Long term physical, emotional and sexual abuse and neglect of several children within a family. Family had complex needs, requiring the involvement of multiple agencies over a period of nearly 20-years. Children were exposed to a highly sexualised environment and had unsupervised contact with an individual believed to be a risk to children. For two brief periods some or all of the children were placed on the child protection register; care proceedings were initiated in 2013. History of: domestic abuse; inter-sibling violence; parental alcohol misuse; and an aggressive, manipulative and litigious paternal response to professional interventions. Identifies learning points including: need for supervision to encourage staff to take a long term perspective on cases; importance of considering the meaning of repeat disclosures from children, even if they are found to be unsubstantiated; and need to exercise discretion in excluding parents from conferences where there is a history of staff intimidation. Makes recommendations including: children's services should convene multi-agency meetings to discuss major concerns by other agencies; records should be easily accessible so a family's full history is taken into account and clear processes should be put in place to allow multi-agency discussion of chronic cases without a single trigger event.
      
 Title:  Serious case review relating to the Q Family. LSCB: Isle of Wight Safeguarding Children Board Author: Alan Bedford Date of publication: 2015  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1            ISLE OF WIGHT SAFEGUARDING CHILDREN BOARD     SERIOUS CASE REVIEW RELATING TO THE  Q FAMILY                           Approved by the IOWSCB on 8 July 2014                                         Published March 2015                                                   Independent Reviewer:    Alan Bedford    2  CONTENTS  Section  Page 1 INTRODUCTION 3 1.1  Background to the Review  1.4  Terms of Reference  1.6  Review Process 4 1.12 Independent Reviewer 5 1.13 Anonymity  1.14  Agencies Participating  1.15 Report Structure 6 1.19 Acronyms used     2  HISTORY and  IMPACT ON CHILDREN and PROFESSIONALS  7    3 INTRODUCTION TO FINDINGS  10    4 ILLUSTRATED APPRAISAL OF PRACTICE 11 4.1  Introduction  4.4 Actions and Appraisal  4.63 Summary 25    5  LEARNING AND WHY 27 5.1 Introduction  5.3 The Influence of the Father  5.17 Managing Different Views on Risk 30 5.28 Single Issue Thinking 32 5.36 A&E Attendances 34 5.37 Management of Allegations 36 5.46 ADHD  5.51 Meetings 37 5.66 Overarching Themes 41 5.81 Views of the Family 45    6 CONCLUSION 48 6.1 Introduction  6.2 Could one or more of the children have been protected earlier?  6.5 What would need to happen to protect more quickly children in the future in a similar position?    49    7  RECOMMENDATIONS 50    8 WHAT IS BETTER NOW? - UPDATES FROM AGENCIES  52    App 1 Collated learning points from Section 5 ‘Learning and Why’   61 App 2 Police Review June 2014. Conclusion and Recommendations 64      3                                             1. INTRODUCTION  1.1 Background to the Review: In October 2013 the new Chair of the Isle of Wight Local Safeguarding Children Board (LSCB) concluded that the circumstances of the case concerned met the statutory requirements for a Serious Case Review (SCR) as set out in statutory guidance Working Together to Safeguard Children (DfE March 2013). These are that there should be an SCR for every case where abuse or neglect is known or suspected and either a child dies or a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child. The SCR was accepted by the LSCB on July 15th 2014. Publication was delayed to avoid compromising further Police inquiries.  1.2 The Q case had originally been referred to the LSCB for consideration of an SCR in 2009 but it was thought the criteria were not met, and was referred back to the Council for a review. It was referred again in March 2013 but was not considered by the SCR Working Group until June 2013. The new LSCB chair made the SCR decision on taking up post, on the grounds that abuse or neglect were suspected, a child has been seriously harmed, and there were concerns about how agencies and professionals had worked together with the family.  1.3 The statutory guidance says that ‘when compiling and preparing to publish reports (an LSCB should) consider carefully how best to manage the impact of publication on children, family members and others affected by the case’. In this case there are a number of children involved, who have experienced much unhappiness and abuse over many years.  The Chair of the LSCB has concluded that it is possible to publish a SCR without the children being identified and further harm being caused to them. However, this requires that only a certain level of detail can be given and some identifying facts might be left out or changed. This report, whilst giving a full appraisal of agency performance, therefore reduces detail that could lead to anonymity being breached.  1.4 Terms of Reference: The 2013 guidance no longer provides core terms of reference for SCRs, but says that final SCR reports should provide a sound analysis of what happened in the case and why, and what needs to happen in order to reduce the risk of recurrence.  1.5  This SCR will :   Appraise the quality of work in this case  Establish what lessons can be learned about the quality and effectiveness of agency and multiagency working  Identify the key themes that characterised work with this family  Make proposals for improvement where any shortfalls are identified  4   Involve front line staff and family members in the Review  There is a key underlying question:   Could one of more of the children have been protected earlier? If so, why, and what would enable this to happen with future children in a similar position?  1.6 Review Process:  The Review used the flexibilities contained in the guidance to follow a methodology that fitted local needs. It was decided, as the case was so large, and covered nearly two decades, that it would be an unnecessary use of agency resources to study the whole case in detail as in the traditional model of SCRs. For example, full chronologies would be vast, as would full analysis of all agency actions.   1.7 To think through a way forward, a scoping day was held, chaired by the independent reviewer, with around 30 involved staff (the ‘staff group’) who had available brief agency reports and some chronologies commissioned either for the SCR Working Group when making its recommendation to hold an SCR, or for the scoping day itself.  The Chair of the LSCB’s SCR Working Group was in attendance.  1.8 The conclusion of the scoping day was to focus on themes of how the family impacted on professional staff (and what could be done better with similar families in future) and on some key turning points in the case, rather than the whole case history.  The independent reviewer would work with agency staff and documents to elaborate on these areas of focus. It was also agreed that the staff group would be reconvened to consider the draft findings and to contribute to the learning and how things could be done better. This meeting was held and the staff contributed further analysis and thoughts about recommendations.  A participative approach like this was thought to enhance learning and buy in, and also for staff who found the case so hard to play an active part in shaping the Review’s conclusions. Around 40 staff took part in one or both of the staff group meetings.  1.9 To support the process there was a Reference Group of senior staff from involved agencies which the reviewer could use as a sounding board, and if necessary to facilitate any stumbling blocks in the process. The Board’s SCR Working Group quality assured the final draft before presentation to the Board.  1.10 The independent reviewer met all the children who were a focus of the Review, and their views are reflected in this report. The father and mother were seen separately, and their views are also in the report.   1.11 At the end of the process the reviewer was provided with an internal Police management review of the Police response to allegations of abuse to the children  5  in the Q family. The findings from this have been incorporated into the SCR. It is referred to as ‘the Police Review’ below.  1.12 Independent Reviewer: Alan Bedford was asked by the LSCB to undertake this Review. He has a background in child protection social work with the NSPCC, where he was also national training manager. Following this he spent 18 years in the NHS, the majority of the time as a CEO in Trusts and Health Authorities. He now works independently as Alan Bedford Consulting on a range of issues from infection control, to emergency health care, to safeguarding. From 2009-11 he was Director of Safeguarding Improvement for NHS London, leading a London wide peer review programme, and from 2009-13 was chair of the Brighton and Hove Safeguarding Children Board. He has conducted many SCRs, is accredited as a SCIE Systems Reviewer, and has completed the 2010 and 2013 national training for SCR authors.  1.13 Anonymity: As described in 1.3 the LSCB believes it is important to preserve the identity of the children. This Review will not therefore describe the family in detail. Some facts may be altered a little to enhance anonymity. This is also necessary to comply with the legal requirement not to publish the identity of victims of sexual offences.  1.14 Agencies Participating: All involved agencies participated in the Review. These included:  Isle of Wight Council:   Children’s Social Care   Youth Offending Team  Education/schools  Legal   Hampshire and Isle of Wight Police  Isle of Wight NHS Trust  Child and Adolescent Mental Health Services  Hospital services  Midwifery  Health Visiting   Isle of Wight NHS Clinical Commissioning Group  General Practice  Two surgeries  Hampshire Probation Trust  Portsmouth and Isle of Wight area  6    1.15 Report Structure:  This report describes the history in Section 2, not in detail so anonymity is preserved, but by describing the sort of family this was and the impact it had on professional staff.   Section 3 introduces the Findings, which begin in Section 4 by an illustrated appraisal of practice.  1.16 There is a ‘Learning and Why’ Section 5 which identifies the key themes of professional practice and why those patterns of work occurred. It is in understanding ‘why’ that needed improvements can be identified. The ‘Conclusion’ in Section 6 summarises the learning, and answers the key question about whether protection could have been quicker.  1.17 There are recommendations in Section 7 for the LSCB to consider. They are addressed to the Board rather than each agency separately, given the Board’s collective responsibility for assuring the quality of child protection systems.  1.18 This report does not set out to describe and analyse each agency’s contribution in detail. This is to adhere to the planned intention to focus on what is most important in the story, and for priority learning.   1.19 The following acronyms are used in this report:   A&E Accident and Emergency ADHD Attention Deficit Hyperactivity Disorder CAMHS Child and Adolescent Mental Health Service CCG NHS Clinical Commissioning Group CPS Crown Prosecution Service CSC Isle of Wight Council Children’s Social Care D A CAMHS worker H One of the children LSCB Local Safeguarding Children Board R One of the children SCIE Social Care Institute for Excellence SCR Serious Case Review X A non-family member now deceased Y A non-parent adult family member          7  2 HISTORY and IMPACT ON CHILDREN AND PROFESSIONALS  2.1 This section describes what characterised the case, what professionals and the children were faced with over the years, and the impact this had on them.   2.2 The family, which had several children, was characterised by continuous problems which involved professional agencies, over the life time of those children. The parental relationship was subject to numerous domestic disputes which included violence, and many Police interventions. The disputes continued even after the parents had split up and had new partners, and the atmosphere of conflict and physicality was such that some of the children themselves became violent between themselves, and with others outside and inside the family. The father also had convictions for violence (often alcohol related, but not against his children), and there was concern about over chastisement within the family.  2.3 There were concerns about the quality of parenting when children were young, frequent A&E attendance including injuries when young, and concerns about their failure to thrive. There were also practical issues such as housing where agency help was sought.  2.4 The children’s behaviour was the subject of much medical/therapeutic endeavour with diagnoses of specific behaviour disorders, although the cause was, in the main, likely to be mainly the upbringing and modelling they received at home. At least two of the children had youth offending problems, involving violence.  2.5 After the parental split there was much to-ing and fro-ing of children between parents (with the children alternating which ‘side’ they took), with little consistency of care. There were child protection concerns about children in their parents’ new families which are not the subject of this Review.  2.6 Over many years there were allegations that one or more or the children were at the very least subject to a highly sexualised environment, or sexually abused or at risk of such abuse, either through parentally uncontrolled access to a high risk individual, or by a family member. Such suggestions of sexual abuse were investigated on a number occasions over a decade by the Police and/or Children’s Social Care (CSC) but with ‘no further action’ conclusions, for reasons that will be explored in ‘Findings’ below. There was eventually a conviction in relation to a number of offences against a child subject of this review, but the fact that most of the allegations looked into led to no further action, created a sense in some professionals that little could be achieved.  2.7 For two brief periods some or all of the children were placed on the Child Protection Register, but most names were removed within months.  The off-on nature of the concerns was a characteristic of this case, especially for CSC, which opened and closed the case of one or more children, or parental support, or took  8  referrals without further action, on numerous occasions. Reasons for the cyclical nature of the case are explored in Findings below.   2.8 There were also tensions between agencies with, typically, health and education staff having higher levels of concern about the children’s safety than CSC.  2.9 Over a period of nearly two decades, professionals have found dealing with the family hard, mainly because of the volatile, aggressive and manipulative nature of the father, and because of the turbulent relationship between the adults. Children have taken sides, and then changed their minds, and allegations received about their well-being were often unclear as the allegations appeared to be part of the adult battles to prove each other the problem. One child told the Review that evidence was withdrawn because of fear of retribution at home.  2.10 Staff have told the Review how daunting it has been to work with the family.  Paternal complaints about staff have led to several staff being changed, which had another undermining effect on their confidence in working with this challenging family. Staff have felt a degree of fear in face of such challenging and aggressive responses. A Police officer noted that he ‘felt (the father’s) volatility and anger were such that I felt in real danger, as did my colleagues’. Some social work staff have described being harassed in a way that has been most uncomfortable for them, and indeed quite unacceptable.    2.11 The author was struck by the strength of feeling in a number of staff created by this case (and how it was managed) even many years after their last involvement. A health worker could describe vividly how bad she felt knocking on the family door over 15 years ago. In other workers, emotions still ran high sometimes many years after last contact with the family. These feelings were of sadness about the extreme plight of the children, and also frustration that little was done to intervene for so long.  2.12 The children were of course the prime victims of the family dynamics and lifestyle.  They have witnessed domestic violence, and have often had to switch allegiance from one parent to another. It is not possible to give their overall perception as they vary in their public acceptance that anything untoward has happened to them. But from a combination of official records, relative comments and discussions the children had with the Review, there is little doubt that they experienced a chaotic upbringing where heavy handedness and sorting problems through violence was seen to be the norm. As they grew older, two of the children had serious behaviour issues leading to considerable involvement with the justice system for violence.  2.13 There was (at the very least) an over-sexualised environment around the home quite inappropriate to their ages, and there was insufficient protection from known risks inside and outside the family.  9   2.14 The children were at one time on the child protection register for emotional abuse. They were the subject of, or the initiator of, numerous allegations of physical and/or sexual abuse for over a decade, and in only one incidence was an allegation proven, and that after the children had become Looked After.  This meant that at least for one, probably two, of the children there was a long term sense of not being listened to or believed and their vulnerability to abuse not stopped. At one point, the school said it was hearing almost daily accounts from one or more children that suggested abuse.  2.15 It is also likely that one or more children were unable to adhere to original allegations when formally investigated for fear of further abuse if they stuck to the allegation.                                  10  3.  Introduction to FINDINGS   3.1 Section 4 summarises the findings of the Review in an appraisal of how well agencies worked separately and together over the period. This is not easy to do as the case goes back over many years when organisations, procedures, understanding, and expertise were different or developing. It could be wrong to judge agency activity of, say, a dozen years ago by today’s standards. On the other hand, it does help to identify what needs to be in place now. The closer any activity described is to now, the more one would expect it to approach good current practice. 3.2 The appraisal is followed in Section 5 which looks at Learning and Why. This elaborates more on the appraisal themes and identifies the lessons to be learned for future action. (The Conclusion is in Section 6, Recommendations in Section 7 and an update from agencies on current progress in Section 8).  3.3 The LSCB believes it is not in the interests of any of the children involved for them to be identified by this report, and where any child is a victim of sexual offences, it would be illegal to do so. This means that at times there may be a lack of specificity in this report, and that general conclusions are described.  3.4 The account and comment below does not intend to tell the full story but key events.  3.5 It is for the LSCB to form a view on how widespread is any issue identified in the Review. The Review identifies what can be learned from this case, and it is where the Findings reflect patterns that are wider than this case that action should focus.                    11  4. ILLUSTRATED  APPRAISAL  OF PRACTICE  4.1 Introduction: This section illustrates an appraisal of agency action over the course of this case, and indicates whether children could have been protected earlier. It needs to be born in mind that the events in this case covered a period of nearly two decades, and it is not necessarily appropriate to judge practice some time ago by today’s standards or knowledge.  The reasons why something was, say, not good enough, are explored in ‘Learning and Why’ from page 27.   4.2 This section does describe some detail in order to demonstrate the volume of concern over many years, as the learning comes from considering the accumulation of knowledge about the family against actions taken. The detail given is still only a part of what could have been described. There is a deliberate lack of clarity about family composition to avoid identification of the children and other children in the wider family.  4.3 This section says what happened and comments on the quality of work. The following section looks at ‘why’ agencies and professionals acted as they did.  4.4 Actions and Appraisal: Across 2013, each of the children subject to this SCR was made subject to a full care order, and are deemed as ‘Looked After Children’ by the Council.   This process marked a firm, thorough approach leading to child protective action. There were good multiagency child protection case conferences through this process. There were comprehensive core assessments on each child which marshalled together the events and risks over nearly two decades, and accurately highlighted the current risks to the children. Appropriate legal steps were taken by the Council to initiate care proceedings.  The Police, after an internal audit, had identified an insufficiently robust decision making about sexual offences involving a child, and subsequently did charge someone who was later convicted.   4.5 It might be argued that the court could have ordered the removal of some of the children from their home earlier in the year than did happen, but the end result of them all being protected allowed the children at least a chance of experiencing life in a more stable environment.  The key question is whether this could and should have happened earlier and, if so, why it did not?    4.6 One or more of the children experienced: frequent attendances at A&E when young, failure to thrive in early years, parental rows and violence (including coincidental injury to a baby), violence between siblings and between siblings and parents, violence to and from peers, over chastisement, physical abuse, sexual abuse, severe behaviour problems (in some cases leading to Police intervention) with associated heavy medication, exposure by their parents to adults known/feared to be a risk to children and against whom most serious allegations were made, ongoing parental disputes about their custody often played out in  12  private court hearings, and problems with education as a result of the chaos and poor parenting.  A Police chronology for 2009-13 alone had 94 entries relating to the family, indicating the degree to which one or other member of the family, separately or jointly, came to their attention. Could the helping agencies have done better?  4.7 In the half a dozen years after the first child was born, the professional involvement was about ongoing domestic disputes and violence (often involving alcohol), consequential risk to the children, failure to gain weight, and numerous A&E attendances, maternal mental health, paternal violence, and a number of anonymous or neighbour referrals concerned about the children. The father, for example, received a caution after the mother’s arm was broken in a domestic incident, and by 2003 had also been convicted for several offences of violence and threatening behaviour. There is no evidence that in those earlier years, despite the level of violence, and insecurity for the children, that a child protection conference was any more than threatened.  4.8 Police and CSC were involved, but no record has been seen of multiagency meetings to review the overall position. These should have happened. A pattern began of making decisions on the evidence for criminal action, and if that was deemed lacking, no other action was taken such as multiagency consideration of registration, or an holistic assessment of what was going on in the family. This also applied to CSC.  4.9 In mid-2002 there was a ‘professionals meeting’ (a private meeting of involved staff) concerned about frequent A&E attendances by the children, and by the father who would be aggressive with hospital staff. (The father had also attended A&E twenty times in a six year period, during which several children were born, including for self-harm and post-fight injuries).  Such a meeting was good practice, and drew together known information, but did not involve the Police so missed their (considerable) background knowledge. It recommended a core assessment by CSC but it seems that was not done. A strategy meeting/child protection case conference would have been a more proportionate action given the accumulated concern. In the autumn of 2002, a hospital paediatrician, whilst continuing to draw attention to more A&E attendances, implied that the explanations were consistent with the injuries, which would have lowered concern. He also asked for a CSC core assessment so must still have had concerns. Some of the parental explanations of injury might have warranted more scepticism, especially given the frequency of attendance.  4.10 A child protection case conference was eventually held in 2005, but the prior three years had been very fraught. In early 2003, there were disclosures by two of the children about inappropriate sexual behaviour by X (not a family member). At the very least it was clear that the parents had not kept them from X despite being made aware of the risks.  Police and CSC related well in attempting to assess the  13  risks, but despite the family history and the potential severity of the allegations there was no child protection case conference.  With the children changing their stories, and no corroborating evidence, again no action was taken. In the autumn of 2003 CSC passed on information they had received about X to the Police, but again joint work led to no action.  4.11 Father’s assurance that he would keep his children away from X was accepted despite the father’s own erratic, aggressive and challenging presentation. This confidence in the father was rather optimistic, and at a number of later points when it was clear one or more children were being allowed contact with X, there was no change of plan.  4.12 Even if the allegations about X were not true, the children’s graphic accounts would suggest a sexualisation (at 5 and under) that would suggest something rather worrying. CSC closed the case mid-year, and another pattern in this case was of frequent closures once any sort of calm emerged, rather than assessing the long term needs of the children.  4.13 By 2004/5 the attention was moving to behaviour problems of two of the children, and child mental health services (CAMHS) and paediatrics were involved, but parental cooperation was poor. Child behaviour then became associated with inappropriate parental (mainly paternal) attempts to control. One such led to a referral to Police, but judged not worthy of further action, and CSC kept the case closed. By February 2005, CSC told CAMHS that family non-cooperation had led to the case being closed as ‘no present role’. In the same month, the father sought help from CSC with one child said to be running amok, but the next day the case is recorded as closed. A few days later father says they will cooperate and the case is opened again.   4.14 Two months later, there is a referral about over chastisement, and on a home visit the social worker hears a child’s suggestion that the father is using a belt on another child, but also of sexualised games – with one child implicating another relative. Police and CSC looked at the chastisement together. The 2014 Police Review concluded that the school/s should have been involved in strategy discussions to help inform and plan the investigation. Two children were interviewed in the presence of their grandparents, which was unlikely to lead to any critical evidence about family members. The comment in the Police chronology says “This was not the original plan and was clearly recognised as not ideal by the officer”. The father was interviewed under caution, but the children’s evidence was inconsistent and no further action was taken.  Again, the accumulated concern merited a full multiagency case conference to assess the overall risks. In the early autumn, Police attended another domestic violence incident, and found the home to be ‘disgusting’. Initial assessments of the children did not lead to any new action. A month later there was an anonymous allegation that the parents were abusing a child who had lower body bruises. A joint Police  14  /CSC interview led to disclosures by several children and the father’s arrest. The Police Review concluded the arrest was good practice to ensure the children could be interview without the suspect’s influence. As was often the case, the children’s story changed and a pogo stick was blamed. A decision was taken to take no further action on the basis of insufficient evidence.  4.15 However, it was good practice to hold the case conference at the end of 2005, and both parents, both paternal grandparents and a family solicitor attended. This scale of family attendance is exceptional and would have increased the difficulty of professionals sharing all they knew, and the minutes show how much the social worker was criticised by the family. The minutes do show a thorough sharing of background, ranging from the father’s convictions for violence to various abuse allegations, to the risks from X. All the children discussed were put on the child protection register for ‘the likelihood of emotional harm’.  4.16 The conference conclusion was about a ‘vigorous’ support package for the family, and this was reported to be working well at the follow up two months later in 2006, but registration was continued. (There was no Police attendance or report at this conference). The next review was in mid- 2006, by which time the parents had split, with the father, now with a new partner, retaining most of the children. The conference (from which Police apologised) heard about the father allowing at least one child (described here as H), access to X, despite commitments to the contrary, and that X might be grooming children and parents. The children were said still to be witnessing domestic violence, and that there was considerable instability and a violent atmosphere. The Police had submitted a report on prior convictions for the conference, but the details are not recorded in the minutes.  4.17 This conference, whilst clearly conscientious, and working well to try and plan for the needs of each child, recommended an anger management course for the father (presumably because he had not adhered to the same plan at the previous conference six months earlier). Why it was believed he would comply this time was not stated, a further illustration of undue optimism. Within a month of the conference CSC referred to the Police, concerned about risks to the children from domestic violence including threats of potentially life threatening arson. It was agreed that the risks would be looked at by CSC alone as each particular incident had been investigated by the Police, and also covered in private law family court proceedings about the residence of the children. The following month CSC again approached the Police when the mother alleged the father was allowing the children access to X. It was agreed that only CSC would inquire into this as there were no specific allegations of criminal offences. The Police Review, seeing that information at the time included suggestions of X going into the children’s bedrooms, concluded that the decision was not appropriate, and that this should have led to Police inquiries, which that Review added would be done now under current guidance in similar circumstances.   15  4.18 Optimism was shown again at a review conference in the autumn, where the children were removed from the Child Protection Register as there was said to be good parental progress, despite there still being concern about the children having access to X, with the mother’s written comments to this effect being shown to the Conference. Indeed a Paediatrician wrote to CSC after the Conference and described the minutes as ‘optimistic’. The pattern of health staff taking a more concerned view of the children’s well-being at home became common in this case. There was no mention in the minutes of a Police investigation into threats of extreme violence from father to mother since the previous conference.  4.19 Within a few months, in early 2007, there was a joint Police/CSC look at an allegation that the father (or his new partner) had assaulted one of the children, but it could not be substantiated. A further three months on there was an allegation that the same child had been unlawfully held by X and forced to make a tape implicating several family members as having had sex with H. A month later another child alleged an assault by X. A Police investigation led to no corroboration as the child’s evidence was inconsistent. Whether the tape or allegations were true or forced, this was more evidence that the parents were unable to keep children safe from either X or inside the family, yet there was no multiagency meeting or child protection conference to consider the overall well-being and future of the children. This should have happened, as inability to prosecute does not stop child protection through other means. The Police Review again concluded that it would have helped if the school/s had been involved at the strategy discussion stage. It also concluded that X’s premises should have been searched. The SCR author concludes it was unwise to use the father’s parents to accompany the child to the Police interview suite (though not in the interview) given the taped allegation was against their son.  4.20 At the end of 2007 there was another allegation of paternal over chastisement of a child. An investigation by CSC only was agreed. The Police Review says it should have been joint with the Police given previous referrals of over chastisement, and now it would be joint.  4.21 2008 brought further investigations that the father had hurt a child, but no further action could be taken for lack of evidence. The Police Review says that while one child was appropriately medically examined, it was a ‘superficial investigation’ and that two children should have had ABE interviews. There were more disputes between the now estranged parents, and allegations and counter allegations between them. A combination of the children’s known behaviour problems, the long history of disputes, and inconsistent stories, meant that there was always something to complicate any assessment.  4.22 In 2008-9 there was a pattern whereby professionals outside CSC were consistently seeking greater CSC involvement, with the response being usually, in general terms, that there was a limited or no role for social work. This led to  16  considerable tension between agencies which is analysed in ‘Learning and Why’ in section 5.  In early 2008, a head teacher wrote to the Director of Social Services and others on behalf of a ‘professionals meeting’ which included teachers, social worker, and a paediatrician, referring to ‘almost daily reports’ about from a child about incidents which ‘suggest abuse’. She referred to the longstanding nature of the case, and high concern that the children were not registered and CSC was not visiting regularly. The letter suggested that CSC were reluctant to get more involved in case the father disengaged more. It ended ‘and still the children remain without support’.  CSC said there was no programme of visits as the case was closed 7 months previously, pointed out that CSC had not been getting referrals from the school, and that there were other organisations providing support.  There was no offer to explore the concerns, which seems inappropriate given by then a 12 year history of worrying events in the family, some quite recently,.    4.23 Through 2008 and into 2009 there continued to be allegations of possible physical harm from the father, but also concerns about violence between the children. In the autumn of 2008 a paediatrician, following another professionals meeting, wrote to CSC asking for a case conference because of the escalating violent behaviour of one of the children. It suggested removing the child from home for stabilisation and to wean the child off extensive medication for ADHD. No multiagency meeting was held in response to this accumulated concern. Generally any agency should be able to ask CSC to convene such a meeting.  4.24 In early 2009, there were continued concerns by other agencies, and a CAMHS/Sure Start worker (D) wrote on behalf of her and the paediatrician to CSC  seeking respite for child known here as  H who was said to be the victim of violence at the mother’s home from a child relative  and violence between child relatives. The CSC replied to worker, and said that their view was that short removals were not helpful and that working ‘to improve the parenting was the right course’. As it was stated in the reply the case was currently closed, this was not based on any current assessment, and participation in a new assessment was rejected.  Again, given the accumulated concern, some sort of new assessment or multiagency assessment was warranted. The same CAMHS/Sure Start worker wrote again concerned that the mother and partner were not cooperating, not engaged with therapy, and so were being re-referred to CSC as she had had to close the case due to that failure to engage. A case conference was requested. The Early Years Team were also told the same day by D that the children were deemed to be ‘at risk of serious harm’. There was no strategy discussion/case conference.  4.25 Two months later, in response to a long email referral from D, concerned about violence between children at home, and parental non-cooperation, CSC suggested a common assessment framework (CAF) could be undertaken ‘in order to highlight any additional support needs’ of a child, about which there were  17  particular concerns. This might have been a reasonable suggestion had there not been so many longstanding concerns.    4.26 On the same day that CSC received a referral from a neighbour about the care of the children living with the father, D made a several page written referral. D’s concerns included hearing disclosure from H about sexual abuse which the child said had been reported to school, Police and CSC some years ago, but which D had not heard mentioned before and needed to know if it had been actioned.  D requested an urgent assessment as the child was receiving inadequate emotional support and was distressed by the disclosures. None of the advice D received from CSC, when this had first been phoned in, involved any action by CSC.  4.27 The disclosure about sex with X, which H said was known by the father, was reported to CSC in detail in the letter. The disclosure also referred to violence from the father. D declined CSC advice to report the disclosure to the parents as she felt this would put the child at risk. The letter was widely copied. A senior CSC manager agreed to a meeting between D and a Team Manager. That meeting took place and the following day there was a multiagency professionals meeting called by the designated nurse for safeguarding. CSC, education, community health and CAMHS were represented. All the children in this Review were discussed plus others from their parents’ new relationships. The minutes said that ‘all the professionals expressed frustration at the lack of progress and intervention available to reduce the negative circumstances on the children both physically, emotionally and educationally’. The meeting concluded that CSC should do initial assessments and if these were not done, the health professionals would consider calling a child protection case conference themselves. A senior education representative at that meeting recalls being shocked that the social worker present said, as the meeting commenced, that what those present said would be listened to but it would not make any difference to the CSC position of not being involved.  4.28 A written response to that meeting 6 weeks later from a CSC social worker who had done the initial assessment said that ‘I do not share the view that H is at risk of serious harm, and that statements made at the professionals meeting about ‘neglect, weight loss, poor presentation, and self-harm proved difficult to unravel, put in context and still more evidence’. However, it went on to say that ‘clearly’ one child had ‘experienced sexual abuse in the past’. If it was that clear one wonders why protective action was not taken. The letter commented on another child in this review and another child not the focus of this Review. The conclusion was that ‘no role’ could be identified for targeted CSC intervention and urged other agencies to ‘share concerns with the parents and/or CSC as they arise’. This may well have been the judgement of the social worker concerned, but a response from someone more senior was warranted given the weight of concern expressed by so many professionals.  In the same month as the reply, and the next, there were several disputes, some violent, between adults or children and adults in both the homes of the separated parents, and Police were involved.  18   4.29 In the autumn of 2009 a professionals meeting of a wide range of NHS staff and education (with apologies from CSC) met to discuss H following that child’s admission to a paediatric bed for observation around behaviour. Despite very significant behaviour problems at home, none were seen on the ward. A psychiatrist concluded that the behaviour issues related to environmental issues. It was noted that, a few days before, H had disclosed sexual abuse which had been reported to CSC. It was agreed agencies would make referrals to CSC about their ongoing concerns.   4.30 That disclosure by H was of very serious sexual offence by an adult relative (not the father) referred to here as ‘Y’. There was a thorough investigation by Police which the Police Review described as ‘very good example’ of good process. This included the arrest of Y, but insufficient and inconsistent evidence prevented prosecution. Again there was no multiagency child protection meeting to discuss the safety and well-being of H which must have been in question simply in making such allegations. Again, it seems that proving a crime became the yardstick for child focussed protective considerations. Prosecution is only one means of protection.  4.31 The following month children in the care of father were made subject to Police Protection when the father was very drunk in charge of the children.  He was later convicted of assaulting Police in this incident, receiving a sentence that included supervision by Probation. The home was said by Police to be ‘a total mess’ and ‘filthy’. The next month, December, a health visitor shared with CSC her difficulties visiting the mother and partner (where H was then living) as she had been rejected by them. She said she would keep trying. In January 2010 the case was ‘closed to the CSC Family Support and Intervention team’.  The reason is not clear.  4.32 In March 2010 there was, at last, a child protection case conference, the first since 2006. It was on H, and a sibling and step sibling also living with the mother. The parents and three family solicitors attended - a degree of legal presence which was probably without precedent. Isle of Wight Council legal services were not invited to attend this Conference despite the large legal presence. From this conference onwards Police attendance was regular. It was called due to an injury to a step sibling eventually judged to have an innocent cause. There were also concerns about H’s relationship with the mother’s partner, and H’s emotional well-being in that household. There was no discussion about the children still cared for by the father. All the children with mother were made subject to a Child Protection Plan. It was good practice that H was able to give signed advance views to the conference.  4.33 There was no invitation to Probation, even though they had called CSC twice to obtain information to help prepare a pre-sentence report on the father who was shortly due in court for assaulting Police when they attended the home of a children related concern. Indeed this serious incident was not referred to in the  19  minutes at all. It might have been because the conferences, and the next two, were on children in the care of mother, but such were the complexities of the relationships that any risk related to the father should have been detailed.   4.34 In May 2010 the CPS decided they could take no further action with Y about H’s allegations of sexual abuse.  4.35 The March 2010 case conference was reconvened in June as the mother and partner had complained about the first one.  It was appropriately arranged that the father and mother’s partner were not present for discussions of the other. It referred to various private law court orders on which child lived with whom, as in parallel with any professional concerns there were many private law hearings initiated by parents to resolve disputes over residence and access. It acknowledged that H had alleged sexual abuse by two perpetrators. H had chosen to live with mother despite there being a residence order to be with the father. H was still in treatment with CAMHS. All bar H were removed from Child Protection Plans, with H to get social work support, and a re-referral to CAMHS. At the conference the father said there were three sexual abusers of H not two, and   is recorded as having named the third. The Plan said H should have no contact with Y until there had been a risk assessment by CSC.  4.36 At the June conference, the Probation Officer gave apologies, but submitted a brief report. The fact that this answered ‘none known’ to the proforma question about any child related issues, and ‘none known’ to the question about risk of serious harm e.g. domestic violence, sexual abuse etc suggests limited contact between CSC and Probation and their mutual client.   4.37 Shortly after the conference the father told the school that a child (described here as R) had genital bruising from a fight with a boy, but shortly after had said that it was caused by a bike. Apparently R had spent the weekend before with Y. There is no record of a CSC or Police investigation despite the differing stories, or a medical examination, despite Y having been recently arrested (later convicted) for an offence (not with relatives) which might be deemed relevant. Differing stories is a well-known indicator of possible abuse (See the CPS guidance described on p35 below).  4.38 H was seen at school by a new social worker, and confirmed the allegation of  a very serious sexual offence by Y. H was on new medication for ADHD, and agreed a referral to CAMHS to help deal with the aftermath of abuse. In the same month the mother alleged a very serious historical offence by father, but Police could not pursue as she did not follow up her complaint.  4.39 In September 2010 there was a further case conference on H, to consider if H still needed to be on a Child Protection Plan. H’s bedroom at the mother’s house was said to be without door, equipment or furnishings. CAMHS had still not decided how to respond to the referral.  The conference decided to remove H from a Child  20  Protection Plan and move H to a lesser Children in Need (CIN) plan. It was recorded that if H had access to Y then CSC should be informed immediately ‘so H can be protected’. There was input from Probation who were supervising father. Again, the earliest opportunity is taken to lessen the degree of oversight, which was an example of agencies not taking a longer term perspective - which would have indicated that nothing stays better for long with this family.   4.40 The CIN plan was reviewed the following month with no new major concerns but on-going work on health, behaviour, education, safe sex advice. In December a psychiatrist convened a professionals meeting, so they would all work together closely around H. (No Police or Probation were ever invited to professionals meetings). Also in December, Police were informed of father being heavy handed in public with a child. CCTV was examined, but no one spoken to, or the child identified, and no further action was taken. The Police Review described the investigation as ‘not being of an acceptable standard’. In the same month Police were called to a violent dispute between H and a peer. A further CIN review in January 2011 focussed on H’s behaviour.   4.41 In February 2011, Police were called to the mother’s home as H wanted to give further information about the rape by X, that H had alleged in 2008.  Police records say CSC thought it unnecessary for the Police to do anything and CSC would look at it alone. (X was by then deceased). The Police Review says that the Police should still have obtained a full account in case others still alive were involved. This event does not appear in the CSC chronology provided to the SCR. Through the first half of 2011 concern was mainly around H’s behaviour but also H’s allegation of violence against the mother’s partner (where the Police judged his constraint to be justified) and his counter allegation that H was harassing him. H decided to move back to the father (fed up apparently from aggression from other children at the mother’s) and, appropriately, a risk assessment was done by CSC of this. The father agreed not to allow H access to the alleged abuser Y.  The conclusion of the assessment was that concerns about the father were ‘not current’. The father’s assurances about Y were accepted (even though his similar assurances about X were not kept in the past).   4.42 In June, the mother spoke to CSC about her fears about her child R spending time with relative Y, who by this time had been convicted of a non-family related but relevant offence, and been the subject of serious allegations by H. She said R was visiting Y alone. The father regarded the concern as harassment from his ex-wife. The mother asked to speak to a manager as it was ‘a child protection issue’.  The next month the mother called again concerned R was spending ‘most of the time’ with Y despite his recent conviction. The mother was told that a previous social worker had not been concerned about the contact with Y, so nothing would be done now, and it was also R’s choice. When spoken to, R was angry with mother’s intervention.   21  4.43 Not long after this, father was arrested after his ex-wife’s partner alleged he had assaulted H, but the lack of visible injuries contributed to the Police decision to take no further action. The day before H had reported a sibling to the Police for an assault, and due to the sibling’s age the matter was left to CSC. H had disclosed several incidents of the father being violent to her.   4.44 CSC did a core assessment on H in August 2011. There was no reference in it, despite its main function being to look at how or whether H should stay with father, to relative Y. A conference only a few months earlier had seen father restricting H’s access to Y as very important. There was no mention of father’s convictions for violence.  4.45 A ‘Section 7’ report was prepared the following month to advise the court during private law proceedings (in this case the parents’ battles over the children). This was a very good report, being quite clear about all the children suffering from parental dysfunction. It refers to H’s disclosures, and says H’s behaviour difficulties are not unexpected given it is ‘likely’ H has experienced ‘all levels of abuse: sexual, physical, emotional and neglect’. There was, however, no reference to father’s convictions for violence, nor any contribution from Probation who were supervising the father.   4.46 Given this clarity in the Section 7 report, it is surprising that by that point it was still deemed acceptable for H to be with either parent. It is remarkable that the next month CSC closed the case. With the court determining who lived with whom, CSC records said …‘There is no requirement for Children’s Service in this process, and as there are no ongoing concerns of a child protection nature, case to close’.  4.47 H was by this time back with mother although father wanted to see H and there were the usual disputes. H was also in regular trouble for violence, and had two offences dealt with by the Youth Justice Team (YOT). The Police were involved in a drunken brawl between father and partner’s ex-husband (no action taken).  Father was planning to sleep (in mid-winter) in the car with the children. The children were taken to be cared for by Y, an interesting decision given the allegations against Y. When CSC inquired, they found that child R was actually residing with Y. After an Initial Assessment (which concluded erroneously that alcohol had not been an issue historically) the CSC group manager decided that the case should be closed again.  The potential implications of Y and children seem un-noticed, despite previous concerns.  The fact that the notes say that if there was repetition that child protection procedures should be initiated only emphasises the strangeness of the decision to completely close the case. There is though concern about mother and an impending new baby, but notes say she was giving no cooperation.  4.48 The first few months of 2012 were characterised by disputes over where H would reside, and H was back with father. In May, H was given a referral order following  22  an assault. YOT made contact with CSC mid-year, but were asked to consider doing a CAF. A few days later Police contacted CSC concerned H was frequenting a house where cannabis was used. CSC phoned the father - whose response was mainly about not wanting H to see the mother. Police were also involved in relation to R and a relationship with an adult.  4.49 In July 2012, R reported to Police an assault by Y. The Police investigation decided that Y had acted reasonably in trying to restrain R. CSC was told but there was no further action. In August 2012 CSC received a referral from worker D, now with YOT, saying that H was living with Y despite H’s allegation of a very serious sexual offence against Y, and asking for a CSC investigation into H’s circumstances.   4.50 A few days later a child (not covered by this SCR) alleged that one of the Q family children had been sexually abused in his and others’ presence by Y. The allegation was also Y encouraging sexual acts between children/young people, and engaging in sexual acts. Police told father that neither R nor H should go to Y’s house. After investigation, there was no Police action and indeed no question put to the Crown Prosecution about the wisdom of prosecution as the Police thought there was insufficient evidence to do so. Given the severity of the story, even if later denied, this was not appropriate and indeed the later Police audit ruled that the investigation was substandard, and re-instituted action.   It is unacceptable that despite all the previous history and concerns about child protection there was no multiagency conference to think through what was happening in the family given these allegations. The recent Police Review says that during the first week ‘what was absent was a coherent strategy between Police and CSC’ which could have led to more joint inquiries into the various allegations which included sexual abuse within the family. That Review also thought Y should have been arrested rather than invited to be questioned voluntarily.  4.51 The absence of any protective action was highlighted by a September agency referral saying that the alleged victim in the August events described above had stayed at Y’s house. The CSC chronology says the child was strongly advised not to stay with Y”. There is no record of any action to keep the child safe, bearing in mind earlier recorded concern about such contact by Q family children.  At the end of September 2012 Police become aware from the child that the child was still staying over with Y. CSC were also aware of this from the child directly. CSC decided to do an initial assessment. That this was not done until 12 days after the YOT referral shows the priority given to assessing the risk  to the child  from Y who was on bail for an alleged serious assault against the child. The initial assessment showed ‘no disclosures of concern’.  4.52 Towards the end of October, R reported to Police wanting to stay with mother, with R saying there had been sexually assaults by Y for over a year, and as recently as  23  the day before. Y was arrested. No forensic examination was deemed necessary (clothes had gone in the wash), nor was there a medical examination but the Police Review says it was offered and turned down. Police found R’s evidence unclear and imprecise and R, they said, lacked credibility, so no further action was taken and the case not referred to the CPS for a decision. The SCR has seen what R actually said happened and it was quite specific, and also said to be a daily occurrence at one time.  There was to be a CSC Section 47 inquiry, but it is likely that this did not happen as a temporary senior manager later could find no record of it and instituted discussions and conferences which led to protective action in 2013. Whatever the doubt about the evidential quality, what R described indicated at the very least a most dysfunctional and over sexualised family and it should have led to a strategy meeting and case conference - especially as allegations against Y continued. Also, it was evidence that the father was not keeping his children away from Y which had been a long standing requirement (although not actioned when the requirement went unheeded).   4.53 The following month, the mother’s partner reported that R was being bribed by Y to drop allegations. Police spoke to R, and looked at bank accounts, and ruled the suggestion unfounded.  In December 2012, R told a therapeutic worker of a sexual assault by Y, that there was an attack by father with a fork, and ‘could not understand why the Police did nothing’. (That specific incident is not in Police files).   4.54 Generally, the concerns about the behaviour of two of the children have not been built into the above account which has focussed on child protection issues.  In summary, both children had been treated for ADHD, often with significant quantities of medication. Both were involved in violence with each other, with peers, sometimes with their father and were under the supervision of the youth justice system. By the end of 2012 one had had a final warning, then a 6 month referral order for assaults. The other had also had a Police reprimand,  and a final warning after both property and violent offences  4.55 2013 was the year during which the children were finally protected. The Section 47 that should have occurred the previous October commenced around the children’s access to Y. A strategy meeting was held in mid-January, and according to Police notes ‘there was no apparent risk of serious harm requiring emergency protection powers’ but there was discussion about how to prevent the father allowing contact with Y. The day after the meeting a PC and social worker spoke to the children at school and no confirmation of risk from Y was received so the matter was left with CSC. The Police Review concluded that the matter was too serious for only a PC to attend the strategy meeting given several recent sexual abuse allegations.  Eight days before the meeting R had told social workers about sexual assaults by Y, and also relayed an incident about a sibling and Y that at least hinted of inappropriate sexual activity.   24  4.56 Core assessments on the children in the review were commenced in the first week of February 2013 and concluded in mid-March.  In H’s, it refers to the ‘high level of possibility’ that H had suffered sexual abuse from Y not prevented by the parents, and that H reported ‘being sexually and physically assaulted by a number of family members throughout childhood’. It also referred to the suggestions of abuse from X. It says that without change H would be at risk of a wide range of harm. The assessments testify to the failure of the parents to provide any boundaries. R’s assessment says the father will not protect R from relative Y.  Whilst these reports do describe the father’s behaviour they do not specifically mention his violent convictions. A child protection case conference was recommended for H and siblings. The assessments were very clear about the overall risks to the children. This was good, and for a change was not based on whether any one allegation was proven or not.  4.57 In the period leading up to the Case Conference held towards the end of March 2013, the children’s behaviour continued to create challenges and the family disputes continued. In early February, the child involved in the events of August 2012 which led to Y’s arrest confirmed being involved to the police.   4.58 Also, H told Police about being subject to a very serious sexual offence by Y regularly through childhood. The Police chronology said that H’s disclosure did not add to the case, no further action was taken against Y, and he was not interviewed about the rape allegations. There were also allegations that two children including R had been assaulted by father but an injury was found to have been accidentally caused at school and no further action taken. There were further altercations between R and father, ending with R being charged with assault. There was another assault by R against a peer.  There were also altercations involving H.  4.59 The decision by the Police to take no further action was subject to a review by Police internal audit and found ‘inappropriate’ and there were concerns about the standard of the investigation. The matter was looked at again by a Detective Inspector, and as a result papers were forwarded to the CPS who subsequently authorised the charging of Y (who was later convicted). The Police should be praised for having internal audit processes which identified the need for CPS involvement. In the view of this SCR, children who make repeated allegations of the most serious nature should not be denied justice because in the past they gave inconsistent evidence leading to no further action then. They should have every opportunity to improve their evidence rather than just concluding that the matter was dealt with before. (The Police decision is analysed in section 5). The 2014 Police Review quite rightly says that the Police will be making sure that evidence is not overlooked now just because there have been earlier no further action decisions. The Police have assured the SCR that ‘if a victim denied an allegation took place and at that point a decision was made that there was insufficient evidence to charge, but later made a "statement" (or ABE interview)  25  that the events did take place (and particularly if it was explained why it had been said otherwise in the past e.g. coercion), this would amount to additional evidence and the no further action decision would be re-visited’. This seems to provide a good safeguard for victims who may not be able to give consistent evidence at the time when still under the influence of perpetrators, but who later when freer feel that they can.  4.60 At the case conference, H said the father had taken money in return for X having sex with H.  There was a good analysis of the risks, although whilst there were references to numerous allegations, the minutes made no reference to the father’s convictions for violence. All the children were made subject to a Child Protection Plan for all four categories of abuse, with a conclusion that they all needed placement away from home, with interim care orders to be applied for in the next few days.  The LSCB was to be asked if it should conduct a review of the case. This meeting marked a turning point in the case as it was the first time there had been a fully agreed conclusion that whatever the rights and wrongs of specific allegations, the children would continue to be significantly harmed and needed protection.    4.61 The council had already decided to issue care proceedings in relation to R, and seek accommodation for H. The court (at a private law hearing), learning of these intentions, ordered that any contact with Y prior to a Police decision about charging Y should be supervised by the father.  This seems to be a most remarkable decision, given the father’s proven inability to protect the children from Y and the allegations H and R had made against Y. When the interim care order applications were made, the children’s guardian ad litem did not support the council and the judge denied the application, presumably accepting the father’s commitments.  4.62 The positive planning in the case conference, in the opinion of this Review, could  have happened months if not years before as the evidence of the children’s overall well-being was not significantly different than at many times in the past.  R was placed shortly after the conference, as was H. The court initially refused for other children to be moved to foster care.  4.63 Progress was looked at in a review case conference in June 2013. The father ‘is not prepared to stop Y having access to the children’ but he had agreed not to let them stay overnight. It is not clear how this breach of the court’s requirement that he keep children from Y was dealt with.  4.64 After a review of decision making by the Police, Y was charged and eventually convicted of a number of offences against one of the children.  4.65 Summary: Explanations will be looked at in Section 5 below. However this Review concludes that protective action should and could have been taken earlier. No abuse had been proven when the decision was taken in 2013 to seek care  26  proceedings on the children, so the absence of proof in the past is not sufficient reason for not seeking protection before. The pattern that seems to have been repeated over many years was that the inability to prove a criminal case led to scrutiny of the family quickly reducing or stopping, rather than rigorous multiagency assessment of the long term needs of the children.  There were a number of occasions when the inability to establish abuse should not have led to a step back, but rather to an in depth study of what even the existence of such extreme and at times sexual allegations meant about the family and the children’s well-being. There were long periods without multiagency meetings to share concerns and form such a conclusion.  4.66 There was insufficient focus on the overall life experiences of the children, but rather a pattern of attempting to solve presenting issues sequentially. Not until very late in the case were the issues around the children’s behaviour, violence to and by the children, sexual abuse of children, parental dysfunction and non-cooperation, and frequent un-proven allegations of abuse, put together into a coherent picture about the physical and emotional safety of the children.  4.67 There were times when other agencies had major concerns but CSC decided there was no role, despite considerable knowledge over many years of the chaos and violence in the home/s and the impact of this on the children’s emotional health and behaviour, which for two of them involved many offences.   4.68 At the time of the disagreements between CSC and other agencies about council intervention there was no effective, senior enough escalation process to ensure such disagreements were resolved at a high level. The Review has been advised that such arrangements are now in place.  4.69 The Police were unable to obtain sufficient evidence (for charging) on any allegations of sexual abuse against the children in this case until those that led to Y’s conviction, and even that was after initially deciding not to consult the CPS. It is possible that that conviction might make it more likely that at least some of the children’s earlier allegations were true, which raises questions about the style and thoroughness of previous investigations.  4.70 The council should be praised for its work in 2013 to remedy the previous weak assessments, and to initiate care proceedings on the children. The decision by a court to leave some of the children at home for many months after proceedings were started, and even require the father to be the protecting force for them against relative Y, does not seem to have been in the interests of the children. However, the Council legal department advised the Review this was in accordance with current case law.      27  5. LEARNING AND WHY   5.1 Introduction: This section looks at what can be learned from this case and where agency action could have been better, and why this was the case. It is important to put what happened in a systemic context rather than looking at individual action.  The approach is to look at themes rather than an agency by agency analysis, and to show the complex processes that impacted on decision making.  5.2 It was also decided in conjunction with the staff involved in the case and the LSCB that given the enormous scale of the case that it would be better to focus on key themes or turning points in the case than attempt to describe or analyse it all.  There will be a degree of repetition as some factors impacted in many different ways  5.3 The Influence of the Father:  (Although focussing on the father, the principles of the learning points in here would apply to more than the father). The author has found this to be the single most pervasive factor in this case. Many staff have described how the aggressive and manipulative environment he created made them most uncomfortable, and sometimes created real fear. The mother and a child made similar comments.  Para 2.10 described a Police officer’s sense of ‘real danger’ from him.  CAMHS describe how the mother and partner were so angry and abusive when a medical assessment determined a child did not need powerful medication for behaviour issues that it was judged not safe for them to be seen at the CAMHS office. A sense of impending violence can be a very paralysing factor for staff. Although only actually violent to Police, staff have described what can only be described as harassment and intimidation even whilst this Review was underway. The father had a number of convictions for violence, often when in drink, and on one occasion had been cautioned after his wife’s arm was fractured. The Police were called to numerous incidents of domestic violence and family disputes. He had frequent A&E attendances for fight related injuries and self-harm.  5.4 He had a legalistic and complaining approach, so that for example case conferences were appealed on more than one occasion. Lawyers were brought to conferences.  A number staff had to be reallocated away from the case after his complaints, and the expectation that they might be next undermined the confidence of other staff.  Also, the fact that no allegations against the father in relation to the case were ever proven (other than an assault on Police) built a sense of untouchability that also undermined confidence.  5.5 At case conferences, he would take advantage of the proper involvement of parents in such deliberations to hector staff and even tell children present what they should say. It is likely that many of the times where allegations against him and others were unproven that he instructed, through fear, the children to say what he wanted them to say.  28   5.6 Scrutinising the minutes of key meetings (where that father was usually present and at times with legal back up) it is a hard to see a very focussed analysis of his role. At many meetings there seems to be no reference to his convictions, little reference to his serial non-compliance with previous conference requirements (or even signed agreements), but more attempts to keep going as if something would change. (This is analysed further in ‘overarching themes’ below). What is also interesting is that where there are assessments that read damningly of his (or parental) capacity the decisions do not seem to reflect the power of those statements. (From 2013 this changed- see 4.54).  5.7 Over the years, there was hardly any evidence of him cooperating with professionals, and no evidence of him taking active steps to protect his children against those he knew to be a risk. When, for example, he did not keep children away from X or Y there were never any consequences from the authorities. The situation was complicated by a veneer of respectability that he and Y had which seemed to provide a protective wall around him.  5.8 More than just non-cooperation, other than for very short periods there was little sign of the children’s lives ever improving, or at least two of them being kept safe, yet he managed to persuade courts that he could be a protective factor for them. This was despite evidence over the years of him openly defending abusers, or at the least refusing to acknowledge potential risk.  5.9 Why did this situation carry on for so long?  There are many answers to this - some which will be seen under other headings in this section - but at its simplest, aggressive men who are manipulative, argumentative, serial complainers etc do have the capacity to undermine professional assessment, decision making and action. In many walks of life, similar men ‘get away’ with things that seem in hindsight inexplicable. One senior social worker speaking to the Review said, ‘He creates a lot of self-doubt, so staff feel they are incompetent’.  A very experienced social worker who was involved in removing the children from home said, ‘It was the most frightening removal I have ever done’.   5.10 There is reluctance in professionals, who rely on a relationship with family members and cooperation from parents in the interests of children, to be too authoritative and controlling in case it damages that relationship. And when firmness is tried, it is countered by a barrage of complaints, legal defences and implied threats which deflects the attempt.  This can only be countered by the highest quality supervision and support of staff so that their fears and concerns are understood and addressed, by high quality appraisals of parental functioning, and decision making meetings where the presence of the parent does not diminish the depth of analysis as seems to have been the case here.  5.11 There was also an issue with the continuity of knowledge, as the case was open and closed many times, as workers were changed, and in long periods (such as  29  before December 2005 , 2007-9, and 2011-12) there were no meetings of the status of multiagency case conferences. The Review has seen how such meetings and others might not mention the father’s violent records, or to past sexual abuse allegations, and when the staff group met to discuss the case for this Review there were some who were surprised at what they did not know. CSC did keep a running chronology throughout most of this case but one wonders how often it was scrutinised as its growing story is one of great concern.   5.12 One child, the victim in many of the allegations of abuse, described being unable to stick to evidence on those allegations about several alleged abusers for fear of the father’s wrath. The fear created prevented evidence which might have led to the protection of children and so the non-protection continued. (The father’s view is that the allegations by the children were false and made at the instigation of their mother in order to get at him).  5.13 Many SCRs have written about fathers who are under the radar, insufficiently seen or understood, and whose risks are never grasped. This case is different in that he was very upfront, known well, very involved (if not co-operative) and there was more than enough knowledge, if pooled, to know he was unreliable, violent, un-protective of his children, and so on. The likely reason for him being able to retain control of his children (or at least those residing with him, but often the others) was a combination of i. his manipulation and grip over the children resulting in inadequate evidence on allegations;  ii. his ability to undermine the confidence of staff; his forceful presence at key conferences preventing more realistic assessments, and where assessments were more accurate, a sense that nothing much could be done; iii. the lack of any high level stepping back and looking at the case coolly and dispassionately over history, and instead dealing only with the current challenge;  iv. the absence through most of the case of any in depth analysis of his capacity as a parent and the risks he posed.  It should be pointed out that the father’s overriding sense was that his frustration was created by social work staff not listening to his point of view, and not taking seriously enough his concerns, for example about one child’s serious behaviour problems, or the difficulty he says the mother’s emotional well-being created for him.  5.14 Given the fear and anxiety he created it is surprising that that there is no record of any meeting where a corporate plan could have been created to manage relationships with him. This might have benefitted both staff and children, and created a structure for him. One social worker told the Review that around 2006 the father used to phone many times a day and this was unmanageable, and the  30  father was set a limit of one call a day which was largely heeded. This was good practice to provide some boundary to contact.   5.15 This section has focussed on the father. There were other adults in the wider case who also created difficulties for staff, if not of this magnitude. This is not described here for two reasons. Firstly, to make the scope of this review manageable it focusses on the core family. Secondly, to describe more than the core family increases the likelihood of identifying children.  5.16  The summary learning points are:  Fathers with such personalities as this one, can have a debilitating impact on case management   Staff must feel free to share their feelings about working with such families and expect support  Those providing management and supervision, especially in CSC which runs the multiagency meeting, must be aware of the potential of aggressive fathers to undermine confidence and objective decision making  Those providing supervision and quality control of cases must check to see that assessments and decisions fit the evidence accumulated over the years  Agencies should have formal processes for agreeing how aggressive parents are managed to ensure the safety of their staff   Review meetings/conferences should always be reminded of historical risk factors, and not assume those present will all be aware of them  5.17 Managing Different Views on Risk:   In the Illustrated Appraisal of Practice above, a key period in this case was described whereby CSC and other agencies took different stances about the need for council action or intervention. Education staff who saw children daily and health staff who were addressing the children’s emotional well-being and behaviour communicated formally in writing on a number of occasions in 2008-9 seeking CSC involvement and sometimes child protection case conferences.  Their concerns, from the evidence seen by this review, seemed well founded given what they saw of and heard from the children, the serious behaviour problems, the parental discord and lack of cooperation, violence between children and ‘daily disclosures’ of abuse. One letter on behalf of medical nursing and mental health staff referred to the children being ‘at risk of significant harm, and, at times, are experiencing significant harm’. Another letter described H repeating the allegations of being ‘sold for sex’ by the father, and having to have penetrative sex with X. A number of the letters were copied up to Director of Social Services level.  5.18 The responses from CSC took the stance, in general, that there was no role for CSC, no specific allegations had been made other than those that had been investigated, why not do a CAF, and ignoring request for case conferences.  The fact that where there had been investigations, no further action could be taken, would have raised the sense that nothing could be done.   31   5.19 The impact of this on the referring staff was significant. One head teacher told the review that at the time they had a sense of ‘being completely let down as a school…no one wanted to pick up the case...a real sense of issues not being taken seriously’. The head teacher also added that at the time (2008) this was a general issue with other heads beginning to feel there was no point in referring to CSC. Another senior teacher recalls feeling ‘blocked’.  5.20 This Review concludes that there was indeed little that could be done to improve the lives of the children in their then home environment, but the response to this should have been for CSC to hold the ring while there was the best possible assessment of what would need to be done to protect the children and not standing back. The children’s overall welfare was a different issue than whether specific allegations were found to be true.  5.21 Such tensions about the thresholds in CSC for taking on work are not uncommon, and need to have a clear escalation process in place to resolve disputes. The Review has been told that such a process is now in place but then it was not. Staff interviewed have acknowledged that there were limits to how hard or high they pushed ‘up the line’, and indeed a number conveyed a sense that they didn’t know what to do or who to speak to. Given that the strength of those concerns 5-6 years ago was still felt in 2014, it is interesting that neither the NHS Trust executive director for safeguarding (then a statutorily required position) nor the CEO was brought in to raise matters with counterparts in the Council.  5.22 It was not just that the case might not meet the threshold. One school recalled that when the school tried to refer R’s serious behaviour problems to the CSC early intervention team, the response was that R was beyond their help, yet nothing else was offered.  5.23 Why were there these problems with CSC?  It would appear from discussions with a CSC manager at that time, that it was likely CSC saw the referrals as vague, looking at issues explored before, and where little practical could be done. The Review was also told that at the time of this dispute specific allegations would always be looked at, but there were high vacancy rates and ‘due to the frenetic nature of the work, there was a clear difficulty in being able to stand back and reflect … the service responded reactively when having to balance competing priorities ... although not an excuse it was the reality of working in that pressured environment’.  5.24 Ofsted reported in early 2013 on the adequacy of council safeguarding services at in inspection in 2012 and found them ‘inadequate’. This report referred to a 2010 LSCB finding that in most child protection cases, assessments of risk were weak and child protection plans were poor or incomplete. The inspection found that no significant progress has been made in those areas. For example it concluded that in 2012 … ‘the effectiveness of help and protection provided to children, young  32  people and their families is inadequate. Despite a clearly outlined thresholds document, the initial response to referrals is variable, lacks consistency of decision making and fails to correctly identify risk. As a consequence not all children are being correctly identified as at potential risk of harm, they are not always being protected and in too many cases their needs are not being responded to in an effective and purposeful way’.  5.25 At a previous inspection, in 2010, Ofsted concluded that risk and protective factors were not always clearly identified.  Some assessments contained insufficient information to make effective decisions or plans. For example, some assessments were closed prematurely leading to further contacts being made soon after case closure. It added that the frequency and quality of recording of supervision were inconsistent, supervision was not providing appropriate challenge to the quality of casework and the professional development of some staff. Decision-making and effective planning was not sufficiently well evidenced in case records. A social worker who managed the case for a time said that the degree of risk could be lost as new staff taking over a case would not have sufficient time to study past records very thoroughly, and that time for cool dispassionate review of progress and risk was hard to come by.  5.26 It is likely then that weaknesses seen in the year or two before the 2010 inspection, and later, reflected a department that needed considerable improvement. These issues have been widely publicised and are being addressed through special measures and the oversight of Hampshire County Council, and need not be repeated in this report. However the learning points remain to check against current performance.  5.27 The summary learning points are :  The need to ensure that robust escalation processes are in place, and understood and used by staff when there are concerns between agencies about the quality of responses  Requests from staff in other agencies for child protection case conferences should normally be accepted  Even if there appears to be a good reason not to accept a particular referral, CSC should regard repeated referrals/conference requests from multiagency sources as needing further understanding, especially when there are clearly stated concerns about child safety  Investigations that do not prove offences do not necessarily in themselves prove that children are safe, or that their development is not being harmed  5.28 Single Issue Thinking: This was identified at the staff group meeting as a theme that beset this case, and has been mentioned above already. The pattern seen is that with a family that is constantly throwing up challenges, the specific challenge is addressed rather than what that challenge ‘means’ for the children in the longer term. Before the parents split, there were numerous Police attendances for  33  domestic violence. Each was assessed and dealt with in its own right, and mostly referred on appropriately to CSC. But if the incident was resolved (calmed down/no offence proved etc) then the basic question of ongoing child physical and emotional safety was rarely addressed. The mother described this stop start approach very clearly to the Review. The same applied to extreme behaviour by the children, so the issue was whether the behaviour had been addressed (doctors/medication/containment etc), rather than why are these children behaving so badly and can the parents affect the change needed? Later their offences focussed things more on them than their family.  5.29 When the health staff were involved to address psychological/behavioural issues, that was seem as the solution, with no role for CSC, despite only CSC having legal authority. When health staff challenged this there were barriers created by the quality of CSC organisation, as described in 5.25 onwards.  5.30 This pattern was also seen over many years in relation to allegations of neglect, physical abuse and sexual abuse. As has been illustrated above, allegations were normally explored but never proven until Y’s conviction (for reasons explored below). It was not until 2013 that there was any appreciation through formal multiagency process, as in the fourth bullet of 5.27 above, that being unable to prove something beyond reasonable doubt does not mean there is nothing of concern, nor that the children have been other than deeply affected. Any retrospective look at the history screams this out, although it was clearly not obvious to everyone at the time.  5.31 The fact that the case (in reality several cases due to the parents’ split and reconstituted families) was closed so many times, despite very serious events sometimes adjacent to these decisions, illustrates the lack of long term focus. The closures were by CSC which did not see a role, and by health agencies due lack of family cooperation.  5.32 Why did this happen? There seem to have been a multitude of reasons, interacting on each other. As the father challenged every allegation so vigorously and with such impact, it is likely there was a degree of relief when investigators could move on. There was also a view, amongst some, that the allegations reflected disputes between adults who used allegation and counter allegation to prove their supremacy in any argument, rather than them being ‘true’. The no further action conclusions to Police or CSC investigations also provided a reason (justified or not) to cease involvement when priorities had to be made by CSC.   5.33 Staff also identified that as the case was so difficult, there might be a sense of relief and let’s move on when a particular referral event was found not to be proven as that was one more challenge out of the way. They also identified the lack of opportunities to ‘stop the clock’ and review the whole case and what it meant for the children, given pressure of work.  34   5.34 The pattern of taking a short term issue focussed approach, rather than the bigger picture, is further evidence of the weaknesses in supervision and lack of opportunity for deep reflection described above.  5.35 The summary learning points are :   The need for a long term perspective when so many short term problems are posed by a family  The need to regard chronic issues as important as the single dramatic event  The need for time to reflect on the meaning of events (even if disproven) on children’s physical and emotional well-being  The need for robust supervision to identify, and to support/challenge, staff who do not look at the bigger picture  5.36 A&E Attendances: There were high levels of attendance when the children were young many years ago.  There might have more suspicion about some injuries, but it is only with hindsight of later events that some look particularly worrying and it would have been hard at the time to prove this.  The SCR is satisfied that there are good processes in place now for spotting frequent attenders and child attendances that need wider professional involvement. Indeed much of this was in place many years ago. At the time good processes led to a multiagency meeting to discuss the situation which was concerned about parental health and capacity, child development and neglect (seeing some of the accidents as preventable). However there is no evidence of the recommended core assessment and there was no further multiagency meeting for three and a half years despite many corroborating concerns.   5.37 Management of Allegations: Other than the conviction of Y, no allegation of abuse about any of the children subject to this Review has been substantiated over a period of at least a decade and a half. This is whether it was related to over chastisement, neglect, assault, being forcibly held, or sexual abuse, whether against family members or non-family members and whether investigated by CSC or Police or both.  If suggestions of domestic violence, referrals from concerned neighbours, disclosures by the children (including those repeated when earlier investigations had led to no action) and allegations from one parent are considered then there at least 35 occurrences which did not lead to any formal action. Several of these were very serious allegations of sexual assault. Some of the overall number may have been false, some would have had little evidence, and some might have been vexatious suggestions.  However, even the allegations that led to Y’s conviction were initially not even referred for a CPS view by the Police, and it was only a (good practice) internal audit of a random number of Police investigations into offences against children and young people that led to the conclusion that the investigation could have been better, and that the decision should be reconsidered.  The scale to which family, children and public concerns  35  were found unsubstantiated requires this Review to see if there are lessons to be learned.   5.38 Why did this happen?  Investigating possible offences was never easy. The evidence was often contradictory, or not repeated in formal settings.  It is very likely that the children were under great pressure within the family to withdraw or change disclosures, or to side with whichever parent held most sway at the time.  This is a very well-known possibility in familial abuse, and it is the opinion of this Review that insufficient thought was given by agencies to this, especially that it was quite clear that the father was a manipulative, frightening, violent man.  To balance this, the 2013 CPS guidance1 on disclosure and evidence was not in force in the period under review. This guidance makes it clear that such contradictory evidence may well be a sign that supports the likelihood of sexual abuse having occurred, and does not rule out taking such cases to court so that the court can if it wishes decide between versions of a changed story. It is likely that had this guidance been in place before 2013 then the children’s difficulty in giving consistent evidence would not have been such a barrier to action.  5.39 The 2014 Police Review also described changes in the law in 2004 about when ‘reasonable punishment’ can be used as a defence by parents, and how in this case there seemed to be some uncertainty about how to assess cases alleging excessive parental force. That Review recommends that the Hampshire Constabulary issue additional guidance to investigating officers regarding the investigation of parents using excessive force to punish children.  5.40 The children’s behaviour issues and communication limitations also made it hard for their evidence to be seen as convincing, but this could have argued for them being interviewed in even more specialist ways rather than their accounts put to one side. The scale of allegations and some of their extreme nature in terms of sexual assault, would strengthen this need for the very highest level of skill being applied to discussions with them. Achieving Best Evidence (ABE) interviews were used in some inquiries and some allegations could be seen to have been thorough. One investigation was described by the Police Review as being best practice but there were instances of children being interviewed at home, or in the presence of the father or other involved relative, when making initial inquiries about the need for more in depth work. There were also instances where children made a repeat allegation, and because the initial allegation had been discounted the Police left it to CSC alone to talk the child concerned as it was an ‘old allegation’.  Whilst it may have indeed have been old, there is no sign in the files that CSC or the Police were considering the possibility that the repeat allegation may have been because the child was indeed a victim and was desperate for justice to be done. The risk these children took in repeating allegations about                                                  1 ‘ Guidelines of Prosecuting Cases of Child Sexual Abuse. CPS 2013  36  adults they lived with or saw regularly was high, and would not have been made lightly.  5.41 The Police Review also pointed out that on several occasions the agencies consulted in strategy discussions/meetings were too narrow which led to information that might have helped investigations be better was not heard.   5.42 The decision not to initially refer the allegations (which were eventually subject to a conviction) to the CPS, was changed after an internal Police review, but the senior officer who made the non-referral decision did so because, he said, in his experience the level of evidence was similar to that which he felt would have been turned down in the past. The Police review also concluded that the decision not to refer reflected their perception of what the CPS might be seeking. At the time the CPS did not have the chance to consider the evidence so one cannot conclude what the outcome would have been.   5.43 Until considering submissions for this Review recently, the Police had no plans to revisit the most serious previously unsubstantiated allegations by the children against Y following Y’s conviction, but there are now plans to explore this. The Review strongly supports this, so that at the least the children’s voice can be heard, even if formal action is deemed still not possible.  5.44 The 2014 Police Review has looked at detail at most of the child abuse related investigations (not domestic violence, or other crimes) and has given a frank appraisal of the process of work with the Q family. Its appraisal of investigations is reflected in the previous paragraphs. It is not clear from the Police Review why there were problems with the quality of work with this case. The Internal audit which identified the inadequate decision making about the investigation of Y did not, according to the Police, identify similar issue in the other cases reviewed. The Police Review conclusion and recommendations are in Appendix 2.  5.45 The summary learning points are:   The need to be very aware of the possibility of intimidation of children by relatives when disclosures are made  The need to tailor investigations to any likelihood of relative’s attempts to intimidate children  The need to use the new CPS guidance to test in court evidence that might have some vulnerability  The need to strongly consider the meaning of repeated disclosures by children, even if a prior investigation had found those disclosures unsubstantiated  The value of internal case audit in establishing the quality of work assessing abuse inquiries  The need to be clear about the current laws on excessive force/reasonable punishment  37   5.46 ADHD: Two of the children were diagnosed with, and treated for, ADHD (attention deficit hyperactivity disorder). Prescriptions for medication came from hospital paediatrics who worked with CAMHS. The parents, according to a psychiatrist, were ‘pushing so much for medication’, and were ‘very threatening and aggressive’ when denied it. This came after an admission to a paediatric ward where a child was not seen to demonstrate any of the behaviours seen while living at home. A paediatrician also spoke about the tension felt between the pressure from parents for more medication and concern that too much was being prescribed.   5.47 During this period there were tensions between clinicians about the best way to treat ADHD, and the balance between environmental and genetic causes. An audit showed that children were being given antipsychotic drugs (which have strong side effects) at a very high level comparatively, and for a while joint clinics between CAMHS and paediatrics were paused over this. Relationships between CAMHS and paediatrics are now stabilised, with new dedicated medical leadership on ADHD, and antipsychotics are only given with joint agreement. There is also a 2013 Shared Care Agreement between general practice and paediatrics on the use of medication with for children with ADHD.   5.48 This Review is not the place to discuss in detail the differing views around the nature and meaning of ADHD or the debate about its treatment. It is hard to say whether the varying views between clinicians about ADHD treatment had an impact on the children concerned, and whether the medication regimes were helpful or not. What is relevant is that going forward there needs to be a shared understanding between agencies about appropriate care pathways, and especially the balance between medical treatment through medication, or through therapy, and work more focussed on the family/social environment.  In 2008-9 when there was tension between other agencies and CSC described in 5.17 onwards above, it was seen that CSC did not see a role on the family/social environment side, and saw the health input as the answer. It has been put to the SCR that CSC could now have more understanding of environmental factors and their role in behaviour disorder, rather than seeing the solution as mainly a ‘medical’ one. However, there is still an NHS view that CSC does not yet appreciate how significant their role needs to be in the tripartite work across health, education and social work.   5.49 It does have to be pointed out that the parents were not cooperative with health or CSC. For example a 2009 paediatric note said that neither parent ‘would undertake Managing Challenging Behaviour or Parenting Support programmes’. Interestingly the mother told the Review that what was needed was programmes like those, so it is possible that the objection was just the father’s.   38  5.50 The two children, speaking with the Review, were generally positive about CAMHS and also felt they could not do without the medication prescribed by paediatrics.  5.51 Meetings: The Review has not researched each meeting in detail, but some themes emerge which the LSCB and agencies can check against current practice, to see if the themes could repeat now. The LSCB’s website says much of the guidance around case management is under review so it may be timely to consider comments from this review.  5.52 Calling a Child Protection Conference:  There are two issues: not calling one when it would have been a good thing to do, and not convening one when agencies strongly request one. This SCR has already described how there were no such conferences such as before December 2005, and from 2007-9, and 2011-12. In each of those periods there were events which seem to be of considerable concern. On a number of occasions, there were investigations into quite awful allegations/disclosures which led to no further action, and it is the author’s view that these events (especially when taken together with a relentless history of problems for the children) still indicated ‘something’ seriously wrong. It is a strong theme of this report that not being able to meet the threshold for prosecution does not negate the need for strong review of family functioning in a child protection context. This comment does not mean that there is a prejudgement that abuse has happened whatever the conclusion of an inquiry, but that the meaning of events for children should have been much more strongly considered. The author can see nothing in the procedures which says a conference cannot be called in such circumstances. The result in this case was often long periods with no formal and widely attended multiagency meetings.  5.53 The other issue was about not calling one when other agencies ask for one. The Isle of Wight procedures (shared with three other LSCBs) give, in the author’s opinion, too much authority to CSC. The current procedures, based on the 2010 national guidance, do say that CSC should strongly consider any request from other agencies. And if differences remain it should be resolves between the respective agencies’ LSCB representatives. The Review has not heard of any such use of such a process and the LSCB must make it clear this arrangement can be used. Additionally, the author suggests that if still no agreement the LSCB independent chair should decide.  5.54 One implication of the lack of meetings for long periods is that, according to a senior NHS child protection adviser, NHS staff might not know about referrals to CSC that were open and closed quickly, so were unable to contribute any background information.  5.55 Strategy Meetings:  5.46-48 above discusses child protection conferences, but procedurally these should follow a strategy meeting or discussion between key  39  agencies where the need for and nature of any prompt action or assessment is determined. The Review saw hardly any reference to strategy discussions in the files, so in most cases it is likely that where this Review has said there should have been a multiagency conference there was no strategy meeting either. This means that on those occasions there was no formal process with other agencies to mull over the best way forward. This could mean that, for example, when CSC turned down an education/health request for a conference, there might be other referrals coming into CSC around the same time of which the education/health referrals were unaware.  5.56 The Police Review of June 2014 says that it highlighted the importance of strategy discussions and meetings in planning joint investigations, and identified the importance of inviting agencies in addition to Police and CSC if they are likely to be involved in the investigations, especially referring to schools. The Police Reviews recommendations are in Appendix 2.   5.57 Parental Attendance: Whilst it was good practice to ensure parental invites to conferences, there is little evidence that the discretion to exclude relatives, notably the father, was used. There was an exception in 2006 when both parents were asked to leave due ‘interruptions and disputes which were not helpful to the conference’. Given how staff have described his oppressive stance, how he would tell children what to say in meetings, and that he was subject to a number of allegations, it would have been better if there had at least been some time at conferences when agencies could pool their views as frankly as they wished.  The procedures say that exclusion should be rare, but this may have been one of those cases where the degree to which staff felt daunted should have led to some discretion being used. Even in conferences where the minutes seem to describe a very open discussion, parental presence might have impacted on what meaning staff were prepared to put on that information. It may well be, with conferences being appealed, parents inviting solicitors, and the father’s persistent complaining that there was some reluctance to stimulate more of this by persuading him that his absence might be in the children’s interests.  Decisions here are difficult judgement calls, and staff should be encouraged to make it clear to conference chairs when they think it would be in the child’s interests to have at least some time alone with other professionals. The Review saw some good illustrations of gathering children’s and parental views before conferences.  5.58 ‘Professionals Meetings’. In 2002, and 2008-9 there were several ‘professionals meetings’. These do not seem to be part of formal procedures and consisted of multiagency staff (never Police) who met to discuss the case. It seems likely from interviews with staff that they were convened as a way of achieving two things: being able to have a frank discussion without family members, and to gather information which could be used to press CSC into action. The notes sometimes indicate that the social worker present shared the view of other professionals   40  there, but a different stance would be taken by say a CSC team leader on hearing the recommendation of the meeting (usually to say ’no’).   5.59 The Review has two comments, accepting that getting together with colleagues to discuss a case is a ‘good thing’. Firstly, if such meetings are being called to get round another process which is deemed not to be working, it would be better to escalate the issue so that the process is put right. Secondly, if professionals do meet and with their combined skills and expertise come up with clear recommendations, then those receiving those recommendations should start with an assumption of their validity. In this case had the views of those meetings in 2008-9 been more heeded it is possible that the process leading to the children’s protection would have started earlier.  5.60 Consistency of Information: It is hard to track through conference minutes what, for example, was or was not known about the father as only rarely is his history of convicted violence recorded. This may have been either because of the heavy parental involvement, or might have been an assumption that everyone knew because of some prior reference. At the staff group it was clear there was a range of knowledge about risk factors, and some were surprised when the history was clarified.  Some were also not clear about the background of sexual abuse disclosures. It is important, with allocated staff changing, new services becoming involved, and with some only seeing minutes, that care is taken to ensure the multiagency team know what they need to know.  5.61 GP attendance: The Review has seen notes of nine child protection conferences between 2005 and 2013. At none was there a GP present or any record of a report from the GP. Indeed in the three 2013 conferences there is no minuted indication of any GP being invited. The Review met with the two main GP practices and they had a good record of relevant parental health, and of the children’s treatment for ADHD, so could have contributed even if in writing. It would appear that conference decisions were made without GP input which should have been actively sought if not forthcoming.  GP records did show that minutes were received and read.  5.62 Why were the multiagency processes not used more?  There was a circular process by which CSC, in not believing that allegations were proven, or that  there was an ongoing role for them to fulfil, also determined that such multiagency meetings were not needed (not always but for substantial periods). In not getting together, opportunities to pool everyone’s views were lost, and nothing changed.  5.63 Secondly, the procedures are rather event based, and emergency based, and are not so clear to staff when the need is to have a very serious discussion about overall progress and child well-being when there might not be a specific allegation to investigate.  In this case the need was to have a very well attended comprehensive discussion about whether (should specific allegations be proven or  41  not) the overall progress and well-being of the children was such as to justify them remaining at home. During the Staff Group discussions there was no shared view of how that need fitted the formal procedures. This is not to say that the formal procedures do not allow for such discussion.    5.64 The national guidance at least as far back as 2006 says that “A strategy discussion may take place following a referral, or at any other time”, so is not tied to specific events or allegations. The guidance also encourages a broad attendance (‘CSC, Police, health and other bodies such as the referring agency’). It is important that there is a shared understanding that strategy meetings can be used to discuss professional concerns about chronic situations, and without a specific trigger event.   5.65 The Summary Learning Points are:   Strategy meetings can be used for concerns about chronic situations, where multiagency pooling of information and views would allow a step back and review.  Strategy discussions/meetings may need to involve more than just CSC and Police, and should involve health and any other agency to be involved in the investigations  When professionals set out an argued case for a child protection conference it should be only in exceptional circumstances that CSC do not convene one. (If there are disputes about interpretation of thresholds the escalation process should be used).  The LSCB needs to be sure staff understand that disputes about calling a conference can be escalated to LSCB level  The discretion to exclude parent/s from part of a conference needs to be exercised  when there is a history of staff feeling intimidated, and there is any chance that parental behaviour would inhibit discussion in a child’s interests, or impact on decision making  Staff need to make their views about this very clear to the conference chair  Where two parents in dispute attend conference the possibility that one might feel unable to contribute for fear of the other should be considered.   Conferences need to be aware of the risks from assuming those present or receiving minutes know prior risk factors  5.66 Overarching Themes: Through the case run, to one degree or another, three dynamics which the LSCB and its member agencies must continually guard against. They are not new issues to SCRs, but no apology is made for writing about them again as they are so powerful. Without the best training, supervision and management they continue to impact on child protection work because they are common human tendencies.   42   A rule of optimism. (Described in Brandon et al2, as a ‘common and previously identified theme’ in their biennial review of learning from SCRs).  Failure to revise judgements. (Fish, Munro and Bairstow3, say that ‘One of the most common, problematic tendencies in human cognition … is our failure to review judgements and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture’).  Lack of challenge of parents and fellow professionals (Brandon et al4, describe numerous lessons from lack of challenge and critical thinking in SCRs). 5.67 The rule of optimism is where professionals wrongly assume positive outcomes for children.  It rationalises evidence that contradicts progress – so even where the facts show that risk is on-going or increasing, professionals tell themselves that the opposite is true.  It is more likely to exist when staff feel under pressure, or when staff find it hard to face up to potentially life changing decisions. It is fair to say that not all agencies were optimistic and in 4.17 onwards this report describes those difference of views. However, there were many signs of undue optimism, especially in CSC. As far as this Review can see, the father never stuck to commitments, even signed ones, about receiving help or about protecting children from high risk adults. These included not going on domestic violence or alcohol related training, keeping children away from X, then Y, or cooperating with CAMHS. Even a court asked the father to protect his children from Y, with little evidence of prior cooperation.  5.68 The current national guidance, Working Together 2013, puts it well. ‘A desire to think best of adults and to hope they can overcome their difficulties should not trump the need to rescue children from chaotic, neglectful and abusive homes’.  5.69 Related to this is a feature that E. Munro5  describes as, “The single most pervasive bias in human reasoning is that people like to hold on to their beliefs”.  This leads to a failure to revise judgements whatever the evidence. There was in this case, for a long time, a ‘failure to revise judgments’. Again, this was primarily in CSC as health and education repeatedly drew attention to their view that enough is enough, and recommended more vigorous intervention.  5.70 Whilst CSC might have been the most strongly optimistic, other agencies were involved in decisions to remove children from Child Protection Plans after only ten                                                  2 ‘New learning from serious case reviews: a two year report for 2009-2011’     Brandon, H. et al. Department for Education, 2012  3 Fish, S., Munro, E. and Bairstow, S. (2008) Learning together to safeguard    children: developing a multi-agency systems approach for case reviews,    London: Social Care Institute for Excellence. 4 op.cit  5 Munro, E. (2008) ‘Improving reasoning in supervision’, Social work now, 40   (August), 6.  43  months in October 2006, and in September 2010 removing H from such a plan after only six months.  In the period prior to the first removal there were continued concerns about Y and his grooming, parental separation, a very serious threat from father to his estranged wife, knowledge of father’s convictions (as far as I can see for the first time at conferences), and father resisting requirements to keep H from X which was reported at the de-registration conference.   5.71 In the period between registration and deregistration in 2010, there were a number of events which hardly suggested any long term change. Y was arrested for a non-family relevant offence, H repeated allegations of sexual assault by Y, R had abdominal bruising after a weekend with Y, and the mother alleged  an historical very serious offence against her by the father. There were also two anonymous referrals to the Police about shouting in father’s household which led to no further action.  Whilst only Y’s arrest (eventually) led to a conviction, the concerns do not seem to suggest life for children being that different.  5.72 A feature of these dynamics is a lack of challenge – both professional to parent and professional to professional.  A dictionary definition of challenge includes ‘summons to engage in a contest’ and ‘demand an explanation’. Often it can be the fear of coming over as engaging in a contest that stops professionals demanding explanations.  This can apply to work with families (such as not challenging parents too much in case it lessens their motivation or impacts on relationships with staff).  Also, it can be hard for workers to challenge parents when certain of their answers might lead to life changing decisions about the family such as the removal of a child, and the consequential pain for parents.   5.73 In this case, there was, as with optimism, not a uniform pattern but a number of examples of where challenge could have been greater. There is little sign that  the parents were seriously challenged about failure to follow formal agreements, and there is little evidence that there was ever any consequence to father not only not protecting his children from X and Y, but openly arguing against the need to do so.  On the contrary, the moment anything looked a little better, the pressure was reduced for example by removing the children from Child Protection Plans, or by repeatedly closing the CSC case.   5.74 One version of this was brought to the attention of the Review by the staff group.  This was in relation to the children moving or being moved between parents/relatives and how certain moves were deemed to be beneficial. Whereas in the view of those staff, the children might be safer with one than another, but in neither place actually safe.  5.75 In terms of interagency challenge, there was challenge, especially in 2008-9 from health and education, but even that was at a relatively junior level, and the Review has seen no evidence that more senior staff copied in became involved.  It is unlikely that there were robust processes of (positively) challenging supervision in CSC or it would be difficult to believe that the case could have drifted for so long.  44  (There was some positive internal challenge when a temporary social work manager found no record of a Section 47 being undertaken, and instituted a range of processes in 2013 which led to the protective action despite, says that manager, some discouragement from doing so).   5.76 Why do these overarching themes happen?  A preliminary answer is that this is simply what happens in child protection work. There is always a tendency or wish to be optimistic about making things better, to work in partnership with parents, and produce change, and to see maintaining the family as the first objective. This has been seen, in many SCRs, around a sense of sympathy for parents, giving them every chance, or a last chance and so on, and this had led to errors due to insufficient child focus as evidence of continuing or increasing risk is overlooked, as views become unchanging, and over optimistic, and challenge is held back.  However, in this case it does not seem to emanate from sympathy, more from everything seeming to be so difficult, or even threatening.  The pattern of parental complaints, aggression, manipulation, and the high resistance of both real help and any suggestion of poor parenting, created a sense that getting anywhere with this family was so hard, that proving anything was so hard, and that no one told the same story twice. This seems to have led to either keeping on trying in old ineffective ways, or giving up and closing the case, or not accepting referrals. One can see from the files that CSC did not accept there was a serious problem, and held a picture of risk to the children which (looked at over time) was extremely worrying.   5.77 The area of challenge is one where there needs to be a culture of supporting it (in the sense of seeking explanations), where a challenging culture is seen as a good thing, and modelled by supervisory and management staff.  In other words supervisors need to show good constructive challenge of staff who can then be more comfortable in challenging parents or each other. A Safeguarding Board needs to be challenging of its members who in turn can respond well to it, and so model the benefits of challenge.  5.78 In small communities, where people may know each other better than larger areas, there can be a culture of expecting the best of local people, and it is sometimes hard to believe that awful things can happen. This can lead to there being an insufficiently sceptical or querying mind-set, that may in turn lead to less pursuit of suspicions and less challenge when something untoward is quickly ruled out. In considering the findings of this Review the LSCB and member agencies should consider whether there is a culture which encourages professional challenge, or whether this requires more work.  5.79  The tendencies described above need management. David Jones, the vice chair of the English Association of Independent LSCB Chairs said6 ‘If you need to help                                                  6 Professional Social Work (Nov 2013)  45  people as a social worker you have to be optimistic, but you also have to be realistic, which means you have to hold the possibility that people are playing games with you, or there is deception going on. Holding that together is really quite complicated which is why it is essential to have supervision. The key thing is having someone outside the situation who can talk it through and take another perspective’.  The principle of having someone to talk to applies to other professions whether ‘supervision’ is part of their arrangements or not, and the LSCB should ask its members to ensure that there are good arrangements for all staff to have the opportunity to discuss cases like this, and their feelings about them, with someone more distant from the direct management of the case.    5.80 The summary learning points are:   The need for all agencies to expect there to be a tendency towards optimism, fixed views, and insufficient challenge in child protection cases and...  … to ensure that there are sufficiently robust processes of supervision and case review in place  The need to recognise that not only getting too close to parents can create such unchanging views, but also where parents can paralyse staff thinking by aggressive, confrontational and manipulative behaviour  The need for ‘challenge’ to be accepted part of professional and agency culture, and modelled by senior staff  The need for a sceptical and challenging mind-set, especially around any suggestion of children being at risk. 5.81 Views of the Family: The Reviewer met each of the children subject to the SCR, and the parents. Seeking a view about how the children could have been protected earlier, and how agencies might have helped more, was difficult as some children did not seem to share the view of the court that any protection was necessary. They did have some issues about the looked after process which were fed back to CSC. Comments from children are given here without comment from the Review. The father was also seen, and as he thought the children’s allegations, even those proven in court, were falsely made by children at the instigation of their mother (his former wife) it was again difficult to discuss with him whether protection could have been earlier. His views are also given without comment from the Review. The mother was also seen, and had a different perspective which is reflected below.  5.82 Two children separately gave views about what might help children in interviews about allegations about abuse. They (and both are now young people) said that there should be toys and drawing materials to help the child or young person be more relaxed. One said there should be an opportunity ‘to talk about what I want to talk about’, in other words not just answering questions. The same child said that Police should not take pupils out of class to discuss such distressing issues,  46  because going back into class afterwards, with fellow pupils knowing where they had been, was awful.  5.83 A child did say that many untoward things had happened, and described how upsetting it was that whilst teachers and CAMHS worker D (who was highly praised by the child) believed what they heard, Police and social workers did not. The child did acknowledge that inconsistent evidence was given due to fear of adult relatives, and feeling unsafe if allegations were maintained.  There was also a description of how it felt to witness domestic violence - ‘I was always in the middle’ - and how the mother would ‘stick up for’ the father even after making allegations against him, making it hard for the Police to act.  5.84 The same child, in discussing how protection could have happened earlier, said that children’s services did not investigate allegations thoroughly enough and shied away from confronting the father. The child’s advice for children’s services was to ‘make them investigate more thoroughly… try harder… and not believe parents so much’. Another child said that children’s services should ‘return calls quicker’ and ‘listen before coming to conclusions’.  5.85 When asked how professionals might handle someone with an approach like the father’s, another child said that such a person should be ‘approached gently’, ‘don’t push him to the limit’, but also added that staff ‘should be firmer’.   5.86 The father’s take on the same issue was that his frustration was caused by staff, social workers in particular, because they ‘don’t listen’ and that they were ‘like robots’ as if ‘pre-programmed’.  Also because he felt he was trying very hard to care for children, some of whom were at some point diagnosed as having ADHD, and the difficulty they created was not taken seriously enough. In other words, he was blamed when in fact he needed more help.  He also thought any allegation against him or Y made by children or other parties were at the instigation of their mother as part of her disputes with him, so he felt accusations were unfair.  5.87 He also felt let down by services in relation to abuser X. He said he was referred to live in the property rented out by X by a council funded agency, but then found the council criticising him for having children near a man of apparently known risk. He also said that he had verbal and written permission from CSC to leave H alone for short periods while he struggled to deliver a number of children to different schools, and it was on one of those occasions that H became the victim of X’s behaviour.  5.88 In discussing how services did help, or might have helped her and the family during the period when there was domestic violence, the mother usually felt unable to challenge her husband’s own conclusion on what help she or the family needed. She said he kept her quiet as she would be ‘victimised’ for having her own view. The mother could not recall any advice given about how to keep  47  safe/get help when there was domestic violence. She also felt unable to give her views in child protection conferences (other than in advance to the chair) due to the father’s forceful views and she ‘didn’t want him flying off the handle across the room’.  5.89 She thought health visitors did not take a feeding problem seriously enough with one child and that no one took that child’s behaviour problems seriously enough for some time.  5.90 On the ADHD the mother felt that medication levels were too high, and that ‘there should have been more help for the parents in teaching them how to manage ADHD’ rather than just looking at a medication solution.  5.91 She said that she passed on to the social workers that children were afraid of their father, but the response was always that nothing could be done without a specific event. The mother said that she did her best to protect children from X, and after the parents split made sure social workers were aware of risks from X and then Y. With Y, the mother thought the Police had done all they could, but thought CSC should have been ‘much more active’ in checking whether one or more children were staying with Y despite major concerns being investigated. She thought that there should have been more checks to be sure the children were not left unsupervised, and that they ‘should have been seen more often’.   5.92 The interview with mother was after this SCR had been nearly finished, and she made a comment that echoed what the Review, unknown to her, had already concluded. She said ‘Social Services should be there (i.e. attached to the family) constantly, not in and out, in and out’. Whilst she thought their investigations into allegations were ‘quite thorough’ she did not agree with them withdrawing support ‘on so many occasions’. She said ‘if there is a problem they would come’, and when the presenting problem was sorted or an allegation unproven their stance would be ‘everything is ok, we’re off’’.  5.93 The differing perspectives given in interviews with family members, illustrate the difficulty staff would have had in reaching clear conclusions over the facts of alleged abuse.            48  6. CONCLUSION  6.1 Introduction: This section looks at the answer to the key question in this Review: Could one of more of the children have been protected earlier? If so, why, and what would enable this to happen with future children in a similar position?  The specific recommendations which are in addition to the learning points in 5 are in the next section.  6.2 Could one or more of the children have been protected earlier? The Review concludes that the answer to this is ‘yes’. Regardless of the difficulties in proving specific allegations, there were many indications of serious dysfunction within the family. The fact that young children even had the language to make certain of the allegations, the frequency with which there were serious concerns, the behaviour of the children, the non-cooperation of parents, the failure by parents to protect children from abusers, the lack of change, and the chaotic, sexualised, violent nature of life for the children, all warranted intervention at an earlier stage. In the absence of action through the criminal courts, earlier use of care proceedings should have happened.  6.3 Why did this not happen?  Section 5 analysed this in detail.  In summary, the reasons, at the time, included the following:   The intimidation perceived by staff from the father to some extent paralysed objective analysis, and limited challenge by agencies  There was insufficient assessment of parenting skills, and a varying understanding across agencies of risk factors  Insufficient weight was given to the lack of parental change and cooperation, and the father’s inability or unwillingness to protect the children  Too much focus was given to the presenting problem of the day, rather than assessing the long term well-being of the children  On a number of occasions when serious allegations were unsubstantiated for court purposes, there should nevertheless have been multiagency discussions to considered the implications for children  Too many of the investigations were single agency, and CSC took an approach where if there was insufficient evidence for a conviction they also did not intervene  This led to CSC frequently closing the case, when the overall evidence was of an unchanging or worsening situation where the children were at risk emotionally and/or physically and/or sexually  More consideration could have been given to why, after investigations had found insufficient evidence, children repeated allegations of abuse by relatives, especially given the risk to the children in doing so  Escalation arrangements to resolve disputes between agencies were not then sufficiently well-defined or used  49   The degree to which there was undue optimism in CSC, regardless of the evidence, suggests supervision and case review processes were not sufficiently robust  There was not a shared understanding between clinicians, and between clinicians and CSC, on the importance of social/environmental factors in extreme behaviour disorder  6.4 This list explains why opportunities were missed but these are not the root cause, which lies in the system within which the staff worked and the degree to which that provided sufficient preparation, support, supervision, and management of staff working with the most challenging of families, and had sufficiently robust interagency working. Improvement lies in making sure the system within staff work operates effectively.  6.5    What would need to happen to protect more quickly children in the future in a similar position?   The Staff Group wanted it to be clarified in this SCR that any change would not just benefit children referred in the future, but current  families with chronic, not improving, situations where there is a similar need to take a long term and less event based perspective. Generally the answer lies in training, supervision and management being robust enough to ensure that good practice is followed and that the specific issues highlighted by this Review have been or are being addressed.   6.6   To address a similar situation, the approach would need to be less event-based and more focussed on the long term well-being of children. It would require the meaning for children of repeated ‘no further action’ referrals to be considered. It would need a level of resilience nurtured in staff which would be able to deal with the pressures from an aggressive parent/s, and a degree of challenge that would be appropriate to a long term non-improving situation. It would need supervision and management processes that are able to identify where there is undue optimism, and where assessments remain similar despite changing circumstances. It would need strong interagency relations where professional views are respected and heeded, and a good process for resolving disputes. It would also need clear processes for multiagency discussion of the overall progress of families and childcare that does not necessarily need to be linked with a specific referral.  6.7 This Review is not saying that the position described in 6.5 is not in place, as the Review has not being auditing current practice. There have been a number of improvements since this case, and each involved agency has provided the SCR with a note on progress to date, which can be seen in Section 8.  The recommendations that follow are not, as traditionally done, a list of specific actions for each agency, but a menu of what needs to be in place for the LSCB and its member agencies to consider, and then provide assurance of progress.   50  7 RECOMMENDATIONS    7.1 Introduction:  The recommendations are set out for the LSCB, which with its member agencies will decide the priority for each and develop an implementation plan or a process for assurance of compliance, as necessary. In the main the recommendations apply to all agencies to one degree or another.  The recommendations are based on what was found in this case, but will have a more general application, which is the intention of Serious Case Reviews.   7.2 Whilst 7.3 lists the formal recommendations, Section 5 above also contains around 30 learning points from the Review which can also be seen in Appendix 1.  7.3 Recommendations from the SCR for the Local Safeguarding Children  Board (LSCB)7  The LSCB should require member agencies to ensure there is the necessary and appropriate training, guidance, supervision and support so that the following will happen, which will be subject to ongoing assurance processes. There should be no automatic assumption that the list below is not now in place, but that the LSCB and agencies should be sure that it is, or take appropriate steps to ensure it is.     That in complex long term cases there is time to step back and reflect, away from the heat of current crises  That the impact of aggressive parents is understood, and staff are supported with this so that they become resilient in face of the pressures  That the value of ‘history’ is high, that records are easily accessible, and that assessments always take the full history into account  That optimism in the face of changing evidence will sometimes happen and needs to be addressed through good supervision and case review  That challenge is valued, and modelled by supervisors and managers by both giving and receiving challenge well  That escalation procedures to resolve inter-professional and inter-agency disputes are understood and used  That the resolution of a current problem, does not prevent the consideration of the long term well-being of the children  That there are clear processes in place for multiagency discussion of chronic cases without necessarily a single trigger event                                                  7 The LSCB’s response to these recommendations, and action plan, will be published alongside this SCR  51   That, whilst valuing the contribution of parents to conferences, there are clear processes in place to ensure staff can have some time to discuss their views without the parents being present   That CSC would, other than in the most exceptional circumstances, convene multiagency meetings to discuss major concerns by other agencies, and that the procedural requirement for the LSCB to rule on any dispute is understood   That contradictory evidence from children about an allegation or disclosure does not lead to a failure to consider what is happening overall in the children’s lives  That contradictory evidence is considered as a possible indicator of abuse rather than something that disproves it                                     52   8. WHAT IS BETTER NOW? - AGENCY UPDATES  8.1 This section sets out, from each agency involved and the LSCB, a self-report on what has already been put in hand as a result of their learning from this Review, or has improved since the events described.  Quality assuring these contributions was outside the terms of reference of the SCR, and the LSCB will need to be assured that progress described is ongoing. The updates were written as at July 2014.  8.2 Isle of Wight Local Safeguarding Children Board This update is set in the context of Ofsted finding the effectiveness of arrangements to protect children to be inadequate in January 2013 and declaring the LSCB to be under developed in terms of its role and impact.  The inspectors identified specific statutory failures in relation to the LSCB’s role and functions and an absence of effective oversight of child protection services.  Since that time the Board has undergone a transformation in terms of its strategic leadership and accountability.  A new independent chair was appointed in October 2013 and its governance arrangements reviewed so that senior managers from all agencies lead on key areas of business, as set out in its refocused strategic plan. There are new governance arrangements with the Health and Wellbeing Board and the Children’s Trust.  The Board re-introduced multiagency training on the Island in January 2014.  This is having a positive impact on frontline practice across all agencies, as evidenced by the attendance of over 350 staff at serious case review learning lessons events delivered from January 2014 to May 2014.  120 staff attended a conference on Neglect in June 2014 picking up the local theme highlighted in recent case reviews.   Sandstories events (cited by Ofsted in their neglect report ‘In the child’s time: professional responses to Neglect’, March 2014) were delivered on the Island in June and July 2014. The one day workshops will support staff to work more effectively with hostile and uncooperative parents in the context of neglect.  The escalation policy has been recirculated to all staff across the Island and reinforced through all of the events held since January 2014.  The LSCB reviewed, in partnership with Hampshire, the multiagency thresholds document which sets out the eligibility criteria for referral of child protection and child in need cases, and this was launched in April 2014. Safeguarding procedures have been updated to reflect Working Together 2013 and an event took place in July 2014 to make staff aware of updates to a range of 4LSCB policies and protocols. The redesigned LSCB website www.iowscb.org.uk  53  has made up to date information on events, policies and procedures more readily and easily accessible to frontline practitioners. The LSCB now has in place a multiagency audit plan overseen by its Performance and Quality Assurance Subgroup.  The effectiveness of supervision and management oversight is looked at in all types of audits.  A look back over the year will take place at its annual conference on 9 September 20148 which is focusing on adolescents at risk.  The event is aimed at engaging 200 frontline practitioners with LSCB members along with input from a range of young people. The LSCB is committed to learning lessons swiftly from cases that go wrong and commissioning Serious Case Reviews where children die or suffer significant harm. The findings of all SCRs are published and placed on the LSCB website.  8.3 Isle of Wight Council   Children’s Social Care: The report of the Ofsted inspection of local authority arrangements for the protection of children on the Isle of Wight was published in January 2013 and found the local authority inadequate in its ability to protect children. A Children’s Improvement Board was established, chaired by Professor Ray Jones, and the improvement plan developed. In June 2013, the Isle of Wight Council’s education department was also inspected by Ofsted. Ofsted judged that the local authority was not providing the level of support and challenge to schools that was required to promote high standards and fair access to educational opportunity for all their children.   In response to these inspections, the Isle of Wight Council entered into a legal partnering arrangement with Hampshire County Council in July 2013 over a three to five year period. This arrangement has since provided in situ senior managers for education and children’s social care since October 2013. The Director and Assistant Director of Children’s Services for Hampshire County Council are also the Director and Assistant Director of Children’s Services for the Isle of Wight. The senior managers from Hampshire County Council joined the Children’s Improvement Board and have since integrated the improvement plan with the service plan and through into the team plans.  The impact, effectiveness and influence of this partnering arrangement with Hampshire County Council is evident and is clearly responsible for the rapid improvements achieved in the last six months9. The Isle of Wight children’s social care front door, through Hampshire’s Multi-Agency Safeguarding Hub and Children’s Reception Team is now safe. Leadership and management, custom                                                  8 This event did take place 9 This is ongoing, as evidenced by Ofsted inspection published November 2014. “The five-year strategic partnership between the Isle of Wight Council and Hampshire County Council is providing essential stability and is driving demonstrable improvements across children’s services on the island.”    54  and practice, and systems and processes in children’s social care on the Isle of Wight are now very different and much improved since the last Ofsted inspection. In addition all Policies and Procedures for the Isle of Wight have been updated, are available to all staff and briefings/workshops set up to support staff with their application.  The partnership has also led to the electronic social care system for the Isle of Wight Children’s Services being updated to the most recent version assisting in recording compliance and expectations.  In addition, there is a revised, shared and embedded threshold document which there is evidence is being applied within Children’s Services.  The partnering arrangement has stabilised children’s social care through the reorganisation of services in line with Hampshire County Council. This was to deliver the identified priorities within the improvement plan. The reorganisation was completed swiftly and with minimal disruption to children, families and staff. The partnering arrangement has stabilised the workforce for staff and families. Agency staff numbers have fallen dramatically as successful recruitment drives have appointed permanent staff. Partnership working has enabled good practice, knowledge and experience to be shared rapidly. There are numerous formal and informal opportunities for peer mentoring, buddying and coaching between the Isle of Wight and Hampshire County Council staff.   The partnering arrangement has provided the Isle of Wight with the updated ICS system it needed through accessing Hampshire’s ICS system. Again, this implementation was completed swiftly and with minimal disruption to children, families and staff. The changeover has provided an increased intelligent use and sharing of data to provide management oversight and to improve performance. The partnering arrangement is inculcating a culture of performance, continuous improvement and learning within the organisation. This is evidenced through improving social work practice, safeguarding and outcomes for children on the Isle of Wight. Education: Key areas of learning for educational institutions and services relate to the knowledge and ability to challenge partner agencies and ensuring staff had opportunities to stand back and reflect on the history and decision making in very complex cases and to be challenged about their decisions in such cases. Guidance and training that has been given to school and education staff and changes to supervision processes of the Education Welfare Service staff have enabled these key points to be addressed and practice strengthened.  The LSCB escalation policy has been disseminated to schools and education agencies and this has enabled staff to feel confident that it is their professional responsibility to escalate concerns to senior staff in Children’s Social Care should they feel the action that has been proposed by Children’s Social Care or another agency does not address concerns they have raised. This is routinely and regularly restated within all safeguarding training and Learning Lessons events. All educational institutions have staff who are trained in safeguarding including a  55  Child Protection Liaison Officer with level 3 safeguarding training. This training has also enabled educational institutions to have a greater understanding of their right to request a child protection conference if they have sufficient concern that a child might require protection. There is a greater awareness amongst staff now that disputes regarding conferences can be escalated through Children’s Social Care and to the LSCB.  Child Protection Liaison Officers meet regularly with senior managers from Children’s Social Care and this provides another opportunity for this message to be reinforced and for education staff to share concerns.  The Hants Direct line and Multi-Agency Safeguarding Hub enables information to be collated and for historical information to be reviewed and taken into account more readily and this has led to better recording in schools which has given greater confidence to staff to share their information and knowledge from the chronologies their files provide. This has been noted in the multiagency audits that have taken place. Change in systems and more open and challenging leadership within Children’s Social Care has also modelled to educational institutions the open, supportive and challenging working that Children’s Social Care expect within their staff and with partner agencies and this is enabling greater inter-agency challenge. Challenge is seen less as a contest but more professional support. Children’s Social Care staff now model the benefits of challenge which is supporting improvement in relationships between agencies and greater trust that information will be shared, taken seriously and acted upon appropriately/consistently. There are robust processes of supervision within the Education Welfare Team, providing officers with monthly supervision that enables them to be supported with cases and for challenge to explain their decision making.  8.4    Youth Offending Team:      In November 2012, IOW Children’s Services had been inspected by Ofsted. As a result, (and in conjunction with other education Ofsted inspection results on the island) the IOW Council entered into a partnership arrangement, following a DfE direction, with Hampshire County Council which commenced on 1st July 2013. One of the tasks for Hampshire was to reconstitute a Children’s Services Department, several parts of which, including the YOT, had been placed in other directorates. With regards to the Isle of Wight Youth Offending Team (IOW YOT), partnership arrangements commenced formally on 1st October 2013 with the Head of Service for Hampshire YOT assuming line management responsibilities for the IOW YOT Operational Team Manager and strategic oversight of the work of the team. This resulted in more specialist resource being made available to support and manage the work of IOW YOT, and a greater alignment with wider children’s services as well as Children’s Social Care.    56  Additionally, in line with feedback received via Peer Review undertaken in September 2013, the role and membership of the IOW YOT Management Board has been strengthened, with the Deputy Director for Children’s Services and the Area Director for the Isle of Wight both joining the management board and additional resource allocated to the YOT by the management board in terms of frontline staff. Both have had the result of strengthening the way in which IOW YOT delivers its functions, how these are supported or monitored and also integrated with others.   Indeed, the IOW YOT is now better positioned to work with partners to identify areas of strength and stretch as well as to resolve any difficulties or concerns which arise. Importantly, IOW YOT is now specifically represented at a variety of forums, including LSCB and Children’s Trust, which provide greater opportunity for partnership working and identification/addressing of concerns as well as areas of good practice. This ties in well with the circulation of escalation policies by Children’s Social Care and LSCB which can be followed when necessary, and now means that there is a clear, written process for addressing any concerns arising in relation to a particular child and/or their family, as well as mechanisms for notifying them to the appropriate Senior Manager or local forum if not resolved in this way. Operationally, whilst IOW YOT staff have always been able to raise concerns for addressing with IOW Management at any time, there is now a specific ‘escalation’ agenda item on regular IOW YOT Practice and Team Meetings to ensure these can be considered across the Team (where appropriate) to identify trends, blocks or positive outcomes for wider team learning. All of these factors have been key in ensuring a more integrated approach is taken by IOW YOT in relation to safeguarding, but also that there are clear mechanisms in place to challenge processes or decision making in relation to specific referrals (if that is required).  Furthermore, an increased and more broadly varied range of training is available locally to IOW YOT staff and managers via Children’s Social Care and LSCB to equip them in dealing with difficult issues and support them in ensuring that safeguarding duties are fully met. Whilst this is a relatively recent development, IOW YOT staff have been able, and will continue, to access training across a broad range of subjects including lessons learnt, working together in child protection, and working with disguised compliance and/or disengagement (including application of the reviewed Threshold document).  IOW YOT also has identified its own training resources to support broader work in this area (e.g. assessment of vulnerability), which will be rolled out across the coming year. Therefore, there seems to be now a greater opportunity for workforce development and increased worker confidence to tackle difficult issues which was not consistently available in the past.  Overall, these developments provide an increasingly robust approach to safeguarding and child protection work and form part of a wider process of  57  improvement both within the IOW YOT and local children’s services which not only recognised the need for change, but ensured that it is implemented within well-established improvement plans.    8.5     Hampshire Probation Trust  The following summarises improvements made in child safeguarding practice within Hampshire Probation Trust.  From the June 6 2014 Hampshire Probation Trust has been replaced by two new organisations. The National Probation Service (NPS), which manages offenders subject to Multi Agency Public Protection Arrangements (MAPPA) and those offenders assessed as likely to cause high risk of harm and Hampshire, and IOW Community Rehabilitation Company (HIoWCRC), which manages those offenders assessed as presenting with lower risks.   Both organisations are however working to the following set of arrangements:-   The Revised Hampshire Probation Trust Safeguarding Children Policy and Practice Guidelines were published in October 2012 and now adopted by the NPS and HIoWCRC. This policy provides for the requirements on probation staff where there are child safeguarding concerns, either at pre- sentence stage; during the management of a Community Order or pre and post release from a period in custody.   It strengthens arrangements in respect of notification of concerns; information sharing; attendance at child safeguarding meetings; management oversight of cases where there are child safeguarding concerns; home vesting and recording in all cases with child safeguarding issues.  All staff have been briefed on this policy and practice guidelines and this is now fully operational.   All staff in the NPS and HIoWCRC with direct access to children or their information are required to undertake mandatory Safeguarding Children training as part of their induction.  This training must be refreshed every 3 years.  Both organisations are keeping detail records of staff training and requiring team managers to ensure their staff access refresher other training as appropriate.   Senior Probation Officers as team managers undertake supervision with Offender Managers on a monthly basis. It is a requirement that cases involving safeguarding children issues are discussed in monthly supervision and staff are able to escalate concerns to their line manager as and when required.   The NPS and HIoWCRC are now actively involved in LSCB multi-agency case audits.  Both organisations also undertake an annual audit of a sample of cases where child safeguarding issues are present to inform development of policy and practice.  8.6 Hampshire Constabulary   58  Larger, dedicated child abuse investigation teams now investigate all categories of child abuse - they previously dealt with only the most serious and complex. This is leading to improved consistency and professionalisation of the constabulary's child abuse response and ensures that accredited and well trained staff deal with child abuse cases. A Central Referral Unit has been established which is the single gateway and assessment centre for all vulnerability reports including those relating to child abuse, adult abuse, domestic abuse and hate crime. This enables central oversight of all force public protection matters and enables the easy identification of repeat cases, linked incidents etc as well as acting as a Single Point Of Contact for all local authorities' social care teams. The Central Referral Unit recently became co-located with Hampshire Children’s Services Department, Adult Services Department and Solent Health to create a Hants and Isle Of Wight Multi Agency Safeguarding Hub (MASH). The Multi Agency Safeguarding Hub presents opportunities for more efficient, timely and informed assessment, through information sharing, strategy discussions etc leading to evidenced-based decision-making, and ultimately better outcomes for children. We have established a dedicated Serious Case Review team which is responsible for managing the Police contribution to, and actions/recommendations arising from, all child and adult Serious Case Reviews and partnership reviews, as well as Multi Agency Public Protection Arrangements and Domestic Homicide Reviews. This team is part of a wider review and force organisational learning team, focused on raising standards of policing across the board and embedding good practice. The 4 LSCB policies and procedures, including those on escalation, have been reinforced with the specialist child abuse investigation and safeguarding teams across the force.  There is a clear expectation on supervisors to challenge issues of concern until an appropriate resolution has been identified. 8.7 Isle of Wight NHS Trust There is a good and efficient system of Emergency Department (ED) safeguarding liaison in place, now supported by the Named Nurses for Safeguarding Children.   All children admissions to ED (also known as A&E) are screened daily on weekdays. There are good processes in place for spotting frequent attenders and child attendances that need wider professional involvement. There is a ‘safety net’ mechanism and chronology of attendances is being done. Safeguarding staff escalate if needed and provide feedback to A&E staff.   There is a clear, written escalation policy, supported by senior managers which can be implemented in the case of professional disagreement. The escalation policy was introduced, advertised among staff both in hospital (via intranet) and  59  community (health visitors, school nurses) and included in team briefing and staff training. There is much better awareness of how to escalate if a professional is not satisfied with the safeguarding decisions. There is evidence of this policy being applied and escalation happening. Regular meetings between Social Services, Police and Health were introduced over the last year and provide an additional forum for an escalation.   The provision of care for children with behavioural and mental health issues is much better now. At the period of time described in the Serious Case Review (SCR) the Child and Adolescent Mental Health Service (CAMHS) was staffed by a single, locum child psychiatrist. Now there are two substantive consultants in child psychiatry employed by IoW CAMHS supported by a team of psychologists and therapeutic workers.   In September 2013 a new consultant paediatrician with expertise in mental health was employed. She is a new lead consultant for Attention deficit hyperactivity disorder (ADHD), Autism spectrum disorder (ASD) and paediatric mental health problems in paediatrics.  An audit of antipsychotic treatment in paediatric patients was done in 2012 and presented to the Clinical Directors Forum (Medical Director, Clinical Directors and Associate Directors). Now the joint clinics of paediatrician and psychiatrist are taking place and antipsychotic treatment is prescribed only with a joint agreement between psychiatrist and paediatrician.  Since 2013 regular bi-monthly meetings of CAMHS and paediatric team have been taking place addressing both governance and clinical issues. There is also better access for counselling and family therapy.  Since summer 2013 families of children with ADHD take part in New Forest Parenting Program provided by the Barnardo's charity.   8.8 Isle of Wight Clinical Commissioning Group  The improvements in provision of Attention Deficit Hyperactivity Disorder (ADHD) service, Children and Adolescent Mental Health Service (CAMHS) and counselling services described in 8.7 were actively facilitated by commissioners from CCG working closely with clinicians from the NHS Trust.  GP non-attendance at safeguarding conferences is being addressed. There was concern that attendance at safeguarding meetings is not given a high enough priority, which is exacerbated by the current pressures and vacancies in primary care. The importance of submitting a written report, particularly if they are unable to attend, is raised at all safeguarding training events.  The main topic of the GP practice closure afternoon in March 2014 was safeguarding which was attended by the majority of GPs and representatives of all  60  practices. A variety of safeguarding professionals presented the current issues and responsibilities for primary care, including the issue of information sharing in safeguarding, underlining the rules of information sharing by GP and their duties in this area. This remains a priority area for improvement and is being closely monitored.                                          61  Appendix 1: Collated learning points from Section 5 ‘Learning and Why’    The Influence of fathers  Fathers with such personalities as this one, can have a debilitating impact on case management   Staff must feel free to share their feelings about working with such families and expect support  Those providing management and supervision, especially in CSC which runs the multiagency meeting, must be aware of the potential of aggressive fathers to undermine confidence and objective decision making  Those providing supervision and quality control of cases must check to see that assessments and decisions fit the evidence accumulated over the years  Agencies should have formal processes for agreeing how aggressive parents are managed to ensure the safety of their staff   Review meetings/conferences should always be reminded of historical risk factors, and not assume those present will all be aware of them  Managing differing views on risk  The need to ensure that robust escalation processes are in place, and understood and used by staff when there are concerns between agencies about the quality of responses  Requests from staff in other agencies for child protection case conferences should normally be accepted  Even if there appears to be a good reason not to accept a particular referral, CSC should regard repeated referrals/conference requests from multiagency sources as needing further understanding, especially when there are clearly stated concerns about child safety  Investigations that do not prove offences do not necessarily in themselves prove that children are safe, or that their development is not being harmed  Single Issue Thinking  The need for a long term perspective when so many short term problems are posed by a family  The need to regard chronic issues as important as the single dramatic event  The need for time to reflect on the meaning of events (even if disproven) on children’s physical and emotional well-being  The need for robust supervision to identify, and to support/challenge staff who do not look at the bigger picture     62  Management of Allegations  The need to be very aware of the possibility of intimidation of children by relatives when disclosures are made  The need to tailor investigations to any likelihood of relative’s attempts to intimidate children  The need to use the new CPS guidance to test in court evidence that might have some vulnerability  The need to strongly consider the meaning of repeated disclosures by children, even if a prior investigation had found those disclosures unsubstantiated  The value of internal case audit in establishing the quality of work assessing abuse inquiries  The need to be clear about the current laws on excessive force/reasonable punishment  Meetings  Strategy meetings can be used for concerns about chronic situations, where multiagency pooling of information and views would allow a step back and review  Strategy discussions/meetings may need to involve more than just CSC and Police, and should involve health and any other agency to be involved in the investigations  When professionals set out an argued case for a child protection conference it should be only in exceptional circumstances that CSC do not convene one. (If there are disputes about interpretation of thresholds the escalation process should be used)  The LSCB needs to be sure staff understand that disputes about calling a conference can be escalated to LSCB level  The discretion to exclude parent/s from part of a conference needs to be exercised when there is a history of staff feeling intimidated, and there is any chance that parental behaviour would inhibit discussion in a child’s interests, or impact on decision making  Staff need to make their views about this very clear to the conference chair.  Where two parents in dispute attend conference the possibility that one might feel unable to contribute for fear of the other should be considered  Conferences need to be aware of the risks from assuming those present or receiving minutes know prior risk factors  Overarching themes (optimism, not revising judgements, lack of challenge)  The need for all agencies to expect there to be a tendency towards optimism, fixed views, and insufficient challenge in child protection cases and...  63   … to ensure that there are sufficiently robust processes of supervision and case review in place  The need to recognise that not only getting too close to parents can create such unchanging views, but also where parents can paralyse staff thinking by aggressive, confrontational and manipulative behaviour  The need for ‘challenge’ to be accepted part of professional and agency culture, and modelled by senior staff  The need for a sceptical and challenging mind-set, especially around any suggestion of children being at risk                                    64  Appendix 2   Police Review - June 2014   Conclusion and Recommendations  Note: Due to issues arising from this case, and after the conviction of Y, the Police commissioned an internal detailed review of previous Police investigations of abuse in the Q family. The following extract was that Review’s conclusion and recommendations.  Conclusions and  Recommendations  This review has highlighted the importance of strategy discussions and strategy meetings in the effective planning of joint investigations.   It has identified the importance of inviting agencies in addition to police and children’s social care to these meetings if they are to be involved in the investigation.  Working Together (2013) states strategy discussions and meetings should involve at least police, social care and health but this review has also identified the importance of also inviting schools to attend when appropriate.  This review has identified the importance of police managers being involved in strategy discussions and meetings to plan joint investigations rather than constables undertaking this role. Recommendation 93 in the Climbié Inquiry Report (2003) is explicit about the involvement of managers in setting strategy both at the initial referral stage and thereafter.    The lack of strategy meetings and discussions in joint investigations plus involvement of police managers have both been identified in other recent serious case reviews including one on the IOW and Child K and Family A in Southampton.   Recommendation 1  Hampshire Constabulary should give clear instructions to those officers supervising joint investigations into allegations of child abuse that having multiagency strategy discussions and/or meetings is a compulsory element of the investigative process and it is their responsibility as a supervisor to represent the police in these discussions or meetings.    Recommendation 2  Police supervisors involved in strategy discussions and meetings to plan joint investigations should actively encourage attendance of all agencies involved in the investigation.  This review has highlighted the need for allegations of parents using excessive force to punish their children to be investigated more thoroughly and decisions made regarding “reasonable punishment” to be in line with Section 58 of the Children Act 2004.  The “victim” has to be seen as part of the investigation to  65  determine what injuries, if any, s/he has and the suspect spoken to establish if s/he can rely on this defence.   This issue has also recently been identified in a case review on the IOW and Child K in Southampton.  Recommendation 3   Hampshire Constabulary should issue additional guidance to frontline officers regarding the expectations regarding investigating allegations of parents using excessive force to punish their children and this guidance needs to include an explanation of Section 58 of the Children Act 2004.  This review has identified the difficulties encountered by frontline uniform officers in undertaking joint child abuse investigations with children’s social care.  This is in respect of their skills and experience (including conducting ABE interviews of child victims/witnesses) but also their availability in working with other agencies taking into account their 24 hour duty patterns and their response role.  This issue has also been identified in the Child K serious case review in Southampton but since then the Child Referral Unit (CRU) grading and allocation policy has been amended in January 2014.  The amendments will mean if applied strictly that joint investigations or investigations regarding intra familial child abuse will be allocated to Child Abuse Investigation Team (CAIT) investigators.  This is likely to have resource implications for CAITs and it would be helpful for Hampshire Constabulary to know whether this policy is working in practice or whether resourcing is impacting on its application in all of these cases.   Recommendation 4 ( updated August 2014)  In light of recent changes to both the CRU grading process and the increase in resources within CAITs, Hampshire Constabulary should conduct a review and evaluation of how grade B referrals are being allocated to ensure specialist CAIT resources are now being routinely deployed for joint investigations and investigations into intra familial child abuse  H made several allegations of serious child sexual abuse against a suspect that had since died.  These were not investigated by police and were passed to children’s social care to offer support to the victim.   High profile national investigations have identified the importance of obtaining an account from the victim in these cases to be clear what it is they are alleging and about whom.  Only then can a decision be made as to whether any action should  66  be taken to prevent offences, safeguard children or instigate any investigations into other suspects who are still alive.  Recommendation 5  The CRU grading and allocation policy should be amended to include what investigative action Hampshire Constabulary expects, and from which teams, when allegations of historic child sexual abuse are made against suspects who are deceased.    The introduction of the 2013 CPS Guidance on Prosecuting Cases of Child Sexual Abuse may result in some cases that would have previously not resulted in charges being authorised now been assessed as meeting the evidential threshold for charging.  Police supervisors would benefit from having some guidance on what their threshold should be in child sexual abuse cases for submitting cases for CPS advice.  Recommendation 6  Hampshire Constabulary should provide guidance to police supervisors as to the threshold for submitting child sexual abuse case files to CPS for CPS to make charging decisions.     In a number of investigations into serious indictable offences (including serious child sexual abuse offences) the suspects were not arrested but invited to their local police station for a voluntary interview. This had implications regarding the standard of the investigations (e.g. houses were not searched as Section 18 PACE powers were not able to be utilised) and the ability to protect vulnerable victims (e.g. by applying conditional pre-charge bail).  Officers seem to have difficulty in applying the “necessity test” to justify arrests in these cases.  Recommendation 7  ( updated August 2014)   Hampshire Constabulary is currently conducting a review of recent changes to legislation and police practice in relation to the requirement for officers to consider the 'necessity' to arrest individuals suspected of an offence.  The content of this review should be considered in that ongoing piece of work.     SCR   Ends     