Death of a 15-week-old baby girl, J, in May 2014. A post-mortem confirmed she died of a head injury and further tests concluded this was likely to have been as a result of shaking. J's mother and her partner were convicted of causing or allowing her death and given custodial sentences. J was born prematurely with suspected foetal alcohol syndrome. A month before her birth, she and her three siblings were made the subject of child protection plans for neglect. Family history of: domestic violence and alcohol abuse; ongoing animosity between J's mother and the father of J's siblings over contact arrangements; significant involvement of children's social care during both Child J's mother's and her new partner's own childhoods; and offending behaviour and cannabis use by mother's new partner. Findings include: recording systems do not include fit-for-purpose chronology templates, making it harder for practitioners to understand a family's history; standardised tasks and contracts of expectation are used too routinely and without consequence in child protection plans making them ineffective at tackling deep-rooted, learned behaviour. Sets out key findings using a systems-based approach developed by Social Care Institute for Excellence (SCIE). Poses questions for Newcastle Safeguarding Children Board based on the review findings.
      
 Title:  Serious case review: “Child J”: overview. LSCB: Newcastle Safeguarding Children Board Author: Edi Carmi and Sarah Peel Date of publication: 2016  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.                                     SERIOUS CASE REVIEW  “CHILD J”   MAY 2016             1 CONTENTS  INTRODUCTIONINTRODUCTIONINTRODUCTIONINTRODUCTION    2222 1111 SCOPE OF THE REVIEWSCOPE OF THE REVIEWSCOPE OF THE REVIEWSCOPE OF THE REVIEW    3333 2222 OVERALL APPRAISAL OFOVERALL APPRAISAL OFOVERALL APPRAISAL OFOVERALL APPRAISAL OF    PRACTICEPRACTICEPRACTICEPRACTICE    3333----12121212 3333 WHAT MAKES LEARNING WHAT MAKES LEARNING WHAT MAKES LEARNING WHAT MAKES LEARNING FROM THIS CASE MORE FROM THIS CASE MORE FROM THIS CASE MORE FROM THIS CASE MORE WIDELY APPLICABLE?WIDELY APPLICABLE?WIDELY APPLICABLE?WIDELY APPLICABLE?    13131313----15151515 4444 REVIEW FINDINGSREVIEW FINDINGSREVIEW FINDINGSREVIEW FINDINGS    15151515----66664444 6666 LEARNING ADDITIONAL LEARNING ADDITIONAL LEARNING ADDITIONAL LEARNING ADDITIONAL TO THE FINDINGSTO THE FINDINGSTO THE FINDINGSTO THE FINDINGS    66665555----66667777 APPENDIX 1APPENDIX 1APPENDIX 1APPENDIX 1     REVIEW METHODOLOGY &REVIEW METHODOLOGY &REVIEW METHODOLOGY &REVIEW METHODOLOGY &    PROCESSPROCESSPROCESSPROCESS    66668888 APPENDIX 2 APPENDIX 2 APPENDIX 2 APPENDIX 2  REFERENCESREFERENCESREFERENCESREFERENCES    77772222 APPENDIX 3APPENDIX 3APPENDIX 3APPENDIX 3     GLOSSARY OF TERMSGLOSSARY OF TERMSGLOSSARY OF TERMSGLOSSARY OF TERMS    77773333           2 INTRODUCTION Newcastle Safeguarding Children Board (NSCB) initiated a Serious Case Review (SCR) in May 2014 following the unexpected death of J when she was 15 weeks old.  She and her siblings had been subjects of Child Protection Plans for neglect for five months. An initial post-mortem concluded that her death was caused by a head injury.   Further tests confirmed that this was likely to have been as a result of shaking.  J’s mother and her partner were convicted of causing or allowing J’s death in December 2015 and given custodial sentences.  The exact circumstances of her death still remain unclear.  This SCR was undertaken between May 2014 and February 2015.  The lead reviewers had to wait for the criminal proceedings to be completed to be able to speak with family members.  Following this, the report was amended to include family members’ perspectives and to reference changes implemented since the LSCB’s acceptance of the findings in March 2015.  Succinct summary of the case J was born prematurely and with suspected foetal alcohol syndrome.  A month prior to her birth, she and her three siblings (all under 5) had been made subjects of Child Protection Plans for neglect, primarily due to concerns about their young mother’s lifestyle and the continued disputes between her and the father of J’s three siblings.  After J’s birth, her mother and siblings moved to a new tenancy in a different part of the city. Mother’s ex-partner had not been part of the family household for some time but had regular contact and care of his three children three days per week as part of the Child Protection (CP) Plan. Contact arrangements were rarely straightforward due to the ongoing animosity between him and the children’s mother and much of the professional attention focussed on this conflict throughout the case.  At the time of J’s death her mother was in a new relationship with a young man who had also been known to authorities since childhood. He had been living with J, her mother and siblings for three months, although J’s mother had repeatedly denied that she was in a relationship prior to him moving in.  She became less available to professionals after he moved into the home. A Review Child Protection Conference held two months before J’s death had been generally positive in its prognosis for the future.  The structure of this report Section 1 highlights the scope of the review and the research questions that focussed the analysis.  Section 2 gives an overview appraisal of professional practice at the time, summarising what happened and why.  Section 3 shows why the learning generated by this case is more widely applicable.  Section 4 presents a detailed series of Findings.  The process that the review followed and the methodology used are both outlined in Appendix One.  Appendix Two lists the document references and Appendix 3 is a detachable glossary of acronyms used in the report.   NOTE: Where the perspectives of family members have been integrated within the appraisal or Findings these are shown in italics. 3 1 SCOPE OF THE REVIEW  Research questions  Integral to the SCIE Learning Together methodology used for this SCR is the formulation of ‘research questions’ to provide a framework for investigation and analysis.  These questions are agreed at the outset and identify which aspects of multi-agency safeguarding work it is hoped to learn more about.   NSCB identified two linked and over-arching questions: A) What can we learn about the effectiveness of multi-agency analysis of risk and intervention in relation to: • Babies on Plans (Child Protection or Child in Need)? • Pervasive patterns of inter-generational abuse and neglect? B) What can we learn about what helps and hinders professionals' ability to effectively challenge other professionals, families and systems, in the context of families who have had lifetime involvement with Children’s Social Care and other agencies?  Review scope  The review examined in detail the period between May and December 2013, looking at multi-agency decision-making, assessments and interventions up to and including the professional response immediately following J’s death.  More recent and historical context was also considered and has informed the review’s Findings. For detail about the review process and methodology, see Appendix One.  2 APPRAISAL OF PRACTICE – AN OVERVIEW This review’s focus is the functioning of professional systems, not the apportioning of responsibility for J’s death; this has already been determined by court processes. In order to understand what happened the case needs to be set in the context of the entirety of child protection casework at the time. The family was well known when the case entered the system and this also coincided with a time when resources in most agencies were unusually stretched.  Both of these factors had an impact upon practice – the former in terms of the way that some professionals thought about and assessed risk and the latter because capacity to reflect upon practice was more restricted than would usually be the case.  Cases involving child neglect require extra vigilance from agencies that are highly attuned to make immediate response to serious incidents, because the warning signs may not be so obvious.  That said, even if practice had been better or different at certain times the outcome in this case may well have been the same.   For the purpose of this overview appraisal of practice we have divided the nine month review period into three: a period of assessment prior to the children being made 4 subjects of CP Plans (J was unborn); the period immediately prior to J’s birth; and the 4 month period between J’s discharge from hospital and her death.  Period 1: leading up to unborn J and siblings being made subjects of Child Protection Plans, April – July 2013 The circumstances of this family were similar to many others referred to Children’s Social Care (CSC) at the time; a recently single, young mother with three young children (siblings1, 2 and 3), well known to the system and with intermittent crisis points relating to domestic violence and drinking. In particular there was a history of reported domestic violence with the children’s father (Partner1), from whom she was separated, but with whom she continued to argue about contact arrangements. This view that the immediate risks to her children were largely linked to this relationship prevailed, not just at this stage but throughout the period under review. Concerns about the impact of mother’s lifestyle increased at the beginning of the period under review, because she was pregnant and homeless, having just returned from a stay in another area of the country. She had come to the notice of the local children’s social work service there, who made a referral to Newcastle CSC.  An initial assessment of need was started in April 2013, which progressed to a core assessment after mother had missed appointments with both CSC and Housing Advice staff. Meanwhile the family were provided with emergency housing (which included a childcare facility) and the children placed in school/nursery.  In May, while the social work core assessment was open, mother was suddenly admitted to hospital under the influence of drugs and alcohol and she initially made an allegation of serious assault, which she later withdrew.  Because there was an assessment already in progress, a decision was made to incorporate this incident into that work and to then form a view as to whether more action was necessary.  At this point mother was about 16 weeks pregnant. Given this fact and what was already knowable about her past history (albeit possibly not known to practitioner and manager at that point), the Review Team judge that it would have been more appropriate to have held an immediate multi-agency strategy discussion to explore the circumstances of this episode further with other agencies and initiate a child protection enquiry under Section 47 Children Act 1989 (s.47).  Finding 1 addresses the importance of understanding someone’s past history and the contextual barriers that inhibit professionals from doing this.   The value of s.47 investigations as opportunities for more probing investigation is highlighted in Finding 2. The health visitor, commendably, twice requested a strategy discussion/meeting at this stage but in response to being told that the core assessment needed to be concluded first, there was no further professional challenge. Any professional can and should challenge a decision not to hold a strategy meeting if they believe one to be necessary and escalate this challenge if need be.  It is possible that people are deterred from doing this because of the absence of any specific reference to challenge in this context in national guidance; nor are strategy meetings referenced in the ‘escalation’ section of Newcastle’s CP procedures. The Designated and Named Nurses are not aware of any such escalation ever having taken place by health staff. The allocated social worker (SW) went on extended sick leave at the end of May.  Although support was now being provided to mother and the children by community health, school and housing staff there was a short period of delay before a new SW 5 (SW2) was allocated in June, partly because it was not immediately apparent that the sick leave would be long term.  SW2, having previous knowledge of this family, recognised the outstanding need for a multi-agency strategy meeting and convened one at the beginning of July. This was effective practice, facilitating the sharing of information and the agreement of an appropriate level of intervention from this point forward, including convening an initial child protection conference (ICPC). However, although a number of agencies were very appropriately represented at the strategy meeting (health visiting; school; supported housing provider) the absence of any invitation to midwifery and substance misuse services was a weakness, given their critical role in relation to the unborn child and concerns about a possible premature birth. It has not been possible to establish the reasons behind this omission.  The police also did not attend: this was not unusual at the time, it is understood, due to ‘operational capacity issues’. The absence of the police from key meetings is considered in report section 6, ‘Learning Additional to the Findings’.  July 2013: Initial Child Protection Conference (ICPC) On the date set for the ICPC, mother was in hospital, having self-admitted a few days before with abdominal pains; the children were staying with their father, Partner1. The Independent Reviewing Officeri [IRO] deferred the Conference by a day to enable Partner1 to be there and ensure that the process was understood by at least one parent. The decision to defer by just one day (rather than longer) was understandable and on balance appropriate given legitimate fears about an imminent premature birth, as well as the need to consider any urgent responses to the safety of the children, but it did impact upon professional attendance despite the best efforts of SW2 to contact everyone. The absence of Mother from the conference, itself far from ideal, was compounded by the fact that she had avoided all SW2’s attempts to contact her.  The report and assessment that went to the conference had therefore to be completed without any input from her.  Vulnerability in the system relating to the process for identifying and inviting people to Conferences is explored in greater detail in Finding 3. See Finding 4 for further discussion about the limitations the system places on capacity to produce a quality assessment at this stage.  The Conference agreed that all children, including unborn J, should be made subjects of Child Protection Plans for neglectii.  This was an appropriate decision given the known and potential risks to the children and the unborn child arising from mother’s lifestyle. Case transfer in Newcastle between IRS and a long term social work team usually takes place at the initial conference, but did not in this case because unusually, no social worker had been allocated to receive the case. To their credit, the IRO and SW2 made sure the long term team were represented at the meeting by seeking out the                                             i Child protection conferences are chaired by an independent reviewing officer [IRO]. S/he is independent of the social worker’s line management ii Neglect is currently described in government guidance  as: “The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. ” Under the same definition, neglect may involve a parent or carer failing to: • Provide adequate food, clothing and shelter (including exclusion from home or abandonment) • Protect a child from physical and emotional harm or danger • Ensure adequate supervision (including the use of inadequate caregivers) or ensure access to appropriate medical care or treatment Respond to a child’s basic emotional needs. 6 responsible Team Manager on the day. The long term team manager resisted immediate case transfer until certain tasks had been completed.  The absence of a receiving social worker, the key health professionals and the mother meant that there was no real ownership to the child protection (CP) Plan at this stage, an outline for which had been provided by SW2. In effect, the IRO developed the Plan in the Conference largely on her own. Finding 5 highlights the importance of developing a Plan to properly fit the circumstance. The IRO did recognise the value of placing the family in the context of the wider family network (who were known to professionals) and tasked the long term Team Manager with drawing up “an up to date and detailed family tree” since none existed. This never happened. The IRO also reinforced the seriousness of the situation by requiring legal advice to be sought by CSC and if necessary following this, a Pre-Proceedings meetingiii to take place prior to the case transferring from SW2 to the long term social work team. Period 2:  From the ICPC to the birth of J at the end of August This was a period of almost exactly one month, half of which the children spent living with their father (Partner1), until professionals were confident that heavily pregnant mother was not misusing any substances - she was subject to random toxicology testing.   The team manager of the team to which J’s case was transferred was retiring at the end of August and did not supervise any work in this period.  The manager allocated a new social worker (SW3) to the case, but did so whilst SW3 was on leave, which is not good practice. The rationale for allocation of SW3 is not clear (the manager when spoken to could not remember), although it is likely to point to a lack of options at the time.  It factored against consistency from the perspective of the family since SW3 was herself pregnant and due on maternity leave within 3 months.   An experienced senior practitioner (SP1) took temporary responsibility for the case at the first core group meeting in early August until SW3’s return in the second week of August because, contrary to plans agreed at the conference, the case transferred from SW2 to the long term team at the first core group.  This also meant that there was no direct handover between outgoing and incoming social workers at the meeting, as would usually be the case. SP1 continued in a supporting role on SW3’s return and up to the start of new interim management arrangements – pragmatic, but not ideal given SW3 had limited experience of CP casework and would have benefited from an opportunity to have more formal, reflective supervision.   The early August core group meeting did not further develop the outline plan as procedures intend. Since mother was present, it went over what had happened at the ICPC, in order that mother understood what she had missed and what was expected.  The Pre-Proceedings meeting presented the Review Team with an anomaly that we were not able to resolve.  The date was set by SW2 before the case transfer but there were no records of it, either in CSC or in the Legal Service.  That a meeting took place is not in doubt, as there is verification of that from a later solicitor’s letter.  It is likely that it was chaired by the Team Manager who retired at the end of August, but any detail                                             iii A pre-proceedings meeting is usually held if social workers are considering legal intervention. It provides an opportunity to meet with parents and their solicitor and see if it is possible to reach agreement about what needs to happen to protect the child from harm, so that court proceedings can be avoided. 7 relating to who attended, process and decisions is missing.  This is unusual given the formal context for such a meeting, which should have been clearly laying out the conditions that mother needed to meet in order for her children to remain at home, and attended by legal representatives of the local authority and the parents.  The child protection plan that was actively being addressed in subsequent Core Group meetings contained no reference to the meeting after this point. Core group members effectively supported the family over August and communicated well with each other.  The Family Intervention Project (FiP) worker (who had been temporarily seconded to work with mother to support her move to a new tenancy and was also a qualified SW) provided intensive support for mother.  She built a relationship with her at this time that was both supportive and appropriately challenging. The school too were in regular contact with both parents, acting as intermediary to resolve conflict over contact and monitoring the appearance and behaviour of the children, two of whom attended regularly over the summer holidays. That they were able to do this over a holiday period was an exceptionally high level of service.  The youngest child had contracted scabies in July and although was not at school, was being monitored regularly at home by the health visitor. See Section 6 ‘Additional Learning’ for more on the value of high quality support services. SW3 formally met the Core Group when it met for the second time at the end of August, without mother but with Partner1 present. The meeting focussed entirely upon making practical arrangements with him for the care of Siblings 1, 2 and 3, given the imminent arrival of baby J.  While it was entirely appropriate to assure the children’s safety and wellbeing, what the meeting did not do was review J’s Birth Plan to make sure that hospital staff had access to the information that they needed or that the information was accurate, nor was there any further reflection on the viability or otherwise of the various aspects of the CP Plan (Finding 5). Barriers to effective Core Group functioning are explored in Finding 6. J was born the day after the Core Group meeting, 6 weeks prematurely by emergency Caesarean section. She was transferred the next day to a neighbouring hospital Special Care Baby Unit (SCBU) because of a lack of cots. The FiP worker had helped mother to secure a new tenancy by this stage and a date had been set for the house move at the end of the month.  Even though mother had been discharged after 3 days (J remained in SCBU for 19 days) she was very weak; her request to postpone the house move was denied in order to avoid housing benefit being liable on two properties. Just eight days after J’s birth therefore, mother moved from emergency accommodation to a new home in a different part of the city. The Review Team commented on the inflexibility of this approach, particularly given the family’s child protection status, but did not have sufficient evidence to make it a systems Finding.  Mother told the lead reviewers that this was a 'nightmare' for her and chaotic, trying to decorate her new home when she had just given birth. J’s half-siblings stayed with their father until early September.  The Community Midwife did not find out that mother was in hospital or that she had been discharged until 5 days after the event and most members of the Core Group found out about J’s birth via mother herself, not from the hospital. This was in part attributable to the transfer of baby J between hospitals, but still exposed shortcomings in the communication between staff of both hospitals and their community colleagues. 8 Period following Baby J’s birth, September – December 2013 The potential and actual risks to J and her siblings are most evident over this period but the level of professional intervention reduced.  Two main contextual factors seem to have contributed to this: stretched capacity which impacted upon opportunities for multi-agency reflection and analysis and, feeding into this, a fixed idea of the nature of the risks, compounded by mother’s likeability and her plausibility if challenged.   The interim organisational and supervisory arrangements that were put in place in CSC pending a permanent replacement for the team manager who retired in August had an impact on both social work staff and managers.  Line management responsibility for SW3’s team was temporarily and pragmatically split between remaining permanent team managers to cover the gap. As a consequence, the team was split between different managers and SW3’s interim team manager had a temporary increase in her management responsibilities with additional staff and cases. SW3 had two handover meetings with the interim Team Manager at the end of August; and early September, to go over all her allocated cases.  Neither meeting was an opportunity to think very reflectively because so much ground had to be covered.    At roughly the same time, mother’s circumstances changed.  During her preparation for moving house, staff in the emergency housing service had identified that a young man was visiting her. They alerted the FiP worker to the existence of a new partner, but Mother’s assertion that he was just a friend was accepted. On one level this was understandable as she had acknowledged that he was a friend some months earlier and had never given any indication to the contrary. However, given the emphasis in research and SCRs on the appearance of new ‘boyfriends’ as risk indicators, the Review Team would have expected that this information should have at least been passed on to CSC at this point.  Mother did not disclose anything either about a new partner in the plans being made to support her with the care of J at the Pre-Discharge Planning meeting in early September. The Pre-Discharge Planning meeting had found no reason not to discharge J home: although there was a suspicion that J had been born with Foetal Alcohol Syndrome, this was still being assessed; and mother had had regular and random toxicology tests since July, all of which had been negative. Planning centred on practicalities, drawing up a schedule of daily visits from different professionals over the next week.   The midwife made a planned home visit the day after the baby was discharged and saw a young man, holding J, through the locked front door. She was initially unable to speak to him, but demonstrated good safeguarding practice by immediately notifying CSC, the GP and FiP and returning to the house later to gain access.  She asked to speak to mother’s “friend” and established that he was staying there, was on a tag for theft and was using the address for bail purposes. Mother eventually admitted that he (Partner2) had been her partner since she was 3 months pregnant, but she had not mentioned him as she had not thought the relationship was serious. Mother later repeated this to the lead reviewers when they met, explaining that she had not planned to live with him, but because he was unexpectedly homeless she took him in. Finding 7 highlights the potential for dangerousness in court processes for setting bail addresses. In the absence of SW3 on that day, a duty SW acted promptly and appropriately in seeking further information about Partner2: he was known to the 16+ team having been a Looked After Child; he was known to use cannabis, but there were no concerns about 9 him being violent. The interim Team Manager advised that there would need to be a risk assessment but that there were unlikely to be legal grounds for intervention should the mother refuse to ask her new partner to leave the home. On the basis of what was known about Partner2 at this point, the Review Team agreed with this judgement.  The duty SW then undertook a joint visit with the FiP worker, evidencing good partnership working, but they were unable to persuade mother to ask Partner2 to leave. In the absence of legal grounds for intervention, mother agreed to sign a Contract of Expectations which stated that Partner2 should not be left unsupervised with the children.  Given the circumstances and clear need to build evidence for a legal outcome, use of a Contract in this instance was appropriate.  Finding 1 highlights the importance of presenting an argument to legal services which embraces the full context of a case rather than focussing solely on the ‘incident’.  Finding 5 concerns the use of Contracts and Written Agreements. SW3 subsequently made telephone calls to establish further information about Partner2 and to seek legal advice, although the latter is not evidenced in CSC or in Legal records. She contacted the Probation Team, who were also unaware of the relationship and had limited knowledge of Partner2.  SW3 and the FiP worker visited jointly two days later, and in the absence of any concrete evidence that Partner2 was a risk to the safety of the children, identified contingency measures to make it safer for him to stay: mother and Partner2 agreed to attend an ‘Incredible Years’ parenting programme and Partner2 would attend a Young Father’s course.  While individual professionals were reacting with appropriate urgency, what was missing at this stage was an authoritative and considered multi-agency strategy. This would have best been achieved by consultation with the IRO and either reconvening the Child Protection Conference or, at the very least holding an extraordinary core group meeting. This tendency to assimilate new concerns rather than use them as triggers for investigation is explored in Finding 2. When mother and Partner2 failed to attend the ‘Incredible Years’ group later that month, they were put forward for the next programme starting in January but no interim measures were considered to cover what was a three month gap.  Nor did Partner 2 sign up for the Young Father’s course.  Given the initial efforts to determine the risk presented by Partner2 and urgency with which contingencies had been sourced and put in place, the professional energy appeared conversely to reduce when these failed to work, despite the fact that the potential for risk in what is unknown about Partner2 had not changed and J remained particularly vulnerable in the household.  Key here was the prevailing professional mind-set: risk to the children was still associated more with mother’s previous relationship with Partner1, which was now being managed via contact arrangements, and her past patterns of substance use than it was with her present circumstances.  Greater reflection as to possible behavioural triggers for mother in any relationship would have been helpful, as would a more sophisticated understanding of child neglect and its symptoms. Sibling 2 and Sibling 3 presented at school with injuries on separate occasions in late September and early October, and on two occasions Sibling 2 alleged rough handling and physical harm caused by mother. Although mother provided an explanation at the time, ‘accidents’ such as this to children subject to CP plans, following significant changes in circumstance, should always be fully investigated. When allegations have been made it is especially important that a rigorous process is followed, involving strategy discussions, multi-agency information sharing and consideration of the need 10 for a s.47 child protection enquiry. The records do not show this as having occurred. A child protection medical did take place in response to the incident in October, but unusually, mother was permitted to accompany Sibling2 to it despite the original allegation made against her, and Partner1’s involvement was not sought. Finding 8 highlights the importance of planning for medical assessments and of understanding their limitations around definite diagnoses; the lack of a forensic investigative approach in response to incidents is discussed in Finding 2.  These events also exposed the fact that Mother was leaving J in the care of her mother (MGM) on occasion, although the child protection plan stipulated that she should not. Most critically, the injuries and what may have caused them were not explored in any subsequent multi-agency meetings; nor did they trigger any direct work with the children concerned and were not discussed with the children's father, despite his high level of involvement in  their lives.  This exposes the readiness of the professional group to believe what mother said and the plausibility with which she said it.   Review Child Protection Conference (RCPC) The IRO deferred the Review Child Protection Conference (RCPC) planned for early October by a week to ensure mother attended; she had gone to hospital with Sibling3 who had breathing difficulties on the day the RCPC should have taken place.  An impromptu professionals’ meeting was held instead that day. This could have been a useful and much needed opportunity for the multi-agency group to ‘take stock’, without parents being present, as it was the first time they had met since J’s discharge home and Partner2 had joined the household. Instead the meeting went through actions and tasks much as would have happened at a regular Core Group meeting. The chance to reflect, both on the impact on the children of changes in household composition and on evidence of lack of compliance with the protection plan, was not taken. Nor were the allegations and concerns reported by the school in the previous weeks explored in any detail, although they were noted.  All professionals and the FiP worker in particular, had noted in their reports to Conference, written by the time of this meeting, concern that mother had become harder to engage since Partner2 had moved in and this alone should have given the group greater pause for thought. The RCPC was held a week later, in mid-October. The FiP worker was on leave on the new date; a significant loss as she was the practitioner most involved with the family.  The police were again absent, although this was not unusual given the lack of police involvement with family members since the ICPC.  Despite the fact that the Conference referred to mother and Partner2 as a couple and to his permanent presence in the family home, Partner2’s presence was not insisted upon, nor were the agencies working with him invited. This was a significant omission. As a consequence the professional interface with Partner2 and with mother was never joined up. There was no multi-agency discussion of Partner2’s background in the context of what was known about mother, nor any consideration of the possible impact of the two on each other. Unbeknownst to the Conference, on the same day as the professionals meeting, Partner2 had been in court for robbery and burglary offences.  He was allocated a Probation Officer because of the seriousness of the offences and the fact that his partner’s children were on child protection plans. Findings 11 and 12 pose a challenge about the way professionals conceptualise ‘family’ and ‘professionals’ in the context of child protection work. 11 The IRO was unable to access the original plan [as opposed to updates] due to “printing problems”, so was hampered in being able to systematically monitor the progress that had been made since July. Consequently, the fact that the one original contingency - that of legal proceedings - was no longer part of the Plan, was missed. Mother was asked to sign a new Contract of Expectations that she would not leave J with Partner2 unsupervised – a contingency that had been used before with no consequence, could not be effectively monitored and therefore carried little authority going forward for her.  The use and limitations of Contracts of Expectations when used routinely are considered in Finding 5.   The CP plans for J’s siblings contained actions that were relevant to J but omitted from her plan, despite the fact that she was arguably more vulnerable to them because of her age, size and condition.  This was a probable unintended consequence of holding a Conference in two parts: one attended by Partner1 that addressed J’s siblings and one attended only by mother since Partner1 had no parental responsibility for J.   The Conference should also have picked up the fact that no direct work had been done with the children despite the fact that Siblings 1 and 2 were old enough to enable this (5 and 4 years old respectively).  Had there been, it might have enabled professionals to discern the degree to which the lived experience of each child reflected what professionals thought they were seeing.  A recent Peer Review in Newcastle warned against a tendency for social workers to avoid direct work with children who they felt to be ‘too young’.  Because this is an issue that is actively being addressed locally, we have not linked it to a systemic Finding in this report. It is the view of the Review Team that the presence of mother at the RCPC with baby J, who she was cuddling throughout, will have impacted upon how challenging and direct the professional group will have felt able to be.  Period post RCPC to J’s death The sense of the case therefore, given to the new, permanent Team Manager who started work the day after the RCPC, was of progress being made towards the children coming off CP plans, with some outstanding tasks.  In the context of other child protection cases at the time, this one did not appear to be alarming.  This then was also the message given to the Senior Practitioner (SP2) allocated the case when SW3 went on maternity leave and the rationale for allocation to an experienced practitioner to in effect manage the probable tail end of the child protection process.  The way in which practitioners have to apportion priority to cases and the impact that this can have, particularly in neglect work, is explored further in Finding 9.  A Core Group meeting planned for early November, just before SP2 took over case responsibility, was cancelled as SW3 was on sick leave and the FiP worker, who might have stood in for her, was being threatened by Partner1.  No other temporary arrangements were made to enable the meeting to go ahead then, or at a later date, and SP2 had no direct handover with SW3.   The Core Group continued to communicate well together outside meetings and SP2 took a co-ordinating role as he familiarised himself with the case.  The view persisted that the case was both manageable and being managed. There was some evidence to justify this: the children were regularly attending school even though after the house move this was some distance away and they needed more help to get there; there was 12 rarely anything to cause school staff any concern in their presentation.  The FiP worker had previously observed mother to have put good routines in place for the children at home; she had the necessary skills.  However this review highlights the importance of recognising the significance of what is not done and not said and reacting effectively to this. The more positive view did not take into account any real assessment of what life at home might have been like on a daily basis with a new partner, for mother but particularly for each of the children.  This was partly because mother and Partner2 were more avoidant of professional contact, but also because no-one was doing any direct work with any of the children in order to assess risks from their perspective and no other family members were asked for a view (see Finding 11).   A further example of concealment was provided when baby J was admitted to hospital with bronchiolitis near the end of November.  She was visited by an unidentified man, who stayed on the ward with her overnight.  Mother, who had previously refused to disclose the identity of J’s birth father, told nursing staff that this was him. Although staff knew of the fact of the child protection plan, they were not aware of the detail in terms of who may or may not be suitable to visit, and did not monitor visitors. They did appropriately notify the hospital Safeguarding Team the following day, who told SP2. When nursing staff discussed the overnight stay with mother she promised that it would not happen again. However, three nights later, staff intervened when they heard a raised male voice and swearing. J’s hospital record referred to both this man and Partner2 as “father”, so it is impossible to know who the raised voice had belonged to. This is of concern given mother’s previous experience of being part of a verbally violent relationship, but the incident did not generate a Cause for Concern note to the Safeguarding Team nor any contact with SP2, which would have been expected.  The need for clarity around the identification and onward notification of ward visitors to children subject to Child Protection Plans is picked up in Section 6, Additional Learning. Professional response following baby J’s death Two weeks after J was discharged from hospital, two separate early morning calls were made to the North East Ambulance service [NEAS] reporting that a baby was not breathing. The NEAS response to the emergency call was rapid, including a pre-alert to the hospital Emergency Department (ED), which is normal practice.  Resuscitation advice was given over the phone.  Resuscitation continued in the hospital ED, according to protocol and under difficult circumstances because Partner2 in particular was very evidently distraught and threatening to staff. It was unsuccessful. The appropriate documentation and investigations were completed after J’s death although there was a lack of urgency in obtaining an eye examination, which delayed a diagnosis of retinal haemorrhage, possible abuse and the identification of potential risk to the siblings. See Finding 10 for a discussion about systemic vulnerabilities in out of hours rapid response arrangements.    It was discovered then that mother had been working overnight in a bar that night, having previously assured SP2 and the FiP worker that she was not going to work there anymore. The requirement to stop working had been made in order for J not to be left in the care of Partner2. 13 3 WHAT MAKES LEARNING FROM THIS CASE MORE WIDELY APPLICABLE? The Learning Together methodologyiv uses an individual case to provide a ‘window on the system’v, identifying whether the learning that has been identified by one case is more systematic and widespread, and so leading to a broader understanding about what supports and what hinders processes and practice locally. NSCB gave the Review Team particular research questions to address because there are known to be other cases locally with a similar profile to this one, in terms of inter-generational issues; the need for greater professional challenge; and in terms of numbers of children (including babies) on child protection plans both generally and specifically for neglect.  At the point that this Review took place, what was not clearly enough identified were the numbers and nature of inter-generational cases and the identity of particular family groups. The need to establish this baseline information is identified in a number of the Findings that follow.  Because ‘risk’ in neglect cases is not always obvious until symptoms become more serious it requires the ‘system’ to be more vigilant.  Neglect can also (mistakenly) be perceived as more benign than other forms of abuse, with the result that risks to the safety of some children can be judged as less of a high priority for action than others.  The need to shift this (mis)perception was recognised in a recent piece of research published by the NSPCC: “The long-term impact of neglect is known to be corrosive, although neglect is rarely perceived to be associated with fatality.  The possibility that in a very small minority of cases neglect will be fatal, or cause grave harm, should be part of a practitioner’s mind-set.” Brandon, M., Bailey, S., Belderson, P., and Larson, B. (2013), Neglect and Serious Case Reviews. England: NSPCC There is a tension between the need for practitioners to be ultra-alert to neglect and the constant demands placed on their time and attention by other cases.  This case hit the Children’s Social Care system in particular at a time when it was unusually under pressure. Northumbria Police face ongoing challenge around their capacity to participate routinely in multi-agency child protection processes, such as Conferences and strategy meetings. Although this case was time-specific, similar pinch points are inevitable for organisations at different times, arguably more so as resources become more limited, and need to be anticipated. Professional vigilance is also affected in daily and mundane ways by the manner in which routine tools of the trade – computer systems, printers etc. – are set up, relate to each other and malfunction. This case contains several illustrations of ways in which people have to adapt around tools and do not realise the impact upon casework as they do so.                                             iv See Appendix One v C A Vincent, Analysis of clinical incidents: a window on the system not a search for root causes (2004)  14 Families who have inhabited ‘the system’ for decades are evidence that the ‘system’ designed to support them to overcome difficulties has not worked well enough. They are likely to have developed strategies to cope with this that are challenging to work with constructively.  Professionals are facing an impossible task if their work does not build in enough time for reflection, individually, jointly and if necessary without family present.  Sometimes, a ‘professionals-only’ discussion is necessary. But it is not just the provision of time that is important but also that professionals recognise the need for reflection and take opportunities when they arise.  This case highlights the danger of becoming too procedurally task-driven.  Processes designed to facilitate thinking (assessments) can become rushed and lose much of their original purpose. Neglect cases are particularly likely to suffer in this context because they are not incident-driven. The Review Team have agreed 12 Findings that are a feature of, but will be common to more than this single case; listed below against the aspect of the multi-agency system in which they are located (for more detail about how Learning Together categorises different systemic issues, see Appendix 1). They do not provide concrete recommendations, but highlight inconsistencies in current practice norms and the potential consequences of leaving these unaddressed. There are also three additional learning points relating to the presence of the police, the monitoring of visitors to hospitals and the strength of support services in Newcastle. Findings about the functioning of child protection processes • Recording systems do not include chronology templates that are fit for purpose, hampering practitioners attempts to understand families’ history; particularly significant in the context of intergenerational neglect (Finding 1: Tools) • The process for inviting people to key meetings does not consistently ensure that that right people will be there (Finding 3: Management Systems) • The current link between completion of assessment as a pre-requisite for case transfer encourages more superficial assessments on the most complex and highest risk cases. (Finding 4: Longer-term work with families) • The overwhelming reliance on social workers to lead, manage and administer Core Groups can diminish the effectiveness of these multi-agency meetings (Finding 6: Management Systems) • Routine processes for agreeing bail conditions contain a loophole that omits checks being made about risks an offender presents to children (Finding 7: Management Systems) • The way that medical staff present their diagnosis of types of injury can be confusing to non-medical practitioners, who interpret lack of evidence as meaning an injury is accidental (Finding 8: Response to Incidents) • It is currently more difficult to coordinate a multi-agency response to unexpected child deaths at weekends and Bank Holidays, with potential to affect the timely diagnosis of likely cause of death (Finding 12: Management Systems)  Findings about professional practice • Are ‘incidents’ less likely to benefit from multi-agency reinvestigation/reflection if a case is already open to Children’s Social Care? (Finding 2: Response to Incidents) • Standardised tasks and Contracts of Expectation are used too routinely and 15 without consequence, making them ineffective when addressing deep-rooted learned behaviour through child protection plans (Finding 5: Communication and collaboration in longer term work with families) • Despite all child protection cases being high risk by definition, practitioners juggle priorities by deciding which is more risky than another, leaving the less obvious neglect cases more vulnerable (Finding 9: Human Bias). • A tendency to focus too much on the nuclear family in isolation from any wider networks, even when extended family members are known to professionals, is limiting the effectiveness of interventions with families that have been subject to child protection measures over generations (Finding 11: Communication and collaboration in longer term work with families) • The attendance of an appropriate range of professionals at CP Conferences is inadvertently being limited by too narrow a definition of family, thereby undermining the effectiveness of planning and the best interests of children (Finding 12 Communication and collaboration in longer term work with families)  4 REVIEW FINDINGS FINDING 1          Recording systems do not include chronology templates that are fit for purpose, hampering practitioners attempts to understand families’ history; particularly significant in the context of intergenerational neglect The understanding of a family’s history with services is a fundamental basis for any assessment from deciding how to respond to a referral, to decisions about threshold and types of intervention further along the ‘child’s journey’ with professionals. The rationale for this is, as noted by Munrovi : ‘The best predictor of future behaviour is past behaviour...’ When there is a long history of professional involvement with children, parents, grandparents and extended family, knowledge of such history should be critical to making decisions about the level and nature of support and/or intervention required in the present. This information is relevant at all stages of a ‘child’s journey’ and needs to be taken account of in all assessment activity. Whilst the non-use of history is well documented as learning from serious case reviews, this Finding seeks to understand the reasons behind this. Although the focus is on Children’s Social Care systems, the issue applies equally to all agencies. How did the issue manifest in this case? This review has identified a number of occasions on which the history and context of the family were not fully taken into account. This led, at times, to risks being assessed                                             vi Eileen Munro 'Effective Child Protection' 2nd edition, Sage Publications 2008.ISBN 978-1-4129-4695-7 (pbk)  16 as lower than they might otherwise have been. Some practitioners only became aware of the full history of the family as a result of participation in this review. The family had a long history of involvement with services, and Mother grew up in a family well known to Children’s Social Care (CSC) and has siblings who were Looked After. Prior to the review period, the family had had significant contact with services, including numerous domestic violence incidents, CSC assessments in response to police notifications and discussion at MARAC. Following a s.47 enquiry and core assessment, the case was closed in July 2012, after the parents had separated and their volatile differences around contact appeared to have settled. Concerns continued about the care mother provided to the children, centring on neglect in the home and mother’s lifestyle, including alcohol and substance misuse. In March 2013 when the family returned from staying in another authority in the South of England, services there re-referred the family to Newcastle, due to concerns about the parenting of the children, and a core assessment was initiated in April 2013, but not completed until July 2013 when a second social worker (SW2) took over the case on the illness of the previous worker.  SW2 had previously been the family's social worker and had long standing knowledge of the family history of 6 previous Initial Assessments and 2 Core Assessments in Newcastle and one in the other authority and promptly convened a strategy meeting and an initial child protection conference. This should have happened in May, when the referral was received that mother (who was known to be pregnant), had been taken to A&E following allegations that she had been assaulted and was under the influence of drugs and alcohol. No s.47 enquiry was instigated because a core assessment was already being undertaken. The responsible Team Manager, on hearing about the entire history of the family as part of this review, reflected that a s.47 enquiry and pre-birth assessment would have been best practice in May.  Subsequently it was not at all clear that many workers fully understood the family context, with the possible exception of the school, with which Siblings 1 and 2 had been registered previously. The next social worker (SW3) who became the lead professional in August understood from case records that the concerns for the children’s safety were around domestic violence and contact arrangements. Whilst contact was an ongoing problem, such an understanding did not reflect the entire history of concerns, especially in relation to lifestyle choices and neglect. That she had had no handover with SW2 may have contributed to this perception (the case had transferred between teams whilst she was on leave), but was also exacerbated by the lack of a clear chronology in records. Professional thinking about the possible impact of a new relationship, not only on the children but also on mother, would have benefited from an understanding of her history as a parent and as a partner in a relationship involving domestic violence. Finally, the social worker reported that legal advice was sought in September 2013 when it was discovered that mother had not been “open and honest” [as per the child protection plan]. The advice at the time, though not recorded, was that there were no grounds for such intervention. However, the Solicitor in the Review Team, after seeing the entire history collected by the review, considered that there may have been grounds for legal intervention at this time had the history (and its implications) been presented 17 as part of the argument. This Review had the benefit of a detailed, integrated chronology, but no such overview was available at the time. How do we know it is an underlying issue and not something unique to this case? Whilst in theory practitioners would wish to be familiar with the history of a family, within CSC there are obstacles to obtaining such an overview due to the way that records have been organised and maintained. For practitioners to be able to easily understand the historical context requires information to be collected together in a way that is easy to read and comprehend. For this reason Lord Laming, in the Victoria Climbie Inquiryvii recommended: “Directors of social services must ensure that every child’s file includes, on the inside of the front cover, a properly maintained chronology” The IRS Team Manager commented that social workers have access to historic family files, though looking at them is dependent on the volume of work/time involved. However, members of the case group spoke about the lack of chronologies in records, unless a case is in legal proceedings. Consequently rather than being used as an assessment and analysis tool, chronologies are used for evidence building once decisions have been taken that legal intervention is required. The chronology that is available routinely through the electronic care record is the detailed entry for every contact with a family member, rather than a succinct list of significant events, which would be more ‘fit for purpose’. Professional capacity to get a sense of what is important is therefore clouded by unnecessary detail.  This issue has already been identified within CSC and is being addressed by the development of a new electronic tool allowing social workers to create a chronology of significant events. It is not clear to what extent the issue has been considered by other agencies. How prevalent and widespread is the issue? The lack of understanding of complex family history is a recurrent problem that often emerges as learning from serious case reviews, and lay behind Laming’s recommendation above. It also is at the root of the  ‘start again syndrome’ described in Brandon et al’s biennial reviews of serious case reviews that were commissioned by the government up to 2010. Brandon et al said: ‘In families where children suffered long term neglect, children’s social care often failed to take account of past history and adopted the ‘start again syndrome’.viii Following the Victoria Climbie Inquiry, the Laming recommendations were widely implemented. As a consequence the lead reviewers saw the introduction of excellent chronologies in all files when undertaking audits in different local authorities. However when paper files were replaced by electronic records and the government introduced the Integrated Children’s System [ICS], this practice was widely observed to be discontinued as ICS produced its own chronology, which consisted of the detailed case records of all contacts. This was not in itself useful in communicating the history of a family, as it provides too much information, giving the full entry for every contact, as opposed to succinct entries for significant events/contacts.                                             vii Recommendation 58, Victoria Climbie Inquiry, Lord Laming, DOH 2003 viii Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005 18 Why does it matter? What are the implications for the reliability of the multi-agency child protection system? The lack of a ‘fit for purpose’ chronology as part of the electronic CSC work flow undermines the critical importance such a tool has for practitioners in understanding the past and its implications for the present, as part of any assessment.  Where families have been known to the child protection system over long periods of time this acquires particular relevance; to identify patterns of behaviour and to understand and avoid the repetition of risk management strategies that have been unsuccessful previously. Such a tool should be available and used within the agency recording system to assist in determining the actions to be taken, or not taken, at any point in time. It is especially critical for first response services such as IRS, where decisions sometimes need to be taken as a matter of urgency, and there is not time to consider a large volume of records. Without chronologies and case summaries, practitioners are encouraged to take a ‘start again’ approach and this risks a partial understanding of the risks involved for some children. This is particularly significant in neglect cases, where typically evidence of harm is accumulated over time. 19 FINDING 1  Recording systems do not include chronology templates that are fit for purpose, hampering practitioners attempts to understand families’ history; particularly significant in the context of intergenerational neglect.  One of the common deficits in learning from case reviews is the ‘failure’ of practitioners to fully consider the implications of family history when assessing risk and planning risk management in the present.  The unintended consequence for CSC practitioners nationally of the creation of electronic tools to generate chronologies has been to make it more difficult for people to easily comprehend what has occurred before. This has ramifications for all casework but particularly for cases such as this one, where families have been known to services over long periods of time and an understanding of the risk for children often relies on an understanding of the past and the patterns of behaviour in the family.    ISSUES/QUESTIONS FOR THE BOARD TO CONSIDER • Does the Board agree that chronologies fulfil a valuable function? • What tools need to be made available so practitioners are enabled to make chronologies a feasible and routine part of their work? • What guidance do practitioners in all agencies receive around the creation and development of significant events chronologies? • How will the Board assure itself that the new significant events chronology in CSC is informing professional practice? Is there clarity around when and how it is to be used? • Is there also a need within partner agencies for such an approach?    • Most SCRs start with an integrated multi-agency chronology – is there value in making an integrated chronology a requirement in all child protection work?  If so, how might this work in practice?     20 FINDING 2      Are ‘incidents’ less likely to benefit from multi-agency reinvestigation/reflection if a case is already open to Children’s Social Care?  Critical incidents provide an opportunity to gain a deeper understanding of the welfare of children, especially if based on a multi-agency approach. They usefully provide a trigger to re-assess and re-examine any potential for fixed thinking there may be about the underlying functioning of the family and the welfare of the children. This may be via s.47 enquiries or other forms of multi-agency assessment, or by convening a core group or early child protection conference meeting. How did the issue manifest in this case?  We are highlighting four examples of critical incidents that took place between May and October 2013. None led to multi-agency assessment and analysis. All were missed opportunities to explore what was happening to the children through an in depth exploration of the way the household functioned. The four incidents were: • The report in May 2013 that mother had discharged herself from hospital prior to assessment. Pregnant, she had been delirious when taken by ambulance to hospital and initially alleged that she had been assaulted. Whilst the social worker did look into the events surrounding the night, the lack of a s.47 enquiry at the time meant that there was no multi-agency investigation into exactly what had happened and then to the assessment of the appropriate level of professional support that was needed.  The absence of such an investigation contributed to professionals never finding out where the children were that night, what happened to mother and any assessment of what this may have meant for the health of the unborn child. • In September circumstances dramatically changed for the children with the move to new, independent accommodation, a new baby and a new unknown adult male joining the household. Despite an immediate attempt to persuade mother to ask her partner to leave, in the face of complete refusal there was no further multi-agency follow up to this change of circumstances, other than performing basic checks on the man’s background. This missed the opportunity for an in-depth look at what was happening via a new multi-agency assessment and/or recalling of the core group and/or of the Child Protection Conference. • In the last week of September, the school reported that Sibling3 had a cut on the forehead and that Sibling2 was alleging she had a sore arm where her mother dragged her. Records show no multi-agency follow up to this.  • In the second week of October, the school reported an injury to Sibling2 together with her allegation that ‘mummy slapped me’.  This resulted in a child protection medical, but no s.47 enquiry, or thorough multi-agency assessment in its place. Police were informed of this incident, but agreed a single agency investigation to gather more information, which perhaps contributed to the perception within CSC that this did not require to be investigated with the rigour that a s.47 would allow. There is no record that anyone spoke to Sibling2, although the Review Team were told that this was done whilst waiting for mother to arrive.  Moreover, the involvement of mother [as opposed to Partner1] in attending the hospital, meant that Sibling2 was less likely to speak 21 openly about what had happened and about life at home. The incident was never used to trigger further single or multi-agency investigation into the circumstances at home and ended inconclusively. In all four instances described above the opportunity to explore what was going on within the household was lost. The assessment that occurs following such changes in circumstance or allegations can be the point at which it becomes possible for practitioners to understand what is happening within a household by ‘digging deeper’ into events.   Mother told the lead reviewers that during the latter period there was stress in the household, because her partner was violent, hitting her and smashing up their home. She thought that his behaviour was triggered by his use of illegal highs, which also had an impact on their financial situation. This was not known by any of the professionals working with the family at the time. Whilst mother is clear she would not have shared this for fear of losing her children, had there been multi-agency assessments and s.47 enquiries in relation to the incidents above, it is possible that further information could have been found at the point of crisis from the children directly or mother or her partner.  How do we know it is an underlying issue and not something unique to this case?  Newcastle’s statistics show that there is no reluctance to undertake s.47 enquiries as a result of incidents, so leading to a higher than average number of enquiries which do not result in initial child protection conferences (32% in 2013). However, what is less clear is the extent to which responses to incidents on open cases trigger new or re-assessments via s.47 enquiries; further specific assessments; consultations with IROs; convening of ‘extraordinary core group meetings and/or conferences.  The fact that this was a repeated weakness in this case in two different social work teams suggests that it may be an underlying issue, but further work is required to establish the extent of it.   How prevalent and widespread is the issue? No national research has been found on this topic, so it is not clear how prevalent or widespread this may be. However, anecdotal evidence from the lead reviewers on other case reviews and audits suggests that this lack of a rigorous response to incidents is more widespread on open cases.    The commonly highlighted risk of ‘fixed thinking’ is associated with the lack of investigation of incidents. In this context, rather than a new assessment, the explanation for the reported incident becomes what fits into the established thinking about the case. This has not been unusual throughout serious case review research. In a review of forty five inquiry reports, Eileen Munro (1996 and 1999)ix described a major problem of professionals being ‘slow to revise their judgements despite a mounting body of evidence against them’ and the need for judgements to be reviewed and sometimes changed as a case progresses and in the light of new information. This is an example of what Reder & Duncan (2000)x describe as ‘selective interpretations’ of the information available, with practitioners ‘only registering that                                             ix Common Errors of Reasoning in Child Protection Work, Eileen Munro, Child Abuse & Neglect, Vol. 23, No. 8 1999 Avoidable and Unavoidable Mistakes in Child Protection Work, Eileen Munro, British Journal of Social Work 1996 (26) x A required mind-set for child protection practice: comments on Munro (1999) Peter Reder & Sylvia Duncan, Child Abuse & Neglect, Vol. 24, No. 4 2000  22 which confirmed their preformed view about the case and, in certain instances, these views appeared to become ‘pervasive beliefs’ that organised all professional responses to the family’.  Why does it matter? What are the implications for the reliability of the multi-agency child protection system?  Incidents provide windows into family functioning that offer an opportunity for professionals to find out what is going on at that point in time. Incidents are sometimes associated with a change in circumstances or a particularly stressful period. At such times, the family members may open up about what is happening and also through exploring an incident in detail it is possible to learn much about relationships and family functioning.     If these opportunities for an in depth assessment are missed we risk the loss of evidence and the perpetuation of potentially flawed ‘fixed’ thinking. This can lead to the professionals missing critical and significant information about the nature of relationships within a household, as well as the nature of the care being provided to the children. 23 FINDING 2 Is there a tendency within CSC to assimilate incidents within cases that are already open, thus missing the opportunities they provide for multi-agency re-investigation and analysis; risking the loss of evidence and the perpetuation of ‘fixed’ thinking?   The lack of thorough and well planned multi-agency assessment in response to incidents that occur, risks missing opportunities to learn about what is really happening within a family. This critically means that without a new assessment taking place it is likely that previous ways of understanding the circumstances may be used to ‘explain’ the underlying causes of the incident.  ISSUES/QUESTIONS FOR THE BOARD TO CONSIDER • Does the Board accept that the practice highlighted by this Finding requires more investigation? • Is the Board clear about what factors might be preventing re-assessment as a response to incidents?   • Is there value in an audit of multi-agency response to incidents on open neglect cases to establish the nature of the response, the extent to which it involves multi-agency assessment and the degree to which understanding changes as a consequence? • To what degree has the assimilation of incidents into open casework become part of the culture, both within CSC and in multi-agency work?  What is contributing to this? • How might all practitioners be helped to understand the importance of raising and escalating challenge in this context, should they disagree with a decision not to convene a strategy discussion/meeting? • How might the Board encourage a culture of re-assessment as part of the professional response, with partner agencies challenging each other when this does not occur? • How will the Board assure itself that any shift in approach is working well enough?       24 FINDING 3       The process for inviting people to key meetings does not consistently ensure that that right people will be there  Statutory guidancexi includes a specific section on information sharing, which starts: “effective sharing of information between professionals and local agencies is essential for effective identification, assessment and service provision” (1:22). The central multi-agency process for assessing the nature of risk to children and for agreeing the particulars of the Plan to be put in place to enable them to remain at home is the Initial Child Protection Conference (ICPC). NSCB sets out clear standards and responsibilities for all professionals regarding this, but particularly places responsibilities on the IRO, Children’s Social Care Manager and Social Worker ‘to ensure that all the relevant people who have had, or are likely to have, a significant contribution to make, are invited and able to attend’. (NSCB online procedures, section 1.3). Where absence is unavoidable, a comprehensive report should be provided instead, which includes an assessment and analysis of the impact of the work undertaken with the family and a recommendation as to the type of Plan required. This case highlights inconsistencies that stand to affect this process in Newcastle and elsewhere, with implications not only for the quality of information shared within the Conference setting but also for the dissemination of information outwards after the event. If the formal system for sending invitations to Conferences is routinely less than robust, how likely are they to work when Conferences need to be reconvened at short notice?. How did the issue manifest in this particular case? An ICPC and a first Review Child Protection Conference (RCPC) took place within the period examined by this review. Neither Conference was held on the planned dates. Both were reconvened to enable one or both parents (mother and Partner1) to attend. Mother was not able to be present at the Initial Conference due to health related issues and the Conference was moved to the following day to enable Partner1 to make arrangements to be there.  One of the children was admitted to hospital on the day scheduled for the RCPC, so it was deferred to make sure the parents could be there, this time by one week.  Unless parents are engaged with the formal Conference and the plan that results from it, the intention behind both will in all likelihood fail.  In this respect the decision to reconvene had a clear rationale, supported by procedures. It did, however, impact upon the attendance of key people. Significantly, the ICPC had a dual role.  In addition to its usual function in relation to three children, it also had to perform as a pre-birth Conference for J, who had not yet been born. This is not unusual, but will impact upon the kind of people who need to attend for different professional reasons. To be able to properly assess and plan for the management of risk in relation to the specific needs of a baby (pre and post birth) and to three children, all aged 5 and under at the time, the input of health professionals such as midwives and health visitors is key.                                             xi Working Together to Safeguard Children 2015 25 The health visitor and Safeguarding Nurse were informed by the social worker, by phone, approximately an hour prior to the ICPC that it was to be stood down and they would be advised of the new date. The health visitor, who had come into work specifically for the Conference from her annual leave, had emailed her report to the social worker prior to the Conference, and arranged with a colleague to attend the reconvened Conference.  No GP was invited although the family did have one. The midwife never received the postal invitation to the Conference, despite being named on the invitation list, and was only aware of it because the health visitor informed her verbally. She prepared a report to take to the Conference but did not receive notification of the changed date.  The report was therefore never seen.  This point is the more critical one, as it highlights the potential for invitations to either go missing or to be delayed irrespective of the fact that the Conference was reconvened. No Health professional received notification of the date and time of the reconvened Conference in time.  This had a direct impact upon the quality of discussion in the meeting, particularly in relation to the analysis of risk to the unborn baby and to the content of the subsequent Birth Plan. The absence of any health input to the Birth Plan meant that there was no analysis within it of the potential impact of birth on the health of the baby in the family context and on each family member. How do we know it is an underlying issue and not something unique to this case? The process in Newcastle for the dissemination of invitations is for the social worker to complete a standard electronic form and email it to the Children’s Safeguarding Standards Unit administrators, detailing the names and contact details of all those who they have determined should be invited, at least two weeks prior to the Conference. There is a standard list of invitees to all Conferences, which includes the IRO, Police, Named Nurse Child Protection and, for Initial Conferences only, Sure Start (if there is a child under 4yrs of age) and the Mental Health Trust. GPs and midwives are not on the standard invite list. This issue has been partially addressed through the design of a new report form for GPs and the introduction of a centralised email system for invitations and reports. Members of both the Review Team and Case Group were able to quote examples of invitations being received with such short notice they were unable to make arrangements to attend and of invitations not being received at all.  A midwife stated that it is ‘not uncommon’ for Midwifery not to receive invitations to Conferences, but it is less clear whether this is due to not being included on the invitation list or a posted invitation not being received.   There are various complicating factors at play here, which make it less likely that invitations will reach their intended destination either in time or at all: • One is the confidentiality of information about families contained within the invitation.  Already this introduces a double standard: invitations to the standard invitees are sent by secure email but all other invitees are sent a typed letter, by second class post, unless the social worker has provided a secure email address or the administrator knows of one.  The use of secure email implies that information will only reach the recipients it is intended for.  The use of second class post on the other hand, while understandable in terms of cost, introduces a number of possible variables in terms of who might read the information and how timely it might be.  Confusion between Head Office 26 (postal) addresses and local delivery addresses, coupled with the availability of part-time workers increases the chance of delay. • Another is the fact that not all professionals have their own secure email address.  This is the case for Community Midwives. It is also true for many voluntary sector organisations, including in this case the charity providing after school support. • Another is the nationally prescribed procedural timeframe (15 working days) between the decision that an ICPC should be convened and the date that it should take place.  This timeframe does not take account of the time required to identify who should be invited, to convey this information to administrators or of the way that post collection is managed within large organisations, which will introduce other variables in terms of times of day and days of the week.  Given the unpredictability of 2nd Class post it is likely that many in receipt of letters of invitation will not receive these until very shortly before the Conference date – with serious implications not only for attendance but also for the quality of any professional report that is submitted.  This is not such as an issue for RCPCs where dates can be set further in advance; minute takers state that they receive far fewer requests to send formal invitations for RCPCs than they do for Initial Conferences as many Social Workers will confirm by telephone to ensure that professionals are aware of the Conference date.  To compensate for this, some agencies and professionals have developed their own informal mechanisms for informing colleagues of meetings by word of mouth, but this is not universal. • Systems used by Children’s Social Care for recording activity (Care First and Total Viewxii) do not automatically cross reference relationships and professionals involved with individual family members to all other family members and rely on social workers to input this information manually. This means that the compilation of a list of invitees to child protection meetings will be dependant not only on which family members’ records are being used but the quality of record keeping by individual workers. Following audit work in early 2014, a recommendation to NSCB that minutes be sent to everyone who has been invited has been implemented. However, GP’s and midwives are not currently on the standard invitation list for any Conferences, meaning that potentially significant health information is not routinely sought and decisions may not be disseminated to significant professionals. Moreover, under the current arrangements, where no formal acceptance or apology is required prior to the Conference, the Conference Chair (IRO) would not necessarily know who was going to attend or if it will be quorate, until the start of the meeting.  How prevalent and widespread is the issue? The issue is known to be one that is affecting health professionals.   A survey of Newcastle’s Public Health School Nurses in April 2014 by the Named Nurse, Child Protection (Community), highlighted 18 cases where invitations had been received with such short notice that people were unable to attend or had not been received at all.  There is also evidence that the same issue affects GPs and is accentuated in cases of school-age children where there is no health visitor involvement, because the relationship between health visitors and GPs is generally such that even if the formal                                             xii Care First is the main electronic recording system containing the ICS process templates; Total View the electronic equivalent of a filing cabinet within this, onto which handwritten documents can be scanned. 27 invitation for whatever reason, does not reach the individual it is intended for, there is likely to be word of mouth communication.  The same routine communication channels are not in place between GPs and school nurses. This has implications for any other professional groups without secure email addresses.    Why does it matter? What are the implications for the reliability of the multi-agency child protection system? The ICPC is the forum where professionals from different agencies, with different knowledge and perceptions of the strengths and susceptibilities of individual family members, weigh up the level of risk attached to children remaining in the care of their parent(s).  It is here that decisions are made as to desired outcomes and what kind of activity is most likely to achieve these. That is why it is so important that all relevant professionals who are either involved, or likely to be involved with a child and their family, attend. Attending in person is obviously preferable to attendance by proxy or by written report as it enables informed discussion to take place. A prerequisite for attendance at Conference are robust systems that ensure invitations are disseminated efficiently to all those who are required, ensuring that they have sufficient notice to be able to attend. This can be particularly difficult in the context of ICPCs, where the nationally prescribed timeframes make the notice period inevitably short. 28 Finding 3 The process for inviting people to key meetings does not consistently ensure that that right people will be there   This case has highlighted an underlying weakness in the process for issuing invitations to CP Conferences that can have a direct impact upon the quality of multi-agency assessment and planning for children.  Evidence indicates that this is particularly likely to impact upon the effectiveness of plans made in relation to babies, both pre- and post-birth.  The dilemma hinges upon the need for confidentiality in the transfer of information and the different mechanisms that are available for use within individual settings in this context.  The current arrangements leave too much to chance.  ISSUES/QUESTIONS FOR THE BOARD TO CONSIDER: • Is the Board aware of the issues highlighted in this Finding?  • How could the Board assure itself that all invitations to conference are received by the people they are intended for? • Is the Board confident that the actual risk attached to emailing letters of invitation to non-secure addresses has been evaluated?  • How could IT be utilised to improve and streamline the process?  • What would be the benefit to the Child Protection process if invitees had to acknowledge receipt and confirm attendance at meetings? • How will the Board assure itself that the new arrangements designed to facilitate the contribution to Conferences of GPs are working effectively?      29 FINDING 4     The current link between completion of assessment as a pre-requisite for case transfer encourages more superficial assessments on the most complex and highest risk cases.    The literature on social care assessment emphasises the importance of a continuing assessment process which is sensitive to changes within the family, as opposed to a one off event. Eileen Munroxiii states that:   ‘Risk assessment is an ongoing, not a once in a lifetime, matter.  Families and their circumstances change and their dangerousness alters - that change can be subtle, incremental.’ Working Together to Safeguard Children 2015 (1:30) explains that: ‘Assessment should be a dynamic process, analyses and responds to the changing nature and level of need and/or risk faced by the child.’ This Finding considers the degree to which such a “dynamic” assessment process was evident in this case and to what extent current arrangements in Newcastle support practitioners in achieving assessments such as this. How did the issue manifest in this case? Following the case being allocated to SW2 and the holding of a strategy meeting in early July 2013, the decision was made to initiate a s.47 enquiry, undertake a core assessment and convene an ICPC. The case was transferred following the conference with an assessment undertaken within just 18 days – in order to be as compliant as possible with the statutory 15 day timescale between the strategy meeting that decides to convene a conference and that conference taking place. This assessment was based on the work of the previous social worker and other professionals, as the mother did not agree to see SW2. It was not informed by observing or speaking with the children directly.  Whilst this assessment provided sufficient information to meet the threshold for child protection plans, it did not constitute the in-depth assessment that is statutorily permitted to be undertaken over 45 days, involving children and other family members.  The fact that further work was needed was recognised by SW2, who was specific in the assessment about some of the issues needing further attention. Subsequently, there was no evidence of any ongoing assessment or further ‘parenting assessments’, despite the protection plan citing the need for the latter. There was no review of the core assessment in response to the change in the family circumstances following in August, the birth of a new baby and the move to independent accommodation and in September, and the arrival within the household of mother’s new partner. How do we know it is an underlying issue and not something unique to this case?  This is an underlying issue for two main reasons: • The need to complete the assessment quickly in child protection cases, before                                             xiii E Munro: Effective Child Protection (Sage 2008) 30 the ICPC and the transfer between teams • The lack of a culture with supporting systems to encourage assessment as a dynamic and continuous process Transfer between teams of child protection cases  Local procedures and national statutory guidance at the time provided for: • A strategy discussion/meeting initiating a s.47 enquiry and an assessment • A 45 day timescale to complete a statutory assessment • An ICPC to be held within 15 working days of the Strategy Meeting that agrees an ICPC is necessary NSCB and CSC procedures indicate that the assessment should be in sufficient depth so as to identify the immediate safeguarding needs of the child and where further assessment work is required following the s.47, this should be completed within the 45 day timescale, which suggests beyond the ICPC. However the recently revised NSCB and CSC procedure, September 2014 also states that: “Where an assessment under Section 47 is agreed as appropriate the timescale for the completion is 15 working days from the point the decision was made”. The rationale for this is because the ICPC is the point at which cases are transferred to the East or West Service social work team for ongoing work. As part of this transfer, local arrangements involve the social worker having to complete not just the s.47 enquiry, but also a core assessment.  This means that, rather than having the 45 days envisaged within national guidance, social workers are completing such assessments more quickly in those cases which reach the child protection threshold. Although there is nothing to prevent work from continuing on an assessment if there are outstanding tasks to complete, the practice norm is for the assessment to be closed at ICPC, the point of transfer between teams.   In discussions with the Case Group we learnt that assessments prior to 2009 would have transferred between IRS and area teams as an open piece of work to be continued and further developed.  Since then the process has changed and the core assessment is completed by the Initial Response Service (IRS) for the ICPC. The electronic recording system is not helpful here: Care First requires a core assessment episode to be finalised and closed prior to case transfer. This means that even if work is acknowledged to be outstanding, the ‘tools’ do not recognise it as a continual process. In order to continue work on an assessment a new episode has to be opened.     The reality for the IRS given the fast pace of its work, means that the Core Assessment will be based primarily on the presenting issue or incident and therefore may only provide a snapshot of the current circumstances (see also Finding 1 about the lack of historical data included in assessments).  This could result in significant information being missed and the child protection plan being based upon limited information and analysis.     Lack of a culture of continuous and further assessment Whilst the ICPC can ask for further assessment it is the general opinion of the practitioners involved in this review that further assessment does not count in the same 31 way as the procedural Core Assessment nor is it always clear what is expected and how to do this. This risks, as happened in this case, that further assessment does not occur. Case group members spoke of Newcastle having a policy of revisiting the core assessments of Looked After Children every 2 years. There is also provision for a Designated Child Protection Conference at 21 months, to encourage reassessment of cases that have been on Child Protection Plans for almost two years. However, neither mechanisms provide for the continuous assessment that is envisaged in guidance. Moreover there is a risk that the existence of a 2 year process for re-assessment may act as a deterrent to earlier re-assessment.   How prevalent is the issue? The practice of brief assessments is common in relation to assessments undertaken within the IRS when an ICPC is to be held, because of the statutory 15 day timescale attached to the interval between the strategy meeting and the Conference taking place – and the accepted practice of transferring to a long term social work team at this point. It is not known to what extent this applies in other circumstances, such as a child in need assessment within the IRS or core assessments undertaken in other teams, where the link with case transfer doesn’t exist, although Review Team members were more positive about assessment practices on non-child protection casework.  How widespread is this pattern? Prior to the introduction of the single assessment, the lead reviewers commonly found that a core assessment was a pre-requisite to enable cases to transfer teams in most local authorities. Also the lack of explicit re-assessment is a norm seen in practice.  What is not known is the extent of any change elsewhere since the single assessment was introduced and the drive for consistency in social workers allocated to families during what Munroxiv refers to as  the child’s 'journey' in receiving help and support from children's social care. Why does it matter? What are the implications for the reliability of the multi-agency child protection system?  Assessment should determine whether the child is in need and/or at risk of suffering significant harm, the nature of any services required and whether specialist assessments should be undertaken to assist the local authority in its decision making. Poor assessment may expose children to risks of further maltreatment, whilst good assessment is a complex activity that involves the systematic and purposeful gathering of information.  The practitioner needs to know why they are seeking the information in the first place, and then be able to ‘process’ a mass of multi-faceted and sometimes contradictory material to come to a view about its meaning, including understanding its meaning to the child and to the parents and to decide how to proceed.  A good assessment should be underpinned by a clear focus on the child and careful attention to analysis. Without the solid foundation of a holistic and ecologically informed                                             xiv The Munro Review of Child Protection, DfE 2011 32 assessment, the edifice of professional intervention is unsafe (Turney et al 2011xv).  The current framework of only 15 working days between the strategy meeting that decides to convene a conference and that conference taking place undermines the principle of ‘good’ assessment and risks information gathering being one-dimensional, with time only for limited contributions from parents, professionals and children and young people.  That this occurs by design in cases going to an initial child protection conference means that when children are deemed to be at  highest risk, assessments of their needs are less likely to be subject to the highest quality of assessments. A further risk is that assessment is undertaken by one social worker, but does not involve the subsequent lead social worker. The assessment process becomes then a one off event, unrelated to the child’s subsequent journey within social care. Moreover undertaking the assessment process in itself enables practitioners to gain an understanding of the family and the children’s needs that cannot be replicated by reading someone else’s work.  The unintended result of a system with only one assessment can be a culture of fixed views as opposed to reflection and challenge and re-assessment in light of new evidence. For the system to be safer a climate and environment needs to be created in which practitioners are supported to make the best assessments they can in order to provide interventions that improve the lives of children and their families, and to understand how and when to make further assessments, especially in the light of changes in circumstances.                                               xv Turney, D., Platt, D., Selwyn, J., Farmer, E. (2011), Social Work Assessment of Children in Need: What Do We Know? Messages from Research. DfE https://www.gov.uk/government/publications/social-work-assessment-of-children-in-need-what-do-we-know-messages-from-research  33 FINDING 4  The current link between completion of assessment as a pre-requisite for case transfer encourages more superficial assessments on the most complex and highest risk cases.    Statutory guidance clearly sets out the purpose of assessment and how it should be undertaken including: conducting interviews with the child and family members; involving the relevant professionals to provide further information about the child and family and securing contributions from the core group.  The current system in Newcastle for undertaking statutory assessments, when a decision to proceed to an ICPC has been made, imposes a reduced timescale. This undermines the quality and breadth of assessment potentially impacting upon the analysis, decision making and protection plan therefore potentially exposing children to risks of further maltreatment. This is then compounded by the lack of systems and culture to support assessment as a continuous process, risking fixed perceptions on the children’s well-being, despite changed home circumstances.   The current system of case transfer at ICPC being dependent on a completed core assessment encourages more superficial assessments on the most complex and highest risk cases.  ISSUES/QUESTIONS FOR THE BOARD TO CONSIDER • Is it right that the most complex cases, which result in an ICPC, should be subject to a curtailed assessment process? • Would completion of the assessment by the receiving social worker following transfer enable better quality assessments and analysis of risk? • Is there value in auditing to establish the quality of assessments undertaken for child in need cases and in other teams i.e. where the pressure to complete prior to a conference does not exist? • Would there be value in auditing to establish the extent to which any subsequent assessments are undertaken once cases transfer across teams? • How might the Board assure itself that the new single assessment process is working effectively and as intended? • Given that the current process is a response to nationally prescribed timescales, to what degree is this Finding replicated regionally, and if so, what might be done to raise awareness nationally?     34 FINDING 5       Standardised tasks and Contracts of Expectation are used too routinely and without consequence, making them ineffective when addressing deep-rooted learned behaviour through child protection plans When children are on child protection plans, social workers (as the lead professional) and the core group of multi-agency professionals working with family members have to evaluate the capacity of parents to change, so the level of risk that they pose to their children’s wellbeing reduces and individuals are helped to understand what the impact of their behaviour can be.  This is a complex task and professionals need to be mindful of the likely impact of a person’s learned experience when thinking about how to make a child protection plan meaningful.  If a parent has had experience of child protection and legal systems over a long period of time and/or since their own childhood, it is likely that they will have developed coping mechanisms that include denial and avoidance, not least because the way that the ‘system’ works has not always inspired trust and confidence.  They may have been actively encouraged in these by their own parents and they may be so engrained that they operate subconsciously.  A plan needs to include sufficient measures to be able to provide gradual evidence of change.  It needs to be realistic about how difficult it is for individuals to change their behaviour patterns, particularly if they have been entrenched since childhood.  It therefore benefits from the inclusion of contingencies, which can be drawn upon in the event that something is not working well or quickly enough.  A parent coming into the social care system with ‘history’ is unlikely to speedily change a pattern of behaviour just because they have been instructed to do so.  Instead, they may reactively draw on their experience to be able to give the appearance of change.   How did the issue manifest in this particular case? J’s mother had been on the receiving end of child protection and welfare services since her childhood. Her own mother was still ‘well known’ to authorities.  J's mother was young – 22 years old in the period of this review – and her memory of her childhood such that she repeatedly said she wanted to be a better parent to her children than her mother had been to her and her brothers.  She was also afraid her children would be taken into care and had direct experience of this happening to her brothers when she was younger.  The Reviewers have selected two examples to illustrate the issues highlighted in this Finding, both of which need to be seen against this earlier context.   The first concerns the way that the Plan was initially conceptualised, both at the ICPC and by the Core Group going forward, and is best illustrated by the way in which one issue and the action relating to it was worded.  There was no differentiation in this example between the issue, and the action that was required to address it.  Both required parents “to work with professionals in an open and honest manner to allow information sharing and assessment of the children’s needs.”  Also relevant to this is the fact that the core assessment, social work report to Conference and the outline Child Protection Plan had been completed without the participation or engagement of J’s mother – factors that would reduce the chance of any real ownership or investment.  35 While openness and honesty are desirable outcomes, when expressed as an action in this way it becomes an instruction. It also carries an emotional charge, as by implication, the person on the receiving end (both parents in this example) is being told that they are dishonest while the professional group is not.  The fact that it is desirable does not either make it easily achievable. The Plan contained no indicators through which the success of the task might be measured and no contingency in the event that it wasn’t proving effective. Professionals would only know with hindsight that it wasn’t working when an evasion or untruth had been exposed, as proved to be the case a number of times, including immediately prior to J’s death when it became known that mother was still working in a bar at night, having promised that she would not.  The action was not well enough thought through in the context of what was known about mother, or indeed in the context of what we should know about human nature, but it continued to be one of the central pegs in the Plan, through the RCPC to J’s death.  The Core Group continued to repeat it as worded, without considering whether it was a realistic expectation or how it might be measured within the Plan. There was immediate and growing evidence that it was likely to be really difficult to achieve; mother had disclosed to the FiP worker that she had “trust issues” with professionals; and she was known to be “economical with the truth yet very plausible” particularly to those such as the health visitor who had worked with her over a longer period.  By September she was known to be in a relationship although she had persistently denied that she was.  Despite this and other examples in the later period, at no time does the Core Group try to conceptualise the task differently, even when there was an unexpected opportunity to meet together without either parent present when the RCPC was deferred by a week in October.   The second example concerns the use of a Contract of Expectations at the RCPC, which mother signed to agree that she would not leave J unsupervised in Partner2’s care.  There had been no real evaluation prior to this, either in the Core Group or at the Conference, of the actual or potential impact of Partner2 on mother in the context of her past history, and what this might mean for the children.  Like example one, the Contract is very difficult to monitor - which will also be evident to those on the receiving end of it.  Mother was known to have left J unsupervised with Partner2 before and at this point in time was reverting to more avoidant patterns of behaviour.  There is no reason to think that she would comply. Equally and to be fair, what other choices might she have, at home and in the moment, with three other young children?     Common to both examples is the absence of any interface between the act of planning/reviewing and an ongoing assessment that provides an evaluation of the likely impact of change of circumstances as they happen (see Finding 4).  There is also an absence of more common-sense thinking in this context about the realities of human relationships and behaviour. The Plan in the case has in fact been enabled by the process in Newcastle to become a substitute for the assessment.  The danger of this is that the professional mind-set has shifted more to tracking of progress against actions than it is engaged in any wider thinking about the Plan’s continued appropriateness. How do we know it is an underlying issue and not something unique to this case? Neither the format nor the content of the Plan was felt by the Case Group to be unusual.  Practitioners spoke of the requirement for ‘openness and honesty’ as being a default within many Plans, which raises a question about effectiveness particularly in relation to parents who have experience of how to manoeuvre around the system to appear to be complying with it.  The phrase, to be “open and honest”, has become a 36 mantra in the professional mind-set. Similarly, Case Group members spoke about how frequently Contracts are used within the planning process and how necessary they are to build a case for legal intervention.   But a sanction like this loses meaning if it becomes used too much and if there has been no obvious and immediate consequence should it be broken.   How prevalent and widespread is the issue? There is no available data that might show how frequently Contracts are used in Newcastle or how frequently Plans contain the same wording irrespective of the individual circumstance.  We are also unable to say what proportion of the total number of children on Plans or Looked After come from families that have been known to services across generations or for lengthy periods of time.  We do know, however, that the tendency to resort to default positions in planning, be they how actions are worded or by the use of particular instruments, will be made more likely within systems that are having to react to pressures of time and volume of work, simply because there is less time for reflection about how realistic or not a task might be in particular circumstances.  This is not just something peculiar to Newcastle but is widespread in child protection practice.  Professor Jan Horwath, writing about child protection planning in her book ‘Child Neglect, Planning & Interventionxvi’, says: “The outline plan can become a ‘to do list’ for both parents and professionals. When this occurs, little time is spent ensuring that parents understand why these actions will be of benefit, how the actions complement each other and the priority that should be given to each action. A further issue with the production of a list of actions is that they do not take into account that some changes will be easier for parents to make than others.” A recent government publication pulling together research evidence on the capacity for parents to change their behaviour, makes a related point. “Change is a complex process, and although it can be supported and promoted through effective interagency interventions, it cannot be imposed.” Harriet Ward et al: Assessing Parental Capacity to Change when Children are on the Edge of Care: an overview of current research evidence (DfE, June 2014). Ward also makes the point in the same publication that if behaviour is to change, that change is likely to happen slowly.  This is particularly likely to be the case where patterns of behaviour are deep rooted.  There is the potential for a collision therefore between a gradual process of behavioural change and the small ways in which this might be evidenced and a system that requires change to take place to a timescale.  Obviously the impact of pace of change upon children and young people is the key thing for professionals to weigh up in this context.  Consideration might usefully be given to the ways in which children’s experiences might be used more directly as measures of parental behaviour change within a Plan. Why does it matter? What are the implications for the reliability of the multi-agency child protection system? To answer this question we need to remind ourselves what the multi-agency child protection system is trying to achieve.  There is research in abundance to support the premise that children do better if they can grow up in their own families than they do if they are in care.  A child protection plan is designed to provide evidence that remaining                                             xvi Horwath: Child Neglect, Planning & Intervention (Palgrave Macmillan 2013) 37 at home is a safe as well as a desirable option.  The point of this Finding hinges both upon the quality of evidence and the manner in which we seek it, and the degree to which plans are based upon a realistic understanding of people and their relationships. Professionals need to be confident that they know what is happening within a household because they are drawing upon a range of different measures to tell them.  They also need room within the process to reflect on what the evidence is telling them in order to be able to properly evaluate it.  The timescales within which they have to operate make this difficult – be that the time allocated to a meeting or the timescale indicator attached to a part of the process. In this context it is not surprising to see the use of standardised tasks and contracts, but the risk is that we establish polarised scenarios using tasks that are not well enough defined and have no measures or contingencies and Contracts, compliance with which is fear-based: if I don’t sign here they will take my children away. The likeliest outcome is surface compliance while on a Plan and understandable reversion to learned behaviour patterns when not.  There is a place for Contracts – but they should not be relied upon in isolation from other steps or measures that allow people to evidence change in a less negative way.  Practitioners need to be better enabled, when managing risk, to tolerate a position of “safe uncertainty” as opposed to the “unsafe certainty”xvii that is potentially afforded by Contracts/Agreements that have become default tools in practice.                                             xvii Mason, B: Relational risk-taking and the training of supervisors (Journal of Family Therapy Vol 27) 38 FINDING 5 Standardised tasks and Contracts of Expectation are used too routinely and without consequence, making them ineffective when addressing deep-rooted learned behaviour through child protection plans  Mistrust of authority, as embodied by formal services, is common but particularly so for people who might have experienced or witnessed inconsistent interventions as children.  Avoidant or evasive behaviour is a likely response to this. To stand the best chance of building trust, the actions and evidence required to change behaviours should be rooted in how people actually behave.  Planning in this context also needs to predict that progress will be influenced by things that are unpredictable and that contingencies set at the outset may need to change.  If we resort too quickly and rigidly to standardised actions and tools we give no opportunity for change to be experienced positively and evidenced incrementally.  In effect, we make veiled threats, and in so doing we may reduce the likelihood of real compliance.    ISSUES/QUESTIONS FOR THE BOARD TO CONSIDER: • What importance does the Board attach to the issues highlighted in this Finding? • Does the Board have access to data that might evidence the frequency with which standardised tasks and written agreements are used and the effectiveness of such strategies? • How might useful differentiation be made between when Contracts are valuable tools and when they are not? • How conducive is the current system to reflective thinking in relation to complex problem solving and effective multi-agency planning?  • Is the Board confident that there is sufficient professional understanding of the importance of the experience of children, not just in its own right, but as a measure of parental capacity? • What might supervision do differently and how?  • Has the quality of Plans improved with the introduction of Signs of Safety and if so, how is this demonstrated?    39 FINDING 6       The overwhelming reliance on social workers to lead, manage and administer Core Groups can diminish the effectiveness of these multi-agency meetings  Social workers are the lead professional for child protection work and carry statutory responsibility for a child’s welfare – but the work and therefore the system is multi-agency in nature.  Core group meetings are a key element of the child protection system and provide a regular forum for practitioners from different agencies to meet and evaluate the progress being made on a plan directly with family members.  Statutory guidancexviii on the operation of core groups has been revised three times in five years and the latest iteration (2015) continues to require social workers to lead and administrate the group as well as manage the development of the plan and the meeting dynamics.  Although responsibility is directed at social workers and their managers, no systematic process for the quality assurance of core group meetings is specified. The core group is therefore a multi-agency function but it is the contention of this Finding that placing too much responsibility on social workers to perform every task weakens the effectiveness of the group and reduces multi-agency ownership.  It can also impact upon willingness to escalate challenge if the perception is that it is ‘not our responsibility’.  How did the issue manifest in this case?  Core Group members who were part of the Case Group for this review all said that the group had worked well together and saw it as a particular strength. There is evidence to support this position in terms of the way that group members communicated with each other, particularly outside meetings.  Compare how the group functioned against its statutory responsibilities, however, and the evidence is weaker. • The first Core Group in August should have amplified the child protection plan and spent time thinking about content, measures and contingencies but instead had to reinforce the headline messages of the ICPC and Plan with mum, who had not been present at the Conference; • Arguably then, the intended function of the first Core Group should have been addressed in the second, but at this stage attention was entirely focussed upon the imminent birth of J; • No Core Group meeting took place between 6th September and J’s death on 14th December, despite the procedural requirement that they meet monthly.   • No extra Core Group meeting was arranged or requested after Partner2 was discovered to be living in the household, despite the fact that this changed the family circumstances and had implications for the CP Plan; • The Core Group meeting planned for 4th October was cancelled because the social worker was on sick leave;                                             xviii Working Together to Safeguard Children 40 • A core group date was set for 11th November 2013 following the RCPC. This was cancelled following representations from the FiP worker who had recently received verbal threats from Partner1.  SW3 was on sick leave and her replacement had yet to formally take over the case. No other options were considered and no alternative date was set.  • No meeting minutes were circulated after core group meetings and although handwritten notes were taken, these were not uploaded onto the CSC system until their absence was spotted by a Team Manager after J’s death.  This had both short and long-term impact: short-term, because meeting notes provide accountability – the group can systematically review actions and progress made; long-term, because there is no evidence on the system that meetings actually took place or of their quality. If the content of a Plan is too vague, this will also impact upon the effectiveness of a Core Group.  All these features raise questions about multi-agency accountability irrespective of statutory lead and about who has oversight of the whole process and can ‘quality assure’ that it is functioning as it should?  How do we know it is an underlying issue and not something unique to this case?  There were specific circumstances that impacted upon the effectiveness of Core Groups in this case that are unlikely to be common: for example, it is unusual for a parent not to be at the initial conference that develops the outline CP Plan and sets the Core Group membership.  It is also the norm in Newcastle for the social worker receiving case responsibility in the long term team to be present at the same conference and to lead the first Core Group that follows it, and neither happened in this case. This notwithstanding, discussions with members of the multi-agency Case Group confirm that it is generally understood that the social worker takes responsibility for all aspects of the core group.  There is a perception that this is to not only to convene meetings and ensure progress of the plan, which is what would be expected, but also to chair.  In reality national guidance and local procedures do not state that social workers have to chair but the understanding of many workers appears to dictate custom and practice.   How far this inhibits non-social work professionals from challenging in the event that a meeting is cancelled because the social worker cannot attend is not clear.  In this case both the school and the FiP worker asked for the group to be reconvened after the cancelled meeting on 11th November but no date had been set by the time of J’s death just over a month later.  There is a question to be posed more broadly around the degree to which professionals are prepared to escalate a challenge above a particular social worker if that person/role is perceived to be in charge. The point about oversight of the functioning of Core Groups is relevant here, because if there was such a line of responsibility, it would be easier to direct professional challenge in the event that it was deemed necessary.  However, guidance has never been clear on this point and has left it unaddressed to the degree that more often than not, Core Groups are perceived to be, and are in fact, self-managing.  The Conference Chair has some kind of responsibility to make sure that Core Groups meet and are progressing the Plan, but there is no procedural requirement for them to oversee the quality of meetings and records of core group meetings were not, at the time of this case, routinely part of the preparation or 41 proceedings of a Review Child Protection Conference.xix  A social work line manager will oversee the work of a social worker on a case but rarely in the context of how they are functioning within a core group and how the core group functions around them.  Newcastle’s LSCB procedures do refer to what to do in the event that there are difficulties - “Where any member of the Core Group is aware of difficulties in implementing the Child Protection Plan, the lead social worker (or Team Manager in her/his absence) must be informed immediately. The member should also discuss the concerns with her/his own agency named/designated professional” (Newcastle LSCB Procedures, 2.7) – but this is a different emphasis and doesn’t directly address responsibility for quality assuring the functioning of the core group.  It also uncouples a multi-agency process by locating escalation channels within individual agencies. How prevalent and widespread is the issue? We are unable to identify specific numbers of cancelled or re-arranged core group meetings as this information is not collected. There is anecdotal evidence that core group meetings are cancelled when a social worker is not available to convene and chair and equally there is anecdotal evidence that sometimes other professionals will step in so that meetings can go ahead if a social worker is unavailable or running late.  There does not seem to be any consistent approach.  The frequent revision of wording in national guidance and associated need to bring all local procedures in line is not helpful here: it is not simply a case of following the rules if the rules read differently in different places. It also takes time for new procedures and guidance to filter through, so professional recall may yet be in relation to what used to be rather than what is. It is accepted practice in Newcastle that core group members are expected to take their own notes from meetings as it is not always possible for social workers following meetings to circulate notes immediately. This is to ensure that core group members take forward their own actions immediately.  Notes from meetings at the time this case was in the system had to be typed onto templates held in the Care First database on each child’s file, which would also take some time; hence the tendency to more commonly use Total View as an interim measure, as handwritten notes can be scanned directly to it. In a positive move, practice has since changed to use standalone Signs of Safety Word documents, which can be uploaded directly.   There is some evidence from CSC monthly case file audits that quality of recording and timeliness of notes being available are areas for improvement: • ‘Recording of core groups and care teams, timeliness of upload on to Care First’ • ‘In some cases, notable lack of recording and variation in the quality and consistency of care team and core groups (i.e. gaps in the recording of activities for meetings, but also completion and availably of the minutes of the meetings on Total View)’ (Source: Monthly Case File Audits – Directors Review April 2014)                                             xix A new Core Group Record has been developed as part of the roll out of Signs of Safety and this now comes to all Conferences. 42 Confusion and lack of consistency in relation to interpretation of core group leadership has been picked up as an issue in other places.  The evidence for the ‘Anytown Neglect Study’xxcommissioned in Wales and published as an appendix in Horwath’s Child Neglect: Planning & Intervention (2013) includes this quote from a conference chair:  “It comes back to each agency taking responsibility and ownership of the core group so that there isn’t this expectation that a social worker has to manage chairing the core group, managing the dynamic of the core group, minuting the core group, getting those minutes out to the core group, because actually that’s just agencies relying on another agency isn’t it?”  Why does it matter? What are the implications for the reliability of the multi-agency child protection system? Consideration of the implications of the above ‘Anytown’ quote tells us why this Finding has the potential to impact upon the effective functioning of the child protection system.  To carry out any one of those responsibilities well is difficult.  To do them well all at the same time is extremely difficult and will depend too much upon a number of variables such as meeting dynamics and skills of individual workers. Core groups are the only procedural multi-agency mechanism for progressing, monitoring and adjusting a child protection plan with family members between Conferences. They are the formal links in the chain between Conferences, which after the first Review take place at six monthly intervals.  It is therefore imperative that core group meetings take place regularly so as to avoid drift and also that they respond to any significant change in circumstance by being convened as additionally needed.  It is also important that records of meetings are as full as possible, so that decisions and actions are clear and evidenced, can be reviewed systematically and individuals held accountable for them. Various factors stand to always affect the capacity of Core Groups to be effective. These include pressures of time; the influence on a meeting of family members or the absence of key figures, whether family or professional; the Plan itself, how thoughtfully it has been developed and how responsive it is to the need to shift direction; the availability of administrative support and the consequence of the lack of it for meeting records.  There is currently no systematic process of management oversight within the multi-agency system that might identify and address these kind of things in a timely way. As a consequence, the effectiveness of Core Groups is subject to too many variables.  There is no obvious solution to this, although the absence of any reference in statutory guidance leaves organisations free to try and find one if they choose.                                             xx  Anytown Neglect Study, in Horwath: Child Neglect, Planning & Intervention (Palgrave Macmillan 2013) 43 FINDING 6 The overwhelming reliance on social workers to lead, manage and administer Core Groups can diminish the effectiveness of these multi-agency meetings   National and local procedures/guidance around the operation of core groups allow for different interpretations of multi-agency ownership and the leadership role of social workers.  If the core group function is to be consistently effective, the Board needs to clarify its position in relation to this and reinforce the implications of this across the multi-agency staff group.  Ideally, and to reflect the importance of core group meetings to the child protection process, they should be supported administratively in a similar manner to Conferences.  Where this is not possible a wider ownership of responsibility is likely to impact positively on the quality of meetings, as long as expectations are clearly defined.     ISSUES/QUESTIONS FOR THE BOARD TO CONSIDER • Is this an issue that the Board is aware of and has previously considered? Might there be value in the Board setting ‘Best Practice Standards’ around the operation of Core Groups? • How confident is the Board that all agencies understand the purpose of Core Groups in relation to child protection planning and review? • Might IRO responsibilities extend to some quality assurance of core groups? What would be the value of/barriers to strengthening the IRO role in this way? • What are the barriers to other agencies taking responsibility (even in a deputy role) to chair and record core groups– practical, cultural, or confidence and skills? • What would be the advantages to the provision of administrative support to the Core Group process and how do these weigh in relation to any barriers?  • How might the Board reinforce the importance of escalating professional challenge when appropriate? • How is the new Signs of Safety template improving the recording of meetings? • How will the Board assure itself that practice is more consistently effective?    44 FINDING 7       Routine processes for agreeing bail conditions contain a loophole that omits checks being made about risks an offender presents to children  Bail is the term used when a person charged with a criminal offence is released from police custody until he or she next appears in court or at the police station.  There are three different types of bail in England and Wales: • Police bail where a suspect is released without being charged but must return to the police station at a given time. • Police to court where having been charged a suspect is given bail but must attend his first court hearing on a specific date.  • Court bail where having already been in court a suspect is granted bail pending further investigation or while the case continues. Generally, in order to grant bail the police will require certain conditions to be met.  It is the job of the Criminal Prosecution Service (CPS) to put forward the argument for any bail conditions in court.  Conditions can include living at a particular address or having someone act as surety, in order to prevent an offender from: • absconding; • committing further offences while on bail • interfering with any witnesses  Failing to comply with bail conditions is not an offence, but may lead to a defendant being arrested and brought back to court, where they will be remanded into custody unless the court is satisfied that they will comply with their conditions in future. Risk is therefore viewed by the criminal justice system as being primarily around flight, repeat offending or intimidation.  Nowhere in the Bail Act (1976) or subsequent amendments is there reference to risk in terms of adults or children who might be affected by an offender, other than the victim(s) of the offence. Information pertinent to the setting of bail conditions is gathered by the police prior to any court hearing; it is not usual for police to be present in a magistrate’s court to advise on the day of a hearing.  Despite this, if a person puts forward an address in court it is dependent upon people who are present in court to put forward a counter argument.  There is no access to information via any other means.  How did the issue manifest in this case? Partner2 was bailed by Court to stay at Mother’s address on the day that J was discharged from hospital. He had been evicted from his supported lodgings that day and provided mother’s address as his bail address, which was deemed to be ‘suitable’ from the perspective of any flight risk.  He was charged with robbery and burglary offences; his eviction was because he had been caught smoking cannabis and tampering with a smoke alarm.  He also had a contextual record of aggressive behaviour towards staff. He was on his second formal warning from the Probation Service for non-compliance with a 12 month Community Order with Supervision for theft.  This had been revoked in light of a second robbery and burglary offence and Partner2 received a suspended prison sentence with an electronic curfew in October 45 2013.  None of the agencies in the Core Group were aware of Partner2, his bail status or offending history until the Community Midwife discovered him in the house the following day.  The police had not been present at the strategy meeting or subsequent ICPC in July so no officer(s) had first-hand knowledge of any discussions about Mother’s history, parenting capacity and/or vulnerabilities which may have been relevant in terms of the potential impact of an offender with Partner2’s profile. Although the fact that mother’s children were all subjects of CP Plans should have been recorded within a police database, the police representative on the Review Team agreed that it is very likely that the potential relevance of this was not explored or seen as significant, given the omission of any reference to safeguarding concerns in the legislation underpinning the granting of bail. It is also unlikely that the police had received notification of J’s birth or that they were aware of plans for discharge; there is no record of any notification taking place.   In short, arrangements were agreed for Partner2’s bail in isolation from any thinking around the possible impact that he might have on anyone in the home that he had named and/or discussion with agencies working with them.   How do we know it is an underlying issue and not something unique to this case? The fact that there is no reference to safeguarding concerns in criminal justice legislation or guidance in the context of what constitutes a suitable address to meet bail conditions, increases the likelihood that neither the police nor the CPS will be looking through this lens when building a case either for or against.  The police representative on the Review Team confirmed that it is not usual to conceptualise risk from the perspective of safeguarding children. The police view risk around bail in terms of flight or intimidation of witnesses and can set conditions to ameliorate this prior to a case going to court.  Even if immediate concerns are raised once bail has been granted it is not straightforward or quick to address: a social worker could make representations to get an address changed after the event to Probation/Offender Manager, but change can only take place when a case returns to court. This is compounded by the tendency for professionals to identify risk in association with a particular type of crime; if the crime does not involve children it is less likely that any risks related to abusive behaviour will be associated with an offender.  Hence we get the conclusion as in this case that an offender can be deemed as being a medium risk of violence to the public but risk-free in the context of a vulnerable family.  Similarly in cases of domestic abuse, it is still quite common to find the risk of physical harm to an adult victim being addressed while the same risk is not seen to apply to children who are living in the same house. How prevalent and widespread is the issue? The Review does not have access to data to substantiate prevalence or to point to occasions when offenders bailed to particular addresses have harmed others in the household.  Nor are we arguing that harm is inevitable, either in this case or more widely. This is a national issue, not one that applies only to criminal justice agencies in Newcastle.  The case being made concerns the need to ensure that safeguarding concerns relating to children are on the radar of all professionals, as enshrined in 46 statutory safeguarding guidancexxi: “Local agencies, including the police and health services….have a duty under section 11 of the Children Act 2004 to ensure that they consider the need to safeguard and promote the welfare of children when carrying out their functions” In the context of this Finding there is a clash with the requirements of a separate legislative framework, albeit that the agencies concerned are the same. Why does it matter? What are the implications for the reliability of the multi-agency child protection system? The lack of any reference to the safeguarding of children or vulnerable adults beyond that of a known victim establishes a direction of thinking, both for those professionals directly responsible for setting bail conditions (and any investigation associated with this) but also for a wider group who may be working with children and family members.  It can present a false assurance and could allow a situation whereby the possible risk posed by an adult to children is unexplored within the criminal justice system even though exploration is a duty under child welfare legislation.  It therefore renders professional duties under the Children Act invisible at the very point that there should be some exploration of the risk (and mitigating factors) of placing an offender in a family home, particularly where that family is already part of the child protection system.                                                 xxi Working Together to Safeguard Children 2015; Introduction FINDING 7 Routine processes for agreeing bail conditions contain a loophole that omits checks being made about risks an offender presents to children   This case exposes how the criminal justice and child protection systems can operate in parallel in the context of a single household and highlights one element of the criminal justice system that routinely performs in isolation from the wider safeguarding agenda.  The law is the driver behind both systems from differing perspectives.  Unless the two are brought more directly together, one system risks causing a situation that the other is designed to safeguard against.     ISSUES/QUESTIONS FOR THE BOARD TO CONSIDER • Is this an issue that the Board is aware of and has previously considered?  • Is the Board aware of any data that might usefully indicate harmful behaviours as a consequence of offenders being bailed to addresses of their choice? • What measures might be taken to raise awareness of the issue locally? • What kind of safeguarding training is available to and taken up by the CPS? • How and where might the Board raise the issue in order that the legal implications can be most effectively addressed? • How will the Board assure itself that practice is more consistently effective? 47 FINDING 8         The way that medical staff present their diagnosis of types of injury can be confusing to non-medical practitioners, who interpret lack of evidence as meaning an injury is accidental   When there is concern about physical abuse of a child, a paediatric child protection assessment is arranged. This may or may not provide definitive evidence of such abuse. The conclusions of such assessments are not often clear cut and are likely to state that the injury is “consistent with” the explanation provided by a parent/carer. Such a diagnosis does not mean that it could not also be consistent with alternative explanations, including abuse.  How did the issue manifest in this case? Early in October Sibling2 alleged to nursery staff that ‘mummy slapped me’, which contradicted mother’s later explanation that a taxi door had hit Sibling2’s face and caused a possible mouth injury. The nursery appropriately notified the social worker and following discussion with the police it was agreed that she and the senior practitioner would arrange a paediatric child protection assessment. No s.47 enquiry was initiated as it was not thought to meet the threshold for this without further information. The social workers went to the school and waited for mother to arrive before taking Sibling2 to the medical examination, which concluded that the injury was consistent with the explanation mother had provided. The conclusion was accepted by school staff and social workers as a factual determination that mother had been telling the truth, as recorded by the school: ‘later found that [mother’s] account was factually correct’. On the basis of this perception the child’s allegation was ignored and not explored further, nor shared with the core group a few days later or the subsequent child protection conference. This reflects a (mis)understanding that a medical examination is able to provide definitive evidence one way or another about the cause of an injury. In reality, whilst such a conclusion does not provide evidence of non-accidental injury, it also does not rule this out and certainly did not mean that mother’s account was ‘factually correct’. It could have been correct, but we do not know what alternative explanations could also be correct, including the child’s allegation that her mother slapped her.  Like other practitioners, in making a diagnosis, the paediatrician is reliant on the information provided to her/him and the observations of the parent /child relationship, along with any physical evidence. The arrangements made for this assessment were those least likely to have led to the child being able to disclose anything further about the circumstances of the injury, or indeed about her comment that her mother had slapped her. This was the second time she had made allegations about her mother, who was present at the examination; the need to give the child space to speak without her was not recognised. It is also not clear why Partner1 (Sibling2’s father) was not told about the allegation and involved at this stage instead of mother. This would have increased the opportunity for the child to speak more openly.  48 How do we know it is an underlying issue and not something unique to this case?  It is not clear to what extent practitioners misinterpret the intention behind medical diagnosis of non-accidental injury in Newcastle, but anecdotal discussions with case group and review team indicated that they are likely to do so. How prevalent and widespread is the issue? The lead reviewers have found evidence of the same issue in several case reviews undertaken over the years. The Daniel Pelka SCR (2013) highlighted it in a public report: ‘For professionals from Children’s Social Care or the Police to defer to medical staff for the provision of the primary evidence to confirm or otherwise whether an injury to a child was the result of abuse or not, could be unhelpful, particularly when no definitive view one way or the other can be given. To do so could lead to any following investigation being inappropriately downgraded and implies that other aspects of the child’s life are less significant for the purposes of assessing the existence of child abuse.’xxii  Why does it matter? What are the implications for the reliability of the multi-agency child protection system?  The understanding of the role of the paediatric child protection assessment is critical to the ability of the multi-agency safeguarding system to be able to protect children. To rely on the ability of such a diagnosis to provide definitive evidence of abuse, and to use this to decide whether to progress to a s.47 enquiry, or more often whether to cease a s.47 enquiry, is dangerous. Whilst the paediatrician is sometimes able to provide positive evidence of abuse, the lack of such evidence does NOT in itself rule out abuse and further enquiries are required to do so.                                             xxii Daniel Pelka – serious case review, Coventry LSCB (2013)ttp://www.coventrylscb.org.uk/files/SCR/FINAL%20Overview%20Report%20%20DP%20130913%20Publication%20version.pdf 49  FINDING 8 The way that medical staff present their diagnosis of types of injury can be confusing to non-medical practitioners, who interpret lack of evidence as meaning an injury is accidental  This case highlights the misunderstandings that exist about the role of the child protection paediatric examination and the limitations of its findings in many instances. Like all practitioners the paediatrician needs optimum circumstances to be able to provide a good assessment, and this is not reliant totally on physical evidence. Hence the presence of the subject of allegations during the examination is less likely to be conducive to a reliable diagnosis. It is vital for the safety of children that the limitations of paediatric assessment are understood, and that the lack of definitive medical evidence is not seen as the end of investigations or the proof that there is no cause for concern.   ISSUES/QUESTIONS FOR THE BOARD TO CONSIDER • How might the Board increase understanding that the role of the paediatric CP assessment is part of the safeguarding process, but not the only way to obtain evidence of physical abuse?  • How might practitioners be supported to understand that, generally, such assessments are part of s.47 enquiries – as opposed to providing the evidence to initiate a s.47 enquiry? • How might practitioners be supported to understand the need for careful planning of who is involved and how – including issues relating to parental agreement and participation?   • There is an urgent need for practitioners to understand that a child should be given the opportunity to explain the circumstances of any injury or allegation without the presence of the alleged perpetrator.  How will this be facilitated? • Is there a need to review how paediatricians record their diagnosis, so that it is better understood by non-medical colleagues? Is there benefit in aligning the kind of sliding scale judgements required for criminal cases more closely to all child protection medicals?     50 FINDING 9        Despite all child protection cases being high risk by definition, practitioners juggle priorities by deciding which is more risky than another, leaving the less obvious neglect cases more vulnerable Child protection work represents the highest level of intervention that professionals undertake with families while children remain living at home.  Organisations apply criteria for meeting this threshold for intervention slightly differently but common to all will be the assessment that a child is at risk of, or is suffering significant harm. Any case that requires a child protection enquiry and which proceeds through the conference, child protection planning and review process is therefore a high risk case, in relation to others that are assessed not to meet this threshold. However, ‘risk’ is conceptualised differently in relation to different families, even when all sit within the highest risk threshold. It will be active or it will be latent.  Pragmatically this then equates to the need for intervention urgently or at a slower pace, especially when there is a high volume of work. One vulnerability inherent in this understandable, necessary and often informal approach to case management is that it doesn’t account for the unpredictable in cases where there is no obvious immediate risk. Another is that, where it is informal, it becomes more of an unspoken assumption about a case which may not be tested with other practitioners. Practitioners are then shocked when something happens, because the case has not been high on their radar.    How did the issue manifest in this particular case? Although the most immediate examples from this case concern Children’s Social Care the issue is relevant to professionals across all organisations engaged in decision-making about risk. The identification of risk aligned to significant harm in this case was a subject for some debate in the Review Team. There was no child protection enquiry when risk was high in April/May; at the point that the ICPC took place the children’s presentation and attendance at school had improved and mum was beginning to engage with FiP, although much remained unknown, particularly in relation to the impact of a new baby.  There were several opportunities to review risk assessments once Partner2 had moved into the home which were not taken.  The children were made subjects of Plans against the category of ‘Neglect’ but it was the social work view that the problem was most substantially related to the previous relationship between mum and Partner1, which played out in fractious contact arrangements. There was limited thought about what might constitute neglectful behaviour after the ICPC, other than by checking for more obvious symptoms in the children’s presentation.  This view persisted when case responsibility transferred again in October 2013. A significant compounding factor over the period was the churn in the CSC long term team within which the case was allocated: the social worker who took over in August had no handover and went on maternity leave herself in October; her line manager (and the manager of her team) retired in August, with interim cover until a new manager started in mid-October. The interim manager had a temporary increase in staff and case responsibility. The new permanent manager had to allocate responsibility for multiple cases very quickly across a team that was already stretched.  The practitioner who took over then, did so in the context of experience but with an already higher than average caseload. In this context, it is not surprising that cases were conceived as being urgent 51 or less urgent.  The language used by both managers and practitioners was that this was an ‘amber’ rather than a ‘red’ case. How do we know it is an underlying issue and not something unique to this case? The readiness with which Case Group members described the difference between cases with high presenting risk and those without was a firm indication to the Reviewers that this kind of informal prioritisation takes place all the time.  Under stressful conditions the odds that it will happen increase, because it is so understandable in the context of time management.  While caseloads in Newcastle are commendably lower than the regional average, this is likely to be placed under pressure for different reasons at different times.  The long-term children’s social work service in Newcastle has fairly recently been restructured to better reflect the child’s journey through the system.  While this is a good move from the perspective of families, there will be implications for practitioners’ time if their caseloads include child protection, children in care and children in need cases.  Inevitably there will have to be priority attached to some cases at the expense of others and especially so if resources on the ground are stretched.  This is not by default a bad thing, but it could be in the context of neglect cases if professional understanding of the potential for dangerousness in ‘neglect’ is not well enough informed, particularly in the context of babies and very young children .  How prevalent and widespread is the issue? Newcastle has the fourth highest rate in the region of children on CP Plans per 10,000 population and the third highest rate of Looked After Children, according to information shared regionally. 467 children became subject to CP Plans in the 12 months up to July 2014, an increase of 12% on the previous year.  This is consistent with the national average, which was also up by 12% at the end of March 2014, having increased by 23.5% since March 2010xxiii. The volume of work coming into and living within child protection systems both locally and nationally is therefore high. The presenting issues are also highly complex and changing, particularly as local demography changes. Also very relevant to this Finding is the percentage of children who are coming back into the system and onto CP Plans for a second or subsequent time (22% according to the same benchmarking exercise), a significant proportion of which are neglect cases.  This either means that they were taken off Plans prematurely or that the Plans were not working well enough or both.  Work is currently being done to address this issue and emphasize the need for evidence that apparent progress can be sustained before removing children from Plans, but the prolonged success of this initiative also depends upon how progress is interpreted in neglect work and the degree to which root causes rather than symptoms are being addressed.  Currently, there is no multi-agency training available in Newcastle specific to understanding and working with child neglect, other than an on-line course where it is considered more generally alongside other forms of abuse.                                             xxiii Characteristics of children in need in England 2013 – 14 (DfE) 52 Why does it matter? What are the implications for the reliability of the multi-agency child protection system? The majority of families with children on CP Plans are subject to this level of statutory intervention because of neglect, not just in Newcastle but across the country. That all practitioners struggle to respond effectively to ‘neglect’ cases has also been recognised as a national issue.  If professional attention has to be prioritised according to court deadlines or what appears to be the most immediately risky, it is unlikely that a ‘quieter’ neglect case will receive the time and attention necessary to really understand and work with causal factors.  As such, it is more likely that a family will appear to make progress while support is provided via a Plan and regress once that support is withdrawn.  It also takes no account of the unpredictability of events in the context of so-called ‘chaotic households’: if professionals are only alert for the non-accidental ’incident’ of abuse, the significance of accidents or implication of changes in circumstance may not be investigated thoroughly enough or at all.  Finding 9 Despite all child protection cases being high risk by definition, practitioners juggle priorities by deciding which is more risky than another, leaving the less obvious neglect cases more vulnerable.  Managers and practitioners across agencies always and necessarily have to prioritise work in order to address the immediate and urgent.  Child protection cases have a level of priority just by virtue of their status relative to other work, but at this level and because of volume, cases are still ‘sorted’ in terms of what needs attention now and what can wait. The way that judgement is reached around this has implications in particular for work around child neglect, where the immediate risks may not be so visible but the potential for an adverse outcome is high.    ISSUES/QUESTIONS FOR THE BOARD TO CONSIDER: • There is no quick solution to the issue highlighted in this Finding, but does the Board accept that it needs to be addressed? • Is the Board confident that the opportunity for effective and reflective supervision is provided to professionals engaged in child protection work, either in a timely way or at all? • Is the Board confident that managers in all settings have the skills and support to be able to provide effective and reflective supervision, particularly in relation to neglect cases? • How might the Board support managers and practitioners to better understand, assess and manage risk in the context of child neglect? • How does the Board evaluate the learning needs of particular staff groups and then measure the impact of any training or other learning programme? • Are there ways in which neglect cases could be approached differently, in the context of the current procedural framework? • How will the Board assure itself that the issue highlighted by this Finding is being effectively managed?    53 FINDING 10       It is currently more difficult to coordinate a multi-agency response to unexpected child deaths at weekends and Bank Holidays, with potential to affect the timely diagnosis of likely cause of death Statutory regulations and guidancexxiv set out the functions and process for the care and investigation of a sudden and unexpected death of a child. NSCB has a multi-agency Rapid Response procedure in place to ensure these functions are carried out effectively and in accordance with the principles of the Baroness Kennedy report (2004)xxv.  In addition to this, and in recognition of a reduced capacity at weekends and bank holidays, the North of Tyne Child Death Overview Panel (CDOP) developed a Rapid Response policy to ensure there is a consistent approach across the North of Tyne area.  The procedure stipulates that a meeting is required when:   • A child/young person under the age of 18 dies and a Rapid Response is required and  • The death occurred out of office hours including weekends/bank holidays and the information needs to be shared urgently - before the ‘in hours’ information sharing meeting can be convened.  Newcastle upon Tyne Hospital Foundation Trust also implemented a local proforma in 2008, known as the ‘Green Book’, to assist medics in ensuring that all necessary actions are undertaken and recorded in the event of an unexpected child death. How did the issue manifest in this case J died in the early hours of a Saturday morning. The issue highlighted by this finding arose when resuscitation had been ended by the Emergency Department Team and J had been pronounced dead. The on-call Consultant Paediatrician, having spoken briefly to the police, left the Paediatric Registrar to go through the list of things that needed to be done as part of the ‘Green Book’ protocol so he could do ward rounds.  The Green Book list includes a comprehensive physical examination, various medical samples to be taken and relevant key professionals to be contacted. Medical examinations did reveal a 0.5cm bruise to the right knee, a scratch in the nappy area and a ‘bloody tap’ from the lumbar puncture, although these were not considered to be potential safeguarding concerns until the Rapid Response Meeting, which was held on the Monday morning following the weekend. The Consultant was not aware that J had been on a CP Plan at the point that he had conducted his examination.  Although he thought Partner2’s behaviour ‘odd’ over the period of attempted resuscitation and had flagged this to the police, he was not aware of the family context. Although there were conversations between individuals – for example, the duty police officer and duty social worker,  - which ensured a plan for the care of the other children, there was no multi-agency “immediate response” meeting over the weekend period such as local procedures require, to debrief or respond to any immediate issues. Had there been, concerns could have been shared about J’s child protection status earlier.                                             xxiv Regulation 6 of the LSCB Regulations (2006) and Working Together to Safeguard Children (2015) xxv Baroness Kennedy report on Sudden and Unexpected Death in Infants (RCPath and RCPCH, 2004) 54 As part of the ‘Green Book’ protocol it is usual practice to contact the Ophthalmologist to request an eye examination, but the examination did not occur in a timely way as the Ophthalmologist was led to believe it was not urgent.  Essentially this meant that significant evidence relating to retinal haemorrhaging was missed at an early stage and not picked up until the post mortem 4 days later.   Research indicates that bleeding inside one or both eyes is a common symptom of ‘shaken baby syndrome’ that can be detected by a paediatric ophthalmologist.  Medical opinion provided to the review suggests that if the eyes are not examined swiftly after death they cloud over, which obscures the ability to see the fundi [back of the eyes] and any possible retinal haemorrhaging.  According to the Consultant Paediatrician when spoken with as part of this Review, early diagnosis by an ophthalmologist “might have changed the course of the [cause of death] investigation earlier“.  The detection of possible retinal haemorrhaging occurred too late after death to be able to provide conclusive evidence of cause. Accurately establishing cause of death was not just important from a criminal point of view, but also for the immediate safeguarding of J’s siblings. How do we know it is an underlying issue and not something unique to this case?  It is usual practice to have a single ‘on call’ Consultant Paediatrician at weekends and bank holidays for general paediatrics (not sub-specialities) as opposed to a full complement of medical professionals Monday – Friday, including the hospital Safeguarding Team, who provide advice and guidance to all hospital staff. This Consultant works with a supporting team of junior doctors, but has overarching responsibility for decision-making. ‘On call’ cover on a weekend or bank holiday means that the Consultant has to do all the ward rounds in addition to attending any emergency that presents itself, which on this occasion was the unexpected death of J. The Great North Children’s Hospital has 140 beds, excluding day and intensive care.  About thirty of them would have been occupied by general paediatric patients at that time of year, which meant that ward rounds could take up to “5 hours” to complete. Discussions with the Case Group and Review Team revealed that, unlike the multi-agency response to an unexpected child death in the week, whereby face to face meetings are called at very short notice between key professionals and information and concerns shared quickly, the response at a weekend usually occurs through telephone conversations, which appear to be less well coordinated and recorded – this despite the existence of Out of Hours response procedures requiring an immediate response meeting to take place.   Further examples of a less thorough response following a child death out of normal office hours are: • Skeletal surveys are not routinely carried out at weekends although they can be requested • MRI/CT scans out of hours are not routinely done on an unexpected child death or as part of current national medical protocol. • The hospital Safeguarding Team is not available for advice and support. If the level to which different tasks can be covered differs according to which day of the 55 week it is, we might reasonably expect some system of prioritisation to identify which cases are particularly important; but there are differences between agencies in terms of their access to information to identify those children who are subjects of CP Plans.  Unlike the hospital and police system, which flags the names or addresses of such children, the NE Ambulance Service do not have a system to support early identification and diagnosis of non-accidental injury or harm in this way. Neither are they ever asked for information as part of the CP process despite possibly attending and treating patients at home.  Were they to have this information an alert could be raised at the point of initial response at the scene. How prevalent is the issue? The number of unexpected child deaths that professionals have to deal with is small therefore not common practice. The Review Team also agree that the system does work well most of the time, partly because of ‘informal’ practices that can kick in to support a Consultant Paediatrician if needed. National statistics indicate that around 1% of children were the subject of a CP Plan at the time of their death and 2% of all child deaths had a serious case review carried out on them (DfE 2014).  These figures are not dissimilar to local data collated through the North of Tyne CDOP. Arguably, the very fact that numbers are so small should strengthen the case for a thorough response at all times. How widespread is this pattern? The implications for practice potentially have a wide reach.  The services involved in the rapid response process cross local, regional and national boundaries.  The North of Tyne CDOP recognised this and developed an Out of Hours Rapid Response Procedure in response to the need to have uniformity across the three local authority/LSCB areas (Newcastle, Northumberland and North Tyneside), although the procedure does not currently cover the requisite detail in relation to assuring the timely input of key medical practitioners. Why does it matter?  What are the implications for the reliability of the multi-agency child protection system? The death of any child is a tragedy. The majority of sudden unexpected child deaths are natural tragedies, but a minority are a consequence of neglect or abuse.  The purpose of the rapid response process therefore is for professionals to maintain an open mind, keeping an appropriate balance between medical and forensic requirements, whilst taking account of the possible cause of death and risks to other children in the household.  Not only is there a professional responsibility to respond to the unexpected death of one child, identifying as quickly as is possible whether it might have been non-accidental, but there is a linked responsibility then - notwithstanding the implications for criminal proceedings - to make suitable arrangements in relation to the protection of any other children in the household.  ‘Response’ in these circumstances is a multi-agency, co-ordinated and consistent activity to ensure that all information that is available is known and shared to ensure a speedy and accurate diagnosis, including over the weekend and bank holidays.  56  FINDING 10 It is currently more difficult to coordinate a multi-agency response to unexpected child deaths at weekends and Bank Holidays, with potential to affect the timely diagnosis of likely cause of death  This Finding hinges around the capacity of a Consultant Paediatrician to fulfil child death responsibilities, out of hours, as well as attending to general paediatric work. The current system to support a rapid response to the unexpected death of a child during a weekend or bank holiday was put in place as recognition of reduced capacity whilst needing to maintain a robust and effective response.  The system includes an Out of Hours Procedure and medical protocol, which sets out roles, responsibilities and processes for information gathering and sharing in these circumstances, in particular to ensure the safety of any other children in the household.  The review of the response to the unexpected death of J has highlighted further improvements that can be made to its effectiveness.   ISSUES/QUESTIONS FOR THE BOARD TO CONSIDER • Is the Board confident that there is a robust escalation plan in place to support Consultant Paediatricians in the event that they face capacity issues out of hours? • Is the Board aware that face to face immediate response meetings do not routinely take place at the weekend or Bank Holidays? Does this provide a sufficiently good service? • Are investigating agencies aware that skeletal surveys can be requested out of hours and that MRI/CT scans are not routinely done on an unexpected child death or part of current medical protocol, but that these can be negotiated?  • How might the current North of Tyne ‘Out of Hours’ procedure be usefully strengthened? • Should the names of children on Child Protection Plans by made available to paramedics and is NEAS included in the roll out of the Child Protection Information System (CPIS)?? • Does the Board think that there should be more dedicated safeguarding cover in hospitals over weekends and Bank Holidays?    57 FINDINGS 11 and 12 The following two Findings are linked and relate particularly to the research question governing this review that concerns the effectiveness of interventions when families have been involved in neglectful or abusive behaviours over generations.  The degree to which services are likely to have been involved with such families over time, the nature of that involvement and the pervasiveness of issues, will almost certainly make it more difficult to achieve family-professional relationships that are based upon trust, quickly or at all.  The ‘usual’ ways of working may not be sufficient and it is in this context that these Findings are placed. FINDING 11    A tendency to focus too much on the nuclear family in isolation from any wider networks, even when extended family members are known to professionals, is limiting the effectiveness of interventions with families that have been subject to child protection measures over generations? How we define who is part of a family will dictate who we then communicate with, invite to meetings, involve in support and protection plans.  It may also impact upon the effectiveness of those plans in different ways which affect the chances of getting a balanced view of strengths and risk factors and the likelihood that families will engage with the process. As ever in the child protection world decision-making as to who is or is not ‘family’ is unlikely to be straightforward; there may be serious conflict or legal issues between family members that rule out the usefulness of having them in the same room at the same time.  There are also issues around confidentiality of information and who should be party to information about another.  Balanced against these factors is the value that can be gained, both for parents and for professionals, by acknowledging and working with the reality of a family support network.   How did the issue manifest in this particular case? The people in this case who were identified as family in terms of their direct involvement with child protection processes were mother, Partner 1 and the children themselves. Extended family and Partner2 were not fully involved by practitioners in the assessment process or in the formulation and implementation of protection plans.  ‘Family’ in this instance was complicated by previous history and current circumstances, both of which contributed to a professional view that the maternal grandmother (MGM) was not safe (mother’s brothers were both in prison so the same judgement applied to them).  MGM was herself part of a different child protection plan at the point that this case was brought to conference, the subject of which was her youngest daughter (mother’s youngest sister).  She was therefore not included in any assessment work relative to this case nor invited to come to Conferences or Core Groups.  This was on one level understandable in terms of her perceived status as a risk factor but it does not consider the child protection planning function from a wide enough perspective: while it was possible to remove MGM from the formal process it was not possible to remove her from the family. This meant that professionals were working with a false ‘version’ of the family, in which MGM was not included, which did 58 not reflect the reality of family life.   For mother, despite the history of family conflict, MGM was part of her practical support network whether she was permitted to be or not. Rather than seek to work with MGM in the acknowledgement that she would almost inevitably be needed by mother in some capacity just by virtue of who she was, MGM became an “inappropriate person” in the language of the Plan and mother was instructed not to leave children with her unsupervised.  What this did was drive things underground: it was a surprise when one day in early October 2013 MGM brought the children to school and picked them up at the end of the day.  Had more attention been paid to the implication of mother’s earlier admission to the FiP worker that she had ‘trust issues’ then arguably her continued use of MGM might have been more predictable and less of a shock. This was one incident of MGM’s ‘hidden’ involvement but there had been a previous one in September and it is highly probable that there were others, especially after the move to a new house and in the context of a new relationship.  It happened shortly before the RCPC but only resulted in a repetition at the conference of MGM as “inappropriate” rather than any reflection around mother’s realistic support needs with three young children, a small baby and a new, teenage boyfriend.  Nor was there any consideration of the possible constructive use that might be made of MGM (or other family members and friends for that matter) as managed contingencies given that there was a 3 month wait before mum could register with the Incredible Years programme having avoided attending in September. It was therefore known that MGM was being used by mother to provide ad hoc childcare even though their relationship was a difficult one.  It was also known that mother would sometimes use other relatives (paternal great grandfather) and friends to look after the children but these were never formally assessed or explored as part of a potential support network that together might make the Plan a more realistic one.   When the reviewers met with J’s mother as part of this review, she said that her relationship with her grandfather (J’s great grandfather) had been particularly close and that he knew of the problems she was facing with regard to Partner2's use of legal highs, consequent stress arising from financial problems and his violence to her and property. She also said that although she had liked her social worker (SW3) - “if I was going to tell a social worker anything it would have been her” - she could not tell her or any of the other professionals of her problems for fear of having the children removed. She recognised that all those supporting her were obliged to report concerns to the social worker. Whilst J's great grandfather may not have shared his knowledge, professional involvement with the wider family is more likely to identify tensions and concerns, as well as provide additional resources to support the children.   How do we know it is an underlying issue and not something unique to this case? The degree to which the issue highlighted by this Finding is underlying is one where an evidence base is lacking at the moment and for the Board to pursue.  For the Review Team it raises two main questions about how we work with families: The first relates to the issue of trust and the fact that families who know the system well will also know how to manage it.  The dots were never joined by the multi-agency professional group in this case, in relation to what mother’s ‘trust issues’ were likely to mean in terms of evasive behaviour.  Arguably, granting permission to involve wider family in the process, albeit in a managed way, would be more encouraging of trust 59 than trying to excise them from it.  Not doing so increases the likelihood that family members will continue to do what they have been told not to do, only not say so. The risk therefore is that the whole working relationship is grounded in unreality. The second question concerns the way we visualise work with families where members of the same family are on concurrent, but differently managed, child protection plans as was the case here.  We heard from members of the Case Group that sometimes an informal ‘checking out’ took place between social workers but that there is no more formal bringing together of linked cases than that, despite the fact that each may be part of the same family.  So a family is not considered holistically at the point that core assessments are undertaken, nor in relation to building a realistic protection plan, unless they happen to be allocated to the same worker and this will not always be possible.   A possible knock on effect deriving from the lack of any linked discussion is the propensity for professional myth-building about family members and for the lack of any opportunity to consider evidence to the contrary.  In this case, Case Group members spoke loosely about MGM’s reputation but when pressed as to what exactly she had done that had been so awful they did not really know. The risk here is that plans become built around reputation rather than fact. How prevalent and widespread is the issue? Again the evidence base for this is something that requires further testing.  Relevant is the degree to which process (targets, timescales, audit work etc.) has overtaken the more qualitative work around relationship building which is fundamental to any interaction between people that builds both trust and respect.  This is a widespread issue nationally and not only a consideration for Newcastle.  It also links to the use of standardised tasks in Plans (Finding 5).  In terms of potential solutions that are more embracing of a wide definition of family, family group conferencing has a track record, although the evidence base in relation to outcomes varies.  This is the Family Rights Group definition of FGCs: “A family group conference is a process led by family members to plan and make decisions for a child who is at risk…. Families, including extended family members [Reviewers’ formatting] are assisted by an independent family group conference coordinator to prepare for the meeting. At the first part of the meeting, social workers and other professionals set out their concerns and what support could be made available. In the second part of the meeting family members then meet on their own to make a plan for the child. The family should be supported to carry out the plan, unless it is not safe.”   Newcastle Children and Young People’s Service has had a commissioned Family Group Conference project in place for a number of years but Review Team members were frank that, after initial enthusiasm, the arrangement has not been well enough used.  Signs of Safetyxxvi Family Meetings, which adhere to similar principles, are currently being introduced so there is acknowledgement locally that there is benefit to being able to implicitly say to a family that the system trusts them to come up with a solution.  These meetings will be embedded in existing systems and therefore will not                                             xxvi Turnell, A. and Edwards, S. (1999). Signs of Safety: A safety and solution oriented approach to child protection casework, New York: WW Norton.   60 be dependent on individuals making referrals to an external provision.  This is a positive step, although it is too early to point to impact. Why does it matter? What are the implications for the reliability of the multi-agency child protection system?  The degree to which a Plan to enable children to remain living at home is likely to be both effective and lasting links to how we gain a realistic understanding of how family members relate to each other and then how we use this constructively and in a managed way to build resilience.  The capacity of an individual social worker and core group to do this will be hampered if different and separate processes are working with different parts of the same family – it makes it less likely that there will be a balanced and considered view of the risks and strengths within the family network.   This in turn makes it less likely that Plans will be perceived by families as being realistic and appreciative of their world, which stands to impact upon the degree to which there will be any trust in the process.  This is a point argued strongly by Carole Smithxxvii, who distinguishes between the ‘confidence’ that professionals invest in their systems and regulatory frameworks as fit for purpose, and the trust that is necessary between family/professional and inter-professional relationships to achieve what the system intends.                                             xxvii C Smith: Trust & Confidence (British Journal of Social Work Vol 31) 61  FINDING 11 A tendency to focus too much on the nuclear family in isolation from any wider networks, even when extended family members are known to professionals, is limiting the effectiveness of interventions with families that have been subject to child protection measures over generations  The manner in which families are identified, and by whom, can influence the information that they make available to professionals and the level to which family members invest in a Plan as being theirs. If people feel that professionals have an unrealistic view of their world, they are less likely to work with what to them is an unrealistic Plan. Without this investment Plans are unlikely to succeed on a level that is other than superficial compliance.    ISSUES/QUESTIONS FOR THE BOARD TO CONSIDER:  • Do the LSCB know how many children are currently on CP Plans within families that have been known to services across generations? • Given that each family is part of a wider system, would there be value in the LSCB considering the adoption of a theoretical framework for work with families that is rooted in a systems approach and what are the options? • Is there a rationale (beyond pragmatics) for the allocation of different social workers / different social work teams to members of the same family? • How might practitioners from all agencies be facilitated to work together across a whole family spectrum? • Is there value in the development of genograms that can both map complex families and show who is working with them?  If so, how might this work be taken forward? • How will the Board assure itself that the new Signs of Safety Family Meeting approach is both effective in the short-term and being sustained     62 FINDING 12      The attendance of an appropriate range of professionals at CP Conferences is inadvertently being limited by too narrow a definition of family, thereby undermining the effectiveness of planning and the best interests of children. This Finding continues the thinking of the previous one in terms of the benefits of working with a wider network and questions how professionals identify who should or should not be directly involved in child protection processes and more specifically, who is entitled to attend the Conferences that assess the risks to children remaining at home and then plan for their protection. How did the issue manifest in this particular case? The clearest example that this case provides concerns the way that professionals did not consider Partner2 a family member after September 2013, even though he was living in the house as Mother’s self-declared partner.  No proper assessment was done in relation to the risks he might actually or potentially present, although telephone checks were made at different points with professionals who were working with him (16+ Team; YOT; Probation Service). None of these professionals were invited to attend the Review CPC in October.  Three days before the Conference took place, Partner2 had been in court for robbery and burglary offences and had received a new Order which included a 3 month curfew.  On the same day he had also been apprehended on the street by the police for taking legal highs.  None of this information came to the Conference. Had Partner2 and professionals involved with him been present or been invited to submit reports in absence, there would have been the opportunity for the Conference to reconsider both the assessment and the Plan in a way that took more realistic account of the risks Partner2 presented to each of the children, both in his own right and in his relationship with Mother.  The absence of the police from the Conference was also significant here and an issue the review highlights in Additional Learning, section 6. How do we know it is an underlying issue and not something unique to this case? When discussing this point with the Case Group it became clear that decisions are made as to which family members should attend Conferences according to whether or not they have legal parental responsibility (PR) for the subject children.  The driver behind this is decision-making about who has a right to hear the information being discussed about whom. What is likely is that if the presence of a particular family member is vetoed then the professionals working with that person will to all intents and purposes become invisible. What this misses is consideration of attendance in terms of the best interests of the children. The readiness with which the Case Group explained the importance of PR in the context of Conferences made the Reviewers concerned that this was highly likely to be something that is being repeated routinely, although the impact each time will differ. How prevalent and widespread is the issue? While we suspect that this kind of filtering does take place, often inadvertently, we do 63 not know how often or how regularly.   Nor is there evidence to easily draw upon from policy and guidance.  Working Together 2013, current at the time of this case, did not place restriction on who is invited to Conference, rather it encourages range: “Following section 47 enquiries, an initial child protection conference brings together family members (and the child where appropriate) with the supporters, advocates and professionals most involved with the child and family, to make decisions about the child’s future safety, health and development.” (p.40, Reviewer’s bold font) It is likely that any confusion has its roots in how information sharing is being interpreted, albeit that Working Together 2013 was blunt in its expectations:  “fears about sharing information cannot be allowed to stand in the way of the need to promote the welfare and protect the safety of children” (ibid 1:24, p.15).   Information sharing is not only permitted, but a duty under the 2004 Children Actxxviii Why does it matter? What are the implications for the reliability of the multi-agency child protection system? A system designed to protect children is based on the premise enshrined in the Children Act 1989, that the welfare of the child is paramount.  Statutory powers under s47 of the Act protect the right to share information once a strategy meeting has decided it is necessary to pursue a child protection enquiry.  The system is reliant on information being effectively shared at every stage of the cycle thereafter of assessment, planning, intervention and review, in order to stand the best chance of identifying how to tackle and overcome the difficulties that are impacting adversely on a child’s safety and wellbeing.   Decisions about who should attend must be made in this context and no other, or they risk being skewed more towards the interests of the adults than the children.  The planning that results from taking such a narrow view is likely to be poorer as a consequence, as not only does it stand to miss information that is pertinent to the assessment of risk but it may also omit consideration of the potential strengths offered by a wider network of people.                                             xxviii Duty to Safeguard & Promote the welfare of children, s.11 Children Act 2004 64  FINDING 12 The attendance of an appropriate range of professionals at CP Conferences is inadvertently being limited by too narrow a definition of family, thereby undermining the effectiveness of planning and the best interests of children.  Most information sharing guidance concentrates on the earlier part of the child protection process prior to decision making about whether or not to initiate a child protection enquiry under s47 Children Act 1989.  Guidance that is specific to child protection conferences is thinner – possibly because by implication, if a case has reached this statutory level then it is assumed that information will be shared.  Where there are concerns about particular family members it is important that they are present to hear these voiced directly and that they have the opportunity to contribute to any discussion. Linked to this is the additional risk that fears about breaching confidentiality can sometimes result in the omission of relevant practitioners from the meeting and possibly the child protection process.  The process of selection has become too restricted in a move away from what is likely to be in the best interests of the children.  ISSUES/QUESTIONS FOR THE BOARD TO CONSIDER • Is the Board confident that the process whereby family members are invited to take part in Conferences and Core Groups is fit for purpose? • How might the adoption of a theoretical framework for working with families help to address this? • Is there an identified responsibility for Conference Chairs in pre-planning invitations to Initial and Review Conferences? • Is there value in reviewing guidance to organisations in relation to attendance and information sharing at CP Conferences? • If new/different guidance to professionals is considered, how will the Board assure itself that it has reached all relevant practitioners? • How will the Board assure itself that the right people are being invited to participate in conferences and for the right reasons?      65  6  LEARNING ADDITIONAL TO THE FINDINGS This section highlights additional learning points that have emerged from the review process. 6.1 POLICE PRESENCE IN CHILD PROTECTION WORK The main police involvement in this case review relates to the criminal investigation following J’s death. Earlier involvement within the review period was limited to 2 brief contacts.  Prior to the review period and the start of child protection processes, the police had had regular contact with mother and Partner1 in relation to reported domestic abuse and historically with mother’s family. Despite their knowledge of mother and her family, the police were not active participants in the child protection processes relating to J and her siblings, such as the strategy discussion and child protection conferences. The review was told that the reason for this was “operational capacity issues”. It has been suggested by practitioners and managers that this is a wider problem than this particular case. It is understandable, particularly in the context of resource restrictions, that immediate operational pressures will cause decisions to have to be made about what needs priority attention and what does not. It is also understandable from a police perspective that priority will be attached to criminal investigation and proceedings.  The danger here is that the more preventative side of police work will be side-lined in favour of ensuring an appropriate response to crimes that have been committed. The presence of the police at CP Conferences, for example, reinforces of the seriousness of the proceedings whether or not it is evident that a crime has been committed or whether or not the subject(s) of Conferences are known to the police; their role is not limited to reading out police records.  Moreover, the broader police perspective can be a valuable one in any multi-agency decision-making about risk. We understand that the capacity of the police to contribute meaningfully to multi-agency child protection work has been raised as an issue before in Newcastle.  There will inevitably have to be a division of resource in relation to demand.  When considering this issue, it may be helpful to reflect on the value that the police add to effective child protection system, which is not restricted to the information that they hold about particular individuals. 6.2 VISITORS TO CHILDREN WHO ARE IN HOSPITAL AND ON CHILD PROTECTION PLANS  J was admitted to hospital in November 2013, where she stayed on a ward for one week.  Over this time and in addition to her mother, she was visited at different times by different people, including an unidentified (at the time) man and by Partner2.  J’s mother told ward staff that the man was J’s birth father. J came to no harm from either man while in hospital, although night staff did hear a raised (male) voice and swearing on one occasion.  It does, however, raise a question about how hospital staff are notified about any visitors that either pose a potential risk to a child or who should be prevented 66 from visiting altogether.  There is then an associated question about who they should notify if they are concerned, both within and outside working hours. The fact that a child is on a CP plan with Newcastle is flagged on hospital computer systems. But hospital staff cannot protect that child adequately unless they are aware of the specific and/or potential danger presented by visitors to that child on a ward. Copies of CP Plans are not routinely available on hospital systems although within working hours they could be accessed via the hospital Safeguarding Team. Even if they were available, they do not tend to include alerts in the event that a child is admitted to hospital. Agencies are advised to consider the benefits of a clearly outlined procedure, covering the way which CSC staff are notified by hospitals when children on CP Plans are admitted and in turn, how hospital staff receive notification of any visitors that present a risk to that child.  Such a procedure should also attempt to outline what hospital staff should do in the event that such a visitor turns up, with particular reference to what happens out of working hours.  No eventuality can be completely planned for or predicted, but the current position is that procedures are unclear and that introduces unnecessary risk. 6.3 THE VALUE OF SUPPORT SERVICES TO NEWCASTLE’S CHILD PROTECTION WORK Social work is the agency tasked with statutory responsibility for managing child protection casework but any social worker is reliant upon other professionals to be their ‘eyes and ears’ in relation to the daily progress being made by families; and particularly by those who, for whatever reason, statutory services find difficult to work with.  Equally, families may find it easier to access and to trust support services, as they are less closely associated for them with a ‘system’ that has the power to take their children away. The support services in this case were excellent and offered both an exceptionally high standard of practical help to families and the capacity to keep an eye on them from the perspective of the social worker who held statutory responsibility for the case.  The consistency of their involvement with the family was in contrast with the number of social workers (6) across service areas who had case responsibility for varying periods of time over nine months.   Benefits included: • FiP’s low caseload (3 families) enabled, in theory at least, 3 home visits per week plus telephone contact outside this.   • The extended school offered a range of day care and family support services in addition to schooling and children could attend from 6 weeks to 11 years old.  It was open all year round, so had a consistent presence both for the family and the Core Group even over August when schools are typically closed.   • The supported housing provider was staffed 24 hours a day and had additional support services on-site, including a crèche and out of school facility for children. Access to the accommodation was monitored and all visitors and resident comings and goings noted, with no visitors admitted after 1800hrs.  Staff had 67 daily contact with residents and if not seen within 24hrs then staff will discuss the need to report them missing at a daily team meeting.  Both parents contacted support services when they needed help; made use of the school in particular as a kind of mediator to their constant friction over contact arrangements; and passed messages through them to social workers who were less predictably available on the end of the phone. Although mother has told this review that she never felt able to completely trust anyone, the extent of the outreach work offered by these services, particularly in the earlier timeframe of this review, made it more possible to monitor what was going on in her life and in the lives of her children. This learning presents a particular challenge for Newcastle in the context of shrinking resources and the review illustrates the value of support services to the multi-agency child protection system as a whole.  Without them, statutory services risk knowing less about out the reality of family life and families risk being more isolated from practical help, whether wilfully or otherwise.   68 APPENDIX 1  REVIEW METHODOLOGY & PROCESS Methodology  This review was conducted using SCIE’s Learning Together methodology (Fish, Munro & Bairstow; SCIE 2008). Learning Together is a systems approach which seek to understand professional practice in context. Learning Together reviewers work collaboratively with practitioners and leaders to identify the factors in the system that influence the nature and quality of work with families, using the issues highlighted in the case under review as the primary evidence base.  Solutions then focus on redesigning the system to minimise adverse contributory factors, and to make it easier for professionals to practice safely and effectively.  The methodology is based upon a number of key principles:  • Avoid hindsight bias: in order to understand why people acted as they did, it is important to avoid the wisdom of hindsight; the tendency to judge actions from the standpoint of knowing what happened later, when it is easier to see which bits of information were significant and which were irrelevant.   • Provide adequate explanations: appraise and explain decisions, actions and inactions in the professional handling of the case, by seeing performance as the result of interactions between the context and what the individual brings to it. • Move from individual instance to the general significance: use a single case to provide a ‘window on the system’xxix, finding out whether weaknesses or strengths in its management are widespread, and so leading to a broader understanding about what supports and what hinders the reliability of the multi-agency child protection system. • Produce findings and questions for the LSCB to consider: Some findings lead to the simple recommendation of a new rule or way of doing something, but others require LSCBs to consider how to balance identified needs with other demands on agencies’ resources. • Analytical rigour: use of qualitative research techniques to underpin rigour and reliability and a very open process so that others can see how conclusions were reached. Data comes from structured conversations with involved professionals, case files and contextual documentation from organisations. Principles are supported by a suite of SCIE’s analytic tools.  One such tool is a typology to help identify which aspect of the child protection system the findings are located within and thereby make it easier to know where to focus solutions. SCIE has developed a typology of 6 broad categories, each of which relate to a different (although linked) aspect of the work and within which it is common to find patterns of practice or behaviour that are systemic: • Multi-agency working in response to incidents and crises • Multi-agency working in longer term work • Human reasoning: cognitive and emotional biases • Family – Professional interaction • Tools                                             xxix C A Vincent, Analysis of clinical incidents: a window on the system not a search for root causes (2004)  69 • Management systems Findings are structured to present a transparent and evidence based account of how the practice issue features in the particular case; in what way it is an underlying issue – not a quirk of the particular individuals involved and in the particular constellation of one case; how widespread a problem it is perceived to be and/or data about its prevalence both locally and nationally.  Finally, each Finding addresses the consequence of not doing anything about it, or why it matters in the context of multi-agency child protection work.   Organisational learning & improvement The Findings of Learning Together reviews require debate.  They highlight relevant points for LSCBs to consider when deciding upon the most appropriate course of action for local circumstance and do not tend to prescribe specific recommendations at the point of delivery.  Considerable learning will have been generated for practitioners and managers as a consequence of their involvement in the review process. The discussions that take place following the completion of a review build upon this and enable the creation of a development planxxx going forward that is fully owned by the Board and its member agencies.  Reviewing expertise and independence The SCR has been led by two people independent of the case under review and of the organisations whose actions are being reviewed.  Edi Carmi is an independent consultant with extensive experience of SCR authorship and Sarah Peel is Deputy Head of the Learning Together programme at SCIE.  Both are accredited by SCIE to carry out Learning Together reviews.  Neither has any previous or current relationship with Newcastle Council, neighbouring authorities or partner agencies.    NSCB commissioned SCIE’s mentoring programme in order to build local capacity to undertake a systems approach once the review process was over.  The independent Lead Reviewers mentored three internal people to build their theoretical and practical skill-base over the course of the process, each of whom had previously attended training on the approach.  Sue Kirkley is Newcastle LSCB Manager; Phil Hayden is Lead Specialist Standards & Effectiveness, for the Wellbeing, Care and Learning Directorate and Vanessa Powell is the Named Nurse Child Protection (Community).  None of the three had had any involvement with the case prior to this review.   Review team The Review Team was made up of senior managers from the agencies involved in the case, who themselves had no direct part in it.  Led by the independent Lead Reviewers, they worked as a Panel throughout the review, gathering and analysing data, and reaching conclusions about general patterns and findings.  They were also a source of data in themselves, about the services they represent: their strategic policies, procedures, standards, and the organisational context relating to particular issues or circumstances such as resource constraints, changes in structure etc.                                                xxx Reference the LSCB Learning & Improvement Plan 70 The Review Team have met together 8 times over this process, including twice after the criminal trial.  The Review Team were: • Assistant Director Children’s Social Care • Service Manager Children’s Safeguarding Standards Unit, Wellbeing, Care and Learning • Designated Doctor Safeguarding Children • Designated Nurse on behalf of Newcastle Clinical Commissioning Groups • Named Nurse/Operational Lead, Newcastle upon Tyne Hospitals (NUTH) • Community Safety Specialist, Domestic and Sexual Violence • Deputy Head of Safeguarding and Public Protection, Northumberland, Tyne & Wear Mental Health Trust • Solicitor, Newcastle Legal Team • Detective Chief Inspector, Northumbria Police Protecting Vulnerable People (PVP) • NSCB administrator (notes) Sources of data  Case Group Practitioners who were involved with the case at the time formed a ‘Case Group’.  Their experiences were captured through individual and group conversations with Lead Reviewers, mentees and members of the Review Team.  We held 27 conversations with a total of 31 practitioners in order to build the evidence base for this review. In addition to this, the case group met together in four collaborative events with the Lead Reviewers and mentees, in May, July, September and December 2014. These allowed the review team to check factual accuracy, clarify any issues and amplify the analysis contained in the review Findings. The Case Group was made up of:  4 Social Workers, CSC Extended Schools Manager Community Midwife 2 Senior Practitioners, CSC School Family Support Worker Drug & Alcohol Midwife 3 Team Managers, CSC Lead Practitioner, local children’s charity Detective Sergeant, Northumbria Police 1 Social Care Officer, 16+ Team Manager, local children’s charity Detective Constable, Northumbria Police 1 FiP Worker, local housing provider 1 Health Visitor Housing Support Officer, statutory emergency accommodation 1 Team Manager, local housing provider Nurse Advisor Safeguarding Children Manager, statutory emergency accommodation Probation Officer Named GP  Perinatal worker North East Ambulance Service lead  71 In addition to the Case Group members, conversations were held with a group of nursing and medical staff and the family GP.  Individual conversations were held with a Team Manager and Independent Reviewing Officer, both of whom have left the authority and were not involved in any Case Group meetings. Family members Of all the family members notified about the review, only Mother requested to see the reviewers and participate in the review.  We were unable to meet with her until after the conclusion of criminal proceedings and sentencing, but the review’s Findings are the richer for the insights that she gave us, both into her own experience and her interface with professionals.  If there is one message that is stronger than anything else, it would be to never underestimate the fear that a mother can have that her children will be removed from her - and its impact then on how she behaves with professionals that have the power to do this.  Documentation A wide range of documents were requested and assessed by the Lead Reviewers, some of which were signposted by Case Group members during conversations.  In addition, an integrated multi-agency chronology covering a three year period was provided at the outset and events in the period outside that being reviewed in detail were further captured in narrative so that the reviewers had access to the family’s context.  Methodological comment and limitations The process has benefited greatly from the involvement of a dedicated administrator, who was able to take detailed notes of all Review Team and Case Group meetings and some conversations.  The commitment of both Review Team and Case Group members is to be commended, giving up time to attend individual conversations and group meetings so as to enhance the learning from this case. The involvement of the practitioners meant that generally the review was able to explore why things were done, so as to better understand what occurred. However, learning was more limited in the following areas: • Police capacity to attend Case Group meetings or provide timely answers to outstanding queries meant that it has not been possible to completely understand the role police played in relation to this family and other agencies  • The non-involvement in the Case Group meetings of staff who had left Newcastle (a Team Manager and an Independent Reviewing Officer) meant that it was not possible to resolve differences in memory of some events, in the absence of any written records.        72 APPENDIX 2  REFERENCES Brandon et al, Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005 Brandon, M., Bailey, S., Belderson, P., and Larson, B. (2013), Neglect and Serious Case Reviews. England: NSPCC Daniel Pelka – serious case review, Coventry LSCB (2013) http://www.coventrylscb.org.uk/files/SCR/FINAL%20Overview%20Report%20%20DP%20130913%20Publication%20version.pdf Featherstone, White & Morris: Reimagining Child Protection (Policy Press 2014) Fish, S., Munro, E., Bairstow, S., SCIE Guide 24: Learning together to safeguard children: developing a multi-agency systems approach for case reviews, Social Care Institute for Excellence (SCIE), 2009 M. Hester, The Three Planet Model: Towards an understanding of contradictions in approaches to women and children’s safety in contexts of domestic violence (British Journal of Social Work, 41; 2011) Horwath, J: Child Neglect, Planning & Intervention (Palgrave Macmillan 2013) Baroness Kennedy Report on Sudden and Unexpected Death in Infants (RCPath and RCPCH, 2004) Mason, B: Relational risk-taking and the training of supervisors (Journal of Family Therapy Vol 27) Munro E, Effective Child Protection Sage Publications 2008 (2nd Ed) Munro E, Common Errors of Reasoning in Child Protection Work (Child Abuse & Neglect, Vol. 23, No. 8 1999) Munro E, Avoidable and Unavoidable Mistakes in Child Protection Work (British Journal of Social Work 1996 (26) Newcastle Children’s Services Procedures http://newcastlechildcare.proceduresonline.com NSCB Procedures http://newcastlescb.proceduresonline.com/ Public Inquiry into the death of Victoria Climbie Rec 58, Lord Laming DoH 2003 Reder & Duncan, A required mind-set for child protection practice: comments on Munro (Child Abuse & Neglect, Vol. 24, No. 4 2000) Smith C, Trust & Confidence: Possibilities for Social Work in ‘High Modernity’ (British Journal of Social Work 31 2001) Turnell, A. and Edwards, S. Signs of Safety: A safety and solution oriented approach to child protection casework, (1999) New York: WW Norton Turney, D., Platt, D., Selwyn, J., Farmer, E. Social Work Assessment of Children in Need: What Do We Know? Messages from Research. DfE (2011) https://www.gov.uk/government/publications/social-work-assessment-of-children-in-need-what-do-we-know-messages-from-research C. A. Vincent, Analysis of clinical incidents: a window on the system not a search for root causes (2004) Working Together to Safeguard Children: A Guide to Inter-agency Working to Safeguard and Promote the Welfare of Children DfE (2013/2015)        73 APPENDIX 3  GLOSSARY OF TERMS  CCIN  Complex Children in Need CDOP  Child Death Overview Panel CNE  Children North East CP  Child Protection CSC  Children’s Social Care DV  Domestic Violence EDT  Emergency Duty Team ED  Hospital Emergency Department [commonly called A&E] FGC  Family Group Conference FIP  Family Intervention Project FSW  Family Support Worker GP  General Practitioner ICPC  Initial Child Protection Conference ICPP  Initial Child Protection Plan ICS  Integrated Children’s System IRO  Independent Reviewing Officer IRS  Initial Response Service LSCB  Local Safeguarding Children Board MARAC Multi Agency Risk Assessment Conference MGM  Maternal Grandmother NASC  Nurse Advisor Safeguarding Children NEAS  North East Ambulance Service NSCB  Newcastle Safeguarding Children Board   NTW  Northumberland, Tyne & Wear Mental Health Trust PR  Parental Responsibility PVP  Protecting Vulnerable People RCPC  Review Child Protection Conference SCBU  Special Care Baby Unit SCIE  Social Care Institute for Excellence SCR  Serious Case Review SP  Senior [social work] Practitioner SW  Social Worker TM  Team Manager YHN  Your Homes Newcastle YOT  Youth Offending Team   1        Newcastle Safeguarding Children Board Response to Serious Case Review Child J  1. INTRODUCTION   Working Together 2015 stipulates that the Local Safeguarding Children Board response to a Serious Case Review should be published alongside the publication of the review report either as part or in a separate document.  The response should include information about actions that have already been taken in response to the review findings; the impact these actions have had on improving services; and what more will be done.    This report is Newcastle Safeguarding Children Board’s [NSCB] response to the Serious Case Review undertaken in respect of Child J.  NSCB commissioned two Lead Reviewers from the Social Care Institute of Excellence [SCIE] to lead the review, who used the SCIE ‘Learning Together’ systemic review model, and worked in collaboration with a NSCB multi-agency review team.     12 Findings have been approved by NSCB and each one allocated a lead officer responsible for arranging multi-agency discussions or focus groups to consider the detail, the questions posed by the Lead Reviewers and the necessary action to be undertaken.  The outcome of these discussions and focus groups have informed the formulation of an action plan, which is monitored by NSCB, and the NSCB response to the review report and Findings.   NSCB acknowledges that the review was not completed within the Working Together 2013 & 2015 recommended timescale of 6 months.  This was due to a combination of factors which included the scale and complexity of the case and the conclusion of criminal proceedings, in order to be able seek the views of mother.  However learning and improvements have been ongoing throughout the review process and are reflect in the report.  We would also like to take the opportunity to thank the Lead Reviewers for a thorough and professional approach to undertaking the review and to Board members and practitioners.  Their leadership and contributions to the process and discussions, have assisted us to continue to improve on what we do to safeguard children and young people in Newcastle.    2  2. SUMMARY OF FINDINGS AND NSCB RESPONSE Finding 1  Recording systems do not include chronology templates that are fit for purpose, hampering practitioners attempts to understand families’ history; particularly significant in the context of intergenerational neglect NSCB acknowledges that one of the common deficits in learning from case reviews is the inadequacy of practitioners to fully consider the implications of family history when assessing risk and planning risk management in the present.  The unintended consequence for Children Social Care [CSC] practitioners nationally of the creation of electronic tools to generate chronologies has been to make it more difficult for people to easily comprehend what has occurred before.  This has ramifications for all case work but particularly for cases such as this one, where families have been known to services over long periods of time and an understanding of the risk for children often relies on an understanding of the past and the patterns of behaviour in the family. Response  In order to strengthen the system CSC implemented a new recording process for capturing significant life events.  This process has been designed to not simply rely on the data recorded within the system, but requires the social worker to apply judgement to identify and add significant life events.  Progress is monitored through reports to CSC Senior Management Team. All social work staff across the service have been trained in using the new system and all new cases coming into the Initial Response Service must have a current and comprehensive chronology, which supports the single assessment process [cross reference Finding 4].  Progress is monitored by the CSC Senior Management Team.   The review report also asks the Board to consider the use of chronologies in a multi-agency context, including partner agency chronologies and the possibility of an integrated multi-agency chronology.  From experience of completing multi-agency chronologies for audit and case review purposes we know that it is highly resource intensive and felt to be unachievable for every case.  However the importance of how single agency chronologies from partner agencies are used to inform assessments is acknowledged. Ongoing work Further consideration will be given to how we can improve the sharing of single agency chronologies at key points and also the use of multi-agency chronologies in certain complex cases.  3  Finding 2 Are ‘incidents’ less likely to benefit from multi-agency reinvestigation or reflection if a case is already open to Children’s Social Care  The lack of thorough and well planned multi-agency assessment in response to new incidents that occur, risks missing opportunities to learn about what is really happening within a family.  This critically means that without a new assessment taking place it is likely that previous ways of understanding the circumstances may be used to ‘explain’ the underlying causes of the incident. Response To ensure that open cases to CSC receive the same level of response and assessment when a new incident occurs CSC has revised its internal procedure, which provides clear expectations about when further multi-agency meetings are to be held in the light of new concerns and triggers for reassessment.   Ongoing work NSCB Policy and Procedures Committee to review the NSCB Conflict Resolution policy to ensure that remains fit for purpose; NSCB training to include how practitioners can escalate any case related unresolved concerns in accordance with NSCB the policy; NSCB member organisations to disseminate the policy to practitioners and managers.  CSC practitioner and manager briefings to embed practice improvements in terms of CSC’s lead role in convening and chairing strategy meetings; s47 investigations, core groups, use of single assessment on open cases etc.   Finding 3  The process for inviting people to key meetings does not consistently ensure that the right people will be there This case has highlighted an underlying weakness in the process for issuing invitations to Child Protection Conferences that can have a direct impact upon the quality of multi-agency assessment and planning for children.  Evidence indicates that this is particularly likely to impact upon the effectiveness of plans made in relation to babies, both pre-and post-birth.  The dilemma hinges upon the need for confidentiality in the transfer of information and the different mechanisms that are available for use within individual settings in this context.  The current arrangements leave too much to chance.  4  Response  In order to strengthen the invitation process for child protection conferences a whole system review of the process was undertaken.  The review was expanded to include other safeguarding meetings.  The review considered exploration of other mechanisms to provide secure transfer of information required for invitations.  As a result of the review, guidance, procedures and the standard invitation template were revised, signed off and in place by March 2015.  Processes for monitoring and reporting attendance of key professionals were also agreed and implemented as well as a centralised email system for some partner agencies to assist a more streamline process for invitations and reports for conferences to be circulated.  Early indications demonstrate that the new processes have improved the attendance of the right people to conferences.   Ongoing NSCB will monitor how effective the system has improved since implementation.  Finding 4  The current link between completion of assessment as a pre-requisite for case transfer encourages more superficial assessments on the most complex and highest risk cases Statutory guidance clearly sets out the purpose of assessment and how it should be undertaken including: conducting interviews with the child and family members; involving the relevant professionals to provide further information about the child and family and securing contributions from the core group.  The current process for undertaking statutory assessments when a decision to proceed to an Initial Child Protection Conference [ICPC] has been made, imposes a reduced timescale.  This undermines the quality and depth of assessment, potentially impacting upon analysis, decision-making and protection plan therefore potentially exposing children to risk of further maltreatment. This is compounded by the lack of systems and culture to support assessment as a continuous process, risking fixed perceptions on the children’s well-being, despite changed home circumstances.  5  The current system of case transfer at ICPC being dependent on a completed core assessment encourages more superficial assessments on the most complex and highest risk cases. Response  Full implementation of a single assessment system by CSC was achieved in June 2015.   This will help to mitigate against the risk of more superficial assessments being undertaken on some of the higher risk cases as it allows for the continuation of assessment post ICPC to the long term social work teams.  On ongoing, open cases, assessments will be reviewed and updated on an annual basis.   Ongoing work CSC Service Managers to ‘dip’ sample audit the quality and timeliness of assessments.  Finding 5  Standardised tasks and Contracts of Expectation are used too routinely and without consequence, making them ineffective when addressing deep-rooted learned behaviour through child protection plans Mistrust of authority, as embodied by formal services, is common but particularly so for people who might have experienced or witnessed inconsistent interventions as children.  Avoidant or evasive behaviour is a likely response to this. To stand the best chance of building trust, the actions and evidence required to change behaviours should be rooted in the reality of how people actually behave.  Planning in this context also needs to predict that progress will be influenced by things that are unpredictable and that contingencies set at the outset may need to change.  If we resort too quickly and rigidly to standardised actions and tools we give no opportunity for change to be experienced positively and evidenced incrementally.  In effect, we make veiled threats, and in so doing we may reduce the likelihood of real compliance. Response CSC Senior Management Team acknowledge and accept the learning from the review on the use of Contracts of Expectations.  A decision has been made by the Assistant Director of Children’s Social Care for practitioners to stop using Contracts of Expectations, which can detract from the purpose and focus of a Child Protection Plan [or Child in Need Plan] outcomes and actions.  Where there is no plan yet in place, for example following an initial referral, practitioners will prepare a Danger Statement and put in place with the parents or carers a robust Safety Plan until an assessment is completed.  All Safety Plans will include detailed contingency plans.  6  The introduction of the Signs of Safety (SoS) approach in Child Protection Conferences has sought to strengthen parent and child participation through a strengths based process for identifying and agreeing the concerns that professionals have and the associated risks.  Independent Reviewing Officers [IROs] have received bespoke training to support chairing and facilitating an inclusive Child Protection Conference using this approach.   Findings from a recent NSCB audit demonstrates evidence that parents feel more involved in the discussions and much clearer about plans and what needs to happen.   Ongoing work Discussions with legal services about the decision to cease the use of Contracts of Expectations as the legal system tends to ask for these to be formulated during some public law proceedings.  Subsequently formalising with practitioners the date cessation of Contracts of Expectations as a practice tool.  A task and finish group to develop a common approach to enable ‘safe uncertainty’ as suggested in the review report.    Further joint workshops between Independent Reviewing Officers (IROs) and Team Managers to focus on high quality, outcome focused Child Protection Plans, which provide the opportunity for change to be experienced positively and evidenced incrementally. NSCB audit of the quality of Child Protection Plans since the introduction of the SoS approach.  Finding 6  The overwhelming reliance on social workers to lead, manage and administer Core Groups can diminish the effectiveness of these multi-agency meetings National and local procedures and guidance around the operation of Core Groups allow for different interpretations of multi-agency ownership and the leadership role of social workers.  If the core group function is to be consistently effective, the Board needs to clarify its position in relation to this and reinforce the implications across the multi-agency staff group. Ideally, and to reflect the importance of core group meetings to the child protection process, they should be supported administratively in a similar way manner to Conferences.  Where this is not possible a wider ownership of responsibility is likely to impact  7  positively on the quality of meetings, as long as expectations are clearly defined.  Response  In considering the Finding NSCB partner organisations unanimously agreed that the management and administration of Core Group meetings should be the responsibility of CSC in order to ensure that: the meetings are formally chaired and minuted; records are uploaded into the CSC system in a consistent and timely way; a record of the meeting is distributed to the core group members; and minutes are provided to the IROs for Child Protection Conferences.  The chair of a Core Group meeting will always be the Social Worker or Team Manager unless in exceptional circumstances, where this does happen the reason will be clearly recorded.  Partners have agreed that other agency practitioners can share the task of recording the meeting, which the Social Worker will administrate as above afterwards.       Implementation of the SoS approach and introduction of mobile working through ‘Think Pads’ to facilitate and record Core Group meetings, is with the intention to significantly reduce the administrative process and improve the quality of recording; this has yet to be realised.  NSCB has reviewed its training on Core Group meetings to ensure it provides a clear outline of practitioner’s roles and responsibilities and purpose and function.     The introduction of IRO data capture forms in November 2014 provides direct feedback to social workers team managers in relation to compliance and quality issues from Core Group minutes provided to Child Protection Conferences.   Ongoing work CSC Service Managers to undertake a ‘dip’ sample audit of Core Groups records to scrutinise attendance [including how effectively parents and family members are invited], the quality of information, progress on actions and the impact of mobile working and SoS.  Development of Best Practice Standards, to include shared ownership and increased understanding across partner agencies regarding their role.     8  Finding 7  The routine processes for agreeing bail conditions contain a loophole that omits checks being made about risks an offender presents to children This case exposes how the criminal justice and child protection systems can operate in parallel in the context of a single household and highlights one element of the criminal justice system that routinely performs in isolation from the wider safeguarding agenda.  The law is the driver behind both systems from differing perspectives.  Unless the two are brought more directly together, one system risks causing a situation that the other is designed to safeguard against. Response  Northumbria Police presented the learning from Finding 7 to 200 magistrates in November 2015.  Whilst the magistrates acknowledged that they are constrained by bail powers, they embraced the learning and have since raised issues about the kinds of information being submitted to them at court and reflected in files.  This includes all relevant safeguarding information and references to appropriate or inappropriate bail addresses.  They also have raised the need to tighten up on checking mechanisms at court.    Finding 8  The way that medical staff present their diagnosis of types of injury can be confusing to non-medical practitioners, who interpret lack of evidence as meaning an injury is accidental  This case highlights the misunderstandings that can exist about the role of the child protection paediatric examination and the limitations of its findings in many instances. Like all practitioners the paediatrician needs optimum circumstances to be able to provide a good assessment, and this is not reliant totally on physical evidence.  Hence the presence of the subject of allegations during the examination of a child is less likely to be conducive to a reliable diagnosis. It is vital for the safety of children that paediatric assessments are carefully planned and that their limitations are understood, so that the lack of definitive medical evidence is not seen as the end of investigations or the proof that there is no cause for concern.   Response The standardised Child Protection Medical proforma has been updated to include a page summarising the findings of the assessment and giving a scaled opinion about the likelihood of non-accidental injury.  This page is photocopied and given to the social worker attending the assessment so that there can be  9  no confusion about either the assessment findings or the paediatrician’s opinion about what they mean in terms of possible non accidental injury.  This opinion will also be reiterated in a standard paragraph in the Child Protection medical report. Ongoing work The new process with regards to the communication page of the proforma will be subject to audit to provide evidence that it is well embedded in practice.  In addition the Hospital’s Children’s Safeguarding Team will contribute to single agency and multi-agency briefings held by the NSCB on the learning from the review and will be available to deliver any other training felt to be necessary about this matter.    Finding 9  Despite all child protection cases being high risk by definition, practitioners juggle priorities by deciding which is more risky than another, leaving the less obvious neglect cases more vulnerable Managers and practitioners across agencies always and necessarily have to prioritise work in order to address the immediate and urgent. Child protection cases have a level and because of volume, cases are still ‘sorted’ in terms of what needs attention now and what can wait. The way that judgement is reached around this has implications in particular for work around child neglect, where the immediate risks may not be so visible but the potential for an adverse outcome is high.   Response  Since the onset of the Serious Case review in January 2014 there has been a number of innovation projects implemented with a focus on specific vulnerability areas, e.g. neglect and provide additional capacity to provide specialised, targeted and intensive support to those children and families who need it.  These include: • Family Insights – Transformation of how Children’s Social Care is delivered in Newcastle (DfE funded innovation project) • MST CAN – Multisystemic Therapy for Child Abuse and Neglect is an evidence-based program designed to support children, young people and their families who have come to the attention of Children’s Social Care as a result of concerns relating to physical abuse or neglect • NSPCC Thriving Families Newcastle- built on extensive experience and research to develop a consistent approach to child neglect, NSPCC  10  make sure families receive the right support at the right time by working with them at every step of their journey • PUP [Parents under Pressure] - The Parents under Pressure program combines psychological principles relating to parenting, child behavior and parental emotion regulation within a case management model. The program is home-based and designed for families in which there are many difficult life circumstances that impact on family functioning  NSCB also has neglect as an ongoing priority in its Business Plan and reviewed in December 2015 its Neglect Strategy and practice guidance procedures. NSCB Learning and Development Committee also launched a revised multi-agency neglect rolling training programme in January 2016.  Dates and booking details are available on its website  http://www.nscb.org.uk/sites/default/files/NSCB%20NSAB%20Joint%20Training%20Programme%20V8.pdf   A multi-agency Neglect Special Interest Group has also been set up for practitioners to share experiences, ideas, research and develop best practice; this work contributes to NSCB Neglect Strategy.    Ongoing work NSCB will monitor the effectiveness of these services and their impact on outcomes for children and young people as a result of the innovation work through twice yearly progress reports.  Analysis of this will be included in its Annual Reports.  Finding 10  The effective co-ordination of a multi-agency response to unexpected child deaths is compromised over weekends and bank holidays, directly affecting the capacity for timely diagnosis of likely cause of death and the implications of this for others. This Finding hinges around the capacity of a Consultant Paediatrician to fulfil child death responsibilities, out of hours, as well as attending to general paediatric work. The current system to support a rapid response to the unexpected death of a child during a weekend or bank holiday was put in place in recognition of reduced capacity whilst needing to maintain a robust and effective response.  The system includes an Out of Hours Procedure and medical protocol, which sets out roles, responsibilities and processes for information gathering and sharing in these circumstances, in particular to ensure the safety of any other children in the household. The review of the  11  response to the unexpected death of J has highlighted further improvements that can be made to its effectiveness. Response  The Hospital Trust has considered how it can best address this issue, which is a difficult one as it potentially requires considerable resource being allocated for infrequent events, albeit high risk ones.  The Trust Board has agreed to appoint more general paediatric consultants in order to cover the full range of paediatric work including child death at peak times which include   weekends and Bank Holidays.  The doctor for Child Death has discussed with key partners the out of hours information sharing meetings and it has been reiterated to all partners how important attendance at these meetings is.  The proforma that has been devised to gather information following the unexpected death of a child has been modified to include a section to record the details of matters discussed at these meetings and any actions agreed.  The doctor for Child Death has raised awareness amongst consultant colleagues, the Police and Children’s Social Care that Skeletal Surveys can be obtained on dead infants at the weekends and on Bank Holidays and the process for doing this.   Ongoing work There have been preliminary discussions with Paediatric Radiology about the possibility of other types of imaging being performed on dead infants shortly after death to help determine the cause of death in a more timely fashion e.g. CT head scan, MR head and body.  This will be an ongoing piece of work as although it is entirely possible to obtain the images, interpretation of such images remains a controversial area which will need further exploration.  Finding 11  A tendency for work to focus too much on the nuclear family in isolation from any wider networks, even when extended family members are known to professionals, is limiting the effectiveness of interventions with families that have been subject to children protection measures over generations The manner in which families are identified, and by whom, can influence the information that they make available to professionals and the level to which family members invest in a Plan as being theirs.  If people feel that professionals have an unrealistic view of their world, they are less likely to work with what to  12  them is an unrealistic Plan. Without this investment Plans are unlikely to succeed on a level that is other than superficial compliance.   Response  The review specifically asked whether there would be value in NSCB considering the adoption of a theoretical framework for work with families that is rooted in a systems approach and what the options may be.   There is already investment by the board in SoS which puts greater emphasis on understanding the families’ view of the world and therefore the intervention, together with focus on the family network.  The use of family/network meetings is in the early stages of development, but will aim to provide more realistic plans. The use of SoS is currently overseen by a steering group which provides updates to the NSCB.  Audits via NSCB Standards and Effectiveness Management Group have also provided evidence its effectiveness in child protection conferences, and includes positive feedback from families. The use of SoS complements and provides a great foundation for the work Family Insights [reference Finding 9], which adopts a systemic approach to social work practice.  Training is also being provided to the CSC Workforce by Morning Lane Associates, which was instrumental in promoting the redesign for child and family social work as outlined in the Munro Review in England in 2011; the programme is also being evaluated with encouraging early findings.   Both SoS and Systemic Practice place great emphasis on the use of genograms that can map complex families and show who is working with them.  The review highlighted the use of genograms as a way of avoiding seeing families in isolation and thereby increasing the potential impact of intervention. Ongoing work The effectiveness of SoS and Systemic Practice will be scrutinised by NSCB through update reports on evaluation and audit activity e.g. Child Protection Plans, which will include the voice of the child and family.   More recently in May 2016, as part of finalising the review report, an additional question was posed by the Lead Reviewers to the NSCB.  They asked NSCB to consider how many children are currently on CP Plans within families that have been known to services across generations.  Scoping this is a task  13  currently being overseen by the NSCB SEMG and include how we define inter-generational and the scale.  Finding 12  The attendance of an appropriate range of professionals at Child Protection Conferences is inadvertently being limited by too narrow a definition of family, thereby undermining the effectiveness of planning and the best interests of children Most information sharing guidance concentrates on the earlier part of the child protection process prior to decision making about whether or not to initiate a child protection investigation under s47 Children Act 1989.  Guidance that is specific to child protection conferences is thinner – possibly because by implication, if a case has reached this statutory level then it is assumed that information will be shared.  Where there are concerns about particular family members it is important that they are present to hear these voiced directly and that they have the opportunity to contribute to any discussion.  Linked to this is the additional risk that fears about breaching confidentiality can sometimes result in the omission of relevant practitioners from the meeting and possibly the child protection process.  The process of selection has become too restricted in a move away from what is likely to be in the interests of the children. NSCB Response  As outlined in Finding 11 Newcastle is committed to SoS and Systemic Practice, which provide theoretical frameworks for working with families.  There is great emphasis on understanding the families’ view of the world and therefore the intervention, together with the focus on the family network. In addition a significant amount of work takes place to ensure the right people attend child protection conferences.  IROs take on a key role in planning who attends and challenge any gaps.  Data is also collated and will be reported to NSCB as part of its performance scorecard to enable the scrutiny and challenge of partner agencies where appropriate.    14  3. ADDITIONAL LEARNING  Police presence in child protection work Northumbria Police are committed to multi-agency working and safeguarding, during the time period of the review, the Organisation had undergone significant change, which had an impact upon resource levels.  Northumbria Police have recognised the increase in demand and responded by investing in the Safeguarding Arena, providing extra resources by increasing the establishment and creating a centrally located hub. A Police Officer has been allocated to work within the Newcastle Multi Agency Safeguarding Hub and six Safeguarding Advisors have been employed to attend all initial child protection conferences across the Force area. This has improved attendance and partners are complimentary about these new staff. In addition a performance framework has been implemented to capture and evaluate data in relation to police presence in child protection work.  Ongoing work Moving forward and in order to improve service delivery the Force has committed to being outstanding in the area of vulnerability and safeguarding, and has now created a stand-alone Safeguarding Department with a vision to enhance the current partnership working in to protect the most vulnerable in our communities.   Northumbria Police are working closely with partner agencies in the design of the new approach to safeguarding and will be based upon the common principles of information sharing, joint decision making and coordinated intervention.    Visitors to children who are in hospital and on Child Protection Plans The process has been strengthened to ensure that as soon as a child is medically stable and health staff become aware that they are on a Child Protection Plan they will contact Children’s Social Care from the relevant local authority (including out of hours teams) to establish the nature of the concerns and whether there are any restrictions on contact between the child on the plan and any other person.  Whilst this was common practice at the time it is acknowledged that there was some delay in this particular case.   Ongoing work  The Hospital Trust’s Child Protection and Safeguarding Children policy is being amended emphasise the importance of this issue, which will be reinforced in training and supervision throughout the organisation.     15  The value of support work services to Newcastle’s child protection work A fundamental review of early years and family support services in Newcastle has resulted in a new service delivery model which was implemented in April 2015. The new model includes an intensive family support service which embraces the Family Intervention Project principles and methodology i.e. intensive, whole family working, one identified keyworker working towards the achievement of outcomes and one family plan which is captured in the CAF. This service is designed to support families assessed as being at Level 3 on NSCB Continuum of Help and Support.   4. QUALITY ASSURANCE AND MEASURING IMPACT ON OUTCOMES NSCB acknowledges the extensive learning from the Serious Case Review for it to consider along with its partners.  To date it has resulted in the identification of 33 actions, 23 of which have been fully completed, although subject to change as discussions continue; NSCB will monitor the action plan through to its completion and sign off.  Progress on the action plan reflects that NSCB partners have implemented learning at the earliest opportunity and continue to do so.  The impact of the learning and the associated actions has yet to be realised and will be followed up through the Case Review Committee at an agreed time that will provide the most efficient feedback e.g. 6 months following final and approval and sign off of the Action Plan by NSCB.  NSCB will also consider the learning from the NSPCC and SCIE Learning into Practice innovation project, which looked at how to more effectively improve and embed learning from serious case reviews in to practice.  5. DISSEMINATION OF LEARNING Two multi-agency Learning from Practice events have been arranged for June and November 2016 to disseminate wider learning across the children’s workforce, in addition to single agency staff briefings held by NSCB member organisations.  The final report will be put on to NSCB website, shared with the NSPCC for their repository, the Association of Independent Chairs Network and the Northern Region LSCB Network.   NSCB will also produce a ‘briefing in a minute’ to sit alongside the review report and its response. 