A potentially life threatening injury to Child O carried out by the resident parent. The resident parent had displayed worsening mental health problems over a number of months. A suicide attempt which put Child O at risk, resulted in hospitalisation of the resident parent during which time the resident parent's partner was assessed to be able to care for Child O. After discharge the resident parent was rated 'red, high risk' and the Out of Hours Social Services team were involved in actions to protect Child O. The wider family repeatedly raised concerns with a number of agencies about the resident parent's mental health despite a GP assessment of risk to be low. Learning includes: joint working to assess risk and plan; recognising the risks to children of parental mental illness; listening to family concerns; overreliance on specialist consultant's diagnosis; reliance on partners to care for patients and ensure safety of dependent children. The review followed the Partnership Learning Model. Recommendations were made for Bournemouth and Poole Safeguarding Children Board relating to multi-agency working, listening to families, Think Family messages being translated into practice and tracking risk assessments.
      
 Title:  Serious case review: Child O. LSCB: Bournemouth and Poole Safeguarding Children Board Author: Moira Murray Date of publication: 2017  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           Child O Overview Report July 2017  Page 1 of 14       Bournemouth & Poole Safeguarding Children Board  SERIOUS CASE REVIEW CHILD O            Independent Lead Reviewer: Moira Murray until 26 August 2016 Updated by Child O Serious Case Review Panel June 2017  Approved by the LSCB Executive Board on 12th June 2017  Publication date: July 2017  Child O Overview Report July 2017  Page 2 of 14   INTRODUCTION .................................................................................................................................. 2 1. BACKGROUND TO THE REVIEW ........................................................................................... 2 2. THE REVIEW PROCESS ........................................................................................................... 3 Purpose of the Review ................................................................................................................ 3 Leadership and membership of review ..................................................................................... 3 Focus of the Review .................................................................................................................... 4 Time Parameters for the Review ............................................................................................... 4 Parallel Processes ....................................................................................................................... 4 Involvement of the family in the review ..................................................................................... 4 Methodology .................................................................................................................................. 4 3. SUMMARY OF THE CASE: ....................................................................................................... 5 4. EVALUATION OF EFFECTIVENESS OF PRACTICE .......................................................... 7 5.  PRACTICE LEARNING POINTS…………………………………………………………………………………….…...7  6. THEMATIC ANALYSIS: LEARNING FROM THE CASE ..................................................... 9 Joint working to risk assess and plan ........................................................................................ 9 Recognition of mental health and illness ................................................................................ 10 Think Family ................................................................................................................................ 10 Over reliance by professionals on a specialist consultant’s diagnosis ............................... 10 Children seen as a protective factor for parents who are mentally ill ................................. 11 Reliance on partners to care for patients and ensure the safety of dependent children . 11 The need to listen to and respond to the concerns of extended family members ............ 11 Baton of risk................................................................................................................................. 12 Management oversight, supervision and confidence to raise issues with managers ...... 12 7.  RECOMMENDATIONS…………………………………………………………………………………………………………12 Appendix 1: List of agencies who contributed to the Serious Case Review ............................. 14  INTRODUCTION  1. BACKGROUND TO THE REVIEW  1.1. Child O was involved in a potentially life-threatening incident by his resident parent who was suffering from poor mental health at that time. The child survived this incident.   1.2. Notification of the serious incident was made to Ofsted by the relevant local authority.   Child O Overview Report July 2017  Page 3 of 14  1.3. The Bournemouth & Poole LSCB Serious Case Review Group was requested by the Independent Chair of the Bournemouth & Poole LSCB to review the case.  Initial briefing reports from agencies involved with Child O and their resident parent were considered and it was the majority recommendation of the Serious Case Group that criteria were met for a Serious Case Review.  1.4. The decision to initiate a Serious Case Review was made by the Independent Chair of the LSCB, based on the criteria defined in Chapter 4, paragraph 8 of Working Together to Safeguard Children, 2015, and in line with the Pan Dorset Inter-Agency Safeguarding Procedures, in particular:   “Serious Case Review (see page 75) for every case where abuse or neglect is known or suspected and either:   a child dies; or  a child is seriously harmed and there are concerns about how organisations or professionals worked together to safeguard the child”    2. THE REVIEW PROCESS Purpose of the Review  2.1. The purpose of a Serious Case Review is to:  Establish whether there are lessons to be learned from the case about the way individual agencies work, individually and together, to safeguard and promote the welfare of children;  Identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result;  Improve individual agency working and inter-agency working and communications in order to better safeguard and promote the welfare of children1.  Leadership and membership of review   2.2. The Serious Case Review Panel was chaired by the Designated Nurse Consultant for Children, NHS Clinical Commissioning Group. Moira Murray was appointed as the Lead Reviewer, Overview Report Author. Moira Murray is an independent safeguarding children consultant. Neither the Chair of the SCR Panel nor the Lead Reviewer had any previous involvement with the case. The Lead Author role moved to the Child O SCR Panel team, once criminal proceedings were concluded and the key areas to explore were identified.  2.3. A Panel of Senior Managers representing each of the agencies involved was appointed to support the Review.  Panel members and agencies which provided reports to the review are listed in Appendix 1.                                                            1 Working Together to Safeguard Children, 2015 Child O Overview Report July 2017  Page 4 of 14  Focus of the Review  2.4. The Serious Case Review considered the following:  Effectiveness of multi-agency working and information sharing. o How effectively were the child’s needs and the impact of the resident parent’s mental health on the child considered by all agencies involved? o Which agency identified what risk and how was this: - Understood, shared and managed? - What was the outcome of the action? - What were the processes used and were they adhered to?  The Child’s Experience  How were the extended family’s concerns responded to?   Time Parameters for the Review  2.5. The Serious Case Review period was agreed as a period of one year and ten months leading up to the serious incident. Relevant background information was also included to inform the review and to put the incident into context.  Parallel Processes   2.6. Care proceedings under the Children Act 1989 were initiated by the local authority in respect of Child O; during the Serious Case Review Child O remained in the care of family members.   2.7. A Serious Untoward Incident Review (SUI) was undertaken by the Mental Health Care Trust (MHT) Quality and Clinical Risk Group into the involvement of health professionals in the case. This has been viewed by the Author and Chair of the SCR Panel and the findings of this SUI correlate with the findings of the SCR. An action plan from the SUI will be implemented and progress monitored by the MHT Management Board.  Involvement of the family in the review  2.8. Family members were informed of the Serious Case Review, and following an initial delay because of criminal proceedings in respect of the resident parent, interviews were undertaken with the resident parent and other relevant family members. Attempts to meet with the resident parent’s partner were made, but were not successful. An offer of an interview was made but not responded to by the non-resident parent.  Methodology  2.9. The Review broadly followed the Partnership Learning Model. Individual Agency Reviews were undertaken by each agency involved to identify their own learning and a combined chronology of events and interactions was created. Child O Overview Report July 2017  Page 5 of 14  The Serious Case Review Panel met to consider these findings and to draw together the learning from the multi-agency working. This was followed by a Practitioner Workshop giving the opportunity for participation of managers and practitioners directly involved with the case.  3. SUMMARY OF THE CASE:   3.1. In this anonymised version of the report, a very brief summary of the case is provided to protect the identity of the child and family. The confidential Overview Report produced for the LSCB Executive Board has full details, to provide assurance that the review scrutinised events in the family history thoroughly.  3.2. There were no concerns about Child O as a baby or young child. Child O started school at the same time as a family member died of cancer and the resident parent was prescribed anti-depressants and offered some mental health services, which they did not use. The resident parent reported difficulties in their relationship with another family member, which was leading them to experience low self-esteem.   3.3. Four months later the resident parent was assessed by mental health professionals as experiencing depression and anxiety and was referred to the Community Mental Health Team. At this point, risks to themselves or others were assessed as not being present and the resident parent’s partner was seen as supportive as a carer for them and Child O. Child O was noted to be a protective factor for the resident parent’s mental health. Their partner expressed some concern at this point about resident parent’s honesty with services.   3.4. Children’s Social Care (CSC) were initially involved in mid-way through the review period, following an anonymous referral with concerns about resident parent’s mental health, alcohol and drug misuse. These concerns were also shared by the referrer with the resident parent’s GP. CSC made referral enquiries with the school and GP, they met the resident parent and saw Child O alone. They heard from the resident parent and partner that there was an acrimonious relationship in the wider family. CSC took the decision that the concerns did not reach a threshold for a referral or assessment as there were no concerns about care offered to Child O and the referral was malicious. The resident parent was advised to access mental health services and their GP.   3.5. Later that month the resident parent took an intentional overdose and took actions that could have endangered the young Child O, who would have witnessed some of these behaviours. Mental Health and CSC referrals were made by hospital staff and a Strategy Discussion was held the following day involving CSC, Police and Health. A plan to undertake section 47 child protection enquiries was made and the resident parent’s partner was to be Child O Overview Report July 2017  Page 6 of 14  assessed to be able to care for Child O. A social worker visited twice, seeing resident parent’s partner and Child O, who was reported not to be aware of the resident parent’s distress.   3.6. The multi-agency assessment to undertake section 47 enquiries, led by CSC, was not completed until seven months after the overdose incident and there was no formally recorded assessment of the risks to Child O until the risk escalated again.   3.7. On the resident parent’s discharge from hospital there was a ‘red, high risk’ rating given by the mental health services and CSC were involved in the discharge arrangements. The Out of Hours Social Services team (OoHSS) were involved in the actions to protect Child O. In the period following discharge there were some visits by mental health services and CSC. Some concerns were raised about paranoia but the resident parent denied this and suicide intention or thoughts of harming others.  3.8. There was limited services involvement for a period and in this time, extended family members periodically tried to raise concern about a deterioration in resident parent’s mental health.   3.9. A month before the multi-agency assessment was finalised, the resident parent was seen by a consultant psychiatrist who assessed them as having mixed anxiety disorder and depression, to be treated by their GP and mental health services and by the resident parent reducing their cannabis use. Immediate risks were considered to be low and the level of input was reduced from intensive support. CSC decided that once it was confirmed that the resident parent’s partner was clear in their role as carer for the resident parent and Child O, they would withdraw.  3.10. In the days leading up to the serious incident, family members contacted a range of agencies again expressing concern over the further deterioration of the resident parent’s mental health, including reference to a text from the resident parent to a family member that clearly implied a further attempt had been made at serious self-harm and harm to Child O. None of the agencies contacted or visited the resident parent or Child O at this point, but gave the family advice on what to do or other agencies to contact.   3.11. On the following day, a potentially life threatening injury to the child by the resident parent was disrupted and the resident parent was taken into custody; while the Child O was saved from harm and placed with extended family members.   Child O Overview Report July 2017  Page 7 of 14  4. EVALUATION OF EFFECTIVENESS OF PRACTICE  4.1. This publication version does not contain the full evaluation undertaken, which is available in the confidential report to the LSCB, however the good practice identified and the practice learning points formulated are summarised in the following list:  4.2  Good Practice Points  a) It was good practice by a junior doctor to recognise symptoms of mental ill health and non-compliance with a treatment plan and to bring this to the attention of a Consultant. b) The GP understood the need to consider Child O’s welfare in well-being concerns for resident parent at one point. c) The plan produced at the Strategy Meeting was robust and child focussed, with actions allocated to appropriate agencies, within timescales.   d) Hospital staff recognised the need to alleviate resident parent’s anxiety about being ill (based on family history) and provided a scan to provide reassurance.  5. PRACTICE LEARNING POINTS  5.1  Referrals, Risk Assessment/Management and Planning:  a) Agencies need to make referrals on every case that meets the threshold for CSC assessment. They should not rely on others to do so as they may have key information not known to others. b) Anyone making a referral to CSC must consider all the information available to them and share each element that may support the assessment of risk. c) Multi-agency assessments, meetings and shared plans are key to ensuring shared understanding of risk and joined up working. All agencies are responsible for ensuring joint working is effective and to challenge each other on progress of agreed actions.  d) Completion of section 47 enquiries is key to safeguarding children who are identified to be at risk. CSC need to be assured that systems are in place to quality assure timeliness and quality of these key assessments. e) Professionals need to be fully aware and informed of a patient’s past and recent history when making an assessment. The importance of professionals adopting a triangulation approach when reaching decisions about the assessment of risk cannot be underestimated. f) When making assessments, professionals need to take into account the whole picture of a child’s environment and consider what it is like to be a child living in that family, especially when a parent has engaged in actions which could significantly harm themselves and their child. There always needs to be consideration of the ‘worst case scenario,’ whilst still managing risk proportionately. Child O Overview Report July 2017  Page 8 of 14  g) The risk assessment process must promote the use of open questions and enable people to explain concerns. h) Where there are concerns about the outcome of an assessment by a senior clinician, other professionals need to have the confidence to challenge such findings if there is a risk of possible harm to a child. i) Practitioners across adult and children’s services must be aware that considering a child to be a protective factor for an adult has been shown in previous Serious Case Reviews to increase the risk to the child. Thorough assessment is needed before this conclusion is drawn and when a vulnerable adult self-harms or attempts suicide the risk of filicide needs to be considered. j) Practitioners across adult and children’s services need to be aware of the risks cannabis use can pose, to inform their assessments. k) Practitioners need to ensure there is a shared understanding of the actions agreed at the end of a discussion. l) Requests made to OoHSS (Out of Hours Social Services) need to be clear about the expectation of action and that this will be effective in protecting children. All requests to OoHSS should be in addition to ongoing risk assessments and safety plans. In turn, OoHSS need to be clear about their capacity to respond.   5.2  Information sharing and record keeping : a) Schools need to maintain accurate, timely and appropriately detailed records where there are child in need/child protection concerns. b) When Children’s Social Care contact other agencies for information they should summarise the reason for the enquiries and the agency involved should make a record of this. Agencies should insist on knowing the reason for the enquiry, to enable them to play their part in safeguarding children. c) Changes in the allocation of services need to be communicated promptly to the other agencies involved to improve the effectiveness of communication d) Professionals need to be aware that where there are concerns about the well-being or behaviour of people who work with children or adults they should liaise with the Local Authority Safeguarding Adults Lead for Adults and the Local Authority Designated Officer for Children.  5.3  Recognition of and responding to mental health and illness: a) A Mental Health Act Assessment provides an appropriate framework to identify risk to adults and their children. They must be used in cases where there are serious suicide attempts. b) Those undertaking assessment of mental health needs should consider that some patients will be able to ‘mask’ symptoms for short periods and they should use other sources of information to support diagnosis. c) Those working with adult mental health needs have to expect this to have an impact on children in the household and then need to work as part of a multi-agency team to identify the level of impact and risk.  Child O Overview Report July 2017  Page 9 of 14    5.4  Whole family approach:  a) Where there is conflict between family members, professionals must be careful to explore risks to children, despite reports appearing malicious. b) When responsibilities to safeguard adults and children are given to family carers, their capacity to do so needs to be evident / assessed and recorded. c) Practitioners working across children and families’ services / agencies need support to fully embed the ‘Think Family’ approach of being aware of the well-being of all members of a service user’s family and acting on this awareness. d) The importance of listening to the concerns of family members to inform assessments is important; usually families do not express concerns easily. e) The reliance on family members to support parents who are mentally ill, and protect children from harm, is an essential part of planning. However, this needs to be based on an assessment of their capacity to do so, and their feedback needs to be considered in further risk assessment and planning. f) Families should not be left to deal with acute, complex mental health situations without clear planning and intervention by professionals.  5.5 Management and Supervision: a) Practitioners need to be realistic about what can be achieved within their own capacity and flag unmet need with strategic managers b) There are recognised capacity issues within School Nursing Services nationally.   6. THEMATIC ANALYSIS: LEARNING FROM THE CASE  Joint working to risk assess and plan  6.1. The resident parent received services from their GP, the hospital and a range of mental health services.  Child O received services from their school, Children’s Social Care and their GP.  Unfortunately, apart from one Strategy Meeting held two months before the serious incident, there was no other evidence of agencies formally developing a shared assessment of risk to Child O, or of a joint plan on how best to manage such risk.  The plan produced at the Strategy Meeting was robust and child focussed, with actions allocated to appropriate agencies, within timescales, but no further plan was agreed.   6.2. If there had been a joined up, multi-agency approach to this case the risk might have been more clearly identified and agencies would have been clearer about each of their expected roles. It is possible that resident parent’s partner’s capacity to care for Child O and support the resident parent would have been assessed and that the wider family would have been brought into this planning Child O Overview Report July 2017  Page 10 of 14  as a resource to support Child O their resident parent, and the impact of cannabis use might have been explored. Recognition of mental health and illness  6.3. A number of professionals identified and responded appropriately to resident parent’s symptoms of mental health at different stages.  6.4. The overdose and concerning behaviours in the two months before the serious incident were acute and should have prompted a Mental Health Act Assessment.  This did not happen, and although the resident parent stated that they had no suicide ideation, the amount of medication they took indicated otherwise. The resident parent was able to minimise their mental illness to the mental health services, including to the Consultant who saw them in outpatients. This resulted in the risk presented to Child O being underestimated.   6.5. There was no evidence that the Consultant Psychiatrist’s assessment had been triangulated with other professionals or family member’s accounts to understand the concerning behaviours being exhibited.  6.6. The subsequent alerts raised by family members about deterioration in the resident parent’s mental health were not heard.  6.7. The case raised the challenging aspects of working with denial, lack of insight and concealment of mental health symptoms and how practitioners need to work with others to be able to draw together a wider assessment than the patient’s own account. They need to be highly vigilant for incongruence. Think Family  6.8. There were times when the impact of the resident parent’s mental health on Child O was considered. However, this was not robust or consistent enough and did not result in effective joint risk assessment and planning. The impact on Child O and level and nature of the risks faced were underestimated.  6.9. Practitioners working across adult and children services need to be supported to maintain a focus on the Think Family agenda, to understand the impact in a family of single or multiple issues. They need to use this awareness and translate it into practice for their specialism.  Over reliance by professionals on a specialist consultant’s diagnosis  6.10.  There was a distinct shift in the way in which agencies considered the risk presented to the resident parent and to Child O after the consultation with the Consultant Psychiatrist a month before the serious incident. Agencies need to maintain their own assessment of risk and need based on their assessment rather than relying solely on specialist diagnosis.   Child O Overview Report July 2017  Page 11 of 14   6.11. There was no evidence that other professionals challenged the diagnosis when they had information which contradicted it. Children seen as a protective factor for parents who are mentally ill  6.12. This case has highlighted the danger of professionals seeing children as being a protective factor when a parent is exhibiting mental health issues and where there are concerns about suicide ideation. Numerous Serious Case Reviews have shown that children are often at an increased risk of harm in such situations. Their welfare and safety need to be seen as a paramount concern for all professionals involved with the family. It is crucial that children are seen as individuals in their own right, with appropriate risk assessments being undertaken before such a conclusion is reached. Reliance on partners to care for patients and ensure the safety of dependent children  6.13. The expectation by professionals that the resident parent’s partner could ensure their safety and that of Child O was misplaced and had not been drawn from any assessment. Resident parent’s partner had given some indications that they could not fulfil these roles, but was not listened to. The need to listen to and respond to the concerns of extended family members  6.14. This Serious Case Review has demonstrated the importance of the need for professionals to take seriously the concerns of family members.  Concerns about the resident parent’s deteriorating mental health and its impact on Child O should have been given greater credence; they could see the longer-term changes in behaviour and wellbeing.  The extended family should have been involved in professional discussions about the resident parent’s mental health, and should have been given the opportunity to explain their concerns in detail to professionals.  The minimisation by the resident parent of their mental illness could have been challenged, and more scrutiny could have been made as to whether it was appropriate for the resident parent’s partner to be given the responsibility of supervising them and protecting Child O.  This information may have informed decisions about the resident parent’s care. This did not happen and family were left with a feeling that they were not being listened to and not taken seriously.   6.15. In the month leading up to the serious incident, when very acute concerns were raised by the extended family, there was a lack of appropriate intervention by both Mental Health Services and the Out of Hours Social Services team (OOHSS).  A risk assessment should have been undertaken by both agencies and it was unrealistic to put the onus back onto the family to manage the resident parent’s deteriorating mental health and increasingly dangerous behaviour. This was unrealistic and abdicated professional responsibility.   Child O Overview Report July 2017  Page 12 of 14  Baton of risk  6.16. There have been a number of examples in this review where the risk being passed between individuals (family and professionals) has not been securely ‘handed over’ or ‘picked up’. The terminology of Baton of Risk was used in both the SCR Panel discussions and the Practitioner Workshop and is a useful analogy to use in learning from this review. Management oversight, supervision and confidence to raise issues with managers   6.17. There is little information available to the Serious Case Review as to the management oversight or supervision of professionals involved in this case.  Professionals need to have the confidence to raise issues with their managers where there is uncertainty about how to proceed or decision making and this was not evident.   6.18. Managers need to have oversight of key assessments to ensure they are completed in a timely way and to promote significant agendas such as Think Family and the joint working that arises from this.   6.19. The provision of specialist advice and supervision for professionals involved in cases concerning children with parents who have mental health concerns is crucial if awareness is to be raised and children safeguarded.  There was no evidence presented to the Panel that this was sought in this case.  7. RECOMMENDATIONS   Individual Agency Reviews have captured actions identified from their own analysis. Some of these will respond to the issues raised in thematic learning. The Action Plan from the MHTT SUI will be progressed and monitored by MHTT.  The following recommendations are made for consideration by Bournemouth and Poole Safeguarding Children Board and relate to multi agency effectiveness and the LSCB’s role of scrutiny:  7.1. The Practice Learning Points of the Review need to be shared widely for agencies and individuals to consider how they could influence day to day practice.  7.2. This review should be used to remind staff in all partner agencies of the importance of listening to and taking appropriate action when concerns are raised by family members. Agencies should consider how they can audit or monitor their practice in this area.  7.3. Further promotion of Think Family messages and how these translate into practice is needed across services. It needs to include the impact of mental health and substance misuse on children, the capacity of partners and family Child O Overview Report July 2017  Page 13 of 14  members to provide care and protection and the need for good multi-agency assessment and planning.  7.4. Children’s Social Care services should be asked to provide evidence of how they track and monitor progress of significant assessments (such as section 47 enquiries) in everyday management practice.  7.5. Awareness of the risks associated with cannabis use needs to be promoted with practitioners to ensure this is included in assessments where cannabis use is known or discovered.  7.6. The LSCB should identify the best way to quality assure that joint working arrangements between adult mental health services and children’s services are effective and have captured the learning from this Review.  7.7. The LSCB should continue to promote the use of escalation and challenge where there is difference in professional views / drift identified. The LSCB should revisit whether this is common practice, as it is expected to be.   Child O Overview Report July 2017  Page 14 of 14  Appendix 1: List of agencies who contributed to the Serious Case Review  1. Organisations required to undertake an Individual Agency Report:   Police  Children & Young People’s Social Care, local authority  Mental Health Care Trust  Clinical Commissioning Group (CCG)  Hospital  Out of Hours Service, local authority  Education, local authority/school  Ambulance Service Trust   2. The Serious Case Review Panel was comprised of   Designated Nurse Consultant, CCG - Chair   Children’s Service Director, local authority   Deputy Designated Nurse Consultant, CCG   Head of Adult Mental Health Services, Mental Health Trust  Safeguarding Lead, Ambulance Trust  Strategic Safeguarding and Quality Manager, local authority  Detective Chief Inspector, Public Protection, Police  School Head Teacher       Date of publication:  July 2017  Report published by:   Independent Chair, Sarah Elliott Bournemouth and Poole Local Safeguarding Children Board  Bournemouth Learning Centre Ensbury Avenue Bournemouth  BH10 4HG  01202 458873  http://www.bournemouth-poole-lscb.org.uk     