to assess Grandmother was deferred. It was recorded that the children were not accommodated under Section 2013 and that the placement was being supported under Section 1714.                                                   11 Initial Child Protection Conferences are convened by Children’s Services following an enquiry under Section 47 of the Children Act 1989 which indicates that a decision has to be made about further action under the Safeguarding Children Procedures. 12 A Connected Person is defined as "A relative, friend or other person connected with a child”. 13 Under Section 20 of the Children Act 1989, children may be accommodated by the local authority if they have no parent or are lost or abandoned or where their parents are not able to provide them with suitable accommodation and agree to the child being accommodated. A child who is accommodated under Section 20 becomes a Looked after Child.  14 Under Section 17(1) of the Children Act 1989, local authorities have a general duty to safeguard and promote the welfare of children within their area who are In Need; and so far as is consistent with that duty, to promote the 13  6.6.2  The Section 47 enquiry was not completed and no risk or parenting assessment was carried out in relation to the placement with Grandparents – even though four children under four years were placed there. After the Panel in June, no action was taken for some time.   6.6.3  Although Grandmother’s complaints to other professionals about her stress in caring for the children were passed on to Children’s Services, the ‘placement’ continued and no risk assessment was completed. When Grandmother stated that she had had no financial assistance, a Section 17 payment was made to her in July. It does not appear that the children were visited regularly in the placement by the Social Worker.   Just a few days before the injury to Baby O, a Social Worker visited and apparently asked Grandmother to keep the children until October 2013.  6.7 ASP 5: Mother’s vulnerability and life-threatening chronic ill-health and Father’s involvement was not sufficiently shared or considered in relation to her capacity to care for her children.   When Mother’s health deteriorated during 2013, she was under hospital care but neither her GP nor her Consultant seemed to have communicated with Children’s Services or other health colleagues about the support she needed or the impact on her ability to look after her children.  Her non-compliance with medical advice and non-acceptance of required treatment put her own life at risk and prevented her recovering sufficiently to be able to care for the children.                                                            Throughout the history of this case, Father’s involvement was not fully considered and he was rarely seen or sought out.   7 Agency learning and actions taken   7.1 All the agencies involved in this SCR worked with the practitioners involved from their service to produce a Single Agency Learning Report (see Appendix 2). The information contained in these reports highlights that the individuals who contributed to the process either as a member of the Review Team or the Practitioners Group were able to identify learning as well as a greater understanding of the circumstances of other professionals and agencies.  7.2  Not all of the reports identified in detail, how this learning would be transferred to wider practice within individual agencies. Where necessary, the Lead Reviewers have identified or clarified additional actions that should be undertaken and which should be monitored by SSCB.    7.3 The pathway for interventions in relation to services for Baby O was determined by a range of key points and decisions. The significant issues are identified below and are linked to previous case reviews in Sunderland.                                                                                                                                                                      upbringing of such children by their families, by providing a range and level of services appropriate to those children’s needs. 14   8  The Findings   8.1  The Review Team identified eight findings, which helped the team to understand why some practices happened in the way they did. Each of the findings is explained with a rationale, an indication of its impact on the wider systems in Sunderland and a series of questions designed to enable the Board to strengthen safeguarding by addressing the root causes underpinning the finding.  8.2  The findings fall into different typologies of systems issues, with a clear link between each of the findings and each of the typologies.  This is not unusual, as it would be expected to find links between findings when adopting a whole systems approach. There are five findings for the Board to consider, these are covered within:   Management of Systems 1. Managerial oversight and effective decision-making is central to supporting critical thinking, challenge and good assessments in multi-agency work and this was not evident in some of the practice in this review.  2. Few interagency meetings were held in this case and this led to a lack of clarity about what action was being taken to challenge the avoidant behaviour of the Parents and the level of care provided to the children.    3. The legal status of the children whilst in the care of their Grandparents was not resolved for many months and nor were they protected through a child protection plan.  Professional-Family interaction 4. In this case the co-operation of Parents was very variable and clouded the intervention. Generally the family did not comply with the plans made and therefore did not achieve the progress required to care safely for the children. 5. There was tendency for the focus to be on the adults rather than the children when Early Help and Children’s Services were involved with the family. This resulted in a lack of full appreciation of the impact of neglectful care on the children.   Multi-Agency work 6. There were some good examples of joint working and information sharing between the health professionals involved but there was a lack of robust multi-agency collaboration from Children’s Services.  The school acted promptly to identify that Baby O was being left at home alone. At the same time, when Children’s Services was involved with the family, the delay in action and lack of challenge to the Parents was too readily accepted by, and not sufficiently challenged by, other professionals.  Use of Tools   7. In this case, various assessment tools were used – the midwifery Adult Vulnerability tool, Initial Assessments in Children’s Services but these were not widely shared. A Core Assessment was not completed in a timely way even when a S47 enquiry was required in May 2013. This meant there was insufficient reflection and consideration.  15  8. There is no multi-agency tool for assessing and tracking neglect in place – such as the Graded Care Profile.  Finding 1 _________   _____              Management of cases of neglect  There was a lack of an effective system and collaborative working and a tool for tracking patterns of neglect over time. The pattern of neglectful parenting was not tracked or consistently monitored.  In this case there was evidence of managerial oversight and challenge in some key agencies with specialist safeguarding advice and support in some cases. However, within Children’s Services there were some delays and a gap in allocating and managing the case.   There was no multi-agency tool for identifying, tracking and monitoring neglectful care. This could also have served as an established means of establishing together whether the threshold for Children’s Services intervention had been reached.   There will always be competing priorities and limited resources will always impact on service delivery. It is therefore important for there to be shared ways of considering risks together and the required actions. Given that much of the neglect concern related to poor uptake of health care and no engagement with health professional, it was important for there to be a shared framework across agencies for assessing the issues and the risks for the children.    Finding 2                                                     There was a lack of robust multi-agency collaboration from Children’s Services.    There were some good examples of joint working and information sharing between the health professionals involved but there was a lack of robust multi-agency collaboration from Children’s Services.    As the case progressed beyond Early Help, there was insufficient multi-agency coordination and planning to address the needs of the children. Child in Need meeting and reviews were not held as required.  This left professionals unclear about what was happening and resulted in delay and a lack of intervention with the family and the need for other professionals to make contact with Children’s Services again and again.    There was a high turnover of staff in Children’s Services and significant organisational change within Children’s Services and, in this context, there was considerable difficulty for the local authority.    16   Finding 3            Fathers and Extended Family  Understanding the presence and role of males in families and the circumstances and history of the extended family is critical to understanding family functioning and assessing risk  How was this manifest in this review? SCRs have repeatedly highlighted failures by Social Workers to engage Fathers or significant males effectively in the family and this was clearly evident in this review.  In this case it was also important to understand Father’s extended family.  The professionals focused mainly on Mother which was clearly appropriate when she was separated from Father but not throughout. From the beginning of 2013, they were living together again but there is still limited information about him and any risks he may have posed. This was particularly crucial when Mother’s health deteriorated and he was necessarily providing more care to the children. This does not seem to have been considered at all even to look at whether he needed additional support to cope.  The involvement of Father’s family was not fully understood nor assessed. Paternal Grandmother was clearly very influential in this case. We know now that she made various comments to professionals about LO even before the children were placed with her in May 2013. There was insufficient scrutiny and risk assessment of her and her partner when the children were placed with her.  The Police check was inaccurate because the family did not provide full information. Significant information about her background and that of Step Grandfather was not seen or considered. Even when reservations about the placement were voiced, nothing was done to expedite the need to find alternative carers.   Finding 4                                                  Working with non-compliant Families – disguised compliance15  Working with this family was complex because Mother - despite her vulnerability – avoided professionals and consistently failed to take the children to health appointments or to attend to her own medical needs.  Occasionally, she would cooperate and appear to be willing to change.  Several SCRs and the Biennial Reviews have raised concern about ‘resistant’ families who do not change despite intervention. C4EO’s research described these resistant behaviours as follows:   • Ambivalence: not sure of need to change or when families are ‘stuck’ at a certain point • Denial/avoidance: not willing to acknowledge abuse and/or purposely avoid practitioners                                                  15 'Disguised compliance' involves 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. 17  • Unresponsiveness: no demonstrable improvements in a timely manner (despite compliance)  In addition, in this case, Mother’s own very low self-esteem and sense of worth appears to have led her to following self-destructive behaviours.  Finding 5                          System failure to plan for and protect Baby O and her Sister.  Planning for Baby O (and her Sister) May to August 2013 was flawed and drifted leaving the children insufficiently safeguarded.   The legal status of the children was not resolved when they were placed with Paternal Grandmother. In the circumstances in which the children were removed and placed by Children’s Services, a Regulation 24 Assessment16 and management authorisation was not completed.   Not all the checks required were successfully completed - the Police check was not accurate because Grandmother did not disclose all her names - and a Connected Persons’ Assessment was not completed. It is possible that they were seeking to mislead with giving incorrect information because they knew that information of concern would have been found.   The Section 47 enquiry was not completed and an Initial Child Protection Conference was not held. There was no formal interagency plan in place. There were care proceedings under way but this did not provide an interagency framework for protecting and planning for the children.   The Practitioners involved in the Review felt that they had not been provided with the right legal advice or training about Regulation 24 placements.                                                      16 Regulation 24 of the Care Planning, Placement and Review (England) Regulations 2010, which became effective from 1 April 2011, sets out the process for placing Looked After Children with relatives or friends or (Connected Persons) where the carers are not already approved as foster carers. 18   9.  Summary   The serious injuries suffered by Baby O could have been prevented if there had been more rigorous and timely planning for both Baby O and her Sister, Victoria, and, if the warnings given by other professionals had been heeded.   The placement of Baby O and her Sister with Paternal Grandmother was not thoroughly considered by Children’s Services. Errors were made by the local child protection system in this case in checking out the Grandparents’ backgrounds. It appears that Grandmother was providing some misleading information. The legal basis of this ‘placement’ and the decision-making were not clear. The continuing need to have in place a plan to safeguard the children was not managed with neither Child Protection or Looked after Children plans being in place to ensure regular monitoring and visits.  Although Care Proceedings had been initiated, a clear plan with timescales for the children was not in place with the sole initial consideration being that of rehabilitation to Father and Mother.  Even when several agencies told Children’s Services that Paternal Grandmother said on many occasions that she was not coping with looking after four under four year olds, this was questioned and separate conversations were held with Grandmother. There was no assessment of the needs of all four children.   The crisis which led to Baby O suffering such a serious injury as well as other distress was predictable given the strong indications given repeatedly by other professionals of concern about emotional wellbeing.  However, it could not be predicted that the crisis would result in Baby O having such a serious injury.   There is a great deal of useful learning from this Review for all the agencies to consider and to absorb. There are some areas for improving practice but there was also some good and focused practice by professionals – particularly the Health Visitors – keeping the children as the central focus. Cases of neglect and parents whose compliance and co-operation are unreliable pose particular challenges to multi-agency working and systemic joint approach needs to be set up to overcome the difficulties identified in this case.      10. Recommendations   These recommendations are provided to the SSCB to consider. They have emerged from the findings of this Review as areas for continuing and further focus.  10.1 SSCB to implement the Graded Care Profile (GCP) for interagency use in cases of neglect. This should be completed urgently within the next 6 months. The GCP has recently been positively evaluated by the NSPCC. A workshop with external facilitation should be held within 3 months to discuss and plan.  19  10.2 As in the Baby P SCR, SSCB to promote effective joint working through designing and developing regular multi-agency workshops and other opportunities for front-line practitioners and managers to share issues and discuss priorities across local services.   10.3 SSCB to consider carrying out an audit of Section 47 enquiries to test whether cases are proceeding to Initial Child Protection Conference when appropriate.        20  Appendix 1  The Serious Case Review (SCR) Review Team  Function To conduct, on behalf of the SSCB, the Serious Case Review, ensuring timely progression and taking responsibility for the production of the final SCR report presented to the Board at an agreed date.   One or two lead reviewers, one of whom must be independent of any agency represented on the Review Team, will lead the work of the SCR Review Team.   Membership of the SCR Review Team Membership will usually be senior representatives from the various agencies working with or known to the family. They must not have had any direct contact with the family or children or have held decision-making or supervisory role in relation to the frontline practitioners working with the family.  Members of this Team will be expected to have the authority to hold their own agency to account to ensure that required reports/documents are made available and key staff supported to take an active role in the SCR process.  Responsibilities of members of the Review Team • Represent their agency  • Understand the broad details of the case under review  • Ensure that a very broad outline chronology is undertaken • Identify key frontline practitioners who were known to the family • Undertake tasks related to data collection and analysis • Take ownership of the contents of the final report in presenting findings to the SSCB  Rationale: This SCR Review Team may well involve many of the same managers involved in the SSCB Learning and Improvement in Practice sub-committee, it’s function and purpose however, are different in that its work is solely to lead and work on a specific SCR.  Members need to be clear about their responsibilities, as this model requires far greater involvement from senior managers than the previous prescriptive IMR type methodology.  21  Appendix 2  Single Agency Learning   1. City Hospitals Sunderland (CHS) Learning Points and Actions taken:  • The Midwife failed to follow up on the ‘housing issue’ as disclosed on the ante-natal VAP and the past pregnancy VAPs were not taken into consideration. The Midwife reflects that this should have been followed through and has identified that the VAP needs to be improved to allow more free text.  Improved communication with the HV would have identified the concerns sooner • Where there are no risks identified on the VAP and the GP or HV has information to the contrary, direct communication between themselves and the Midwife should take place • The maternity and acute care is well documented from a clinical perspective, however the observed social factors of the family such as home conditions, presentation of the parents and children, interactions between parents and children also needs to be documented.  Action: Full social history to include full name of the males within the child’s life, who attends with patient at all CHSFT attendances and the reason for failure to attend outpatient appointments needs to be documented  2. South Tyneside NHS Foundation Trust (STNHSFT) Learning Points and Action taken:  • The implications upon Baby O of frequent HV ‘no access’ visits and failed to attend health appointments remained unchallenged • The emerging pattern over time of Neglect of Baby O’s health and social care needs were not recognised • The use of the significant event form to support early recognition of risks to children was not utilised to its full potential • The impact upon LO’s parenting capacity and caring responsibilities would appear not to have been considered by health professionals  • Staff will be reminded of the importance of escalating concerns to or seeking advice from the Safeguarding Team at STNHSFT • Supervision and actions recommended by STNHSFT Safeguarding Team were never re-evaluated or fed back to enable additional action to be provided • Communication between GP practice and Health Visitors regarding vulnerable families, failed access and FTA’s requires review • The contribution health professionals can make to Multi-agency working was felt not to be recognised, leaving assessments, decision making predominantly as single agency decisions   22  The actions being taken by STNHSFT in relation to these points is included within an action plan for all health agencies  3. Learning for General Practitioners  Learning Points and Action taken:  • Communication and information sharing - There were missed opportunities for the GP to share information with Children’s Services particularly concerning mother’s non-compliance with treatment for a life threatening illness and the impact of this on her ability to effectively parent and meet the health needs of her children; however there was no evidence that the SW contacted the GP for information on Mother’s health needs and compliance with treatment  There was a lack of analysis of the large volume of information from the Renal Consultant and safeguarding information from the Health Visitor.  GPs need to understand their responsibility to look at the information being shared by other clinicians or professionals and consider this in the context of family functioning  • Hidden/Invisible Fathers - When GPs are seeing male adults and they are aware of mental health problems, domestic violence and substance misuse they should enquire if the patient has children and contact or care of children in order to assess risk; indeed it could be argued that this question should be included when taking a history from any male to ensure their parenting/caring responsibilities are documented • Front Line factors - There was a lack of professional curiosity in relation to Mother’s life threatening condition, her non-compliance with treatment,  its impact on parenting and exploring the possibility of both possible domestic abuse/control or post-natal depression.  Given the life threatening condition and non-compliance of treatment consideration could have been given to undertake a home visit • Mother was not considered as a potential vulnerable adult.  Given that she had recently given birth, had a life threatening illness and there was reference to her having a black eye in April 2013 (2 months post-natal) which indicated she may have been a victim of domestic violence, she could have been assessed for post-natal depression had a home visit been undertaken • Criteria for discussing families/children at Practice Multi-Disciplinary Team Meetings (MDT) - There was no information in the GP records to indicate that this family was discussed at the practice MDT though the Practice Manager confirmed the family were discussed at MDT on 22/05/13 and 24/07/13 • Advice and Support - The GPs in the practice did not consult with the Named GPs for Safeguarding Children or Adults for professional advice and guidance, or the CCG Safeguarding Nurses   23  4. Children’s Services Learning Points and Action taken:  Multi- agency working • All referrals need to be acknowledged and recorded by staff in Children's Social Care • There needs to be improved communication between Partner Agencies, including informing them when difficulties with staffing and other work issues arise • Agreement needs to be made about who records meetings and how these are circulated after meetings. • Risk assessment tools should be agreed and introduced across SSC practitioners   Front Line/Family factors • Staff need to improve their skills in working with challenging and difficult to engage  families and invisible fathers • Focus of work needs to be on the voice and needs of children   Staffing/Workers/team issues • Work needs to be progressed on the development of an early help offer and single assessment • Consistent and effective case management, evidenced through the introduction of reflective auditing • Consistent and effective casework supervisions with management oversight and timely case discussion • Consistent and effective performance management and quality assurance introduced through the Performance Management Framework • A training needs analysis needs to be undertaken across Children's Social Care and Early Interventions Services • A comprehensive workforce strategy needs to be agreed and shared with staff and managers   Managerial issues etc. • There needs to be consistency by managers in overseeing and making decisions related to children, young people and their families, with appropriate levels of supervision in place • There needs to be robust policies in place for Regulation 24 placements with Grandparents and other family members •   Context/Organisation Structures • Significant changes in organisations need good planning and communication     24  5. Police Learning Points and Action taken: Multi agency working - Police Checks - need to ensure that full and accurate information is shared and that: • All possible aliases and linked addresses are explored • Consideration to be given for personal documentation to be asked for/supplied by potential carer  6. Children’s Services: Education  Learning Points and Action taken: • There are some really good and valuable examples of good practice from the schools involved with Victoria and Baby O e.g. school raised concerns with Children’s Services (Social Care) about Grandmother’s ability to cope with the responsibility of looking after the four children • All three schools appear to have focused very clearly on the needs of Victoria, keeping the child at the centre of practice, but in doing so this led to escalating concerns where appropriate • General learning points for all schools as follows: o Recording even the most insignificant item of concern accurately and immediately o Information sharing with relevant professionals quickly o Following up on actions and pushing for feedback once information has been shared    25  Appendix 3 How has the learning from this SCR improved practice?  Sunderland Safeguarding Children Board: • The SSCB is reviewing the compliance with procedures, the quality of S47 investigations and whether S47s are progressing to Initial Child Protection Conferences as required through multi-agency audits to be undertaken in 2016/17.  This audit will provide the SSCB with a clear understanding of how effective this part of the child’s journey is • 104 multi-agency staff have attended the SSCB Learning and Improvement Workshop to learn about the findings of the SCRS in Sunderland.  Staff attending the sessions report (see Appendix 4) that they have learnt from the sessions and are applying this to their practice • The Board has consulted on its draft SSCB multi-agency Neglect Strategy including the implementation of the Graded Care Profile  and it will be agreed at the SSCB in July 2016   • Whilst not a specific recommendation from this SCR, learning has highlighted the need to strengthen the SSCB so the SSCB has strengthened its approach to obtaining assurance about the safeguarding system in Sunderland and its partner agencies through: o Undertaking a Section 11 audit in 2015-2016 which evidenced compliance by partner agencies in respect of their staff supervision arrangements  o The SSCB Chair is undertaking assurance work through requesting Board partners to provide assurance of their current safeguarding arrangements and their agency annual safeguarding report for 2015-2016.  This will be one element contributing to strengthening the SSCB’s understanding of how effective the safeguarding system in Sunderland is o Refocusing on the behaviours, values etc, that the SSCB wants to be embedded into safeguarding practice in Sunderland o Implemented a learning and improvement monitor which is providing robust scrutiny and high challenge on the implementation of all recommendations from all SCRs the Board is undertaking   Sunderland Clinical Commissioning Group: • Large GP practices to identify a GP lead for individual families to deal with the safeguarding issues when there are concerns o This will provide consistent oversight of care to vulnerable children where there are safeguarding concerns o This will ensure a co-ordinated approach to receipt of information and dissemination of information  • When taking a social history from men, GPs to establish if they have children and/or care of children o GPs will include men in their assessments of children and families and use the information on fathers/male carers to inform referrals to other services 26  o This has been included in the Level 3 GP Safeguarding Locality Briefings, Time in Time out Sessions, the CCG Quarterly Safeguarding Newsletter for Primary Care and the quarterly support sessions with GP Safeguarding Leads  • When parents are neglecting their own health needs GPs must consider how this may impact on their parenting capacity and take responsibility for referring to Children’s Services/other agencies for support o The impact of self-neglect by parent/carers is considered for children in those households o GPs will refer to Children’s Services when it is recognised that self-neglecting parents/carers are not meeting the needs of their children o GPs may then, potentially, identify vulnerable adults and follow adult safeguarding procedures where necessary  • MDT meetings must be recorded in a consistent manner, documenting what actions and timescales have been agreed o There will be a consistent approach to recording MDTs in Primary Care o The impact of this will be reflected in improved communications and recording within Primary Care and improved outcomes for vulnerable families o This is included in the safeguarding children annual audit cycle  City Hospitals Sunderland: • The Midwife failed to follow up on the ‘housing issue’ as disclosed on the ante-natal VAP and the past pregnancy VAPs were not taken into consideration. The Midwife reflects that this should have been followed through and has identified that the VAP needs to be improved to allow more free text.  Improved communication with the HV would have identified the concerns sooner o The ante natal VAP has been reviewed and is now at version 5, due to several other SCR recommendations. Midwifery services have been reviewed and there are 5 permanent Community Midwife Teams, which has supported individual Midwives overseeing complex CP cases  • Where there are no risks identified on the VAP and the GP or HV has information to the contrary, direct communication between themselves and the Midwife should take place o Each midwifery team is attached to specific GP practices which have supported their attendance at GP multi-disciplinary meetings where vulnerable adults and unborn are discussed      27   • The maternity and acute care is well documented from a clinical perspective, however the observed social factors of the family such as home conditions, presentation of the parents and children, interactions between parents and children also needs to be documented.  Action: Full social history to include full name of the males within the child’s life, who attends with patient at all CHSFT attendances and the reason for failure to attend outpatient appointments needs to be documented o The electronic patient records system ‘Meditech’ has been updated with mandatory fields to ensure the full names of adults attending with children is documented o A failed to attend guidance has been produced and failed to attend out-patient appointments can be seen by all professionals on Meditech  Children’s Services (Social Care) • Improved communication and working relationships between Children’s Services and partner agencies at the first point of contact o MASH has now changed its operational structure (04/04/16) to be a multi-agency team who receive the first contact.  There are processes built in to share information to determine that the decision making is informed and at the correct threshold o A Strengthening Families Worker is now in MASH full time to progress early help for families who do not meet the statutory criteria but are in need of support to, where appropriate, prevent them entering Social Care  • Robust plans for children in need that are reviewed and have managerial oversight to avoid drift and delay o There are revised CIN procedures with built in reviews o Effective plans for children appropriate to their level of need leading to improved outcomes o Child in Need workshops were delivered in April 2016 to embed the procedure and ethos with all staff  • Assessments of risk using thresholds/frameworks to support the evidence and that they are inclusive of all family members o Risk assessment frameworks introduced in 2015, Bruce Thornton including the Graded Care Profile o Neglect Strategy now circulated and multi-agency workshops are planned for the end of the year (2016) o A reviewed and revised Quality Assurance Framework has been agreed (July 2016)   • For any child being placed with family/connected carers that the appropriate legislation is used and that there is regulation of the placement o The scheme of delegation has been revised (June 2016) and all Service Managers , Head of Service and Director are able to agree Schedule 4 assessments, children will not be placed without the Schedule 4 being 28  completed. The scrutiny by the designated Service Manager flags any practice/non-compliance issues o Regulation 24 workshops have been delivered to all staff during July 2016  • To establish a stable workforce that provides consistency in Social Worker and Manager who are accountable for decisions and planning o The structure of the Children’s Social Care workforce has been revised to reduce the size of the teams and increase the number of managers. Teams are made up of no more than 8 social workers with case loads of 20   Children’s Services (Early Intervention) • New non-engagement policy has been put in place for all workers to follow          o All workers are clear of the expectations when trying to engage hard to reach families whilst acknowledging that work at EI is voluntary o Process of closure for non-engagement requires management oversight    South Tyneside NHS Foundation Trust (STNHSFT) • The impact upon the child regarding ‘no access’ visits should be re-emphasised with all health visitors o STNHSFT Safeguarding Children Policy clearly identifies the action required when ‘no access’ visits are experienced by health visitors and the potential impact this may have upon the child. This policy has been revisited through Team Meetings, embedded within Safeguarding Training Presentations, and individually with Health Visitors through Safeguarding Supervision  • Individual supervision should be undertaken between the lead nurse safeguarding and individual HV o Individual supervision was offered to this professional, but unable to be undertaken as the practitioner did not return to STNHSFT employment  • The use of the significant event form to support early recognition of risks to children should be revisited with Health Visitors o Health Visiting and School Nursing Child Health Records all contain a Significant Event Form with a requirement in accordance with STNHSFT Safeguarding Children Policy, this is completed and reviewed at all contacts to support early identification of risk, analysis of information and inform decision making when working with families.  The use of the significant event form has been revisited at team meetings, revisited within Safeguarding Training Presentations, and raised individually with Health Visitors and School Nurses through Safeguarding Supervision and discussions.  Child Health Records are reviewed by the Safeguarding advisors at Safeguarding Supervision Sessions to ensure compliance with completion of Significant Event Form    29  • The individual roles and responsibilities of health professionals and the safeguarding team in escalating concerns and access for support should be revisited o The specialist safeguarding roles and responsibilities of the Safeguarding Team have been revisited across STNHSFT through Safeguarding Training, Safeguarding Website, Safeguarding Newsletter, and the Safeguarding Forum, with specific reference to supporting professionals with escalation of safeguarding concerns. Safeguarding advisors provide safeguarding support and advice daily through face to face contact, telephone contact with professionals and Safeguarding supervision. The use of Datix Incident Reporting has supported escalation of safeguarding concerns by health professionals to the Lead Nurse, ensuring prompt safeguarding advice and support with regard to escalating concerns                   • Safeguarding supervision documentation should be reviewed to include identified actions, responsible person, timescales and feedback/review o Safeguarding Children/LAC Supervision Case Discussion form has been amended. Health professionals who are clear of their roles and responsibilities during and following safeguarding supervision prevent delay and drift with interventions for families and children o Communication between GP and HVs to be improved with regard to vulnerable families and non-engagement o STNHSFT Safeguarding Children Policy clearly identifies the action required when ‘no access’ visits are experienced by the Health Visitor. It is an expectation that Health Visitors will contact the family GP when difficulties are experienced with access to children and their families. Sharing information with regard to vulnerable families promotes effective communication, enabling primary care practitioners to share and analyse information to progress the most appropriate support and intervention for children and families  Children’s Services (Education) Recording even the most insignificant item of concern accurately and immediately • Information sharing with relevant professionals quickly These messages reinforced through designated persons training, dip sampling file audits as part of preparation for Ofsted, school improvement visits  Following up actions and pushing for feedback once information has been shared • Schools now should receive acknowledgement/outcomes of referrals and have been reminded to follow up for feedback if this is not forthcoming  30  Appendix 4  References relevant to this Review  Action for Children – The state of child neglect in the UK, Action for Children and University of Stirling, 2013; www.actionforchildren.org.uk/media/5120220/2013_neglect_fullreport     Brandon M, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane Dodsworth and Jane Black - 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, Sue Bailey and Pippa Belderson - Building on the learning from serious case reviews: A two-year analysis of child protection database notifications 2007-2009; DFE 2010  Brandon M, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis & Matthew Megson - University of East Anglia & University of Warwick – July 12: New learning from serious case reviews: a two year report for 2009-2011   C4EO – KNOWLEDGE REVIEW 1 - Effective practice to protect children living in ‘highly resistant’ families  Department for Education – Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children – 2013  DH 2011 Health Visitor Implementation Plan: A Call to Action  DH Healthy Child Programme 2009  GMC - Protecting children and young people - The responsibilities of all doctors GMC 2013  NSPCC 2011 - All babies Count  Dual Diagnosis Nursing - edited by G. Hussein Rassool (2006) Blackwell  Ofsted - Learning lessons from serious case reviews, 2009–2010 (100087), Ofsted, 2010; www.ofsted.gov.uk/resources/learning-lessons-serious-case-reviews-2009-2010   Ofsted In the child’s time: professional responses to neglect – March 2014 Tony Morrison Staff Supervision in Social care,” Tony Morrison, 3rd edition and “The Impact of Supervision on Child protection practice – a study of Process and Outcome” 2003  Wonnacott, Jane; Effective supervision in social work and social care, Professor John Carpenter and Caroline Webb SCIE Briefing 2012   31  Appendix 5  Learning and Improvement Workshops – Impact as described by staff attending  Please give one example of how you will embed the content of this training into your role: • I have noted the importance of professional challenge and have encouraged colleagues to use this too • I will ensure I chase up any referrals promptly • To ensure that myself and the staff based in my room are aware of the procedures to follow • I will be feeding back to staff within a staff meeting what was discussed and to look at our own practice and if there is room for improvement to ensure all documentation is consistently recorded and detailed information is being recorded • This has given me the confidence to challenge  • I will now be more aware of parents who may have disguised compliance • I will challenge where I feel is necessary, knowing the proper procedure can be followed • If I disagree with the decisions taken in child protection meeting, I will voice my concerns • I might be wary of overly compliant parents who lend lip service to the changes in child care which has been demanded • When seeing children in my GP surgery I will:  1. Always check the relationship of adults bringing the child to the appointment.  2. Speak to the child on their own where appropriate.  3. If I feel uncertain about the truth of the facts presented, endeavour to seek confirmation from another source (eg attendance at counselling) • I have read my trust policy on safeguarding and this is implemented into my practice • It has made me very aware of how I can and should challenge professionals and not accept low standards as the norm • Encourage staff who "have niggles" to take concerns seriously and report and record • Ensure that the voice of the child is heard by relevant professionals • I will not leave a meeting with questions • To further ensure practice remains child centred. To always be mindful of disguised compliance • Reinforced the need to reflect on cases with my supervisor • Future course/ training development • Ensure that I keep up to date accurate records  • Making sure that I understand all the factors learnt from serious case reviews and to make sure that I take this into practice • Always recap in meetings to make sure all professionals are aware of their role and actions • If in any doubt, seek further advice • I will ensure that all of the professionals involved with my young people are provided with the relevant information • Be specific in conferences about the expectations of the plan in relation to the safety of the child/ren eg not just tell them to attend a service but to explain what they need to do and learn • I will be more aware of vulnerable babies • Challenging other professionals when appropriate  