Death of a two-year-old boy in May 2021 from natural causes due to a bacterial infection. There had been prior social care and multi-agency involvement with the family and issues of parental neglect, domestic abuse and alcohol abuse by the childrens father. Learning includes: consideration needed of the level of support given to victims of domestic abuse who repeatedly resume relationships with perpetrators; better promotion and oversight of use of the Graded Care Profile (GCP2) tool is required; a need to review how support is delivered and co-ordinated for families with complex needs; and a need for better use of professional curiosity with families, particularly in relation to disguised compliance. Recommendations include: ensure all multi-agency professionals are aware of, and have access to training and resources for the systemic practice model; examine the role of Multi Agency Risk Assessment Conference and how wider support for victims of domestic abuse is managed; ensure the use of the GCP2 tool in all cases of suspected or known neglect; and highlight the features and impact of disguised compliance and parental alcohol misuse on safeguarding children.
      
 Title:  Child safeguarding practice review: Noah. LSCB: Wirral Safeguarding Children Partnership Author: Wirral Safeguarding Children Partnership Date of publication: 2023  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.                           Child Safeguarding Practice Review  Noah   March 2023  Wirral     Safeguarding    Children  Partnership Table of Contents   Executive Summary          2  Introduction, Terms of Reference and Methodology   4  Context            6  The Incident           8  Analysis of Key Practice Episodes       9 • How effective was multi-agency working with this family?  9 • Was the SUDIC protocol correctly applied in this case?   11 • Did the parent’s have the required capacity to change                   11                     to ensure the safety and wellbeing of their children? • To what extent did the Covid-19 crisis impact either on           12                                 the circumstances of the child or family or on the capacity                                       of the services to respond to their needs?    Strengthening Safeguarding Arrangements     14  Summary of Recommendations       16  Appendices           17 • Agencies involved in the review      17 • References          17 Wirral Safeguarding Children Partnership                Page 1 Executive Summary 1.1 Noah was two years old when he was found unresponsive in his bed at home. Despite attempts at resuscitation paramedics confirmed he had sadly died. He had been poorly a few weeks before but had been on antibiotics and he seemed fine when he went to bed.  1.2 As the cause of death couldn’t be immediately ascertained the police viewed Noah’s death as potentially suspicious which caused them to step outside the established SUDIC procedure. It   wasn’t until several month later that a post mortem concluded Noah had died from natural causes due to a bacterial infection. 1.3 Prior to Noah’s death there had been significant social care and multi-agency involvement with the family. Noah’s parents have had five children removed from their care due to longstanding    issues of parental neglect, domestic abuse and alcohol abuse by the children’s father.  1.4 A feature of the parent’s relationship was a repeating pattern of being together and splitting up with parental conflict and domestic abuse regular occurrences. Prior to Noah’s death the parents were living apart and Noah’s father was not permitted to be in the family home, but he was known to be regularly present. 1.5 At the time of Noah’s death there were three children living at home, and all had been subject to child protection, child in need and team around the family plans over during the past few years with frequent step-up and step down between levels of intervention. 1.6 Based on the level of involvement with the family, and the known previous issues of neglect, the WSCP decided to proceed with a review to identify learning. 1.5 Four key practice episodes were identified and formed the basis of the review:  How effective was multi-agency working with this family? • Neglect and home conditions—Concerns about home conditions were raised periodically throughout the review and neglect had been a significant feature in the family’s history.  Unfortunately, most descriptions of neglect were subjective and descriptive and practice lacked the use of an evidence based tool such as the Graded Care Profile 2 • Domestic abuse and parental conflict –These are also recurring themes in the reviews and neither is satisfactorily addressed, nor is there evidence that the risks posed by domestic abuse and the impact it has on children have been successfully mitigated against • Alcohol misuse by Noah’s Father— This is closely linked to disguised compliance in this case. Noah’s father has engaged with agencies in relation to his drinking, but his              engagement has been patchy and his self reporting of abstinence has not been supported by evidence. His drinking is a key factor in the fragility of his relationship with Noah’s mother, and the instances of domestic abuse have almost always been linked to his drinking.  Was the SUDIC protocol correctly applied in this case? • The SUDIC protocol sets out the steps to be taken by partners following the sudden and unexpected death of a child. Wirral is part of a pan-Merseyside protocol which has been in place since 2000. Children who unexpectedly die at home should be taken to Arrowe Park hospital for examination, and to enable the family to visit. Wirral Safeguarding Children Partnership                Page 2 •In this case, when arriving at the family home the attending police concluded that the deathmay have been suspicious and asked for Noah to be taken to Alder Hey hospital inLiverpool rather than Arrowe Park, causing confusion for Ambulance and hospital staff.Did the parent’s have the required capacity to change to ensure the safety and wellbeing of their children? •Without the capacity or the necessary will to change it will be impossible for any family tochange their pattern of behaviour•In this case there were a lot of examples of genuine good intentions by the parents toprovide a safe and settled environment for their children. Unfortunately the foundationsfor this were quite shaky because the issues of neglect, parental conflict, domestic abuseand the impact of parental alcohol misuse were not adequately addressed to enable thefamily to move forwards. Until that happens their capacity to change will be limited.To what extent did the Covid-19 crisis impact either on the circumstances of the child or family or on the capacity of the services to respond to their needs?  •Most agencies involved in the review stated that the lockdowns and changes to service provision as a result of Covid-19 undoubtedly had an impact on the family as fewer face to face services were available, a number of key meetings such as TAF meetings were held virtually, and a number of staff could not routinely attend meetings.•However, agencies also reported that in this case the impact on the family was minimised; places at school and nursery were still offered, and support from children’s services and the children with disabilities team and other services continued. Noah’s mother also fre-quently utilised 111 and 999 whenever she had medical concerns about the children.1.11 Key findings: •Noah’s death was caused by a bacterial infection and the post mortem concluded his deathhad been by natural causes. Noah’s death was not related to any safeguarding concerns•The family were struggling with a variety of issues, including relationship concerns, parentalconflict, domestic abuse, and the impact of parental alcohol misuse•There was a repeating pattern of the parents splitting up, reconciling and then splitting upagain, and also a pattern of the case repeatedly stepping up and down•There was considerable multi-agency involvement with the family and it is unlikely, at themoment, that the family will achieve positive outcomes without this continued support.1.12 Recommendations – Eight recommendations are made: •To promote systemic practice•To audit a selection of step-up/ step-down cases to identify features•To examine the role of MARAC and wider support to victims of domestic abuse•To promote the use of the GCP2 tool•To highlight the features and impact of disguised compliance and parental alcohol misuse•To update the SUDIC protocol•For Merseyside Police to consider further SUDIC training and guidance•For agencies involved in the case to develop their own single-agency action planWirral Safeguarding Children Partnership  Page 3Introduction and Methodology 2.1 On morning if the 29th May 2021, the mother of 2 year old Noah found him lying unresponsive in his bed. His mother phoned an ambulance which arrived a few minutes later. Despite attempts at resuscitation, the attending paramedics confirmed that Noah had sadly already died. 2.2 Police officers who arrived a few minutes later declared the house a potential crime scene and were concerned about the fact that Noah had blood and saliva around his mouth, and the presence in the house of his father—who lived st a different address and should not have been in the house due to domestic abuse, and was suspected of causing a non-accidental injury against one of Noah’s siblings a few days earlier. 2.3 As a result of these concerns a crime investigation pathway was followed rather than the     Sudden Unexpected Death of a Child (SUDIC) process which would usually have been followed. 2.4 The attending police also described the house as ‘messy and unkempt’. 2.5 An initial  post-mortem was held a few days later and its outcome on the cause of death was       inconclusive, although it stated that ‘foul play’ was unlikely. 2.6 Given the uncertainty about the cause of Noah’s death, and the considerable amount of multi-agency involvement with the family, the case was referred to the Wirral Safeguarding Children Partnership Case Review Committee who undertook a rapid review to determine if a statutory Child Safeguarding Practice Review1 (CSPR) should be undertaken. The committee unanimously agreed that CSPR should be undertaken given that Noah had died and there were a number of concerns about the functioning of his family and his parent’s ability to keep their children safe. There was also a concern in this case about the decision to step outside of the SUDIC protocol and how this was managed.  2.7 The Child Safeguarding Rapid Review National Panel agreed with the decision to proceed with a CSPR. The CSPR was completed in December 2022. CSPR Terms of Reference 2.8 The Wirral Safeguarding Children Partnership agreed that the CSPR should consider: • the history and effectiveness of multi-agency working with the family, and in particular the parents’ capacity to change, and support for caring with children with disabilities  • the application and management of the SUDIC protocol • the potential impact of Covid-19 lockdowns and the family’s visibility • the effectiveness of the multi-agency response to domestic abuse • the effectiveness of the multi-agency response to alcohol abuse • whether neglect was a feature in this case, and if so how it was responded to __________________________________ 1Child Safeguarding Practice Review (CSPR). A CSPR should be undertaken in circumstances where a local authority knows or suspects that a child has been abused or neglected and the child dies or is seriously harmed. The purpose of a CSPR is to establish what lessons can be learned in a case to strengthen safeguarding arrangements to reduce the risk of similar incidents occuring. Wirral Safeguarding Children Partnership                Page 4 CSPR Methodology 2.9 The approach for completing CSPR’s is based on the Social Care Institute for Excellence   Learning Together methodology2 which involves the gathering of information from agencies        involved in the case and consideration on decision making—why certain decisions were made at the time and consideration of the family’s daily lived experience and whether there were any     additional stressors on the family.  2.10 The methodology also includes the identification of key practice episodes. These are single events, or events over a period of time which had a significant influence on how the case unfolded, and particularly on the quality of safeguarding practice.  2.11 Consideration of key practice episodes also provides a window into the wider safeguarding system and can help identify weaknesses in the system which need to be addressed.  2.12 The views of the family were also gathered as part of the review process. 2.13 It took the WSCP longer than it usually would to gather and analyse all of the information   relevant to this review, due to delays caused at the start of the review process due to the impact of Covid-19 which restricted the access to and availability of multi-agency staff. However, as    learning was identified it was shared and a number of changes were made to policies, practice and strategies as a result. 2.14 The WSCP is aware that the tragic death of Noah was not caused by abuse or neglect or    related to other safeguarding concerns. However, the review was completed to determine    whether it would reveal opportunities to strengthen the safeguarding system, particularly in      complex cases where numerous concerns or issues are present.  Key Practice Episodes 2.13 Four key practice episodes were identified and considered as part of this review are: • How effective was multi-agency working with this family, in particular in relation to:   - Neglect and home conditions   - Domestic abuse, parental conflict and their relationship   - Safeguarding children with disabilities   - Parental alcohol abuse   - Non-engagement and disguised compliance • Was the SUDIC protocol correctly applied in this case? • Did the parent’s have the required capacity to change to ensure the safety and wellbeing of their children? • To what extent did the Covid-19 crisis impact either on the circumstances of the child or   family or on the capacity of the services to respond to their needs?  __________________________________ 2Learning Together Methodology Developed by the Social Care Institute for Excellence (SCIE), the Learning Together Methodology provides a  framework for under-taking Child Safeguarding Practice Reviews where the identification of learning to strengthen safeguarding arrangements is key Wirral Safeguarding Children Partnership                Page 5 Context What was known about the Family? 3.1 Noah came from a large family and he lived at home with his mother and two older siblings in a terraced house in Wallasey. Noah’s father lived in a flat a few streets away. Three older siblings had been adopted, and two others were in care. Family members all identified as white British. The family genogram is shown below:            3.2 Prior to the death of Noah there had been considerable involvement with the family by chil-dren’s social care and other services. Noah’s parents had previously had five children removed from their care due to longstanding issues of neglect, domestic abuse and alcohol abuse by the chil-dren’s father. At the time of Noah’s death there were three children living at home—Brother 3, Brother 4 and Noah.  3.3 At the time of his birth in 2019 Noah was subject to a child protection (CP) plan for emotional abuse; the same plan that also applied to his siblings (brothers 3 and 4). In October 2019, when Noah was 6 months old the CP was ended and the case stepped down to child in need (CiN), and closed to children’s social care two months later when the case was stepped down again to team around the   family (TAF). The step down to CiN and then to TAF were prompted by reported improvements in the functioning of the family, particularly in respect of the parents relationship and Noah’s father’s     alcohol misuse. The agreed actions related to the parents accessing counselling and attending parenting courses. The children remained in TAF for the next 19 months, despite issues of domestic abuse,  compromised parenting, home conditions and alcohol misuse continuing.  3.4 Shortly before Noah’s death another initial child protection conference (ICPC) was arranged in    respect of brother 3 following him receiving a non-accidental injury from an incident where he was grabbed by his father. This later resulted in both brothers 3 and 4 being placed on a CP plan for the third and second times respectively. 3.5 In May 2020 the children came under the care of the Children with Disabilities team—brother Wirral Safeguarding Children Partnership                Page 6 35 Noah’s Mother Noah’s father—doesn’t live at family home  38  14  2 12 10 Brother 1 CLA  13  6 7  4 Brother 2 CLA Sister 1 Adopted Sister 2 Adopted Sister 3 Adopted Brother 3 At Home  Brother 4 At Home  Noah Born April 2019 Died May 2021   3 has a diagnosis of epilepsy, ADHD and global development delay, and brother 4 has a diagnosis of global development delay and has difficulties with expressive and receptive language. The children’s mother is their carer.  3.6 As well as significant children’s services involvement the family also received a lot of input from  universal and specialist health services. The majority of the interventions were in response to the acute health needs of brothers 3 and 4. Brother 3’s epilepsy and his tendency to have seizures   almost daily prompted a number of 111 and 999 calls to the ambulance service during the review period. 3.7 The boys were also under the care of a number of clinics and as a result had to attend a      considerable number of out-patient appointments, but there is evidence that they were not always taken to those appointments. In the period covered by the review, brother 3 was not taken to 9 scheduled health appointments, and both brother 4 and Noah missed 3 each, all without explana-tion. From March 2020, the impact of Covid-19 led to their being fewer health appointments and most of those being  virtual. 3.8 Noah’s parent’s relationship was marked by a repeating pattern of being together, arguments and domestic abuse, splitting up and then getting back together again. This pattern appeared to   repeat in a cycle regardless of the level of intervention provided by agencies. During the period covered by the review there were 12 police call outs to the family home related to arguments and domestic abuse  incidents. The police also reported that since 2006 they had attended the family home 43 times. The police call outs were most often instigated by Noah’s mother and reflected the pattern of the parents falling out, splitting up and then getting back together.  3.9 There is evidence from the chronology that the parent’s case was discussed at MARAC on a     number of occasions, but it is difficult to see what the outcome of these meetings were. It is clear from the chronology that the pattern of behaviour, including behaviour that would constitute     domestic abuse was not broken by any intervention, despite the children being stepped down and up between different levels of plans. It is acknowledged in a number of assessments that the parent’s pattern of   behaviour would not change until they started putting the needs of their     children before their own, again however, there is little meaningful evidence that any lasting      positive change happened. 3.10 Analysis of the combined chronology from agencies involved with the family revealed that    despite the significant level of involvement by different organisations there was a lot of evidence of non-engagement and likely disguised compliance by the parents. For example, Noah’s father’s      alcohol abuse was a recurring feature of this family’s life throughout the review period, and it was clear that he often under-reported his alcohol consumption or claimed abstinence at various      review meetings for his children despite evidence to the contrary.  3.11 It was also reported that Noah’s father engaged with Wirral Ways to Recovery (WWR)—a local alcohol treatment service, but the chronology shows that his engagement was cursory and his non-attendance at sessions was greater than his attendance. He was open to WWR for almost two years, and during this time he failed to attend 15 of the 26 scheduled appointments. 3.12 A less obvious, but still significant pattern of non-attendance at health appointments by Noah’s mother was also apparent. Wirral Safeguarding Children Partnership                Page 7 3.13 Despite the level of multi-agency involvement, with the family, including the level of interven-tion quickly stepping down from child protection, to child in need, and then to team around the family, there is limited evidence that following the step-down/ step-up pattern, Noah or his siblings lived experience, or the parenting ability of his parents significantly improved. The Incident 4.1 Noah was found to be unresponsive by his mother, lying in his bed, some time after 9am on the 29th May 2021. An ambulance was called at 9.27am and arrived seven minutes later, with the police arriving shortly afterwards. Noah’s mother was attempting CPR but the attending paramedics quickly diagnosed that Noah had died. 4.2 Merseyside Police took a history from the parents—Noah was put to bed at 7.00pm and was heard awake at 8.00pm. He had been poorly a couple of weeks earlier and had been on a course of antibiotics since but he seemed fine when he went to bed. The police then declared the house a potential crime scene and requested that Noah be viewed ‘in situ’. This meant stepping outside of the SUDIC procedure which caused some confusion, as ordinarily the child’s body would be              immediately taken to the local Arrowe Park hospital and examined by a consultant paediatrician—whether the death was immediately suspicious or not. In this case the senior investigating officer (SIO) requested that Noah be taken to Alder Hey hospital in Liverpool. In the event he was taken to Arrowe Park, but much later in the day.  4.3 Police suspicions had been raised both by the position of Noah and that he had blood and saliva around his mouth, and because Noah’s father was present in the house—although his mother had agreed not to let him be there, and there had been al allegation that his father had caused a non-accidental injury against brother 3 a few days earlier, which was going to result in an Initial Child Protection Conference (ICPC) being held.  4.4 The attending police also described the house as ‘messy and unkempt’. 4.5 Noah was transported from Alder Hey to Arrowe Park hospital later the same day and he was then examined by a consultant paediatrician. The paediatrician noted that there was no external bruising, but as the parents were not present –following the suspicions of the police– a recent medical history could not be taken. 4.6 A post-mortem was held on the 3rd June and the outcome was inconclusive, although it stated that there was no evidence (no head injuries or marks)  to suspect “foul play.”  Further tests were to be completed to see whether Noah may have had undiagnosed epilepsy, as brother 3 had the condition. Noah’s cause of death remained unknown until November 2021 when a conclusion was reached that he had died due to a respiratory tract viral infection, and had therefore died of natural causes. Following this finding no further police action was pursued. 4.7 Following the incident on the 29th May agencies responded quickly to safeguard brothers 3 and An immediate strategy discussion was held and the boys were placed in the immediate care of    maternal Aunt and Uncle who agreed to supervise any contact between the children and their parent’s.          4.8 Children’s social care also informed the older siblings who were currently living in foster care Wirral Safeguarding Children Partnership                Page 8 that Noah had died. 4.9 A follow up strategy discussion was held on the  4th June,  and at the meeting it was agreed that brothers 3 and 4 should be returned to the care of their mother, who was now living at her own mother’s address.  Analysis of Key Practice Episodes 1. The effectiveness of multi-agency working with this family, in particular in         relation to:   - Neglect and home conditions   - Domestic abuse, parental conflict and their relationship   - Safeguarding children with disabilities   - Parental alcohol abuse   - Non-engagement and disguised compliance 5.1 The five year period covered by the chronologies –and the years before that– featured a      considerable amount of multi-agency activity with the result that the children in the house travelled up and down Wirral’s continuum of need whilst their parent’s pattern of relationship behaviour deteriorated and improved in what became a predictable cycle. Despite the children often ‘stepping’ down from statutory interventions under a child protection plan into the child in need and team around the family arena’s, and then stepping back up, there is little evidence that their outcomes improved. At the time of undertaking this review, brothers 3 and 4 have both returned to being placed on child protection plans. Understanding the extent and wider impact of the      repeated step-up and step-down of cases forms one of the recommendations from this review. 5.2 There are a number of recurring themes in the chronology which seem not to have been          addressed in any sustainable way. These include: • Neglect and Home conditions. Poor home conditions is a sign of neglect. In this case concerns about home conditions were periodically raised  throughout the review period, most latterly by the police on the 29th May when they described the house as ‘messy and unkempt’. However, there is no evidence that any professional used or considered using the Graded Care Profile2 (GCP2) tool to provide an evidence based assessment of the home conditions which can inform an assessment and provide a framework to help parent’s       improve their care, before May 2021.  • The GCP2 is the agreed multi-agency tool and the WSCP expects it to be used in all cases of known or  suspected neglect. This finding also informs one of the recommendations. • Domestic abuse and parental conflict are recurring themes throughout the review     period, and neither appear to have been satisfactorily addressed. The relationship between the parents has followed a pattern of being settled, and then marked with arguments, conflict and domestic abuse often associated with Noah father’s drinking. This has always invariably Wirral Safeguarding Children Partnership                Page 9 led to the parent’s splitting up, and after a short amount of time they get back together and the cycle begins again. During the review period there were many police call outs to the house and it wasn’t uncommon for very serious allegations to made, including an allegation of rape which was later withdrawn. • Professionals from a number of agencies have commented on the repeated pattern of the parents splitting up and getting back together, but the mutually dependent nature of the     relationship has never been fully explored or understood, despite the high level of interven-tion with the family over the years. There is a clear link between Noah’s father’s alcohol    misuse and domestic abuse and the breakdown of the relationship, but there is no evidence that this was challenged by any professionals, nor that his disguised compliance towards     professionals was challenged. • There were a number of referrals to MARAC, and the Family Safety Unit over the course of the review period, and these often resulted with an offer of support to Noah’s mother.   However, the interventions were not based on a clear understanding of the dynamics of the parent’s relationship. Noah’s mother openly admitted that she struggled to look after all the children when she was by herself, and relied on his father for support. Until that reliance was assessed and understood the pattern of parenting behaviour would continue. There is a wide body of research about the negative impact on children of being in a house where domestic abuse exists, but this doesn’t appear to have been considered as part of plans made. • Alcohol misuse by Noah’s father is another recurring theme throughout, and before  the review period. It is clear that his engagement with Wirral Ways to Recovery was cursory at best and illustrates a clear example of disguised compliance. Over the course of the review Noah’s father used alcohol almost on a daily basis—with some of his consumption being self-reported as very high—between 10 and 14 cans of alcohol daily. • His pattern of attendance and engagement with Wirral Ways was good at times, but at other times was very poor so it was difficult for the service to know whether or how much alcohol he was consuming. Noah’s father also often self-reported that he was abstaining from alcohol or drinking very little, but these reports were difficult to verify, and the later evidence of him having been involved in a domestic abuse incident whilst intoxicated would suggest that he was regularly untruthful. Assessments recognised that his drinking was an issue, and rightly recorded progress when he agreed to work with Wirral Ways, but the plans that followed were not robust enough to be assured of positive and sustained progress over time. • Disguised compliance can often be challenged, or be a more difficult strategy for individuals to use, when practitioners maintain a heightened sense of professional curiosity. During the review period the WSCP has sought to develop its current model of practice into a systemic practice model with a focus on relationship based practice. This type of approach to working with families, which by definition includes understanding the family’s context and their        relationships, including those with professionals, can help prevent difficulties with engaging with families or issues such as disguised compliance, and instead help form a strong trusted relationship. Wirral Safeguarding Children Partnership                Page 10 2. Application of the SUDIC protocol 5.3 The SUDIC protocol3 in use at the time of the review was the pan-Merseyside protocol         published in June 2020. The protocol is a minor update of an earlier version, and there has been a SUDIC protocol in Merseyside since September 2002. The protocol is overseen by the Merseyside CDOP which is a thriving multi-agency group. It is a fair assessment to believe the SUDIC protocol would be well known and well understood across agencies in Merseyside, especially the key     agencies of LA’s, health partners and the police. 5.4 The local protocol sets out the steps to be taken following receipt of a notification of the death of a child. Importantly the protocol also states that in all cases of sudden unexpected death,    whether immediately suspicious or not, the protocol is to be followed unless HM Coroner         determines otherwise.  5.5 In this case the senior investigating officer (SIO) from Merseyside Police requested that Noah be taken to Alder Hey hospital in Liverpool, rather than Arrowe Park hospital in Wirral. The SUDIC protocol had already been triggered which meant Arrowe Park hospital were expecting Noah to arrive there, where he would be examined by a consultant paediatrician and arrangement would be made for his family to visit him. Equally staff from the North West Ambulance Service were also expecting to convey Noah to Arrowe Park. In the event, Noah was taken to Alder Hey hospital, and was later taken to Arrowe Park, however, it was unsatisfactory that this was delayed or that the protocol had not been followed.  5.6 The SUDIC protocol is clear that when a child has died they should be taken by ambulance to hospital where they will be examined by a consultant paediatrician. The protocol is less clear about which hospital as it only states ‘local’ hospital. Noah was examined at Alder Hey, but as his parents were not present, no accurate history could be taken. 5.7 Wirral resident children would be expected to be taken to Arrowe Park Hospital, but this is largely by convention rather than explicitly stated in the protocol. There is a recommendation from this review about updating and being explicit with expectations in the protocol.  3. Parent’s capacity to change 5.8 Parent’s capacity to change is a central part of this case review. Without the capacity or the necessary will to change it will be impossible for any family to change their pattern of behaviour, and improvements will only likely be possible through long term the intervention of agencies. In this case the daily lived experience of the children and their outcomes were at their most positive when their parents relationship was settled. That in turn relied on there being no parental conflict or domestic abuse incidents, which in turn relied on Noah’s father not drinking.  5.9 Professionals were aware of the precarious nature of this families context, and as a result a hight level of support was often in place to support them. __________________________________ 3Merseyside Sudden Unexpected Death in Childhood (SUDIC) Joint Agency Protocol (June 2020). The SUDIC protocol sets out the multi-agency steps to be taken to investigate all sudden and unexpected deaths of children in Merseyside. https://www.wirralsafeguarding.co.uk/wp-content/uploads/2020/07/SUDiC-0-18-YEARS-FINAL-23.6.2020.pdf  Wirral Safeguarding Children Partnership                Page 11 5.10 At  multi-agency meetings the parents, Noah’s mother in particular, spoke positively about wanting to create and maintain a safe and happy environment for the children. It was doing this in practice that proved most challenging. The review has illustrated the repeated patterns of           behaviour by the parents and that unless or until the underlying causes of their dysfunctional       relationship are addressed they are unlikely to have the capacity to change, and the current pattern will likely continue. It can be seen in this case that when support has been withdrawn and the cases has stepped down and then closed, then things have started to deteriorate and only improve by the                 re-introduction of services. 5.11 Breaking this cycle is a challenge for agencies, and moving forwards they will need to consider all the options open to them to ensure the best possible outcomes for the children. Whilst        professionals should always hope for the best in their work with parents and families, they should still plan for the worst—balancing optimism with realism, and understand that there will be families who require constant support.  4.  Impact of Covid-19 5.12 In their feedback to support this review most agencies stated that the lockdowns and changes to service provision as a result of Covid-19 had undoubtedly had an impact on the family as fewer face to face services were available, and work such as the use of staff to visit the family home and support the children could not be utilised. A number of key meetings such as TAF meetings were held virtually rather than face-to-face.  5.13 However, agencies also reported that in this case the impact on the family was minimised    because brothers 3 and 4 were offered (and used) places at school and nursery throughout the     pandemic, support from children’s services and the children with disabilities team continued, and the boys mother still utilised 111 and 999 whenever she had medical concerns about the children. 5.14 Covid-19 did, however prevent access to some services, for example the school were keen for Safe Families to undertake work with the family, but due to the lockdowns they were unable to allocate a volunteer. Other courses such as parenting support courses which were run face-to-face couldn’t operate during the pandemic.  5.15 The pandemic meant that many NHS staff were redeployed to support the NHS acute        services. As a result the 0 to 19 service stopped attending Team Around the Family meetings,   however, the Health Visitor in this case did continue to attend for as long as they possibly could. Health colleagues also stated that the impact of the pandemic was minimal as Noah’s mother      attended Arrowe Park hospital numerous times for appointments for herself, and the children, and also attended the Emergency Department on numerous occasions to access health services. 5.16 Holding online/ virtual meetings instead of face-to-face meetings also caused issues, for         example on one occasion Noah’s mother stated that she was in the barbers with the children    during one meeting and even though she felt it was ok to continue it clearly was not appropriate. 5.17 It was clear that agencies did attempt to respond as best they could to the restrictions placed on them by the Covid-19 pandemic, and agencies did keep in contact as much as possible with the family, even though the opportunities for face-to-face meetings were limited. Wirral Safeguarding Children Partnership                Page 12 Strengthening Safeguarding Arrangements 6.1 Child safeguarding practice reviews are primarily tools to help improve the quality of practice and the strength of local and national safeguarding systems by identifying issues and obstacles which prevent children, young people and families being as safe as possible.  6.2 This review has highlighted that in many families there exists a complex mix of issues which   interact with each other in difficult to predict ways. It can be very challenging for agencies and     individual professionals to unpick the issues in a particular family and to understand the complex interactions. 6.3 As part of the review, agencies were asked to identify learning from this case for their own agency, and learning for the wider partnership. A summary of responses is set out in the tables     below.  Wirral Safeguarding Children Partnership                Page 13 Single-agency Learning • Considering the repeated patterns of behaviour and history of the case warning signs could potentially have resulted in escalation at an earlier stage  • Analysis if the chronology indicate some potential aspects of neglect e.g. frequent attendances at urgent care which need to be flagged at supervision • No evidence of Graded Care Profile being completed by our staff • Ensuring step up and step down arrangements are robust and include details of repeating patterns of    behaviour which negatively impact the children’s daily lived experience Multi-agency Learning • Consideration needed of the level of support given to victims of domestic abuse who repeatedly resume relationships with perpetrators. In this case Noah’s mother appeared to ‘get back’ with his father as a source of child support • The case indicates that Noah’s mother was anxious about her children’s health and may have required further support • No evidence of use of Graded Care Profile is assessment of neglect. Suggests better promotion and  oversight of use of the tool is required • Records show significant social care involvement and improvements made when support is in place but improvements often lost once support is withdrawn. Indicates need to review how we deliver and        co-ordinate support for families with complex needs • The case indicates we need better use of professional curiosity with families, particularly in relation to disguised compliance 6.4 The reflections of agencies and the findings from the review highlight a number of ways in which the local safeguarding system can be strengthened: 6.5 In 2022 the Wirral Safeguarding Children Partnership (WSCP) resolved to strengthen its model of practice by introducing a systemic practice model as the next iteration of its Supporting Families Enhancing Futures (SFEF) framework. The systemic practice model builds on the central core of SFEF—to understand the daily lived experiences of children and adults in the household, by taking a relational practice approach to understanding what creates and drives those experiences.  6.6 As development and implementation of the model proceeds throughout 2023 the WSCP is confident that the practice model will provide a sound multi-agency framework and enhanced skills for professionals which will help them support and achieve positive outcomes for families affected by multiple issues and concerns, such as in this case. Over the next 12-24 months the WSCP will   continuously evaluate the impact of the model to improve outcomes. 6.7 The WSCP is also acutely aware of the impact the current cost of living crisis is having on    families locally. Recommendation: 6.8 For the WSCP to ensure all agencies and professionals have access to the training, resources and     support provided to the partnership for the implementation of the systemic practice model. Professionals should also have regular opportunities to contribute to the ongoing evaluation of the model. The WSCP should particularly focus on how the model supports families with complex and multiple needs and those living from multiple indicators or deprivation.   6.9 The review has illustrated how this case has travelled up and down the continuum of need from Child Protection, to Child in Need, to Team Around the Family, and back into Child in Need, and into Child Protection, and back down again into Child in Need and into Team Around the Family. What is less clear is how the outcomes for the children have improved as a result of these changes in plans over time. Therefore, it is important for the WSCP to understand the reasons for step-up step-down and the impact that is having on children and families. Recommendation: 6.10 For the WSCP to audit a selection of cases with a repeated pattern of step-up  and step-down      between early help and children’s social care. The audit should identify common themes and make         recommendations to be considered and actioned by the WSCP Executive 6.11 Parental conflict and domestic abuse were both features of this case and there were a number of referrals to MARAC. However, it isn’t clear from this case about how decisions are made at MARAC and how progress is monitored, or how MARAC relates to the wider system of support for victims of domestic abuse.  6.12 At times when Noah’s father wasn’t living at the home address it appeared that his mother had responsibility for ‘policing’ that he didn’t attend. There was no evidence she was able to do this, but there was evidence that agencies were aware her regularly stayed, and there appeared to be no consequences of this. Therefore it is recommended that the WSCP review MARAC to    Wirral Safeguarding Children Partnership                Page 14 understand its role and impact and to identify any changes to improve outcomes for families. Recommendation: 6.13 For the WSCP to examine the role of MARAC and how wider support for victims of domestic abuse is managed, particularly for those who remain or return to abusive relationships 6.14 Neglect is a common feature of case reviews, and recent reviews in Wirral have led to the development of a new multi-agency strategy to combat neglect. The strategy is due for implemen-tation in the spring and includes a multi-agency delivery plan focusing on supporting professionals to recognise and respond to neglect, but also to measure the impact of their interventions. It isn’t proposed to repeat that in this review, but to use the findings from the review to reinforce the  importance of the use of evidence based tools such as the Graded Care Profile 2 in the assessment of neglect.  6.15 This case includes numerous references to home conditions, most often with a subjective    description such as ‘poor’ or ‘improving’. The Graded Care Profile provides an evidenced bench-mark which can inform plans and also help measure change and its use in cases like this with long term concerns about neglect is very important. Recommendation: 6.16 For the WSCP to ensure the use of the GCP2 tool in all cases of suspected or known neglect,        including repeated concerns about home conditions, and to understand its limited use  6.17 Disguised compliance was a feature of this case and it was closely linked to parental alcohol abuse and Noah’s father’s attempts to minimise his alcohol consumption by partially engaging with services. There is already a recommendation about supporting systemic practice, but it is important that the WSCP ensures it is offering clear guidance and training to professionals about identifying and responding to disguised compliance, and building confidence in being professionally curious. Recommendation: 6.18 For the WSCP to highlight the features and impact of disguised compliance and parental alcohol     misuse  6.19 The review has shown how the SUDIC protocol was not followed in this case, but also high-lighted that the pan-Mersey guidance can be misleading on a borough basis. Therefore, it is        important that the protocol clearly sets out the multi-agency steps to take in Wirral, and partners are assured their staff know the local pathway. Recommendation: 6.20 For Merseyside CDOP to update the SUDIC protocol so it explicitly sets out the local  process Recommendation: 6.21 For Merseyside Police to consider whether further training and resources are required for officers who Wirral Safeguarding Children Partnership                Page 15 may attend a scene where a child has unexpectedly died 6.22 As well as multi-agency learning the review has also identified learning for individual agencies. The WSCP should ensure itself that all agencies who were involved in this case have identified learning which will be taken forwards to help strengthen practice. Recommendation: 6.23 For individual agencies involved in the review to develop their own learning action plan and to share regular progress with the WSCP case review committee until all actions have been completed  Summary of Recommendations 7.1 Eight recommendations are made to the WSCP as a result of this review:  1) For the WSCP to ensure all multi-agency professionals are aware of, and have access to    training and resources for the systemic practice model  2) For the WSCP to audit a selection of cases with a repeated pattern of step-up  and step-   down between early help and children’s social care. The audit should identify common    themes and make recommendations to be considered and actioned by the WSCP Executive  3) For the WSCP to examine the role of MARAC and how wider support for victims of    domestic abuse is managed, particularly for those who remain or return to abusive      relationships  4) For the WSCP  to ensure the use of the GCP2 tool in all cases of suspected or known    neglect, including repeated concerns about home conditions, and to understand its limited    use (also identified in previous reviews)  5) For the WSCP to highlight the features and impact of disguised compliance (also identified   in a recent review) and parental alcohol misuse on safeguarding children  6) For Merseyside CDOP to update the SUDIC protocol so it explicitly sets out the local    process  7) For Merseyside Police to consider whether further training and resources are required for   officers who may attend a scene where a child has unexpectedly died  8) For individual agencies involved in the review to develop their own learning action plan and   to share regular progress with the WSCP case review committee until all actions have been   completed.  Wirral Safeguarding Children Partnership                Page 16 Appendices 1. Partner organisations involved in the review 8.1 The following agencies participated in this rapid review: • Local Authority Children’s Social Care Services • Health services including the Wirral University Teaching Hospital NHS Foundation Trust,  Wirral Community Health and Care Foundation Trust, Cheshire and Wirral Partnership NHS Foundation Trust, GP, and Wirral Ways to Recovery alcohol treatment service • Merseyside Police  • North West Ambulance Service • Somerville Nursery and Elleray Park School (in respect of siblings)  2. References 8.2 Documents and resources referenced in the review: • Developed by the Social Care Institute for Excellence (SCIE), the Learning Together Method-ology provides a framework for undertaking Child Safeguarding Practice Reviews where the identification of learning to strengthen safeguarding arrangements is key: https://www.scie.org.uk/publications/reports/report19.asp   • Pan Merseyside SUDIC Protocol: https://www.wirralsafeguarding.co.uk/wp-content/uploads/2020/07/SUDiC-0-18-YEARS-FINAL-23.6.2020.pdf  • Working together to safeguard children (2018): Statutory guidance on inter-agency working to safeguard and promote the welfare of children. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2          David Robbins March 2023 Wirral Safeguarding Children Partnership                Page 17 