Death of a 9-year-old boy in June 2019. Leo was found unresponsive in the family home, and taken to hospital where he was pronounced dead. Leo died from bacterial meningitis and orbital cellulitis and had been unwell for six days prior to his death. A police investigation for neglect concluded that the cause of death was due to natural causes. Leo and Sibling 1 were subject to a child in need plan, due to concerns regarding neglect and unsatisfactory home conditions. The family were receiving support from several services and the children's school. Leo and his father had a history of physical health issues and Mother had mental health issues. Leo was of White British and American heritage. Learning includes: social workers should take the think wider family approach, considering all members of the family or household to assess their impact on the whole family; professionals should be involved in multi-agency meetings, including healthcare professionals, to ensure effective plans are in place; when families are living in poverty focus needs to remain on the cause and impact of poverty on the children, and professionals should escalate cases where families' access to funds and services is not sufficient; children's services and partners should use specialist assessment tools in cases of neglect to quantify need and measure perceived improvements or deteriorations; when an adult or child is recognised as a carer, the full extent of their role and its impact should be clearly articulated in assessments and shared with partners. Makes no formal recommendations.
      
 Title:  Local child safeguarding practice review: Leo. LSCB: Thurrock Local Safeguarding Children Partnership Author: Nicki Walker-Hall Date of publication: 2021  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                    Thurrock Local Safeguarding Children Partnership      Local Child Safeguarding Practice Review      Leo                  Nicki Walker-Hall  October 2020   2Table of Contents 1 Context ................................................................................................................ 3 1.1 Introduction ................................................................................................... 3 1.2 Initiation of the review ................................................................................... 3 1.3 Purpose of the review ................................................................................... 4 1.4 Methodology.................................................................................................. 5 1.5 Time Period for the Review ........................................................................... 6 1.6 Parallel Processes ........................................................................................ 6 1.7 Limitations ..................................................................................................... 6 2.     Outline of the Circumstances Resulting in the Review ....................................... 7 2.1 The review period .......................................................................................... 7 October – December 2016 .................................................................................. 7 January – June 2017 ........................................................................................... 8 July – December 2017 ........................................................................................ 8 January – June 2018 ........................................................................................... 9 July – December 2018 ........................................................................................ 9 January 2019 – March 2019 ............................................................................. 12 April – May 2019 ............................................................................................... 15 3.     Analysis ............................................................................................................ 18 3.1 Introduction ................................................................................................. 18 3.2 The Child in Need (CIN) process – to consider communication between the agencies involved with the family ......................................................................... 18 3.3 To establish the policy and process requirements of Integrated Care 24 (111) and examine the decision not to send an ambulance when the service was first contacted ....................................................................................................... 24 3.4 To examine the attendance of Leo at A&E 4/5 days prior to his death in its entirety .................................................................................................................. 27 3.5 To look at the record keeping in this case and examine any disparity in information including dates, times, locations across different agencies ................ 29 3.6 Examine the expectations and response made by adults and children in the family home with caring responsibilities for other family members ....................... 30 3.7 Thresholds – Examine the understanding and application of thresholds and explore the use of risk assessments regarding neglect ........................................ 31 3.8 Is there evidence that the history of the family was considered at points of assessment and influenced intervention ............................................................... 35 4. Conclusion ........................................................................................................ 37 Glossary ................................................................................................................... 39     31 Context  1.1 Introduction  1.1.1 This Local Child Safeguarding Practice Review (LCSPR) concerns Leo. Leo was nine years old at the time of his death. Leo lived with his parents, his sibling (Sibling 1) aged 15 and his half-sibling (Sibling 2) aged 23 at the time of his death. The family were of dual heritage both in terms of their ethnicity, nationality and culture. This review will only consider Leo, his siblings and his parents.  1.1.2 Leo died from bacterial meningitis1 secondary to orbital cellulitis2 caused by streptococcus constellatus. Leo was deemed a Child in Need (CIN) of support and services and was subject to a CIN plan at the time of his death. This followed concerns regarding neglect and unsatisfactory home conditions.  1.1.3 Leo had been unwell for six days prior to his death. Leo initially had a fever, was hallucinating, had vomited and had pain in his eye. Mother sought advice from the Integrated Care 24 (111) service. Mother was advised to administer paracetamol and encourage fluids and to ring her General Practitioner (GP) or the Out of Hours’ (OOH) service if Leo was no better. Mother, in a call with the GP practice nurse later the same day was advised to take Leo to Accident and emergency (A&E). After a delay in attending Leo was seen in A&E. It was thought by the attending doctor that Leo might have an abscess of the eyelid, cellulitis, a stye3 or that he may have received an insect bite. Leo was prescribed eye drops and antibiotics.  1.1.4 Two days later Leo went to bed at around 20:00. Mother checked on Leo twice during the night and when she went to check him at 07:20, Leo was unresponsive, an ambulance was called and Leo taken to hospital. Resuscitation was attempted but Leo did not respond and was pronounced dead at 08:45.  1.2 Initiation of the review  1.2.1 Following notification of the circumstances of this case, and a decision by the Rapid Review Panel that this case met the criteria for a LCSPR, there was agreement by the chair of the Thurrock Local Safeguarding Children Partnership (TLSCP), in accordance with Working Together4 (2018), to                                                       1 Meningitis is an infection of the protective membranes that surround the brain 2 Orbital cellulitis is inflammation of eye tissues behind the orbital septum. It is most commonly caused by an acute spread of infection into the eye socket from either the adjacent sinuses or through the blood 3 A Stye is a bacterial infection of an oil gland in the eyelid 4 Working Together to Safeguard Children (2018)   4undertake a LCSPR. A Review Panel made up of agency representatives from the Local Practice Review Group, that had not had any direct involvement in the case, was established in accordance with guidance. Nicki Walker-Hall, an experienced reviewer from a health background, was commissioned to undertake the review with support from the TLSCP Business Manager and Learning and Practice Review Co-Ordinator.  1.2.2 The review will take into account Working Together and the principles of the systems methodology recommended by the Munro review.5  1.2.3 Whilst the review was initiated as a result of Leo’s death, reviewing the history of the child and family is not the primary purpose of the review. Instead it is an effective learning tool for Safeguarding Children Partnerships to use where it is more important to consider how agencies worked together.   1.3 Purpose of the review  1.3.1 The purpose of this LCSPR is to:-  Establish whether there are lessons to be learned from the case about the way in which local professionals and organisations worked together and/or independently 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 to be expected as a result and  As a consequence, to improve inter-agency working and better safeguard and promote the welfare of children and young people  1.3.2 The role of the Safeguarding Children Partnership is to engage and contribute to the analysis of case issues, to provide appropriate challenge and to ensure that the learning from the review can be used to inform systems and practice development. In so doing the Partnership may identify additional learning issues or actions of strategic importance. These may be included in the final review report or in an action plan as appropriate.  1.3.3 This review will concentrate on those aspects of the case which suggest systems and processes designed to safeguard children in these circumstances are not working effectively. As well as considering the case, the review will also draw on previous local and national learning where similar issues have also been identified.                                                           5The Munro Review of Child Protection: Final Report: A Child Centred System (May 2011)   51.4 Methodology  1.4.1 The methodology chosen was based on an adapted version of the Child Practice Review process.6 This is a formal process that allows practitioners to reflect on cases in an informed and supportive way.  1.4.2 All relevant agencies reviewed their records and provided detailed chronology’s including history and analysis of key episodes or events that their agency was involved in with this family. The agencies chronologies were merged and used to produce a composite chronology. This chronology and supporting documents were carefully considered by the reviewer and the panel; this informed the key focus areas for further exploration and consideration.   1.4.3 Key practitioners were identified to attend separate practitioner and manager learning events in order to understand the detail of the single and interagency practice in this case. Arrangements had been made for the reviewer to meet with the family. In March 2020 COVID-19 impacted the review. A decision was made that, in order to ensure this report was completed in a timely manner and to ensure learning was shared, and due to some of the restrictions placed by COVID-19 working, that it was not possible to hold practitioner workshops. All relevant agencies attended panel meetings and produced agency reports which contained the information required by the author to complete the review. The findings and learning from this review will be shared across the Partnership through learning workshops.  1.4.4 The reviewer collated and analysed the learning and developed a draft report. The draft report was provided to the panel in June. This provided the panel with an opportunity for organisations to conduct further analysis and consider changes that have already occurred which would impact on any recommendations made to address the learning points.  1.4.5 The reviewer was subsequently able to have telephone contact with Mother which provided additional information to the review. This was incorporated into the report; Father declined an offer to speak with the reviewer.  1.4.6 Learning from the report will only be made publically available after consideration by the TLSCP and development of a media strategy.                                                          6 Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012   61.5 Time Period for the Review  1.5.1 The primary time period of the review covered the period from October 2016 to June 2019. It was agreed that other information relevant to the key lines of enquiry, that sat outside of this period, could be included to provide context and relevant family history.  1.6 Parallel Processes  1.6.1 This case was notified to the Coroner. The case did not progress to an inquest as the cause of death was deemed natural causes. The Police investigation pertaining to neglect concluded that what led to Leo’s death were a series of unfortunate medical episodes that were beyond the parents’ control, or ability to influence, which ultimately led to his untimely death. The Police decided they would not be taking any further action.   1.7 Limitations  1.7.1 COVID-19 has caused significant limitations to this review. The reviewer has been unable to speak to the practitioners involved in this case to gain an understanding of their experiences of the family and of any difficulties they encountered working with this family in the confines of current systems, policies and procedures. The reviewer has been unable to establish whether there were any external factors that influenced their practice in relation to this case.  1.7.2 Whilst the reviewer has been able to have a helpful conversation with Mother on the telephone, she was not able to explore some areas with Mother. The reviewer was concerned that to do so might negatively affect Mother’s mental health as, due to COVID-19, there was no professional present to support Mother.       72.     Outline of the Circumstances Resulting in the Review  2.1 The review period   October – December 2016  2.1.1 At the beginning of the review period Sibling 1 was being supported by the Student Wellbeing Support Team for issues regarding self-esteem. Father was issued a blue badge for mobility issues due to arthritis.  2.1.2 Leo attended A&E with chest and abdominal pain on the advice of the 111 service. Leo had an X-ray and Electro-Cardiogram (ECG), nil abnormal was found. The GP received information regarding the attendance from both 111 and A&E.   2.1.3 Sibling 1 won an award at school for being kind hearted and looking after a less able friend.  2.1.4 Leo received treatment from the GP for Eczema7.  2.1.5 In November 2016 a referral was made, by housing, to Multi-Agency Safeguarding Hub (MASH) following an inspection of the home which raised concerns regarding serious mould within the property. This was said to have been caused by parent’s lifestyle. The MASH completed a risk assessment and the case was assessed as amber, requiring statutory intervention from Children’s Social Care. A decision was made to conduct a Child and Family Assessment (C&FA) to assess on-going issues in relation to the “poor and neglected” home environment. It was believed the home environment was having a detrimental effect on the children’s health, social and emotional wellbeing. A Social Worker (SW) was allocated the case and conducted agency checks, visited the family home and spoke to Mother and spoke with Sibling 1 (aged 12) in School, Father did not engage. The parents were given a notice of eviction.  2.1.6 Throughout December the SW made announced and unannounced visits noting improvement with the house being less cluttered. The Housing Officer and SW also made a joint home visit.                                                         7 Eczema is the name for a group of conditions that cause the skin to become itchy, inflamed, or have a rash-like appearance.     82.1.7 Sibling 1 was unwell with a cough and cold. On the advice of 111 she was seen by the GP and diagnosed with a respiratory tract infection and prescribed antibiotics.   January – June 2017  2.1.8 In January the SW had supervision. It was decided that, in light of the improvements made by the parents, there should be consideration to step the case down to Troubled Families (now known as Prevention and Support Services (PASS)). This was to follow the completion of the assessment, and a meeting with school, housing and Troubled Families.  2.1.9 The C&FA was completed. Both Leo and Sibling 1’s school attendance was good and their presentation had improved; parents were engaging with services and were willing to work with Troubled Families and housing, who were keeping the property under review as the mould kept returning. The family were not keeping the house ventilated and housing were considering putting some air bricks in for ventilation. The case was referred to Troubled Families and the case closed to Children Social Care (CSC). The referral to Troubled Families was not accepted as they assessed that there was not enough evidence around Father’s arthritis or Mother’s mental health to meet their criteria. The outcome of the referral was shared with the SW who referred the case.  2.1.10 In February Mother was seen by the GP for an Asthma review.  2.1.11 In May the GP information, requested during the C&FA, was recorded as being received by Social Care, some four months after case closure. The GP did not raise any concerns.  July – December 2017  2.1.12 In July Leo’s end of year report was sent to parents. Leo was working above the expected standard in maths and reading and had 99.4% attendance.  2.1.13 In August Sibling 1 attended the GP with an odour from her ear, there was no discharge and ear drops were prescribed.   2.1.14 The following month Mother attended the GP for seasonal flu vaccination.  2.1.15 In November Sibling 1 started to arrive in school early, the Attendance Team were concerned and started to monitor this. Sibling 1 asked if the school had any underwear she could have; she indicated she only had two pairs, had run out, and the family could not afford any. A member of staff bought Sibling 1 new   9knickers and socks, and advised her who to contact if she needed anything else. Four days later Sibling 1 was seen by a Practice Nurse with Vulval irritation. A blistered rash was observed; she was prescribed cream.  2.1.16 In December Leo was seen by the GP with a history of persistent bed wetting for five years. The GP did not refer Leo to the School Nurse (SN). Mother reported this had been an issue for father, and Leo’s siblings, that eventually stopped. Leo was diagnosed with a urinary tract infection and antibiotics were prescribed.  January – June 2018  2.1.17 In February Mother attended an ophthalmic appointment, a test for glaucoma was negative.   2.1.18 In May Mother was referred by the GP to a respiratory clinic for review of asthma as the surgery were struggling to control her symptoms.  2.1.19 In June Sibling 1 (aged 14) attended the GP practice with mother and saw a Practice Nurse. Sibling 1 reported a vaginal odour for two months. Sibling 1 was not seen on her own and the reasons for the odour were not fully explored. Sibling 1 declined examination and was given advice and an option to self-swab and return if it got worse.   2.1.20 Leo and another child were fighting at break time and spent lunchtime in the Red Zone as a consequence.  July – December 2018  2.1.21 Leo had another positive end of school year, he was above average for reading, writing and maths, with excellent effort and 100% attendance. There were some issues with Leo’s behaviour. Leo had pulled away a chair from another child and as a consequence spent the morning in the ‘consequences for choices room’. Leo was also working with a mentor at lunchtimes, twice a week, due to friendship issues.  2.1.22 Sibling 1 attended A&E with abdominal pain, was admitted, had blood tests and a scan. Sibling 1 was discharged the next day with no definitive diagnosis.  2.1.23 In September Sibling 1 attended the GP practice with an itchy rash to her arms. Cream was prescribed. Sibling 1 was advised to return if there was no improvement in a week.    102.1.24 The Occupational Therapy referral was closed in 2016 for Father. This was to complete an assessment. No paperwork had been returned.  2.1.25 In October the family contacted 111 regarding Leo, who had abdominal pain. It was reported Leo had been hit in the stomach six days previously by another child. Mother agreed to take Leo to A&E. Leo was admitted onto a ward for four days for investigation of possible appendicitis, it was thought Leo being hit in the stomach was unrelated; no definitive diagnosis was made. Staff were concerned as Leo, on several occasions, told staff he felt safer in hospital rather than at home as it was cleaner. Leo was noted to be interacting well with both staff and his family. The hospital staff referred their concerns to CSC. A joint plan was put in place to visit the family home and conduct an assessment. Leo was discharged.  2.1.26 A C&FA was completed. The SN and SW made a home visit the following day. The living room was cluttered, smelt of smoke, and there were clothes and rubbish on the floor. The children’s bedrooms had no carpets, wallpaper was stripped off the walls and there were no bed sheets. There were not many age appropriate toys, and the rooms lacked personal touches. Clothes were strewn across the floor. Mother indicated she was struggling to do the house work as Leo had been in hospital and she was caring for Father. It was clear to the professional’s conditions had built up over time. Mother had a history of depression and was said to be open to support. It was agreed PASS would work with the family for three months. If there was no improvement, PASS would consider escalating the case to the Children and Families Assessment Team (CFAT).   2.1.27 Three days after discharge from hospital there was a further call to 111 as Leo had abdominal pain. Mother was advised to change Leo’s pain relief from Ibuprofen to Paracetamol and see the GP if further management was needed.  2.1.28 The PASS team conducted a risk assessment and referred the case to CFAT. The case was allocated the same day. The SW discussed the case in supervision that day. The Team Manager was of the view that “the family needed intensive, co-ordinated support to improve their living conditions and sustain changes” and had the view that “the concerns are at a level that requires statutory intervention.” Parents were indicating the mess was due to Sibling 1 not picking up after herself and planned a deep clean at half term. A C&FA was commenced.    112.1.29 Leo was seen by a GP physician associate8 with on-going abdominal pain, said to be worse after food. Leo was struggling to open his bowels. The physician queried a food allergy/intolerance and planned further blood tests, and a referral to paediatrics, if the pain did not settle or if the blood tests were negative. Leo was noted to be alert and well with good interaction with his Mother. Mother was advised to seek urgent advice should the pain worsen or Leo get any other symptoms.  2.1.30 In November Leo had the planned blood tests. The SW conducted a home visit. The SW noted a slight improvement to the living conditions. The children indicated they had not had any new toys in years and got bored at home. Sibling 1 indicated she was too embarrassed to have friends over. All her drawers were broken causing arguments between the siblings when they could not find things. The SW recommended an assessment of Father’s benefits, and immigration checks on Mother and the children as Mother had no recourse to public funds. The children were referred to young carers as they cared for Father who had arthritis, diabetes and cellulitis.   2.1.31 The SW sought information from the GP. There was no discussion between the SW and the GP as to why information was required. Information was shared, in report form, a week later; the GP made no mention of Leo’s enuresis9. Further SW supervision took place with a plan of action agreed.   2.1.32 Leo attended the GP practice with on-going abdominal pain. The results of the blood tests were normal except a borderline thyroid result. The GP physician associate referred Leo to a Paediatrician.  2.1.33 In December the SW referred Sibling 1 for mentoring. The SW also contacted school apologising for not informing school earlier that they were conducting a C&FA. A referral was made to the Student Well-Being Team from Sibling 1’s School, due to Social Care involvement and neglect. The SW was recommending the family be subject to a CIN plan. Sibling 1 commenced weekly one to one sessions with a Mental Health (MH) support worker.   2.1.34 A letter was received by the GP from a mental health service. Mother had a gateway assessment during which she indicated she had taken an overdose of pain killers the previous month. She was struggling to cope with the children, looking after her husband, and she had financial difficulties. Mother had been referred for counselling and given contact details for support services. No referral had been made to CSC.                                                        8 Physician associate – a physician associate supports doctors in the diagnosis and management of patients under the supervision of a qualified doctor. 9 Enuresis – otherwise known as bedwetting. It's common for children to accidentally wet the bed during the night. The problem usually resolves in time. https://www.nhs.uk/conditions/bedwetting/   12 2.1.35 Sibling 1 indicated to her MH support worker that she liked the support that the family got from the SW. Sibling 1 expressed a wish to attend the services support groups.  2.1.36 An initial network meeting, attended by school and Social Care staff, was held at Sibling 1’s school. Parents were initially blaming of Sibling 1 for her attitude at home, which they felt was rubbing off on Leo. Mother was able to agree that that the family had perhaps been singling out Sibling 1, and took responsibility for blaming her. A CIN plan was agreed with both professionals and the family. The family recognised the need for things to change and committed to making improvements. School were very complementary regarding Sibling 1, who was a model student and who had won an award based on effort levels. Leo was reported as slightly moody, with labile10 mood. Sibling 1 was accessing daily religious studies online prior to school, and was sometimes late to school. Mother reported the only reason Sibling 1 was late was due to worrying about her hair and how she looks.  2.1.37 Three days after the meeting the SW conducted a home visit, and informed the family that she would be introducing a new SW in the New Year. The home environment was the same, but with less clutter and warmer.  2.1.38 Mother sought advice from the 111 service as she had burnt her foot with boiling water five days earlier; she was advised to attend A&E but did not. It is recorded that the SW had completed a Graded Care Profile 211 (GCP2).  January 2019 – March 2019  2.1.39 From January 2019 sibling 1 and Leo regularly engaged in respite activities.   2.1.40 Mother contacted the 111 service regarding Leo who was said to have a three day headache and been depressed for a month with on-going stomach pains. Mother was advised to contact the GP within three days. Mother did not comply and this was not followed up by the GP on receipt of the information.  2.1.41 The case was transferred to the new SW who had supervision and a plan of action was agreed.  2.1.42 A young carer’s assessment took place for both children.                                                       10 Labile - readily or frequently changing 11 Graded Care Profile 2 (GCP2) is an assessment tool which helps practitioners measure the quality of care a child is receiving. The NSPCC have evaluated the tool and found it to be effective in helping identify whether a child is at risk of neglect.    13 2.1.43 Sibling 1 commenced attending a support group. Sibling 1 identified to her MH support worker she needed help with exam revision and prioritising her work; she was tearful.  2.1.44 Sibling 1 later confirmed the revision timetable was helping.  2.1.45 The SW conducted a home visit to undertake direct work with the children. Leo discussed his worry over his stomach pains. Leo’s bed was broken. The children did not have adequate furniture and the home conditions, although improved, were not acceptable. Mother had depression and needed help. The SW made onward referrals to assist in cleaning the house and obtaining furniture.   2.1.46 A network (CIN) meeting took place. Concerns were expressed regarding Sibling 1’s use of social media and the need to stay safe online. Leo had told parents he was being bullied but was complaining less about abdominal pain. A chore chart was completed for each of the children  2.1.47 During February the SW conducted a home visit; there was little food in the house as money was being diverted for heating. Lunch club had provided food and clothing to the family. Leo had been put in the red zone for pushing during a basketball match and a punctuality postcard was sent home. Mother requested and received a food voucher and Sibling 1 started some 1:1 support around her stress and anger management.  2.1.48 The SW discussed the case in supervision, all the issues were discussed. The SW was to check with mother if she had sought advice from the Citizens Advice Bureau regarding her application to remain in the UK, and was instructed to update the chronology. Two single beds were purchased for the children.  2.1.49 In March the date of a CIN meeting was changed due to confusion and put back a week. As a result, the SW did an unannounced visit, conditions remained a concern. Sibling 1 stated she had no privacy and nowhere to study, she indicated lack of finances was preventing her going on school trips; the SW planned to do a financial assessment.  2.1.50 The MH support worker spent time with Sibling 1 in preparation for attending the CIN meeting. Sibling 1 was very open and honest about her situation, identified she had positive friendship groups and was positive regarding the support she was receiving from her SW.  2.1.51 The family’s finances were discussed at the CIN meeting, as was the dirty and cluttered state of the family home. A breakdown of the family’s incomings and   14outgoings indicated there was more going out than coming in. Father discussed his worries regarding the relationship between Sibling 1 and Leo; it was discussed Sibling 1 would benefit from positivity. Father’s health and Mother’s mental health problems were discussed. Father was to apply for Personal Independence Payment (PIP). The damp in the house was put down to the family’s lifestyle. Leo was said to have an intermittent stomach ache, Mother indicted she would take him to A&E if it got bad and he had an appointment to be reviewed by a Paediatrician in May.   2.1.52 Home visits continued, the downstairs toilet walls and door were covered in mould and the toilet was covered with black dirt. Mother reported the children were not doing their chores; she was challenged by the SW who did not think this alone could be the cause of the neglected conditions.  2.1.53 A food voucher was supplied as the family needed to pay their car insurance. Leo had another episode of stomach pain and was seen by an OOH GP. The GP prescribed a gut muscle relaxant and suggested Leo see his own GP if there was no improvement.  2.1.54 Both Sibling 1 and Leo were accessing activities with young carers. Leo reported bullying at school however school indicated they were unaware of this. School agreed to ask the Inclusion Advocate to explore this further.  2.1.55 Three days after being seen by the OOH GP Mother was advised by 111 to take Leo to A&E with abdominal pain and mixed blood in his stools. Blood and urine tests were normal and Leo was discharged home. The SW followed up this attendance with Mother.  2.1.56 The following day there was an incident of rough play (Leo) in the playground, Mother and Father were informed.  2.1.57 Mother attended the GP with a history of feeling down for a while. Mother reported a previous overdose, which her husband was unaware of, financial problems and three children. Mother was placed on a waiting list for counselling and prescribed medication. There is no evidence the GP assessed the impact of Mother’s mental health and financial difficulties on the children, and no consent was obtained for liaison with other professionals, namely the School Nurse or a referral to CSC for support.   2.1.58 Leo was the victim of a fight at school.  2.1.59 SW sought further supervision with regards to the case. There was discussion in relation to the family’s finances, Mother being an over stayer, Father’s   15application for PIP12 and concerns expressed regarding the impact of the neglectful living conditions and lack of finances on the children which was increasing their vulnerability to bullying. The children were unable to invite friends home. The SW was applying for funding to improve the family home. There was consideration to stepping the case up to Child Protection (CP) if concerns remained.  2.1.60 Housing conducted a further visit due to repairs, damp and mould issues.  2.1.61 The SW continued to home visit. Leo reported he was now friends with the two boys who had bullied him. The SW informed the parents that if the home conditions had not improved by the following week the case would be escalated to Child Protection as she was concerned about how this was affecting the children’s self-esteem.  April – May 2019  2.1.62 In April, Leo’s teacher wrote another positive school report indicating Leo was “a very bright student, a valued member of the class, bright and confident”.  2.1.63 At the next home visit there was evidence that the family had worked together to improve the home conditions and Sibling 1 reported she and Leo were arguing less. The SW was clear that it was parent’s responsibility to keep the home clean and to stop shifting blame to the children. The improvement was discussed in the SW’s supervision however, the plan was still to consider stepping up into CP at the next CIN meeting if concerns still remained.  2.1.64 Mother attended the GP practice for a review of her mental health and reported improvement in sleeping and general wellbeing. A repeat prescription for one  month’s medication was given.  2.1.65 Leo had a further episode of abdominal pain and was seen by an OOH GP. Leo was assessed and advised to take paracetamol and go to his own GP for review.  2.1.66 Mother had a further GP review; she had commenced counselling but was not sleeping well. Mother was advised to continue with her current regime. Sibling 1 was also seen with a fungal infection between her toes.                                                        12 Personal Independence Payment (PIP) is extra money (a benefit) to help those with an illness, disability or mental health condition manage their everyday life.    162.1.67 At the end of April Leo was seen in paediatric outpatients for a review of his supra-pubic abdominal pain, said to occur two to three times a week, excruciating in nature. Leo was advised to increase his fluids and was to have an abdominal ultrasound of his kidneys, ureters and bladder. This was arranged but Leo sadly died prior to the investigation and four month follow up. The Dr was querying renal calculi13 with constipation. 2.1.68 In May a CIN meeting took place. Sibling 1 was spoken to the previous day and was very positive about the support she was receiving. Leo’s class teacher gave a positive welfare report, though Leo needed more school clothes when new stocks were received. Parents had noted a significant improvement in Sibling 1’s communication skills and they were getting on better as a family. Parents were reminded of their responsibilities to keep the environment clean. Both children were accessing extra-curricular activities and school attendance was good. Mother was attending MIND and had a Citizens Advice Bureau appointment to discuss immigration. The SW was to complete a GCP2.  2.1.69 School provided Sibling 1 with knickers, socks, shirts, trousers and shoes for school. Sibling 1 showed her young carer support worker and was very proud of how she looked.  2.1.70 There was a behaviour incident in school. An older boy accused Leo of being gay then pushed him. School dealt with the situation by giving the other boy a detention.  2.1.71 Both Leo and Sibling 1 attended a MH awareness workshop. Both were loaned Lenovo tablets for five weeks to support their education.  2.1.72 Sibling 1 thanked school for her uniform and asked if she could have a skirt. Sibling 1 offered to pay 50p a week, she wanted to look like the other girls at school and wear a skirt. School agreed to purchase her one; she was extremely grateful.  2.1.73 Leo attended a mini sports day but missed a reptile party, planned for three days later, as he was ill.   2.1.74 The SW completed a home visit observing improved conditions, Leo had some drawers and his clothes were neatly folded. Parents were advised that there was still more work to be done. Leo and mother were unwell with a cold.  2.1.75 The same day mother rang 111 on two occasions, first at 13:26 when she stated Leo had a two-day history of elevated temperature, hallucinating, spaced out, feeling sick and had a painful swollen right eye and was feeling hot. Mother was                                                       13 Renal Calculi – kidney stones   17given advice to push fluids and give paracetamol. Mother did not take Leo for an arranged appointment with the practice nurse at 16:45. At 17:18 the nurse rang Mother who informed that Leo was confused and delusional; she was advised to take Leo to A&E immediately. Mother did not take Leo to hospital as advised, later she indicated she did not take Leo to hospital when advised as it was closed. At 19:53 mother rang 111 again, she was advised to take Leo to hospital urgently. At 21:35 Leo attended hospital. Leo was found to have a raised temperature and had mild swelling to his right upper eyelid no redness or conjunctivitis. The doctor diagnosed possible early cellulitis. Mother was given oral antibiotics, eye drops and Ibuprofen to give to Leo, with the advice if there was no improvement within two days to return as Leo might need  intra-venous antibiotics.  2.1.76 The SW rang mother the following day. Mother indicated Leo was feeling much better than the previous day.  2.1.77 The Frank Buttle Trust agreed a grant award to the family.  June 2019  2.1.78 On the 2nd June mother found Leo unresponsive at 07:30. Mother reported having last seen him fit and well at 05:00, she also reported that Leo had complained of eye pain again on the evening of the 1st June. CPR was attempted by the family, ambulance crew, the air ambulance medical crew and then hospital staff. The Police and Ambulance staff, who attended the home expressed significant concerns regarding the state of the house, and the family’s responses to them regarding Leo during their attendance. Leo was confirmed dead at 08:45. Joint Agency Response protocols were put in place and the Police commenced an investigation. CSC carried out a deep clean of the house shortly after Leo died.    183.     Analysis  3.1 Introduction  3.1.1 The following section will now consider and provided analysis of the key lines of enquiry. Within the analysis of each key line of enquiry the reviewer has considered:  Did all agencies work together effectively to safeguard this child?  Was the outcome preventable?  Were National, Local safeguarding and other procedures followed appropriately?  Was the voice of the child listened to, heard and acted upon throughout agencies involvement?  3.2 The Child in Need (CIN) process – to consider communication between the agencies involved with the family  3.2.1 Neglect forms the majority of the work for Social Care professionals. In 2019 nearly 50% of all children subject to a Child Protection Plan fell under the category of neglect and a further 54% of Children in Need had abuse or neglect recorded as their primary need identified at assessment14. Neglect is also consistently a major factor in the lives of children who die and features in three-quarters of all Serious Case Reviews (SCRs) (fatal and non-fatal) and was the primary issue in 19% of all serious harm cases. 15 One of the emerging themes from a triennial analysis of Serious Case Reviews was the complex and cumulative nature of neglect, often in the context of poverty. It is important to recognise the complex nature of neglect only if we do so, can we construct systems that can take a robust response to neglect cases.   3.2.2 When complexity is recognised the need for a co-ordinated multi-agency response becomes clear. It is unusual for a family who are neglecting one aspect of their children’s needs to not be neglecting many of the children’s needs. It is therefore essential that all agencies are made aware and are given the opportunity to contribute to multi-agency meetings.   3.2.3 Following the C&FA in 2018, CIN meetings were taking place on a regular basis with representation from CSC, Young Carer’s, Housing and the school; no one from health was present or invited. Information was requested from the GP by CSC on two occasions during the review period to inform the C&FA. On both occasions (January 2017 and November 2018) Primary care were not made                                                       14 DFE (2019) Characteristics of children in need: 2018 to 2019 England 15 DFE (2020) Complexity and challenge: A triennial analysis of serious case reviews 2014-2017   19aware of the outcome of the C&FA, this is contrary to Local CP procedures. The GP practice safeguarding lead followed up the outcome of the November assessment in January 2019 and was informed the case was open to the Family Support Team. Contact details were provided for the SW however, this was not recorded in either child’s records so would not have been known to clinical staff when the children attended, or when records were reviewed as new information was received. The GP was not made aware the children were currently subject to CIN plans. The lack of information regarding the children being subject to CIN plans meant that although an entry was made on SystmOne when the children had been subject to CIN plans in 2014, the system had not been updated as changes in status occurred. It would not have been clear to the 111 service.   3.2.4 The School Nurse made a joint visit with a SW following the Hospital referral in 2018. The decision at that time was that the case would be managed by the PASS team. It could be argued that the School Nurse should have remained involved due to the poor conditions in the home and Leo’s abdominal pain however, the SW did not deem the home conditions met the threshold for CIN and recurrent abdominal pain is a very common symptom. Between 4% and 25% of school‐aged children at some stage complain of recurrent abdominal pain of sufficient severity to interfere with their daily lives. Investigations are required to rule out an organic cause but when no clear organic cause is found, the children are managed with reassurance and simple measures.16 Leo had been appropriately referred and was under investigation. School nursing is a service which is recognised nationally as over stretched and underfunded. In order for the School Nurse to remain involved they would need to identify an unmet need. The School Nurse should have reviewed Leo’s health records and would have identified Leo’s bed wetting providing an opportunity to support Leo, his family and other professional’s in the management of Leo’s enuresis and abdominal pain; this did not happen. In addition, the School Nurse was not informed Leo’s pain was continuing or of the five year history of enuresis, nor was the School Nurse made aware that the case had been escalated by PASS to CFAT, and that Leo was now subject to a CIN plan. As a result, the children continued to receive a universal service. Had the School Nurse remained involved after the joint visit, or found out/been informed of Leo’s ongoing health issues there would have been an expectation that Leo be in receipt of a universal plus service.   3.2.5 Under universal service, a School Nurse would not be expected to contact the family if A&E attendances were deemed minor or for routine hospital                                                       16 Martin  AE, Newlove-Delgado  TV, Abbott  RA, Bethel  A, Thompson-Coon  J, Whear  R, Logan  S. Pharmacological interventions for recurrent abdominal pain in childhood. Cochrane Database of Systematic Reviews 2017, Issue 3. Art. No.: CD010973. DOI: 10.1002/14651858.CD010973.pub2.   20attendances thus making the lack of contact understandable in this case. The School Nurse was not aware of and did not become involved in the CIN meetings until after Leo had died. Leo’s abdominal pain was known to all the professionals involved in the CIN meetings and although this was discussed, no one thought to inform or invite the School Nurse suggesting that an opportunity to respond to Leo’s voice was missed.   3.2.6 Lack of involvement of health in CIN is not a new issue within Thurrock, and has featured in a previous SCR.  3.2.7 Although health was discussed, as a result of the lack of health involvement, the CIN meeting attendees were unaware that both children in this family had attended the GP with ailments that could potentially have related to their poor living conditions. An opportunity was therefore missed to consider whether the home environment might be having an impact on both children’s health and wellbeing. Sibling 1 attended the GP six times during the review period with symptoms that, with hindsight, could relate to poor hygiene.   3.2.8 The first CIN meeting minutes’ evidence discussion regarding the concerns around the home environment; the home smelt strongly of stale tobacco. The family were clear that they could not open the windows as, due to their low income, they could not have the heaters on in the home. There is also evidence that the family’s financial situation was discussed. Father was reported to have been reluctant to provide details regarding their expenditure; the breakdown appeared incomplete. Father was a heavy smoker and the impact of this on the household finances was not fully understood. However, what was clear was that the family had insufficient monies to meet all their requirements. The lack of food and heat in the home was considered in the context of its impact on the health and wellbeing of the children. It is likely that, as the only person in receipt of monies, Father had greater control within the family. The relationship between the couple was not sufficiently explored or understood. Professionals did consider that there might have been opportunity for coercive control however this did not lead to any assessment; these concerns could have led to completion of a DASH17 risk assessment. The SW planned to revisit finances with the family and successfully linked the family to a charity to support them with groceries, furniture and clothing. There is no evidence that the family’s finances were revisited thus missing an opportunity to consider any of the wider issues. Father was largely present at CIN meetings however he is less visible within assessment processes and plans, with Mother appearing to be the spokesperson for the couple.                                                         17 DASH – Domestic Abuse, Stalking and Harassment risk assessment used to help frontline practitioners identify high risk cases of domestic abuse   213.2.9 Leo and Sibling 1 had an older sibling (Sibling 2) who lived with them but she does not feature within any assessments or meetings. Sibling 2 may have been an additional source of support for all the family members. In conversations with Mother the reviewer learned that Sibling 2 was not included in any discussions as she was not a child. Mother reported Sibling 2 was a support to the family and would help in the home and in caring for Sibling 1 and Leo. Omission of Sibling 2 in assessments, meetings and plans suggests that professionals were not applying “think family” with regards to Sibling 2.18  3.2.10 It is recorded that a GCP2 was completed in December 2018 and used to inform the CIN plan. There is evidence within the C&FA that supports this. This was a family that were not operating under the radar they were very visible to the professionals involved. The issues within the family were also well known and there were plans of action. What was missing was a think wider family approach, a fully holistic assessment and clear plan of action with timescales for completion.   Learning point: Whilst the family were discussed in meetings professionals were not always taking the “think wider family approach”. When making assessments SW’s must consider all members of the family or household to assess their impact on the family and household as a whole.  3.2.11 Communication between the agencies invited to the CIN meetings was regular in nature and appropriate. In addition, all attendances at the hospital for Leo were communicated with the GP and with the school nurse. What is less visible is any action being taken by those in receipt of this information. The Sschool nurse did not make contact with any member of the family prior to Leo’s death and the GP only made contact with the family when Leo was not taken to an appointment at the GP surgery. When mother attended the GP and there were concerns regarding her mental health, there was a lack of consideration of the impact of this information on the family dynamics and her children. Because the GP were unaware that the children were subject to CIN plans an additional factor that might have triggered the GP to consider the impact on the children was missed.  3.2.12 Whilst the GP practice manager had been made aware there was CSC involvement the practice manager did not record the CSC involvement. None of the health organisations received formal notification that the children were subject to CIN plans; this is contrary to Southend, Essex and Thurrock’s Safeguarding and Child Protection Procedures. Had they been aware they                                                       18 Think child, think parent, think family: a guide to parental mental health and child welfare (2011) aims to promote the importance of a whole family approach   22would have been able to share further information which might have added to the professional’s concerns regarding neglect and lead to alternate decisions being made and possible escalation.  Learning point: Health were not included in the CIN process. All relevant professionals need to be involved within multi-agency meetings to ensure effective multi-agency plans are in place.  3.2.13 Poverty linked to financial hardship was an issue throughout the period under review. Whilst poverty was recognised, the term most frequently used was ‘financial difficulties’. Does the language used sanitise the issues? That is not to say these financial issues were not considered however, the individual aspects of poverty were dealt with on an ad-hoc basis. When Sibling 1 had no underwear, it was bought for her, when Sibling 1 had no school uniform to fit, it was bought for her. The CIN meeting members provided the children with a lot of support however, the underlying causes for the poverty they were experiencing which could be addressed, were not addressed quickly enough. The responses were incident driven but what was needed was a long-term plan to address the causes and consequences of the poverty. Poverty is not easily resolved and in this case there were factors that held the family in poverty. Whilst mother was unable to work and not eligible for benefits and Father was physically unable to work due to health conditions and not receiving the appropriate benefits to meet the needs of the entire family, the children were always likely to be living in poverty so any plan needed to include urgent action to address these issues. Both parents were asked to take certain actions that might have eased the situation for the whole family. Parents successfully completed some of those actions however, when these were not carried out they were rolled over to the next meeting. Mother’s immigration status was another issue that was known but did not start to get resolved. It should be acknowledged that there was no simple solution to this issue. Further issues relating to both parent’s mental health and physical disabilities warranted earlier referral to Adult Mental Health and Adult Social Services.   Learning point: It is important to recognise and acknowledge that when families are living in poverty this is not easily remedied. Focus needs to remain on the cause and impact of the poverty on the children. Professionals, having fully explored the family finances and exhausted access to all the funds and services available across the Partnership, locally and through charities, must escalate cases to senior managers for further consideration if the children’s lives continue to be impacted.   3.2.14 In this case there is evidence that Social Workers spent time building relationships with both children and sought to understand their lived experience. Sibling 1 was very clear about the positive effects the professionals   23involved in her care and support were having. This was less evident for Leo. On one occasion when Leo was asked what he wanted to change he responded that he wanted the pain to stop. This was an opportunity for the professionals involved to consider whether health colleagues needed to be invited. Inclusion of health colleagues, in particular the School Nurse, would have provided an opportunity to consider other factors such as Leo’s diet and nutrition or emotional health that might be factors contributing to his continued abdominal pain however, there is no guarantee this case would have met the School Nurses, criteria for attendance at CIN meetings. Both children had been referred to a number of school and community resources who were providing support that the children were benefitting from. Whilst Social Care, education and Young Carer workers were all having direct conversations and exploring the children’s lived experience, this was not evident within primary care and school nursing. The lack of involvement of health in the CIN process prevented health from considering carrying out direct work with the children.  3.2.15 Neglect, and the pervasive nature of neglect is a frequent issue within LCSPRs and all too often there is lack of use of tools designed to assist professionals to assess the level of neglect. The GCP2 is one such tool many areas use. The Clutter Score, developed to assess hoarding and whether there is a need to intervene, is a tool which is becoming used increasingly in adult safeguarding and could also be helpful in child neglect cases. The difficulty for professionals is remaining objective when working in areas of deprivation and when working with families were environmental neglect is fluctuating. Both these tools have been found to assist professionals to maintain focus and more accurately grade the level of neglect. A parenting assessment was completed however what was lacking was a degree of depth to the assessment, encompassing and making reference to the significant complexities of the case, a clear analysis and a robust action plan.   Learning point: In cases of neglect more frequent and effective use of both GCP2 and the Clutter Score would have assisted in measuring the neglect. The use of specialist assessment tools by CSC and partners in their work with families where neglect is a concern will assist in quantifying need and measuring any perceived improvements/deteriorations. This is important to ensure consistency in assessments when there are changes in the practitioners working in the family.      243.3 To establish the policy and process requirements of Integrated Care 24 (111) and examine the decision not to send an ambulance when the service was first contacted  3.3.1 The family contacted the 111 service on 10 occasions during the review timeframe. All but two related to concerns regarding Leo’s health. On all of the contacts relating to Leo, policy and process were followed in relation to ambulance validation. On occasions the caller was directed to take Leo to see his own GP however, on most occasions Mother made use of the OOH service instead, the reason for this is unclear. Mother informed the reviewer she took Leo to the GP for routine illnesses and used the 111 service, OOH GP and A&E on all occasions where Leo was acutely unwell. Mother had been raised in America so her understanding of the health services in the UK came from her husband who was a born a British citizen.  3.3.2 Four days before Leo died mother contacted the 111 service at 13:26. The health advisor, a trained non-clinical assessor, followed policy and process using NHS Pathways, a national assessment algorithm, to complete an initial assessment. Mother reported Leo had been unwell since the previous day, was feeling hot to touch, had been hallucinating and was dazed, spaced out, felt sick and had pain in his right eye; she had not administered paracetamol. Based on the information Mother gave, Leo was assessed as Category 2/3 which requires a less urgent ambulance to be dispatched. When this happens the call must be transferred to a clinician for validation. If for any reason the call cannot be transferred successfully within an hour of the call, an ambulance is requested automatically. Revalidation of Category 3 and 4 cases is a national directive from National Health Service England (NHSE), due to the amount of Category 3 and 4 ambulances generated by National Health Service (NHS) Pathways, and the wider system pressures this created.   3.3.3 In this case the call was not automatically transferred to a clinician straight away, however a clinician called Mother back within minutes, at 13:42. The clinician had access to the health advisor’s records. Expected practice would be for the clinician to use the health advisor’s records, further discussion with the caller, and their clinical expertise, to assess and decide on a course of action. Mother repeated that Leo was sick, hallucinating, had a fever and had cold hands; she was struggling to get him to drink. The reviewer has considered the consultation report and the call transcript. The conversation between mother and the clinician lasted four minutes and 31 seconds. Mother reported the whole family had recently had a cold, everyone had recovered except Leo. Mother could not say how high Leo’s temperature was as she did not have a thermometer. Mother indicated Leo had been sick the previous day and had not had anything to eat, he was burning up and his hands were cold. Mother   25did not mention the pain in Leo’s eye and the clinician did not ask about this, suggesting the clinician was not making full use of the health advisor’s assessment. Mother indicated she had not given Leo paracetamol as, he would not eat anything and, she did not think she could give him any on an empty stomach. The clinician advised Mother it was fine to give Leo paracetamol on an empty stomach and waited until Mother had successfully administered the paracetamol. The clinician advised Mother to see if Leo’s temperature responded to the paracetamol stating, “see if that brings the temperature down and then hopefully he will not be hallucinating as much”. Mother appeared somewhat distracted throughout the call, organising someone to get the paracetamol and talking to Leo.   3.3.4 Based on the call the clinician downgraded the ambulance response. The decision to downgrade an ambulance response is always difficult; it is based on a number of factors. Clinicians are aware of the pressures on the ambulance service and do not want to increase their burden. Historically the 111 service has come in for criticism regarding the number of ambulances it requests. In February 2017 the media reported that the “overly cautious algorithm used by 111 call handlers is increasing pressure on already overstretched ambulance services and A&E”19. In April 2017 changes to the service started to be made to ensure callers could discuss their illness with a nurse, doctor or other health professional rather than a call handler to manage the callers’ illness more effectively and as a consequence reduce unnecessary pressures on the ambulance service and A&E.  3.3.5 Caring for children is a specialist area. In recognition of this, all children’s care in a hospital setting is overseen by specially trained doctors and nurses who have advanced training in the field. Children’s conditions can deteriorate very quickly and, without seeing the child, it would be unwise for any clinician to overrule the algorithms of the system without clear reasoning. Leo’s symptoms of sickness, a fever, hallucinations and cold hands all support the likelihood he had an infection. It would not be possible to determine whether this was viral or bacterial over the telephone. The fact that the family had all recently had a cold gives a suggestion that this might be a viral infection but it could equally be due to sepsis. Without examination this would be impossible to assess. Mother had not administered paracetamol so it was reasonable to request Leo be given paracetamol to see if his temperature responded. However, the clinician did not take the option of following up with a telephone call, 30 minutes to an hour later, to see if Leo’s temperature had responded and his hallucinations stopped. Had this happened, the fact that he continued to hallucinate and was confused, could have prompted a change of decision and an ambulance to be dispatched.                                                        19 http://www.nationalhealthexecutive.com/Health-Care-News/risk-averse-111-service-sending-more-callers-to-struggling-ae-and-ambulances   26 3.3.6 The clinician advised Mother to contact the GP if she was concerned or call back if it was after 18:30 to get an out of hours’ appointment. Mother was not advised of the circumstances in which she should take Leo to hospital e.g. if he continued to hallucinate, his temperature did not respond to the paracetamol, or his condition deteriorated. Mother was also not informed that if Leo’s temperature persisted for a total of 48 hours he would certainly need to be seen by a doctor.   Learning point: Clinicians must make full use of the health advisor’s information. They cannot assume a caller will restate all their concerns again. When a decision is made to downgrade the category of a call, steps must be taken to ensure the actions required of a parent have been carried out, and there has been an improvement in the child’s condition. Clinicians need to be sure that the advice given has been understood.   3.3.7 Following Leo’s death, the clinician was referred to the NHS Performance Advisory Group and all Category 3 and 4 validators have been retrained. Since this review there has been a new integrated urgent care service specification introduced which will require NHS 111 to be able to directly book patients into Emergency Departments and Urgent Treatment Centres, including information transfer which would have assisted in this case.  GP practice actions in relation to this episode of illness  3.3.8 Leo had an appointment with the practice nurse at the GP practice at 16:25. Mother did not take Leo to the appointment; this was followed up by the GP practice nurse, which was good practice.   3.3.9 The practice nurse, when she contacted mother at 17:17, was informed that Mother had administered paracetamol but Leo remained confused and delusional. Mother was correctly advised to take Leo to A&E immediately. It is reported that Mother took Leo to the minor injuries unit as it was nearest to the family home but it was shut by the time they arrived. Sibling 1 reported, after Leo’s death, Mother had indicated she had been advised to take Leo to the Minor Injuries Unit (MIU), Mother indicated to the reviewer she did not understand the difference between a MIU and an A&E. There was no petrol in the car so Father had gone to get petrol and by the time they arrived at the MIU it was shut. The practice nurse did not follow up whether mother had taken Leo to A&E as instructed.  3.3.10 At 19:53 Mother contacted the 111 service again. She reported she had been advised by the GP to take Leo to Hospital but the Hospital was closed. Mother   27was advised to take Leo to A&E immediately; he arrived at 21:35. This call presented another opportunity for an ambulance to be sent.  3.3.11 Had the practice nurse considered the information held within the practice and had there been an alert on the system to indicate that Leo was subject to a CIN plan for concerns regarding neglect, this might have prompted her to explore further, if there were any barriers to the family following the advice or, whether she needed to arrange transport and follow up the attendance. The practice was aware that the family had financial difficulties, (however not the extent of these), that Mother had mental health issues and Father had mobility issues, so exploration of whether they had the means and were able to get Leo to A&E should have been explored.  Learning point: Whenever a professional advises a family to take a child to A&E they must ensure that the family understands the instruction, and consider whether the family has the means and ability to carry the advice out. The professional should make enquiries to ensure the required action has been taken.  3.4 To examine the attendance of Leo at A&E 4/5 days prior to his death in its entirety  3.4.1 Leo arrived in A&E at 21:35. At triage Leo was assessed. Mother gave a history of a temperature for two days, not measured but felt hot and that that evening mother had noticed Leo’s right eye started to swell. There was no history of trauma. Leo complained of pain to his right eye. Paracetamol had been given at home before leaving. Leo’s temperature was 37.80c, elevated but not sufficient to require medication. There is evidence that the Children’s Early Warning Tool was used. Leo was graded green at triage. Leo continued to be assessed during his A&E attendance. When seen by the Doctor at 00:48, three hours after admission, the history recorded indicated Leo had a two-day history of a temperature and a cough. Leo was noted by the Doctor to have mild upper eyelid swelling to his right eye with no redness and no conjunctivitis. There is no diagram of the eye swelling. There was nothing abnormal detected with the orbit of the eye and no pain on eye movement. Leo’s chest was examined and clear. The doctor diagnosed a possible eyelid infection with a chance it could be early cellulitis. Leo developed a high temperature in A&E and was given Paracetamol and Ibuprofen (pain and temperature relief); Leo was graded amber using the Children’s Early Warning Tool and kept in the department for a further two hours. Over the following two hours Leo’s temperature responded to the medication and Leo was once again graded as green using the Children’s Early Warning Tool. The Doctor indicated Leo could be discharged and Mother indicated she was happy to take Leo home. Leo was sent home with medical   28advice, oral antibiotics and eye drops. Mother was advised to give Leo half a paracetamol tablet. Mother informed the reviewer Leo did not have problems taking tablets which she used over liquid Paracetamol or Ibuprofen as they were significantly cheaper. Mother was not aware she could get them on prescription as this is no longer routinely offered by health staff due to the significant cost to the NHS.  3.4.2 The staff in A&E were aware that CSC were involved as there was an alert from 2014 which had been updated in 2018 on SystmOne, so sent a notification of Leo’s attendance. Leo was discharged home.  3.4.3 The reviewer has considered the recording of Leo’s attendance at Hospital in its entirety. There is no specific concern about practice on this attendance however opportunities were missed to capture Leo’s voice and Leo’s past medical history was not fully explored.   3.4.4 Mother was asked for a history but did not report any hallucinations or confusion to either the triage nurse or the Doctor and there is no record of confusion or hallucinations whilst Leo was in A&E. Mother was advised to take Leo to the GP if she had any further concerns; there was no planned follow up. The reviewer learned from her discussion with mother that she had not received any advice on what symptoms she should be concerned about. Mother was not aware that continuation of a high temperature would be reason to seek further medical advice. Mother believed it was only if new symptoms occurred or she was worried that she should seek extra medical advice.   3.4.5 There is nothing recorded that suggests Mother was asked or informed hospital staff she had been in contact with the 111 service or had been advised to attend by a practice nurse. The gaps in the history given suggest either Mother anticipated that when speaking to health professionals all the information shared would be available across all services or a lack of direct questioning by A&E staff. Had A&E staff been aware of Leo’s hallucinations and confusion they would have been able to explore the cause further. The reviewer has found a few occasions when professionals had questioned Mother’s level of understanding; there is no evidence this was explored in the context of her nationality or experience of services. On one occasion both parents understanding was questioned by professionals however, this has not led to consideration of a formal assessment (see section 3.6).  3.4.6 There is conflicting information as to whether Leo’s condition improved over the next two days. Sibling 1 reported, following Leo’s death, that mother had been unable to administer the paracetamol as she had not been able to cut them in half. Sibling 1 reported no improvement with Leo just wanting to sleep. It is known that Leo was taken with family members shopping but was too unwell   29so sat on a bench. It is reported that in the twelve hours prior to his death Leo was crying with pain, had a temperature and was hallucinating. The family did not contact the GP, 999 or 111. It has been reported that Mother and Father disagreed as to whether Leo should be taken to hospital the night before he died but Mother understood she was following the hospital’s advice.  Learning Point: Communication and information sharing between health services proved problematic in this case. These are not issues that are unique to Thurrock or unknown. Until such times as the information technology systems within health are integrated, a process needs to be in place to ensure that in circumstances where a health professional directs a parent to take their child to hospital they contact the A&E department and make the department aware of the reasons why they have directed them to A&E.  3.5 To look at the record keeping in this case and examine any disparity in information including dates, times, locations across different agencies  3.5.1 The full format of this family was not recorded by any of the agencies involved. What was recorded was the household composition; Father’s older children did not feature. All agencies had accurately recorded the names, ethnicity and address of the family. There is an issue with the recording of dates of birth within Housing records. Both Leo and Sibling 1’s dates of birth were incorrect. Leo’s date of birth is also incorrect within Integrated Care 24 which covers the 111 service and out of hours’ service. A high standard of record keeping was evidenced within A&E.  3.5.2 Learning point: As partner agencies receive information from a service they should routinely check that the unique “identity set” information is correct and inform partners if they identify errors.  3.5.3 Examination of the air ambulance patient report has found discrepancies in timings. There are recordings that register heart rates and the administering of IV fluids prior to the family making the 999 call. It appears that the entries on the graphs on pages four and five are an hour out, suggesting that part of the recording system had remained on GMT when other sections of the recording system had moved into BST. Essex and Herts Air Ambulance identified this issue was due to settings on their new monitors; the issue has since been resolved.  3.5.4 The 111 service consistently informed the GP practice of any calls and advice given by the service.    30 3.5.5 There is discrepancy regarding the sharing of GP information with CSC. CSC record that they did not receive the information requested from the GP in January 2017 for four months. However, it is clearly recorded in the GP records that this was sent, in written format eight days after request, within timescale. It is not known the reason for the discrepancy but this suggests that the information flow of written reports between partner agencies and the Social Worker is not robust.   Learning point: There might be internal barriers to the effective sharing of reports between GP practices and allocated SW’s.  3.6 Examine the expectations and response made by adults and children in the family home with caring responsibilities for other family members  3.6.1 Within the family home there were three adults, Sibling 1 and Leo. The roles of each of the adults and children was not fully explored within assessments. Mother indicated that she had caring responsibilities for Father who had a number of physical health conditions, diabetes and arthritis, the latter was affecting his mobility. The full extent of the care he needed and the impact of this on the children and the family as a whole was not fully explored. Sibling 2 resided within the family home however there is no exploration with her, or other members of the family, of her role within the family.   3.6.2 Both Sibling 1 and Leo were recognised within the 2018 C&FA to have a caring role within the family. The extent of what was required of them, in addition to usual childhood chores, is not clearly articulated within the assessment. However, they were both referred to Young Carers in November 2018. A carer’s assessment was completed on January 2019 and a worker from Young Carers was identified to attend CIN meetings and support the CIN plan. This practitioner gave apologies for the first meeting so the content of the assessment was not shared with the attendees. The children regularly engaged in respite activities. In addition, Sibling 1 received one to one support for stress and anger management, this had a positive impact on their lives.  3.6.3 When professionals articulated an expectation to the family the parents were usually agreeable to the change requested. There is evidence that they followed some of these requests through however, their response was inconsistent. When parents did not comply with the plan there was challenge. However, it was not sufficient and done with enough urgency to bring about change, in a timely way, to improve the home circumstances for the children.  There was consideration as to whether the level of non-compliance might need   31the case to be escalated to CP however this did not lead to a request for an Initial Child Protection Conference. Instead the actions were rolled over until the next meeting. The issue of legal status was quite intractable and parents sometimes indicated they could not comply; on these occasions they gave a rationale.  3.6.4 Father had some unrealistic expectations of Sibling 1, indicating he felt she should be tidying and cleaning the house; it appears he was abdicating his and Mother’s responsibilities to Sibling 1. This was challenged and strategies put in place to address this and improve the relationships between both parents and Sibling 1. These strategies proved effective with Sibling 1 and parents indicating an improvement in their relationships.   3.6.5 Both mother and half-sister were said to be open to the local carers service however, there is no evidence that any information was sought or provided from that service.  Learning point: When either an adult or a child is recognised as assuming a caring role, the full extent of that role and its impact should be clearly articulated within assessments, and shared with partners to inform plans. Professionals must spend time ensuring adults understand what is required of them when making plans to address both health and social issues. Where there are concerns regarding an adult’s level of understanding this should lead to further assessment and, where appropriate, a change in the plan.  3.7 Thresholds – Examine the understanding and application of thresholds and explore the use of risk assessments regarding neglect  3.7.1 There were two clear occasions where professionals were making decisions regarding the level of intervention required to meet the children and family’s needs. These followed referrals by partner agencies, to CSC, with concerns regarding neglect. On both occasions the information contained within the referral met the threshold for the referral to be accepted and it was subsequently deemed that the concerns were sufficient for a C&FA to be completed.  Child and Family Assessment (C&FA) 2016/17  3.7.2 As a result of the referral in November 2016 and following the C&FA, a decision was made that the case could be managed within Troubled Families. A referral was made to Troubled Families by the SW and the case was closed to CSC.   32The C&FA had not explored the family’s finances sufficiently, other than to indicate the family were getting all the benefits they were entitled too. The couple indicated they were managing and then stated they were over-stretched. There was insufficient exploration of the impact of half-sister and Mother not being able to claim benefits because they were over stayers in the country. This family were making one adult’s benefits stretch to support three adults and the two children. In truth they were living in significant poverty. UK Poverty 2017 highlighted that overall, 14 million people live in poverty in the UK – over one in five of the population. This was made up of eight million working-age adults, four million children and 1.9 million pensioners20.The poverty rate for people in families that included a disabled adult, as in this case, was 30% and the poverty rate for children living in workless households was 72%. Whilst the benefit and tax credit schemes put in place in the 2000’s had increased support for families this had, by 2017, been eroded. This is a family that does not fit well into current benefit systems.  3.7.3 People who are in persistent poverty are more likely to lack essential goods and services than those who are in more short-lived poverty. 27% of those in persistent poverty, compared with 16% of all those in poverty, were ‘severely materially deprived’ – lacking four or more essential items.21  3.7.4 The full extent of the neglect the children were being exposed to, was not fully considered within the C&FA in 2016/17. The description of the home environment at that time, does not significantly differ from the description given in later entries that lead to a decision that the case met the threshold for CIN. The lack of use of tools to assess the neglectful home environment e.g. GCP2 and the Clutter Score, meant that any decisions were based purely on the perception of the individual and therefore open to interpretation. This issue can be particularly problematic for professionals who work in areas of high deprivation and might be seeing neglected environments frequently. It is likely that those individuals may become desensitised to what they are seeing without the use of tools to bring some perspective.   3.7.5 The children’s voices were sought and are well documented within the C&FA however, it does not appear sufficient weight was attributed to their voice. Nor was there full consideration of the impact the unhygienic home environment was having on their lives. Father was a heavy smoker and the house smelt of                                                       20 Joseph Rowntree Foundation (2017) Poverty in 2017 21 Annual Survey of Hours and Earnings (ASHE) statistical bulletins: www.ons.gov.uk/employmentandlabourmarket/peopleinwork/ earningsandworkinghours/bulletins/annualsurveyofhoursandearnings/ previousReleases      33stale cigarettes; lack of ventilation within the home likely compounded the issue. Inclusion of health in CIN meetings would potentially have brought clear focus on the impact of passive smoking for the children and provided an opportunity to consider if the children’s diet might be linked to Leo’s abdominal pain. The children clearly stated that they were unable to have friends home and were “living in rubbish”. There was over reliance on the fact that the family had “started clearing out the rubbish and cleaning.”   3.7.6 The referral to Troubled Families was considered and a decision made that the case did not meet the services criteria. The reviewer has reviewed the criteria in place at that time and can understand why the SW felt the family met the criteria. Troubled Families did not feel there was sufficient evidence to progress the referral as there was insufficient evidence of anti-social behaviour, the children were not on CIN plans, and the parents were receiving support with their mental health issues and Father’s physical health issues. In order to be eligible, the family needed to meet two of the criteria. The reviewer has considered the criteria and believes the case should have been accepted by Troubled Families on the grounds that Sibling 1 had been assessed as needing support from Mosaic, parents were experiencing financial hardship and parents and the children had a range of health problems.   3.7.7 The SW was informed by email that the referral had been declined. There is no evidence that, in light of this, there was any further consideration as to what this would mean for the children and family, and whether any alternate intervention might be appropriate. This was a missed opportunity. Partner agencies were not made aware of the decisions made by CSC or Troubled Families and were therefore not in a position to challenge or offer additional support.   Child and Family Assessment (C&FA) 2018/19  3.7.8 The second assessment in 2018 was more thorough, it made use of the four domains of GCP 2 to assess the degree of neglect. The assessment around physical health is limited, with no consideration of dental health and the assessment grade appears overly generous, considering the poor environmental state. The assessment acknowledged the over stayer status of Mother and half-sister and the financial constraints on the family. A decision was made based on this assessment by the SW and Team Manager that the threshold had been met for CIN. It is clear that agencies, excluding health, started to work together to support the family through a CIN plan.   3.7.9 The first CIN meeting took place in January 2019 with finalising of the plan in March 2019, twelve weeks prior to Leo’s death. There is evidence that during this short period the work with the children was having a positive impact on some important aspects of their lives. Sibling 1 was reported to be happier, the   34relationship between Sibling 1 and her family had improved and parents were acknowledging this as a positive. There is less evidence that there had been any significant change to the unhygienic home conditions other than removal of rubbish and the purchase of chest of drawers and beds for the children. A deep clean was planned but had yet to take place. The reviewer is not aware why there was a delay in this being actioned. The SW reported some improvement in the home environment on a visit at the end of May. However, when other professionals attended the family home on the day Leo died they described the environment as in disarray and dirty, and expressed surprise that children were living there. The ambulance service made use of the Clutter Score, and the police took photographic evidence, which depict the very poor conditions within the house. The lack of adoption of the Clutter Score within CSC means this was not available for the SW to use and as a result it is difficult to assess whether the conditions had improved.  3.7.10 In addition, what was missing was the inclusion of school health within these processes. This is somewhat surprising as Leo’s health was identified by the family and Leo as a concern. Leo, within direct work, identified that the thing that was upsetting him most about his life was being in pain. Involving the School Nurse to assess Leo and Sibling 1’s health and provide advice and expertise to the family and partners on the relationship between health issues and neglect, could have brought further benefits to the family. It was identified at Rapid Review that the school nursing may not have attended CIN meetings as currently there are resource issues and competing priorities however their advice could have been helpful.  3.7.11 Plans were put in place to support the family financially through charities but the nub of the issue was the barriers to the adults working and accessing benefits. This could only be addressed by Mother and half-sister being allowed to stay legally and the family had clearly identified they had not the funds to apply. The SW sought help from the Local Authority Immigration Officer who was unable to assist; it is likely the local MP would need to be involved to represent the family’s interests and advise however, it should be acknowledged, that this could have ramifications for the family which might include being returned to the USA.  3.7.12 The progress made and the positive aspects of this family, including the children’s regular school attendance, achievements within school and the positive relationship seen between, in particular Leo and his Mother, potentially masked the level of complexity within this family. There is a need when dealing with unusual or complex cases for reflective supervision and regular managerial oversight of the case; there is evidence of this within education and some evidence of this within CSC.     353.7.13 Since the review, work is being undertaken to match up information technology systems and the Clinical Commissioning Group have agreed a template for GPs to share information with the Local Authority which has recently been signed off.    Learning point: Partners who have provided information as part of CSC assessment should be routinely made aware of the outcome of the assessment; this was not evident in this case.  3.8 Is there evidence that the history of the family was considered at points of assessment and influenced intervention  3.8.1 Within the C&FA in 2018 it is clear that information was sought regarding each member of the family living within the family home. This information included, ethnicity and nationality. Consideration of the wider family including the couple’s older children was not as widely explored. The details of the couple’s children, born through previous relationships, were requested as part of the Rapid Review and this review. A genogram has been developed however not all the details are known.  3.8.2 The family had been living in the UK since 2007. Leo had been born in the UK. Mother and both Sibling 1 and Sibling 2 were born in America. All the children were of dual heritage. Father is White British.  3.8.3 Mother’s parenting capacity was raised as a concern a number of years prior to the review period; she attended a parenting course. However, the impact of that course, and whether it improved her parenting, does not appear to have been revisited.   3.8.4 It is not known whether neglect was an issue identified with Father’s older children. It has been reported that Mother had experienced the death of a child previously; this was not known to any of the professionals working with the family suggesting there is a gap in agencies’ knowledge and understanding of the family.  3.8.5 Neglect was first identified as a concern by professionals in 2012. Concerns relating to the poor home conditions were reported in 2012 and 2013 by school and health. At that time Leo was experiencing frequent respiratory illness believed to relate to the poor home conditions and Sibling 1 was experiencing bullying as a result of her presentation in school. Referrals to CSC in 2012 and 2013 were not deemed to meet the threshold for intervention.     363.8.6 When Father developed arthritis, this had a massive impact on the family. As the sole earner, it would be reasonable to assume that Father’s inability to work lead to the family’s poverty and the neglect issues identified. Father was known to Adults Social Care from 2013, when he applied for a blue badge and minor adaptations in the home. The family were supported weekly by Family Mosaic, a local housing service, with benefits and general advice. Adults Social Care have not been involved with the family since 2016.  3.8.7 The impact of Mother and Sibling 2’s status as over stayers was not fully considered. Whilst CSC practitioners were aware that this meant Mother and Sibling 2 could not work and could not claim benefits, there was limited acknowledgement that, they were both in the UK illegally and at risk of deportation, and that the family would never be able to acquire sufficient additional monies independently to bring themselves out of poverty. Whilst acknowledging the complexity of the situation there are circumstances which allow over stayer’s to regularise their status which needed to be explored further. These circumstances include being in a relationship with someone who is settled in the UK, and having children who are British, settled or resident for seven years, so it might have been possible for them to apply had they had the finances to do so.  3.8.8 The CIN plan included an action for Mother to seek advice from the Citizen’s Advice Bureau; this had not been actioned prior to Leo’s death.  Learning point: There is evidence that CSC, were considering previous referrals regarding the children in this family, in their decision making. What was missing was a full picture of the whole family and consideration of whether there had been any safeguarding concerns for Father’s, now adult, children.     374. Conclusion  4.1.1 The death of Leo was a tragedy that was not foreseeable by either the parents or the professionals involved. The seriousness and life threatening nature of Leo’s illness was not recognised or identified by anyone in the days leading up to his death. The Coroner concluded that Leo’s death was from natural causes.  4.1.2 Whilst a decision to not send an ambulance to take Leo to hospital, four days prior to his death, was questionable, when Leo was seen in A&E some hours later, there was nothing to alert the attending Doctor that Leo was acutely unwell and required immediate admission. It could be argued that had the 111 service, or the practice nurse requested an ambulance for Leo, this would have increased the level of information available to the triage nurse and the Doctor in A&E. Currently the information technology systems within health are not compatible, thus information known to 111 and the GP practice was not readily available to the acute hospital. Whilst communication systems are in place to inform primary care of any contact with the 111 service via letter, this also does not allow for immediate transfer of information. Had A&E staff been made aware that the family had contacted the 111 service and spoken to the GP practice, and the content of those discussions shared, this would have been an opportunity to explore this further, both with the service and with Mother. Knowledge of Leo’s hallucinations and confusion might have changed Leo’s treatment plan.   4.1.3 Parents are a crucial part of managing a child’s health needs; they act as historians, giving a voice to their children when they are unwell. There is an expectation that parents will follow medical advice. It is therefore imperative that professionals make sure the advice they are giving is clear and understood, and that parents are supported to carry out the advice given. Mother informed the reviewer that she was on her own with Leo in A&E. Mother felt it would have been helpful to have greater clarity on when to seek additional advice, and that the provision of written information would have helped both her and the family have the clarity needed to know when to seek additional help. Had the seriousness of Leo’s condition been recognised by anyone, this would have presented an opportunity for additional tests and treatments which might have saved Leo’s life.  4.1.4 Poverty was a significant issue for this family with no easy solutions. Those professionals involved with the family were trying to find ways of reducing the impact of poverty on the children. However, there was inconsistent use of tools to assess neglect and a lack of urgency in progressing the CIN plan or escalating the case to a CP plan. The introduction and use of the Clutter Score could help professionals working with the most deprived families objectively   38assess whether the children’s environment might be detrimentally affecting their lives.  4.1.5 Lack of health involvement in CIN processes has been noted in a previous Serious Case Review within Thurrock, and whilst there has been scrutiny of the CIN process and information sharing, and discussion regarding how this can be improved across the partnership, this requires further exploration. Primary care holds much of the health information regarding children and families. The lack of inclusion and involvement of health within multi-agency meetings is preventing a truly holistic and effective package of support and intervention being provided to families.   39Glossary  111 Integrated Care 24 A&E  Accident and Emergency C&FA Child and Family Assessment CFAT Child & Family Assessment Team CIN Child in Need CP Child Protection CSC Children’s Social Care DASH Domestic Abuse, Stalking and Harassment ECG Electrocardiogram GCP2 Graded Care Profile 2 GP General Practitioner LCSPR Local Child Safeguarding Practice Review MASH Multi-Agency Safeguarding Hub MH Mental Health MIU Minor Injuries Unit NHS National Health Service NHSE National Health Service Executive OOH Out of Hours PASS Prevention & Support Services PIP Personal Independence Payment SCR Serious Case Review SN School Nurse SW Social Worker TLSCP Thurrock Local Safeguarding Children Partnership 