Severe neglect of twins aged 22-months in June 2016. Mother had three children removed from her care in March 2005 due to neglect and emotional abuse. Twins were born prematurely in 2014 and required treatment at several hospitals. On discharge, the twins were made subject to a child in need plan for six months but this was closed after three months. A health visitor supported the mother and twins with community services. A referral in May 2016 from the housing department to Children's Services identified child protection and welfare concerns for the children. A month later they were taken to hospital where a paediatrician confirmed they were suffering from extreme neglect. The mother was arrested for cruelty and neglect; the police decided not to take further action following completion of their investigation. Findings include: the need to remind key practitioners of national and local safeguarding policies and procedures; identification of concerns as to the function of the governance and supervision of child protection cases; the need to remind police investigating officers of agreed guidance on sharing information in parallel processes involving criminal proceedings and SCRs; the need to review case allocations and ensure that key practitioners have the necessary experience and supervision. Recommendations include: to remind all staff of the need to have knowledge and awareness of learning from SCRs when carrying out their child protection roles; to ensure there is compliance in place, for all staff, when there is a conflict of interest; to ensure record keeping is enhanced and expeditiously recorded onto the computer management system.
      
    Serious Case Review No:  2018/C7416  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.    1CHILD L AND CHILD M  SERIOUS CASE REVIEW           Overview Report            Independent Overview Author - David Byford A LOCAL SAFEGUARDING CHILDREN BOARD COMMISSION    2Chapter 1 - Executive Summary ........................................................................................... 4 Introduction ........................................................................................................................... 4 Chapter 2 - Initiation of the Serious Case Review ............................................................. 6 Purpose of the review ......................................................................................................... 6 Terms of Reference (ToR) ................................................................................................. 6 Scoping ................................................................................................................................. 7 Key Issues to Consider ...................................................................................................... 7 Introduction (Initial details provided to the Board) ......................................................... 8 Agencies Participation ........................................................................................................ 8 Membership and Conduct of the SCR Panel .................................................................. 8 Family .................................................................................................................................... 9 Methodology ......................................................................................................................... 9 Statutory Guidance ........................................................................................................... 10 Publication .......................................................................................................................... 10 Chapter 3 - Analysis of key events and professional practice ....................................... 10 Period 1 - Mother’s previous three children were taken away ................................... 10 Period 2 - The twins antenatal period ............................................................................ 11 Period 3 - The decision to discharge the twins home, to the care of their Mother . 13 Period 4 – The care, support and assessment provided to Mother and children ... 14 Period 5 – The incident of serious neglect and the subsequent Police investigation.............................................................................................................................................. 15 Practitioner’s contribution to the review enquiries ....................................................... 19 Other Areas Identified by the Review ............................................................................ 22 Culture and Diversity ........................................................................................................ 24 Chapter 4 - Professionals Overriding Responsibility ....................................................... 24 Learning from previous SCR’s ........................................................................................ 25 Chapter 5 - Findings – Lessons learnt and suggested recommendations for consideration .......................................................................................................................... 25 Finding 1 – Compliance to Safeguarding Policy and Procedures ............................. 25 Finding 2 – Governance and Supervision ..................................................................... 26 Finding 3 – Record Management ................................................................................... 27 Finding 4 – Enhancement of the LACMS ...................................................................... 28 Finding 5 – Supporting Families ..................................................................................... 29 Finding 6 – Case Allocation and Research ................................................................... 29 Finding 7 – Conflict of Interest ........................................................................................ 30 Finding 8 – Information Sharing ...................................................................................... 31  3Finding 9 – Learning from SCRs .................................................................................... 31 Finding 10 – Parallel Processes ..................................................................................... 32 Inhibitors to the process ............................................................................................... 32 Chapter 6 - CONCLUSIONS ............................................................................................... 33 Predictability ................................................................................................................... 33 Preventability.................................................................................................................. 33 Engagement with professionals and family ............................................................... 35 Opportunities to intervene prior to Child L and Child M’s neglect taking place ... 35 Chapter 7 - Learning on the Fringes .................................................................................. 36 Further considerations for Agencies to consider .......................................................... 36 Overview Report submission to the LSCB .................................................................... 37 Chapter 8 - Individual Agency Recommendations ........................................................... 37 Children’s Social Care (see also Implementations below) ..................................... 37 Hospital 1 ........................................................................................................................ 37 Hospital 2 ........................................................................................................................ 38 Hospital 3 ........................................................................................................................ 38 Local Community Foundation Trust ........................................................................... 39 Clinical Commissioning Group .................................................................................... 39 Housing Department ..................................................................................................... 40 Children’s Centre ........................................................................................................... 40 Integrated Care 111 Service ....................................................................................... 41 Implementations ................................................................................................................ 41 Children Social Care ..................................................................................................... 41 Children and Targeted Outcomes (CATO) ............................................................... 42 Chapter 9 – Glossary ............................................................................................................ 42 Chapter 10 - Initial Response to Serious Case review from the Chair of the LSCB .. 44    4Chapter 1 - Executive Summary Introduction  1.1 This Serious Case Review (SCR) was commissioned by a Local Safeguarding Children Board (LSCB) following a notification in June 2016 of the severe neglect of Twins, (aged 22 months) referred to as Child L and Child M for the purposes of this review. Their Mother is in her 30’s, single, unsupported and resides in a Local Authority (LA) one bedroom flat.  1.2 In 2000, there had been Child Protection (CP) concerns of Mother’s failure to safeguard her children. CSC received a referral from a Health Visitor (HV) expressing concerns for her only child that she had at that time (aged 15 months) due to poor hygiene and concerns with the parenting capacity of both parents. An Initial Assessment (IA) was completed and on-going support from Sure Start Services was recommended and implemented.  1.3 Further referrals to Children’s Social Care (CSC) were received, one in 2001, a period when her second child was born and two referrals in 2002, a period when her third child was born. The referrals were in reference to the poor home conditions and the children appearing unkempt and dirty. A Core Assessment was carried out and was closed in February 2002, on the basis that any further referrals would result in an Initial Child Protection Conference (ICPC).   1.4 In March 2004, HV’s made a further referral to CSC due to the same CP issues, in addition to developmental delay and failed health appointments.  Furthermore, a male family member, who was on probation for a serious offence, was living within the household.  1.5 In April 2004, a Doctor (Associate Specialist in Community Child Health) completed a medical assessment on the two younger children. It was assessed that they both required a management plan in relation to their speech, as they were deemed to be significantly delayed in their development. As a result, all three children were appropriately placed on the Local Authority Child Protection Register (CPR) under the category of neglect and emotional abuse.  1.6 Mother and Father separated in June 2004. Father returned to reside with the Paternal Grandmother (PGM) in another area.  1.7 In June 2004, a Review Child Protection Conference recorded that the child protection plan was difficult to implement as Mother was not demonstrating a commitment for change.  Sure Start withdrew their services due to her lack of willingness to engage and non-compliance with recommendations to adequately meet the basic needs of the children.  1.8 Core Group Meetings were held in October and November 2004 to discuss the fact that mother was not working with the CP Plan as it was felt that the children were failing to thrive.  In December 2004, Mother agreed to a Section 20 Children Act 1989  5voluntary accommodation and the children were placed into foster care by the Local Authority.  1.9 One day later, Mother approached the Local Authority stating that she had discussed private family care arrangements with the PGM in preference to foster care.  1.10 The Local Authority carried out relevant child protection checks on the PGM and extended family. The children subsequently left the foster placement and relocated to reside with the PGM at the request of Mother. A subsequent full medical examination was carried out on the children by a Consultant Paediatrician. There were no visible signs of abuse found.  1.11 In March 2005, a transfer CP Conference took place in the PGM Local Authority area, who decided not to place the children upon their CPR. Their names were subsequently removed from the Mothers Local Authority CPR who agreed they would support the Paternal Grandparents in their application for an Interim Residence Order.   1.12 The Mother’s three children then became subject to a Private Court Hearing in July 2005 when the Local Authority were requested to provide the court with a s.37 Children Act 1989 report, as Mother was requesting to have the children returned to her care.  1.13 The outcome of the s.37 report was that the children were deemed to be thriving in the care of their birth Father and PGM.  A decision was made by the Local Authority not to apply for an order due to the fact the children’s immediate basic needs were being met by their Father and the PGM. It was the view of the assessing social worker (SW) that Mother had not made sufficient progress to demonstrate an improvement in her ability to care for the children.  It was recommended that a more comprehensive feasibility assessment is undertaken on Mother in order to assess her long term commitment to change, in order to meet her children’s needs.  1.14 The future of the three children became subject of private proceedings. The outcome is that they remain to this day, in the care of the paternal family. Mother subsequently disclosed at the time of this review that she has not had any contact with her children for approximately six years and prior to that it was supervised contact only.   1.15 Mother again came to the attention of Health Services and CSC when in 2014 she became pregnant with her twins.   1.16 In 2014, the twins were born prematurely. Significant medical and health conditions at birth meant they required treatment at several Hospitals.   1.17 After an initial pre-discharge meeting in December 2014 and a final discharge meeting in January 2015, from Hospital 1, the twins were discharged into their mothers care  1.18 On discharge, the twins were made subject of a Child in Need (CIN) plan, initially for six months, but against that recommendation, at the first CIN meeting, after a three-month period only, the case was closed to CSC. The Health Visitor (HV1) became  6the Lead Professional (LP) to support the Mother and twins with community services and provision.   1.19 A referral from the Local Authority Housing Department to CSC, after a home visit in May 2016, identified there were CP and welfare concerns for the twins.   1.20 There followed a one-month period of inaction from professionals. During which time the twins remained in environmental conditions described later by the Police as ‘disgusting’, until they were taken by the Allocated Social Worker (ASW) to Hospital 1 at the end of June 2016.   1.21 A Paediatrician at Hospital 1 carried out a medical examination and confirmed the twins were suffering from severe neglect. The Police attended the Hospital and took out a Police Protection Order (PPO) and the twins placed into emergency foster care.   1.22 The Mother was arrested for Cruelty and Neglect. At the completion of their investigation the Police decided No Further Action (NFA) would be taken against Mother.   1.23 The twin’s future prospects, after this safeguarding action, looks assured as they begin the adoption process.   1.24 The LSCB considered advice regarding publication of this SCR overview report, from the Independent Overview Author (IOA), an expert on similar publishing decisions, and the LSCB Legal Services representative, who was a SCR Panel (SCRP) member. The LSCB took the decision this SCR will be published anonymously, due to the unique features. All geographical references have been removed in order to protect the identity of the twins, their siblings and family members.  Chapter 2 - Initiation of the Serious Case Review Purpose of the review  2.1 The purpose of this SCR is to: - • Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children and young people. • Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result, and • As a consequence, to improve inter-agency working and better safeguard and promote the welfare of children and young people.  Terms of Reference (ToR)  2.2 1. This SCR will be undertaken by the LSCB, being the Board area in which this young person/s normally resided (Working Together 2015).  72. An Independent Author has been appointed to undertake the Overview Report and make any necessary enquiries to establish the circumstances and any subsequent learning. 3. An Independent Chair has been appointed to oversee the “Child L & Child M” SCRP and process, who has not had direct involvement in the case. 4. Specific areas for consideration will include: - a. The role of the LP, what did this mean and what were the expectations? b. The decision making behind Child L & Child M becoming CIN as opposed to CP. c. Closure of the CIN plan, who was involved in this decision and the rationale behind this. d. Information sharing between all agencies e.g. minutes of meeting. 5. The publication date of the final overview report will take into account the statutory responsibilities of any other statutory body or criminal proceedings.  Scoping  2.4 The scoping within this review was:-  1. The time period of the review will cover from the date from time of notification of pregnancy until the point Police issued a PPO  2. In addition to the completion of the Individual Management Reviews (IMRs), there is a requirement to provide a detailed chronology to show key episodes or events when each organisation was involved in with this family. 3. The scope of the Review, in respect of family information, to be limited to the twins, any siblings, parents and maternal grandparents only. 4. The SCRP will examine all relevant information provided by individual agencies and professional’s reports. 5. The family to be informed that a SCR is to be undertaken. 6. As well as receiving IMR reports from the statutory LSCB member agencies, the SCRP will request an IMR report or disclosure of information from any bodies believed to have engaged or had involvement with the family as required. 7. Given the potential press interest of this Review, the Panel will agree a media strategy involving the media lead from the LSCB partner agencies and a proactive press release prepared should this review be approved for general publication. 8. The Panel will utilise the LSCB Legal Advisor to the Board and call upon any expert witness or adviser as required. Key Issues to Consider  2.5 The Key Issues to Consider were:-  1. Did all agencies work together effectively to safeguarding these children?  8 2. Was the outcome preventable?  3. Were the safeguarding procedures followed appropriately?  4. Were the young person’s voices heard throughout agencies involvement? Introduction (Initial details provided to the Board)  2.6 Following a recommendation from the LSCB, the Independent LSCB Chair, took the decision to commission a SCR as the circumstances met the criteria in accordance with s5(2)(a) and (b)(I) LSCB Regulations 20061 and Working Together to Safeguard Children 20152:   • “Abuse or neglect of a child or young person is known or suspected and • The child or young person has died or 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 or young person”. 2.7 Ofsted, Department for Education (DfE) and the National Independent SCR Panel were notified by the LSCB of the decision to commission the SCR on 10th November 2016. Additional time during the course of completing the review was requested and agreed.  This was due to the complexity and number of agencies participating in the SCR, the parallel criminal investigation procedures and other inhibitors outlined below. Agencies Participation  2.8 The following Agencies were asked to provide an IMR and chronology or summary report. Local Authority Children’s Social Care - IMR and chronology Local Authority Housing Department -  IMR and Chronology Local Area Community Foundation Trust (LCFT) - IMR and chronology  Clinical Commissioning Group (CCG) – on behalf of NHS England Primary Care - IMR and chronology Hospital 1 - IMR and chronology Hospital 2 - IMR and chronology Hospital 3 - IMR and chronology Local Police Service - IMR  111 Integrated Service - IMR and chronology  Membership and Conduct of the SCR Panel  2.9 The Independent Chair for the SCR is a member of the LSCB and the IOA, David Byford, was appointed to carry out the SCR on the 14th February 2017. He has met all deadlines set by LSCB.                                                        1 Local Safeguarding Children Board Regulations, 2006 Section 5 (2) (a) and (b) (i) 2 Working Together to Safeguard Children, 2015  92.10 Both the Independent LSCB Chair and the IOA have no operational involvement, connection or conflict of interest with the case.   2.11 All Agency IMR and Report Authors have demonstrated their independence within their agency responses to the SCR except in the case the Local Police Service who were requested to complete a revised IMR. A summary report was completed and submitted that was not independent and did not comply with the SCR ToR.  2.12 The SCRP met on four occasions and comprised of the Independent Chair, IOA and the following Senior Representatives from agencies:  • LSCB Project Officer • LSCB Learning & Practice Review Co-ordinator • Local Authority CSC • LSCB Legal Adviser • Local Authority Housing Department  • Local Police • Local CCG • Local Area NHS Foundation Trust • Hospital 1 Representative • CAFCASS • National Probation Service • Community Rehabilitation Company (Probation Services) Family  2.13 The following family members were subject of the review:-  Subjects Twins - Child L and Child M Other relevant family members Mother - Declined LSCB attempts to participate in the SCR process.  Father - Not concerned or involved in the twins’ life. Significant Others Maternal Grandmother - Declined LSCB attempts to participate in the SCR process     Maternal Uncle (MU) - Had concerns with Mother’s parenting capacity, due to the concerns of her previous children being removed.    Methodology  2.14 The LSCB agreed a mixed methodology to understand professional practice contextually, to identify factors which influenced agencies and professionals in their decisions taken and, the nature and quality of work with the twins’ family. The IOA identified at an early stage, areas which required further information to be provided and requested these from the agencies. This additional information was predominately provided within the agencies final submissions.  102.15 In carrying out this review the following approaches were made: - • Liaison with Police, Local Authority CSC personnel including CSC key practitioners and managers, the CSC IMR Author, the current Head of CSC (HCSC2) and previous Head of CSC(HCSC1) and the Service Manager of the Children and Families Assessment Team (CFAT). • Interviewed key practitioners. • A research and review of local and national safeguarding policies and procedures, care plans, CIN review meetings and consideration of previous LSCB SCR’s, previous Ofsted Inspections together with additional research of guidance material. • Analysis of agency SCR submissions to ensure compliance with the ToR and statutory requirements. Statutory Guidance  2.16 The DfE,3 provided statutory guidance and requirements on how to conduct a SCR which:  • Recognises the complex circumstances in which professionals work together to safeguard children; • Seeks to understand precisely who did what and the underlying reasons that led to individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • Is transparent about the way data was collected and analysed; and • Makes use of relevant research and case evidence to inform findings. Publication  2.17 The LSCB have considered the options for the publication of this SCR and in recognition that there is learning that should be shared, have agreed to publish this report in an anonymised version. This decision has been taken to protect the family subject to this review due to the unique identifying features that prevail. In reaching its decision the LSCB obtained independent expert and legal advice regarding publication.  Chapter 3 - Analysis of key events and professional practice  3.1 The review identified five distinct and significant periods of concern from Mother’s background information and from professional interaction.  Period 1 - Mother’s previous three children were taken away  3.2 The family first came to the attention of CSC in June 2000 when a HV made a referral concerning her first child that Mother had at that time. This was due to the child’s poor hygiene and the parenting capacity of both Mother and Father. An Initial Assessment was completed with on-going support provided by Sure Start Services                                                       3 Working Together to Safeguard Children, 2015 Chapter 4  11which, was later withdrawn due to Mother’s unwillingness to engage and failing to cooperate with professionals. 3.3 Information obtained within the SCR, showed Mother also had a miscarriage during this period, with a later self-disclosure that she also suffered post-natal depression. When this occurred, the wellbeing of Mother appears not to have been identified or considered further by professionals. 3.4 CP concerns persisted, as three further referrals to CSC were received in 2001 and 2002 in reference to the poor home conditions and the children appearing unkempt and dirty. A Core Assessment was carried out. It was directed that if there were any further referrals, this would result in an ICPC being initiated. Her second and third children were born respectively within these two years. 3.5 In March 2004, a HV again made a referral with the same CP concerns as before, including developmental delay and failed health appointments for the children. 3.6 In April 2004, a medical assessment on the two younger children assessed they both required a management plan for their speech and were deemed as significantly delayed in their development. The Local Authority placed all three children on the CPR on a CP plan for neglect and emotional abuse. Core Group meetings were held in October and November 2004. It was evident that the CP plan was not working and the children were not thriving. 3.7 In December 2004, Mother requested the Local Authority to place her children into voluntary accommodation under Sec 20. They were all placed into foster care. The following day, Mother contacted the Local Authority and informed them she had made a private arrangement for the birth father and PGM to assume care for the children. 3.8 CSC carried out child protection checks on the PGM and extended paternal family. As a result, the children were placed into the care of their birth Father and PGM in another part of the country. A CP ‘Transfer in Conference’ was held and the CP Plan discontinued by both Local Authorities and the children were removed from the CPR. Mother disclosed she has had no contact with her children for over six years. 3.9 There was a subsequent private court hearing where Mother was requesting to have the children returned to her. A Sec 37 report in 2005 determined that the children were thriving with their Father and the PGM. A SW assessing the Mother stated she had not made sufficient progress to demonstrate her ability to care for them. 3.10 Private proceedings were considered by Mother; however, the children to this day remain with the paternal family.  Period 2 - The twins antenatal period  3.11 Mother became pregnant with the twins in early 2014. The Specialist Midwife for Safeguarding (SMS) at Hospital 1 raised concerns to CSC regarding possible CP concerns.  3.12 Records show a meeting was to be arranged between senior management of CSC, CCG and Hospital 1 to discuss the case further. There is no record to show this  12meeting ever took place, with no reason given. (Note: It is not normal practice for the CCG to attend these meetings).  3.13 In order to ensure compliance with the local safeguarding policy and procedures, the SMS requested information be shared by CSC of any current or historical safeguarding concerns that may exist in the family, requesting contact details if the case was open to CSC.  3.14 Mother voluntary disclosed to the Community Midwife (CM1) her three children were placed in temporary care for six months and were later subsequently removed from her into the care of their Father (stated by Mother) then subsequently the PGM. Mother stated she had supervised access with the children. This is a contradiction to Mothers’ later disclosure that she had not had any contact with the children for six years.  3.15 Mother declined to give full details of the three children and the name of the Father; however, SMS later discovered the family name. Mother also declined to provide SMS with the Father’s identity of the unborn child.  3.16 The SMS informed CSC that Hospital 1 had grave concerns Mother was pregnant again, highlighting her other three children had been removed previously from her care, with only supervised access permitted. SMS requested further information to complete the relevant referral. 3.17 This request was received by CSC and addressed by Team Manager 2 (TM2), who was the Multi Agency Safeguarding Hub (MASH) Manager.  3.18 CSC records showed the previous concerns as pre – 2005. It was agreed SMS would complete a CAF Referral in the first instance. It was agreed following this consultation by SMS that a referral to CSC would be made.  3.19 On receipt of the CAF by CSC, there was a disagreement between the CFAT TM1 and MASH Manager TM2, over safeguarding concerns regarding Mother’s parenting capacity.  3.20 TM1 wanted MASH to carry out enquiries which was not within the MASH remit. TM2 advised that the CAF assessment received was poor and advised that consideration should be made for CFAT to complete a Children and Family (C&F) Assessment and to consider a Pre-Birth Conference (PBC).  3.21 CFAT did not follow this advice. An opportunity to speak to TM1 was unsuccessful for the purposes of this SCR because the practitioner had since left the Local Authority and not available  3.22   The records show that TM1 closed the referral in August 2014 on the basis that the concerns were historical with no current CP concerns.  Mother was engaging with ante-natal services, Health professionals to monitor progress, engagement and hygiene. CM1 had agreed to make a referral for community mother’s involvement and CM1 will be expected to contact the Department if there are still concerns. 3.23 Author comment: This review strongly rejects this opinion, which is both questionable and optimistic, against the concerns raised by some professionals and Hospital staff about Mother’s personal hygiene and the  13cleanliness of her home, which mirrored the CP concerns made ten years previously. 3.24 There were several missed opportunities to hold a PBC, considering the previous CP concerns of Mother’s parenting capacity. No Initial Child Protection Conference (ICPC) was considered. 3.25 The twins were born prematurely in September 2014 at Hospital 1. Complications persisted for both twins which resulted in them being transferred the same day to Hospital 2.  3.26 The twins then returned to Hospital 1 in October 2014 following which Child M was transferred to Hospital 3 a week later, to treat a specific medical condition.   3.27 Child M, after intensive treatment in Hospital 3, was transferred back to Hospital 1 in December 2014. On their return, an x-ray was carried out. This showed an isolated left side 8th rib fracture with a callus formation, not seen in previous x-rays.  3.28 The fracture was believed to be three to four weeks old, occurring whilst at Hospital 3. Notes on the Doctor’s plan recorded Hospital 1 were to contact Hospital 3 about this finding but this did not occur.  3.29 The CCG reported the fracture from their enquiries in their IMR. This was not followed up by Health professionals in LCFT, Hospital 1 and Hospital 3 IMR’s. 3.30 The outcome of the fracture causation was eventually obtained (January 2018) after the IOA, with assistance from the LSCB Manager, repeatedly requested a Health response. Hospital 1 confirmed the likely cause of the fracture to be rickets due to prematurity. Mother had been informed of the fracture at the time and there were no CP concerns. (See Learning on the Fringes of the SCR).  3.31  In November 2014 a referral was made into CFAT by a Social Worker involved with the Maternal Uncle who had disclosed concerns of Mother’s ability to cope with the twins. As a result a C & F assessment was undertaken. Period 3 - The decision to discharge the twins home, to the care of their Mother  3.32 As the twins’ health improved, Mother was anxious to have them home. Mother lived in a cramped, one-bedroom Local Authority flat which professionals later describe as cluttered and dirty.  3.33 Children’s Social Worker (SW1) chaired a pre-discharge meeting at Hospital 1 in December 2014. The governance and supervision of this is subject to a recommendation (Recommendation 1). The meeting took place with SW1, HV1 and a NICU Senior Sister and Staff Nurse from Hospital 1. During the meeting it was recommended that the children be placed on a CIN plan upon discharge. 3.34 It was agreed Mother would have an extended stay at Hospital 1 to show she could cope with the care of her babies before a decision to discharge from hospital. If there were no further concerns, the babies would be discharged into the care of Mother, with support provided in the community and supported as a CIN.  3.35 During mothers stay at Hospital 1 hygiene issues and concerns around general care of the twins were recorded, in Hospital 1 records provided to the review.  143.36 Early January 2015, the twins were discharged from Hospital 1 into Mother’s care.  3.37 At this time, Mother disclosed to professionals and to SW1 she had previously suffered from post-natal depression. The details when this occurred and whether it was relevant to her ability to care for vulnerable premature twins was not fully investigated from the information supplied to this review. There was no ICPC held and there were several failed opportunities to hold a PBC. These issues were not sufficiently explored before or after the twins’ discharge from Hospital 1 into the care of their Mother. There was also no professional scrutiny displayed to verify this self-disclosure.  3.38 There had been continual concerns regarding Mother’s personal hygiene, which were repeatedly reported by staff at Hospitals 1 and 3 whilst the twins were in-patients and during mothers stay at Hospital 1. 3.39 The LCFT IMR provided to this review, shows that HV1 was under the impression that a CIN plan was in place on discharge from Hospital 1. CSC IMR states that the C & F assessment was not completed until two weeks later when the twins were then placed on a CIN plan.  3.40 The twins’ ability to thrive, achieve growth and development was reliant on Mother’s parenting abilities and support from her own Mother, the Maternal Grandmother (MGM).  3.41 Mother stated on several occasions she relied upon MGM as her only family support, but this was never assessed or confirmed by CSC. It was noted by nursing staff in all contact with Mother, at both Hospital 1 and Hospital 3, that no other family member visited the Hospital in support of Mother, or to visit the twins. 3.42 On implementing the CIN, a Family Support Worker (FSW) was allocated the case, who personally knew the Mother, and this was a conflict of interest which is not acceptable. 3.43 The additional concerns as to mothers personal hygiene, home conditions and previous neglect, that persisted, was not considered thoroughly to ensure a robust support system was put in place, with the decision to treat the twins as CIN rather than a CP case subject to a CP Plan.  Period 4 – The care, support and assessment provided to Mother and children  3.44 It is not clear why in January 2015 the twins were not considered as CP rather than a CIN case, but the decision was agreed by supervisors.  3.45 The CIN Plan stated the family would be supervised for six months. After three months, there was a CIN Meeting and the case closed. This decision was not challenged by supervisors or other agencies. The reason for closure stated there was no further role for CSC, with the rationale the family should be monitored through health service providers. HV1 was to be designated the LP and support provided by the local Children’s Centre and enrolment of the twins on the two-year Maternal Early Childhood Sustained Home-visiting (MECSH) programme.    153.46 The MECSH programme, however, was not available to the twins but, this information was never communicated to CSC for consideration of reviewing the support options and care provided to the family.  3.47 The Family were referred to a local Children’s Centre, Mother was booked to attend an Attachment and Bonding Programme and advised that she could visit the Children’s Centre to access Universal Services.  Mother did not attend the programme. 3.48 The last attended GP appointments were with Child M in October 2015 and Child L in November 2015.  3.49 From January 2016 until June 2016, there was no contact or support provided by LP or health colleagues.  Period 5 – The incident of serious neglect and the subsequent Police investigation  3.50 At the end of May 2016, Local Authority Housing employees, after repeated attempts, eventually gained access to Mothers flat, to carry out necessary annual gas checks.   3.51 A Court warrant had been obtained for entry due to Mothers apparent avoidance, but was not required. On entry, the condition of the property was of serious concern to the Housing Officer (HO3).  3.52 HO3 saw extremely poor and uninhabitable conditions of the home - a continuing theme throughout professional contact with her. The home was described as unclean, cramped and cluttered. Due to the unhealthy conditions and concern for the twins, HO3 reported the concerns to colleagues.   3.53 HO1 appropriately made a referral to CSC three days later. It was not until four days later that the case was allocated by CSC TM6 to an in-experienced ASW who was in their first year as an Assessed and Supported Year in Employment (ASYE)   3.54 There was no sense of urgency by professionals to assess the need or to conduct an emergency welfare home visit to check on the condition of Child L and Child M. Delays then persisted with no immediate safeguarding action taken.   3.55 Two weeks later, HO1 and HO2, attended the home again and found the living conditions as intolerable. This was another opportunity to telephone CSC and/or Police, to come to the scene or request further safeguarding guidance. The flat was dirty with no natural light, sheets up at the windows and the atmosphere was very smelly. Flies were so prevalent, HO1 was worried about speaking in case a fly went into her mouth - yet, this was the environment the twins, described as motionless in a double buggy in the living room, found themselves in, with the twins presenting as unclean and grubby. HO1 tried to interact with the twins but they did not react.  3.56 The same day HO1 emailed ASW describing the conditions which again, did not stimulate an immediate response from CSC.  3.57 Also the same day, ASW, on the instruction of TM6, was requested to conduct an unannounced visit early morning or late afternoon and inform the HV’s. ASW, states she carried out several unsuccessful attempts to visit the family home address, but no one was in.   163.58 Five days later ASW managed to carry out a home visit. Mother was concerned as the HO’s had informed her of CSC’s involvement and was worried ASW was going to take the twins away from her. Mother reluctantly allowed ASW into the premises and was initially reluctant to open the kitchen and bedroom doors because she disclosed to ASW they were a mess. The rooms were extremely dirty and a toxic atmosphere in the kitchen made ASW gag.  Mother said the smell was bleach and then changed her mind stating it was fly spray.  3.59 ASW was concerned as to the presentation of the children, their development and lack of facial expression and balance. It appeared the children were kept for long periods in a sitting position in their buggy. They were unable to sit up or bear weight. Mother said they could walk around holding onto furniture. ASW pointed out the array of boxes that were in the lounge and the dangers for them to do so. Mother agreed it was cluttered. In relation to their nourishment Mother stated she took the twins to MGM’s who feeds them.  3.60 No consideration was given as to the concerns that had been reported by Housing Officers on their two recent visits to the property to enact immediate safeguarding procedures. The day after the visit ASW contacted the Health Centre to request HV1 carry out a joint home visit to check on the development and weight of the twins with a view that it will go to an ICPC. 3.61 Four days later ASW personally attended the health clinic as she had not received a response. As a result, HV1 contacted Mother to bring the twins into the clinic for a health developmental check.  3.62 Three days later the twins were seen by HV1 and colleagues. They had grave concerns as to the condition of the twins, who scored alarmingly low on gross motor skills, problem solving and fine motor skills. There were significant concerns for their development and weight loss. As a result, HV1 sent an email detailing her examination and concerns to ASW. There was some difficulty contacting one another but eventually ASW spoke with HV1 two days later to progress the case.  3.63 The next day HV1 carried out an opportunistic home visit but was refused entry by Mother. Mother was told to bring the twins to the clinic that day, at noon, to be assessed again, due to the poor score on the previous assessment. 3.64 Mother brought the twins as requested. Child L on examination was described as particularly ‘jittery’ - a possible indication that a more serious medical and health condition could have been present. HV1 decided to implement safeguarding procedures and spoke with ASW, as both twins had lost further weight since the health development assessment three days earlier.  3.65 Later that day, following the mounting safeguarding and health concerns, ASW picked up Mother and twins from MGMs house and transported them to Hospital 1 for a medical examination and requested Police attendance. 3.66 A Paediatrician at Hospital 1 diagnosed the twins were suffering from severe neglect and malnourishment. Child M had Gross Motor developmental delay, had made no development progress since January 2016 and had also lost weight over the same period. Child L was found to have the same issues as Child M. There was severe  17eczema on the feet of both twins, which had been untreated. Their socks had to be peeled off due to the dryness of ‘serous fluid.’  3.67 Police in attendance at Hospital 1, placed the twins on a PPO and they were taken into emergency foster care. An Interim Care Order (ICO) was applied for and the case was made subject to Family Court Proceedings.   3.68 Mother was arrested by Detective Constable 1 (DC1), on suspicion of Child Cruelty/Neglect.    3.69 DC1 attended the family address. The smell within the flat was described as ‘disgusting and overwhelming.’ It appeared to be, amongst other things, damp. “There were no suitable sleeping facilities for the children, no suitable bathing facilities for the children. There are no cooking facilities in the flat. The toilet bowl was in a disgusting state. There was no food in the house. No fridge in the home.”  3.70 This was the Police first involvement in this case. They were provided with the history of the case as reported in this review and obtained subsequent witness statements from professionals involved in the family. 3.71 Mother was interviewed on two occasions. The first upon arrest in June 2016 and the second interview, after obtaining statements, when answering bail in August 2016.   3.72 During the interviews, Mother provided an account saying she was a single mother who struggled to cope financially and physically. She said the flat was cleaner than it had been recently. She did not have a working fridge or cooker, but the children were fed hot meals at MGM’s home. The children slept in Moses baskets as she could not afford to buy cots, Mother knew this was wrong, but had no choice financially. She fed the children in their buggy at breakfast and they then played on the floor with toys. She accepted the general condition was neglectful but she felt she fed the twins sufficiently. They would have a bottle of milk for breakfast and Weetabix and for lunch have 'lunchables' (cheese and biscuits) with a microwave meal in the evening, such as ‘Spaghetti Bolognese’. Mother said she did not think the children were under weight and fed them 'like horses' and the last time the children were seen by a medical person they did not raise concerns. 3.73 Mother did not accept wilful neglect but did admit the state of the flat was unacceptable and not suitable for the twins. Things started to get on top of her after the twins’ birthday; she should have got help and was ashamed. Mother asked family members for help but none of them helped. MGM could not leave her own house because she was a full-time carer.   3.74 When challenged on the contents of the medical statements, Mother said the Doctors were wrong and did not see what she saw in the twins, insisting the twins behaved differently around strangers and they could stand with support and not as described in the Doctor’s report and a friend could vouch for this.   3.75 Up until her arrest, Mother believed her children were developing ok and she had never been told anything else. She could not account for the weight loss and insisted she fed them three times a day. She denied Child M had dry and itchy skin on his legs and had photos on her phone to prove it. She became aware of the eczema about three weeks previous to attending Hospital 1 with ASW. She tried to  18phone the Doctor's but could not get an appointment. Mother suggested they probably had eczema because she had it and she had applied cream to the twins. They were bathed three times a week at MGM’s home and Mother claimed they did not have head lice (reported by Foster Carer). The children were able to put food in their mouths and her friend, who Police spoke too, could also confirm this. At the end of the interview she wanted to add she had made considerable improvements to the flat and cleaned the place up.  3.76 DC1 referred to mother’s account, when in Court for an ICO, saying that Mother stated she could not cope due to being a single mum. She had asked for help but had not been given any. She could not afford to get suitable cots for the children (this was apparently being pursued by ASW). Mother accepted the conditions at her home were disgusting and totally inappropriate for the children. There were lots of fruit flies within the flat and agreed the children should not be returned to the property.  3.77 The decision whether the case met the threshold for prosecution was made by DS1. The initial evidence had been referred to CPS, who raised some issues with relation to Family Court material, which they were not authorised to view at that stage. This included Mother’s psychiatric report (not available for this review). That report stated Mother was suffering from clinical depression, had a low IQ and was unable to put the needs of her children before herself and she had general cognitive difficulties.   3.78 DS1 recorded in the decision notes that in order to prove an offence of neglect they needed to be able to prove the neglect was wilful. When the twins were first born, due to Mother’s previous children being removed, there had been intervention from Social Care and Health. This support and intervention gradually dropped off which resulted in her having no support in caring for her children. Eventually concerns were raised by Housing to Social Care and then Police. This resulted in Mother being arrested for neglect and her children being removed.  3.79 After consideration of the evidence, the Police were of the opinion the case had not reached the full test code for a prosecution and the case was not referred back to the CPS. This rationale was due to the mental health issues of Mother and the inability to prove the neglect was wilful. They concluded that whilst Mother was receiving sufficient support, she was able to care for the children, when the support dropped off, for whatever reason, mothers’ ability to care obviously declined as well.’ The police therefore recorded the case as NFA.  3.80  The LSCB were notified of the outcome of the investigation in November 2017.  3.81 Author Comment: The decision not to proceed against Mother was taken by DS1 and agreed subsequently by senior officers without the need to refer to the CPS in determining the final decision to take NFA, as outlined above. It does not state whether there was an appropriate adult present during the Police interviews considering the general cognitive difficulties of Mother as suggested. Additionally, it was confirmed CSC applied to the Family Court for an ICO. An application was submitted to the Family Court to share the Court’s findings which were relevant to the Police neglect investigation at the time.  19Practitioner’s contribution to the review enquiries   3.82 The IOA was able to speak to a number of the practitioners involved with the family to clarify documented records and accounts.  3.83 FSW had informed TM3 that she knew Mother from her school days and now understands this is a conflict of interest. FSW will ensure they are not allocated a case in similar circumstances in the future and will escalate if necessary. FSW was aware from their school days, that Mother had hygiene problems, with school staff often changing her into clean clothing. This leaves a question mark against MGM’s care of Mother when she was a child.   3.84 Whilst a CIN case, FSW visited the family and worked with a Parental Outreach Worker (POW1).   3.85 At the CIN meeting in March 2015, no one present had any concerns regarding the twins. FSW was asked to Chair the meeting by TM3 and understands it should have been someone else. They discussed keeping the home clean. Mother said she had been doing this and would continue to make improvements. They discussed the need for larger accommodation to be made available when the twins reached one year old.    3.86 As all checks were carried out, it was decided to close the CIN to CSC as the main issue was the home conditions and these were improving. It was agreed the children’s health and development would be monitored under Health with support including the Children’s Centre and the MECSH programme, the case was stepped down to Health. FSW was not made aware that the MECSH programme was unavailable to the family.   3.87 FSW agreed that in her interaction with Mother, she did not challenge enough, and this is learning. She had a handover previously from SW1 but did not recall the previous history of Mothers elder children and could not recall if she looked it up on the Local Authority Computer Management System (LACMS) or whether there was a chronology available. She acknowledged she did not check with MGM regarding support and ensured she would complete her own chronology in the future. At that time, the twins were not on solid foods and she had no concerns for them, as Mother cared and stimulated them.  3.88 FSW did not consider whether Mother may have needed support and was a possibly vulnerable adult. Mother’s personal hygiene, according to her, seemed to have improved since school and she did not know whether this influenced her opinion of Mother’s ability. It was admitted she should have challenged her more about the home conditions and feels Mother got away with more things than other clients and looking back now recognises disguised compliance and has recently received training on this.  3.89  Within supervision it was asked whether concerns were appropriately shared and considered. FSW did not think it was included in supervision but was a case discussion at the desk. Learning through the SCR process has empowered her to argue her case and is fully aware now, how to escalate a case if necessary. It was confirmed that entries on the LACMS are placed on the system as soon as possible  20and she backs up everything by email. She said TM3 kept a note pad and any original notes were not kept but later destroyed (Confirmed by TM3).  3.90 TM3 - She was the previous TM3 in the Family Support Team (FST) and the supervisor of FSW. She has since left the LA. On receiving the referral, she allocated the case to FSW. TM3 was surprised as she was unaware FSW knew Mother and that she had her three previous children taken away from her years earlier.   3.91 As there is no record of this matter, the review cannot make a judgement decision either way as to whose account is correct.  TM3 stated if she had known of the conflict, another worker would have been allocated. Furthermore, now knowing the circumstances of the twins and the removal of the elder children, she would not have closed the CIN after three months. She further confirmed her original notes were not kept when details are placed onto the system. TM3’s original case notes were destroyed when she left the LA.   3.92 TM3 felt there should have been a Pre-Birth plan, as it is very different from a single assessment, as it focuses on specific issues and agreed there was no thought of holding an ICPC.    3.93 Author Comment: In relation to information from FSW and TM3 about being unaware of the previous history of Mothers elder children being removed, this SCR can confirm the information was available as it was recorded on the C&F Assessment (January 2015) and in the CIN meeting minutes.  3.94 ASW - After receiving the referral from the HO1, ASW was allocated the case by TM6 in the first week of June 2016 and completed a C&F Assessment. No advice was given regarding the allocation by TM6, considering, as ASW acknowledged, she was inexperienced.   3.95 ASW appropriately spoke with Housing and attempted to contact Mother without success. This also included an unannounced visit when Mother was not in. When she managed to speak to Mother, on the telephone, to arrange a home visit, she did not challenge Mother when she said she was either going to be out or too busy and Mother dictated the date.   3.96 Author Comment: The ASYE Manager, Peoples Services, informed this review the AYSE programme supports newly qualified SWs. The AYSE helps to bridge the transition from initial qualification to the realities of practice. Managers have to consider the complexity of the case allocated. Guidance of AYSE in the LA has provided workshops on AYSE for managers, discussion presentations at management forums and guidance circulated by HCSC1.   3.97 The first belated home visit was arranged for two weeks later, which, ASW agreed, was not ideal. ASW was asked whether she considered calling Police as she described seeing ‘minor neglect’, but she did not. The twins were seated in the middle of the lounge in a buggy and the door closed. In the flat, there were flies and a strong smell that Mother said was fly spray. ASW became aware that none of the white goods, oven or washing machine was working and Mother admitted the fridge was also not working. There was no food, but Mother stated she takes the twins to  21MGM to be fed every day. (This was never checked). Mother had to wash the clothing in the bathroom.   3.98 ASW admits she did not understand the complexity at that point (underweight and lethargic) but would now recognise and understand neglect. She raised her concerns with TM6, who was apparently of the opinion Police would not attend to carry out a joint home welfare visit (This opinion was not recognised by other practitioners spoken to).   3.99 ASW discussed the case with TM6 when she received information from Housing in the middle of June 2016. She was told “she was not Health and they should wait for Health to do their checks.” When the referral originally came in, they were not thinking about a s 47 investigation.   3.100 ASW felt it was not a suitable case for her to have been given and had never dealt with a neglect case before. She is now aware of the escalation policy for the future.    3.101 ASW was asked about record keeping, the delay in writing up the outcome of the PPO and action taken to protect the twins. She stated she attempted to speak to TM6, but she was busy. ASW was also busy, or on annual leave, but could not remember why there was a delay.  She admitted her findings were recorded on handwritten notes and later typed on to the case notes with the original note destroyed. ASW now appreciated the possible need for retention and transparency.  3.102 ASW felt she was not adequately supported, as she had gone to TM6 with her concerns, and felt she could not do so again after she was told she was not a professionally trained health adviser. At the time, ASW wanted to believe Mother would change, but retained the focus on the twins. It was pointed out the importance both internally and externally of escalating matters if a practitioner felt unsupported and this was agreed.    3.103 NICU Senior Sister and Staff Nurse (Hospital 1) – Both saw the Mother and the twins in the NICU. Their involvement was being on duty when the Pre-Discharge Meeting was carried out. They had no specific concerns regarding Mother and both believed the Named Nurse for Safeguarding, who was not available, should have been at the meeting, as they were not in a position to challenge decisions. An agreement was made however, for Mother to have an extended stay of five days at the Hospital to see how she cared for her babies. If there were no others concerns, the twins would be allowed home with Mother and support provided.   3.104 HCSC1, at time of the review, has since left the LA. The twin’s case was not brought to their attention, as it was not treated as high-risk by supervisors or TMs within CSC.   3.105 HCSC1 confirmed they are reliant on good managers identifying concerns that can be addressed. The fact the CIN was closed early was contrary to guidance for CIN cases and should have been challenged by supervisors.   3.106 The effectiveness of the LACMS recording process and supervision was discussed including the new High Risk Notification (HRN) form being introduced by the new HCSC2. HCSC1 confirmed although this form had not been available to them, they regularly interrogated the system to identify possible challenges.   223.107 In the present format of the HRN form, the twins case would not have necessary been considered a high-risk case (amendments to the form have been suggested within the Report Recommendations). HCSC1 view is the previous CP concerns should have been treated as high-risk until circumstances dictate otherwise.  3.108 HCSC1 explained the learning improvements identified by this review in their time in post, were being implemented by CSC and this was confirmed by the CSC IMR Author.   3.109 HCSC2 – Having arrived during the review, introduced a HRN form. Relevant cases must now be immediately brought to the attention of HCSC2 to consider the risk and take the required action if necessary. The form suitably amended, will ensure that in such cases considered a high-risk case will be brought to their attention and encourage supervisors to scrutinise more comprehensively. (See Findings).   3.110 LACMS - A meeting was held with the LACMS Knowledge Centre Manager and LACMS staff. Suggested recommendations were made to enhance the system and support staff in the integrity and transparency of the system. In particular CP cases when closed down are shown on the system however this does not happen when a CIN is closed and this should be remedied.   Other Areas Identified by the Review  3.111 Voice of the twins – This should have been reliant on the professionals engaged with the twins to identify the signs of safety and is subject to learning within both LSCB and agency recommendations.  3.112 Disguised compliance by Mother - When Mother was challenged or prompted, she complied with requests and advice from professionals and with community services when supported. Mother regularly attended the Children’s Clinic and was seen by HVs. When the Children’s Centre stopped working with her however, the LP/ HV1, would have been expected to ensure support and assessment was continual. The current record keeping is not clear whether HV1 saw the twins in the health centre or at home. The system automatically reverts to ‘home’ if not completed. (See LCFT Recommendations).   3.113 The last time a HV or GP saw Child M was in October 2015 and Child L in November 2015. From that period until January 2016, communication was made with Mother to make arrangements for home visits by HV1. On every occasion, these home visits were cancelled by Mother with an excuse that was accepted. (She was clearly attempting to keep professionals away from her home, probably due to the unhealthy condition later discovered).   3.114 Mother has been described as having an answer for everything by FSW. Considering the reason why her three previous children were taken away and the similar concerns that surfaced with her care of the twins, professional optimism still prevailed.  It was pointed out to Mother that improvements to the home were needed to ensure the care of the twins.  Mother never fully complied with advice or requests and always had an excuse that she would make improvements, but this never occurred.  Mother continually showed a reluctance to allow practitioners into her  23home, this is detailed within the narrative of this report.  Training within the Local Authority has commenced to recognise ‘Signs of Safety’, neglect and implementing Graded Care Profile 2, disguised compliance and professional optimism.  3.115 Considering the psychiatric assessment completed for the Family Court, as to Mothers understanding and mental health and the previous self-disclosure of depression, if the disclosures earlier had been thoroughly investigated it may have had a different outcome.  It would have probably resulted with a PBC, ICPC and CP Plan, and possibly may have considered Mother to be a vulnerable adult herself.  When she received the support, Mother was more compliant, but when this support stopped, she did everything not to have professionals come to the home.  She took every opportunity, ignoring calls, requests for home visits, changing/cancelling appointments and refusing in any attempt to keep professionals from entering her home which, suggests she knew of the concern for the twins.  The behaviour and traits she was displaying suggests her voice and actions were not heard or identified.  The role of the LP, what did this mean and what were the expectations?   3.116 The LP in the case of the twins was HV1. An LP is a practitioner that takes the lead to co-ordinate provision and is the single point of interest for contact with the family and children when, integrated services are required to be involved with the family. The LP is an important role to ensure provision was scrupulously applied. HV1 was interviewed by the LCFT IMR Author and could not remember being given the role but acknowledged receiving a letter from SW1 detailing the request that she was deemed the LP at the CIN meeting. The IMR states “there is little evidence she undertook the role, with sickness that may have impacted her ability to fulfil the role.” HV1 was long term sick and not available to meet with the IOA.  The decision making behind Child L and Child M becoming CIN as opposed to CP?  3.117 Decision making concerns, including the questionable quality of supervision, are permeated throughout the report. There was no appropriate consideration to treat the twins case as CP, which would have had a greater scrutiny with a PBC or ICPC where another outcome may have occurred. These concerns are subject to both LSCB and Agency Recommendations. In the Hospital pre-discharge meeting the risks highlighted were both current and historical. In Brandon et al (2010)4 ‘Start again Syndrome’ is a helpful way for professionals of conceptualising practice particularly in cases of neglect. The past is put aside to focus on the present and on short term thinking. In the twins case, there was too much professional optimism and insufficient focus of all the CP concerns which, should have insured the twins were treated as a CP case and not as CIN. Both SW1 and HV1 were concerned in the decisions made in the pre-discharge meeting with little or no managerial oversight for the case becoming a CIN as opposed to CP.                                                            4 Start again syndrome, Brandon et al (2010).  24Closure of the CIN plan, who was involved in this decision and the rationale behind this?  3.118 The CIN plan should not have been closed early, particularly when there were unresolved concerns and actions outstanding. FSW and HV1 were involved in the decision for closure and the outcome was agreed by TM3. TM3 in interview was apparently unaware there were CP concerns with her three previous children, even though the C&F Assessment and CIN minutes of the meeting record this fact, and are subject to both LSCB and agency recommendations. TM3 and FSW both accept the CIN should not have been closed in hindsight. When CIN cases are closed this should be included on the LACMS and is a recommendation to be implemented.  Information sharing between all agencies e.g. minutes of meeting?  3.119 Information sharing weaknesses and failures in some cases have been identified by IMR Authors and are commented upon within this report. The C&F assessment and the CIN minutes clearly outlined the previous CP concerns that some key practitioners were not apparently aware of. These concerns are challenged and addressed (See Recommendations).  Culture and Diversity    3.120 Culture and diversity was not an issue identified within this SCR.   Chapter 4 - Professionals Overriding Responsibility  4.1 As stated within Working Together to Safeguard Children 2015,5 professionals working within CP must ensure compliance with the following doctrine:  4.2 ‘Local Authorities have overarching responsibility for safeguarding and promoting the welfare of all children and young people in their area. They have a number of statutory functions under the 1989 and 2004 Children Acts 6which make this clear, and this guidance sets these out in detail.  This includes specific duties in relation to children in need and children suffering, or likely to suffer, significant harm, regardless of where they are found, under s17 and s47 of the Children Act 1989.   4.3 The Director of Children’s Services and Lead Member for Children’s Services in the Local Authorities are the key points of professional and political accountability, with responsibility for the effective delivery of these functions.   4.4 Whilst Local Authorities play a lead role, safeguarding children and protecting them from harm is everyone’s responsibility. Everyone who comes into contact with children and families has a role to play.                                                        5 Working Together to Safeguard Children 2015 - HM Government March 2015 6 Children Act 1989   254.5 Safeguarding and promoting the welfare of children is defined for the purposes of this guidance as:  • protecting children from maltreatment;  • preventing impairment of children's health or development;  • ensuring children grow up in circumstances consistent with the provision of safe and effective care; and • taking action to enable all children to have the best outcomes.   4.6 Local agencies, including the Police and health services, also have a duty under s11 of the Children Act 2004, to ensure they consider the need to safeguard and promote the welfare of children when carrying out their functions. Under s10 of the same Act, a similar range of agencies are required to cooperate with Local Authorities to promote the well-being of children in each Local Authority area. This cooperation should exist and be effective at all levels of the organisation, from strategic level through to operational delivery. Professionals working in agencies with these duties are responsible for ensuring they fulfil their role and responsibilities in a manner consistent with the statutory duties of their employer.’  4.7 Author Comment: It is clear that standards of Child Protection fell seriously short of this expectation, the fundamental responsibility for safeguarding and promoting the welfare of all children and young people was not consistently followed (See Recommendations).   Learning from previous SCR’s  4.8 This is subject to a recommendation to ensure learning from SCR’s within the Local Authority is captured and complied with.  Chapter 5 - Findings – Lessons learnt and suggested recommendations for consideration   5.1 This chapter outlines the findings identified from the analysis of professionals practice. They are produced for the consideration of the LSCB to identify and implement any learning from this SCR. There is an expectation from the National Panel of Independent Experts for SCRs, that overview reports should have recommendations that are concise and smart. The findings and suggested recommendations overarch, support or complement, but do not repeat the Individual Agency Recommendations which, are set to capture learning for their own respective agencies within their IMR submissions to the SCR process.   Finding 1 – Compliance to Safeguarding Policy and Procedures. Does the LSCB agree there is a need to remind all CP practitioners of their responsibilities in complying with local and national Safeguarding Policy and Procedures?    What should be considered? It has been identified there is a need to remind key practitioners of national and local safeguarding policies,  procedures, Working Together to Safeguard Children 2015 and other safeguarding guidance. There are sufficient and effective policies, procedures and guidelines in place, but some professionals did not follow  26even the basic rules for safeguarding children and young people in the case of Child L and Child M. It has identified training that has commenced.  LSCB Overview Report Recommendation (1) for the Local Authority CSC and Child Protection Safeguarding Agencies Partners  It is recommended that all the Local Authority Child Protection Safeguarding Agencies Partners, remind key practitioners to regularly familiarise and comply with National and Local Safeguarding Policy and Procedures and Working Together to Safeguard Children 2015 and other agency guidance and subsequent updates at all times.   Finding 2 – Governance and Supervision. Does the LSCB agree this SCR has identified concerns as to the function of the governance and supervision of CP cases with previous concerns and the suitability of Chairs of Strategy, Discharge, CIN and all other meetings where there are CP concerns and the appropriateness of scrutiny of the decisions made?   What should be considered? There is a need for a system where senior management in agencies are made aware of cases with potential high-risk or where there is or has been safeguarding concerns that are liable to escalate. This is to ensure supervisors are also supervised as reflected in the findings of this review.  • All CP meetings, including discharge meetings, must be chaired by an experienced professional and the outcome supervised, particularly when there are contributing factors and previous CP concerns, as in the case of the Mother’s three elder children. There must be a consideration of completing a HRN form for the information of the Head of CSC. If there is doubt whether it is or is likely to be a High-Risk case, then a HRN should be completed for the Head of CSC to be the final arbitrator.  • There should be an improvement of supervision, including supervision of supervisors, in CP cases and the quality of Children Looked After (CLA), CP Plan and CIN forms. • The current forms need revising, to be more user friendly and not rely on cut and paste. They must be concise and clear in order to identify when actions have not been followed. They should include a narrative, by professionals, of any action updates from the previous meeting that is reviewed to ensure accountability and challenge.  • Any decision to close a CIN or CP Plan must be subject to scrutiny and an appropriately experienced chair must ensure all concerns and actions are addressed, otherwise no closure can be sanctioned.  • Decision to close cases to CSC should be placed onto the LACMS for scrutiny and notification to the Head of CSC through a HRN form if considered relevant.  • Safeguarding meetings should be chaired by an experienced practitioner.  • The IOA, in conversation with the new Service Manager of the FST, MASH and CFAT, discussed escalation and this has now been addressed within his department with the implementation of an improvement action plan.    27LSCB Overview Report Recommendation (2) for all the Local Authority Child Protection Safeguarding Agencies Partners  It is recommended that all the Local Authority Child Protection Safeguarding Agency Partners must ensure all meetings, involving any safeguarding and CP concerns, are chaired by a suitably experienced practitioner.  Any decisions made must be appropriately supervised, with staff reminded of the escalation policy where there is a disagreement as to process or course of action, to ensure that all decisions are acknowledged and supervised. All decision making should be recorded and uploaded onto the respective Local Authority or Individual Agencies Computer Management Systems for transparency and for governance of the supervision within the designated timeframes.   Finding 3 – Record Management. Does the LSCB agree there is a need for a robust and thorough system to ensure that all relevant information and records of discussions and action taken by professionals in any safeguarding case, is effectively recorded. This is to ensure a record is available for future reference and transparency?  What should be considered?   • A HRN form must be completed promptly with a copy to be uploaded on to the LACMS. • As Finding 2 states above, there must be effective supervision and supervision of supervisor’s entries. Supervisors should ensure any actions allocated are carried out in compliance with the outcome recorded on the LACMS, with a rationale if they cannot for any reason, be completed.  • Immediacy of entries for transparency. Key practitioner’s notes should be scanned onto the system for accountability and transparency with original notes being retained by practitioners. • Back record conversion of the LACMS of previous CP records, which remain outstanding. Many have not been put onto the system as they predate the instigation of the current LACMS, as in this case, the details regarding Mother’s previous three children were outstanding and not placed on the system but was within CP records. • Head of CSC authorisation to agree for HRN forms to be uploaded onto the LACMS.  • CIN closure outcomes to be recorded on LACMS and an alert made when an early closure, by use of the HRN form, for the attention of the Head of CSC must be made. If there is a doubt, refer in any case.  LSCB Overview Report Recommendation (3) for Local Authority Head of CSC   It is recommended the Local Authority CSC ensure record keeping is enhanced and staff reminded to ensure all CP cases are expeditiously recorded onto the LACMS. Original notes should be uploaded and scanned onto the system for retention and transparency. They must comply with supervision actions and that supervisor’s guarantee the actions and directions recorded are comprehensively completed, with a rationale, if for any purpose an action or directive was not followed. If any case is  28considered or is potentially a high-risk case, then a HRN form must be completed.  Finding 4 – Enhancement of the LACMS. Does the LSCB agree there is a need for the current LACMS to be enhanced and adapted to capture and support learning identified from this SCR?  What should be considered?    • Transparency – Clear criteria to ensure entries are completed as expeditiously as possible, with clear management oversight  to challenge any late entries placed on the system • To ensure that all original notes and accounts which may be subject to challenge if later required evidentially are included. • Supervision - Monitor supervision entries to ensure that practitioners complete any actions and advice of allotted tasks. • Can the current system address supervision of staff but also how to supervise the supervisors? • The supervision of supervisors could be monitored by the new HRN form implemented by the Head of CSC.  • HRN Form – It is suggested HRN forms are put on the system. There should be a consideration to adapt the HRN form for the purpose to include serious neglect, historical CP cases that have resulted in a CP or CIN and when CIN’s are closed, particularly if not in compliance with an agreed plan. • Request for the HRN form to be placed onto the LACMS on the instruction of the Head of CSC. It will ensure supervisors, completing the form, realise it is flagged to the Head of CSC and will stimulate entries on the system and supervisor’s actions and advice have been complied with by their staff. This will hopefully make sure TMs and supervisors supervise their staff and check they have complied with any of their actions and to deal with any outstanding matters promptly. • Closure of CIN – It was noted when CP cases are closed this information is available on the LACMS. However, CIN case closures are not placed onto the system and it is recommended they are for continuity, supervision and future reference. • LACMS back record conversion - Mothers previous historical CP concerns and the details of the removal of her three children was not on the system and this needs to be addressed. This was because a back-record conversion of previous CP files has not been completed several years after the implementation of the LACMS.   LSCB Overview Report Recommendation (4) for Local Authority Head of CSC   It is recommended the Local Authority Head of CSC ensure the LACMS consider the findings from this SCR to enhance support and system improvements to include transparency, supervision, HRN forms, closure of CIN cases and complete back record conversion of CP records, required for historical background research by practitioners.    29Finding 5 – Supporting Families. Does the LSCB believe there should be a process in place to ensure that when support and actions agreed for CIN or CP cases, alter, resulting in potential or significant changes of circumstances to the agreed Plan, this is reported to CSC with a view to consider a strategy meeting or other action required to maintain welfare, care and support to children and young people?   What should be considered?   Parents and guardians should be informed when a child or young person is subject to any assessment or s47 joint investigation. This is to ensure they have the appropriate knowledge, understanding, information and support in place to allay any concerns of the safeguarding process taking place for their child or young person. This may assist staff when dealing with anxious or reluctant parents or guardians. When agreed support is in place, and that support changes, is refused or does not progress (as in this case of the MECSH programme) to support the family, there should be a notification to CSC even if a case is closed to them. This will ensure the outcome and reasoning, with the rationale, is recorded for future reference. In this case HV1/LP did not report the MECSH programme was unavailable at that time to the family or CSC. It is not known when this information was known. This programme was being relied upon as part of the support for Mother and the twins at the first and only CIN meeting. Furthermore, contingency plans should be in place regarding practitioner’s continuity of cases when on sick leave to ensure support is maintained. This stimulated a response from LCFT and is learning for the enforcement of contingency plans to ensure this does not reoccur.   LSCB Overview Report Recommendation (5) for the Local Authority CSC and Child Protection Safeguarding Agency Partners   It is recommended the Local Authority CSC and CP Safeguarding Agency Partners review the policy and procedures regarding when there is any divergence of an agreed CP plan of support for safeguarding the welfare of children and young people. Any changes of support must be supervised and reviewed with a robust response, to ensure that welfare and protection is maintained, with the consideration of holding a strategy or other meeting, to discuss whether alternative action is immediately required, even if the case is closed to CSC.  Finding 6 – Case Allocation and Research. Does the LSCB agree there is a need for CSC to review case allocations, to ensure that historical CP research is carried out to capture all available information, and that key practitioners are only allocated cases that have the necessary experience and/or supervision in support. Furthermore, any unresolved concerns and differences of opinion are subject to escalation processes if necessary and High-Risk cases are identified and reported?  What should be considered?    • There must be a full assessment of any previous history of a CP case prior to allocation by a supervisor. It should be acknowledged by the key practitioner and supervisor on the LACMS to outline the action to be taken. Only experienced practitioners or supervised inexperienced practitioners, matched to the task are allocated after a review of the surrounding  30circumstances of the case.  • Any previous CP concerns, where a child or young person is removed from the care of a parent, if the parent(s) subject of the initial concern is expecting the birth of further children, then a PBC should be held where a full account of the possible CP concerns, both historically and currently, could be considered within a multi-agency forum.  • Any disagreement of opinion in a CP case must be escalated. The IOA raised this issue with the incumbent Service Manager responsible for the FST, MASH and FCAT, who subsequently submitted to this review an Action Plan to address this and other concerns. High risk cases must be subject to completion of a HRN form (this will ensure compliance with governance and enhance supervision). The HRN form should be entered onto the LACMS for supervisors to complete for the information and consideration of the Head of CSC.   LSCB Overview Report Recommendation (6) for the Local Authority Head of CSC  It is recommended the Local Authority CSC review: - • Case allocations to ensure all CP history is researched thoroughly, particularly where there have been previous CP safeguarding concerns, to capture all available information.  • Key practitioners are only allocated cases that have the necessary experience and/or supervision in place to support them. • Any previous CP concerns, where a child or young person is removed from the care of a parent, a PBC must be held, regardless of when this occurred, where a full account of the history known to agencies and any other concerns, both historically and currently, can be considered to ensure the continual safeguarding and welfare of children and young people.  • All unresolved concerns and differences of opinion on a CP case are made subject to the escalation processes and recorded on the LACMS for future reference. • Any CP cases with previous safeguarding concerns and other High-Risk or potentially High-Risk cases if in doubt must be subject to the completion of a HRN form, supervised and submitted for the attention of the Head of CSC and recorded on the LACMS for retention.  Finding 7 – Conflict of Interest. Does the LSCB agree there is a need to ensure the Local Authority specifically addresses and reminds key practitioners of their responsibility and duties when there is a case of conflict of interest in a CIN/CP case?  What should be considered?   • No professional can work on a CP case knowing the family. • Professionals must disclose their conflict of interest on the LACMS and this will be acknowledged by their supervisor and appropriate action taken to reallocate the case to another practitioner.  31LSCB Overview Report Recommendation (7) for the Local Authority CSC  It is recommended the Local Authority CSC review guidelines, to ensure there is compliance in place, for all staff, when there is a conflict of interest. It is incumbent on both the key practitioner to report the fact to a supervisor and both must record the details of the conflict of interest onto the LACMS with the recorded outcome for transparency. Another key practitioner must be allocated to the case.  Finding 8 – Information Sharing. Does the LSCB agree there is a requirement to remind CSC and Health professionals of their responsibility to share CP safeguarding issues as outlined in current and up to date Safeguarding Policy and Procedures?  What should be considered?   There are sufficient current national and local safeguarding guidelines, policy and procedures in place. Staff need to be reminded of them and the need to share information, as it is their own personal responsibility to know the guidance and comply. Regular communication and information sharing between agencies may have resulted in a different outcome being taken for the removal, at the first CIN meeting, of the twins, with the case being closed to CSC.   There is no suggested LSCB Overview Report Recommendation as this issue has been addressed within agencies IMR submissions.  Finding 9 – Learning from SCRs. Does the LSCB agree there is a need to remind staff of the learning from previous SCRs to ensure the learning is captured and complied with whilst completing their own respective safeguarding responsibilities?   What should be considered?  All safeguarding agencies must remind staff of the requirement to make themselves aware and to comply with the learning from previous SCR’s. The NSPCC,7 on their website every year, publishes recent SCR’s. This is extremely helpful, containing identified learning professionals should familiarise themselves with in their own CP roles and duties. In supervision, there could be a consideration that staff are made aware of learning from SCR’s and that access to the NSPCC SCR website is known and available.   LSCB Overview Report Recommendation (8) for the Local Authority CSC and Child Protection Safeguarding Agency Partners   It is recommended the Local Authority CSC and Child Protection Safeguarding Agency Partners remind all staff of the need to have knowledge and awareness of learning from SCRs when carrying out their Child Protection roles with the publication of any previous learning made readily available to them.                                                         7 NSPCC Yearly audit of published SCR’S.  32Finding 10 – Parallel Processes. Does the LSCB agree there is a need for the NPCC to remind Police personnel of the agreed guidance for the Police service, CPS and LSCB’s to share information regarding parallel processes of a criminal proceedings and a SCR when they coincide?  What should be considered?  There is a need to remind SIO’s of the agreed guidance on sharing information in parallel processes involving criminal proceedings and SCR’s. This is necessary in order to ensure the progression and support for each process.   LSCB Overview Report Recommendation (9) LSCB for the NPCC  It is recommended the LSCB request the NPCC to remind all Police Senior Investigating Officers (SIO) of the agreed Police Service, CPS and LSCB’s guidance on sharing information during parallel criminal proceedings and SCRs to ensure progression, support and cooperation for both processes.  Inhibitors to the process  5.2 The following inhibitors have impacted the timeline of this review: -   • There were delays by some agencies completing identified actions and required escalation by the LSCB Business Manager. • Due to parallel processes the SCR was delayed awaiting a Police decision, as to whether criminal proceedings would be taken. The final outcome was NFA was to be taken. A completed Police IMR was received but was not adequate and did not comply with the LSCB ToR. This is subject to Learning on the Fringes at Chapter 7. • The LSCB, with the IOA, had to remind the Police of the available guidance for the Police Service, the CPS and LSCB’s regarding sharing information in SCR’s, to progress and support both procedures when they coincide and is subject to a national review for the National Police Chiefs Council (NPCC) to remind SIOs of the expectation and guidance8  • The CCG IMR reported in 2014 Child M had sustained a left 8th rib fracture. It was not considered or analysed further and was not mentioned in Hospital 1, 3 or the LCFT IMR’s. It required enquiries to be made on behalf of the IOA by the LSCB and further requests for health to resolve whether there were any CP concerns. The outcome is recorded within the narrative of this report and was not obtained until January 2018 and is Learning on the Fringes of this SCR. • CSC archive research and detailed information was not carried out into the CP concerns of Mother’s previous three children. Clarification was only obtained after the initial drafts of the Overview Report were completed (February 2018). This necessitated further editing. This information should have been checked at the outset and is learning for future SCR’s (See Finding 9 and LSCB Recommendation 8).                                                       8 Liaison and information exchange when criminal proceedings coincide with SCR’s. ACPO May 2014.  33• Approximately thirteen key practitioners had left the Local Authority who were of significance for completing the SCR.  Some staff were traced and spoken to by the IOA, but others were invited but did not participate or acknowledge the LSCB request to meet with the IOA. The former CFAT Manager had left the Local Authority and HV1/LP has been on long term sick and has not been seen for the purposes of this review. HV1’s involvement and analysis was obtained from within the Agency IMR and a Police statement that was obtained.  Chapter 6 - CONCLUSIONS Predictability  Was the severe neglect of the Twins predictable?   6.1 It is the finding of this review that the twins’ case was predictable. The evidence of severe neglect identified within this SCR, mirror’s the significant CP concerns that were known to CSC from 2000 until 2004.  Mothers three previous children were initially placed onto the Local Authority CPR before being permanently placed into the care of the birth Father and PGM. At that time, she was only allowed supervised access. She was displaying similar worrying signs of personal hygiene, the condition of the home, serious developmental delay of the children and missed appointments with health professionals that were also evident in the twin’s case. When it was confirmed in 2014 Mother was pregnant with the twins, Community Midwives at Hospital 1 correctly referred the case due to these historic CP issues to CSC. It was considered, but not progressed further and was the first of several opportunities, to hold a PBC.  It is suggested the twins, on the facts known, may not have been initially considered as a high-risk case by some optimistic professionals, due to the period passed since the previous CP concerns. This SCR believes however, it is irrelevant whether there are long periods between CP concerns. The emphasis must be that any new case must be considered as high-risk where there were previous CP concerns and where children and young people are removed from a parent or guardian, until the facts are investigated, and evidence is obtained to the contrary. The fundamental principle is the welfare of the child.   6.2 This case has highlighted the lack of professional inquisitiveness, reinforced governance, intrusive supervision of decisions and challenge of disguised compliance. Preventability   Was the severe neglect of the Twins preventable?   6.3 It is the finding of this review that the twins case was preventable. The warning signs were there for professionals to see. There was no consideration, on several occasions, to hold either a PBC or an ICPC. An initial CAF was completed, which was considered weak, and after a disagreement between two managers in the MASH and the CFAT, the MASH manager suggested CFAT should complete a C&F assessment and hold a PBC. The CFAT Manager did not agree with this advice. The  34latter was of the opinion that the previous CP concerns were historical, and it would be ‘punitive’, with no evidence, to suggest there were any concerns Mother could not care for her unborn twins. Considering the difference of opinion, escalation processes were not implemented. A C&F Assessment was later carried out, after the Maternal Uncle of the twins confided his concerns of Mother’s inability to care for them to his own Social Worker, who appropriately made a referral.   6.4 SW1 chaired a pre-discharge meeting at Hospital 1 in December 2014. The decisions taken should have been strictly scrutinised, as there had been reported concerns from Hospital staff, both from Hospitals 1 and 3, as to Mother’s personal hygiene, worries about her ability to put the care of her babies first, her financial difficulties and the reported uncleanliness of the family home. A decision was made for Mother to stay at the Hospital over a five-day period and supervised by nursing staff. If there were no concerns during this period of observation the twins could be discharged home with Mother. Mother stayed at the hospital with the twins and she was not prepared, with no toiletries or suitable clothing brought with her. Comments made by Hospital staff suggested Mother would make excuses like she needed to go out of the room or have a cigarette when the babies needed changing or feeding. It was stated however, at times she displayed bonding and motherly instincts, but concerns still persisted.  6.5 In January 2015, the twins were discharged to Mother’s care to return home. There was no intrusive supervision, considering the previous historical concerns and those that were current, to allow the twins home with Mother. A C&F Assessment carried out highlighted concerns and plans put in place to monitor and assess Mother, with regular visits by professionals, as the twins were considered as CIN. There was no consideration for holding an ICPC or treating the twins case as CP, with the extra safeguards CP cases have, which would have been a better option. The CIN was recommended to be in place for six months. The FSW working with the family, who was a school friend of the Mother, a definite conflict of interest, after three months, chaired the first CIN meeting and closed the twins’ case to CSC, for Health to provide support in the community with HV1 nominated as the LP. There was no challenge or management oversight by supervisors as to the early closure. This review has addressed these factors.   6.6 The support provided by HV1 was concerning and the MECSH programme was not available to the family and this was not reported by HV1. The GP and presumably HV1 last saw Child M in October 2015 and Child L seen by the GP in November 2015. There were attempts by HV1 to carry out a home visit that was frustrated by Mother who kept cancelling appointments. The last contact with any Health Professional was when Mother cancelled an appointment in January 2016. HV1 was often sick during this period but there was no contingency plan in place and the twins were effectively forgotten until June 2016. The following up of missed appointments is now a requirement for all NHS Trusts and was introduced in response to the Protection of Children report by Lord Laming, 20099. Missed appointments are a theme within previous SCR’s and the continual failure is unacceptable and must be reinforced for compliance.                                                        9 Protection of Children report, Lord Laming 2009.  35 Engagement with professionals and family    6.7 Mother and MGM were invited by the LSCB, on several occasions, to participate in the SCR. No reply was received and therefore there was no opportunity to obtain their account for the SCR process.  Opportunities to intervene prior to Child L and Child M’s neglect taking place   6.8 Considering the predictability and preventability above, further opportunities to intervene, are outlined below. Conditions of concern seen by the practitioners did not stimulate an immediate safeguarding response being taken to protect the twins, until a month later as follows: -   • End of May 2016 when Council employees and HO3 attended the home address to exercise a warrant to effect entry for an essential gas service. As a result of the conditions found, HO3 appropriately shared the information to HO1, who completed a CAF form referral to CSC. There was a slight delay in submitting the referral. • Three days later, referral from HO1 received by CSC. There was a delay in allocation. • Four days later, case allocated to inexperienced ASW. Historic background research not completed by ASW and TM6. • Eight days later, HO1 follow up visit with HO2 Team leader, email submitted of the worrying conditions that still persisted in the home, with concerns for the welfare of the twins, made to CSC on the same day. •  Five days later, ASW home visit (delayed by Mother and accepted). ASW and TM6 did not apparently recognise the clear safeguarding concerns for the safety and wellbeing of the twins. • The next day, ASW telephones HV at the Health Centre for HV1 to carry out a joint home visit to check on the children.  • Three days later, ASW went to the Health Centre to find out about the requested development check on the twins.  • Three days later, HV1 saw twins in the local Health Centre.  • Three days later, HV1 attends home address but Mother denied access as twins were asleep (9am). • Same day, HV1 saw Mother and twins in Heath Centre (12 noon). • Same day, ASW informed of concerns and instructs HV1 to inform Police. • ASW at Hospital 1 with Mother and twins, who are examined by Paediatrician 1 who confirms both twins are suffering severe neglect. Police attend, and a PPO carried out with the twins removed from Mother who is arrested by Police for cruelty and neglect.   6.9 The question everyone must ask themselves, considering the situation and environment observed by professionals the twins were exposed to, what action would you have taken to ensure a child or young person is safeguarded in similar circumstances?  36Chapter 7 - Learning on the Fringes  7.1 The issues below were identified and raised within Agency IMR’s and within SCRP meetings. It is suggested they should be addressed outside the processes of this SCR, to establish whether there are further lessons to be learnt. They will be monitored by the LSCB Action Plan that will accompany this Overview Report: -  1) Police - The Local Police did not complete an acceptable IMR. An initial IMR was submitted that was not completed as required by the SCR ToR set by the LSCB. It lacked detail and analysis, with some sections not completed and left blank. A further request was made for a revised IMR after the Police decision to take NFA in criminal proceedings against Mother.  A written report was submitted instead, completed by the officer in the case and supervised by a line manager. It was not however, an independent report, with no analysis or consideration for any learning required to be considered for the SCR. 2) LCFT, Hospitals 1 and 3 - The CCG IMR detailed a previous rib fracture on Child M. The report did not comment or elucidate on the circumstances, diagnosis or causation and neither the IMR’s from LCFT, Hospital 1 nor Hospital 3 had identified the fracture. There was a failure of sharing information by Hospital 1 and Hospital 3, where it was believed the rib fracture occurred. The outcome and the rationale of the causation necessitated requests and enquires to be made by the LSCB. This issue was further raised within the November 2017 SCRP meeting. If an IMR Author records an incident, that raises a significant concern, such as a rib fracture in a baby, the circumstances must be investigated and analysed for the purposes of supporting the review and included in their response. There was a significant delay in investigating this occurrence that was known for several months by agencies. 3) Key Practitioners who have left the Local Authority - There is an expectation that key practitioners, when they have left the Local Authority and were concerned or involved in the circumstances of a commissioned SCR, would assist and participate in the process. Several key practitioners who have left were considered significant in order to obtain information and thereby possibly identity learning for the SCR. LSCB made several requests for their participation but received no response or any reason given for not assisting the SCR. It is therefore imperative the findings and learning from this SCR are promulgated to those practitioners to ensure lessons are learnt to promote the safeguarding and wellbeing of children and young people in the future. Further considerations for Agencies to consider  7.2 Agencies were asked by the LSCB to consider further considerations for other agencies. These have been addressed within the recommendations.  Those that do not impact on the outcome of this SCR are Learning on the Fringes, to be pursued outside of this SCR process.  37Overview Report submission to the LSCB  7.3 The SCR has established whatever safeguarding policy and procedures exist, and training received, lessons learnt from previous SCR are not always followed explicitly.  7.4 Guidelines, policies and procedures are written with the fundamental principal to protect children and young people. Practitioners must be conversant and up to date with their own knowledge and awareness of safeguarding procedures and it is their professional responsibly to do so, with regular refresher training for all levels of staff within an agency.  Chapter 8 - Individual Agency Recommendations Children’s Social Care (see also Implementations below)  Recommendation 1 - CSC staff to receive input regarding the following procedures: - • Pre- Birth assessments. • Thresholds regarding neglect. • Strategy meetings. • Escalation of concerns. • Recording information and decisions on LACMS. • CIN meetings.  Recommendation 2 - Training for staff (ongoing). • Universal risk indicators. • Graded Care Profile 2. • Analysis. • Challenging professionals. • Disguised compliance.  Recommendation 3 - Update CIN procedures to include timeframe if and when meetings should take place: - • Strengthening the rigour of multi-agency professional meetings that operate below Child Protection threshold. Hospital 1 Recommendation 1 - Hospital is to create a questioning culture, by encouraging staff to go beyond recognising risk and be party to managing and analysing risk. This is to be emphasised through the Level 3 Safeguarding Children Training.  Recommendation 2 - The Hospital Safeguarding Children Team create opportunities for case discussions in training, supervision or huddles to improve professional curiosity in safeguarding children.   38Recommendation 3 - Through training and meetings, awareness raised on how to capture, record and respond to the Voice of the Child.  Recommendation 4 - Escalation in response to recognised risk factors and CSC being the lead agency, in future it is an expectation that hospital staff should use their escalation policy for any risks that do not appear to be met by a robust safeguarding plan.  Recommendation 5 - Safeguarding supervision is recommended for all staff working with children and young people in the hospital. The process of safeguarding (not this case) will support staff to identify, respond and manage risks in future.  Recommendation 6 - Hospital to consider risk factors of individual patients when cancelling outpatient clinics and to make reasonable and robust arrangements to see them sooner. Hospital 2  Recommendation 1 - All information, including pyscho-social and safeguarding should be part of the transfer process between hospitals.  Recommendation 2 - Notes should be organised clearly, identifying all staff by name, role and dated. Contact with professionals and content of parent frequency of visits; observed care provided by parents or key family members diligently recorded.  Recommendation 3 - Information to be followed up in all instances and a complete record made.  Recommendation 4 - A better understanding of the thresholds to statutory services.  Recommendation 5 - A need to carry out earlier checks if the family are registered with a GP and to ensure that transfers in from other hospitals where there are Child Protection safeguarding issues to be made aware of.   Hospital 3  Recommendation 1 - Earlier Calls to Children’s Social care to establish if a family is open to them, on what basis and the Social Workers contact details.   Recommendation 2 - To contact the Safeguarding Children Team in the hospital to raise awareness and management oversight of all neonatal babies on the NICU unit over 28 days of age with safeguarding concerns, when midwifery services are no longer involved.   Recommendation 3 - To be professionally curious about issues of emotional regulation, self-neglect, previous parenting difficulties.  Recommendation 4 - There is a parent councillor for NICU currently in post who, should the baby be in NICU now, would have been an additional emotional/practical support for mother.   39Recommendation 5 - To continue to write clear contemporaneous notes and file them electronically in appropriate ‘safeguarding notes’ keeping alert in the patient header with the safeguarding headline and contact details of the Lead Professional e.g. Social Worker and the outline of concern e.g. open for assessment, previous issues of neglect etc.  Recommendation 6 - Continue to promote staff accessing tools such as Graded Care Profile or use of tools within supervision.  Recommendation 7 - Invite and include discharge coordinator for NICU who has daily oversight to the Safeguarding Children Team monthly meeting.  Local Community Foundation Trust   Recommendation 1 - To ensure LCFT practitioners have an understanding of the LSCB Threshold Document.  Recommendation 2 - Safeguarding children training to be strengthened to impress upon practitioners the requirement to be assertive to multi-agency decision making and use the escalation process as appropriate.  Recommendation 3 - Where children are subject to a CIN or CP plans, LCFT practitioners to provide feedback from the outcome of assessments.  Recommendation 4 - Where children are subject to CIN or CP plans, representation at meetings should be by a qualified Health Visitor or School nurse.  Recommendation 5 - Following attendance at safeguarding meetings, a brief account of the meeting, decisions made, and outcomes should be recorded in the electronic records within 24 hours and the alert updated.  Recommendation 6 - Practitioners to use the Assessment Framework tool to analyse risk and plan care.  Recommendation 7 - Consideration to be given to functionality for use of the Assessment Framework tool to be created on SystmOne.  Recommendation 8 - Where practitioners are off sick for a prolonged period of time, LCFT to ensure there is a robust business continuity plan in order to safeguard vulnerable children and families. This includes a communication pathway whereby when the practitioner returns they are fully appraised of their responsibilities. Clinical Commissioning Group   The following NHS CCG and NHSE recommendations have been made for Primary Care and they will be implemented by all GP Practices working in the local area. Lessons will be disseminated to GP’s through local GP forums.   40Recommendation 1 - GP Protocol for receipt and review of hospital letters: All GP Practices in the Local Authority to ensure all letters received at the Practice containing safeguarding children information must be reviewed by the Clinical Safeguarding Lead for the Practice to ensure GP’s are aware of safeguarding risks for all children young people registered at the Practice.  Recommendation 2 - Information sharing: All GP’s and Practice Clinicians on SystmOne must check if any information has been entered on the safeguarding children palette to ensure they were aware of all safeguarding risks to inform their assessments and decision making, when seeing children and young people for health consultations.   Recommendation 3 - If a GP/Clinician became aware from another health colleague that a child is subject to CIN/CP Procedures they must contact the Social Worker to obtain information about the risks to the child and request a copy of the CIN/CP plan and be invited to future meetings.  Recommendation 4 - Escalation: If a GP practices becomes aware that they have not been formally notified that a child is subject to CIN/CP procedures, they must escalate this to Children’s Social Care and escalate to the CCG if they encounter any challenges/conflicts.  Housing Department  Recommendation 1 - Corporate staff refresher training on Children and Adult safeguarding awareness for Housing and Registration Officers.  Recommendation 2 - Housing Staff reminder on how to access CAF forms on EDRMS.  Recommendation 3 - Housing Officer Refresher training on the Tenancy Audit process once a year.  Recommendation 4 - Housing staff reminder in how to record customer information/warnings on Northgate (replaced Saffron).  Recommendation 5 - Vulnerable Persons Protocol – staff refresher briefing to all Housing Officers and Registration Officers at least twice a year.  Recommendation 6 - Housing Officer Refresher briefing on ‘Know your Tenant’ checks.  Recommendation 7 - Update Gas Servicing with guidance for the Housing Officer to refer to the Joint Area Safeguarding Procedures. Children’s Centre  Recommendation 1 - Ensure all relevant signatures are obtained where required on documents.  Recommendation 2 - Children’s Centre service adding to the case file diary when a case is closed to Parent Outreach Support.  41 Recommendation 3 - Parental Outreach Worker case closure document should state recommendations and a clear exit plan.  Recommendation 4 - Process/monitoring for following up non-engagement at Children’s Centres for families that have been on CP or CIN Plan following closure of Parent Outreach support.  Recommendation 5 -  All Parental Outreach Workers to use the GCP2 neglect tool. Integrated Care 111 Service  Recommendation 1   It is recommended the Integrated Care 111 Service continue with the introduction of Child Protection Information Sharing (CPIS) system. This will  enable information to be shared to services such as Emergency departments, minor injuries, GP Out of Hours, Walk in Centres, Ambulance Services  on the statutory position of ‘Looked After Children’ (LAC) or children (including unborn) subject to Child Protection Plan They also can see when and how often the child has attended for emergency treatment. It is intended this information be available to appropriate clinicians in any unscheduled health care service in England to see this for a child wherever they present to these services across England.   For further consideration - The special notes are highly significant and there should not be any delay in these being updated by the GP. This is to ensure all pertinent information is recorded and can be viewed as necessary to ensure appropriate decisions in care are made. The 111 service has limitations within their assessments t carried out as they are dependent on the information being provided, not only by the records but also by the caller. (This is Learning on the Fringes of the SCR which did not impact on this case which the CCG and NHS England may wish to consider outside the SCR process for possible learning). Implementations  The following are implementations that have been identified during the SCR process and meetings with the IOA to address agreed findings of concern. They are a supplement to the SCR and are subject to CSC Agency Recommendations and overarched within LSCB Overview Report Recommendation and Findings to the review. This work is current and ongoing and been implemented or in the process of being implemented. Children Social Care  1) The LSCB now has a multi-agency neglect strategy. 2) The adolescent neglect tool continues to be rolled out across partner agencies. 3) The Graded Care Profile 2 neglect tool continues to be rolled out across all partner agencies.  424) Signs of Safety (SOS) is now being implemented. Training started for multi-agency staff in October 2017. The Signs of Safety10 is an innovative strength based, safety-organised approach to CP casework. The model was created in Western Australia by Andrew Turnell and Steve Edwards, and based on what practitioners know works well with difficult cases. The Signs of Safety approach has attracted international attention and is being used in jurisdictions in North America, Europe and Australasia. 5) There is now a supervision tracking tool to monitor frequency and staff workload.  NB. The NSPCC in 2013 completed a Signs of Safety in England11 report, based on the 1990’s work by the aforesaid authors. It is an NSPCC commissioned report on the Signs of Safety model in child protection.  Children and Targeted Outcomes (CATO)  CATO has developed a detailed Improvement Action Plan to address learning and improve services. It covers: - management oversight, supervision, decision making when cases progress to ICPCC, timeliness of assessments, care planning and case transfer, voice of the child, improve the accuracy and quality of case records, the escalation process and how to deal with disputes that this review has identified as a concern are to be addressed. Chapter 9 – Glossary  ASW Allocated Social Worker ASYE Assessed and Supported Year in Employment C & F Child and Family Assessment CCG Clinical Commissioning Group CFAT Children and Family Assessment Team CIN Child in Need CLA Child Looked After CM1 Community Midwife 1 CP Child Protection CPR Child Protection Register CSC Children's Social Care DC1 Detective Constable 1 DfE Department for Education FST Family Support Team FSW Family Support Worker HCSC1 Head of Children Social Care 1 HCSC2 Head of Children Social Care 2 HO1 Housing Officer 1 HO2 Housing Officer 2 HO3 Housing Officer 3 HRN High Risk Notification                                                       10 Signs of Safety. Andrew Turnell and Steve Edwards 1990’s. 11 NSPCC Signs of Safety in England, Amanda Bunn 2013.  43HV1 Health Visitor 1 ICO Interim Care Order ICPC Initial Child Protection Conference IMRs Individual Management Reviews IOA Independent Overview Author LA  Local Authority LACMS Local Authority Computer Management System LCFT Local Community Foundation Trust LP Lead Professional LSCB Local Safeguarding Children Board MASH Multi-Agency Safeguarding Hub MECSH Maternal Early Childhood Home Visiting Programme MGM Maternal Grandmother MU Maternal Uncle NFA No Further Action NPCC National Police Chiefs Council PBC Pre Birth Conference PGM Paternal Grandmother POW1 Parental Outreach Worker 1 PPO Police Protection Order SCR Serious Case Review SCRP Serious Case Review Panel SMS Specialist Midwife for Safeguarding SOP Senior Investigating Officer SW1 Social Worker 1 TM1 Team Manager 1 TM2 Team Manager 2 ToR Terms of Reference                 44Chapter 10 - Initial Response to Serious Case review from the Chair of the LSCB  The findings of this serious case review identify a number of missed opportunities, and a number of areas where safeguarding practice needs to improve.   The Board has developed a detailed action plan to implement the recommendations.  It will monitor closely implementation of all recommendations, both those which relate to interagency working, and those specific to individual agencies.   In preparing the report for publication, the Board has taken account of the potential impact upon and needs of the children and family, and it has been written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults in the case.    The LSCB will ensure that all agencies have put in place effective local responses so that learning from this review improves the way professionals keep children and young people safe in the future.  Detailed learning plans are being undertaken by individual agencies in response to the specific findings and the outcomes will be overseen by the Board. Lessons from the review will be addressed through the LSCB generic ‘Learning from Review Sessions’ delivered as part of the Learning and Improvement Framework and training provided by the Board. The Board is clear that improvements in practice will follow from implementation of these recommendations, as part of its ongoing programme of improvement.   LSCB Independent Chair 