Non-accidental injury of child M1 in August 2016 aged under-one-month which led to M1 and M2 becoming subjects of interim care orders and being placed in foster care. M2 had disclosed to the school twice earlier that year that mother (MM) had hit them, but no further action was taken at the time. MM denied inflicting the injury on M1. Sibling C1 died in 2013 after choking on a small item whilst under the care of father (FM). A serious case review was carried out and M2 was made subject of a full care order at the time but was returned to their mother's care in July 2014. MM was a victim of domestic abuse throughout her relationship with FM and reports continued in spite of MM agreeing not to see FM because of domestic abuse and the choking incident. Family was known to multiple agencies including police, general practitioners, children's services and health visitors. Family is Black Caribbean and White. Findings include: professionals were generally over optimistic about MM's ability to protect her children; M2's poor behaviour in school was an example of listening to the voice of the child; where there is conflicting information professionals need to seek independent sources and escalate concerns when they have evidenced based doubts on decisions pertaining to safeguarding children. Uses a variant of the systems approach developed by Social Care Institute for Excellence (SCIE). Recommendations include taking account of and thoroughly understanding any previous serious case reviews in relation to a family.
      
 Title:  Child M1 and M2: serious case review. LSCB: Manchester Safeguarding Children Board Author: David Hunter and Paul Cheeseman Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                                CHILD M1 and M2 SERIOUS CASE REVIEW This report has been commissioned and prepared on behalf of the Manchester Safeguarding Children Board and is available for publication on the 20th August 2018   Ratified: May 2018 Independent Reviewers:  David Hunter Paul Cheeseman  MSCB Child M1 and M2 SCR Page i   Contents 1. INTRODUCTION .......................................................................................................................... 1 2. METHODOLOGY ......................................................................................................................... 3 3. IMPORTANT EVENTS .................................................................................................................. 6 4. PROFESSIONALS UNDERSTANDING OF THE CASE IN JANUARY 2014 ........................................ 6 5. THE FIVE KEY PRACTICE EPISODES ............................................................................................. 7 6. FINDINGS FOR THE BOARD’s CONSIDERATION ....................................................................... 24 APPENDIX 1: Extract from MSCB SCR Screening Panel ........................................................................ 28 APPENDIX 2: Practitioner learning event ............................................................................................. 28 APPENDIX 3: GMP DVA Policy .............................................................................................................. 29 APPENDIX 4: Working Agreement ....................................................................................................... 30 APPENDIX 5: Over Optimism ............................................................................................................... 31     MSCB Child M1 and M2 SCR Page 1 of 31    1. INTRODUCTION  1.1 The family structure  1.1.1 The following table sets out the family composition. Family member Anonymisation Age at August 2016   Mother (of M1, M2, C1) MM Under 30 years Father   (of M1, M2, C1) FM Under 30 years Youngest child /sibling M1 Under one month Eldest child /sibling M2 Under six years Deceased child /sibling C1 Under two when died in mid-2013   1.2 The circumstances leading to the 2016 Serious Case Review 1.2.1 Child C1 died in mid-2013 having choked on a small item. MM was visiting friends and FM was in sole charge of C1 and a sibling M2. C1’s death met the criteria for a Serious Case Review which established that MM had not protected the children from harm prior to the event. M2 was made subject to a full care order and removed from the care of their1 mother. The Serious Case Review also learned that MM was a victim of domestic abuse perpetrated by FM. When M2 was returned to their mother’s care in July 2014, she agreed not to reform a relationship with FM because of domestic abuse and FM's neglect of C1 at the time of the choking incident.    1.2.2 In July 2014 M2 returned to live with MM under a care order.  In March and May 2016 M2 disclosed to school that MM hit them. These reports were investigated and no further action taken.  1.2.3 When it was known in March 2016 that MM was pregnant a pre-birth assessment concluded the unborn child (M1) should be designated a child in need. MM declined to say who M1’s father was, but did say it was not FM.  1.2.4 On 6 September 2016 Child M1 was a few weeks old when a health visitor attended the home for a routine appointment. MM pointed out a bruise to M1’s ear.   1.2.5 The health visitor knew the family's safeguarding history and invoked the child protection procedures. Child M1 underwent a child protection medical the same day which concluded the injury to the ear was very likely inflicted. MM provided conflicting and implausible accounts for the injury.   1.2.6 Child M1 was made subject of an Interim Care Order2 and along with Child M2 went to a foster placement.  1.2.7 Greater Manchester Police (GMP) told a strategy meeting on 8 September 2016 that there had been several reports of domestic abuse between MM and FM since M2 returned to                                                       1 To protect the gender of the children the ‘he/she’ pronouns have been replaced by using, ‘they, theirs and them’ as singular pronouns 2 Section 38 Children Act 1989 MSCB Child M1 and M2 SCR Page 2 of 31    MM’s care. These reports were not shared with Children’s Services. M2 made subsequent disclosures of being handled roughly by MM and witnessing domestic abuse between MM and FM.  1.2.8 MM was interviewed under caution by the police and denied inflicting the injury on M1. The Crown Prosecution Service (CPS) received a file from the police and concluded there was insufficient evidence to prosecute.   1.3 Decision to hold a Serious Case Review 1.3.1 On 4 November 2016 Manchester Safeguarding Children Board (MSCB) Serious Case Review Subgroup screened the case and recommended to the Board’s Chair that the criteria for a Serious Case Review were met.3   1.3.2 In brief the subgroup concluded ‘M1 suffered a non-accidental injury and there is evidence of ineffective care planning, monitoring, supervision and oversight of multi-agency care planning and assessment processes’.  1.3.3 On 16 November 2016 the Independent Chair of Manchester Safeguarding Children Board made the decision to hold a Serious Case Review and that M1 and M2 would be its subjects.                                                         3 See Appendix 1 for criteria and reasons. MSCB Child M1 and M2 SCR Page 3 of 31    2. METHODOLOGY 2.1 Systems methodology 2.1.1 Manchester Safeguarding Children Board use a variant of the systems approach4 to Serious Case Reviews which is aimed at:  finding out what happened  fully understanding of why it happened  establishing the context in which decisions were made  identifying whether professional practice needs altering.  2.1.2 Agencies were asked to identify key practice episodes and to submit these in writing to the review. A combined chronology was produced and this together with the key practice episodes were discussed by the review panel who formed some initial thoughts.  2.1.3 These thoughts were used to inform the agenda for a practitioners’ learning event. This saw the professionals from agencies who made decisions in the case coming together to discuss their involvement in a structured forum.   2.1.4 Participants were provided with the key practice episodes and the combined chronology in advance of the learning event. The review panel judged that pre-knowledge of all the information would be beneficial to learning in that professionals would not only see their part, but also the role of all other colleagues and the full sequence of events, thereby adding context and understanding to the case.  2.1.5 One key professional was unable to attend the learning event and was seen separately by three members of the review panel. After the learning event additional information was provided by the school safeguarding coordinator and a separate meeting was held with an independent review officer.    2.2 The review panel 2.2.1 David Hunter and Paul Cheeseman5, were appointed as the lead reviewers. This happened because David was one of two lead reviewers in the Child C1 Serious Case Review in which Paul also had an involvement.  2.2.2 The review panel had representation from the following agencies:  Service Manager, Children’s Services, Manchester City Council (MCC)  Education Case Worker, Education, Manchester City Council   Strategic Lead Early Help and Interventions, Manchester City Council   Housing officer, Manchester City Council   Consultant Paediatrician, Children’s Community Services  Specialist Nurse Safeguarding Children, Manchester Clinical Commissioning Group (CCG)  Acting Head of Safeguarding, Manchester Clinical Commissioning Group                                                        4 A multi-agency systems approach for case reviews, Social Care Institute for Excellence 2009 5 Both reviewers have complete Serious Case Reviews, Domestic Homicide Reviews, Safeguarding Adult Reviews and Multi-Agency Public Protection Arrangement (MAPPA) Serious Case Reviews and were judged to have the experience necessary for the M1 and M2 Serious Case Review MSCB Child M1 and M2 SCR Page 4 of 31     Detective Inspector, Greater Manchester Police (GMP)  Consultant Paediatrician Children’s Community Services, CMFT6  Named Midwife, CMFT  Independent Review Officer, Children’s Services, Manchester City Council7  Paul Cheeseman, Lead Reviewer  David Hunter, Lead Reviewer.    The review panel was supported by staff from the Manchester Safeguarding Boards Business  Unit.  2.2.3 The Children and Family Court Advisor and Support Service (CAFCASS) were not represented on the review panel. In December 2017 the Court gave permission for Manchester City Council’s Care Proceedings Court Bundle (hereinafter referred to as the court bundle) to be released to the review. The files containing reports from: social work professionals including family assessments; the Guardian ad Litem8; the police; health visiting; medical reports; a school; Looked After Child review minutes; and MN and DS statements; were read by the lead reviewers and where applicable form part of this report.   2.2.4 The review panel met on five occasions. They conscientiously examined and discussed the material, including the evidence from the learning event, and avoided judgements based on hindsight.   2.2.5  The draft SCR report was presented to the Manchester Safeguarding Children Board on 15 May 2018 where it was approved.  2.3 Time period under review 2.3.1 The time period under review was from 1 January 2014 to 10 September 2016. The starting date takes into account the looked after children9 processes prior to M2 being returned to MM. The end date caters for the safeguarding arrangements made following the discovery of the injury to M1’s ear.   2.4 The key periods/episodes 2.4.1 From the material provided by agencies the review panel established the following five periods as requiring scrutiny.                                                          6 Central Manchester University Hospitals National Health Service  Foundation Trust (CMFT) 7 For meetings three and four 8 A “guardian ad litem” (GAL) is a person the court appoints to investigate what solutions would be in the “best interests of a child.” 9 The definition of a looked after child is found in Section 22 Children Act 1989. ‘…any reference to a child who is looked after by a local authority is a reference to a child who is in their care; or provided with accommodation by the authority in the exercise of any functions (in particular those under this Act) which are social services functions within the meaning of the Local Authority Social Services Act 1970 apart from functions under sections 23B and 24B MSCB Child M1 and M2 SCR Page 5 of 31     Episode Dates Details of Key Periods/Episodes 1 01.01.14 to 31.07.14 To examine the decision made to return M2 to the care of MM. 2 01.08.14 to 09.02.16 To examine the decisions made to safeguard M2 after M2’s return to MM.  3 10.02.16 to 05.09.16 To examine how agencies responded to the knowledge that MM was pregnant with M1. 4 May 2016  To examine how agencies responded to the disclosure M2 made to school that mother was ill-treating M2 and also having contact with FM. 5 06.09.16 to 10.09.16 Identification of injury to M1 and safeguarding actions thereafter.  2.5 The learning event   2.5.1 The learning event took place in central Manchester in early June 2016 and practitioners from all the relevant agencies attended. Their openness and willingness to learn was evident and the review panel would like to place on record its thanks to them for showing a positive attitude to what could have been a difficult day.  Appendix 2 shows the participants by agency.  Members of the review panel were in attendance to facilitate the event.   2.6 The parents’ involvement with the Serious Case Review 2.6.1 Both MM and FM were written to and told that the review was taking place. They were invited to contribute and provided with the contact details of David Hunter and a named person in the Manchester Safeguarding Boards Business Unit.  2.6.2 Neither responded to the invitation which is in contrast to their engagement during the Child C1 Serious Case Review.   2.6.3 At the conclusion of this review, both parents were written to again and asked whether they would like to be briefed on the report before it was published.   2.7  Diversity considerations of the family  2.7.1  The next table shows the family’s ethnicity as it appears in the SCR Subgroup screening minutes.  Family Member Ethnicity MM White Irish  FM, M1, M2 & C1 Black Caribbean and White  2.7.2 Neither adult was known to have learning difficulties or other needs that required particular consideration. FM was advised by his general practitioner to stop using cannabis. There was no material to suggest the parents lacked full capacity.10                                                           10 Mental Capacity Act 2005 MSCB Child M1 and M2 SCR Page 6 of 31    3. IMPORTANT EVENTS  3.1 The review panel considered a detailed chronology of important events broken down into five key practice episodes between January 2014 and September 2016. This chronology has not been reproduced as part of this report out of respect for the anonymity of the family. However, an analysis of these events appears in section 5 of the report.   4. PROFESSIONALS UNDERSTANDING OF THE CASE IN JANUARY 2014 4.1 The review examined events beginning on 1 January 2014. At this time all the agencies involved with the family knew of the tragic death of Child C1 in mid-2013 and that M2 was not living with MM. They also knew that MM had been the victim of domestic abuse from FM and had reported that their relationship was over. M2 was in foster care as a looked after child and was having contact with MM but not FM.   4.2 In February 2014 M2 was made the subject of an interim care order and remained in foster care. The aim of children’s services was to return M2 to the care of their mother while still under the protection of a care order. Part of the reintegration plan was to allow FM to have supervised contact with M2. The court bundle suggests that FM’s family could supervise his contact with M2. That did not happen and no assessment as to suitability took place. The reintegration plan was known to children’s services, M2’s school and health visiting; but was not known to the police who did not attend M2’s looked after child meetings as there was no requirement for them to do so.  4.3 The following extract from the Child C1 SCR report illustrates how professionals viewed  MM:   'All the practitioners experienced MM as a private person who is ‘compliant’, but they do not feel they know her or the children particularly well. In the Health Visitor’s description “there was something intangible about her”.  MM informed staff that she is no longer having contact with the father (FM) and their relationship is over’.    4.4 Therefore social workers and health visitors who knew this could have been predisposed to thinking that MM would cooperate with them, thereby providing a protective factor for M2.  That is different from saying they would automatically accept what MM told them; they did not, a point evidenced later in the report.   4.5 Children’s services, health visiting and the police knew that MM was a victim of domestic abuse from FM and that he posed a risk to M2 as a result. Children’s services practice is not to quantify risk as: standard, medium or high. The current practice is to use the Signs of Safety model; a tool intended to help practitioners with risk assessment and safety planning in child protection cases.11                                                       11 Its purpose is to enable practitioners across different disciplines to work collaboratively and in partnership with families and children. The tools are designed to help conduct risk assessments and produce action plans for increasing safety, and to reduce risk and danger by identifying areas that need change while focusing on strengths, resources and networks that the family have; ref: www.nspcc.org.uk  MSCB Child M1 and M2 SCR Page 7 of 31     4.6 The social worker (social worker 1) involved with MM and M2 in January 2014 was the same one who had supported them after the death of C1 and therefore had an excellent understanding of the family, its history and aspirations. MM’s wish was for M2 to return home and to have the care order discharged. Her position is clearly and consistently articulated within the court bundle.  5. THE FIVE KEY PRACTICE EPISODES 5.1 Introduction 5.1.1 This section of the report examines each of the five key practice episodes. The analysis of each episode is made against the policies, procedures and practices in place at the time and what professionals knew at the time or could have been reasonably expected to know or find out.   5.1.2 The most important and valuable part of the review is to understand how and why professionals arrived at their decisions, as opposed to simply knowing that they did. Recognising the ‘how and why’ is fundamental to spreading good practice and supporting professionals in their desire to do a good job.   5.2 Key Practice Episode 1   Return of M2 to MM: 01.01.2014 to 31.07.2015  Child and Family Assessment April 2016 5.2.1. Social worker 1, who completed the child and family assessment, is no longer with Manchester City Council Children’s Services and unfortunately is not available to contribute to the review.   5.2.2 Children’s services felt that the long term future of M2 was with MM and in that respect it matched MM’s aspiration. On 4 April 2014 social worker 1 completed a child and family assessment in which it was recommended that M2 was returned to MM under the provision of a Care Order for 12 months.12   5.2.3 In preparing the assessment, social worker 1 saw MM and FM. Social worker 1 advised FM to see his general practitioner regarding temper and anger management. In mid-April 2014 FM attended the practice on another matter but also mentioned that at times he was short tempered for trivial reasons. FM said he was under stress at the time over the death of his young child. The doctor advised FM to self-refer13 for counselling and an anger management course; FM was advised to stop smoking cannabis.  5.2.4 The social worker showed good practice when asking FM to visit his general practitioner to discuss anger management and for the doctor to signpost FM to appropriate services.  It would have been better practice for the doctor to have explored with FM whether his anger spilled over into domestic abuse and whether he had care or control of any children or                                                       12 On 27.05.2014 a care order was made for M2 with rehabilitation back to MM’s care. 13 Big Life Families, is a social enterprise which delivers high quality, welcoming support and services to the families who need it most ref: www.thebiglifegroup.com  MSCB Child M1 and M2 SCR Page 8 of 31    vulnerable adults. Ideally the doctor could have suggested a follow up appointment after FM had completed his anger management course.   FM’s general practitioner medical record is not endorsed with a ‘read code’14 to indicate there are children in the family.  FM attended SelfHelp15 on 29 April 2014 who assessed he did not need its Psychological Wellbeing Service and referred him to its Boost course for emotional and wellbeing resilience. It is not known if he attended. FM attended SelfHelp again on 10 January 2017 (this was part of his parenting assessment) but was assessed as not requiring services and discharged.  The suggestion FM should see his doctor was within M2’s children’s service’s file and available for him to be asked about should it become necessary during a future assessment.  FM’s general practitioner did not know M2 was a looked after child and heard there was no routine system for sharing such information. It would have required a bespoke decision by M2’s social worker or a looked after child review meeting for M2’s doctor to be told. Learning point 1  5.2.5 The assessment would have benefited from a more thorough analysis of the risk from domestic abuse that FM presented to M2 and MM. For example, MM was approached in the street by FM who subsequently sent her a threatening letter. There was emphasis within the child and family assessment of MM being open and honest. MM did not disclose FM’s approach in the street or the threatening letter thereby suggesting she was not always open and honest. FM had no insight that his continuing relationship with MM presented a risk to Child M2.   Domestic Abuse Incident one  GMP Policy  5.2.6 Greater Manchester Police’s response to domestic abuse is governed by a document titled 'Tackling Domestic Abuse Policy and Procedure'. Appendix L of that document ‘Domestic Abuse Referrals’ tells staff the criteria for sharing information with children’s social care and health16. See Appendix 3.  5.2.7 The fourth criterion is:  ‘A child/children under the age of 18 years ordinarily resides in the household and it is the third reported incident within the previous 12 months (whether the child was present or not at the time of the incident) (AND there are vulnerability issues/concerns)’.  5.2.8 The seventh criterion is:  ‘Notification of CSC (children’s social care) Open cases at request of CSC.  5.2.9 The criteria end with:  ‘Officers will still have the ability to use professional judgement to make a referral which may fall outside of the above criteria, and to also use professional judgement to decide not to make a referral if there are other agencies better placed to support the family’.                                                       14 Read codes are the standard clinical terminology system used in General Practice in the United Kingdom. They are used primarily to encode information in a standardised way for recognition of significant patient events. 15 Part of The Big Life Group. SelfHelp provides a range of support, services and opportunities, across the North West of England, for people living with mental health problems such as anxiety, depression, phobias and panic attacks. 16 Health is taken to mean Health Visiting Services MSCB Child M1 and M2 SCR Page 9 of 31     Incident Details  5.2.10 On 15 April 2014 MM contacted Greater Manchester Police to say that she was approached by FM who said that she would get what was coming to her in an upcoming court case in relation to M2. They argued and FM said something along the lines of ‘I will make you pay for this’ in a threatening manner. This is thought to be a reference to the proceedings associated with M2’s return to MM’s care.  5.2.11 The attending officer completed a DASH17 risk assessment which identified that MM faced a standard risk of serious harm from FM and in line with policy a letter was sent to MM signposting her to domestic abuse services. The Tackling Domestic Abuse policy does not define ‘standard risk’. In the Multi-Agency Public Protection Arrangements (MAPPA) Guidance 2016 ‘low risk’ is defined as ‘Current evidence does not indicate a likelihood of causing serious harm’.  5.2.12 In line with police policy, a referral was made to children’s services and health visiting on 5 May 2014. The domestic abuse incident of 15 April 2014 post-dated the completion of the child and family assessment on 4 April 2014 and therefore could not have been considered when the recommendation to return M2 to MM was made by the social worker. The 5 May 2014 referral does not appear in children’s social care or health visiting records and it has not been possible to determine why that is. Learning point 2 5.2.13 MM had demonstrated some good faith by reporting unwanted contact with FM to the police but as will be seen later she did not share this information with her social worker.   Police knowledge of M2 as a looked after child 5.2.14 M2 was a looked after child. This was not recorded on any police database because there was no requirement. 5.2.15 The facility for children’s services to request details of domestic abuse incidents on open cases (criterion seven) was not known to attendees at the practitioners’ event. The practitioners discussed whether the police and selected other agencies should flag all looked after children to ensure that incidents involving them were always passed to children’s services. While there was support for the proposition, the practicalities of doing so appeared very difficult. Finding 1 /Learning point 3.  Sightings of MM in the company of FM 5.2.16 Throughout the period under review there were sightings of MM and FM together, sometimes with M2. There was plenty of evidence based suspicion that they were in a relationship despite MM’s consistent denials.  5.2.17 In Key Practice Episode 1 there were two opportunistic sightings by different professionals of MM in the company of FM; on the second occasion M2 was present.    Working agreement and Child Protection Plans 5.2.18 The Local Authority had shared parental responsibility for MM and as such had a duty to protect them. This duty was acted upon after the sightings and resulted in a fourteen point ‘working agreement’ being drawn up between children’s services and MM, the purpose of which was to ensure MM was ‘adequately safeguarding M2 from the risk of significant                                                       17 Greater Manchester Police use the DASH model (Domestic Abuse, Stalking, Harassment and Honour based violence) to risk assess domestic abuse victims. Standard is the lowest of three levels of risk. The others are medium and high. MSCB Child M1 and M2 SCR Page 10 of 31    harm’. The main mechanism was to place restrictions on FM’s contact with M2 and for MM to tell children’s services should she re-enter a relationship with FM. The agreement was signed by MM and social worker 2 on 9 July 2014.  The full conditions appear at Appendix 4. 5.2.19 Three points particularly relevant to FM were:  MM should not take M2 to visit the home of FM’s grandparents   M2’s only contact with father (FM) is supervised by children's services. M2 should have no other contact with father (FM) and MM should not allow this to happen under any circumstances  MM must inform children services if she intends to resume her relationship with FM so the appropriate risk assessments can be undertaken.   5.2.20 The agreement ended with the following entry:  ‘WHAT WILL HAPPEN IF THIS AGREEMENT IS NOT COMPLIED WITH:   It is fully understood and appreciated by MM that M2 is subject to a care order and that the Local Authority share parental responsibility in respect of M2. Any breech of this agreement may result in children services seeking an alternative placement for M2.’  5.2.21 Prior to the working agreement MM understood from social workers 1 and 2 that she must not allow FM unsupervised contact with M2. This point was also included in the Care Order. Also, that supervision was to be provided by professionals at a contact centre and not by MM. The reason for not allowing MM to supervise FM’s contact with M2 was because she had been a victim of domestic abuse from FM and was thought incapable of protecting M2 should FM put pressure on her.  5.2.22 The working agreement stemmed from the sightings of MM, FM, and on one occasion M2, together. In brief children’s services had limited confidence in MM’s ability to prevent FM from having unsupervised contact with M2; had they, the agreement was unnecessary. MM demonstrated by her contact with FM outside of the verbal understanding with social workers 1 and 2 that she could not be fully relied on to work openly and honestly with professionals.   5.2.23 The practitioners’ event heard from children’s services managers that the value of working agreements is limited. They may give social workers false assurances that the subjects will comply. Nevertheless, they do document a clear set of requirements and allow for the subject’s actions to be measured against them. They are also a potential source of evidence in any subsequent court proceedings should the person to who they apply renege. 5.2.24 The Quality Assurance and Performance Improvement (QAPI) Subgroup of Manchester Safeguarding Children Board had agreed the next multi-agency audit for looked after children beginning in September 2018 should focus on children who are looked after at home.       MSCB Child M1 and M2 SCR Page 11 of 31    The review panel’s view: Key Practice Episode 1 5.2.25 In January 2014 the risk to M2 came from FM in two ways; the first was M2’s exposure to domestic abuse between FM and MM; and the second from FM’s inability to protect C1 from harm when under his direct supervision in 2013.  5.2.26 In early April 2014 when the decision was made in principal to return M2 to MM’s care it was not known or suspected that she was seeing FM. That suspicion came a few weeks later when MM and FM were seen together on two occasions.  This put doubt in the minds of children’s services as to whether the rehabilitation under a care plan should continue. MM was challenged about her relationship with FM but denied there was one. MM told social worker 2 they were chance meetings. While that cannot be verified it nevertheless drew a cautious response from children’s services.  5.2.27  That caution resulted in a working agreement which set out prohibitions on FM’s unsupervised contact with M2 and the consequences of breaching it. Social worker 2 drew up a care plan to assist the court.  CAFCASS in a report dated 24 May 2014 recommended that M2 was made the subject of a care order with a plan that to return to MM. The Guardian ad Litem reported MM had maintained her separation from FM.  The court approved the care plan.   5.2.28 Children’s services continued with the rehabilitation plan and any legacy view that MM was compliant and cooperative with children’s services was weakened by her behaviour. Any optimism by social work professionals should have been tinged with the evidence that MM was not always reliable. Some professionals were over optimistic.18 Finding 2. 5.2.29 M2 returned to live with MM on 31 July 2014. There is evidence in the court bundle that MM continued to have a relationship with FM after M2 returned to live with her. For example, M2 told school staff that daddy slept with mummy. The police attended a number of call outs to MM’s home involving FM and on one of these MM told the officers that FM stayed with her sometimes. However, that information was not shared with children’s services until after the injury to M1. The reasons for this appear at 5.3.16 and 5.3.17 of this report. 5.2.30  While MM’s unreliability was recognised at the time, professionals never fully understood why she hid her association or relationship with FM.  MM told a professional that she believed parents should stay together no matter. This stemmed from her childhood experiences when her parents remained together despite challenging circumstances. MM partly accepted that she was manipulative but felt that professionals would not understand if she told them she occasionally saw FM. At one level MM accepted the emotional and potentially physical impact of domestic abuse on M2. Nevertheless MM felt that she was able to provide a loving home for M2. It was noted by professionals in their assessments that MM chose to put her relationship above the child’s needs.  5.2.31 Understanding MM’s motives would have enabled social workers to work with her to provide a more effective safeguarding plan for M2. There is no evidence that professionals considered whether MM was in a coercive and controlling relationship with FM that may account for her reluctance to engage. Finding 3.  There is no record or suggestion that FM was approached and asked about his meetings with MM. It seems it did not occur to the                                                       18 See Appendix 5 for one explanation of over optimism. MSCB Child M1 and M2 SCR Page 12 of 31    social worker to see him. The case would have benefitted from a separate plan aimed at understanding and dealing with MM’s reluctance to engage. Part of that plan could have been to engage with FM.  Finding 4 / Learning point 4. 5.2.32 MM did not respond to invitations to contribute to the review and therefore her motive for misleading professionals about contact with FM is not fully understood.  Similarly FM did not respond. In May 2014 the police told children’s services and health visiting about the April 2014 domestic incident between MM and FM. That information does not appear in either organisation’s record.  That was unfortunate as it would have provided additional material to discuss with MM and an opportunity for her to share her concerns about FM, thereby helping professionals to understand what was really happening in the family and offer appropriate support. The fact that she chose not to disclose the police involvement is probably further evidence of her reluctance to fully engage. 5.2.33 The decision to return M2 to MM under a care order on 31 July 2014 was appropriate as was the care plan which included discharge within 12 to 18 months.  5.3 Key Practice Episode 2   Safeguarding M2 after return to MM: 01.08.2014 to 09.02.2016  Information Sharing 5.3.1 This key practice episode covered about eighteen months.  Examination of the chronologies identified significant information sharing between M2’s school’s safeguarding coordinator and other school staff, health visiting, the case social workers and the family intervention worker. The school entries are detailed, attributed, timed and dated which is seen as good practice. 5.3.2 On 11 August 2014 the family health visitor was unable to access M2’s health visiting records because they had been removed to support the Child C1 Serious Case Review. This meant a delay in the health visitor seeing MM and M2 as they did not want to visit without being in possession of the full facts. The health visitor obtained the full family background from the school safeguarding coordinator. There was no system in place for health visiting files to be copied before they were released to a Serious Case Reviews. At the point of release a new record was commenced. However, Central Manchester Foundation Trust (as was) would have facilitated the heath visitor in reviewing the notes, as they were available and accessible with supervision on site. Learning point 5 5.3.3 The school record has many examples of poor behaviour by M2 including punching and pinching pupils, destruction of furniture, swearing and non-compliance with staff instructions. On some occasions M2 was sorry for their poor behaviour and on others was defiant and not willing to talk about the incident. 5.3.5 An analysis of M2’s conduct revealed an increase in the frequency and severity of M2’s behaviour. In the few months before September 2015 professionals had suspicions that FM was seeing MM and that he may have been living in the house with her and M2, because M2 told staff about domestic abuse between their mother and father.  It is very likely that M2’s behaviour was consequent to being exposed to domestic abuse. (In plain sight: Effective help for children exposed to domestic abuse19).  M2’s verbal and non-                                                      19 Ref report www.safelives.org.uk/In_plain_sight_the_evidence_from_children_exposed_to_domestic_abuse.pdf  MSCB Child M1 and M2 SCR Page 13 of 31    verbal messages to adults (the ‘voice of the child’20) were not given the weight they should have been. MM’s explanations were accepted. The voice of the child was not listened to. Finding 5.  5.3.6 School staff often spoke with MM about M2’s behaviour, highlighting M2 lacked remorse and did not take their rebukes seriously.  On many occasions staff asked MM for explanations of M2’s behaviour. On one occasion MM brushed it off by saying M2 did not like Mondays without further explanation. When asked whether the behaviour happened at home or what the triggers might be, MM said she was confused and had not seen these behaviours at home. The staff member pressed MM and recounted an incident of M2’s bad behaviour in MM’s presence.  MM acknowledged that M2’s behavioural issues occurred more when M2 was ‘around others or had an audience’.   FM’s involvement with MM and M2 5.3.7 The return of M2 to MM was partly predicated on FM only having independent supervised contact with M2 and a requirement for MM to tell her social worker before reforming her relationship with FM. In that event a risk assessment would be done and an alternative setting may be found for M2. 5.3.8 The key to protecting M2 during Key Practice Episode 2 was knowing if FM had re-entered MM and M2’s life.  Throughout the period there was plenty of suspicion that FM was seeing MM and M2. 5.3.9 This table catalogues the suspicions and evidence. Suspicions of FM’s involvement with MM and M2 Date  Narrative 2014 No information on FM but evidence that MM was told twice not to allow him unsupervised contact with M2. 2015  x.03.2015 Family intervention worker saw a man entering MM’s home using a key. MM said it was a new boyfriend. x.05.2015  Family intervention worker saw a man and M2 enter the house with keys.  x.05.2015 Teacher asked M2, who lived at home. M2 said ‘Mummy and Daddy’. M2 was asked where daddy slept. M2 stated ‘in Mummy’s bed, adding, ‘sometimes at Mummy’s and sometimes at Nanna’s’. x.08.2015 MM refuses to provide details of a man she was seeing to social worker. x.09.2015 MM provided the social worker with some details of the man she had been seeing. She refused to provide the address. x.09.2015 The police attended a verbal argument between MM and FM regarding FM’s contact with M2.                                                        20 This phrase is 'shorthand' and means that professionals listen to and understand what children tell them. Lord Laming (The Victoria Climbié Inquiry) reiterated the importance of frontline professionals getting to know children as individual people and, as a matter of routine, considering how their situation feels to them. Ofsted’s evaluation of 50 Serious Case Reviews conducted between 1 April 2007 and 31 March 2008 highlighted ‘the failure of all professionals to see the situation from the child’s perspective and experience; to see and speak to the children; to listen to what they said, to observe how they were and to take serious account of their views in supporting their needs as probably the single most consistent failure in safeguarding work with children.’   MSCB Child M1 and M2 SCR Page 14 of 31    Suspicions of FM’s involvement with MM and M2 Date  Narrative x.11.2015 The police attended a verbal argument between MM and FM after FM accidently damaged an ornament belonging to C1. FM was leaving the address as police arrived and was verbally abusive to officers.  2016  x.01.2016 FM went to MM’s home and banged on the door, shouted verbal threats as she still had contact with the offender’s family for the sake of M2 whom she still allows to see FM’s grandparents.  x.01.2016 The police attend a verbal argument between MM and FM regarding FM’s contact with M2.   5.3.10 It seems likely that FM was seeing M2 and FM. M2 refers to living with ‘mummy and daddy’ adding they slept together. Therefore it is likely that MM allowed FM to stay in the house and have unsupervised contact with M2 in direct breach of the court approved care plan and the working agreement.  5.3.11 M2 made reference to MM and maybe FM staying at Nanna's. By inference it is likely M2 was also there. It is not known who Nanna is. However if it was FM’s grandparents, that would be another direct breach of court approved care plan and the working agreement. 5.3.12 Allowing, or being passive about, FM’s contact with M2 meant that MM was not protecting her child as required by the court approved care plan and the working agreement. However, this has to be contrasted with MM calling the police on three occasions after she argued with FM over contact with M2.  This action suggests she was protecting M2.    5.3.13  At one point MM said the man she was seeing was not FM but a new boyfriend.  The risks presented by FM were known but the risk presented by an unknown male were not and potentially left M2 exposed to unassessed risk including emotional and physical harm.   5.3.14 Registered social landlords record potential safeguarding information on tenants’ files and MM’s social landlord was a source that professionals could have considered. In this case there was nothing relevant to the review’s terms of reference on the housing record.    Reported Domestic Abuse between MM and FM 5.3.15 The next table provides the detail of the police’s involvement with reports of domestic abuse between MM and FM in Key Practice Episode 2. Reported Domestic Abuse between MM and FM Date Details  Referral required by police policy21 x.05.2015 MM reported a male outside. Reading the full log this is likely to be FM. No: not identified as a domestic incident x.09.2015 Dispute over contact with M2. No x.11.2015 Damage to C1’s ornament.  No x.01.2016 Dispute over contact with M2. Yes: three within the last twelve months                                                       21 See paragraph 5.2.6 for the policy MSCB Child M1 and M2 SCR Page 15 of 31    5.3.16 The last three incidents provide evidence that MM was in contact with FM. In particular the damage to C1’s ornament suggests FM was in the house. The Greater Manchester Police domestic abuse policy appears at 5.2.6 and apart from the incident in January 2016 there was no direct requirement to share the information with children’s services and health visiting.  5.3.17 The incident in January 2016 was the third within the last twelve months and therefore required sharing with children’s services and health visiting in line with the police policy. It was not shared because the officer was unaware of the policy requirement. The officer was also unaware of what a looked after child was. These matters will be dealt with through internal police training. Learning point 7  The difficulties faced by professionals  5.3.18 Professionals describe MM as very plausible while at the same time recognising she was not wholly committed to working with them. There are seven specific mentions in agency records of MM not engaging, including a worrying entry querying whether she was feigning compliance. It appeared MM knew where the boundaries were and how far she could obstruct professionals before they actively considered removing M2 from her care. The case was managed by four different social workers in Key Practice Episode 2, which made building rapport and trust with MM and M2 a stop-start process. However, MM often used the school staff as a conduit to the social workers. The school safeguarding coordinator said this happened when MM did not have any credit on her telephone and made the requests when she dropped off, or picked up, M2 from school. Finding 6. 5.3.19 MM robustly rebutted all suggestions that she was involved with FM and by extension that FM had unsupervised contact with M2. She was adamant in her denials and on one occasion walked out of a looked after child meeting because of the challenges made by professionals about her not revealing the identity of the male she was suspected of being involved with.  5.3.20 Professionals were concerned that if they pushed too hard she would simply disengage from any cooperation with them. That concern was understandable. The premise that underpinned it, was that some contact with MM was better than none. M2’s safety was more important than MM’s feelings. The Local Authority had shared parental responsibility for MM and therefore a duty to protect the child. Ultimately M2 could have been removed from MM if other protective measures were ineffective.  5.3.21 The reality was that MM was not really engaged with children’s services. She mislead them, failed to keep at least twelve appointments for her and/or M2 with social workers, health visitors and other medics and minimised M2’s poor behaviour at school. MM also elected not to share with her social worker that she had called the police to disputes between her and FM. A separate plan to manage MM would have helped professionals engage with her.  5.3.22 On 14 October 2015 a child and family assessment was completed by the family social worker because of concerns that MM was back in a relationship with FM. The assessment noted:  ‘Throughout the assessment MM denied this and stated that she chose to conceal the identity of a male as this was her personal life and she did not want professionals to pry. MSCB Child M1 and M2 SCR Page 16 of 31    Although MM stated on several occasions that she understood why professionals were worried, her behaviour and reactions when challenged have been inappropriate’.   ‘Although the identity of the male has not been established, there have been no further sightings of him at the home address during visits. Children's services have not pursued obtaining details from MM as she has stated that she is no longer in a relationship with him. There have been no reported incidents of DV at the home address’.  5.3.23 The children’s services panel representative had the following critique of the assessment:  ‘The child’s voice does not come through in the assessment and it is not evidenced that the social worker asked M2 questions about daddy. The social worker completed the assessment as there had been various sightings of a man that was said to be FM.  MM stated that M2 had called her boyfriend ‘daddy’. Although an assessment was completed no police checks are evident and extended family members were not spoken to’. 5.3.24 The social worker who completed that assessment was unavailable to the review. The children’s services manager who approved the non-pursuance of the male’s identity was not available.  5.3.25 The October 2015 child and family assessment would have benefitted from a forensic analysis of MM’s non-cooperation and the suspicions she was involved with FM. Information could have been gathered from a wider range of sources. For example an enquiry with the police would have identified the September 2015 and April 2014 domestic incidents between MM and FM.   5.3.26 After the October 2015 assessment had been completed there was a significant deterioration in M2’s behaviour as catalogued by the school. While the general decline was known about there is no evidence of a more detailed look at what was happening in the family. When M2’s conduct in school is looked at with other information it begins to raise the suspicion that M2’s poor behaviour may be linked to what they saw or heard in the home. 5.3.27 There was some evidence to say FM was back with MM and M2, but professionals never got to the bottom of this important point during Key Practice Episode 2.  5.3.28 Children’s services allowed MM too much leeway. The case would have benefitted from a more detailed analysis; wider information gathering to inform risk assessment; and firmer management. Learning point 8. 5.4 Key Practice Episode 3   MM’s pregnancy with M1: 10.02.2016 to 05.09.2016 5.4.1 On 10 February 2016, MM saw her general practitioner who noted MM was seven weeks pregnant. MM’s medical notes contained a copy of a looked after child assessment but this would have to be searched for because parents of looked after children do not have their medical records flagged with that fact. Ideally the doctor should have seen the looked after child assessment and discussed the background with MM. Having done that the doctor should have agreed with MM that the information would be passed to children’s services. Learning point 9 5.4.2 On 10 March 2016 MM saw the medical centre practice nurse for a pregnancy review. MM was referred to antenatal services at Saint Mary's Hospital. Information on the referral MSCB Child M1 and M2 SCR Page 17 of 31    form included C1’s death and MM’s mental health history. The practice nurse did not know that MM had a looked after child. Ideally this knowledge gap should not have existed. Learning point 10 5.4.3 On 30 March 2016 MM attended a pregnancy booking appointment at Saint Mary’s Maternity Hospital. MM told staff about C1’s death and how she had stopped taking medication for depression when she knew of the current pregnancy. MM also gave a history of bulimia and self-harm. Maternity staff who knew the history of C1 recognised that MM had a looked after child. MM was told a referral would be made to children’s services. MM said she had no current social worker. MM declined to name father of the unborn baby hereinafter referred to as M1. 5.4.4 The referral to children’s services was appropriate. The family was an open case to children’s services something that MM would have known.  In the absence of seeing MM it has not been possible to say why she stated she did not have a current social worker.   5.4.5 Midwifery asked children’s services for the name of M1’s social worker but were told the case was unallocated. Midwifery pursued this several times as they felt a pre-birth assessment should be undertaken. Children’s services said that until M1 had a social worker, the one allocated to M2 would look after matters.  A social worker should have been allocated to M1 at this point and the ongoing delay in not allocating a social worker was inappropriate. 5.4.6 Midwifery referred MM to the specialist midwifery team who felt the case could be safely managed without their support. Therefore community midwifery became involved and supported MM with the pregnancy and also the death of C1. 5.4.7 Children’s services decision to suspend discharging the care order because of MM’s pregnancy with M1 was appropriate. There was some evidence that MM neglected her own health during the pregnancy with C1.  MM reported on-going anxiety about the upcoming anniversary of Child C1’s death. While MM felt that her decision to stop taking the antidepressants during pregnancy was right, there was a down side in that she felt more depressed. 5.4.8 In June 2016 children’s services began a pre-birth assessment and shared with midwifery that the likely outcome was a recommendation that the baby (M1) should be supported as a child in need as opposed to a child on a protection plan.  5.4.9 The social worker who completed the assessment was unable to attend the practitioners’ event but saw the lead reviewers together with a manager and children’s services panel member. 5.4.10 The social worker was allocated the pre-birth assessment in July 2016 following the unavailability of the original worker. The social worker was told the pre-birth assessment had been commenced; however it had not. There was no formal handover briefing between the two social workers. The new social worker discussed the case with the team manager whose view was that M1 could be managed as a child in need. This influenced the social worker’s thoughts and pre-disposed the worker towards a recommendation which would deliver a child in need outcome. This outcome would complement the proposal to discharge M2’s care order and manage the case as a child in need.   MSCB Child M1 and M2 SCR Page 18 of 31    5.4.11 The social worker felt the case was not a very high risk one when compared to others they held, including a high risk missing teenager, two adoptions and an unusual volume of other high risk cases. Additionally there was limited time between allocation and birth in which to complete the assessment.  5.4.12 The social worker knew the background to C1’s death and discussed domestic abuse with MM and the importance of knowing who M1’s father was. MM refused to name the father and said it was someone she met at a party and that there was no ongoing relationship. MM was happy to have M1’s blood tested after birth to show that FM was not the father. MM was upset that the incident leading to C1’s death happened while C1 was in the sole care of FM and was persuasive when saying she wanted nothing to do with him.   5.4.13 The social worker knew that M2 had made disclosures to the school of being hit by MM and of FM living in the home, but did not think there was a lot of evidence. The social worker said MM was cooperative. The social worker saw M2 as part of the pre-birth assessment but did not receive any disclosures of being abused or witnessing domestic abuse between MM and FM.  After the injury to M1 both siblings (M1 and M2) were placed in foster care where M2 disclosed witnessing domestic abuse between MM and FM in which FM was violent towards MM. However that was not known at the time of the pre-birth assessment.  5.4.14 After reflecting on the case the social worker would do things differently if faced with the same or similar circumstances. For example: the social worker would identify to the team manager their heavy workload; make enquiries with the police; look for more independent sources of information and not place as much weight on MM’s testimony. The social worker can now see that MM was manipulative and would give just enough information to satisfy a professional’s enquiry on a particular point. An example of this is MM’s agreement to allow a DNA test on the baby to establish it had a different father to M2. MM will have known the DNA test would find her out in a lie, but for the moment her apparent cooperation satisfied professionals. Additionally, the social worker would be wary of being over influenced by the anticipated outcomes and look for more evidenced based conclusions. Learning point 11 5.4.15 The social worker was shocked when M1 was found with an injury and added that the learning in this case is about identifying all the information and factoring in the time constraints when completing assessments.  5.4.16 This family had been subject of a previous Serious Case Review which should add further caution to how professionals’ approached assessments. A ‘Serious Case Review’ flag should be placed on the front screen of a child’s MiCARE22 record. Whether agencies need to identify families who have undergone Serious Case Reviews is something for consideration by the Manchester Safeguarding Children Board. Learning point 12 5.5 Key Practice Episode 4  M2’s disclosure to school: May 2016  5.5.1 On 4 May 2016 the following entry was made in the school record.                                                       22 The Manchester integrated Care and Recording Environment (MiCARE) was implemented at the end of October 2008. It replaced four legacy systems and a number of paper based systems that held client information on adults and children.  MSCB Child M1 and M2 SCR Page 19 of 31      ‘M2 hurt their head yesterday because … got hit by … with a stick. M2 was upset and I told M2 that we'd let mum [MM] know. When I said about calling mum, M2 cried and lay down on the floor saying "no, no I don’t want my mum, I don’t want to go home."... Whilst the other children washed their hands, M2 said, "I don’t want my mum, I don’t love my mum". I asked why. M2 said "she smacks me" and pointed at their back" and she hits me and kicks me" pointing at their ankles" and she scratches me with her nails" pointing at their neck. "I don’t want to go home, I am sad, I want to go to your house...I don’t love my mum because she smacks me." M2 was very distressed at the thought of going home. Lately when M2 heard the words 'home time' they got upset and said "I don’t want go home."  5.5.2 Later on 4 May 2016 the school safeguarding coordinator telephoned the social worker to discuss the disclosure. The social worker was not available and the safeguarding coordinator spoke with the duty social worker who in turn sought advice from the team manager.    5.5.3 The duty social worker telephoned the school safeguarding coordinator about an hour later and said there does not seem to be ‘…a direct disclosure of a specific incident but rather a general disclosure of being hit, and therefore it is less likely M2 will have a mark. A message has been passed to the social worker who is in London today but will be back tomorrow (Thursday 5 May 2016) and will deal with the incident then. A message has also been passed to manager [named removed] and so we can contact [named manager] if needed’.  5.5.4 While M2’s disclosure was not considered ‘a direct disclosure of a specific incident’, it was nevertheless a direct disclosure of physical abuse and emotional harm that was likely to have taken place over time. It merited M2 being seen the same day. Instead M2 went home for the night without being seen by a social worker and the risks thoroughly assessed. A telephone consultation and assessment was not an appropriate response to a disclosure of what could have been significant harm. After the injury to M1, both siblings (M1 and M2) were immediately placed in foster care. At one placement M2 made further disclosures. The team manager was unavailable to be seen.  5.5.5 On 5 May 2016 M2 attended school with a cut eye. MM told a teacher that M2 had dropped an apple yesterday and when she bent down to comfort M2 she caught the child with her nails. The teacher asked M2 about it by saying it looked sore. M2 said 'I not tell you, I can’t’. The teacher asked why, M2 said, ‘Mummy said no’. The teacher told M2 that they needed to know so they could look after M2 who said ‘Just scratched me with her nails’. When the teacher asked M2 how they felt the reply was 'scared'.  5.5.6 The social worker visited M2 in school the same day and saw M2 in the presence of a member of staff. M2 did not repeat the disclosures made to the teacher. M2 said 'daddy', was locked outside by MM and that M2 does not like MM because she is 'naughty'. It was note that M2 was very tired and grumpy; M2’s clothes appeared grubby with a faint smell of damp.  5.5.7 It appears that on 5 May 2016 the social worker asked the police to attend a strategy meeting. An officer declined to attend saying that M2 was a looked after child and there MSCB Child M1 and M2 SCR Page 20 of 31    was no role for the police. The refusal should have been escalated. This was an inappropriate response and the request to attend a strategy meeting should have been accepted. Learning point 13 5.5.8 Children’s services sent an e-mail referral about the ‘smacking’ to the local Police Protection Investigation Unit. It should have been sent to the North Manchester Public Protection Investigation Unit because that was where the family lived. This was a simple error caused by a misunderstanding of the correct routing by the social worker who was based in the local office.  No action was taken by the police at that time because the e-mail was not read.  5.5.9 On Friday 6 May 2016 the Independent Reviewing Officer (IRO) send an e-mail to the social worker and the team manager which read: ‘This is just to confirm our conversation on the phone. I expressed my concerns about M2, regarding recent concerns of neglect and M2’s alleging mum hits M2 and that she has had to 'lock daddy out'. You also said that M2 has recently been unwilling to go home. M2 has a scratch which may be accidental, but M2 had another in March that was also 'accidental'. They may be accidental but could also be a sign of rough handling. MM’s continued lack of engagement is worrying, given that the local authority shares parental responsibility on a care order. Given that we now know MM is pregnant, when we did not know she was in a relationship, and given the tragic death of C1, I don't think we can be too careful about who may be in the house. For all we know it could be M2’s daddy, FM, who is in a relationship with M2’s mum. It is unsatisfactory that the police have not been available for a strategy meeting before the weekend, when this was referred yesterday. I think there are immediate safeguarding concerns for M2 this weekend and recommended that emergency duty services should be asked to visit for a 'welfare check' over the weekend, as police are unlikely to be willing to do so. I think M2 should also be visited this evening and MM spoken to’.  5.5.10 On 9 May 2016 a police officer viewed the e-mail from children’s services. A police supervisor spoke to the social worker and declined to attend a strategy meeting.  The social worker recorded the following reason: ‘They do not see a role for themselves here as the child has no apparent injuries and there is a full care order in place. Police feel that it is the role of children's services to establish whether there is cause for concerns and make the decision to remove M2 if necessary’. The police’s view was wrong and not in accordance with established procedures. The social worker should have escalated the police’s refusal to attend. The three day delay before the e-mail was read did not have an adverse effect on M2’s safety. 5.5.11 Children’s services felt this telephone call was a strategy discussion and marked the file accordingly. The police did not record the details of the call between the police officer and social worker and did not believe they were taking part in a strategy discussion. The decision of the police supervisor not to attend a strategy meeting because M2 was subject of a care order is not the policy of Greater Manchester Police and was the view of one person. 5.5.12 A strategy meeting23 was essential and to comply with policy should have taken place within twenty four hours of the allegation being made by M2 on 4 May 2016.  The police’s refusal to attend a strategy meeting should have been escalated by children’s services.                                                       23 The requirement for a strategy meeting can be discharged by having a telephone strategy discussion.  MSCB Child M1 and M2 SCR Page 21 of 31    One benefit of a strategy meeting would have been to decide if M2 needed to undergo a child protection medical to examine the injury to their face. The police officer who made the decision not to attend the strategy meeting failed to understand that such meetings create a framework for the thorough investigation of serious concerns.  5.5.13    In the absence of a strategy meeting the team manager and social worker saw MM on 10 May 2016. The team manager’s note of that meeting is reproduced below with suitable anonymisation.   ‘We have had MM into the office this morning. She is insisting that she does not smack or hit M2 “as M2 does as they are told and doesn't need to be smacked', and is not having contact with M2's father who she believes now lives in London, she understands that a DNA test of the new baby will be carried out to confirm that M1 (the baby) has a different father to M2. MM seems to be okay with this’.   ‘MM acknowledges that she came off her anti-depressants due to being pregnant and that due to C1 passing away she is feeling very anxious about the pregnancy and everything that could go wrong. We have wondered whether this could be impacting on M2 and their behaviour as M2 is picking up on their mother's anxiety and I know that M2 was greatly impacted by their sibling’s  death even at their young age and Mum has kept C1’s memory fresh in M2’s mind through photographs and talking about C1’.  ‘On Friday afternoon there was an incident where M2 became upset and accused a lunchtime supervisor of grabbing M2 by the arm when M2 was asked to leave the lunch table for fighting. There were multiple supervisors and teachers present and there was no grabbing or touching at all, so it does seem that M2 is distressed at the moment and this is perhaps causing M2 to make statements for attention and we have to consider this. We will continue to monitor and assess this until the situation settles down’. 5.5.14 The decision to monitor and assess was not supported by the evidence. The use of the phrase ‘until the situation settles down’ indicates professional’s expectations. There was independent information from professionals that MM had been seen with FM, and on at least one occasion M2 was also present. M2’s disclosures of being hit by their mother and witnessing arguments between MM and FM were not given the weight they should have been. M2 referred to ‘daddy’ picking them up from school and on another occasion said that FM was going to take them on a school trip. MM consistently refused to say who the father of the unborn child (M1) was. M2’s behaviour was deteriorating. No checks were made with the police which is surprising given that MM had been a victim of domestic abuse in the period leading up to C1’s death. Professionals were over optimistic and placed too much reliance on MM’s reassurances that she was not seeing FM or hitting M2. M2’s poor behaviour was attributable to M2 picking up on MM’s anxiety and depression around the death of C1.   5.5.15  A more detailed analysis of the events of the last twelve or so months would have enabled the pattern of M2’s behaviour and MM’s attitude to cast significant doubt on MM’s claims that she had not hit M2 and was not seeing FM.  Several social workers and other professionals involved in the looked after child process were sceptical about MM’s claims and felt a more robust approach with MM was needed. When this was discussed at the practitioners’ event there was a consensus that their concerns should have been escalated. MSCB Child M1 and M2 SCR Page 22 of 31    The learning points for professionals are: where there is conflicting information, seek independent sources; escalate concerns when they have evidence based doubts on decisions pertaining to safeguarding children. Learning point 14.   5.5.16 The police investigation into M2’s disclosure and allegation by M2 that a lunchtime supervisor pulled M2’s arm concluded in no further action based on verbal discussions with the social worker. Neither MM nor M2 were seen nor the Local Authority Designated Officer (LADO - now known as the Designated Officer) informed. Finding 9 / Learning point 15.  5.5.17 In conclusion professionals made decisions in good faith and an over optimistic view of MM’s ability to protect M2, partly brought about by MM’s persuasiveness. A lack of information gathering and the absence of a detailed analysis of events meant that MM was able to keep professionals at arm’s length.    5.5.18 M2’s subsequent disclosures to foster parents and professionals and the information in the court bundle led the court to conclude that FM was back in MM’s life and she was suffering domestic abuse at his hands. That may have accounted for her reticence in confiding in professionals. Had MM agreed to contribute to the review the point would have been explored.   5.5.19 M2’s verbal and non-verbal voice was not given enough credence nor was M2 given sufficient opportunities to expand on their disclosures. The starting premise for professionals should be to believe the child while searching for other evidence. Finding 5  5.5.20 M2’s non-verbal voice as illustrated by their poor and sometimes aggressive behaviour was not given the weight it should have been. Some professionals thought it stemmed directly from what was happening at home between MM and FM. The analysis needed to develop that hypothesis was not done and in this respect M2’s non-verbal voice went unheard. There is no hierarchy of testament and when dealing with disclosures of abuse, a child’s voice is as valuable as an adult’s voice, particularly one who is ‘accused’ of the abuse.  5.6 Key Practice Episode 5  Identification of injury to M1 and safeguarding actions thereafter: 06.09.2016 to 10.09.2016  5.6.1  The family health visitor undertook a primary birth visit on 6 September 2016 and explained to MM that they wanted to complete a top to toe assessment of M1. MM showed the health visitor the left side M1’s face where a dark blue mark, which looked like a bruise, was visible around the top and inside of the ear. 5.6.2 Mother said she had noticed it the night before but it was not there when she brought M1 home from hospital. The health visitor questioned MM about the cause. MM thought it could have been caused by M1 lying on a dummy. Again MM did not divulge M1’s paternity when asked. 5.6.3 The health visitor invoked the safeguarding procedures. Thereafter M1 and M2 underwent child protection medicals, the school was updated and a strategy meeting arranged.  It was MSCB Child M1 and M2 SCR Page 23 of 31    at this strategy meeting that the police revealed the four domestic incidents between MM and FM. 5.6.4 The injuries to M1 were deemed to be inflicted and M1 was made subject of an interim care order. M2 was already subject to a full care order. Both children were placed with the same foster parents while their future was considered.  MSCB Child M1 and M2 SCR Page 24 of 31    6. FINDINGS FOR THE BOARD’s CONSIDERATION 6.1 Findings 6.1.1 This Serious Case Review has identified the following findings and learning points and invites Manchester Safeguarding Children Board to consider how to respond.  Finding 1. There is no process or shared understanding, for looked after children placed at home, across the child protection partnership of the benefits of notifying all agencies of:  which children are looked after  where they live  that a family has been subject to a previous Serious Case Review.  2. Professionals were generally over optimistic about MM’s ability to protect her children.   3. Professionals never considered whether MM was subject to coercion and control by FM as an explanation for her lack of effective engagement and the impact of this on her decision making.  4. MM was generally viewed as a difficult person to fully engage with and at times would be challenging.  Professionals would have benefitted from a separate plan to understand and deal with MM’s reluctance to participate.   5. M2 provided significant verbal and non-verbal information about their exposure to harm from MM and domestic abuse but M2's voice was not listened too.  6. Having a succession of social workers allocated to MM hampered continuity and relationship building and made it easier for MM to follow her own agenda.    7. Some professionals approached assessments with preconceptions which, compounded by incomplete information gathering and restricted analysis, produced limited assessments.  8. Some professionals did not use the escalation process when they felt their concerns were not being listened to or understood.   9. The investigation into M2’s allegation that they were assaulted by a school lunch time supervisor was not handled in accordance with the Board’s procedures in that the local authority Designated Officer (formerly LADO) was not consulted.   10. The key professionals recommending and taking decisions on how to safeguard M1 and M2 do not appear to have had a thorough understanding of the 2013 Child C1 Serious Case Review and in particular the experiences of MM.     MSCB Child M1 and M2 SCR Page 25 of 31    6.2 Learning points extracted from the report Learning point 1. FM’s general practitioner did not know M2 was a looked after child and heard there was no routine system for sharing such information. It would have required a bespoke decision by M2’s social worker or a looked after child review meeting for M2’s doctor to be told. (5.2.4)  2. In line with police policy, a referral was made to children’s services and health visiting on 5 May 2014. The domestic abuse incident of 15 April 2014 post-dated the completion of the child and family assessment on 4 April 2014 and therefore could not have been considered when the recommendation to return M2 to MM was made by social worker. The 5 May 2014 referral does not appear in children’s social care or health visiting records and it has not been possible to determine why that is.  (5.2.12) 3. The facility for children’s services to request details of domestic abuse incidents on open cases (criterion seven) was not known to attendees at the practitioners’ event. The practitioners discussed whether the police, and other selected agencies, should flag all looked after children to ensure that incidents involving them are always passed to children’s services with the need for a request. While there was support for the proposition, the practicalities of doing so appeared very difficult. (5.2.15)  4. Understanding MM’s motives would have enabled social workers to work with her to provide a more effective safeguarding plan for M2. There is no evidence that FM was approached and asked about his meetings with MM. It seems it did not occur to the social worker to see him. Good decisions are based on being in possession of all the relevant material that is reasonably available. (5.2.31)  5. On 11 August 2014 the family health visitor was unable to access M2’s health visiting records because they had been removed to support the C1 Serious Case Review. This meant a delay in the health visitor seeing MM and M2 as they did not want to visit without being in possession of the full facts. The health visitor obtained the full family background from the school safeguarding coordinator. There was no system in place for health visiting files to be copied before they were released to the Serious Case Review. However, Central Manchester Foundation Trust (as was) would have facilitated the heath visitor in reviewing the notes, as they were available and accessible with supervision on site.  In the future health visitors may wish to arrange for a photocopy of the notes prior to sending them; however this should be done in a timely manner as notes should be secured as soon as possible. The named Nurses for Safeguarding should develop a process for how this can be done. (5.3.2)  6. An analysis of M2’s behaviour in school revealed an increase in frequency and severity. It is not known what was influencing M2 but their behaviour was an example of the ‘voice of the child’.  It is known that during the months leading up to MSCB Child M1 and M2 SCR Page 26 of 31    Learning point September 2015 professionals had suspicions that FM was seeing MM and may have been living in the house with her and M2. (5.3.5)  7. The domestic abuse incident in January 2016 was the third within the last twelve months and therefore required sharing with children’s services and health visiting in line with the police policy. It was not shared because the officer was unaware of the policy requirement. The officer was also unaware of what a looked after child was.   These matters will be dealt with through internal police training. (5.3.17)  8. Children’s services allowed MM too much leeway and that the case would have benefitted from more detailed analysis, wider information gathering to inform risk assessment and firmer management. (5.3.28)  9. On 10 February 2016 MM saw her general practitioner who noted MM was seven weeks pregnant. MM’s medical notes contained a copy of a looked after child assessment but this would have to be searched for because parents of looked after children do not have their medical records flagged with that fact. Ideally the doctor should have seen the looked after child assessment and discuss the background with MM. Having done that the doctor should have agreed with MM that the information would be passed to children’s services.   10. On 10 March 2016 MM saw the medical centre practice nurse for a pregnancy review. MM was referred to antenatal services at Saint Mary’s Hospital. Information on the referral form included C1’s death and MM’s mental health history. Ideally the practice nurse should have known that MM had a looked after child. (5.4.1)  11. After reflecting on the case the social worker would do things differently if faced with the same or similar circumstances. For example the social worker would identify to the team manager the heavy workload, make enquiries with the police and look for more independent sources of information and not place as much weight on MM’s testimony. The social worker can now see that MM was manipulative, would give just enough information to satisfy professionals at the time. Additionally, the social worker would be wary of being over influenced by the anticipated outcomes and look for more evidenced based conclusions. (5.4.14)  12. This family had been subject of a previous Serious Case Review which should add further caution to how professionals’ approached assessments. A ‘Serious Case Review’ flag should be placed on the front screen of the child’s MiCARE record. Whether agencies need to identifying families who have undergone Serious Case Reviews is something for consideration by the Manchester Safeguarding Children Board. (5.4.16)  13. It appears that on 5 May 2016 the social worker asked the police to attend a strategy meeting. An officer declined to attend saying that M2 was a looked after child and there was no role for the police. The refusal should have been escalated. MSCB Child M1 and M2 SCR Page 27 of 31    Learning point This was an inappropriate response and the request to attend a strategy meeting should have been accepted. (5.5.7)  14. A more detailed analysis of the events of the last twelve or so months would have enabled the pattern of M2’s behaviour and MM’s attitude to cast significant doubt on MM’s claims that she had not hit M2 or was seeing FM.  Several social workers and other professionals involved in the looked after child process were sceptical about MM’s claims and felt a more robust approach with MM was needed. When this was discussed at the practitioners’ event there was a consensus that their concerns should have been escalated.   The learning points for professionals are: where there is conflicting information seek independent sources; to escalate concerns when they have evidenced based doubts on decisions pertaining to safeguarding children. (5.5.15)  15. The police investigation into M2’s disclosure and allegation by M2 that a lunchtime supervisor pulled M2’s arm concluded in no further action based on verbal discussions with the social worker. Neither MM nor M2 were seen which was inappropriate. (5.5.16)    MSCB Child M1 and M2 SCR Page 28 of 31     APPENDIX 1: Extract from MSCB SCR Screening Panel Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1) (e) and (2) set out an LSCB’s function in relation to Serious Case Reviews, namely: 5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned;    (2) For the purposes of paragraph (1) (e) a serious case is one where: Abuse or neglect of a child is known or suspected; and Either - (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. “Seriously harmed” includes, but is not limited to, cases where the child has sustained, as a result of abuse or neglect, any or all of the following:  A potentially life-threatening injury;  Serious and/or likely long-term impairment of physical or mental health or physical, intellectual, emotional, social or behavioural development. Cases which meet one of the criteria (i.e. regulation 5(2) (a) and (b) (i) or 5(2) (a) and (b) (ii)) must always trigger an SCR.  ‘It is felt the criteria for a SCR is met based on the above criteria. M2 suffered a non-accidental injury and there is evidence of ineffective care planning, monitoring, supervision and oversight of multi-agency care planning and assessment processes’.   APPENDIX 2: Practitioner learning event Agencies participating  in the learning event held June 2017 Children’s Social Care, Manchester City Council  Community Consultant Paediatrician  Early Help, Manchester City Council  Education, Manchester City Council  General Practitioner Greater Manchester Police Health Visitor Service, Central Manchester NHS Foundation Trust Independent Domestic Violence Advocacy, Manchester City Council M2’s school, Education, Manchester City Council  Manchester Clinical Commissioning Group Midwifery Service, Central Manchester NHS Foundation Trust Facilitators Independent Lead Reviewers MSB Business Unit  MSCB Child M1 and M2 SCR Page 29 of 31     APPENDIX 3: GMP DVA Policy Greater Manchester Police Tackling Domestic Abuse Policy and Procedure Appendix L – Domestic Abuse referrals  Information involving incidents of domestic abuse should be shared with Children’s Social Care and Health where the incident involves any of the following:     victim or alleged/perpetrator is known to be pregnant; (or has given birth within the last 12 months);  child abuse marker (CA) on the address (AND there are vulnerability issues/concerns);   a child/children under the age of 18 ordinarily resides in the household and a child has made a call for assistance (AND there are vulnerability issues/concerns);   a child/children under the age of 18 years ordinarily resides in the household and it is the third reported incident within the previous 12 months (whether the child was present or not at the time of the incident) (AND there are vulnerability issues/concerns);   serious incident or crime recorded (where, in the professional judgement of the officer, a concern warranting a referral exists);   all incidents that involve a previous MARAC case with the last 12 months;   notification of CSC Open cases at request of CSC; or   domestic incidents with High Risk Status (DASH).   Officers will still have the ability to use professional judgement to make a referral which may fall outside of the above criteria, and to also use professional judgement to decide not to make a referral if there are other agencies better placed to support the family.       MSCB Child M1 and M2 SCR Page 30 of 31    APPENDIX 4: Working Agreement Conditions of Working Agreement between MCC Children’s Services and MM 1. MM must reside at her home address with M2 at [specified address]. Prior consent is required from discussion with the allocated social worker to allow M2 to stay overnight at any other address.  2. MM must ensure M2 is not witness to negative comments about their father from any of her friends or family members including her mother [named person]. If FM is spoken about in a negative way, MM must remove M2 from that environment immediately.  3. MM should speak to the allocated social worker should M2 experience negativity from family or friends about FM so that she can be supported to address any difficulties in the most appropriate manner to safeguard M2.  4. MM should not take M2 to visit the home of FM's grandparents at [specified address]   5. M2’s only contact with their father is supervised by Children's Services. M2 should have no other contact with their father and MM should not allow this to happen under any circumstances.  6. MM must inform Children Services if she intends to resume her relationship with FM so the appropriate risk assessments can be undertaken.  7. MM must ensure M2 continues to attend [named nursery]. This can be reviewed once M2 is settled at home.  8. MM must work in an open and honest manner with all professionals to evidence she is caring appropriately for M2.  9. MM agrees to accept all support services offered to her by Manchester City Council.  10. Visits will be undertaken by Manchester Children's Services and some will be conducted without prior notice.  11. MM will allow professionals access to her home and M2 on request. MM understands that the social worker will need to see where M2 is sleeping to check that the sleeping arrangements are appropriate.  12. If MM is struggling with any aspect of M2's care the key social worker must be contacted for advice and support.  13. Family Intervention Project (FIP) has been identified as an appropriate service to offer support to the family. MM agrees to engage with this service.  14. Home conditions must be kept safe. There should be no dangers for a young child. This includes the floor being clear of potential hazards such as small items and debris and cleaning products must be kept out of M2's reach. Home conditions will be assessed at each visit.      MSCB Child M1 and M2 SCR Page 31 of 31     APPENDIX 5: Over Optimism I have recently been reading the work of Brandon et al., (2012) on learning from Serious Case Reviews in the UK for the period 2009-2011. It reminded me of the “Rule of Optimism” that exists within social work – indeed most of the helping professions.  In essence, we want things to work out. After all, we go into these professions seeking to make a positive difference in the lives of our clients. We want to believe that what we are doing is working. The rule of optimism can blind us to what is really going on. This can lead to several areas of practice concern:  1. believing that what we are seeing is progress; 2. filtering out or minimizing areas of concern; 3. anticipating that the intervention will work; 4. believing that “one more try” and the family will get it; 5. focusing only on strengths and ignoring what is not working and the risks that arise from that; and 6. overly positive interpretations of what is going on.  This is not to say that we should be looking only for the negatives. But it does tell us that we need to ensure a balanced view. When a client is not doing well, it is fair to ask if we are providing the correct services. It is also important to ask if the issue is that the client is not progressing – and if not – why not? There can be many reasons that are not associated with the worker – client refusing to see the problem; poor engagement in change; feigned compliance to make it look like they are working.  Source: Peter Choate: www.socialworkhelper.com/2014/07/28/the-rule-of-optimism/  Dr. Peter Choate is a Registered Social Worker and Member of the Clinical Registry and Approved Clinical Supervisor for the Alberta College of Registered Social Workers. He is an Assistant Professor at Mount Royal University in the Faculty of Social Work and Disability Studies and a Professional Development Instructor at the University of Calgary. His particular emphasis is on parenting capacity as well child and adolescent mental health including maltreatment, neglect and abuse (physical, sexual, emotional) and these issues within family systems.   