Death of two children by their parents in May 2019 as a result of strangulation. Four surviving siblings are in local authority care subject to care proceedings. Mother and uncle (later known to be father) convicted of two charges of murder, four charges of attempted murder and six charges of conspiracy to murder; in November 2019 both sentenced to life imprisonment. Parental history of: neglect; child protection plans; being in care; child sexual abuse; separation and loss. Family known to multiple agencies. Family are white British. Issues identified include: need to recognise and respond to harmful sexual behaviour by professionals; professional optimism and the need to be more professionally curious and take a holistic view; invisible male carers/fathers; eligibility to services; impact of delays to provision of services and the need to meet needs in a more timely way; need for a more integrated offer to families with children with Attention Deficit Disorder; need to align special educational needs and disabilities (SEND) processes; need to understand the impact of lived experience, especially trauma, on parenting. Recommendations include: streamline specialist support; consider how professional optimism impacts on assessments; consider fathers in assessment; develop an integrated offer for harmful sexual behaviour; Child and Adolescent Mental Health Services to consider the impact of delays to service provision and how to meet needs in a more timely way.
      
 Title:  Serious case review: Family G review report. LSCB: Sheffield Children Safeguarding Partnership Author: Alex Walters Date of publication: 2020  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1      Serious Case Review FAMILY G REVIEW REPORT   Independent Reviewer: Alex Walters  Published: August 2020   2   Contents  1  Introduction ............................................................................................................................... 3 2  Process for conducting the Serious Case Review ............................................................... 3 3  Relevant background information prior to the timeframe under review ....................... 5 4  Family Structure and views ..................................................................................................... 6 5  October 2015 – May 2019: Brief chronology of agency engagement with the family.8 6  Agency involvement and improvements identified through the agency report process: ........................................................................................................................................ 12  7  Findings and Analysis ............................................................................................................. 20 - Recognition of and response to Harmful Sexual Behaviour - Professional optimism/curiosity - Invisible fathers/male carers  - Thresholds to services - Resources/timeliness/delays to services  - Information sharing and risk assessment processes  - Impact on children and their lived experiences  8   Effective practices that had a positive impact on Family G ......................................... 25  9   Recommendations ............................................................................................................... 25    3  1. Introduction  1.1  Sheffield City Council notified the Department for Education (DfE) of a serious safeguarding incident in May 2019, which related to the death of two children by their parents as a result of strangulation/asphyxiation. Facilitated by the Sheffield Safeguarding Children Board (SSCB), now Sheffield Children Safeguarding Partnership (SCSP), the key agencies undertook a Rapid Review as required by statutory guidance Working Together to Safeguard Children (2018). The Rapid Review requires all agencies to undertake a review of their records and to submit a timeline, analysis and summary of agency involvement.  1.2  The Rapid Review Report was submitted to the national Child Safeguarding Practice Review Panel in June 2019. The national panel agreed that the criteria had been met and a Serious Case Review (SCR) should be commissioned in July 2019 and that a national review would not be undertaken in August 2019. An Independent Reviewer and an Independent Chair were commissioned in November 2019.   1.3  The four surviving siblings are looked after by the Local Authority and subject to care proceedings. Two adults MG and FG, the children’s mother and uncle (later known to be father), were arrested on suspicion of murder. It would appear MG’s intention had been to overdose her children and then take an overdose herself. When the initial overdose plan failed, MG and FG resorted to each killing a child by ligature strangulation. They subsequently appeared in court and pleaded guilty to two charges of murder, four charges of attempted murder and six charges of conspiracy to murder. In November 2019 they were both sentenced to a life sentence with a minimum period of 35 years in prison.   1.4  The purpose of a review, as confirmed in the current statutory guidance, Working Together (2018) is clear that the focus is on learning, not holding individuals or agencies to account. This review has therefore been undertaken in a proportionate way to ensure the key learning is identified to support improvements in single and multi-agency practice. It is, therefore, deliberately not detailed but provides a summary of the family circumstances and key agencies’ engagement with the family.   2. Process for conducting the Serious Case Review  2.1  The SCSP recognised the criteria for undertaking a Serious Case Review were met and there was potential to identify learning from this review regarding the way that agencies work together in Sheffield to safeguard children.   2.2  An SCR Panel was established and the Terms of Reference (TOR) were scoped and amended by the Independent Reviewer. The timeframe for the review is from 28/10/15 up to the day of the incident on the 24/05/19. The Independent Reviewer is Alex Walters, an independent safeguarding consultant, experienced Local Safeguarding Children Board (LSCB) and SCR Panel chair and Independent Reviewer and member of the national panel of reviewers. The Independent Chair is Russell Wate who has extensive experience of chairing safeguarding partnership boards and SCR panels. He is also an experienced lead reviewer and a member of the national pool of reviewers. Both are fully independent of SCSP and its partner agencies.  4  2.3  An Agency Report Authors briefing was held in December 2019 to discuss the scope and TOR in detail. The Authors contributed to a multi-agency chronology as well as producing agency reports. The reports provided agencies with the opportunity to consider and analyse their practice and identify any systemic issues. They provide details of the learning from the case within their agency, but also allowed agencies the opportunity to reflect on actions and make recommendations for improving practice within their own services.   2.4  Agency reports and chronologies were submitted from 14 organisations/functions. These included:  - Three reports from Sheffield City Council- Children’s Social Care; Early Help services and Education - South Yorkshire Police; - Four reports from Sheffield Children’s NHS Foundation Trust- Acute services; 0-19 services; CAMHS (Child and adolescent mental health services); S&LT (Speech and Language therapies) - GP - Sheffield Futures- Community Youth Teams - Sanctuary Housing- Housing provider   - Local Secondary School - Golddigger Trust- Charity for young people - Sheffield Teaching Hospital (STHNHSFT)- Midwifery, Emergency Department (ED), Community dentistry and Out of Hours GP.  2.5  The Authors of the agency reports and the SCR Panel then met in February 2020 to discuss their reports, identify learning, areas of effective practice and identify any further information required. The Independent Reviewer through follow up e-mail exchange subsequently sought further information and clarification. Relevant information prior to the timeframe of the review was also considered, particularly historical involvement with the family.  2.6  A central component of the SCR process is understanding the perspective of front line practitioners and the opportunities and challenges about the 'system' within which they work to analyse why incidents occurred and the contributory factors rather than just what occurred. A key element of the methodology was therefore the learning event for front line practitioners involved with the family. It was held in March 2020 and involved 14 practitioners from the following agencies:  - SCC – Children’s Social Care - SCC – Early Help Service (MAST) - ADHD nurses from Ryegate Children’s development centre - The local Secondary School Deputy Designated Safeguarding Lead and Student Support Leader - Sheffield Futures – Community Youth Teams - Midwifery - 0-19 - Health Visiting - Golddigger Trust - Speech and Language Service - South Yorkshire Police - GP - CAMHS services (Unfortunately no practitioner was able to attend due to previous commitments) 5   2.7  Practitioners considered a key learning themes document prepared by the Independent Reviewer. The perspectives and opinions of all those practitioners involved at the time were discussed at the event, practitioners were highly engaged and have significantly informed this SCR report and its recommendations. A further event for practitioners was held July 2020 to feed back the recommendations of the review and further comments have been incorporated into the report.  2.8  The contribution of family members is an important part of the review as their perspective on agency engagement is always helpful to the learning. Both parents were informed of the SCR process by letter and through their respective prison leads and invited to contribute to the review. The Independent Reviewer and Chair visited MG in prison in March 2020 and were due to visit FG in late March 2020 but this was postponed, as was telephone contact, due to the Covid-19 pandemic. Video contacts were subsequently enabled and the Independent Reviewer met virtually with FG in July 2020.  Both MG and FG have received feedback on the recommendations from the review, which they received positively. Consideration was given to trying to elicit the views of the oldest surviving siblings but the professional view was that this would not be in their best interests.   2.9  Both MG’s and FG’s views were most helpful and highly valued by the reviewer in identifying improvements and are incorporated into the review and its recommendations.  3. Relevant background information prior to the timeframe under review   3.01  MG and FG are half siblings, raised in different homes but were both known to Children’s Social Care as children and subject to Child Protection Plans as a result of neglect. FG was made subject to a Care Order from the age of 9 and lived in several residential units before moving into independent accommodation.  3.02  MG was subject to two periods of child protection planning -1990-93 and 1999-2000. She was in care under S.20 (Children Act 1989) for a year at the age of 14 in 1999. At that time, MG made historical allegations of sexual abuse against a number of individuals and one was convicted of her rape in 2000. In 1998 GMG reported to the police that she believed MG and FG were in a relationship after she had found ‘love letters’. A review of the letters and a denial of any relationship by MG led to no further action being taken by the Police and Children’s Social Care. At the time MG was aged 14 and FG was 18 years old.  It is understood from records kept by MG’s residential care home that there were rumours from residents of a relationship between MG and FG but these do not appear to have been formally raised. MG left care in 1999 and the family moved to another local authority area where she continued to be subject to a Child Protection plan until June 2000.   3.03  MG and FG experienced a number of Adverse Childhood Experiences (ACEs) and research identifies the long term impact of toxic stress on individuals who have suffered a number of ACEs including sexual abuse, violence, separation, loss and neglect as a child.  3.04  MG was 19 when she had her first child and at the time of the incident was a single parent to six children whose ages ranged from 9 months to 14 years. She had never informed any of the many professionals who had involvement with the family or 6  her friends of the six children’s paternity. She had confirmed latterly that the children had the same father but always maintained that he was not involved in raising the children.   3.05  Professional’s view of mother’s parenting was overwhelmingly positive and she was seen as a competent, caring and articulate parent who supported and fought hard for her children’s access to appropriate support and help. She frequently self referred to support services and the police.  3.06  Between the period of October 2004 and December 2006 MG and her children presented in temporary accommodation on four occasions.  In 2012 she moved into a 3 bedroomed house and had a firm support network of FG who was always described as her brother and her friends who frequently supported her at appointments for the children /meetings etc.   3.07  Little information was known about FG. He is the half brother of MG and is the eldest of the two children from his mother’s first marriage. He had his own accommodation separately from the family but was understood to spend all day at the family home.  3.08  Neither MG or FG had any previous convictions and neither were known to mental health or substance misuse services.  3.09  The oldest four children in the family had all been diagnosed with various disabilities and SEND (Special educational needs/disabilities). G1 was diagnosed with ADHD (Attention deficit hyperactivity disorder) in February 2012 by the neurodisability team at SCH and had been an open case to the ADHD community service at Ryegate children’s development centre since 2011. G1 also had speech and language and communication difficulties and was known to the Speech and Language Therapy Service.  3.10  G2 was diagnosed in December 2015 with ADD (Attention defecit disorder) following referral to CAMHS in November 2013. In addition to ADD support, he received art therapy in 2015 and solution focussed therapy in 2018-2019. G2 also had serious allergies and speech and language difficulties and was known to the speech and language service. It had been agreed to commence an Education, Health and Care Plan (EHCP) for G2 in April 2019, a formal process to address his learning needs.   3.11  One previous initial assessment had been undertaken in 2012 by the SCC Children with Disabilities team (CDT), regarding G1 and siblings. It recommended family support and SNIPs (Special Needs Inclusion Playcare Service).   3.12  The family are all White British and neither parent was in employment.   4. Family Structure and views  4.01 The relevant family members in this review are:   Relationship Code Child G1 Child G2 7  Child G3 Child G4 Child G5 Child G6 Mother MG Father FG Grandmother GMG  4.02  The Independent Reviewer met with MG in prison with the independent chair, a prison voluntary sector advocate and an offender management officer who were most supportive of the process. The focus for the discussion was on the agencies that had worked with the family, what services MG had found helpful, less helpful and what could be improved. Overall MG was clear that the support she’d received from most agencies and individual workers had been good and she felt particularly listened to by the Ryegate ADHD nurses. She did however describe the struggles she had with schools to initiate the diagnoses and the support that she felt all four of the children required and stated that responses were not always timely or consistent and were frequently hindered by changes in the SENCO function. She also described a high level of bullying of G2 and in her view inappropriate exclusions that didn’t take account of his diagnoses. MG had only recently felt she had persuaded the school to initiate an EHCP plan for G2. However, she was positive about the support to G2 provided by the Aspire function and teacher at the secondary school- a separate learning unit as well as the special school attended by another child.  4.03  MG’s perception is that G1 and then G2’s obsession with online pornography and level of masturbation was not “normal” and that she felt she was given no answers about what she should do as a mother. She denied access to phones/electronic devices, as had the school, but felt she needed more advice. Following a sexual assault she was advised to have an open door policy at all time and to separate the older from the younger children so they were not alone together. She clearly found this difficult in a small 3 bedroomed house with 6 children and described taking one child out with her whilst she had a cigarette.  4.04  MG described the impact of her childhood sexual abuse on her parenting (although this recognition may be as a result of more recent therapeutic interventions) and that she was terrified that she was “raising monsters” and the impact on her children of being perpetrators and victims. She described feeling how could she as a mother support two of her children who she felt were developing as sexual predators and also protect her other four children. MG did describe that she felt unable to tell her children or agencies about the father’s paternity but reflected that this might have helped them understand better. MG recognised that assurances had been provided consistently by the social worker about the children’s removal from her care but that due to her past she felt unable to believe them.  4.05  When MG was asked what might have helped her or her family in terms of improvements to services, MG wished the supportive interventions from a number of the agencies had begun earlier. She described wanting a larger property to help her manage the situation but that this had not occurred. She welcomed the support that also involved collecting and returning the children and described her wish that there had been some sort of more formalised “respite” to support her in her parenting. She also 8  described that having separate ADHD services from Ryegate and CAMHs for the four children was really practically unhelpful in terms of the many different appointments and the services weren’t coordinated and information was not shared and they were not seen as one family.  4.06  The Independent Reviewer met virtually with FG in prison with the offender manager. As with MG, the focus for the discussion was on the agencies that had worked with the family, what services FG had found helpful, less helpful and what could be improved. FG made a number of similar points to MG. He was clear that he felt the family needed more support around the older children’s sexualised behaviour and he felt that MG being seen by professionals as a “good mum” was a disadvantage to accessing services. He felt that they had been asking for help for too long. FG was also aware of the impact of MG’s abuse as a child and her concern around children becoming perpetrators. Overall he was positive about the individual practitioners and agencies who were involved with the family but also raised concerns around many delays to service provision. In relation to questions about additional respite support, FG described having G2 stay with him for a few nights to give MG a break but that MG couldn’t fully relax as the children were always on her mind.  4.07  In response to discussion on engagement by agencies with FG, he was clear that there was minimal contact with himself despite his significant involvement with the family but also added he was not sure he would have said much. He was clear that MG took on the role of advocate for the children. He however shared MG’s concern that the children might have been removed from their care and there was increasing stress and tension within the family.   5. October 2015 – May 2019: Brief chronology of agency engagement with the family.  5.01  Throughout this period, GI was being monitored by the Ryegate Children’s centre ADHD service and G2 received services from CAMHS for ADHD, art and family therapy. Both children transitioned from their primary to a mainstream secondary school. G3 and G4 were also involved with specialist services due to their special educational needs. G5 and G6 were also born in this period and mother received routine antenatal care and health visitor services. From July 2018 the family received additional early help services focussed on supporting G1 and G2 and from November 2018 received a statutory social care service.  5.02  In September 2015, MG had raised concerns around G1’s sexualised behaviour and the paediatrician at Ryegate Children’s Centre wrote to the school SENCO and had advised MG to discuss this with the school. In October 2015, MG contacted the Police who referred on to Children’s Social Care as G1 had been asked via social media to share a photo of his penis on his mobile phone. MG had seen this interaction but G1 had not. The outcome was No Further Action (NFA) as MG had taken all appropriate action and SYP were unable to identify the contact despite robust attempts.   5.03  In 2016 a referral was made to Children’s Social Care by the ADHD nurse in relation to another child in the family with concerns about sexual exploitation who advised the referrer to contact MAST (Early Help). The outcome of this was for MAST to suggest referral to the NSPCC for advice /support.  5.04  In March 2017, G2 was admitted to ED for a mental heath assessment as he had 9  described suicidal ideation. He had been experiencing suicidal thoughts for four days He was admitted to a ward, and a CAMHS assessment took place with MG present. A management plan was developed, and coping strategies were identified for G2 to use again, should he experience more suicidal thoughts. The next day he was reviewed again by CAMHS. He was discharged home with information about how to manage thoughts of self-harm, and distraction methods. He was referred for a further assessment by community CAMHS. The diagnosis was G2’s response was felt to be a result of increased anxiety and stress.   5.05  In June 2017, SYP and Children’s Social Care were involved when MG referred G1 as she had been told that G1 was spying on a 12 year old child in the family’s shower. MG explained that she also had concerns that G1 was frequently looking at online pornography, despite attempts to restrict his access. MG stated she was supportive of police action at this point, even suggesting that G1 should be arrested. MG disclosed that she had been sexually abused as a child and stated she was worried G1 ‘may become a monster’. Advice was provided to refer to MAST but no further action taken and the case was closed.   5.06  In July 2017, the ADHD nurse at Ryegate referred G1 to Community Youth Teams (CYT) following a telephone discussion and appointment with MG who expressed concerns that G1 was accessing online pornography, demonstrating increased risk taking behaviours i.e. driving his aunt’s car and was becoming more aggressive towards his siblings. MG stated that the police and children’s social care had been involved following an incident when G1 was seen spying on a child, but no further action was going to be taken by either agency. The ADHD nurse observed that G1 was showing rigidity of thought process, was unable to show emotion, and talked obsessively about different forms of sexual activity and formulated an opinion that G1 may be on the Autistic Disorder Spectrum (ASD), and, to support this assertion, arranged for Social Communication Questionnaires (SCQ) to be completed by both MG and G1’s school.  5.07  The outcome of the referral was that the concerns did not meet the CYT criteria for involvement as it was primarily seen as sexually harmful behaviour which was not in their remit and CYT suggested a referral to Children’s Social Care (Sheffield Safeguarding Hub) and provided information on the process.  5.08  In September 2017, MG and G1 attended an appointment with the ADHD nurse at Ryegate Children’s Centre. MG felt that the situation had improved and there had been a reduction in some of the sexualised behaviours. The ADHD nurse however recognised the existing and continuing vulnerabilities and referred G1 again to CYT. The referral was not accepted.  5.09  In February 2018 a multi-agency meeting was held at the school involving the ADHD nurses, SENCO and MG. The outcome was for the school to refer to “safeguarding” but there is no evidence that this took place. In March 2018, the ADHD nurse again referred G1 to Early Help (MAST) as concerns still existed around G1’s obsession with online pornography and risk taking behaviours. In addition the school also made a referral outlining similar concerns. The outcome of this was assessment using the Brook Traffic Light Tool (an assessment of risk for Harmful Sexual Behaviour) and it was decided the eligibility for service was not met.  5.10  In April 2018 the ADHD nurse referred G1 to Children’s Social Care regarding harmful sexual behaviour. This stated that CYT and MAST had both declined the referrals 10  in respect of G1, but that significant concerns existed about G1’s obsession with online pornography, highly sexualised behaviour, and impulsivity. The assessment included use of the Brook Advisory tool and the outcome was the eligibility for service was not met and the advice to the ADHD nurse was to refer to MAST.  5.11  In May 2018, the ADHD service received a letter from G1’s GP. MG had seen the GP, asking for support and help in managing G1’s obsession with online pornography. The GP requested a multi-disciplinary team review, and that consideration be given to a psychological opinion. In May 2018 another meeting was held in G1’s school, to discuss G1’s deteriorating behaviours, including fighting in school, continuing to access online pornography and the fact that he was struggling socially. The outcome was for the ADHD nurse to make a further referral to MAST and to refer G1 to the Golddigger Trust, a Charity working to equip young people with the confidence and skills to make positive choices for themselves.  5.12  In June 2018, the ADHD nurse referred G1 again to MAST, as did the secondary school outlining continuing concerns around G1’s obsession with online pornography and masturbation. The case was discussed at the early help “gateway” meeting in July 2018 and the case was allocated to a MAST intervention worker. However this work was delayed and didn’t begin until the end of October 2018. Intervention ended in February 2019.  5.13  In July 2018, the ADHD nurse completed the referral of G1 to the Golddigger Trust and the referral was accepted. 1-1 work and attendance at drop in sessions began that month and continued until the date of G1’s death.  5.14  In October 2018, the school referred G2 to CYT about concerns that he had a knife like implement and his focus on violence/weapons. The case was allocated and work began in November 2018 including a 4 week targeted intervention programme also attended by G1. Intervention closed in January 2019.  5.15  In November 2018, the school made a referral to Children’s Social Care as MG had stated she observed G4 squeezing their genital area and when asked why by MG, G4 replied because G1 does it. G1 is stated to admitting to MG asking G4 to touch G1’s genitals, but G4 had not done this. MG then stated to school she ‘battered’ G1 but he did not have any marks or bruises and none were observed. MG later confirmed she had slapped G1. The case was allocated to a social worker for assessment. The outcome of this was a referral to be made to the Harmful Sexual Behaviour (HSB) panel and a Child in Need meeting to be held.   5.16  In December a Child in Need meeting was held with MG being supported by FG. This is a multi-agency meeting involving key practitioners to share information, agree support required and actions to be taken. This meeting reinforced MG and school’s actions to prevent internet access for G1 and agreed actions to support MG’s housing application.  5.17 In late December 2018, MG contacted the allocated social worker as G4 had made further disclosure regarding the incident reported in November 2018, which implied penetration but when spoken to alone this was denied by G1.  5.18  In January 2019, a second CIN meeting was held which confirmed steps by school and MG to reduce internet access for G1and shared information on all the children in 11  the family to ensure their needs were being met.  5.19  In February 2019 G1 was discussed at the Harmful Sexual Behaviour Panel (HSB) panel for the first time. Panel members agreed that the social worker needed to make a referral through to Forensic CAMHs.  5.20  In early March 2019 the HSB panel was updated by the allocated social worker who advised a retrospective Strategy Meeting was to be held on the November/December disclosure. The Forensic CAMHs referral was still awaiting allocation and therefore G1 remained on the panel list pending allocation with Forensic CAMHs. A retrospective Strategy Meeting was then held on the same day but the minutes from this meeting have not been located.  5.21  In mid March 2019 a home visit by the social worker was undertaken after a request by MG who was concerned, as G4 had been sitting on the lap of G2 and it was considered by MG to be sexual in its nature, when spoken to G2 also said that he watched online pornography.  5.22  In April 2019, a CIN meeting was held. This focussed on G2’s sexualised behaviour and strategies to manage this as well as pursuing an EHCP and education placements for G2 to better meet his needs.  5.23  In mid April 2019, the HSB panel met and confirmed that the Forensic CAMHS service had received the referral for G1.  As a result of concerns regarding G2’s viewing of online pornography and being found in bed with G4, the Panel requested a further Social Care Assessment should be undertaken for G2 and referred to Panel for discussion and for the allocated Manager to be invited to attend panel in May 2019.   5.24  In May 2019 information from the Golddigger Trust was shared that G1 had disclosed an incident with G2 where he believed G2 was trying to get G1 to masturbate him when he got out of bed to go to the toilet.  The social worker visited the following day to discuss with MG and the children were spoken to alone.  5.25  In mid May 2019, a primary school contacted the social worker to advise a disclosure from a parent who alleged that G2 had sexually assaulted her child the previous day. The social worker undertook a home visit and MG was spoken to along with the mother of the alleged victim. It was agreed a Strategy Meeting was required.  5.26  In May 2019, it was reported that G2 had been with another child of a similar age in his bedroom and had touched him 'inappropriately' over his clothes.  MG also noted that G2 had made a video of himself inappropriately dressed as a baby.   5.27  In May 2019, a well attended Strategy Meeting was held which recognised G1’s addiction to pornography had been a long standing issue and that this has seriously impacted upon his understanding of healthy and appropriate relationships, as well as what normal boundaries should be between people including his siblings. Both G1 and G2 had ADHD and additional needs which impacted upon their understanding and their ability to manage their own behaviours. The decision was for a child protection investigation under S.47 of the Children Act 1989 by Children’s Social Care and to move to an Initial Child Protection Conference.  12  5.28  The outcome of the Strategy Meeting was then conveyed to MG during a home visit by the social worker the same day. MG was concerned that the children would be taken away from her, and she was again reassured this was not the case and the legal process was explained in great detail.   5.29  In May 2019, on the following day, a woman made known to MG that her child had disclosed sexual assault by G2, which had taken place 3 weeks previously.   5.30  The children were then given ADHD medication that night and the older two children died as a result of ligature strangulation the following day.   6. Agency involvement and improvements identified through the agency report process:  Sheffield Children’s Social Care (CSC) 6.01  From allocation in November 2018, the social worker undertook thirteen home visits, frequently saw the children alone, held three CIN meetings, referred to and attended HSB panel and initiated two Strategy meetings. The quality of the intervention was purposeful, skilful and clear and mother described positive relationships between the social worker and herself and the children. The social worker explained and provided assurance on many occasions that the involvement of CSC did not mean removal of the children but when asked by the independent reviewer MG stated that she just could not believe this and was adamant that the children would be removed and placed in care. The social worker also repeatedly requested information on the paternity of the children and this became more robust as the concerns escalated and the case neared child protection processes.  6.02  All procedures were adhered to although on reflection an earlier first strategy meeting should have been held after the more detailed disclosure in December 2018 and there was some delay in the completion of the social work assessment, which included the Christmas period.   Improvements identified by the agency: 6.03  Children’s Social Care have recognised that practice was positive but there are recommendations to further streamline procedures to ensure timely access to specialist support services from the Harmful Sexual Behaviour (HSB) Panel and to reinforce the assessment timescale. In addition to ensure a better understanding for frontline social work practitioners of the impact of SEND in assessing children with learning needs and to consider whether frontline workers have sufficient understanding of how to access respite care.   Additional learning identified by the reviewer: 6.04  In the practitioners meeting it was suggested that the system to refer to the HSB Panel needs to be more streamlined as the requirement for the full statutory social work assessment on G1 and then G2 was a barrier as it slowed the process down. It was suggested that a form on the IT system to refer to HSB Panel would minimise delay and then the social worker could attend the meeting to present the case.   6.05  The Independent Reviewer noted that on three occasions involving previous referrals into Children’s Social Care the outcome was to suggest the referrer should refer to Early Help services (MAST) but this was not facilitated through any “step down” process. This meant referrers having to then re refer to MAST, which is unhelpful and 13  causes delay. Children’s Social Care are clear that this step down process is now taking place.  Sheffield Early Help services-MAST 6.06  The MAST intervention worker became involved with the family from October 2018- February 2019, undertook many home visits and attended relevant meetings. Their involvement ended, as it was clear that the appropriate services to support all the family were in place including from Children’s Social Care and there was no ongoing role. MAST also provided a supportive letter for MG’s request for rehousing to a larger property.  Improvements identified by the agency: 6.07  The MAST service have recognised that the 15 week delay in allocation from July 2018-October 2018 was unhelpful and occurred due to a recruitment freeze. This issue has since been addressed but the service needs to monitor the impact of delays in allocation through its routine performance information provided to the SCSP.  Additional learning identified by the reviewer: 6.08  The referrals to MAST from the ADHD nurse and the school in March 2018 identified concerns about obsession with online pornography and increasing risk taking behaviour but recognised the controls put in place by MG. The assessment was undertaken by use of the Brook Traffic Light assessment tool.  This risk assessment tool, developed by the Brook Advisory Service, supports professionals working across different agencies to identify if sexualised behaviours demonstrated by children and young people are age appropriate, or potentially harmful. G1’s sexualised behaviour was not considered to be harmful by MAST at this point, and therefore did not require intervention. G1 was 13 at that time and the tool does not appear to consider a child’s developmental age rather it is divided into 3 groups by chronological age. From 13-17 obsession with pornography is seen as a “green” light but in the 9-13 the category is rated as “amber” light.  6.09  This will be considered as a later recommendation but the key issue to note is that any tool is just that – it is to support the assessment and further discussion with those involved in the family would have provided clearer evidence of the level of concern.   South Yorkshire Police (SYP) 6.10  SYP’s involvement with the children in Family G originated from concerns MG had around the harmful sexual behaviour displayed initially by G1, and latterly G2.  SYP had no prior involvement with the other children in the family until the day of the incident. SYP had five contacts during the time period of the review already described earlier in the report in relation to incidents of harmful sexual behaviour, the first in October 2015, the second in July 2017, the third in February 2019, the fourth May 2019 and the final strategy meeting on the day of the incident.  Improvements identified by the agency: 6.11  The review has identified failures to appropriately record and where they could have been the lead agency, investigate certain offences, which SYP will continue to audit and monitor. In addition, a decision was made at the Strategy Meeting to proceed to a single agency s.47 (Children Act 1989) investigation by children’s social care and Initial Child Protection Conference in May 2019. Given that when considering both children, an offence of sexual assault was recorded and an earlier allegation of sexual 14  assault alleged, it would have been prudent to pursue a joint agency investigation by police and children’s social care.  Sheffield Teaching Hospital (STHFT)- covering Midwifery, Neonatal services, GP services, Community Dentistry and Emergency Department (ED) 6.12  STHFT has had significant contact with this family, which included Midwifery, Neonatal, Dentistry, ED and out of hours GP services.   6.13  Midwifery were historically involved with all the children and in the timeframe of the review specifically with G5 and G6 who had the same community midwife. MG attended for Midwifery care as required but partner / father of baby details although requested, were not gathered or recorded at the beginning of the pregnancies or at subsequent contacts during the pregnancies. Throughout all the pregnancies, MG is recorded as single and a one parent family. In the first two pregnancies it does state that father was not a blood relative, however, this detail is not completed in future pregnancies.  6.14  No further assessment was undertaken via an Family Common Assessment Framework (FCAF)/early help assessment as it was assessed as not required as no vulnerability factors were identified at booking and at interview. However, at 16 weeks, in G6 pregnancy, the midwife indicated an FCAF had been discussed and a decision made to complete this assessment due to the number of children and MG being a single parent rather than there being any specific concerns. However, as the pregnancy progressed, there was no evidence that this FCAF was completed and at 27 weeks, records indicate that a FCAF is no longer required.   6.15  Following a previous SCR in 2012 in a neighbouring authority, a recommendation for Sheffield Midwifery was to complete safeguarding checks on women declining to give the name of the father, but this did not take place. Midwifery were not aware of any other agency involvement and had they been aware of the complex challenges within this family, the author considers that this would have been pursued further by liaising with other agencies and agreement reached how to work together to support the family.   6.16  G6 spent two days following birth in the Neonatal unit who did record that GMG and an aunt were not allowed to attend the unit. There is no evidence that this was explored further or shared on a need to know basis.   6.17  It was evident there was a level of dental neglect for MG and FG and one of the children. However, there was insufficient concern to refer for further support and there were no concerns from the minimal contact with the ED and out of hours GP service.  Improvements identified by agency: 6.18  The agency author identified that there was evidence of a lack of professional curiosity when it came to the father of the children and the support network that was available to MG and her children. The eight detailed recommendations reflect actions to take with regards to these two areas and primarily focused on the need to further develop systems to ensure that if father’s details are not recorded /other agencies are involved this will be identified, that services ensure relevant health records are reviewed. In addition, specific training is to be undertaken on engagement with fathers/male carers.  15   Sheffield Children’s NHS Foundation Trust- Acute services 6.19  G1 was first seen by the Neurodisability team in August 2011 with concerns of hyperactivity, impulsivity and inattention problems. He was assessed, given a diagnosis of ADHD in February 2012 and started on medication. The ADHD service sits within the Neurodisability/ community paediatrics service, which consists of a multi-disciplinary team made up of doctors, nurses, psychologists, occupational therapists and physiotherapists. Once a diagnosis is made children may be followed up in nurse-led clinics for management and monitoring.  6.20  G1 was seen regularly by the ADHD nurses and there was frequent telephone contact in between appointments in response to MG’s concerns. The ADHD nurses were tenacious in their attempts to secure support from other agencies from September 2017 in relation to G1’s obsession with online pornography, levels of masturbation and risk taking behaviour. At least six referrals were made to CYT; MAST; Golddigger Trust and the Safeguarding Hub, which resulted in allocation in July 2018 to the Golddigger Trust, and MAST.  6.21  G2 had some limited contact with Sheffield Children’s NHS Foundation Trust. G2 was seen in ED for two injuries and at the allergy clinic which confirmed allergies in 2016 and the use of Epipen was advised and G2’s school were informed of the need for an Epipen and an emergency treatment plan.  6.22  In March 2017 G2 attended ED, accompanied by MG. He had been experiencing suicidal thoughts and CAMHS assessment took place with MG present. A management plan was developed, and coping strategies were identified for G2 to use again, should he experience more suicidal thoughts.   Improvements identified by the agency: 6.23  G1 was known to the ADHD service for the duration of the timeframe of this review. It is acknowledged that there were areas of good practice, in respect of the continuity of professionals involved in his care; prompt responses to MG’s request for support; ADHD nurses attended the CIN meetings for G1, and liaison with G1’s school and social worker. Both ADHD nurses recognised G1’s vulnerability, harmful sexual behaviour and his concerning risk taking and aggressive behaviours, and referrals were made to a number of services to try and access support for G1 and his family.   6.24  The agency author notes that the health professionals involved in the children’s care did not actively seek expert advice from the hospital safeguarding children team when referrals to organisations and services to support G1 were rejected. In addition, safeguarding supervision was not sought in accordance with the SCH Safeguarding Supervision Policy.  6.25  The recommendations for improvement therefore include a review of the supervision policy to establish that the correct staff groups in acute services are assigned to 1:1 supervision and improvements to the IT system so full demographic details of family members are included. In addition, they recommend training to be delivered to relevant staff about harmful sexual behaviour, including the Sheffield multi-agency guidance and flowchart.   Sheffield Children’s NHS Foundation Trust- provider of CAMHs services 16  6.26  Both G1 and G2 were open to CAMHs. G1 was known to CAMHs from February 2019 and G2 was referred in November 2013.   6.27  The focus of the CAMHs work with G2 until February 2016 was completing the specialist assessment with G2 and feeding back the diagnosis of Attention Deficit Disorder to G2, MG and the school. This involved sharing the diagnosis, but also liaising with school to ensure that G2 had the right level of support. The other main input during this time was starting G2 on medication for his Attention Deficit Disorder and monitoring the medication closely.   6.28 In March 2017, MG reported to the team that G2 had come home and stated he was going to stab himself with a knife through the heart. MG was advised to take G2 to ED to have an urgent mental health assessment. Following the assessment and overnight admission, it was felt that G2 was safe to return home in relation to the risks to his mental health. It was agreed that a further mental health assessment for G2 may be helpful, and he was therefore referred to the Psychiatrists in the Community CAMHS team. The mental health assessment was completed in May 2017 and it was determined that G2 was suffering from anxiety and stress. It was agreed that further therapeutic input might be helpful.   6.29  From May 2017 to August 2018, there was continued support from CAMHs to G2 and MG with regard to the medication that G2 was taking for his ADD. Medication was also prescribed to help with G2’s sleep issues. There was considerable liaison with school to discuss the best ways of supporting G2.   6.30  In August 2018, G2 and MG were offered therapeutic support to help to manage G2’s anxiety. The therapy sessions continued until February 2019. Alongside the therapy sessions, there was continued monitoring of medication requirements for G2, as well as continued ongoing close liaison with school. CAMHs also proactively raised the need for an EHCP to be progressed for G2 from December 2018.  Improvements identified by the agency: 6.31  There are two areas for improvement that have been identified by the agency author. One relates to the accessing of safeguarding advice / supervision. If this had been accessed, it potentially could have promoted a discussion about the relevance of the information obtained, provided opportunity for exploration of this using the Signs of Safety Model. The second relates to appropriate record keeping when attending a multiagency meeting, to ensure clinicians make more detailed notes, even though official minutes were included in the record.   Additional learning identified by the independent reviewer 6.32  The Independent Reviewer has noted additional areas of learning. Firstly for both CAMHs and Ryegate services. They were both offering similar services in relation to ADHD for G2 and G1 respectively over a period of years. In addition, Ryegate were involved with another child in the family and CAMHs also with another child in the family. There is no evidence that there was a joined up co-ordinated approach to this family or to the sharing of information. MG reported when asked, that she had found attending appointments at the two different locations caused logistical difficulties and repeating information unhelpful. There is no doubt that there was therefore no holistic overview from the two services who had the most involvement with the family over a long period of time.   17  6.33  The second issue relates to delays in service provision –firstly in undertaking the initial ADHD assessment of G2 which took a year to complete and secondly the delay between the referral to Forensic CAMHs in February 2019 and allocation which had not taken place by the date of the incident. It is significant in that this was clearly the level of specialist service that G1 needed and may have helped to reassure MG about the risk posed by G1.  Sheffield Children’s NHS Foundation Trust- Speech and Language Therapy (S&LT) 6.34  G1 was re-referred to the S&LT service in May 2018 by his GP due to concerns regarding severe stammering impacting on communication. G1 attended five appointments with therapists until October 2018 and was felt to make good progress. An S&LT referral form was received for G2 from his Community Youth Team Worker in December 2018 because of concerns regarding his ability to express ideas, his memory and social communication skills. The referral was accepted by the S&LT service on 15/02/2019 and G2 was seen twice for assessment and it was felt his difficulties were explained in the context of his diagnosis and advice provided.   Improvements identified by the agency:  6.35  The service identified it did not consistently document the name and relationship of all adults and children in the appointments in the school or clinic setting. It also identified when school staff or others are invited to attend training that is client-specific e.g. stammering workshops, language disorders workshops, staff need to record the invitation in the client’s record and save copies of invitation letters in the patient file.   Sheffield Children’s NHS Foundation Trust-0-19 –Health Visiting and School Nursing services 6.36  From 2004, in view of the identified vulnerabilities the family was offered an extended programme of care. This extended programme of care included additional home visits and attendance at well child clinics.  Health Visitor interventions involved responses to health needs identified in child health/developmental reviews and family health assessments i.e. support with toilet training and behaviour management.  6.37  From 2015 onwards and the birth of G5 and G6, the routine health visiting service consisted of an antenatal contact, a new birth visit undertaken when G5 and G6 were 10-14 days old, a maternal mental health assessment when the children were 6-8 weeks old and child developmental reviews carried out when G5 was one and two years old. Within the Review period MG was seen on seven occasions with G5 and G6. No concerns were identified although she described she had experienced a “terrible childhood” which included sexual and physical abuse, she reported that she did not have contact with her own mother (GMG) but received support from her brother and her friends who lived locally. Health visitors had no concerns around MG’s parenting, her mental health and felt she had a good support network. It would appear MG did not discuss her concerns around the older children’s behaviour with the Health Visitors, as their contact with the family was routine and focussed on G5 and G6.  6.38  School nursing had routine involvement with the children and none with parents but did ensure contact with agencies took place when they became aware of safeguarding issues i.e. hospital admission in 2017.  Improvements identified by the agency: 18  6.39  Where there are multiple children in one family, practitioners to be reminded to ensure that all health records of the children include key significant events and the relevant family history from previous records to assess and review vulnerability and risk. Practitioners are also to be reminded to prioritise attendance and contribution to appropriate safeguarding meetings and to obtain a copy of the meeting minutes, whether they have attended the meeting or not.   6.40  Practitioners are also to be reminded where a Health Visitor and School Nurse are both involved, timely liaison/communication should take place, in order to share relevant information and to agree on the most appropriate 0-19 service representation at safeguarding meetings.  Improvements identified by the independent reviewer: 6.41  Health Visiting were however represented at the Early Help Gateway meeting in July 2018, which considered the referrals from the ADHD nurse and the school. These should have identified the concerns around the sexualised behaviour of G1 and might have resulted in additional input from the health visitor/school nurse. A lack of professional curiosity was recognised.  GP services 6.42  Despite the complex needs of Family G they were not seen frequently or well known to their GP. The children were seen for routine vaccinations and baby-checks, there were few appointments missed and the children appropriately attended occasionally for minor ailments.  6.43  None of the contacts directly with Family G in primary care, or the communications from other professionals, highlighted concerns about MG or how the family was functioning as a unit. There are no consultations, or letters, which explicitly state that MG has been asked how she’s coping or how she’s feeling. Yet from reviewing the GP records and clinic letters for the oldest four children, it appears that MG was constantly advocating for them; to get them reassessed, correctly diagnosed, better supported in school and ultimately transferred to more supportive educational environments.   6.44  There is no mention of a biological father, partner to MG or any extended family throughout all of the GP consultations and secondary care letters. The only mention of another adult apart from MG is of a female friend of MGs that the children referred to as ‘second Mum’ but a good knowledge of who was in their lives would have been crucial in terms of assessing risks and strengths for them.  Improvements identified by the agency: 6.45  A lack of professional curiosity and professional optimism was identified by the agency author. Suggested improvements focussed on encouraging practices to maintain a list of vulnerable families which includes those where there are a number of children with health needs with multiple health professionals involved.   Education- local secondary school 6.46  In relation to G1, through late 2015 and continuing through 2016 there are a number of incidents with other children where G1 had been involved in ‘bullying’ style incidents, the majority of these incidents evidence that at this point G1 was the victim. In 2017 there is a significant decline in the number of behavioural incidents recorded, 19  however in 2018 the incidents of G1 accessing online pornographic sites and materials increased – three incidents are recorded and noted within the chronology and an ‘apparent obsession with accessing pornography and masturbating’ and referrals made to CYT, MAST and that his SEN profile has been shared. The school pro-actively prevented and managed G1’s access to the internet.  6.47  In relation to G2, in early 2017 there are notes that link suicidal thoughts to G2 and there is a link with another female who is also contemplating taking her own life. In July 2017 there are times when G2 self-harms and there are worries that he cannot regulate which means MG is called to school and he is taken home, this links to consideration of a Managed Move to another school which didn’t take place.   6.48  In 2017 a “My Plan” is started, this contains information recorded in the Child Profile, family details and child’s view, there is also a support plan with limited information. The level of need identified within the My Plan indicates that there are level 3 needs linked to Social Emotional and Mental Health, however there is an application for SEND funding made in December 2018 which would indicate wider / higher levels of need.   6.49  A decision to initiate an EHCP was made in early 2019 and in May 2019 a private Educational Psychologist (EP) assessed the needs of G2 in school within a one session appointment and a report was provided. It is recorded within the assessment completed that G2 only understands direct language and will not understand sarcasm; the EP report bases the majority of G2s needs within social communication.  6.50  In April 2019 inappropriate sexual linked searches on the internet were identified and linked with frequent use of the toilet.   Improvements identified by the agency: 6.51  The approach taken by the school regarding the welfare of the children linked to safeguarding appears robust and their communication to social care was frequent and relevant sharing their concerns. However, the agency author identified an apparent lack of joined up thinking across Education, Health and Care and this lead to delay in assessment and professional involvement around SEND. The interface between processes around Safeguarding and SEND need to be reviewed to ensure they are robust and that information is shared and decisions are then informed by a full understanding of the children’s context. There were also some queries around the coding of the children’s attendance at school, which needed further exploration.  The Golddigger Trust 6.52  Golddigger Trust were involved with the family from July 2018 when G1 was referred to the service by Ryegate Children’s Centre (ADHD Nurse). They were actively involved in supporting G1 from July 2018 until May 2019. This support consisted of 12 sessions of 1:1 mentoring with his key worker to discuss self esteem and online pornography, and attendance at open access youth group sessions and holiday activities. MG saw intervention with G1 as helpful and there is evidence of sensitive focused work. G2 was known to the agency through attending informal open access youth group sessions and holiday activities from August 2018 to March 2019.   Improvements identified by the agency: 20  6.53  Through the review the agency identified that further work could be undertaken to further clarify internal supervision models with staff, and to ensure written records of peer/group supervision sessions are recorded and reviewed. The agency recognised the Trust could have been more proactive in seeking updates regarding Sheffield Children’s Social Care’s enquiries into the harmful sexual behaviour concerns in the home to identify if any further support could have been offered by Children’s Social Care or any other partner agency to G1 to help reduce his anxieties. The peer supervision provided during their involvement with G1 and G2 could have been improved through this being more structured and formal with improved recording  Sheffield Futures – Community Youth Teams (CYT) 6.54  This is a targeted, early help service for vulnerable young people aged between 10 – 18, which aims to support young people into positive destinations and reduce the likelihood of them entering the criminal justice system. The service supports young people to engage with education, employment and training opportunities and reduce risk taking behaviours to promote longer term positive outcomes.   6.55  Referrals had been received from the ADHD nurse in 2017, which had raised concerns around G1 and his obsession with online pornography and HSB. The response was to signpost the referrer to the Safeguarding Hub and the HSB pathway and was repeated in July 2018. In October 2018, G2 was referred to CYT by the school who were concerned about risk around use of weapons and violence. The Prevention Worker (PW) undertook work with G2 for a period of six weeks from November 2018-January 2019 including two home visits, two school meetings and picked up and dropped off G2 from the family home to the four week targeted intervention group work programme. This practical support was highly valued by MG. The work concluded that the overall risk to G2 displaying any offending behaviour was low as G2 understood and displayed appropriate attitudes towards offending behaviour.   6.56  During a supervision session the PW raised with their line manager concerns MG had disclosed regarding G1 accessing pornography and asked if G1 was able to attend the Targeted Intervention sessions that were relevant with G2. G1 subsequently attended two of the sessions.   6.57  There was no learning/improvements identified for the agency.  Housing provider 6.58  There had been minimal contact between the housing provider and the family other than the normal repairs/maintenance visits. There were no concerns identified by any of the operatives attending the house or in any of the rent arrangements. MG had applied for a larger property to the Local Authority and this was going through due process.  6.59  There was no learning /improvements identified for the Housing provider.  7. Findings and Analysis  7.1  The deaths of these two children is a tragedy and there is no evidence from this review process that any of the practitioners and agencies involved with the family could have predicted the actions taken by their parents. This review has seen significant evidence of effective and caring practice with the children by all agencies involved 21  with the family.  7.2  As with any review, the process of reflection has identified some areas where the current systems and processes could be improved. All the agencies involved with Family G have identified their own learning and have captured a number of single agency improvements identified in section six of this report and developed recommendations into action plans. The themes identified below set out additional learning identified by the Independent Reviewer and have resulted in recommendations.   Theme one - Recognition of and response to harmful sexual behaviour (HSB) by professionals. 7.3  Concerns around G1’s sexualised behaviours were identified as early as late 2015 when G1 was 11 years old. He was referred by the ADHD service in June 2017 in relation to his increasing risk-taking behaviours (driving aunt’s car) and his obsession with online pornography and levels of aggression. G1’s and G2’s behaviour escalated throughout 2018/2019 with increasing incidents of bullying/fighting/aggression in school and an interest in online violence/weapons and pornographic websites and masturbation at both school and home. In relation to G1, from November 2018 onwards there were 3 incidents of Harmful Sexual Behaviour involving his siblings. In relation to G2, from September 2018 there were 5 incidents of Harmful Sexual Behaviour –two involving G1 and his siblings and three with other children.   7.4  The primary learning issue identified by this review relates to the understanding of and response to Harmful Sexual Behaviour. Overall practitioners appeared to lack confidence in understanding this specialist area of abuse and were not confident in their response. There may be some confusion with child sexual exploitation and also how children with learning disabilities are assessed. There doesn’t appear to be a sufficiently clear definition, shared understanding of terminology or language for Harmful Sexual Behaviour by and between agencies. The ADHD service at Ryegate clinic referred the family on six occasions because of perceived harmful sexual behaviour over a period of 2-3 years. It would clearly have been helpful for specialist direct assessment work to have taken place at an earlier point but referrals were screened out and not felt to meet eligibility criteria. (Recommendation 1)  7.5  Agencies relied on the use of the Brook Traffic Light assessment tool in isolation from an assessment of the family context, which therefore did not provide a full picture both of the historical concerns and that this behaviour involved more than one child in the family. It also didn’t allow assessment of whether the level of obsession with pornography and masturbation was deemed within a normal range of behaviours by children of that age and gender and with their level of functioning. At the time of the first concerns raised, G1 was13 years and 1 month, meaning that the behaviour described had begun when he was 11/12. This included watching and talking about graphic pornography and watching another child in the shower. There is some debate about the level of risk this relates to within the Brook Traffic Light Tool and agencies did not share the same view on the level of risk identified.  7.6  The Harmful Sexual Behaviour (HSB) Panel and pathway was established in April 2018 and is currently under review. Although a helpful multi-agency initiative it requires agencies to have undertaken an assessment against the Brook Traffic Light tool only and then refer to the Safeguarding Hub. This tool is a helpful guide but does not provide all the contextual information that would support a fuller assessment by the Safeguarding Hub. It also requires the social worker to have then completed the full social care 22  assessment before consideration by the HSB panel, which in this case with the Christmas holiday period took 11 weeks. A suggestion from practitioners was that a referral form is used and the social worker could attend the Panel to discuss the case to address any perceived barriers to access more specialist services.   7.7  The review of the HSB Panel needs to also consider how it can offer more advice and consultation to practitioners working with families where HSB has been identified. Although the safety plan involving an open door policy and to separate the children implemented following disclosure in November /December 2018 was intended to address the presenting concerns, there is a question if it was sufficiently robust to minimise harmful sexual behaviour between the siblings. (Recommendation 2)  Theme Two - Professional optimism/curiosity  7.8  It is clear that all professionals involved with the family saw MG as a competent, caring and capable mother who advocated for her children appropriately and sought help and support constructively. However, the impact of caring for six children, four with diagnosed learning difficulties, two displaying risk taking behaviours and showing signs of aggression and harmful sexual behaviour and two children under three must have been considerable. MG talked to the Independent Reviewer of having been offered respite historically and felt with hindsight that this support would have been welcomed. The many services involved with the family understandably saw the need and focus of their work through the lens of their own perspective. In the final year before the incident the family received support from a number of services however simply the fact of a single mother caring full time for six children and the impact of that was not considered in its own right.  7.9  It is also evident that all appropriate professionals involved with the family asked MG about the paternity of the six children. MG was consistent in her response that the children all had the same father but that he was not involved with the children’s upbringing and had no ongoing role with the family. Although many professionals were tenacious in requesting this information, it was only when the case was moving into the child protection arena that MG felt that the truth of the children’s paternity would be revealed. MG was clearly anxious about the impact of the children’s paternity becoming known. However, it is important to note that current agency practice would require a comprehensive risk assessment to be undertaken but there would be no automatic removal of children and any possible criminal prosecution would need to be seen to be in the public interest.  7.10  Many of the agency authors recognised that their practitioners needed to be more professionally curious in their interactions with the family and to undertake a more holistic view of the whole family experience and the largely fractured approach to the agencies working with the family. (Recommendation 3)  Theme Three- Invisibility of father/male carer  7.11  This is a theme found in many Serious Case Reviews nationally and again was identified in many of the agency reports. Although it was not known that FG was the father of the children, he was a significant part of their day to day lives and their parenting experience. He was at the home daily and often accompanied or took the children to their numerous appointments and meetings. There is no sense that any practitioner spoke with him, other than the social worker or that he was considered in the assessments of the family. MG was articulate and clearly able to advocate for her children but FG’s views and a better understanding of his role was not undertaken until 23  the more statutory involvement by Children’s Social Care. (Recommendation 4)  Theme Four- Eligibility to services 7.12  There are a number of occasions when referrals made to services did not meet the eligibility criteria. There were two previous referrals into Children’s Social Care in July 2017 and April 2018, which related to G1 and harmful sexual behaviour which were assessed to not meet the criteria and Early Help (MAST) services were advised but they were not formally stepped down by Children’s Social Care. It is unfortunate that the referral in April 2018 to Children’s Social Care didn’t progress as this was potentially an opportunity to access specialist services six months earlier. (Recommendation 5)  7.13  Referrals directly to Early Help (MAST) from Ryegate and the school did not meet the eligibility criteria in March 2018 as the Brook Traffic Light Tool was used in isolation and further information not requested.   7.14  Three referrals to Sheffield Futures from September 2017 around G1 sexualised behaviour did not meet their criteria and Ryegate were advised to refer to the Safeguarding Hub as per the HSB guidance, which was appropriate.  7.15 The overall outcome is that concerns around G1 and sexualised behaviour, obsession with online pornography and levels of masturbation were known about and referred for services from July 2017. No statutory intervention took place to address these concerns until late October 2018.  Theme Five- Resources/Timeliness/delays to services 7.16  The original referral to CAMHs in November 2013 for G2 resulted in a decision to undertake an ADHD assessment, which took some time to conclude and provide a diagnosis although other therapeutic services were provided in this period.  7.17  Following the referral in November 2018 and additional information on the assault in December 2018 into Children’s Social Care a strategy meeting should have taken place but was delayed until March 2019. Although this does not appear to have had a direct impact it would have enabled multi-agency consideration of risk and the safety plan put in place to manage risk within the family.  7.18  There was a delay of around two months in the case being considered at the Harmful Sexual Behaviour Panel, as the process required the statutory assessment to have been completed by CSC. The concerns were however well known. (Recommendation 1)  7.19 The referral advised by the HSB Panel to Forensic CAMHs was discussed in February 2019 but intervention had not taken place by the time of the incident. Forensic CAMHs is commissioned by NHS England as part of the children and young people’s mental health transformation programme, works with children and adolescents up to the age of 18 years with severe disorders of conduct and emotion, neuropsychological deficits, serious mental health problems and/or learning difficulties and who are engaged in dangerous, high risk behaviours and/or who have become or are likely to become, involved in criminal proceedings. The decision to delay allocation was based on the capacity within the team of the appropriate specialist staffing resource. Given the increasing level of concern around both G1 and G2 this intervention should have taken place earlier. (Recommendation 6) 24   7.20  The delay in allocation of 15 weeks by the MAST Team was as a result of a recruitment freeze. Other agencies, including Ryegate, CAMHs, S&LT and the voluntary agency Goldigger Trust were providing support to the family during this period but it would have been good practice for MAST to have a formal discussion with these other agencies to consider how they were managing these issues in the interim. (Recommendation 7)  Theme Six- Information sharing and risk assessment processes 7.21  There are two health services in Sheffield that have evolved to assess and support families where ADHD has been diagnosed- Ryegate Children’s Development Centre and CAMHs. It would appear the majority of children are referred to Ryegate by their GP/HV/School. However, as in this case the family had four children, two of whom being seen by Ryegate and two by CAMHs ADHD services. They do not share IT systems and there is no formal process of discussing all the children in the family in a holistic, co-ordinated way. MG reported that although she found the services helpful, she found this separation unhelpful and uncoordinated. The significance is that it was G1 being seen at Ryegate and G2 at CAMHs and both children’s sexualised behaviour was increasing. It would therefore be helpful for families who are receiving services from these two separate agencies to develop a protocol to ensure information is shared and increasing risks can be assessed and managed. (Recommendation 8)  7.22  Strategy Meetings- There is evidence that the minutes from the Strategy Meetings and also CIN meetings were not on HV/SN, S&LT or GP records and the minutes from Strategy Meetings were not on police records. There is also a perception of challenges in health representation at strategy meetings on open cases. Work has been undertaken to address both these issues and compliance is monitored by the SCSP. (Recommendation 9)  7.23  Information sharing /involvement of the VCFS. If there is a voluntary organisation involved with a child then they should be invited to attend or contribute to all the relevant statutory meetings by the lead professional assuming their involvement is known.  7.24  The issue about how effectively the SEND processes and safeguarding processes within schools are linked and coordinated needs to be further reviewed. These children were in both systems and the SEND and safeguarding issues overlapped and needed to be seen holistically to consider the most appropriate assessments and supports. (Recommendation 10)  Theme Seven- Impact on children and their lived experience 7.26  Practitioners saw MG as a loving, caring and competent mother. She disclosed her childhood history to a number of practitioners but declined to discuss further the impact this might have on her parenting. MG suffered sexual abuse as a child from a number of different perpetrators and from a young age. This in itself will have clearly impacted on her view of the risk of sexual abuse perpetrated by or on her children. It would seem from the forensic psychologist report presented in the criminal proceedings that MG had a “chronically traumatic childhood and was subjected to sustained neglect and emotional, physical and sexual abuse that impacted on MG’s adult functioning by making emotional closeness uncomfortable, taking a ‘victim stance’, creating a strong need for control in her life and developing a dysfunctional understanding and experience of sex and intimacy”.   25  7.27  In discussion with the Independent Reviewer, MG described her increasing fear that with each disclosure she felt she was raising sexual predators. Her possibly enhanced sensitivity may have resulted in her continually questioning her children. It is also significant that the older two children’s ADHD may have resulted in them functioning socially at a much younger age and “having no filter”. This may have resulted in them being far more open and honest about their sexual feelings with their mother than other teenage males. However it is clear that MG’s childhood history of neglect/sexual abuse needed to be explored further to understand the impact on the children and Children’s services need to ensure that there is no barrier to accessing historical information on parental files. (Recommendation 11)   7.28  MG also described her negative experience of being in “care”. She was very anxious from November 2018 onwards that removal from home might be the outcome for her children and this was communicated to some extent to the children. G1 reported to the Golddigger Trust that he was anxious that someone would just come and take him from school. Although many parents share this anxiety and despite repeated assurances from the social worker, the fear remained and clearly increased significantly with the increased disclosures in the days leading up to the incident.   8. Effective practices that had a positive impact on Family G  8.1  The focus of this Review is to learn and improve services. As such, it is important to learn from practice that is considered effective and supports good outcomes for children. The Independent Reviewer has seen significant evidence of professional effective practice from professionals involved with this family, which is to their credit.  9. Recommendations   9.1  The Review concludes with recommendations to the Sheffield Children Safeguarding Partnership (SCSP), which build on the recommendations and actions already identified for learning by single agencies during the process of researching their involvement in this case. In a number of cases, actions have already been taken to improve arrangements/systems.   9.2  The following additional eleven recommendations are provided under overall learning themes to ensure that SCSP and its partner agencies are confident that any other areas are addressed and that the SCSP is able to monitor progress.  Theme One - Recognition of and response to harmful sexual behaviour (HSB) by professionals  1.  Sheffield Children’s Safeguarding Partnership to ensure the current review of the role and function of the Harmful Sexual Behaviour Panel and pathway for HSB considers the need for advice and consultation to be part of the remit and addresses how the process to access specialist support can be streamlined.  2.  Sheffield Children’s Safeguarding Partnership to ensure the review of the Harmful Sexual Behaviour strategy includes agreed definitions and terminology and its implementation is supported by specialist resources, tools and training to enable practitioners to feel confident in assessing risk including to children with disabilities. 26   Theme Two - Professional optimism/curiosity   3.  Sheffield Children’s Safeguarding Partnership to review their current multi-agency offer /training on addressing professional optimism/curiosity to all practitioners and continue to promote awareness and understanding of how this impacts on their assessments.  Theme Three – Invisible male carers/fathers   4.  Sheffield Children’s Safeguarding Partnership to review their current multi-agency training and review single agency training/supervision/quality assurance arrangements to ensure practitioners proactively consider fathers/male carers in their analysis and risk assessments and understand any barriers.   Theme Four- Eligibility to services  5.  Sheffield Children’s Safeguarding Partnership, as part of the development of the current Contextual Safeguarding strategy, develop an integrated offer for harmful sexual behaviour to include eligibility to services and quality of decision making. Once established, SCSP undertake routine quality assurance to assess the effectiveness of the arrangements   Theme Five- Resources/Timeliness/delays to services   6.  Sheffield Children’s Safeguarding Partnership request NHSE as the commissioners of Forensic CAMHS consider the impact of delays to provision of services and consider how needs can be met for children in a more timely way.  7.  Sheffield Children’s Safeguarding Partnership continues to receive performance data and assurance on the delays in allocation by all agencies and consider ways to manage cases in the interim.  Theme Six- Strengthening multiagency information sharing and risk assessment processes   8.  Sheffield Children’s Safeguarding Partnership request the CCG as commissioners of the ADHD/ASD services at Ryegate Children’s Development Centre and CAMHs review their service provision and arrangements to consider how a more coordinated offer can be made to families with children diagnosed with ADHD.  9.  Sheffield Children’s Safeguarding Partnership to maintain the focus on strategy meetings on open cases to ensure they are minuted, distributed to partners in a timely manner and that there is health representation.  10. Sheffield Children’s Safeguarding Partnership request evidence that all agencies and schools are aligning their SEND and Safeguarding processes to ensure that children’s needs are viewed holistically.  27  Theme Seven- Impact on children and their lived experience/understanding the impact of traumatic adverse life experiences on parenting   11.  Sheffield Children’s Safeguarding Partnership consider how practitioners can be informed with the necessary resources, tools and skills to ensure the impact of childhood sexual abuse/adverse life experiences on parenting capacity and perception of harmful sexual behaviour is understood.  