Injuries and trauma suffered by a pre-school child after father dropped them into a river from a bridge. Learning includes: there is a need for/to: Child and Adolescent Mental Health Services to allow direct referrals; robust single and multi-agency systems for bereavement notification; the whole family approach, especially for bereavement support; seek the views of other professionals to build-up a child centred picture; co-locate children's centres with nurseries and schools; build stronger links and support the sharing of information on services that can be offered from the voluntary and community sector; enquire about significant others even if they do not live with the child; the size and complexity of Early help assessment tool can be a disincentive. Recommendations include: train all professionals in bereavement support; Early help tool should address needs using a holistic assessment, not just to access services; maximise opportunities to engage with the voluntary sector in service delivery; all schools have a robust electronic integrated recording system or ensure robust safeguarding information recording and transfer arrangements are in place; implement a locally-agreed pathway to services for children at risk of self-harm.
      
 Title:  Family E: serious case review. LSCB: Bolton Safeguarding Children Board Author: Maureen Noble Date of publication: 2019  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.                            THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   1    Family E Serious Case Review                  Maureen Noble Independent Reviewer  Published  October 2019    THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   2   CONTENTS 1. Introduction and Methodology     3 2. Summary of Background to Family E     5 and Professional Narrative 3. Analysis of Professional Practice     7 4. Key Learning         9 • Practice Learning • Systems and Strategic Learning • Wider Learning 5. Recommendations       11 6. Response to Recommendations      12 Appendix 1 Family Genogram      16                    THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   3  1. INTRODUCTION AND METHODOLOGY  1.1 Key People  At the time of the incident Family E was made up of Father, Child 1 and a younger sibling, Child 3. The middle sibling, Child 2, had sadly died. Mother had also sadly died two years after Child 2, she experienced poor health, however her death was unexpected. Reference is also made in this report to an incident involving Child 4, an older half-sibling of Child 1 and Child 3 who is now an adult. A genogram in Appendix 1 outlines the family structure as known to the SCR panel. 1.2 Incident Leading to the SCR The Serious Case Review (SCR) relates to the incident described below. Child 3 was around two and a half years old at the time of the incident.  In the early evening on a day in late September Police were called to attend an incident on a bridge in Bolton. The report was from a member of the public who stated that a man was on the bridge with two children and behaving erratically.    Before the Police arrived at the scene Father had removed Child 3 from a pushchair, dangled the child over the bridge wall by the arms and threatening to drop the child. (It appears that Child 1 had been sent home by Father and had returned home unaccompanied).    A police negotiator was called to the scene. Child 3 was heard begging father not to be dropped. After about an hour on the bridge, during which Child 3 was being held over the bridge by Father, he let go and the child fell into the water below, which was a drop of around 40 feet.   Police had put in place specialist equipment and trained staff to retrieve Child 3 in the event Father let go.  Child 3 was retrieved from the water and taken immediately to a local hospital, where it was established that a number of injuries had been sustained; the child was also traumatised and shocked. Father had fallen into the water after letting go of Child 3. Father was arrested and taken from the scene to Accident and Emergency.  He was discharged from the hospital the following day into Police custody. Following discharge Father was questioned and charged with the attempted murder of Child 3.  He was remanded to custody pending investigation and trial.  Father was tried, found guilty of Section 18 wounding and then sentenced to fourteen years imprisonment.  1.3 Decision to Undertake a Serious Case Review A referral was made to the Bolton Safeguarding Children Board (BSCB) Learning and Improvement Group in respect of Child 3.  It was decided that the referral met the criteria for the conduct of a Serious Case Review. Whilst the specific incident that triggered the review related to Child 3, it was determined by the Learning and Improvement Group that Child 1 should also be made a subject of the review.  The review therefore looked at events relating to both siblings in the three years leading up to the incident set out above.  An Independent Reviewer was appointed as Lead Reviewer.  THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   4  The BSCB commissioned a concise SCR using a blend of the SCIE Learning Together SCR Methodology1 and the ‘Welsh Model’ for Serious Case Reviews.2 A combined chronology/timeline was compiled from agency records.  In conjunction with information from individual conversations with practitioners from relevant agencies, this was used to identify significant episodes of practice for analysis and learning. A panel of senior representatives from relevant agencies was established and met on five occasions to oversee the review. Agency and designation of panel members are set out below: Designation Agency Designated Nurse Children Looked After Bolton CCG Detective Sergeant, Serious Case Review Team Greater Manchester Police Named Nurse Bolton NHS Foundation Trust Named Nurse Bridgewater NHS Foundation Trust Head of Service Children Protection and Child Sexual Exploitation Children’s Services, Bolton Council Safeguarding in Education Officer Children’s Services, Bolton Council  It should be noted that the contents of this report have been edited to ensure the safety and promote the welfare of the children involved.  This has been done with the agreement and support of the Child Safeguarding Practice Review Panel. 1.4 Time Period The review team agreed that the starting point for the review would be from the time of Mother’s death to the date that the incident took place. 1.5 Research Questions The review team agreed the following research questions to be answered by the review: • Did professionals recognise and act on the impact of loss and bereavement on the whole family (including Father’s mental health)? • Did professionals demonstrate an understanding of the daily lived experience of Child 1 and Child 3? • Did professionals identify opportunities for early help34 and implement these? • Did professionals share information appropriately and in a timely manner? • Has the review identified good practice? • Has the review identified practice that could be modified to strengthen safeguarding? • Has any additional learning been identified by the review?  1 https://www.scie.org.uk/publications/ataglance/ataglance01.asp  2 http://www.sewsc.org.uk/fileadmin/sewsc/documents/Published_SCR_CPR/Child_Practice_Review_Guidance_-_Welsh_Government.pdf  3 3 http://boltonsafeguardingchildren.org.uk/working-with-children-and-young-people/early-help-and-working-together/   4 http://www.workingtogetheronline.co.uk/chapters/chapter_one.html   THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   5  1.6 Agencies Involved in the Review A learning event was held with professionals who were directly involved in the case prior to presentation of the report to the BSCB. The Lead Reviewer held one-to-one conversations with practitioners from the following agencies:  General Practitioner  Nursery school for Child 3  Primary School for Child 1  School Nursing Lead  Health Visitor  Behaviour Support Service  Local Church  A further learning event was held to refine the learning from the case, promote good practice and discuss modifications to future policy and practice. 2. SUMMARY OF BACKGROUND AND PROFESSIONAL NARRATIVE  2.1 Overview Both Mother and Father had previous relationships, and both had children to previous partners.  Mother had experienced domestic abuse in her previous relationship which had led to her having ongoing physical health needs and experiencing episodes of low mood. Mother had previous involvement with Children’s Social Care in another borough, prior to her meeting Father. Father appears to have had fragmented relationships with his family.  He was estranged from them and left home at the age of 16.  He appears to have experienced some issues with substance misuse in his younger years.  It is unclear whether he had presented with or been treated for emotional or mental health needs before the period under review. Father and Mother moved to the local area from another borough before the birth of Child 1. Child 1 appears to have been a healthy baby and there are no recorded concerns by any agency regarding wellbeing. The couple’s second child was born a few years later and was a healthy baby at birth.  A year after birth, Child 2 became suddenly unwell and sadly died at home of natural causes.  The family were understandably traumatised by the death of Child 2 and professionals observed that Mother in particular had great difficulty in trying to come to terms with Child 2’s death.   One month after Child 2’s death the parents registered Child 1 at a local primary school. Child 1 appeared to settle in well with no apparent difficulties. School were aware that there had been the recent death of a sibling.  THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   6  Child 3 was born without complications, a year after the death of Child 2. The health visitor, who had been involved with the family for some time, remained in contact and had no concerns regarding Child 3. A year after the birth of Child 3, and two years after the death of Child 2, Mother died unexpectedly at home.  It appears that she had been unwell but there was no indication that her illness was life threatening.  Father was out of the home at the time of Mother’s death. Child 1 was at home with Mother and was with her when she died.   Around one month after Mother’s death Child 3 was enrolled in a local nursery. The nursery was aware the Mother had recently died and were keen to support Father.  Father brought Child 3 to nursery every day before taking Child 1 to school.  The school and the nursery were located in close proximity to each other.  The local Children’s Centre, which was co-located with the nursery, offered Father support and the health visitor spoke to him about bereavement counselling, however Father decided that this is not what he wanted.  2.2 Professional Narrative Mother and Father were said by professionals to have had a close relationship and, to some extent, appeared as a couple that did not want professional involvement.  Mother was previously involved with Children’s Services and appeared wary of them.  Professionals emphasised that this was not a suggestion that there was anything untoward happening in the family or that there was anything to hide. Professionals noted the impact of Child 2’s death, particularly on Mother. At that time the health visitor provided a lot of support.  It was noted that Father used to cycle to the cemetery sometimes during the night and the early hours of the morning which was perceived as his way of dealing with his emotions. When Mother became pregnant with Child 3 it was noted that both parents were very happy, and that Child 3 was a wanted child.  Following Mother’s death professionals noted that Father tried to maintain a routine for the children.  He took them to nursery and school and sought support from the Children’s Centre.  He was offered bereavement counselling but did not want to take this up formally, although he did seek support from a local pastor and attended a couple of services and meetings at a local church.   Father appeared to all professionals to have good relationships with the children. He took the children to activities at the school and nursery such as fares and fun days, and he appeared to do his best to ensure that the children were able to participate in the same way as other children. School noted that Father was actively involved in meetings (when an Early Help assessment was initiated) although he did not always progress things that were suggested (i.e. referral to CAMHS). The family were all registered with the same GP practice. The GP had only routine contact with the family (for childhood illnesses and minor medical issues for Father). The GP was aware of the deaths of Child 2 and Mother. All professionals said that they were shocked by the incident.  There were no indicators present that would have predicted that Father would have caused either of the children significant harm.  THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   7  3. ANALYSIS OF PROFESSIONAL PRACTICE  The review analysed professional practice, using a combination of single agency reports, a combined multi-agency chronology, practitioner learning events and one-to-one conversations with identified practitioners.  These informed the responses to the research questions (set out in Section 1 of this report) and to the key practice episodes identified by the review.  This forms the basis of the recommendations set out in Section 5 of the report. The review has also identified learning for practitioners and for the safeguarding system as a whole, which is set out in this section and in Section 4. 3.1 Did professionals recognise and act on the impact of loss and bereavement on the whole family (including Father’s mental health)? All agencies were aware of loss and bereavement in the family, however not all agencies knew about specific aspects of the bereavements (for example that Child 1 had been alone with his Mother when she died and that that there had also been a number of deaths in Father’s family).   The review found that there is no ‘routine’ single or multi-agency system for notification of the loss of a parent which would trigger a single or multi-agency response to examine the needs of a bereaved child.  In the absence of a routine notification system, professionals reported that they tend to notify each other as part of their day-to-day contact. However, it was recognised by all involved in the review that this relies heavily on professional involvement and familiarity with the family and is not a robust way of dealing with such an important issue. As a result of the variability in practice, the cumulative impact on all family members was not fully assessed by any agency (Note: there is currently no expectation that it should be unless issues or problems become apparent – this may be a deficit in the system).  Opportunities for agencies to share information about the impact of multiple bereavements on individual family members are therefore limited. Professionals identified that there is little training available in relation to issues of loss and bereavement, and that some felt uncomfortable with ‘interfering’ at such a difficult time.  Professionals looked to other sources of support for this family, specifically the local church. Bereavement counselling was offered to Father but he did not want to take this up formally.  The review has identified the need for professionals to be equipped with knowledge and skills to offer relevant support at the right time to bereaved families. 3.1.1. Impact of Loss and Bereavement on Child 1 and Child 3 Child 1’s school knew that Mother had died but they did not know the circumstances.  The School noted that Mother’s death had occurred before the current management team was in place and that the previous school management did not keep detailed records, therefore the new management team had only partial information to work on. A referral to CAMHS had been discussed with Father as part of the Early Help assessment.  School said that the CAMHS referral system was something that they would like to see changed.  They said they would have referred Child 1 directly to CAMHS had they been able to do so. The system (at the time of writing this review) for CAMHS referral is that a referral can only be made via a GP at the request of a parent.  The GP felt that this  THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   8  system is unsatisfactory whilst recognising that there is a need to ensure that inappropriate referrals are not made to the service.5 Child 3 was less than one year old when her Mother died.  Nursery did not note any unusual behaviours associated with loss.  They noted that Father had a good relationship with Child 3, although he didn’t spend much time interacting with staff at the nursery.  He tended to drop Child 3 off and then take Child 1 to school, so he was usually in a rush. Nursery observed Child 3 and Child 1 to have a good relationship with each other. 3.1.2 Paternal Mental Health Father did not discuss the impact of multiple bereavements with any professional. He ‘opened up’ to the health visitor on one or two occasions and she offered him a space in which to talk to her. However, he did not want to take up formal offers of bereavement support.  Father did not present to any agency with mental health issues.  Professionals were aware of the likelihood that Father’s emotional wellbeing was impacted by loss and bereavement and he was encouraged to seek support in this respect.  There was a view that Father did not want to talk to professionals about his loss and that it would be intrusive to raise it with him.  Father was offered referral to bereavement counselling but did not want to take this up. With hindsight Father’s displays of anger and aggression appear to have increased during the six months prior to the incident.  School noted on several occasions that he was short tempered with Child 1 and, on the occasion that they conducted a home visit, they found him to be aggressive.  3.2 Did professionals demonstrate an understanding of the daily lived experience of Child 1 and Child 3? School provided support for Child 1 through participation in Winston’s Wish and ultimately referral to the behavioural support service.   There is no reference to the impact of the trauma on Child 3 other than nursery reporting that she did not display any unusual behaviours.  Nursery were not invited to meetings regarding the family.  Although the review does not make a recommendation in this regard it is important that nurseries are involved in all aspects of support to families as they provide a unique insight into the day-to-day lives of pre-school children. 3.3 Did professionals identify opportunities for Early Help6 and implement these? Early Help was offered following Mother’s death via Family First.  Father initially engaged but then decided he did not want to be involved with the service.  Family First suggested to Father that he might benefit from attending a local church.  Father acted on this and attended a number of sessions and events at the church with the children, however this was not sustained.  5 http://www.boltonft.nhs.uk/wp-content/uploads/2016/05/15-02-2016-Bolton-CAMHS-Referral-Criteria-Version-6.pdf  6 http://boltonsafeguardingchildren.org.uk/working-with-children-and-young-people/early-help-and-working-together/   THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   9  School undertook an Early Help assessment; however, the initial meeting was single agency and would have benefitted from wider involvement (including the Nursery, School Nurse and Health Visitor). The review learned that some practitioners found the completion of Early Help assessments as cumbersome and time consuming.  Some practitioners feel that there is a danger that the process may ‘get in the way’ of actually providing a service. Some services can only be accessed by initiating an ‘Early Help’ assessment and some practitioners felt that this may be a barrier to offering and engaging in services designed to help when problems are first identified. 3.4 Did professionals share information appropriately and in a timely manner? The first Child Action Meeting involved a range of agencies and information sharing was good.  The family were known to universal services who worked together locally (co-location was a key factor in joint working) to meet the family’s needs.  Communication between agencies was largely facilitated by day-to-day contact between agencies with the local children’s centre providing the hub for communication. When the Children’s Centre moved to another location, professionals felt opportunities to offer ‘informal’ support became more difficult as did communication about families who are not subject to Child Protection Planning but who have additional support needs.  The Early Help initiated by school involved a meeting with Father, however not all services were invited to this meeting.  It would have been useful to have had a whole perspective on the family at this meeting.   School identified that recording of meetings and actions before the new management team came in was not good and that it was difficult for them to pick up the background to the family from school records. 4. KEY LEARNING 4.1 Practice Learning Professionals in statutory and non-statutory services identified a need for further training and support in relation to trauma7 resulting from loss and bereavement.   The current system for referring to CAMHS is seen by professionals as requiring change.  Practitioners in the School setting felt that they should be able to make direct referrals to CAMHS.  The GP also observed that the CAMHS system needs revision to ensure that all children who would benefit from the service can be referred and assessed. Single and multi-agency notification systems regarding the death of a parent (or significant person) are not robust.  There is inconsistency which in this case led to a lack of awareness and consistency of response to the needs of Child 1, Child 3 and Father. Support for adults experiencing trauma associated with loss and bereavement is largely dependent upon the adult coming forward, asking for help and engaging with services.  Father did not want to attend counselling or respond to enquiries from his GP; therefore he did not receive any formal bereavement counselling or support.  There was good practice from Family  7 https://www.childwelfare.gov/topics/responding/trauma/   THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   10  First in seeking alternative routes for Father to receive support in the form of making links with the local church.  Whole family approaches to bereavement support were not considered. It would benefit practice if there was a mechanism by which agencies could come together to discuss the needs of the whole family. Child 3 was not identified as having any needs in relation to the impact upon her following the loss of her Mother.   Father’s accounts of Child 1’s behaviour at home did not correspond with what was being seen in the school setting, however, his accounts went unchallenged. In the absence of another parent/carer, it may have been beneficial for the school to seek the view of another professional to build up a child-centred picture. Co-location of services is not always possible, however the benefits of working in close proximity to other professionals, particularly where the children are not subject to any statutory intervention, were apparent in this case.  Practitioners expressed the view that having Children’s Centres co-located with nursery/primary schools created strong links and relationships, and enabled parents to engage as they were already ‘on site’. 4.2 Systems Learning Early Help is seen by some practitioners as a process rather than as a way of working. Some practitioners identified some barriers to accessing services (i.e. some services are only available if an ‘Early Help’ has been initiated).  Some practitioners said that the size and complexity of the Early Help assessment tool can be a disincentive to professionals initiating the assessment.  However, School said that they found the Early Help process very helpful. Is it a process driven system at present? The voluntary and community sector (in this case the local church) provided support and may be the preferred option for some families, however, they are not sufficiently ‘linked in’ to local systems.  They are often not seen as a first line resource; this will depend on how much individual practitioners in agencies know about what services can be offered.  Building stronger links and supporting the sharing of information on services that can be offered from the voluntary and community sector would be beneficial. 4.3 Wider Learning Practitioners were aware that Father had begun a relationship with a new partner and that the children were spending time with them.  However, there was no attempt to find out more about the relationship or the frequency with which the children were in contact with the new partner.   The role of the older sibling, Child 4, in the children’s lives was not known by professionals.  There was a missed opportunity for information to be shared regarding Child 4 following an incident at the family home.  Police have noted that current safeguarding procedures would ensure that such a notification would now take place. Building a picture of the day-to-day lives of the children may have helped professionals to understand more about behaviour, school attendance and changes in Father’s presentation.  It is good practice for professionals to enquire about other significant people in a child’s life although they may not necessarily be living with them.    THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   11  5 RECOMMENDATIONS Based on learning identified by the review, the SCR panel would make the following recommendations to the Board: 5.1 BSCB should be assured that professionals in all agencies have access to up to date and effective training in relation to supporting families experiencing trauma due to loss and/or bereavement  5.2 BSCB should be assured that the review of Early Help prioritises addressing the needs of children and families using a holistic assessment and is not used solely for the purpose to access services (i.e. it is not used as a referral process but as tool to identify the right help and support for families)  5.3 BSCB should be assured that opportunities to engage third sector and community agencies (e.g. local churches, community groups) in Early Help and support for families are maximised and integrated into local pathways for service delivery.  5.4 BSCB should be assured that all schools have a robust electronic integrated recording system in place, such as ‘CPOMs’, that enables the tracking and transfer of information within their setting and with partners.  Where an electronic system is not possible the school designated safeguarding lead, with the support of the safeguarding governor, should ensure that school systems for the management and processing of information relating to safeguarding children is of sufficient quality to enable robust recording and transfer of information, specifically where new management arrangements are introduced.  5.5 BSCB should be assured by the CCG that there is a locally agreed written pathway and/or process for accessing appropriate support for children who express thoughts of self-harm or taking their own life which is in line with the ‘I Thrive’ principles.  Further assurance should be provided to BSCB by the CCG of the steps taken to increase awareness and publicise the pathway to stakeholders, including children, parents and practitioners.  BSCB member agencies should provide evidence to BSCB that they have promoted the pathway/process within their service.  THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   12   6. Response to Recommendations  RECOMMENDATION RESPONSE  Recommendation 1 BSCB should be assured that professionals in all agencies have access to up to date and effective training in relation to supporting families experiencing trauma due to loss and/or bereavement BSCB have commissioned “Winston’s Wish” a recognised childhood bereavement charity who provide specialist child bereavement support services across the UK, to deliver training and awareness to practitioners for 2019-2020.   These are advertised as part of the multi-agency safeguarding training offer. The course targets the objectives of: • Understanding the needs of bereaved children and young people • How to make it talked about and not hidden • Techniques that can be adapted for different developmental stages and the wider impact on the family as a whole • Resilience and recovery • Children in the care sector and children with special needs • Self-care technique  Feedback from delegates rated the course as “good” to “great” and that the objectives met were met “strongly agreed” or “agreed”.    There is existing commissioned support available to families experiencing trauma due to loss and/or bereavement.  For adults this is provided through IAPT and for children and young people experiencing trauma, they would be provided appropriate evidence-based intervention via the Bolton CAMHS service.  These services also support practitioners to support families.   Discussions are also progressing with Child Bereavement UK who have been commissioned to deliver bereavement interventions to children and families in Greater Manchester.  This will be further supported by the provision of bereavement support training targeted at schools and wider health and social care professionals.     THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   13  RECOMMENDATION RESPONSE  Recommendation 2  BSCB should be assured that the review of Early Help prioritises addressing the needs of children and families using a holistic assessment and is not used solely for the purpose to access services (i.e. it is not used as a referral process but as tool to identify the right help and support for families) BSCB supported the commissioning of an independent review of the local Early Help system; the review started in September 2018 and completed in 2019.  The learning from this SCR was shared to inform the scope and key lines of enquiry.  The recommendations from the Early Help Review were endorsed by BSCB in July 2019 and work is currently underway to redevelop local thresholds and responses, including a revised Early Help model and process.  This model is underpinned by the principle of building on the child and family’s strengths and supporting families to find the right solutions for themselves.  This will be implemented from early 2020.   Recommendation 3  BSCB should be assured that opportunities to engage third sector and community agencies (e.g. local churches, community groups) in Early Help and support for families are maximised and integrated into local pathways for service delivery As described in Recommendation 2, the commissioned independent Early Help Review has engaged with approximately 250 practitioners, including those in the voluntary and community sector to seek their views on how Early Help processes should be designed and delivered for the future.  The views of children and their families have also informed the Early Help Review report and recommendations.    The voluntary and community sector are key partners on the steering group taking forward the development and implementation of revised local thresholds; they are also key in the Early Help model to linking locality-based approaches to community and voluntary sector groups.     THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   14  RECOMMENDATION RESPONSE  Recommendation 4 BSCB should be assured that all schools have a robust electronic integrated recording system in place, such as ‘CPOMs’, that enables the tracking and transfer of information within their setting and with partners.  Where an electronic system is not possible the school designated safeguarding lead, with the support of the safeguarding governor, should ensure that school systems for the management and processing of information relating to safeguarding children is of sufficient quality to enable robust recording and transfer of information, specifically where new management arrangements are introduced.  BSCB has shared this recommendation with the Safeguarding in Education Team (SET). SET have provided assurance that they undertake regular audits in education settings and that evaluation of an education setting’s recording system is a key audit component.  Where SET identify any areas of concern within this domain immediate advice is given along with suggested actions.  These findings are included within the written report, which is shared with the Headteacher and the Chair of Governors.  Where there are particular issues a further review is undertaken to track progress and ensure recommendations are embedded.  Within their training offer, SET provide guidance and information about good practice in recording and transferring information.  This is supported by additional guidance in the Education Safeguarding Policy.  SET will further strengthen this guidance in response to this recommendation.   At the time of undertaking the SCR review, education settings were alerted to this recommendation with a request to ensure their systems were ‘fit for purpose’.  Following publication of the SCR, further correspondence will take place to remind education settings of the recommendation and good practice in recording.      THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   15  RECOMMENDATION RESPONSE  Recommendation 5 BSCB should be assured by the CCG that there is a locally agreed written pathway and/or process for accessing appropriate support for children who express thoughts of self-harm or taking their own life which is in line with the ‘I Thrive’ principles.  Further assurance should be provided to BSCB by the CCG of the steps taken to increase awareness and publicise the pathway to stakeholders, including children, parents and practitioners.  BSCB member agencies should provide evidence to BSCB that they have promoted the pathway/process within their service The final draft of the revised pathway for accessing appropriate support for children who express thoughts of self-harm or taking their own life is in progress.  The final draft is incorporating feedback from multi-agency consultation.  The pathway is compliant with I-Thrive principles and reflects the emotional health help and support available to children and their families in across both the voluntary sector and statutory services in Bolton. The pathway will be rolled out from December 2019 and its implementation and impact will be have a first evaluation by October 2020.     THIS REPORT IS EMBARGOED BY BOLTON SAFEGUARDING CHILDREN BOARD UNTIL 10.00AM ON 24 OCTOBER 2019.  AS SUCH INFORMATION FROM THIS REPORT CANNOT BE PUBLISHED, REFERENCED OR DISSEMINATED IN ANY WAY UNTIL AFTER THIS DATE AND TIME   16  Appendix 1  Family Genogram – As known to the SCR Panel              