Disclosures of sexual and physical abuse by three children in M family against their mother's partner on 23rd September 2020. The family moved to the local authority area on 1st October 2020. Learning themes include: information sharing protocols between local authorities; risk assessment including the risks that may be posed by male care givers/household members; children living in households where domestic abuse exists; lived experience of the child; victim support, including timely and appropriate support for children who have been victims of or are at risk of child sexual abuse; working with families unwilling to accept support; support for practitioners. Recommendations include: children's social care services should ensure that when a child or family moves into the area, and a request is made for case responsibility to be taken on, a request is made for information outlining historical involvement with children's social care, and the provision of this information is robustly challenged where appropriate; compile a template for use by practitioners within their assessments which prompts for the consideration of all family members and their roles within a unit and their relationships with one another; hold a facilitated workshop with frontline practitioners from police, health, children's social care and education to enable the partnership to explore good practice and better understand the barriers to capturing and using the voice of the child; gain the feedback of frontline practitioners within their agencies regarding the possible barriers to working with families who refuse support or display a reluctance to engage with services.
      
 Title:  Child safeguarding practice review ‘M family’. LSCB: Cambridgeshire and Peterborough Safeguarding Children Partnership Board Author: Hannah Thorpe 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.                             Cambridgeshire and Peterborough Safeguarding Children’s Partnership Board  Child Safeguarding Practice Review ‘M family’ 2023               Report by: Hannah Thorpe, Practice Improvement and Development Lead    Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 2 | P a g e  Contents 1. Introduction ........................................................................................................................................ 3 2. Methodology ...................................................................................................................................... 4 3. Scope of the review ............................................................................................................................ 5 4. Contact with family members............................................................................................................ 5 5. Summary of Agency Involvement ...................................................................................................... 6 Key events in 2018 6 Key events in 2019 6 Key events 2020 9 6. Analysis ............................................................................................................................................. 13 1) How were risk and protective factors identified, assessed and managed within the family? This includes consideration of how agencies worked with “hard to engage” families. 13 2) How did practitioners and agencies that had contact with the family, work together to safeguard the children? 18 3) How well did agencies identify and respond to signs of child sexual abuse? Once the allegation had been made were the children adequately supported? 20 4) How was the voice of the child recognised and responded to within the case? 23 5) Did Covid have an impact on the safeguarding and support for the children? Did  Covid and home working impact on the way in which agencies communicated with each other? 24 6) Can you identify any areas that you consider to be good practice? 26 7. Key areas of learning: ....................................................................................................................... 27 8. Recommendations ........................................................................................................................... 28 Appendix 1 – Genogram ....................................................................................................................... 30 Appendix 2 – Chronologies .................................................................................................................. 30     Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 3 | P a g e  1. Introduction The following children are the subjects of this review: Alice: female, aged six years in April 2018 when the family moved to Cambridgeshire Oliver: male aged five years in April 2018 Claire: female aged three in April 2018 Alfie: male born May 2020 The following adults are frequently referenced through the review: Mother: biological mother to all four children  Ben: partner to mother and biological father to Alfie Liam: ex-partner to mother and biological father to Claire David: ex-partner to mother, biological father to Alice and Oliver A genogram of the family is included at the end of this report. All of the four children are of white British heritage. None of them have any diagnosed additional health or learning needs. Mother and her three children: Alice, Oliver and Claire initially resided in Suffolk before moving to Cambridgeshire in April 2018. Prior to her relationship with Ben, mother had been in a relationship with Liam, who is the father of Claire. During the time that the family resided in Suffolk and mother was in a relationship with Liam, concerns were noted relating to Liam which included perpetration of domestic abuse against mother and physical abuse of the children. This resulted in Liam being charged with assault. Police records indicate that Liam received a suspended sentence for this offence and that a restraining order preventing Liam from contacting mother was also in place in 2017.  In June 2017 Liam was arrested and interviewed for breaching his restraining order. Mother informed Suffolk Police of indecent images on Liam’s mobile phone and that she had concerns relating to his behaviour towards Alice. A number of indecent images were found. He was interviewed in October 2017 whilst in prison for breaching the restraining order and later convicted of possessing indecent images of children in December 2018.  In February 2018, during the investigation into the indecent images, Alice was visited by a Suffolk Police Officer and Suffolk Social Worker. The decision was made that Alice had not disclosed any offences against her and therefore she would not require an Achieving Best Evidence (ABE) interview1. No further action was taken in investigating any sexual offences against Alice by Liam. Whilst this information falls outside of the time frame of this review, it was necessary to explore the information held by Police and Children’s Social Care in Suffolk at the time before the family moved to Cambridgeshire in order to understand what was known about possible risk to the children when they moved to Cambridgeshire in April 2018.    1  Achieving Best Evidence in Criminal Proceedings Guidance on interviewing victims and witnesses, and guidance on using special measures March 2011 https://www.cps.gov.uk/sites/default/files/documents/legal_guidance/best_evidence_in_criminal_proceedings.pdf   Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 4 | P a g e  Alice, Oliver, and Claire had been supported by Children’s Social Care in Suffolk under a child protection plan from July 2017 to March 2018 when the decision was made to support the family under a child in need plan. This decision was made based on the progress that mother had made regarding her insight into violent relationships and the children were also doing well in school and nursery. Liam had been released from prison but was residing in a bail hostel out of the area and mother was actively seeking to move the family to Cambridgeshire to safeguard the children. Mother was, by March 2018, in a relationship with Ben. When the family, consisting of mother, Alice, Oliver, Claire, and Ben initially moved to Cambridgeshire they were supported under Early Help as risk to the children from Liam was believed to be low. Following a Section 47 enquiry2 in July 2018 as a result of disclosures of child sexual abuse by Alice, the children were supported under a child in need plan, until December 2018.  In April 2019, Alice made disclosures that Liam had sexually abused both herself and her sister Claire. A section 47 enquiry commenced, and Suffolk Police also opened a criminal investigation into Liam. Children’s Social Care reported that mum failed to engage with the child in need plan and as a consequence the case was closed in June 2019. In August 2019, another section 47 enquiry commenced as mother reported that Alice had made a disclosure of sexual abuse against Ben. However, a week later mother called Police to inform them that Alice had amended her account of what happened with Ben and as a result the decision was made that there was not enough evidence to pursue a criminal investigation.  All three of the children were then placed on child protection plans: Alice under the category of sexual abuse, Oliver and Claire under the category of neglect, until August 2020 when they were offered support under child in need processes.  In September 2020, Alice and Claire made disclosures of sexual abuse by Ben, and Oliver made disclosures of physical abuse by Ben. A further section 47 investigation commenced and a criminal investigation by Cambridgeshire Police was opened. In October 2020, interim care orders for all of the four children were sought and granted and the children were placed with their maternal grandmother, with whom they continue to reside. The police investigation into possible offences committed by Ben against Alice, Claire and Oliver was closed in June 2021 with no further action being taken.  2. Methodology Following the referral for a Child Safeguarding Practice Review (CSPR) having been received, a rapid review was undertaken. The case was discussed at a CSPR Subgroup meeting on 17th November 2020. Those partner agency representatives in attendance determined that the threshold for a review had not been met and this decision was submitted to the National Panel.3 On 23rd November 2020, a response was received from the National Panel:  2A Section 47 enquiry means that CSC must carry out an investigation when they have ‘reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm’ Section 47 of The Children Act 1989 https://www.scie.org.uk/publications/introductionto/childrenssocialcare/childprotection.asp  3 Child Safeguarding Practice Review Panel  https://www.gov.uk/government/organisations/child-safeguarding-practice-review-panel/about  Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 5 | P a g e  “We noted your decision not to undertake a local child safeguarding practice review (LCSPR). However, based on the information provided, it was our view that there is important learning to be drawn from this case.  It is our view that you should consider commissioning an LCSPR into this case.”  The case was reconsidered at a panel meeting on 26th January 2021, and it was agreed following this that a child safeguarding practice review which would consider all four of the children should be undertaken. Relevant agencies were then required to complete a “key events” chronology which included all four of the children. Once completed these chronologies, were combined into a single composite chronology. The chronology was used as the basis for two virtual multi-agency information gathering events with the chronology authors from the relevant agencies. Those present at these meetings were asked to consider the information within their own agency’s chronology and to participate in an in-depth case discussion regarding the safeguarding issues surrounding the children in the timeframe of the review, which is outlined below. The aim of this discussion was to extract learning and good practice relating to the whole family in order that practice might be improved across the safeguarding children workforce.  A multi-agency practitioner information gathering event was also held which took place virtually and included those practitioners who had worked with the family both during and after the timescale of the review. The aim of this meeting was to explore and understand the context of practice within the timescale of the review as well as considering questions posed within the terms of reference from the practitioners' perspectives. These processes together have been the vehicle used for the review alongside discussion and evaluation of this report for accuracy. As such the analysis included within the report has been either provided by or confirmed with this multi-agency group of authors and practitioners. 3. Scope of the review This review aims to consider those events specifically related to safeguarding within the time period from: 30th April 2018 when the family moved to Cambridgeshire  To  1st October 2020. Disclosures were made by Alice, Oliver, and Claire against Ben on 23rd September 2020 therefore the timeframe covers the action taken by agencies immediately following this event. 4. Contact with family members.  As with all child safeguarding practice reviews, it is important to gain the views of the families of the subjects of these reviews. Contact has been made with mother and maternal grandmother, who now has care of all four children under a Special Guardianship Order. Neither party felt able to take part in the review at that time. It is recognised that as a result, the voice and perspective of the family members who are the subject of this review is not directly included. The lived experience of the children has been considered within the agency records presented as part of this review and explored via the multi-agency information gathering events. Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 6 | P a g e  5. Summary of Agency Involvement Key events in 2018 On the 8th of May 2018, a transfer request from Suffolk Children’s Social Care was made to Cambridgeshire Children’s Social Care. On the same date, the Suffolk Health Visitor provided a verbal hand over of information relating to the family to the duty Health Visitor for Cambridgeshire. On the 22nd of May 2018, a decision was made in the Cambridgeshire MASH for the family to be supported under early help.  On the 16th of May 2018, a high-risk MARAC referral relating to Liam and the ongoing risk to mother and her children from him was received by Cambridgeshire Constabulary. Liam was at that time subject to a restraining order and suspended sentence order. A DASH (domestic abuse, stalking and harassment) risk assessment was completed and recorded as high risk, which triggered support from an Independent Domestic Violence Advocate (IDVA). Despite attempts, the IDVA was unable to contact mother. On 1st of June 2018 a decision was made by a manager in the Early Help Hub to close contact down as mother suggested that her situation had improved and the actions from the child in need plan transferred from Suffolk Children’s Social Care had been completed. A lack of professional curiosity was demonstrated as this information was taken at face value. On the 5th of July 2018, the children's maternal aunt contacted the emergency duty team (EDT) claiming that Oliver was not safe with mother. She suggested that mother’s partner was physically aggressive towards the aunt and that Oliver has disclosed physical abuse by his mother’s partner. A Strategy Discussion was held, and a section 47 inquiry was commenced, and the outcome was for the family to be supported under child in need processes as well as for a DASH to be completed.  On 23rd of November 2018 the decision was made to close the family’s case. It was recorded that the work mother and Ben had agreed to in September had been completed, albeit that Ben had not attended all of the sessions offered. Key events in 2019 On the 22nd of March 2019 Alice’s school made a referral to Children’s Social Care relating to physical abuse against Alice. The referral was closed with no further action because the information provided had come from a third party rather than a direct disclosure from Alice. Significant event: On the 3rd of April 2019 mother attended a police station in Cambridgeshire with Ben, reporting that Alice had disclosed sexual abuse by Liam, mother’s previous partner, between 2014 and 2016 while the family were living in Suffolk. Disclosures of abuse were also made by Oliver against Liam, and Alice also disclosed that she had witnessed sexual abuse against Claire by Liam. Risk assessments were completed within the multi-agency safeguarding hub (MASH) and the disclosures were referred to the Child Abuse Investigation Unit (CAIU) in Suffolk to arrange ABE interviews with the children as this was where the offences had taken place. Children’s Social Care records show receipt of communication from Cambridgeshire Constabulary about these disclosures and a face-to-face Strategy Meeting with Suffolk and Cambridgeshire Children’s Social Care representatives took place. A section 47 enquiry then commenced. This included a medical examination at the Sexual Assault Referral Centre and ABE interviews by Suffolk Police. Children’s Social Care spoke with Alice alone at school and determined that she should be supported under a child in need plan.  Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 7 | P a g e  On the 5th of April 2019, a Social Worker visited Alice at school and spoke with her alone. Alice repeated her disclosures to the Social Worker of sexual abuse against herself and Claire.  On the 18th of April 2019. Alice and Claire were seen at The Elms Sexual Assault Referral Centre (SARC) for medical examinations. There is no reason recorded by the Sexual Assault Referral Centre or Children’s Social Care as to why there was a delay in arranging this examination. No injuries or abnormalities were observed during examinations of either Alice or Claire. Medical reports were sent to the Social Worker and referrals made to the GP and to Addenbrookes Hospital for STI screening for both children. A three week follow up call was declined by mother. Children’s Social Care records show that an ABE interview was undertaken by Suffolk Police with Alice on the 7th of May 2019, in which she made ‘clear historical disclosures of child sexual abuse’. On the 10th of June 2019 Alice and Claire attended Addenbrooke's Hospital for sexual health screening and received all negative results. On the 17th of June 2019, Children’s Social Care concluded the single agency assessment and recommended that the case be closed. Mother had declined any further support for Alice and the school had agreed to signpost Alice to relevant support services if she showed signs of trauma from the historical sexual abuse. Significant event: On the 2nd of August 2019, Children’s Social Care received a referral from Cambridgeshire Police stating that mother had found Ben in bed with Alice and Alice was crying. When asked what had happened, Alice stated ‘it was the same as the other man’ which was interpreted to have been a reference to sexual abuse by Liam against her. Mother had called the Police and Ben had gone to his mother's address. A multi-agency Strategy Discussion took place and a section 47 inquiry commenced. A Sexual Assault Referral Centre (SARC) medical and an Initial Child Protection Conference were planned, and it is noted that the Senior Manager requested an urgent Legal Planning Meeting (LPM)4. Alice was spoken to on the same date by Cambridgeshire Police with the Social Worker present. Ben was arrested but denied the allegations and was bailed. The SARC examination took place later on the same date. Alice attended with mother and forensic samples were taken and a referral made for Alice to have support from a Children’s Independent Sexual Violence Advocate (ChISVA). No injuries or abnormalities were noted. On the 6th of August 2019, Children’s Social Care records show that a Legal Planning Meeting was held, but the threshold for proceedings was not deemed to have been met as mother had acted protectively in suggesting that Ben would not be allowed back into the family home. The plan was to continue with the Initial Child Protection Conference with increased monitoring.  On the 8th of August 2019, mother contacted Police to inform them that Alice had amended her previous account of what had happened on 2nd August to say she had been dreaming. A Police Officer undertook a home visit to see mother and Alice. During this visit, mother also told the officer that she wanted Ben back. The officer advised mother to wait and speak with  4 This is sometimes called a legal strategy meeting or a legal gateway meeting. The purpose of this meeting is to obtain advice as to whether the ‘threshold criteria’ for a care order under section 31 Children Act 1989 have been met. https://coppguidance.rip.org.uk/pre-proceedings/legal-planning-meeting/  Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 8 | P a g e  Children’s Social Care before allowing Ben back into the house. Mother did not follow this advice. On the 14th of August 2019, mother is recorded to have refused Children’s Social Care support for Alice. The recorded plan was for the Initial Child Protection Conference to take place and request a move to pre-care proceedings if there continued to be a lack of engagement from mother and Ben. An Initial Child Protection Conference was held on the 22nd of August 2019. The three children Alice, Oliver, and Claire were all placed on child protection plans: Alice for child sexual abuse and Oliver and Claire for neglect. David and the maternal grandparents both attended the meeting, but mother and Ben did not. It is stated within the records that a contingency plan of moving to public law outline, (PLO) may be used if mother and Ben did not engage with the children’s child protection plans. It was included within the child protection plans that Ben should not have been in the family home. The Social Worker attempted to complete a home visit following the conference to speak with mother and Ben as they had not attended the conference. The Social Worker received no response so no one was seen. On the 23rd of August 2019, Children’s Social Care received an email from mother stating that she was unwilling to work with the current Social Worker. A Legal Planning Meeting was again requested but the advice provided was that as support under the child protection plans had only just commenced, this should continue. On the 13th of September 2019, a Doctor from the SARC contacted the Social Worker expressing concerns that Alice had not been taken to her appointment for sexual health screening. She also stated that during Alice’s most recent attendance at the SARC, mother had disclosed that Ben had displayed coercive and controlling behaviour towards her in front of Alice. On the 24th of September 2019, mother and Ben met with the Social Worker within one of Children’s Social Care’s office bases. Ben expressed anger towards Alice for making disclosures of abuse against him. Mother informed the Social Worker that she was four weeks pregnant. The Social Worker discussed the case in supervision on the 25th of September 2019 and it was agreed that a request for a Legal Planning Meeting should be made again.  Children’s Social Care received contact from a Midwife on the 26th of September 2019, confirming that mother was eight weeks pregnant. Alice and Oliver were seen at school by the Social Worker and Child Practitioner on the 8th of October 2019. Alice disclosed physical and verbal abuse from mother and Ben. Oliver said that Ben ‘sleeps with Alice sometimes’ and that Ben ‘swears and shouts when mother is not around’. A Service Manager completed a request to move to public law outline (PLO). On the 23rd of October 2019, a PLO meeting was held with David who had expressed a wish to be the carer for his children. Separate PLO meetings were being held with the parents due to the negative relationship between David and mother and Ben.  A separate PLO meeting involving mother and Ben took place on the 5th of November 2019. The concerns for the children and the actions mother and Ben were expected to take were outlined, as well as the support proposed by Children’s Social Care. Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 9 | P a g e  CCS records state that a Core Group was held on the same date in which it was discussed that the police investigation relating to the disclosures Alice made against Ben had been closed.  The following day, the 6th of December 2019 education records show that Oliver informed school staff that Alice had been sent to her father’s address and no longer lived with mother and the other children. Mother emailed the school to confirm this information that Alice had moved to her father's address in Essex.  On the 11th of December 2019, the school received an email from mother requesting that Alice return to school as she had moved back into the family home.  Information from Cambridge Rape Crisis Centre indicates that Alice’s school contacted the charity on 16th December 2019 to inform them that Alice had returned to the school and requested that Alice’s referral be re-opened, having been closed because Alice had moved out of the area. Unfortunately, the counsellor’s slot had been reallocated by this time and Alice had to be placed back on the waiting list. A slot for a counsellor did not become available before March 2020 when the Covid-19 pandemic caused significant restrictions on daily activities in the UK. In response to the restrictions, the charity stopped all face-to-face work on 23rd March 2020. Remote or virtual counselling was not offered to children under 10 years. Face to face counselling commenced again in September 2020 but there was not an available counsellor to offer support to Alice, so she was placed on a waiting list. Key events 2020 On the 21st of January 2020, Alice attended Addenbrooke's Hospital with mother for sexual health screening. All tests were recorded as clear or negative. On the 14th of February 2020, a public law outline (PLO) meeting was held with David. At this meeting it was agreed that concerns had abated to the point where Children’s Social Care were no longer considering going to court. The children remained on child protection plans.  On the same day, a Friday, the school contacted Children Social Care to inform them that Oliver had disclosed to his teacher that mother had physically assaulted him. Oliver suggested he would like to be able to speak to the Social Worker alone. It does not appear from Children’s Social Care records that Oliver was seen alone by either the Child Practitioner or Social Worker in response to his disclosure. This was challenged by the school within their records but there is no evidence of a formal escalation of their concerns. On the 17th of February 2020, a PLO meeting was held. Ben and mother were both present, and it was agreed that the PLO process would end, and child protection plans for all of the children would continue. It is recorded at the PLO meeting that all of the suggested actions had been completed although there is no evidence recorded. On the 18th of February 2020, a home visit was completed by Children’s Social Care in response to Oliver’s disclosure of physical abuse. The children were seen but not alone. Oliver was recorded as having ‘no visible injury and not in pain’. Mother denied abusing him. Based on this information, it is recorded within the chronology that Children’s Social Care concluded that there was little evidence to back up Oliver’s disclosure. On the 20th of March 2020, the school attempted to contact mother to offer school places to Oliver and Alice in response to the COVID-19 pandemic which was resulting in the closure of schools across the country. Mother responded that she intended to send the children in each day to school. Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 10 | P a g e  On 23rd March 2020, the UK went into a nationwide ‘lockdown’ of restrictions to activities and travel because of the Covid-19 pandemic. These restrictions included the closure of schools to all pupils with a number of exceptions. These exceptions included children open to Children’s Social Care. On the same date, school staff again contacted the family, Ben stated that mother and the children were out, and the school agreed to make a welfare call to the family each day whilst the children were not attending school.  An unborn baby panel meeting was also held on this date, where the Midwife shared concerns relating to mother's emotional health and wellbeing.  On the 1st of April 2020, Children’s Social Care completed a statutory visit virtually as mother was, at the time, refusing face to face visits due to the risk of Covid 19. The children are recorded to have been seen but there is no evidence that they were spoken to directly. A Core Group meeting was also held on this date. Mother did not attend the Core Group. A discussion was held between the professionals present relating to the possibility of de-escalating support for the family to child in need at the forthcoming Review Child Protection Conference. The midwife and school representative disagreed with this and listed their concerns. The school recorded that they challenged Children’s Social Care’s response to Oliver's recent disclosure of physical abuse and reiterated concerns they had raised on multiple occasions previously relating to Oliver and Claire's consumption of food whilst at school. Mother's midwife communicated concerns regarding Ben’s consumption of alcohol and mother's emotional health, particularly given the current circumstances in relation to the Covid 19 pandemic. The children remained on child protection plans. On the 12th of April 2020, Children’s Social Care records indicate that mother contacted the emergency duty team (EDT) because Ben had been verbally abusive towards Alice, and she required assistance to remove Ben from the family home. Mother also called the police who attended. The children were all seen and spoken to by officers who recorded that the children were in good health. Ben claimed he was ‘under considerable stress due to lockdown, mother’s pregnancy and being furloughed’. It is recorded that there had been a similar incident on the 9th of April 2020, but it is unclear from the chronology whether Ben did leave the family home on either date.  A Review Child Protection Conference was held on the 22nd of April 2020. Concerns relating to physical abuse by mother and verbal abuse by Ben were recorded. In relation to the risk of sexual abuse, it is recorded that there was ‘no solid evidence’. Children’s Social Care appear from the school notes to be considering ‘stepping down’ the family to support under child in need processes. However, the CP chair, with agreement from the school and health representatives made the decision for the children to remain on child protection plans under the category of neglect. On the same date, mother sent a text message to her midwife stating that one of the children was displaying Covid 19 symptoms and therefore mother could not attend her antenatal appointment.  A Strategy Discussion was held on the 30th of April 2020 in relation to mother’s unborn baby. A unanimous decision was reached that the criteria had been met for an Initial Child Protection Conference for the unborn baby. It is recorded within the notes by Cambridgeshire Community Services in relation to this Strategy Discussion that the police had shared a view that Ben did not pose a risk of harm and that this information may have adversely influenced appreciation of risk by other agencies. Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 11 | P a g e  On the same date that Alfie was born, the police shared information with Children’s Social Care that Ben had been caught speeding in the early hours of the morning and his car had tested positive for cocaine. An Initial Child Protection Conference was requested.  A Hospital Discharge Planning meeting was held on the 11th of May 2020. It was agreed at this meeting that daily visiting would be completed by professionals to the family. Mother informed those professionals that she would be returning to Ben's parent’s home where the older three children had been staying whilst she was in hospital. The Initial Child Protection Conference was held on the 1st of June 2020 for Alfie, which fell significantly outside of the relevant timescales. There is no evidence of the reasons for this delay in Children’s Social Care records. Alfie was made subject to a child protection plan for neglect. Both mother and Ben attended the meeting and information relating to Ben's drug use was shared.  The 16th of June 2020 a home visit was completed by the Social Worker. Mother reported during this visit that her relationship with Ben had ended. Ben had taken Alfie to his parent’s house and that mother and Ben planned to share the care of Alfie. Mother accepted an offer of support from a domestic abuse worker and said she was unaware of Ben’s drug use. On the same date, mother contacted Police to request a lock change on her property. Locksmiths attended the property and called the Police when Ben arrived at the property. Police attended and the children were seen. A Domestic Abuse Stalking and Harassment (DASH) form was completed by officers and graded as standard risk. It is recorded within the Police chronology that no further action was required. Children’s Social Care show no record of the DASH being shared with them; however, Police records suggest DASHs with a ‘standard’ risk score were not being actioned because of increased pressures as a result of COVID-19. On the 1st of July 2020, there was recorded communication between the Social Worker and Health Visitor that Children’s Social Care were considering a Legal Planning Meeting. On the 21st of July 2020, mother made a call to the GP as she was concerned for Alfie as he was crying. She was not offered a face-to-face consultation with the GP. It is recorded within the chronology that the author of the GP chronology believed that this should have been a face-to-face consultation because Alfie was a young baby with siblings on a child protection plan. This learning has been noted by the GP safeguarding lead. On the same date mother informed the Social Worker and Health Visitor that she was no longer in a relationship with Ben. She disclosed that she had thought about self-harming. The children were present during this visit, but mother declined an offer of mental health support.  A Review Child Protection Conference was held on the 12th of August 2020. Ben was no longer present in the family home. Whilst a number of outstanding actions had not been completed, as the family’s situation had changed, i.e., Ben had moved out, new actions to support mother and Ben in parenting the children separately were set. It is recorded that relationships between mother and professionals supporting her were better at this point in time. Mother completed a mental health questionnaire. Alfie was doing well. Professionals stated at this meeting that they felt that Ben was a risk to the children, however mother stated that she was unsure whether she wished to continue being in a relationship with him. Mother accepted a referral to the Parenting Together programme and all present agreed that mother was acting protectively towards all four children without Ben in the family home. It was agreed unanimously that the children could be supported under child in need processes. Mother Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 12 | P a g e  suggested that she felt Ben should engage with CGL in relation to drug use if he were to see Alfie regularly. On the 2nd of September 2020, mother called the Police as Ben was in her property without permission. He had taken her phone and left but she had been concerned that Ben would take Alfie. The Police attended, the locks on the property were changed and a marker was placed on the address. A DASH form was completed by officers attending and shared with the multi-agency safeguarding hub. Mother was unwilling to provide a statement, so no further Police action was taken. This was communicated to Children’s Social Care on Friday 4th of September 2020.  On the following Monday, 7th of September 2020, the Social Worker sought advice from management within Children’s Social Care. The advice was for the Social Worker to discuss safety planning with mother and support her in seeking legal advice to secure an order preventing Ben from removing Alfie from the property. The Social Worker visited mother the next day and saw the children the following day, 9th September 2020. The children said that ‘daddy’ had left the house that morning for work. The Social Worker concluded that mother and Ben’s relationship status was unclear, but no further action is recorded. Significant event:  On the 23rd of September 2020, police records show mother contacted police to report that Alice had disclosed sexual abuse by Ben against herself, Oliver, and Claire. Mother had overheard Alice and Claire discussing Ben using language which was suggestive of them having been victims of child sexual abuse. Mother had called 999 when she heard Ben trying to get into the house. Alice and Claire both provided disclosures when spoken to by Police and a plan was made for ABE interviews to be arranged. A DASH form was completed and graded as high risk. Ben was arrested the following day and bailed.  A Strategy Discussion was held on the 24th of September 2020. It was agreed that a section 47 enquiry should take place, that Alice and Claire should receive a SARC medical examination, an urgent Legal Planning Meeting should be held and that the maternal grandparents should stay with the children. The maternal grandparents had been called by mother to the property. A joint visit was agreed between the Police and Social Worker and an Initial Child Protection Conference was planned. A SARC medical examination was booked for the 29th of September 2020. On the 25th of September 2020, a Legal Planning Meeting took place and there was a change of Social Worker. It was agreed at this meeting that the threshold for care proceedings had been met and a further meeting was scheduled for the 30th of September 2020. On the 29th of September 2020, Oliver made a disclosure at school to the Head Teacher that he had been physically abused by Ben and that Alice and Claire had been subjected to sexual abuse by Ben. Oliver also disclosed witnessing domestic abuse against mother by Ben. Oliver told the Head Teacher that he had told mother about the physical abuse and that he was concerned as to the repercussions of his disclosures on the family from Ben. On the 29th of September 2020, Alice and Claire attended The Elms Sexual Assault Referral Centre (SARC) for medical examinations.  On the 30th of September 2020, a review Legal Planning Meeting was held, and it was agreed that an assessment of the maternal grandmother, who was currently living with mother and the children, as the carer for the four children should be undertaken. On the same date, a Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 13 | P a g e  medical report from the SARC was shared with Children’s Social Care. Both examinations recorded no abnormal findings. On the 1st of October 2020, there was communication between the Health Visitor and Social Worker to confirm that permission to issue care proceedings had been granted. 6. Analysis  This section of the report aims to answer the following questions as posed within the Terms of Reference: 1) How were risk and protective factors identified, assessed and managed within the family? This includes consideration of how agencies worked with “hard to engage” families. 2) How did practitioners and agencies that had contact with the family, work together to safeguard the children?  3) How well did agencies identify and respond to signs of child sexual abuse? Once the allegation had been made were the children adequately supported. 4) How was the voice of the child recognised and responded to within the case? 5) Did Covid have an impact on the safeguarding and support for the children? Did Covid and home working impact on the way in which agencies communicated with each other? 6) Can you identify any areas that you consider to be good practice?  1) How were risk and protective factors identified, assessed and managed within the family? This includes consideration of how agencies worked with “hard to engage” families.  It is evident from the information gathered as part of this review that these were vulnerable children who had experienced trauma and adversity from a young age. This section highlights the importance of sharing information across service boundaries and the vital need for services to fully understand and assess the risks that may be posed by adult male care givers/ household members. Information sharing When the family, comprising of mother, Ben and the three oldest children, Alice, Oliver, and Claire, moved to Cambridgeshire in 2018, Suffolk Children’s Social Care contacted Cambridgeshire Children’s Social Care to request a transfer of the case. The family were being supported under child in need processes at that time and the minutes from the latest child in need meeting concerning the children were included with the transfer request. As it was clear within the information that the children had been subject to a child protection plan until the 15th of March 2018, it would have supported Cambridgeshire Children’s Social Care in assessing the family's needs if Suffolk Children’s Social Care had provided the assessment or conference report from the Review Child Protection Conference on the 15th of March.  The transfer of information relating to the family was received by the Early Help Hub in Cambridgeshire, where staff should have demonstrated a greater level of professional curiosity based on the information that the case had been ‘stepped down’ from child protection only days before the transfer was requested. There should also have been a more robust challenge Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 14 | P a g e  to Suffolk Children’s Social Care when additional information was requested but not received. The result was that the decision to support the family under Early Help was not appropriate. A thorough assessment of the children’s situation was then delayed as mother was unwilling to work with services at that time.  Learning point: Information sharing protocols between local authorities should enable the prompt sharing of information relating to children who are supported under child in need processes to ensure that full information is shared, and the process is robust.  Assessing the risks that may be posed by male care givers/household members.  It was clarified with Suffolk Children’s Social Care, that at the point of transfer Alice had not made any disclosures of sexual abuse against Liam or Ben. Mother had expressed concerns about Ben and his behaviour towards Alice, but at the time neither Police nor Children’s Social Care in Suffolk had explored this information beyond speaking with Alice at the time who had not made any disclosures. These concerns expressed by mother, and the resulting action, do not appear to have been shared with Cambridgeshire Children’s Social Care.  Suffolk Children’s Social Care, who were helpful in providing all the additional information requested for this review, agreed that whilst the transfer of information did detail the family’s situation and needs at that time, more information could have been shared to provide the historic context. Additionally, it appeared that whilst mother's new partner Ben, was mentioned in the information provided by Suffolk, his role within the family and his relationship with the three children did not appear to have been considered, nor was this sufficiently explored while the family resided in Cambridgeshire.  This resonates with other Child Safeguarding Practice Reviews undertaken in Cambridgeshire, where male family members have not been fully considered or included within assessments and interventions. It also reflects the findings of the National Panel’s report The Myth of Invisible Men which states:  ‘There is a need to involve fathers in direct work and to support men to be a better resource for the child in their care. Practitioners must help develop parenting strategies with them and explore issues such as how they routinely deal with frustration and anger, their tolerance of unexpected demand, linked where necessary to work around substance misuse and their emotional well-being. Practice needs to address men’s understanding of the emotional and developmental needs of babies and children and to help them explore their views or gaps in their knowledge about what good parenting looks like. 16.3. Evidence shows that at least some fathers respond positively when they sense that there is a genuine interest being taken in them. The need is to develop an authentic engagement which is much less about assessment checklists and more about seeking out the whole person behind the range of risks and concerns.’  Learning point: early exploration of each family member’s role and their relationships with one another support risk assessment. All family/household members should have the opportunity to contribute towards the work undertaken to support them. Domestic Abuse   Discussions relating to this review were focused on the risk of sexual abuse, primarily in relation to the three oldest children. But there were complex interrelating risks of harm to the children. The oldest children witnessed domestic abuse between mother and Liam, and there were concerns that the relationship between mother and Ben may have been coercive or controlling. Whilst mother herself always denied the presence of abuse when asked, this would Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 15 | P a g e  not be unusual behaviour of someone who was a victim of domestic abuse. All agencies spoke of their concerns based on their observations of the relationship between mother and Ben and the impact his presence in meetings or in the home environment appeared to have on her behaviour. This was particularly concerning as mother's willingness to engage and accept support from agencies reduced significantly in the period that Ben was living at the home address. Agency representatives spoke of the short windows of time when Ben and mother were not in a relationship and how much more receptive mother appeared to be to support. Unfortunately, such periods of time were so short that attempts to build relationships and deliver interventions such as support from a domestic abuse practitioner were ineffective.  There is some evidence within Police records of the response to concerns relating to domestic abuse. Domestic Abuse Stalking and Harassment (DASH) forms were completed by officers in June and September 2020 in response to calls out to the family home by mother. Warning markers were placed on mother’s address to alert officers who might attend the address in the future and vulnerability alerts were added to the children’s records. However, additional measures could have been considered such as Domestic Violence Prevention Orders or Domestic Violence Prevention Notices (DVPOs and DVPNs) which might have offered additional safeguards for mother and the children.  Learning point: the impacts of domestic abuse on victims including children are well researched. In circumstances such as these, where intelligence suggests that children are living in households where domestic abuse exists, all possible safeguarding measures should be considered.  Physical abuse – understanding a child’s world. The risk of physical abuse potentially present for the children from both mother and Ben was not fully understood or addressed with specific intervention beyond those actions in place for the short period of time that the public law outline process was underway.  The children had suffered physical abuse previously perpetrated by Liam, and early in the timeframe of the review: July 2018, there were indicators of a risk of physical abuse towards the children. At the Initial Child Protection Conference held in August 2019, there was a reference to the risk of physical harm to the children which was to be mitigated by a parenting assessment and mother ‘acting protectively’. Later in April 2020, at the review child protection conference, concerns of physical abuse towards the children were referenced but it appears from the records that the risk to the children was felt to be linked to domestic abuse within the household, and the risks of physical abuse towards the children did not appear to be sufficiently explored or mitigated.  There are later disclosures made by Oliver that he had suffered physical harm perpetrated by Ben. There are disclosures made by the children in October 2019 of physical abuse and these are responded to appropriately by Alice and Oliver’s school and Children’s Social Care by way of requesting a move to the next stage of initiating care proceedings for the three oldest children. However, challenges are recorded from the school at the time that Oliver was not seen alone by a Social Worker when he requested this, which represents a significant missed opportunity to not only gain Oliver’s voice and lived experience, but also to fully appreciate the potential risk.  Learning point: When a child requests to speak to a practitioner alone, this should be facilitated in a safe location, or a suitable location identified by the child, unless there is cause to believe that this would place the child at risk. The details of any decision not to act on the wishes of a child should be recorded.  Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 16 | P a g e  Responding to ‘physical chastisement’ – sharing full information    In the records relating to the public law outline process which commenced in November 2019, there is clear reference to concerns about the ‘physical chastisement’ of the children. These concerns do not appear to have been linked back to the child protection plans for the children which represented a missed opportunity to consider the risk of physical abuse and build in ongoing mitigating actions.  Learning Point: Records such as letters and meeting minutes relating to the public law outline process should be shared with the relevant Child Protection Chair(s) and included within discussion at Core Groups to ensure that any additional concerns are included in ongoing work to safeguard the children.  Neglect There are recorded concerns of possible neglect of the three oldest children when they spoke on multiple occasions of being hungry whilst at school. It is recorded that Oliver and Claire particularly would eat large amounts of food available at break and lunch times. It is important to note that it is recorded that mother was spoken to about such occasions and always responded that food was available to the children at home. The school are recorded to have shared their concerns with Children’s Social Care on each occasion.  There is no evidence of thorough consideration of the possibility of neglect and the impact on the growth and development of the children.  The Graded Care Profile tool was available to all practitioners to have facilitated this but was not used.  Learning point: the Graded Care Profile tool is the promoted tool for use in Cambridgeshire and Peterborough to assess and evidence child neglect. Its use in this case may have supported discussions relating to possible neglectful parenting and supporting the evidencing of this complex form of abuse.  Responding to child sexual abuse   Following the disclosures made by Alice in April 2019 of child sexual abuse by Ben, appropriate action was taken by the relevant agencies and a more thorough assessment of the family was evident. This assessment did not, however, result in any support for the children, in particular Alice because mother expressed that she was unwilling to work with Children’s Social Care.  Six weeks after the case was closed in June 2019, a Strategy Discussion was held following Alice’s disclosure of sexual abuse by Ben in August 2019. At this point the children were placed on child protection plans and Children’s Social Care made attempts to engage with the family.  Discussion of the risks to the children appears to have taken place via regular Core Group meetings and Review Child Protection Conferences from August 2019 onwards, recording of which suggests good management of the meetings and engagement from the relevant agencies.  Alice was referred for support from Cambridge Rape Crisis in August 2019, but she was never in receipt of therapeutic support from the charity. By December 2019, Alice had been waiting for support from the charity for four months, which is not an uncommon experience. The optimum scenario would be for children and young people to be assessed and offered the support they need without being required to wait for that support to become available. However, it is also recognised that locally and nationally, the timeliness of support available to victims of child sexual abuse owing to the demand for that service is far from ideal. The impact in Alice’s case was that she did not receive therapeutic support relating to her experience of Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 17 | P a g e  child sexual abuse despite making disclosures of abuse on three occasions. It is for this reason that this area cannot be ignored as a learning point.  Due to what appears to be inconsistent assessment of risk, impacted by unwillingness to engage on the parts of mother and Ben, support for the children beyond building positive relationships with professionals, however valuable, was limited.  Learning point: all children who have been victims of or are at risk of child sexual abuse should receive timely and appropriate support in order to reduce the impact of the trauma of this abuse.  Recording Whilst school records included within the chronology demonstrate good recording of observations and the thoughts and feelings of the practitioners who were involved with the family, this did not appear in the records for other agencies. A discussion took place during the learning event for practitioners where most of those practitioners involved suggested that recording their own feelings in relation to a case or a particular visit or meeting would not be their usual practice. It was recognised, however, that the thoughts and feelings of practitioners is important, these thoughts and feelings are instinctive impressions that should be considered and reflected upon in supervision and should be noted in an appropriate way that identifies what is known as fact and what is opinion and is connected back to any assessment of risk to the children.  Learning point: Practitioners should have the mechanisms through training and supervision to reflect on their practice experiences as well as being aware of their own conscious and unconscious biases. It is important for practitioners also to access advice and guidance in relation to the recording of their interactions with families.  Working with families unwilling to accept support.  It is clear from information presented in this review that despite their efforts, professionals experienced difficulty in building constructive relationships with mother and Ben and the impact of this was that the support offered to the family was largely ineffective in reducing the risk of neglect, physical, sexual and emotional harm to the children.  It has been mentioned that there were brief periods of time within the review’s timeframe when mother was responsive to support and demonstrated that she could act protectively towards the children. However, sadly, these periods of time were too short for any positive change to be effective, and for much of the timeframe of the review, practitioners described difficult and fluctuating relationships with mother and Ben.  Children’s Social Care records provide evidence of multiple strategies being used in an attempt to foster engagement with mother and Ben, such as bringing in a Family Worker to offer parenting support when the family were refusing to work with a Social Worker, a Child Practitioner working with the children at school when access to the home was refused and joint visits with representatives from Health to gain access to the house after Alfie was born.  Additionally, the Social Workers would attempt unannounced home visits, send letters, text messages and make telephone calls in attempts to open communication with mother and Ben. A Team Manager had made attempts to speak with mother to try to outline the concerns that Children’s Social Care had relating to the children.  It is regrettable that mother has been unable to add her perspective to this review process in order to create a more balanced presentation of events. Conversations held as part of this Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 18 | P a g e  review focussed on observations of her behaviour and it did not appear that any professionals had been able to build a relationship with mother which allowed for them to challenge that behaviour with any success. It should also be noted that records provided within the chronology offered little evidence of any consideration by practitioners of the possible reasons for either mother or Ben’s responses or behaviour and limited evidence of their voices.  Learning point: This appears to be a case where a focus on problem solving discussions during Core Groups or Child Protection Conferences may have been useful to consider alternative ways that any practitioner might foster engagement with mother or Ben. Practitioners should have access to advice and opportunities to discuss problems or barriers in their work with families.  Providing effective challenge   On occasions when concerns relating to the children increased or when non-engagement by mother and Ben extended over an unacceptable period, it is clear from the chronology that there are examples of appropriate action taken by Children’s Social Care in seeking legal advice and continuing support for the children under child protection plans. However, there is no evidence of challenge on those occasions when a request for a legal planning meeting was denied.  Lastly, when a request was received from mother for a different Health Visitor for Alfie, this request was refused as it was felt that insufficient time had passed to allow for the Health Visitor to attempt to build a relationship with mother in order to support her. This action demonstrated a recognition of the importance of attempting to build a relationship with mother in order to support the children.   2) How did practitioners and agencies that had contact with the family, work together to safeguard the children?  Inter-agency working The Multi-Agency Risk Assessment Conference (MARAC) in Suffolk appropriately shared information with the MARAC in Cambridgeshire when they had been notified that the family had moved as they considered Liam to pose a high risk of harm whilst in the community.  The school described their experience of communicating and sharing information with the Health Visitors and midwifery team involved as good. However, the school did not appear to have been informed of the Strategy Meeting or the SARC examination following Alice’s disclosure against Liam in 2019.  The response to Alice’s disclosure against Liam in April 2019 demonstrated good cross county inter-agency working with colleagues from Suffolk Children’s Social Care and Police and Cambridgeshire Children’s Social Care working together.  Representatives from the SARC shared with Children’s Social Care that Alice had not been taken to attend for sexually transmitted infection (STI) screening at Addenbrookes hospital following her examination at the SARC in August 2019. A Doctor from the SARC contacted the Social Worker and it was agreed that attendance at this appointment should be included as an action to Alice’s child protection plan. This then resulted in Alice's attendance at the hospital.  Cambridgeshire Community Services noted within their analysis that there had been early notification of mother's pregnancy, information sharing in GP meetings and good Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 19 | P a g e  communication between the Health Visitor and Midwife. It was also noted from the chronology that there had been a number of joint visits undertaken by the Health Visitor and Social Worker following the birth of Alfie and good communication between these professionals.  Areas for improvement in relation to interagency working  Working together - health partners   There was an unexplained delay of almost two weeks between the Strategy Discussion held as a result of Alice's disclosure against Liam in 2019 and a medical examination at the SARC. There is no recording present as to the reason for this at the time but it may have been due to availability of clinics or other professionals such as the Social Worker or the availability of the family. For these reasons it is possible that such a delay may happen in any case.  There was limited involvement from the School Nursing service, particularly with Alice. There may have been a missed opportunity here for the delivery of some focused age-appropriate work with Alice and potentially Oliver relating to the risk of child sexual abuse. There should also have been more collaborative working between the school nurses and health visitors on completion of health assessments. Participation by health in multi-agency meetings was inconsistent, most likely due to service capacity and as a result decision making was not always influenced by a health perspective. This issue of quoracy when there is not involvement from all statutory agencies with a child or family has been recognised by the Safeguarding Children’s Partnership Board.   Exploring ‘disguised compliance’  It is not evident that sufficient opportunities were taken by the practitioners involved to collaboratively explore the barriers they were facing in working with the family. The term ‘disguised compliance’5 was used within the information gathering events for this review, but it was questioned whether this term was fully understood in relation to this family and whether the possible reasons why there was limited, or fluctuating compliance had ever been explored. Learning point: Practitioners should detail their understanding of terms such as disguised compliance, where these are utilised, and seek to understand the possible reasons for such behaviour where this is observed.  Working together – Police   There was a potential missed opportunity to involve Police colleagues in engaging with the family following an unsuccessful home visit by one of the Health Visitors and Social Worker in June 2020. It was clarified that whilst Police Officers do not have a power of entry except in very specific circumstances, collaborative working with Police colleagues, particularly local neighbourhood teams, may foster engagement and this is a method worth considering where other practitioners are facing barriers.  Police also noted that had DVPOs and DVPNs been used, links to the relevant housing provider would have been useful in enforcing these orders.   5 The term used to describe when the service user or family members gives the appearance of co-operating with agencies to avoid raising suspicions, to allay professional concerns and ultimately diffuse professional intervention. They may; tell professionals what they ‘want to hear’, not admit that they do not want to change or say that they have completed requests when they have not done so. Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 20 | P a g e  Working together – education   School expressed some frustration in a perceived lack of response from Children’s Social Care to all of their expressed concerns. They also recorded that the minutes from Core Groups and Child Protection Conferences were not always shared in a timely manner.  Working together - challenge and escalation   Finally, there is some challenge by partner agencies evident at Core Group meetings and Child Protection Conferences, but there were some missed opportunities to challenge decision-making by Children’s Social Care, such as the closure of the first section 47 enquiry in September 2018. There is no evidence of the use of the Resolving Professional Differences Policy being referred to or used which, was particularly a missed opportunity for the school when Oliver’s request to speak with the Social Worker alone had not been met.  Learning point: promoting challenge and escalation is intrinsic in multi-agency safeguarding work. Practitioners should be aware of and confident in using the Resolving Professionals Differences policy6.  3) How well did agencies identify and respond to signs of child sexual abuse? Once the allegation had been made were the children adequately supported?  Disclosures of child sexual abuse:  A single assessment was completed by Children’s Social Care on 17th of June 2019, following which the family were closed to Children’s Social Care as mother declined support for Alice. Ongoing risk was thought not to be present as the disclosures, she had made were historic.    In all of the information gathered for this review, there is a focus on the children's disclosures as indicators of child sexual abuse, but no evidence of any indication of other signs of sexual abuse. The school staff, who appeared to have known the children well, described that their concerns were based on the behaviour and presentation of the three children, but this did not specifically raise concerns of child sexual abuse. Similarly, the Health Visitors who became involved following Alfie's birth visited the family on a number of occasions and noted concerns in relation to how the children behaved and were responded to by mother and Ben at home. They agreed that they had not noted specifically any concerns relating to a risk of child sexual abuse.   Children’s Social Care suggest that staff were concerned about the possibility of child sexual abuse but there is no evidence that Alice was directly asked about this, despite being on a child protection plan under the category of sexual abuse. As has been mentioned, it is not clear what specific intervention was offered to reduce her vulnerability.  Learning point: it is a recognised systemic issue, as the 2020 Joint Targeted Area Inspection Report into Child Sexual Abuse in the Family Environment states that: ‘Professionals rely too heavily on children to verbally disclose.’8 And as stated by the Centre of Expertise for Child Sexual Abuse: “This is a heavy, and frankly unrealistic responsibility. Children cannot and should not be the only witnesses to the harm they experience; it is the responsibility of the adults around the child to respond to help-seeking behaviour and to safeguard them” This area  6 https://www.safeguardingcambspeterborough.org.uk/children-board/professionals/procedures/escalation_policy/  Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 21 | P a g e  has similarly been noted in other recent, local Child Safeguarding Practice Reviews relating to child sexual abuse.  Medical examinations The SARC examinations for Alice and Claire, which followed the disclosures made by the children against Ben in August 2019 and September 2020, were appropriate, as was the arrangement of Initial Child Protection Conferences on both occasions. Additionally, staff at the SARC noted the unusual and concerning occurrence of a child, Alice, attending for three medical examinations in 18 months and made an appropriate referral for the consideration of a child safeguarding practice review.  Following her disclosures in August 2019, Alice was seen at the SARC on the same day for a forensic examination and samples were taken as potential evidence. Unfortunately, these samples were not sent to be processed immediately and before they could be sent, Alice had amended the account of her initial disclosure and the criminal investigation had been discontinued. It was recognised as good practice by the Investigating Officer that when the later investigation commenced in September 2020, those previous samples were sent for processing as part of that reopened investigation.  Whilst both Alice and Claire were seen at the SARC for multiple examinations: Alice for three and Claire for two, their brother Oliver was not. Oliver had made disclosures of physical abuse by Liam in April 2019, so whilst a SARC medical exam would not have been the most appropriate at that time, he did not receive a child protection medical either. Similarly, when he made disclosures of abuse by Ben in September 2020, these disclosures were initially evaluated as indicators of sexual abuse as some of the injuries Oliver described, had been sustained in his genital area. However, it was determined by Police that the incidents Oliver had described were indicative of physical assault, but there are no records that he was referred for a child protection medical examination. These are significant missed opportunities to respond to Oliver’s disclosures, check his health and gather information relating to the incidents he described. Arguably, Oliver may be considered to have been a victim of child sexual abuse himself due to his disclosures of having been witness to the abuse of his sisters, but this does not appear to have been considered.  Learning point: Appropriate and prompt medical examinations should always be considered when a child discloses physical or sexual abuse or neglect based on the best interests of the child.  Response to disclosures of child sexual abuse The events following Alice's disclosures against Ben in August 2019 were examined and it was discussed that her two versions of the events of the 2nd of August 2019 appeared to have been given unequal weight. Whilst there was inarguably a prompt response to her initial disclosure, there was insufficient professional curiosity as to the amended version of events that Alice supplied seven days later. The concern was that mother’s response may have impacted upon Alice and her recollection or interpretation of the events of the 2nd of August 2019 but there is no evidence that the change in Alice’s account was explored by agencies. Information presented illustrates that Children’s Social Care did take action to safeguard Alice and her siblings in response to her disclosure against Ben in August 2019 by placing them on child protection plans. The representative for Children’s Social Care described that Alice was considered as having been a victim of child sexual abuse as a result of her disclosures, as they recognised that she was likely to be suffering trauma from historic abuse at the least. Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 22 | P a g e  Requests to escalate intervention for the family via a Legal Planning Meeting followed quickly due to mother and Ben's unwillingness to accept support from Children’s Social Care, although the advice provided was to continue supporting the family through child protection plans.  As previously described, a referral to Rape Crisis was made for Alice in August 2019 and in October 2019 school records show that she was being offered support in school in relation to ‘sexual trauma’. Claire and Oliver do not appear to have been offered support. Blue Smile were also explored as a possible avenue of support but were unable to work with any of the children, as Ben was subject to investigation by the Police for drug related offences. At the time this service were unable to work with children linked to open Police investigations.  A School Nurse became involved following receipt of an invitation to the Initial Child Protection Conference in August 2019 and completed collective health assessments for the children. It was a missed opportunity to explore potential support for the children that the School Nurse did not liaise with the school at the time. Analysis provided by Cambridgeshire Community Services also suggested that this health assessment did not sufficiently consider each child's individual health needs and was representative of the children’s needs at that time only. Reviews of these assessments might have highlighted any changes or concerns but capacity within the service meant that this was not possible.  Whilst it appears from the information supplied that the initial response to safeguard Alice was appropriate in terms of the correct processes having been followed, there is no evidence in the chronology of her voice during this time. It cannot therefore be determined what Alice herself may have wished for in terms of support or response, or how she felt about seeing and speaking with so many professionals. Within the timescale of this review, Alice, Claire, and Oliver did not receive specialist support as victims of historical sexual abuse, and it is not evident that they or mother were asked what support they felt they needed.  Other indicators of abuse It has been recognised in this report that the children's experience of historic sexual abuse was a complicating factor in accurately assessing the risk of child sexual abuse to them in real time. Previous trauma could be blamed for presenting behaviours or disclosures with the potential for this to mask the present risk. Additionally, it was described that the three oldest children were exposed to inappropriate language and discussions by mother and Ben, which was likely to have impacted upon their own understanding and descriptions of events. This analysis was drawn out as part of this review process but there is no clear evidence that the complexity of trauma, abuse and the impact on the children was considered in 2019 or 2020.  Response to most recent allegations, September 2020 The Police response to the children's disclosures made in September 2020, was to focus on offences of sexual assault against Alice and Claire and physical assault against Oliver. Achieving best evidence (ABE) interviews with all three children were conducted. The previous investigation into Ben, which had been closed, was reopen and amalgamated. The Investigating Officer described that evidentially, the investigation was unable to proceed. This officer demonstrated an excellent understanding of the children's presenting behaviour and a frustration against a criminal justice system which does not recognise or make allowances for the fallible nature of children's memory. It became clear that the Crown Prosecution Service (CPS) threshold to prosecute had not been met, but the officer made it clear in both police recording and within the information gathering event, that this was not the same as saying that there was no evidence present which corroborated Alice’s disclosures.  Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 23 | P a g e  Finally, those agencies who remained involved with the children at the time this review was being completed, shared that Alice is now receiving support from Rape Crisis, Oliver is on a waiting list for support from Blue Smile and play therapy is being sought for Claire. This information is included here to reiterate the importance of timely specialist intervention for children who have suffered abuse, which unfortunately cannot be evidenced in this case.  4) How was the voice of the child recognised and responded to within the case?  Children’s Social Care Barriers were identified early on in 2019 to the children being able to share their thoughts and feelings. Mother was present when the children were spoken to at home and the Children’s Social Care representative shared that there were occasions when she refused to permit practitioners to speak with the children at all.  Analysis provided by Children’s Social Care states that a lot of direct work was completed with the children by both the relevant Social Worker and the Child Practitioner who was allocated to the children with the specific aim of building positive relationships with them to support them in making any disclosures. This work was carefully planned and is evidenced in Children’s Social Care records, including observations of the children’s behaviour and presentation. Exploration of the children’s lived experiences is less clear and there were occasions when the children’s voices were not heard.  Health There was limited health involvement with the children before Alfie’s birth in May 2020. A School Nurse completed health assessments in September 2019 but did not adequately consider the children individually.  The Health Visitors who were involved in supporting mother and Alfie following Alfie's birth did demonstrate consideration of what Alfie's lived experience might have been at that time and shared that they had not had any concern for the care he was receiving. They did, however, note observations relating to the elder three children and their ‘unusually quiet’ presentation in the presence of professionals but they did not link these observations to any specific concerns.  On all occasions, the children were seen with a parent present as it is stated within the Healthy Child Programme Guidance to which staff in Cambridgeshire Community Services adhere, that children under 11 years should not be seen alone. Again, the children’s voices and their lived experiences were not fully understood and insufficiently recorded to demonstrate assurance of their wellbeing.  School Staff built positive relationships with the eldest three children and provided them with what were considered to be a safe and neutral spaces within which to speak with professionals. Indeed, Oliver did make disclosures to school staff. School staff also agreed that the Child Practitioner who visited the children in school made significant attempts to engage with the children and ‘hear their voices’.  Police The Police investigation into the disclosures made against Ben appears to have been evidentially based primarily on statements by Alice, Oliver, and Claire. Investigating Officers were believed to have actively listened to the children and recorded their words visually and in writing. The primary Investigating Officer demonstrated a very good understanding of all Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 24 | P a g e  communication by the children, and this was reflected in the statements included within the closure report for the investigation.  Non-verbal communication and behaviour It was clear from the discussions held during the information gathering events that all agencies involved had noted concerns for the welfare of the three oldest children from 2018. The school particularly appeared to have a good understanding of each of the three children's behaviour and were good at recording their observations. What was less clear for any of the practitioners was what the children's behaviour might be indicating at any given time. Once the children were being supported under a child protection plan, Core Groups facilitated discussions that explored this, although agencies do not appear to have been able to reach conclusions as what the children’s behaviour might indicate was happening in their lives.  Learning point: ‘Understanding what a child sees, hears, thinks and experiences on a daily basis, and the way this impacts on their development and welfare, is central to protective safeguarding work’. ‘The child’s views should inform analysis and assessment so that intervention is appropriate to address key concerns and needs.’  Additionally, children often communicate their feelings and their lived experiences through their behaviour – it is important that practitioners are supported to interpret this behaviour to gain a greater understanding of what children are communicating. 5) Did Covid have an impact on the safeguarding and support for the children? Did Covid and home working impact on the way in which agencies communicated with each other?  COVID-19 and safeguarding.  There were many factors resulting from the restrictions placed upon all residents of the UK from 25th March 2020, which had the potential to impact upon the safeguarding and welfare of any child. Those issues which were identified as being relevant to this family, which were identified as follows: • The children did not attend school as usual.  • Ben was placed on furlough by his employers, which meant that he was at home with mother and the children and that very likely, his income would have been affected.  • Mother's pregnancy meant that she was thought to be more vulnerable to the effects of the virus. Pregnant women were advised to exercise even greater caution than other members of the public to protect themselves and their unborn babies.  • Alfie was born during the period of restrictions in May 2020 and there are recorded concerns relating to mother's mental health and the fact that she was believed to have suffered with post-natal depression following at least one of her previous pregnancies.  • The impact on mother and Ben’s relationship when they were expected to spend most of their time together at home with the children. Particularly given the concerns observed by agencies regarding their relationship prior to March 2020.  The mitigations which any of the agencies could offer for these issues, were limited. Children’s Social Care continued to offer face to face visits, although these could not be enforced due to mother’s pregnancy. In the early period of COVID-19 restrictions, contact was often conducted at the front door of a family’s property or in the garden as it was believed that the risk of Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 25 | P a g e  catching the virus was reduced outdoors. This unfortunately meant significantly reduced privacy and confidentiality for any conversations held. It also meant that risk assessments relating to the children in the home environment could not effectively be undertaken.  Food parcels were delivered by Children’s Social Care to the family, which mother was recorded as having been grateful for. It should not be dismissed that she would very likely have been under significant pressure to care and provide for her children in extremely difficult circumstances like so many other families at this time. This was recognised by those agencies involved in this review and there was evidence in the chronology at a Review Child Protection Conference on the 22nd of April 2020 of the impact of ‘lockdown’ on the family being discussed.  The three eldest children were offered school places throughout the period of restrictions, permitted because they were in receipt of support from Children’s Social Care. However, this offer was declined by mother and as a result, the children were not physically in school from March 2020 until September 2020, following the summer holidays. Therefore, the opportunity to monitor their wellbeing and for them to speak with professionals more openly was not possible. The school made daily attempts to contact mother by telephone initially and later by email. Information within the chronology suggests that these calls were often unsuccessful. Although the children could be heard in the background during some telephone calls, they do not appear to have been spoken to directly.  In May 2020, Alice was able to join some virtual lessons, so was more visible to school staff. Work packs for the children were delivered to the home address by school staff and on some of the occasions the children were seen. It must be noted that such action by school was above and beyond the guidance in place at the time.  It does not appear that the impact of the Covid 19 restrictions and the potential for an increased risk of harm to the children was fully explored, although it would have been difficult for any of the agencies to have offered intervention beyond that which was put into place.  Support for the family.  Mother cancelled appointments with professionals including her midwife and the Social Worker because one of the family were experiencing COVID-19 symptoms on more than one occasion. There was also a delay in the SARC exams for Alice and Claire taking place as Alice was experiencing COVID-19 symptoms. This was described as one of a number of episodes of self-isolation, and there were concerns that self-isolation could be used as an excuse by families to avoid contact with services. However, it does not appear that this potential evasion of contact from services was explored at the time.  Certainly, it was the case that Alice was not offered support from Rape Crisis directly because of the COVID-19 restrictions. At the onset of restrictions, counselling was no longer offered face to face, and it was deemed that virtual sessions were not an appropriate method of delivery for children under 10 years old. Alice was eight years old at the time and had been waiting for support for seven months due to a temporary move out of the area.  It is clear therefore that for this family, COVID-19 did have a negative impact on the support that could be offered and delivered, as well as any assessment of risk to the children. COVID-19 made it easy for any family to hide from services who were working to the best of their ability in extremely difficult circumstances.  Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 26 | P a g e  Home working and communication.  Children’s Social Care representatives involved in this review expressed that they had not felt that home working had been a significant hindrance to normal working practice for practitioners. It was suggested that email was used to a greater extent as face-to-face conversations were not taking place, particularly with school staff. Core Group meetings were held virtually with parents or carers being supported to attend. Mother joined some meetings by calling in, and it was agreed by all practitioners that these alternative methods of communicating with children and families presented challenges. Without input from either mother or Ben, their experiences of these changes are unknown.  Assessments were undertaken by some services by telephone or video calls which would likely have meant that some of the richness of interacting face to face was lost and may have impacted understanding of risk.  Personal protective equipment (PPE) such as visors and face masks may have impacted upon children’s willingness and ability to communicate with professionals.  The final consideration is that of the feelings and worries of not only children and families, which are undeniably important, but also those of practitioners. The practitioners involved in this review described their concerns in the early stages of the pandemic for both them and the families they were supporting at the time. There was limited guidance available initially and risk assessments were required for both families' circumstances and those of staff. The perception of the virus at that time was of potentially deadly significance and cannot have failed to have impacted upon practice.  6) Can you identify any areas that you consider to be good practice?  Several areas of good practice have been noted in this report. Joint home visits were undertaken by the Health Visitor and Social Worker after Alfie’s birth, when contact was made with mother and the family daily. The Health Visitor described there was regular and open communication between these professionals and visiting the family together supported this and helped to reduce the pressure on the family of needing to repeat information to more than one professional.  Recording by the children's school was noted to be very detailed. Staff built positive relationships with the children and aimed to offer them a safe space to communicate.  When Alice and Oliver were attending different primary schools in 2018, the communication and information sharing between the two schools were described as good by the children’s second school who attended the learning event for practitioners.  Analysis within the Cambridgeshire Community Services chronology states that the identified areas of practice within their agency were: evidence of practitioners actively seeking safeguarding supervision and good management oversight of the case, communication between the GP and Health Visitor in relation to mother’s postnatal mental health and evidence of the Health Visitor considering the presentation of all the children using a ‘Think Family’ approach.  Analysis provided by Children’s Social Care states:  • The initial section 47 investigation of July 2018 when the maternal aunt raised her concerns was of good quality and had proper multi agency involvement. Following on from this, the work done by the integrated front door and assessment team workers was also of good quality, there is evidence of professional curiosity in relation to mother Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 27 | P a g e  and Ben’s relationship given she had been a victim of domestic abuse in the past. The suggested action was for a DASH to be completed with mother to explore this. Additionally, there was evidence of reflection on the initial response of accepting the case under Early Help not being the correct decision.  • There were occasions where legal advice was appropriately sought when concerns escalated, although this was not always agreed by senior management.  • Frequent direct work was completed with the eldest three children. A dedicated worker was allocated to build relationships and observe any change or concerns relating to the children’s behaviour.  • Response to the critical incident was immediate, appropriate and the children are now placed safely.  Finally, when the police investigation into Alice, Oliver and Claire’s disclosure against Ben was opened in September 2020, the previous disclosures made by Alice were reconsidered and the forensic samples taken at Alice’s SARC examination in August 2019 were submitted for processing. The Investigating Officer’s closing comments were also considered to have been an example of good practice as they represented a holistic assessment of the family and recognised the lived experiences of the children.  7. Key areas of learning: Information sharing a) Information sharing protocols between local authorities should enable the prompt sharing of information relating to children who are supported under child in need processes to ensure that full information is shared, and the process is robust.  Risk assessment b) Early exploration of each family member’s role and their relationships with one another support risk assessment. All family/household members should have the opportunity to contribute towards the work undertaken to support them. c) The impacts of domestic abuse on victims including children are well researched. In circumstances such as these, where intelligence suggests that children are living in households where domestic abuse exists, all possible safeguarding measures should be considered. d) Records such as letters and meeting minutes relating to the public law outline process should be shared with the relevant Child Protection Chair(s) and included within discussion at Core Groups to ensure that any additional concerns are included in ongoing work to safeguard the children.  e) the Graded Care Profile tool is the promoted tool for use in Cambridgeshire and Peterborough to assess and evidence child neglect. Its use in this case may have supported discussions relating to possible neglectful parenting and supporting the evidencing of this complex form of abuse.  f) Practitioners should detail their understanding of terms such as disguised compliance, where these are utilised, and seek to understand the possible reasons for such behaviour where this is observed. This relates to the idea of authoritative practice and suggests a possible gap in practice which should be explored. Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 28 | P a g e  Lived experience of the child  g) ‘Understanding what a child sees, hears, thinks and experiences on a daily basis, and the way this impacts on their development and welfare, is central to protective safeguarding work’. ‘The child’s views should inform analysis and assessment so that intervention is appropriate to address key concerns and needs.’  h) When a child requests to speak to a practitioner alone, this should be facilitated in a safe location, or a suitable location identified by the child, unless there is cause to believe that this would place the child at risk. The details of any decision not to act on the wishes of a child should be recorded. Victim support i) All children who have been victims of or are at risk of child sexual abuse should receive timely and appropriate support in order to reduce the impact of the trauma of this abuse. j) It is a recognised systemic issue, as the 2020 Joint Targeted Area Inspection Report into Child Sexual Abuse in the Family Environment states that: ‘Professionals rely too heavily on children to verbally disclose.’ And as stated by the Centre of Expertise for Child Sexual Abuse: “This is a heavy, and frankly unrealistic responsibility. Children cannot and should not be the only witnesses to the harm they experience; it is the responsibility of the adults around the child to respond to help-seeking behaviour and to safeguard them”. k) Appropriate medical examinations should always be considered when a child discloses physical or sexual abuse or neglect, based on the best interests of the child. Support for practitioners l) Practitioners should have access to advice and opportunities to discuss problems or barriers in their work with families.  m) Practitioners should have the mechanisms through training and supervision to reflect on their practice experiences as well as being aware of their own conscious and unconscious biases. It is important for practitioners also to access advice and guidance in relation to the recording of their interactions with families. n) Promoting challenge and escalation is intrinsic in multi-agency safeguarding work. Practitioners should be aware of and confident in using the Resolving Professionals Differences policy.  8. Recommendations The review highlights several areas of learning regarding both neglect and CSA. The Safeguarding Partnership has workstreams focussed on CSA and neglect and each workstream has its own workplan. The learning identified within this review has been mapped across to the relevant workstream’s workplan. Accordingly, there are no recommendations regarding these areas.  i. Cambridgeshire and Peterborough Children’s Social Care services should: a. ensure that when a child or family moves into Cambridgeshire and Peterborough and a request is made for case responsibility to be taken on, a Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 29 | P a g e  request is made for information outlining the child or family’s historical involvement with Children’s Social Care in the area they are moving from, and b. the provision of this information is robustly challenged where appropriate to ensure a decision can be made as to the support for the family going forward.  c. The process within which this will be achieved, including reviews of information sharing protocols, should be reported back to the CSPR subgroup within six months of the publication of this report. ii. Cambridgeshire and Peterborough Children’s Social Care services should compile a template for use by practitioners within their assessments which prompts for the consideration of all family members and their roles within a unit and their relationships with one another.  iii. A facilitated workshop should be held with frontline practitioners from Police, Health, Children’s Social Care and Education to enable the partnership to explore good practice and better understand the barriers to capturing and using the voice of the child. This should be arranged by the Independent Safeguarding Partnership Service within six months of the publication of this report and the findings reported back to the Safeguarding Children Partnership Board (SCPB). iv. Work should be undertaken to map out the current support available to victims or those at risk of child sexual abuse. This work should be undertaken within the CSA workstream under the Safeguarding Children’s Partnership Board’s priority relating to child sexual abuse. This work should identify any gaps or barriers to service provision and report back to the SCPB within twelve months of the publication of this report. v. Children’s Social Care, Education and Cambridgeshire Community Services should gain the feedback of frontline practitioners within their agencies regarding the possible barriers to working with families who refuse support or display a reluctance to engage with services. This feedback and the corresponding actions should be presented to the SCPB for discussion within 12 months of the publication of this report.   Cambridgeshire and Peterborough Child Safeguarding Practice Review – M Family 30 | P a g e  Appendix 1 – Genogram   Appendix 2 – Chronologies The following agencies were required to complete a chronology on an agreed template: • Cambridgeshire Constabulary • Cambridgeshire Children’s Social Care  • Cambridge University Hospitals NHS Foundation Trust: Addenbrookes Hospital • Cambridgeshire Education Safeguarding Service  • Cambridgeshire Community Services  • Clinical Commissioning Group • Sexual Assault Referral Centre  Cambridgeshire Rape Crisis provided a summary of their involvement with Alice, and this information was considered alongside the composite chronology.  Information from Suffolk Children’s Social Care was provided which included a summary of their involvement with the family.  Suffolk Constabulary provided brief details of their involvement with the family before they moved into Cambridgeshire.  David Oliver Liam Ben Alfie Mother Claire Alice 