Death by drowning of a 10-month-old baby girl in May 2012. Mother stated she briefly left her infant unsupervised in the bath and pleaded guilty to involuntary manslaughter. Family were known to a number of services, including: police, health visitors, social care, probation services and Cafcass. Issues identified include: failure to recognise the impact of parents' mental health, domestic abuse and substance misuse issues on children; and professionals basing decisions on parents' self-reported information and a simplistic perception of the woman as the survivor and the man as the abuser. Uses an approach which engages with the systems methodology. Recommendations include: incidents of children being left home alone must be treated as a child protection issue; all appropriate family members should be included within risk assessments; and the LSCB should ensure that families receive early help and that this help is monitored and evaluated.
      
 Title:  Serious case review: Child G: overview report. LSCB: Nottingham City Safeguarding Children Board Author: Hayley Frame Date of publication: 2015  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                          1  NCSCB / Child G / Publication January 2015             Serious Case Review  Child G   Overview Report Submission Copy   STRICTLY CONFIDENTIAL       Independent Author: Hayley Frame   Independent Chair: Jenny Myers  Date: January 2015  2  NCSCB / Child G / Publication January 2015   Contents        Page No  1. Introduction                 3  2. Methodology                3                  3. Contextual Information               8  4. Genograms               9  5. Summary of Information Known to Agencies and                 10  Agency Involvement in Respect of Child G  6. Contribution and Views of Family Members                           35              7. Analysis including Themes arising from the SCR            35        8. Changes in Practice and Actions Already Taken                52  9. Conclusions               55  10. Recommendations             56  11. Glossary                60                          3  NCSCB / Child G / Publication January 2015   1. Introduction 1.1. Serious Case Reviews are always carried out by a Local Safeguarding Children Board (LSCB), when a child dies and abuse or neglect is known or suspected to be a factor in the death. This procedure is laid out in the NCSCB Safeguarding Children Procedures and is in accordance with the expectations set out in the Government guidance, ‘Working Together to Safeguard Children’ 2010.  1.2. Under this guidance, the purposes of Serious Case Reviews are to:   • Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard children and provide the welfare of children.  • Identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted upon and what is expected to change as a result; and  • To improve intra and inter agency working and better safeguard and promote the welfare of children.   1.3. This report summarises the findings from a Serious Case Review that was established to consider the professional interventions in respect of a child, who will be referred to as Child G, who died as a result of drowning.   Reason for Establishing the SCR  1.4. As a result of Child G’s death, the Nottingham City Safeguarding Children Board (NCSCB) Serious Case Review Standing Panel met on 13th July 2012 and considered her case. The Panel agreed that as abuse and neglect were suspected to have been factors in the child’s death, a recommendation should be made that a Serious Case Review (SCR) be undertaken in accordance with ‘Working Together to Safeguard Children’ 2010. This recommendation was agreed by the NCSCB Independent Chair on 16th July 2012.  2. Methodology   2.1. On 9th August 2012, the Serious Case Review Standing Panel met to consider the scope and terms of reference of the SCR. This was considered and further developed at the first SCR Panel by agencies contributing to the review, the Independent Chair and Author (see appendix 1). Due to the timing of this review, it was agreed with the Department for Education that the Serious Case Review should be undertaken under the guidance within Working Together 2010. In the knowledge of the expected changes to the SCR process however, the NCSCB and SCR panel were keen to embed aspects of systems methodology in to the process and included this within the Terms of Reference.   4  NCSCB / Child G / Publication January 2015   2.2. Individual Management Reviews (IMRs) were requested from the following agencies that had knowledge of Child G:  • Cafcass • East Midlands Ambulance Services • Nottingham CityCare Partnership • Nottingham Clinical Commissioning Group (CCG) for GPs • Nottingham City Council Children and Families Social Care  • Nottingham University Hospitals NHS Trust  • Nottinghamshire Police • Nottinghamshire Probation Service  2.3. It was agreed that NHS Nottingham City would lead the completion of the Health Overview Report. In addition, the following agencies were asked to contribute to the SCR by way of a background information report and/or chronology as their involvement was not extensive and therefore did not warrant completion of an IMR: • Nottinghamshire Healthcare Trust  • Sibling’s Nursery  2.4. Summary information was also sought from agencies in respect of Child G’s parents and older sibling. A summary specifically relating to the antenatal periods for both pregnancies was requested from the Midwifery Service.   2.5. In August 2012, an Independent Chair, Jenny Myers, was appointed to oversee the process. Jenny is a freelance social care and safeguarding sector specialist with 30 years of child protection experience. She has extensive experience of the serious case review process and is an accredited SCIE Learning Together reviewer. She is a qualified and registered Social Worker.  2.6. Also in August 2012, an Independent Author, Hayley Frame, was commissioned to complete the Overview Report. Hayley is an independent safeguarding consultant and as such is independent of all agencies contributing to the SCR. Hayley has 17 years’ experience within safeguarding, as a practitioner and as a manager at various levels, and is a qualified and registered Social Worker.  2.7. In order to ensure that the SCR considered not only what happened but why, the SCR panel agreed to adopt an approach that engaged more in a systems methodology. The aim was to ensure that the SCR process enabled an analysis of what the case might be telling us about the wider multi-agency system to ensure that any improvements had a wider impact and that learning was not just focused around issues that were purely case specific.   2.8. A number of actions were therefore agreed within the SCR process to support this approach, as follows:  5  NCSCB / Child G / Publication January 2015   • IMR authors were invited to the initial SCR panel to develop their understanding of the case, the Terms of Reference and the requirements of the IMRs • IMR authors undertook conversations rather than interviews with staff involved  • The SCR Panel focused on the analysis of the case to develop an understanding of why interventions took place in the way they did and whether this was reflective of the wider safeguarding system.  • The SCR panel identified areas where practice developments were required to ensure lessons are learned from the SCR  • The SCR Panel agreed the learning and the findings of the review and presented these to the NCSCB, through the SCR Standing Panel to enable the development of recommendations that were appropriate to the development of local practice.   Serious Case Review Panel  2.9. The SCR Panel membership was as follows: Jenny Myers Independent Chair Hayley Frame Independent Author Safeguarding Children Lead  East Midlands Ambulance Service NHS Trust Detective Chief Inspector  Nottinghamshire Police Named Nurse  Nottinghamshire Healthcare Trust Service Manager  Cafcass Named Nurse  Nottingham CityCare Partnership Service Manager  Nottingham City Council, Children and Families, Social Care  Named Nurse  Nottingham University Hospitals NHS Trust  Director  Nottinghamshire Probation Service Designated Doctor  Health Overview Report Designated Nurse  NHS Nottingham City Solicitor  NCSCB Legal Advisor Service Manager  NCC, Safeguarding Partnerships (NCSCB) Administrator  NCC, Safeguarding Partnership   The time period over which events were reviewed 2.10. The time period covered by agency chronologies and IMRs for the SCR is from the date of Child G’s birth until the date of her death. Any relevant information from the time preceding the date of birth was summarised. This period was agreed to ensure learning would focus on the specific issues relating to the time leading up to Child G’s death whilst allowing broader issues to be considered within summaries. 6  NCSCB / Child G / Publication January 2015   Terms of Reference 2.11. The scoping of the Terms of Reference identified the following to be examined by the SCR:  • Did the agency have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare?  How did the agency make sure that staff were aware of and using these policies and procedures? • How sensitive were practitioners to the needs of Child G in their work; how knowledgeable about potential indicators of abuse or neglect, and how well informed about what to do if they had concerns about a child’s welfare? Were practitioners appropriately trained / qualified / experienced? • What were the key relevant points / opportunities for assessment and decision making in this case in relation to Child G and her family? Do assessments and decisions appear to have been reached in an informed and professional way? Were the most appropriate decisions made? For example, was there an opportunity to initiate a CAF at any stage?  Can any barriers to decision-making or reasons for lost opportunities be identified?  • How well did actions taken accord with assessments and decisions made? Were appropriate services offered / provided to Child G and her family?  Were relevant enquiries made in the light of assessments?  • Were there appropriate communication and information sharing processes between agencies?   • How well did actions taken accord with information about the family received by the agency?  Were actions always taken when there were opportunities?  Was there appropriate feedback to other agencies involved following actions? • Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability within the family, and were they explored and recorded?   • Were senior managers, or other organisations and professionals involved at points in the case where they should have been? What was in place to ensure management accountability for decision making? Was this sufficient? • Was the work in this case consistent with each agency’s and the SCB’s policy and procedures for safeguarding and promoting the welfare of children, and wider professional standards?  • Were there any organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case?   • Is there evidence of any positive practice by the agency or other agencies? 7  NCSCB / Child G / Publication January 2015    Key Issues  2.12. In addition, it was determined that the following key issues needed to be addressed within the SCR:  • Early intervention and the timeliness of agency involvement • The impact of domestic abuse, mental ill health and drug use on families • The response of agencies to information received and actions taken as a result • The identification and understanding of risk in relation to information received • The sharing of information appropriately and in a timely fashion • Whether the issues identified above have resonance with other similar cases • What the case can tell us about any underlying patterns that either support good practice or create conditions in which problematic practice is more likely. • How the wider multi-agency system is operating now 2.13. The terms of reference and key issues are addressed through the combination of the Overview Report, Health Overview Report and IMRs. SCR Panel Process and Timetable 2.14. The SCR Panel met on 5 occasions. The initial meeting was to provide an overview of the case and agree with both IMR authors and panel members the process to be used and the expectations in relation to reports and panel meetings. Further panels considered the IMRs; discussed the case in full to analyse the information presented; considered the findings of the SCR and established the learning.   2.15. Throughout the SCR process, quality assurance of the IMRs was undertaken by the SCR Panel; the SCR Panel Independent Chair; Independent Author and NCSCB officers.  2.16. A Project Plan has been maintained throughout the SCR to ensure clear deadlines. Any changes to these, including completion and submission dates have been communicated to the NCSCB Independent Chair and the Department for Education.    Parallel Processes and Investigations (updated section) 2.17. The criminal investigation in respect of Child G’s death has now concluded. Her mother pleaded guilty to involuntary manslaughter and was given a two year suspended sentence. The mother stated that she briefly left Child G unsupervised in the bath and it was there that she drowned. 8  NCSCB / Child G / Publication January 2015   2.18. The Coroner has made a decision not to reconvene the inquest into Child G’s death having reviewed the SCR Report, the strategic and agency specific action plans.   Overview Report Structure  2.19. The Overview Report provides a summary of the information contained within the IMRs, ensuring that key events and issues are captured and analysed. Author’s comments are set out in bold.   2.20. The analysis in Section 8 includes a summary of the author’s comments, analysis of the case against the Terms of Reference and identified key issues and the themes that have emerged from this SCR. The conclusion provides the overview text of these learning points and outlines the priorities for action.  2.21. There have been a number of developments and actions already taken and these are set out in Section 9 prior to the conclusions and recommendations of the Overview Report.  3. Contextual Information  3.1 At the time of interventions in relation to this case, Nottingham City had the following demographics. Nearly 60,000 children and young people under the age of 19 years were living in the city which equalled to 21% of the total population of the city. Nottingham City was the thirteenth most deprived local authority area as assessed by the index of multiple deprivation, with 64% of children classified as living in poverty. The city also had high levels of health inequality including smoking, obesity, cardio-vascular disease and mental ill-health.   3.2 The city has a compact boundary within the wider Nottingham conurbation, resulting in uniform but high levels of demand for services across all areas of the city. In relation to the area of the city where Child G’s extended families were based, one of the wards in this area is within the 10% most deprived in the country and only one ward is in the top 60% or above.   3.3 In relation to domestic abuse support and services in the city, key milestones in the development of specialist services and best practice in Nottingham have progressed alongside national developments, or at times, developed ahead of these in terms of provision and practice. Nottingham has had the Women’s Aid advice line and refuges since the 1970s and Rape Crisis and the first refuges for black women opened in the 1980s. In 1989, Nottinghamshire Domestic Violence Forum (NDVF) was launched and Nottingham City Council established its first Domestic Violence Policy Officer post in 1999. Following this, the first free phone 24 hour helpline in the UK was developed to ensure that survivors and agencies had access to advice, support and refuge.   9  NCSCB / Child G / Publication January 2015   3.4 From 2000 until 2012, Nottingham City Council and partners have developed needs assessments, policies, good practice, strategies, task and finish groups and delivery groups in respect of domestic abuse and its various cross cutting themes, seeking to develop a joint perspective on domestic abuse and to improve partnership working.   3.5 A number of units and posts have been developed to support this, including the Police Domestic Abuse Support Unit, Probation’s Perpetrator Programmes and Women’s Support Services; (previously known as Integrated Domestic abuse programme IDAP, and now called the Building Better Relationships BBR).  One of the first specialist domestic abuse nurses in the UK, followed by one of the first specialist domestic abuse nurses based in the Emergency Department.   3.6 The Voluntary Sector has developed new initiatives such as healthy relationship work in schools (GREAT project), training for the statutory and voluntary sector on domestic abuse awareness and working with perpetrators. Good practice for work with male victims and disabled survivors were developed and outreach services and support services for children were developed (Stronger Families). Nottingham also has a Specialist Domestic Violence Court (SDVC), Multi Agency Risk Assessment Conferences (MARAC) and Sexual Assault Referral Centre (SARC). These initiatives lead to the deployment of Independent Domestic Violence Advisors (IDVAs) and Independent Sexual Violence Advocates (ISVA’s).   3.7 The development of the Domestic Abuse Referral Team in 2012 (DART) and the planned development of the Multi-Agency Safeguarding Hub (MASH)1 in 2013 build on the work of the MARAC’s and should have a positive impact on partnership working and outcomes for survivors of domestic abuse and their children. The development of Integrated Offender Management (IOM) teams within Probation and the Police to manage perpetrators of domestic abuse should lead to improvements in holding them to account and in survivor safety.    3.8 The NCSCB / NSCB Domestic Violence Policy and Practice Guidance, with the “Domestic Abuse, Stalking and Harassment and Honour based violence (DASH 2009) Risk Model plus Referral Pathways for use in Nottingham and Nottinghamshire” was launched in September 2008 and updated in and re published in June 2011. This guidance was for use in all agencies.    3.9 In 2011/12 Nottingham City Council’s Children’s’ Social Care Duty and Screening Service responded to over 12000 contacts and referrals. The Screening Team takes 50,000 telephone calls per year.                                             1 See addendum on page 61 for updated position in respect of MASH.  10  NCSCB / Child G / Publication January 2015      4. Genogram   4.1 Genograms were developed for both the maternal and paternal families and were used within the SCR process to enable an understanding of the complexity of the family dynamics and functioning. The genograms have not been included within the SCR Overview Report in order to protect the identity of the family.  5. Summary of Information Known to Agencies and Agency Involvement in Respect of Child G   (Author comments are highlighted in bold)  Information of Relevance prior to the Scoping Period: 5.1. M was briefly known to Child and Adolescent Mental Health Services as an adolescent. This followed two attempted overdoses which were deemed to be impulsive acts. Following the first overdose in 2006, M was assessed by a psychiatrist who concluded that there were no apparent mental health issues. She was referred to CAMHS for follow up but her parents did not make contact to arrange an appointment. Following a further overdose in 2008, a self-harm assessment management plan was completed and it was concluded that M was at high risk of further self-harm and medium risk of suicide. A follow up appointment was offered with CAMHS but M did not attend and when contacted, refused further contact.   5.2. In 2009, M reported to the Police that she had experienced domestic violence and sexual abuse from her boyfriend (not F). M was assessed as being at medium risk of harm. The case was discontinued by the CPS due to insufficient evidence. The following year, the same boyfriend was convicted of harassment against M and given a restraining order preventing further contact.   5.3. The GP records for F indicated that he took an overdose in 2009. He was referred to the Adult Mental Health Service by his GP in 2010 who had requested assessment of whether F had an underlying learning difficulty and possibly ADHD. F was seen for a mental health assessment in September 2010, where he identified that he was living with M and their child, Child G’s older sibling, then aged under a year old.  F disclosed having poor concentration and paranoid thoughts, and would accuse M of being unfaithful. He was subsequently referred to the ADHD Service. In his initial appointment, F spoke of hearing voices in his head telling him that M had been unfaithful and then later finding this to be true. He also disclosed experiencing images in his head about hurting others. F denied acting on his feelings of anger. Further follow up appointments were offered but not attended by F until 11  NCSCB / Child G / Publication January 2015   February 2012. A full assessment of whether F did have ADHD was never completed.   5.4. F is known to the criminal justice system for offences relating to theft and possession and supply of drugs including cannabis, anabolic steroids and cocaine. He received a 2 year Community Order in 2010 following a conviction, to which he pleaded guilty, for intent to supply Class B drugs.   5.5. The Police made contact with the Safeguarding Children Information Management Team (SCIMT) on the 11th November 2010 in order to report a verbal incident between M and F that had occurred on 8th November 2010.2 The Police had assessed M to be of medium risk of harm from F and it was recorded that the abuse was becoming more frequent and getting worse. F was also described by M as exhibiting controlling behaviours. The Initial Contact was logged by Social Care as being ‘seeking/giving information’ and no action was taken.   5.6. On 22nd June 2011, M contacted the Police to state that F had pushed her down, and that she was nine months pregnant. Despite having called the Police herself, M terminated the call and the Police made extensive efforts to find her. When seen by the Police, M admitted to having exaggerated the incident in order to get a quicker response from the Police. DASH forms3 were completed by the Police and the Police recorded that the incident was reported to the Social Care Emergency Duty Team, by way of a message being left on 22nd June 2011, although it is recorded within the Social Care records that this notification was received by email on 25th July 2011.                                              2 The Safeguarding Children Information Management Team (SCIMT – formally known at the Child Protection Register) are located under the Nottingham City Safeguarding Children’s Board and based in the Quality Assurance arm of the service. This Team will deal with safeguarding checks from other agencies and will log information onto the Social Care database, but will only make referrals onto the Screening and Duty Team if they have safeguarding concerns. At the time of this case, the local protocol was that the Police would log incidents of domestic abuse deemed to be standard and medium risk with SCIMT. Where there were 3 notifications, this would trigger a referral to Social Care. These arrangements have now been superseded by the creation of the Domestic Abuse Referral Team (DART).  3 NCSCB inter-agency practice guidance in relation to children and domestic violence contains the DASH risk assessment tool and it is stated that: Practitioners are expected to use the DASH Risk form in all cases of suspected DV in order to assess the level of risk and determine the course of action.   • Explain purpose to the survivor   • Ensure safe and private space with enough time to complete the form (not in front of the children)   • If in doubt record concerns and use professional judgement   • Use the classification grid to determine whether the survivor is at high, medium or standard risk  12  NCSCB / Child G / Publication January 2015    Summary of Information during the Scoping Period: 5.7. Child G was born in July 2011. She was the second child born to M and F who were then in their early twenties M breast fed Child G initially and no concerns were noted during the early post natal period.   5.8. When Child G was 15 days old, an Initial Contact was made to the Social Care Screening and Duty Team by the Police, in respect of the incident on 22nd June 2011. The Social Care record stated that the children had been seen by the Police and there were no concerns reported. The Social Care entry was closed, stating ‘needs met at point of contact’. No further checks were made.   First Incident of domestic abuse reported within the scoping period although it had actually occurred just prior to the scoping period, and second Initial Contact made to Social Care.  5.9. On 26th July, M failed to take Child G to a newborn baby check with the GP. Three days later, the health visitor conducted a home visit and both M and F were present.  Child G was reported to be breast feeding well on demand. No concerns were raised.  5.10. On 1st August 2011, Child G was seen by the GP due to vomiting after feeds which was felt to be a reflux issue. A further appointment with the GP in relation to this on 4th August 2011 was not attended. However on 5th August, Child G was seen by the Health Visitor who reported a good weight gain and that Child G was now being bottle fed and a thickener was being used for reflux as prescribed by the GP. The Health Visitor was aware of the domestic abuse incident on 22nd June 2011, having received notification from the Police via the Health Safeguarding Team, but recorded that she was unable to discuss it as F was in the room. The family were invited to the clinic for future weight checks.   5.11. On 13th August 2011, M called the Police reporting that someone was trying to break into her house. She reported that F was outside her property and that 2 males were trying to rob him. Police attended and F reported that he had been robbed of personal items and threatened by the unidentified males. The Police were concerned that the incident was as a result of a drug debt and F was suspected to be under the influence of drugs at the time of the incident. Whilst at the scene a small amount of cannabis was recovered by the Police in a car parked on the driveway which M stated was for her own personal use. M was given a cannabis warning. The attending Police Officer, when interviewed, could not recall seeing either of the children during the incident, which happened outside of the property and late at night.   5.12. The following day, F attended Unpaid Work as part of his Probation requirements and informed staff that he had a back injury. He also reported to have fallen from his bicycle and possibly broken his hand. The supervisor who saw the injury commented in the records that it 13  NCSCB / Child G / Publication January 2015   looked bad. F also reported that he had been robbed at knife point by two youths. F was sent home and advised to go to hospital.  5.13. On 16th August 2011, M called the Police alleging that F had assaulted her by pouring hot kettle water over her. She declined an ambulance. She reported that the two children were present in the house.  The Police Officers attending the property described M as being extremely aggressive towards them and uncooperative. She was also reported to be screaming abuse at F. It was noted that M had a slight red mark on her back, bruising around her arms and a black eye. There was no report made of an injury sustained from hot water and M stated that all of the injuries had been caused by F the previous week, apart from the red mark to her back which she stated F had caused that day.  F was arrested for a domestic related assault. During interview F denied all allegations and stated that the red mark had been caused during an argument when he had spun round and caught M. Again DASH forms were completed by the Police and it is recorded that these were faxed to Children’s Social Care and the Health Safeguarding Team on 18th August 2011, after the Police Domestic Abuse Support Unit (DASU) had assessed M as being of medium risk of harm. The case was reviewed by the CPS who concluded that there was insufficient evidence to charge F. Although F was on a Community Order at this time, no contact was made with Probation Services following his arrest.   Second incident of domestic abuse reported within the scoping period.  5.14. On 17th August 2011, F attended Court for a review of his Probation order. F told the court that he had been robbed at knife point for his gold chains and that the knife was held to his throat. He stated that the Police had been called but the offenders had not been caught.  5.15. Child G was not brought for her 6 week check with the GP on 19th August 2011.   5.16. On 24th August 2011, it is recorded by Social Care that an Initial Contact was made by the Police following the incident on 16th August 2011 (although the Police records states that the information was faxed on 18th August 2011 as indicated at 5.13 above). The Initial Contact stated that ‘there is a history of violence that M has never reported to the Police. This is not the first injury M has sustained.  M sustained a scolding mark where hot water has been poured. M is frightened that he will do it again. F threatened to hurt M’s family’. It is recorded that the Police have deemed M to be at medium risk of harm. Despite this, the Screening and Duty Team record this as ‘needs are met at the point of contact’.   No follow up enquiries were made by Social Care despite the Initial Contact containing information that would suggest a serious assault. The rationale for this is not recorded. Given this 14  NCSCB / Child G / Publication January 2015   was the third Initial Contact made by the Police to Social Care in respect of domestic abuse, in a family with two very young children, a far more robust response should have occurred, including liaison with the Health Visitor and a recommendation for the CAF process to commence given that this was a case of medium risk.   5.17. M was seen by her GP on 25th August 2011 regarding contraception and was given a depo injection. 5.18. Also on 25th August 2011, the DASU information in respect of the incident on 16th August 2011 was received by the Health Safeguarding Team. 5.19. Later that day, at 22.58pm, F called the Police stating that M had been trying to kill herself all evening. He stated that he had been trying to stop her from hurting herself with knives and was requesting help, stating that they had two young children with them. F reported that M kept trying to attack him but that he did not feel that the children were at risk. The Police attended the home and M was taken to the Police station. No offences were disclosed and no injuries seen. M stayed at an alternative address that night, returning home in the morning with a follow up visit by the Police being made. DASH risk assessment forms were completed and M was deemed to be at the level of medium risk.  DASU informed Social Care and the Health Safeguarding Team. Third incident of domestic abuse reported within the scoping period. The medium level of risk applied to M although it was F who reported that M was trying to attack him.  5.20. The Health Visiting records stated that on 31st August 2011 the Health Visitor received information from the Health Safeguarding Team that a Domestic Abuse Risk Assessment had been completed by the Police following the incident on 16th August 2011. A High Support File was opened by the Health Visitor.   High Support Files should be opened for any family where:  • The case is open to Social Care as a child protection/ child in need or Looked after Child • An infant is on the Care of Next Infant Scheme (following sudden infant death of a sibling) • There are any existing concern regarding a child or family and the case does not meet the threshold for social care intervention or the case is closed by social care.  Each open file is discussed at 3 monthly supervision sessions held between the named Safeguarding Children Nurse Specialist and the Health Visitor. The CityCare Pathway for Responding to Domestic Abuse Incidents states that following the first reported incident of domestic abuse that is assessed to be of medium risk, consideration should be given to opening a High Support File 15  NCSCB / Child G / Publication January 2015   and/or a CAF. In Child G’s case, this was the second reported incident of medium risk that the Health Visiting Service were aware of.   Given the accumulation of concern, and a pattern of behaviours becoming apparent, it is not recorded why a CAF was not considered at this point as well as a High Support File being opened in respect of the family. The Health Visitor stated in interview that she thought a CAF was not appropriate as she perceived herself to be the only agency involved in the case. The involvement of the Police and the GP would have meant that this was not the case.   5.21. A further Initial Contact was recorded by Social Care on 1st September 2011, from the Police, following the incident on 25th August 2011. It was recorded that F had contacted the Police to report his concerns that M had been trying to kill herself all night. The outcome recorded by Social Care was that needs were met at the point of contact. Despite this, the following day a duty Family Support Worker contacted the Health Visitor for Child G. The Health Visitor reported that she last saw the family on 5th August 2011 but due to the presence of F had not discussed domestic abuse with M. The Health Visitor agreed to arrange to see M and to update Social Care if she had any concerns.   This was the forth Initial contact made by the Police to Social Care in respect of domestic abuse. Child G was by this stage still only 6 weeks old. Although it was agreed for the Health Visitor to see M, a joint visit between the Health Visitor and a Duty Social Worker would have been more appropriate given Child G’s and her sibling’s young age, vulnerability and a picture emerging of increasing concern. It would appear that no discussion took place between the Family Support Worker and the Health Visitor regarding commencing a CAF or regarding the risk to which the children might be exposed given the number of reported incidents of domestic abuse.   5.22. On 6th September 2011, the Health Visitor visited the family home and saw M, Child G and her older sibling. It was recorded that M needed to make a further appointment for Child G’s 6 week check with the GP. The Health Visitor discussed the recent domestic abuse incident and M stated that she and F were not really in a relationship and that she wanted him to move out of the family home. The Health Visitor discussed the impact of domestic violence upon the children and it is recorded that M was aware of the need to protect herself and the children. The outcome of this visit was fed back to Social Care who took no further action.  The status of M and F’s relationship is not clear at this stage and there is no record of any discussion taking place regarding how best to support M in her wish for F to leave the family home.  16  NCSCB / Child G / Publication January 2015    5.23. On 21st September 2011, M contacted the Police to report that F had been to her home address and smashed the glass in her door. The Police were unsuccessful in their attempts to speak to M until the following day, when M changed her account and stated that F had not caused any damage and had not smashed any glass. The Police officer did note some minor damage to the door. F was present at the address and the Officer noted that M was not forthcoming with information. No offences or injuries were disclosed or observed and M refused to cooperate with the completion of the DASH risk assessment forms. Both Child G and her sibling were seen and deemed to be safe and well. The Police assessment was that M was deemed to be at medium risk of harm. It is recorded that the Social Care Emergency Duty Team were informed that day and that DASU notified the Health Safeguarding Team and Social Care.   Fourth incident of domestic abuse reported within the scoping period. The risk assessment completed by the Police is likely to have been affected by M’s lack of cooperation which in turn is likely to have been influenced by F’s presence.   The Police’s account of informing the Social Care Emergency Duty Team that day does not feature within the Social Care chronology. The Domestic Abuse Support Unit (DASU) notifications made to Social Care and the Health Safeguarding Team were not received until 26th October 2011 (see below) so over a month after the event. The reason for this delay was due to a backlog of referrals being processed by the Police DASU.  5.24. On 13th October 2011, F failed to attend an appointment with the ADHD service. F was written to, asking for him to contact the service if he required a follow up appointment. However, there is no further contact until 9th February 2012.   5.25. On 18th October 2011 it is recorded within the GP notes that the parents have separated and that F had taken some valuables from the property which led to the involvement of the Police.  This information came as a result of the Health Visitor visiting that day and M having told her that she and F had separated due to F’s infidelity. M stated that F had gained access to her home and had taken valuables and money so she was to change the locks. The Health Visitor gave her a domestic violence card and it is recorded that M was aware of the need to protect herself and the children.   This was the fifth incident of domestic abuse that the Health Visitor was aware of, yet she did not discuss the case with Social Care (as per the CityCare Pathway for Responding to Domestic Abuse Incidents) and nor did she seek advice from the Health Safeguarding Team or the Specialist Domestic Abuse Nurse within the CityCare partnership. A referral to Women’s Aid would 17  NCSCB / Child G / Publication January 2015   have been more appropriate than providing M with a domestic violence advice card. Although it is noted that M was aware of the need to protect herself and the children, it is not clear whether the Health Visitor herself understood the risks, especially given that the risk post separation is known to be significant in cases of domestic abuse.   5.26. Also on 18th October 2011, the paternal grandmother contacted the Police to report having received abusive texts and Facebook messages from M. This included threats to smash windows and to not feed the children. A Police Officer visited both the PGM and M as a result. The Officer saw the harassing text and Facebook messages received by PGM and when later interviewed for the purposes of this SCR, could not recall having seen any that concerned threats to not feed the children. M had refused to allow the Officer to view her sent messages. It was determined that M and F had recently separated and that there were disagreements in respect of property issues.   Of note, was that the Officer visited M twice that day, the second visit being that evening, and on both occasions Child G was observed to be in a car seat on a kitchen work surface although it is not recorded whether this was raised with M as a concern.  5.27. By 20th October 2011, it is recorded in the GP notes that Child G has still not had her 6 week check or first set of immunisations. A subsequent appointment for the 6 week check on 25th October 2011 was not attended by M.  5.28. On 26th October 2011, the Police made a further Initial Contact to Social Care. The Initial Contact was in respect of the incident on 21st September 2011, so again almost a month after the event. The Initial Contact was recorded as ‘seeking/giving information’ and no further action was taken.   Some of the Initial Contacts were taken by the Duty and Screening Team and others by SCIMT. It is therefore not clear how judgements regarding whether the Initial Contact was for information only or required further action were made.   The Police’s expectation was that the information shared would enable Social Care to assess that information against their records; inform decision making regarding interventions and inform the Police of any further data held which may impact on level of risk currently allocated by the Police assessment.   What is evident is that by now the Social Care database had five records of domestic abuse in respect of this family, 4 of which had been made within a 3 month period. Given that two very young children were living within this environment, it is evident to the Author that an Initial Assessment should have been 18  NCSCB / Child G / Publication January 2015   completed. The Initial Contacts appear to have been viewed in isolation, and no consideration given to the risk to which the children may or may not be exposed.   5.29. This same incident is recorded within the Health Visiting notes and it is recorded that the Police determined the situation to be of medium risk.   As per the CityCare Pathway for Responding to Domestic Abuse Incidents, this should have led to the Health Visitor having face to face contact with M and the children within 2 weeks of the notification. There is no evidence of the Health Visitor seeing M and the children until 23rd January 2012, three months after the incident. There is no evidence of liaison with Social Care or consideration of a CAF.    5.30. At 8.44pm on 7th November 2011, the ambulance service was contacted by the maternal grandmother requesting an ambulance as F had ‘chucked M through a car window’ and that there was a lot of blood. MGM was not with M at the time of the call and therefore could not answer any questions with regard to M’s condition.  M’s sister and father were believed to be at the scene with M. A fast response paramedic was dispatched to M and the Police were notified of the incident. Upon arrival at the scene, M refused treatment, refused to be taken to hospital and refused to sign the form to say she would not travel to hospital. It was recorded by the ambulance crew that it was a brick that had been thrown through the car window. No injuries were observed to M. This was also confirmed by the Police who did not see any visible injuries apart from bruising to M’s upper arms. Witnesses reported having seen M throw items at F and F was seen to have pushed M to the ground. Efforts were therefore made to locate F in order to arrest him. DASH forms were completed and M was deemed to be at medium risk of harm.   Fifth incident of domestic abuse reported within the scoping period.  5.31. At- 11.20pm, the Police referred the matter to the Social Care Emergency Duty Team. It was recorded that M and F had been throwing things at each other and that the children were present. M was pushed to the ground. The EDT Social Worker recommended that further assessment was required due to the accumulation of incidents. An Initial Assessment was therefore opened for follow up by the day time team.   5.32. However the following day the Team Manager abandoned the Initial Assessment and requested that checks were completed with health professionals regarding the potential for a CAF to be undertaken. A Duty Family Support Worker then spoke with the Health Visitor and M by telephone. M stated that she and F had separated and he had come to the property at 7pm to see the children. She allowed him into the 19  NCSCB / Child G / Publication January 2015   property and an argument ensued and F pushed M to the ground when she asked him to leave. M stated that she and the children were due to move and although agreeing to support from a children’s centre, asked for this to be put on hold until she had moved and settled into her new property.  5.33. It is recorded by Social Care that the Heath Visitor would monitor the situation and discuss a CAF/children’s centre referral once the family had moved and settled. The Heath Visiting records stated that M declined children’s centre input, which appears to be in reference to Social Care’s conversation with M, and that Social Care were to send her information with regard to domestic abuse services. It is recorded by the Health Visitor that the case is now closed to Social Care.   This was the fifth incident of domestic abuse reported to Social Care by the Police within less than 4 months. Given the escalating nature of concerns, and the vulnerability of the children involved, an Initial Assessment would have been a proportionate response rather than considering the CAF process. However, in interview the Team Manager stated that a response from a specialist service at that stage did not seem commensurate with the low level of risk. This raises questions with regard to recognition and understanding of risk.   In addition, given that the Health Visitor was aware that Social Care were not going to take any further action, it is not recorded why a CAF was not considered, or, if there was disagreement with the Social Care decision to close the case, why this was not escalated by the Health Visitor. It would appear from the records that Social Care had the expectation that the Health Visitor would start a CAF but that, conversely, the Health Visiting records stated that Social Care had discussed extra support with M but that this was declined.   5.34. It is recorded that on 9th November 2011, the Family Support Worker was unable to contact M by telephone so a letter was to be sent to her advising her of the need to protect and safeguard her children from further violent behaviour. This letter is not on the file. An email is received from the Police that day which detailed that M wished to retract her statement following the incident on 7th November 2011. It was reported by the Police that M gave an inconsistent account of this and previous incidents. It was also reported that M maintained that she was separated from F but that he stated that he was still living in the family home.   The information received which indicated that there was a possibility of an ongoing relationship between M and F, plus M having retracted her statement, should have led to a review of the Social Care decision to take no further action. Sending a letter to the suspected victim of domestic abuse presents the potential of 20  NCSCB / Child G / Publication January 2015   further risk to the recipient and does not support any assessment or intervention.   5.35. Also on 9th November 2011 M took Child G for her 6 week check, albeit 11 weeks late. An appointment for her immunisations was made for 11th November although M did not attend this. On the same day, 9th November, F saw the GP and spoke of feeling low and having problems with M whom he felt had bipolar disorder. F was prescribed medication for his low mood, including an antidepressant and a night sedative. It is noted that he was already being seen by adolescent psychiatry for possible ADHD.   It is noted within the IMR that the GP did not explore any alternative approach to helping F and was very swift to medicate. It is not recorded whether the GP spoke to F about the impact of his low mood and problems with M upon the children.   5.36. On 16th November 2011, it is recorded in the City Care High Support File that following the last domestic abuse incident an assessment of medium risk was determined by the Police following the incident on 7th November 2011.   There is no evidence of further action as a result of this information.   5.37. On 17th November 2011, F was arrested by the Police in respect of the incident on 7th November 2011. During interview he stated that injuries sustained by M would have been caused by him trying to defend himself. By this stage, M had retracted her statement and in light of this the CPS deemed there was insufficient evidence to charge F with assault. The case was weakened by the conflicting accounts and the fact that M was actively involved.   5.38. The ambulance service were contacted by M on 24th November 2011, who stated that F had been assaulted and had a deep cut to the back of his head plus other cuts to his hands and blood from his nose. M and F denied knowledge of the assailant. A fast response vehicle was dispatched to the property. The property was described as smelling of cannabis. No children were seen during the visit.  F declined to go to hospital and analgesia was given by the ambulance crew. The Police were notified of the incident by the Ambulance Service and attended the address. F stated that he had been assaulted by an unknown male. F refused to provide a witness statement or assist with the Police investigation.   5.39. On 1st December 2011, at 01.33am, the Police were contacted by a member of the public as a female who was later identified as M had driven a car into his parked car. The caller believed that M was under the influence of alcohol. The Police tried to locate M at her home address and at both sets of grandparents, all of which proved negative. 21  NCSCB / Child G / Publication January 2015   It became apparent that M was missing and concerns were raised about the whereabouts of the children. As a result of these concerns, the Police forced entry to the home address and found both children at home alone, in their bedrooms. The children were taken into Police Protection and placed with their paternal grandparents. The Social Care Emergency Duty Team was informed but did not open s47 enquiries in respect of the children despite them having been taken into Police Protection. Instead, they opened a Initial Assessment.   5.40. It was reported to the Police by the paternal grandmother that M has sent F a picture message that night of her hanging herself. M was eventually found by the Police and arrested for unlawfully taking a vehicle, driving whilst unfit through drink or drugs and child neglect. It was recorded on her custody record that M had informed staff that she was ‘unwell and needs help as she is struggling to cope’. M denied having left the children at home, stating that F had been at the address when she left. She also denied taking the car without permission, stating it was F’s, but admitted to causing the accident, giving false details to a member of the public, having no insurance and driving with a provisional licence. M’s behaviour was described as problematic whilst in custody, including refusing to sign documents, ignoring officers, shouting abuse and throwing a meal up the walls of the cell. M was given Police bail to return on 11th January 2012.   5.41. When interviewed by the Police, F stated that he and M had a volatile relationship and that he was trying to leave. He gave an account of where he had been that evening which was confirmed verbally by a male associate although this person refused to provide a witness statement. F reported receiving a number of text messages from M throughout the evening including threats to harm herself and that she had crashed his car. M’s phone was seized by the Police although it was not examined by the Police. The management of this investigation is subject to an internal police review by the Police Professional Standards Department.  Within Nottinghamshire Police, cases of child neglect are dealt with by the specialist Child Abuse Investigation Unit. However this did not happen in this case as it was agreed that divisional Police would deal with the matter. The reason for this decision was due to the circumstances of the neglect i.e. it appeared that the children had been left on only one occasion and the house was clean and tidy with evidence of food, toys and clothing.   Once children are taken into Police Protection, this is an automatic trigger for s47 enquiries to commence. This is set out within the Children Act 1989:  Section 47(1) of the Children Act 1989 states that: Where a local authority: 22  NCSCB / Child G / Publication January 2015   (a) are informed that a child who lives, or is found, in their area is the subject of: (i) an emergency protection order; or (ii) is in police protection;  (iii) has contravened a ban imposed by a curfew notice imposed within the meaning of Chapter 1 of Part 1 of the Crime and Disorder Act 1998; or (b) have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or likely to suffer, significant harm:  the authority shall make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare.  It is therefore evident that this significant and serious incident reached the threshold, as set out in statute, for a Section 47 investigation on two levels: firstly, the children were made subject to Police Protection, and secondly, the children were at risk of significant harm due to the fact they were left home alone for a number of hours. The Emergency Duty Team did not commence s47 enquiries and in interview the Emergency Duty Team Manager stated that he believed this was missed as the Police had managed the whole investigation, and because the Emergency Duty Team only offers an immediate response in emergency situations until full services are available with the opening of daytime services. On reflection however, the Team Manager acknowledged that rather than opening an Initial Assessment, s47 enquiries should have been opened.    5.42. The following morning, the Screening Team Manager asked a Duty Family Support Worker to establish the whereabouts of the children and whether F was to seek custody of the children. The Team Manager did not open s47 enquiries.  In interview, the Screening Team Manager stated that she understood that the children were to remain in the care of the paternal family and did not open s47 enquiries based on a belief that the children would not be returning to M’s care, as at this point it was M who was perceived to be the risk. The failure to open s47 enquiries would appear to be a significant error in judgement. Had s47 enquiries been opened, this would have ensured that a joint strategy discussion with the Police took place; the case would have been allocated to a qualified Social Worker and a Core Assessment completed. None of this happened.  5.43. The Initial Assessment was allocated to a student Social Worker. She was assisted and supervised by a qualified Social Worker. Together 23  NCSCB / Child G / Publication January 2015   they visited M and F separately and spoke with both sets of grandparents. The children were seen with F at the home of the paternal grandparents.   5.44. During the Initial Assessment, F stated that he was visiting a friend at the time of the incident and did not know that the children had been left at home alone. He stated that he had received a number of text messages from M threatening to kill herself if he did not go round to her house. A picture message showing M holding a noose to her neck was seen by the Social Worker. He stated that he then received a text a midnight threatening to leave the children at home alone. The Paternal Grandmother expressed her concern that M had mental health issues.   5.45. M, when interviewed, stated that F had been at home with her and the children and that she had gone out to buy cigarettes when she had the car accident. She stated that it was therefore F who had left the children.  In interview, the Social Worker stated that s47 enquiries were not opened due to the fact that the children were safe in the care of their paternal grandparents. Since the children were not at risk, the Social Worker believed that a child protection investigation was unnecessary. She also stated that she was not aware that powers of Police Protection had been used by the Police which is of concern as this in itself would have contributed to the failure to instigate a s47 enquiry.  5.46. The following day, it was agreed by Social Care that the children could return to the care of M as she was going to stay with the maternal grandmother, who was viewed as being a protective factor. There was no formal risk assessment made and there was nothing in place to formalise this in terms of a written contract.  There appeared to be confused thinking in respect of process as s47 enquiries were not opened due to a belief that the children were safe in the care of F and the paternal grandparents, yet only the next day were returned to M’s care. There is little documentation of the Initial Assessment focusing upon the risk to the children, instead the focus appeared to be upon who was responsible for leaving the children alone. The Social Worker was also of the view that F was the more worrying parent as he was violent, controlling and had not supported M in her care of the children. She did not feel that M presented a significant risk to the children, based on her assessment and on information provided to her by the Health Visitor. So within the space of one day, F rather than M was now perceived as the risk with very little explanation for why this change occurred.  5.47. On 6th December 2011, the paternal grandmother informed Social Care that M had now moved back into her own home with the children. The Social Worker advised the student social worker to contact M to 24  NCSCB / Child G / Publication January 2015   determine whether this was the case or not. She made two unsuccessful attempts to contact M by telephone, one on 6th December and one on 7th December. This development was not added to the Initial Assessment which was completed on 8th December and recommended no further action.  5.48. When reviewing the information presented, the Duty Team Manager noted that significant information was missing from the Initial Assessment regarding which parent left the children at home alone.  She requested that there be further liaison with the Police regarding their examination of the mobile phones and that only if there is no evidence to suggest the mother left the children home alone should the case be closed.   The fact that the children had reportedly returned to the sole care of M should have prompted a vigorous response from Social Care, including a home visit. No assessment of risk was completed and the information was not added to the Initial Assessment record that was presented to the Duty Team Manager for closure, recommending no further action. The information presented to the Duty Team Manager stated that the children were still residing with M at the home of the maternal grandmother.  This episode demonstrates how dependent a Team Manager is upon the information presented to him or her as often they have no direct meetings with families themselves, although it is the role of the Team Manager to ask critical questions of Social Workers. For the social work student and Social Worker overseeing her to omit from the Initial Assessment record the possibility that the children had returned to the care of M, is not only a practice error but indicates a lack understanding of risk. It was suggested by the Social Care representative that this error was due to individual poor practice as had the Social Worker raised the issues with the Team Manager, a different course of action would have ensued.  In the context of a family with two very young children, where domestic abuse had been reported on 5 occasions within the past 4 months, and there is evidence of concern regarding M (the picture message viewed by the Social worker, her driving a car under the influence, her behaviour within the Police station, the indication that it was she who left the children at home) this was a significant failure to assess the risk to which the children were exposed. In addition, there was minimal engagement with F. A core assessment as was required under s47 enquiries would have ensured a more robust response.  The Duty Team Manager in interview stated that when the case came over from the Screening Team Manager, she was not aware that Powers of Police Protection had been used. This was recorded by the Emergency Duty Team in the case notes 25  NCSCB / Child G / Publication January 2015   however. The Duty Team Manager agreed that on reflection there was enough concern to warrant s47 enquiries even without Police Protection.  5.49. The paternal grandmother contacted the student social worker on 9th December 2011 to express concern that M was sending F text messages including pictures of the children crying. Also that day maternal grandmother informed the student social worker that M and the children were residing with her in the day but returning home to sleep at night.   In interview the Social Worker stated that she believed that M provided a good level of care and that it was F who was the unsuitable parent, despite the lack of engagement with F. On this basis she did not follow up the change in circumstances as she believed M to be a good carer. Given that it was still not known which parent had left the children at home alone, this should have acted as a challenge to the positive assessment of the mother. 5.50. On 12th December 2011, the student social worker contacted the Police for an update on their investigation and left a message. This was followed up the next day with an email to ask whether the mobile phone checks had shed light on which parent had left the children. The Police Officer investigating the case did respond by email to the Social Worker on 14th December 2011 providing an update, including the need to interview F plus advising of his duties for the forthcoming period.   5.51. On 16th December 2011, M made an ex parte application for a non-molestation order. Applications for a Prohibited Steps Order and Residence Order were made at the same time.  The applications contained allegations dated 1st December 2011 of F alleged threats to take the children from M’s care and details of F’s drug history.  In addition it also alleged that in November 2011 F and his new partner slept in the same bed with the two children.  Further, it alleged that since 2nd December 2011 F had made constant threats by text to M including that if she left the area he would break her legs and remove the children.  5.52. A Non–Molestation Order was made on 16th December 2011 by a District Judge that day and the matter was listed to be reconsidered on notice on 22nd December 2011 once F had been served notice and a copy of the application.  An Interim Prohibited Steps Order was also made.  5.53. At the hearing on 22nd December 2011, M and her solicitor attended.  However, F did not attend.  The District Judge made a Non-Molestation Order on the basis that he was happy that F had been given due notice of the application and the Order was made for six months until 22nd June 2012.  This is a usual duration for a Non-Molestation Order. With 26  NCSCB / Child G / Publication January 2015   regard to the applications for a Prohibited Steps Order and Residence Order, these were adjourned until 9th February 2012, pending the outcome of Cafcass safeguarding checks. The interim Prohibited Steps Order was renewed to 9 February 2012.  5.54. On 30th December 2011, the case was closed to Social Care without them having knowledge of the outcome of the Police investigation.   5.55. On 31st December 2011, M informed the Police that she has taken out a harassment order against F but that he was constantly telephoning her. The control room contacted M who told them that she no longer wished to make a complaint. She stated that F had people after her and that she was too afraid to leave the house. M then terminated the call. Police Officers visited M’s address where she showed them a valid Non-Molestation order issued on 22nd December 2011 with powers of arrest should F contact M. No mention of the children was made in the recordings. Despite the Police’s efforts to locate F, he was not arrested until 7th March 2012. The Social Care Emergency Duty Team were informed of the breech on the day that M reported it but no action was taken.   5.56. On 2nd January 2012, Cafcass received a copy of the Court Order made on 22nd December 2011 where they were ordered to complete a Schedule 2 letter. Cafcass received copies of M’s application for Residence and Prohibited Steps Orders on 10th January 2012. They did not receive a copy of the application for a Non-Molestation Order.  Courts send copies of all applications made under Part 2 of the Children Act 1989 to Cafcass. Non-Molestation Orders are made under Part 4 of the Family Law Act 1996 and so are not routinely sent to Cafcass. Upon receipt of applications, Cafcass is required to: • Inform the court of possible risks of harm to the child in accordance with its safeguarding framework.  • Carry out safeguarding enquiries, including checks of local authorities and police, and telephone risk identification interviews with parties. • Report the outcome of risk identification work to the court prior to the first court hearing; this hearing is called the First Hearing Dispute Resolution Appointment (FHDRA).  • The outcome of Cafcass’ risk identification work is reported to the court in the form of a letter known as a Schedule 2 letter. The Schedule 2 letter is the form by which the outcome of the safeguarding enquiries is reported to the court. The Schedule 2 letter generally comprises: • A summary of Cafcass’ screening actions and outcomes. 27  NCSCB / Child G / Publication January 2015   • A summary of telephone risk identification interviews undertaken with each party and any telephone calls with other professionals. • Factual issues arising from screening or risk identification. 5.57. F attended an appointment with his probation officer on 4th January 2012 and informed her that he was now single and that M was not letting him see the children. He also shared details regarding the home alone incident. The probation officer then contacted the Police and Social Care to obtain further information.   5.58. On 10th January 2012, the Social Worker and student social worker again requested an update from the Police regarding their investigations.  This was despite the case having been closed to Social Care. There is no further recording in relation to the incident within Social Care records.  5.59. Also on 10th January 2012, Cafcass screened M’s application for a Residence Order and Prohibited Steps Order that they had received that day. Cafcass requested safeguarding checks from Police and Children’s Social Care as part of the screening process.  5.60. On 11th January 2012, the probation officer contacted the Police and was informed that M was likely to be charged with child neglect.  Had Social Care known about the possibility of M being charged with child neglect, it is reasonable to assume that they may have reviewed the case. To close a case requires Team Manager authorisation, and it is not recorded why this occurred when the outcome of the Police investigation was still unknown and the actions identified by the Team Manager had not been completed.   5.61. The Health Visiting records stated that on 11th January 2012, information was received from the Police of a domestic abuse risk assessment of medium risk having been completed on 31st December 2011 as F was ringing and texting M and being abusive towards her.   5.62. Child G was seen at home by the Health Visitor on 23rd January 2012, 3 months since the last visit. It was reported that M and F remained separated; that F is not having contact with the children and that there is a Non Molestation Order in force. Child G had still not been immunised, and neither had her older sibling. M reported that she was not happy with the booking system for appointments. The Health Visitor gave M information about how to change GPs. There was no recorded discussion regarding referral to a Children’s Centre.  5.63. The following day F attended his probation appointment and stated that he should have attended Court the previous day with regard to the Non Molestation Order but received the letter late. He stated that he was to contact his solicitor regarding contact with the children. 28  NCSCB / Child G / Publication January 2015    5.64. On 26th January 2012, Cafcass reviewed the information that they had gathered and noted that F had drug related and domestic violence related offences and that M had an impending prosecution for an act of cruelty to a child under 16 years4, despite M having asserted that it was F who left the children home alone. The checks undertaken by Cafcass also indicated that Social Care had received 6 referrals from the Police – 4 in relation to domestic violence, one in relation to M’s attempts to kill herself and the final one following the home alone incident. The Cafcass Family Court Advisor contacted Social Care that day and was informed that the case was closed in December as M and the children were living with the maternal grandmother and thus she was a protective factor. It was also shared that Social Care were awaiting information from the Police about text messages and alleged threats from F towards M.    Social Care gave incorrect information to the Family Court Advisor in that it was stated that M and the children were living with maternal grandmother. It is probable that this information was derived from the Initial Assessment that had not been updated. This information exchange was likely to have led the Cafcass Family Court Advisor to understand the children’s living arrangements to have been assessed as safe by Social Care.   5.65. On 31st January 2012 Cafcass completed the Schedule 2 letter and recommended to the Court that the Local Authority were the appropriate agency to ‘assist the Court further in respect of risk management and any conclusion as to residence and possibly contact’. The Cafcass IMR states that the Schedule 2 letter does not explicitly advise that the Local Authority should undertake a s75 report but the phrase is one which is often used to advise that a s7 report should be undertaken.                                              4 When an individual is arrested for an offence the Police National Computer (PNC) is updated which will state there is an impending prosecution and advise for what matter. This does not mean that an individual has been charged or is due to appear at court. 5 A s7 report is a report ordered under Section 7 (1) of the Children Act 1989 which states that: A court considering any question with respect to a child under this Act may—  (a)ask an officer of the Service  [i.e. Cafcass]; or  (b)ask a Local Authority to arrange for—  (i)an officer of the authority; or  (ii)such other person (other than an officer of the Service) as the authority considers appropriate,  to report to the court on such matters relating to the welfare of that child as are required to be dealt with in the report.   29  NCSCB / Child G / Publication January 2015   The ADCS6/Cafcass Protocol clarifies when consideration should be given to Children’s Services Social Care undertaking a s7 report rather than Cafcass. The protocol indicates that Children’s Services will generally be the more appropriate agency to prepare s7 reports where: • The child is the subject of a currently open case. • The case has been an open case but within the past month has been closed by Children’s Services [the local agreement with Nottingham City Children’s Social Care at that point was within the last 3 months], save in circumstances in which an initial assessment or s47 enquiries had concluded that there was no need for further action by Children’s Services. • The protocol also makes clear that where a child’s case was closed by Children’s Services more than a month before the date of issue of the court application, Cafcass may propose that Children's Services should undertake the task of preparing an s7 report, but it should only do so with the agreement of Children's Services. The precise nature of the Local Authority involvement was not ascertained by Cafcass. However, the case did not fall into the category where Children’s Services should be asked to undertake a s7 report. No agreement was sought from the Local Authority prior to Cafcass suggesting to the court that Social Care were the appropriate agency to provide the court with further information. In interview the Family Court Advisor stated that she expected the Court to order Social Care to complete a s7 report.  However, and in addition to the Cafcass responsibilities set out above, Section 16A of the Children Act 1989, introduced by the Children and Adoption Act of 2006, requires a Cafcass officer who is carrying out any function in family court proceedings in which Orders can be made under Part 2 of the Children Act, to carry out a risk assessment if he or she has cause to suspect that the child concerned is at risk of harm. The section is drafted so that the Cafcass officer must make a risk assessment and provide the risk assessment to the court if given cause to suspect that the child concerned is at risk of harm. It is therefore not discretionary; it is a duty and does not require a court order, or indeed the court’s permission, to complete that assessment. This was not completed by the Family Court Advisor in this case who was unclear about what should trigger a s16A risk assessment.  5.66. A final Prohibited Steps Order was made in Court on 9th February 2012 although the Residence Order application remained unresolved.  This was a day (Thursdays) where Cafcass are not in court. Neither                                             6 Association of Directors of Children’s Services 30  NCSCB / Child G / Publication January 2015   parent attended the hearing.  Solicitors representing M attended and explained that M had not been engaging with her solicitor and they had no instructions from M for some time.  The solicitor further explained that she had telephoned and spoken to M the previous day and asked her to attend the solicitor’s offices to give instructions prior to the hearing in the morning.  M said that she would not be attending the hearing as she “did not do mornings”. A copy of the Court Order was sent to Cafcass for their records.  5.67. Also on 9th February 2012, F attended an appointment at the ADHD clinic and was seen by a psychiatrist. Within the documentation it is recorded that F had ‘bad thoughts – harm coming to the baby, partner being unfaithful’. A follow up letter was sent on 14th February for F to attend an appointment on 8th March 2012.  5.68. On 23rd February 2012, M contacted the Police stating that she was receiving threatening calls from F and that he was calling her from a withheld number. Attempts were made to see M and she was eventually seen at home that evening. It was reported by the Police Officer that M refused to provide a witness statement and would not assist with completing the domestic abuse forms. She was assessed as being at medium risk of harm although this was subsequently lowered due to the incidents being deemed to be low level non crime verbal arguments. Children’s Social Care and health were notified of this incident of 1st March 2012.   5.69. On 25th February 2012, the Police were called to an incident at the home of the maternal grandparents. Maternal grandfather alleged that his son had been violent towards him during a family party but others present stated that it was maternal grandfather who was at fault. All were described as heavily in drink and all refused to provide statements. M and the children were believed to have been present during the incident. M was visited by the Police at her home address and was reported to be heavily in drink. She alleged that she had been stabbed by her brother and an injury was seen to her arm although the Officers believed it to be an old injury as it was dry and scabbing over. She confirmed that she had been at the party and that the children had been asleep upstairs.  DASH forms were completed with M.   5.70. The Emergency Duty Team were notified of the incident and it is recorded that M and the children were present in the home (although the children were asleep in bed) when a domestic violence incident occurred between the grandfather and his son involving a meat cleaver and a carving knife. M was reported as receiving a superficial cut during the incident and all adults were reported to be intoxicated, bar grandmother who was deemed to be relatively sober and able to ensure the children were taken care of. The Emergency Duty Team Social Worker spoke to M who stated that she would not allow unsupervised contact between the children and their grandfather. It 31  NCSCB / Child G / Publication January 2015   was recommended that there be further assessment due to multiple issues and the high levels of referrals.   This was now the sixth incident of domestic abuse reported to Social Care by the Police within the scoping period. 5.71. The following day, the Screening and Duty Team spoke with M on the telephone and she stated that the children were back at her house when the incident occurred. Housing issues were discussed and it was agreed that a referral to Shine (a housing floating support service for survivors of domestic abuse) would be made. The Family Support Worker making the call recommended that there be no further action by Social Care. The Screening Team Manager asked for follow up check to be made with other agencies to see if they had any concerns. The Family Support Worker spoke again with M, although this appeared to be with regard to housing issues, and also with the Health Visitor. The Health Visitor was appraised of the situation and informed that Social Care were to close the case.  This was an extreme incident however does not appear to have been viewed as such by the agencies involved. This may have been influenced by the lack of significant physical injury, or the Police’s knowledge of the family. However an incident of inter familial domestic abuse, involving a number of family members, weapons and high levels of intoxication and volatility was an extremely risky situation for the children to be within. In addition, M gave conflicting accounts as to whether the children were in the property at the time of the incident or not. It is evident that she was under the influence of alcohol at the time of the incident yet this does not appear to have been viewed as a risk factor. The records do not indicate that the levels of risk were considered or understood by agencies. It is significant that the Emergency Duty Team recommended further assessment and yet again, their recommendation was over ruled by the day time team.   5.72. On 29th February 2012, Child G was seen at home by the Health Visitor. Neither she nor her sibling had been immunised. M was described as warm and responsive to the children.   There is no record of any discussion taking place regarding recent events or the risk to the children or consideration of additional support and/or intervention.   5.73. The Police were contacted on 3rd March 2012 by the paternal grandmother alleging that M had caused criminal damage to her car. M was arrested the following day. M denied the offence and was bailed with conditions to stay away from the paternal grandmother. M was described as uncooperative whilst in custody.  During the risk assessment which is completed when a person is taken into custody, Mother had either selected ‘yes’ or ‘unknown’ to questions regarding self-harm but then refused to answer any questions on the matter. She 32  NCSCB / Child G / Publication January 2015   refused to sign any documentation whilst in custody and was described as being tearful throughout.    5.74. On 5th March 2012, M reported to the Police that F had been sending her messages threatening to kill her, the children and then himself. A Police Officer visited M and saw the text messages containing the threats. F was spoken to on the phone and agreed to hand himself in at the Police station on 7th March 2012. M refused to provide a witness statement regarding the messages she had received from F. It was reported by the Police Officer that M was extremely aggressive towards the Officers who left without the DASH forms being completed.   5.75. The Police then made a further Initial Contact to Social Care on 6th March 2012 in relation to this incident. It is recorded that this was classed as standard risk by the Police and no action was taken to Social Care.  This was the seventh incident of domestic abuse reported to Social Care by the Police within the scoping period.   5.76. F attended the Police station as arranged and was arrested for the offence and also for the Breach of the Non Molestation Order committed on 31st December 2011. F’s account was that he and M were in daily contact with her using the children as a means of getting him to contact her. He admitted sending the text messages which made threats to kill but stated they were sent in an effort to try and get M to stop contacting him. F was bailed with conditions that mirrored the non-molestation order. The Inspector was informed of the incident and raised the risk level of mother from Standard to Medium.  There is no evidence that the amended risk assessment was communicated to any agency.  5.77. On 8th March 2012, the maternal grandfather contacted Social Care to state that F had been making death threats to M and the children via text message. M was reported to have contacted the Police and F had been arrested. The Duty Family Support Worker taking the call advised that this was a Police matter unless M resumed a relationship with F. It was recorded that ‘needs met at point of contact’ and closed to Social Care.   Social Care were aware of the death threats having already been informed by the Police and it is difficult to understand how this was viewed as a police matter only. Social Care identified that the Police had informed them that they were not concerned about these threats and that this had influenced the view that no action was required. In addition, there had been no previous information indicating the children were at risk of physical violence from father.  33  NCSCB / Child G / Publication January 2015   Despite this, death threats, in the context of known domestic abuse and a volatile relationship, should have prompted an assessment by Social Care of the potential risk to the children. It does not appear that this was considered by Social Care. 5.78. Later that day the Health Visitor was contacted by Social Care and information was shared between the two agencies. The Health Visitor asked whether they would be opening the case and she was told that this was unlikely as M was acting protectively and it remained a Police matter.   There was no further discussion or challenge as to whether the case should be open to Children’s Social Care, nor any action taken by Social Care or the Health Visitor to see M. No discussion took place between the Family Support Worker and the Health Visitor regarding the risks to the children given the increasing concerns regarding domestic abuse and the volatility of the parents’ relationship.  5.79. On 14th March 2012, Cafcass reviewed the case file. It does not appear that the Family Court Advisor undertaking this task (a different Advisor to the one completing the Schedule 2 letter) recognised the risk potentially posed by M or that no order had been made for an s7 report, and no order had determined residence. The Family Court Advisor closed the case.  The Family Court Advisor in interview stated that on reflection she should have made a referral to Social Care at this stage.  5.80. Also on 14th March 2012, the Health Visiting records recorded information having been received from the Police with regard to the incident on 5th March 2012 which resulted in a medium risk assessment following M stating that F was sending messages threatening to kill her and the children.   The CityCare Pathway for Responding to Domestic Abuse Incidents states that face to face contact should have been made following notification of this incident. It has been established that that although the information was received by the Health Safeguarding Team from the Police on 14th March 2012, it was not actually sent to the Health Visitor until 9th May 2012, almost 2 months later. This was reported to be due to a backlog of domestic abuse referrals that the Health Safeguarding Team had to process manually. Although the process was not ideal, it was felt to be an improvement from not receiving information at all.  5.81. Child G was not brought to an appointment for her immunisations on 19th March 2012.   5.82. On 23rd March 2012, F was seen by the Police to be wrapping drugs and was arrested for intent to supply cannabis.   34  NCSCB / Child G / Publication January 2015   5.83. On 28th March 2012, F was charged with Harassment Contrary to Section 4(1) and (4) of the Protection from Harassment Act 1997. The charge stated that F had put M in fear of violence between 25th December 2011 and 7th March 2012 and made threats to cause her harm.  F was also charged on the 28th March 2012 with breaching the Non Molestation Order between 26th December 2011 and 31st December 2011.   5.84. On 2nd April 2012 the Health Visitor received safeguarding supervision on the case. It was recorded that there were no concerns regarding M’s parenting and that her family presented as a protective factor. It was queried whether the High Support File could close after the next visit.   Given the recent events, the situation presented by the Health Visitor appeared to be far more stable than what it was in reality. It is difficult to understand why she viewed the maternal family as a protective factor given the recent incident of inter-familiar violence.  5.85. F was seen by the GP on 3rd April 2012, and disclosed that he was due in court the next day due to harassment of his girlfriend. He was prescribed medication for a ‘stress related problem’. F attended Court the next day in respect of the charges identified at 4.85 above. F pleaded guilty and the case adjourned for pre-sentencing reports.  5.86. On 16th April 2012, F was interviewed for the pre-sentencing report. F was described as co-operating fully with the interview and was open about his relationship with M which he described as volatile.  He admitted sending aggressive texts to M but stated that this was in response to her damaging property belonging to his family. Following this interview, the Probation Officer made referrals to DASU and completed a SCIMT Check which revealed a number of referrals in 2011 and 2012 relating to domestic abuse incidents. The Pre-Sentence Report was completed and recommended a 12 months’ Community Order with unpaid work.  Due to the domestic abuse concerns, F was assessed as presenting a Medium Risk of serious physical and emotional harm to M.   5.87. On 21st April 2012, M was charged with threats to commit damage, following her arrest in respect of damage to the paternal grandmother’s car. She pleaded not guilty but was subsequently found guilty and given a 1 year conditional discharge.   5.88. On 27th April 2012, Child G had her 8-12 month check completed during a home visit undertaken by the Health Visitor. With regard to the outstanding immunisations, M stated that she had a needle phobia and that her sister would take Child G for the immunisations. M confirmed that she was about to move house to a different part of the city and remained separated from F who was unaware of her new address. M stated that she had had no recent contact with F although he was due 35  NCSCB / Child G / Publication January 2015   in court soon for breach of the Non Molestation Order. There was no record of the Heath Visitor having explored this further.  5.89. F was convicted on 2nd May 2012 for breach of the Non Molestation Order and was sentenced to 12 months supervision with 150 hours unpaid work.   5.90. On 10th May 2012, at 9.06 am, M made a 999 call stating that ‘my daughter has just fell out of the bath and I went to pick her up and she’s not breathing’. A neighbour was at the property and basic life support instructions were relayed to her. An Emergency Community Paramedic attended, backed up by a double crew ambulance. Child G was taken to the Emergency department and received CPR and advance life support.   5.91. M informed the hospital registrar that Child G was in a bath seat in the bath with her sibling whilst she was folding towels. She heard a scream and saw that bath seat had dislodged and Child G’s face was submerged underwater. She ran to the child but slipped on the wet floor and by the time she reached Child G, she was fully submerged underwater.  5.92. At 10.41am, resuscitation was stopped and Child G was pronounced dead.   6. The Family’s Experience  6.1 Due to the criminal investigation, the SCR Panel were advised by the  Police that it was not appropriate to engage the parents or extended  family during the process of this SCR. The paternal grandparents have  subsequently met with the author on two occasions and had  opportunity to comment on the review findings.   7. Analysis including Themes arising from the SCR and Associated Learning Points  7.1. Analysis of the case against the Terms of Reference:  Did the agency have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare?  How did the agency make sure that staff were aware of and using these policies and procedures?  7.2. All agencies involved in this case have safeguarding policies in place. All agencies offer internal training to ensure that staff are aware of these policies and procedures. In addition, all agencies are governed by NCSCB Interagency safeguarding procedures. However there are a number of occasions where policies and procedures were not complied with:  36  NCSCB / Child G / Publication January 2015   • Social Care did not comply with the legal requirement to open a s47 enquiry when the children were made subject of Police Protection • Social Care did not comply with the agency protocol to open an Initial Assessment following the receipt of 3 Initial Contacts in respect of domestic abuse • Cafcass did not comply with the ADCS7/Cafcass Protocol and nor did they consider a risk assessment under section 16A of the Children Act 1989 • The Health Visitor did not always comply with the CityCare Pathway for Responding To Domestic Abuse Incidents  The reasons given for the failure to comply are variable, and range from lack of awareness, to individual error.  How sensitive were practitioners to the needs of Child G in their work; how knowledgeable about potential indicators of abuse or neglect, and how well informed about what to do if they had concerns about a child’s welfare?  7.3. The SCR has found that the assessments of Child G’s needs, including the appreciation of the risks to which she was exposed, were not robust. There was a failure to recognise the effect of her family circumstances upon her emotional wellbeing. Despite significant indicators of risk, including the trilogy of risk factors that includes domestic abuse, mental ill health and substance misuse, these were not recognised by the practitioners working with the family. The issue of risk assessment is explored in depth below.  Were practitioners appropriately trained / qualified / experienced? 7.4. All health practitioners had completed mandatory training in safeguarding and some had attended training more specific to their role.  7.5. With specific reference to the issue of GP training and their safeguarding knowledge, there has been significant improvement in the delivery of safeguarding training for GP’s over the last 2 years. All GP’s have mandatory training on a 3 yearly basis and access to a yearly safeguarding update. In addition there is monthly GP safeguarding leads training, which is supported by designated and named professionals with input from Service Managers in Social Care. GP safeguarding leads are GP’s who take responsibility in their practice for safeguarding and provide support and advice to practitioners as well as assuring up to date knowledge and practice.  7.6. The Social Care staff interviewed as part of the SCR were all trained and appropriately qualified. The student social worker worked alongside an experienced Social Worker.                                             7 Association of Directors of Children’s Services 37  NCSCB / Child G / Publication January 2015   7.7. The Family Court Advisors within Cafcass were suitably qualified and experienced for their role within the case.  7.8. During their probationary period, all Police Officers receive training with regards to domestic abuse and child protection issues. The training consists of the legislation surrounding these areas and also includes input on local and interagency procedures. All staff interviewed as part of the SCR has received this training. A two day public protection training package was delivered to all Officers in 2010. All officers interviewed have received training regarding completing Domestic Abuse Stalking and Harassment (DASH) forms and have seen a Domestic Violence DVD commissioned by Nottinghamshire Police.  7.9. The employees of the Probation Service involved in the case were appropriately trained for the role.  What were the key relevant points / opportunities for assessment and decision making in this case in relation to Child G and her family? Do assessments and decisions appear to have been reached in an informed and professional way? Were the most appropriate decisions made?  For example, was there an opportunity to initiate a CAF at any stage?  Can any barriers to decision-making or reasons for lost opportunities be identified?  7.10. The key relevant opportunities for a robust risk assessment by Social Care in this case were following the home alone incident and the incident of inter familiar violence. Cafcass had opportunity to complete a risk assessment as part of their involvement but did not comply with this requirement. The Health Visitor could, in line with the CityCare Pathway for Responding to Domestic Abuse Incidents, have commenced a CAF at several points in this case but did not take this course of action. The Police completed a number of DASH risk assessments although these were incident specific and not an assessment of the overall risk posed within the family. The Police were aware however of ever increasing instability within the family unit and this was not escalated within Social Care.  7.11. The Initial Assessment completed by Social Care found that M was a protective parent. It does not appear that this view was reached in an informed manner, on the basis of all of the information available. A Core Assessment, had s47 enquiries been opened, would have been a more in-depth assessment. If all of the relevant background information had been obtained, including liaison with the parents’ GPs and the probation service, and a robust risk assessment completed as a result, a decision may have been taken that the two young children were likely to be at risk of significant harm, and therefore an Initial Child Protection Conference may have been convened. At the very least, there would have been a greater understanding of M’s difficulties and the relationship between the parents. However it is unlikely that the threshold would have been reached that would lead to consideration of both children being removed from their mother’s care.  38  NCSCB / Child G / Publication January 2015   7.12. As it stood, the Initial Assessment took the view that M was a victim of domestic abuse and F was the concerning parent. The Initial Assessment was not updated with the significant development that the children had returned home with their mother. The Duty Team Manager was clear in interview that had she been informed of this she would have insisted on an immediate home visit and a risk assessment being completed.  7.13. The Health Visitor and Social Care view of M as a safe parent appears to have been a barrier to them forming an objective risk assessment. The Police took a different view of M, in that they perceived her to be difficult and aggressive, but this view was not shared with or by the Health Visitor or Social Care. It is clear that the Police had a different relationship with M, in contrast to that of other professionals, and that confrontation and challenge led to M presenting very differently.  7.14.  At no point is there evidence of discussions between agencies regarding risk. Incidents appear to be seen in isolation and not in the context of an increasingly volatile home situation for these very young children.  How well did actions taken accord with assessments and decisions made?  Were appropriate services offered / provided to Child G and her family?  Were relevant enquiries made in the light of assessments? How well did actions taken accord with information about the family received by the agency?  Were actions always taken when there were opportunities?  Was there appropriate feedback to other agencies involved following actions? 7.15. Other than the DASH risk assessments completed by the Police which were incident specific, the only assessment completed within this case was the Initial Assessment by Social Care. This assessment did not adequately address risk, lacked analysis, and did not contain full and up to date information. In addition, only minimal checks with other agencies were made. This is viewed to be due to the time and capacity restraints within the Screening and Duty team, but does mean that Initial Assessments are not often as full as they need to be. 7.16. No action was taken as a result of the Initial Assessment. There is a lack of evidence to suggest that M was regularly offered support services however those that she was offered, she refused. Despite this M was not viewed by the Health Visitor or Social Care as a parent who showed features of non-compliance. This was in contrast to the Police’s view whose contact with M generally ended with her refusal to cooperate with enquiries.  7.17. Within the health services, there is evidence of M disengaging with services i.e. failing to attend GP appointments and appointments for the children’s immunisation and disengaging with the Family Nurse partnership (pre scope). This did not however trigger any level of concern with regard to her parenting of the children.  39  NCSCB / Child G / Publication January 2015   7.18. There is evidence of Social Care feeding back the outcome of their activity to the Health Visitor. There is some suggestion that the Health Visitor was unhappy with the case being closed to Social Care but no  evidence of her escalating concern in this regard. Indeed, it would appear that the Health Visitor did not have significant safeguarding concerns regarding the case, given the children’s and M’s presentation to her.   7.19. Despite opportunities to undertake more robust assessment of the situation (whether that be via CAF, Core Assessment or 16A assessment), these actions were not taken.   Were there appropriate communication and information sharing processes between agencies?   7.20. There is evidence of communication and information sharing between agencies. The quality and purpose of that information sharing is less clear. For example, the Initial Contacts made by the Police to Social Care were often made several weeks after the incident occurring and did not result in any action being taken by Social Care. It is not evident that the Police had reason to update their risk assessment following the sharing of information with Social Care.  7.21. Similarly, the Police notified the Health Safeguarding Team of domestic abuse incidents but most led to no action being taken by the Health Visitor, although the Health Safeguarding Team created additional delays in getting the information to the Health Visitor. This was not in line with the CityCare policy in place with regard to responding to domestic abuse incidents and rendered the information exchange ineffective.  7.22. These notification arrangements have now been superseded by the creation of the Domestic Abuse Referral Team (DART). 7.23. The Social Care Emergency Duty Team recommended further assessment yet their recommendation was over ruled by the day time Team Manager on two occasions.  It is recognised within Social Care that a process should be established whereby the respective Team Managers communicate if they overrule each other to agree any change in action to be taken.  7.24. There is evidence of the Probation Service being proactive in seeking information from other agencies.  7.25. The information sharing between Cafcass and Social Care was problematic in that Social Care gave Cafcass inaccurate information.  7.26. There is evidence of discussions taking place between the Health Visitor and Social Care, but again, how purposeful these discussions were is questionable and at no point was there a recorded discussion regarding risk.  7.27. This is explored further at 7.71.  40  NCSCB / Child G / Publication January 2015   Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability within the family, and were they explored and recorded?   7.28. There is minimal reference to any of these aspects within the agencies involvement with Child G and her family. Were senior managers, or other organisations and professionals involved at points in the case where they should have been? What was in place to ensure management accountability for decision making? Was this sufficient? 7.29. There is evidence of management involvement within the case, in particular within the involvement of Social Care and the Police. Both agencies have established procedures to ensure management accountability for decision making. There are several instances within Social Care involvement where the outcome of management decision making was of concern, such as the failure to open s47 enquiries, however their accountability was never in question. In addition, each closure of the case by Social Care would require management authorisation and as such, the failure to recognise the need for a more in-depth look at the case was not identified by the managers involved.  7.30. There is less information to suggest management involvement within the other agency involvement in the case. However this may be due to there not having been a need for escalation to management level.   7.31. Within the Health Visiting Service there was evidence of safeguarding supervision, although it is not clear how effective this was as there did not appear to be any robust consideration of risk. This was a flaw of the system at the time as the process of supervision was to discuss all cases which did not allow time for reflective practice. This process has now been amended.   7.32. In addition, there is a Safeguarding Specialist Nurse for Domestic Abuse yet professional advice and support was not sought from her or indeed from any of the specialist nurses within the Health Safeguarding Team.  The reason for this was due to the Health Visitor not being worried enough about the case to escalate any concern.  Was the work in this case consistent with each agency’s and the SCB’s policy and procedures for safeguarding and promoting the welfare of children, and wider professional standards?  7.33. 7.2 above identifies instances where policy and procedures were not complied with.  7.34. The NCSCB Interagency Practice Guidance in Relation to Domestic Violence dated June 2011 outlines that standard risk assessments of domestic abuse should result in signposting to Women’s Aid and key services for survivors of domestic abuse. It states that medium risk assessments require a CAF and high risk cases should result in a referral to Children’s Social Care. It is evident that this guidance needs to be reviewed as the risk levels determined by the Police are in 41  NCSCB / Child G / Publication January 2015   respect of the survivor and not the child(ren). Work is required to ensure that the risk assessment tool used can assess the risk to both.  Were there any organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case?   7.35. The SCR has not identified that these issues had a significant bearing upon the management of and decision making in this case. There is nothing to indicate that the Social Care Screening and Duty Team was under resourced or that the Health Visitors caseload was too high. However, there were issues with regard to backlogs of domestic abuse referrals being processed within the Police and within the Health Safeguarding Team. 7.36. The SCR Panel has had wider discussions with regard to capacity within agencies to manage the volume of domestic abuse cases within Nottingham City and whether in comparison to other cases, this family appeared to be of a lower risk and therefore a lower priority.  7.37. It would appear that the agencies involved did not recognise the risks and based their views upon a superficial yet positive view of M’s ability to meet the physical care needs of the children. Issues of capacity would therefore have little bearing in this instance. New processes have been established to manage domestic abuse cases which are explored below.  7.38. Analysis of the case against the identified key issues: Early intervention and the timeliness of agency involvement/ the response of agencies to information received and actions taken as a result 7.39. Nottingham City has adopted a Family Support Strategy which was launched in 2011 alongside Pathway Guidance for Practitioners. Both documents were developed in consultation with key partner agencies across the Children’s Partnership.  7.40. The purpose of the Family Support Pathway is to ensure children and families receive the right help at the right time. It highlights the level of support that may be needed by children and families from universal through to specialist services. The Pathway also highlights the need for good quality assessment processes and evidence based interventions to meet the needs of the whole family. The Common Assessment Framework (CAF) is integral to the effective delivery of the Family Support Pathway, to ensure that the needs of children and families are assessed and identified earlier and that coordinated multi agency action plans are produced and implemented where needed. 7.41. The Family Support Pathway integrates the CAF toolkit and Nottingham City’s Access to (and exit from) Social Care protocols. This reiterates the message that services need to be joined up and work 42  NCSCB / Child G / Publication January 2015   together to provide a continuum of support rather than working in isolation.  7.42. A communication and marketing plan was implemented to ensure effective implementation of the Family Support Pathway to all Children’s Partnership agencies. Family Community Managers continue to host Advisory Boards for partners and members to discuss the new model of working and how partnership working can enhance delivery and improve outcomes for children and families. However this SCR has raised questions in relation to how well implemented the Family Support Pathway is with some frontline staff of partner agencies. 7.43. It is evident from the chronology, as highlighted in section 5 of this report, that there were a number of opportunities for a CAF to be considered in this case. Indeed, it was discussed as a possible intervention following the domestic abuse incident on 7th November 2011. The CityCare Pathway for Responding to Domestic Abuse Incidents identifies that cases of medium risk should be given consideration for opening of a High Support File and/or CAF. Although a High Support File was opened, consideration of a CAF did not occur. The Health Visitor stated in interview that she was not aware of the Family Support Pathway, which would question how effective dissemination has been to front line practitioners, despite the strategic sign up and governance of the Pathway.  7.44. The NCSCB Interagency Practice Guidance in Relation to Domestic Violence dated June 2011 outlines that standard risk assessments of domestic abuse should result in signposting to Women’s Aid and key services for survivors of domestic abuse. It states that medium risk assessments require a CAF and high risk cases should result in a referral to Children’s Social Care. There is less clarity about who should instigate the CAF if the Safeguarding Children Information Management Team (SCIMT) receives the medium risk information from the Police. However, in each instance in this case, the Health Visitor was also notified of the medium risk assessments and therefore it follows that she would have been best placed to instigate the CAF process.  7.45. The Health Overview Report helpfully outlines the benefits of a CAF in this case: Using the CAF as it was intended, that is as a holistic assessment tool, may have offered an opportunity for multiagency working and provided increased support for mother to ensure safeguarding of Child G and [sibling].  It is known there is misconception about the use of CAFs, with practitioners not recognising its use for assessment but rather seeing it as a monitoring tool.  Ongoing work by Nottingham City Clinical Commissioning Group to understand more fully the offering, accepting and refusal of CAFs in health and the outcomes of CAFs is likely to address some of the difficulties. 7.46. The CityCare IMR recognises that the family would have benefited from a CAF and that Team Around the Child meetings would have 43  NCSCB / Child G / Publication January 2015   enabled a holistic assessment of risk and addressed emerging concerns at an early stage.  7.47. The SCR Panel has considered why a CAF was not undertaken when it was appropriate to do and suggested a number of factors that may have influenced this. Agencies represented at SCR Panel accepted from their agency’s experience that the following are valid factors:  • Lack of CAF training across agencies / lack of knowledge about where training is now commissioned from  • Myths about the amount of work CAF entails  • Capacity / lack of resources • A prevailing view that this is ‘someone else’s responsibility’  • Low level concerns being evident in the case and professionals not being worried enough to do a CAF • Resources have been invested in the strategic development for early intervention rather than an increase in practitioner resources  • A lack of understanding of early intervention, specifically ‘who does what?’ • Lack of knowledge of the Family Support Strategy   7.48. It is suggested that the Health Visitor did not consider a CAF as, as far as she was aware, there were no other agencies working with the family. When asked to reflect upon why a referral to the Children’s Centre was not revisited, the Health Visitor stated in interview that M was ‘ok and had a supportive family’. It is evident from the IMR and indeed from the actions of the Health Visitor, that she did not view the mother’s parenting to be of concern and that M presented positively to the Health Visitor. It is likely that this view, as opposed to whether one or more agencies were involved with the family, or any of the factors suggested above, was the strongest influence in not undertaking a CAF.  7.49. This prevailing positive view of M and less favourable view of F appeared to dictate the interventions of the Health Visitor and of all of the involved practitioners within Social Care. It is possible that only the Police were aware of the true volatility of the relationship between M and F who, it would appear, are two highly complex and troubled individuals. The absence of a robust multiagency risk assessment meant that these different viewpoints were not challenged, and the circumstances of the case were not fully understood by any one particular agency.  7.50. The SCR Panel has considered what would happen in the event of similar cases presenting now. It must be noted that the circumstances of the case prior to Child G’s death are not particularly unique, although the circumstances of her death are highly unusual. Whether the recognition of risk would be greater in similar cases now is dependent upon a joined up multiagency response as it is likely that professionals working in similar cases may continue to have differing views of the 44  NCSCB / Child G / Publication January 2015   parents, especially in cases of domestic abuse. The introduction of the Domestic Abuse Referral Team (DART) and the City Domestic Abuse Panel (CDAP) are responses that would be relevant to this case had it occurred today, and are explored below.   The impact of domestic abuse, mental ill health and drug use on families 7.51. It is evident from the Police IMR that incidents of domestic abuse did not always occur in the manner in which was described by M and that her accounts could be inconsistent. There is a suggestion that she was known to exaggerate events and it is evident that she was not cooperative with the Police following incidents of domestic abuse, and could be aggressive and evasive. In this sense, she did not present herself to the Police as a typical ‘victim’.  Despite the frequency of incidents, the risk assessments completed by the Police were never any higher than that of medium risk. This is likely to be due to the incidents being viewed in isolation, as low level, with minor or nonexistent injuries being received, coupled with the mother’s presentation post event.  7.52. Despite 7 Initial Contacts having been made by the Police to Social Care in respect of domestic abuse these were generally recorded as ‘seeking/giving information’ and not deemed by Social Care to be referrals.  By passing on the information however, the Police believed that they were making a referral to Social Care. 7.53. At the time of this case, the local protocol was that the Police would log incidents of domestic abuse deemed to be standard and medium risk with SCIMT. High Risk cases would be a direct referral to Social Care. Where there were 3 notifications to SCIMT, this would trigger a referral to Social Care. This did not occur in this case.   7.54. In addition some notifications were dealt with by SCIMT and some were dealt with by the Screening and Duty Team although all notifications were deemed to be of medium risk. This would appear to be due to the management of domestic abuse notifications to Social Care going through a period of transition where the SCIMT worker responsible for processing the Initial Contacts made by the Police in respect of domestic abuse moved into the Duty and Screening Team.  This occurred so that they could easily discuss any standard or medium risk information from the police that appeared more serious. There is no evidence that such discussions took place in this case. 7.55. It is therefore likely that the Social Care Duty and Screening Team would not have been aware of the Initial Contacts made to SCIMT unless they had specific reason to check the Social Care database. The accumulation of Initial Contacts did not result in a review of the situation by SCIMT or the Screening and Duty Team.  7.56. To agencies such as Health and Social Care, M was viewed as a protective figure and her having obtained a Non Molestation Order was evidence to support this view. Indeed, the Health Visitor had a very different perspective of M to that of the Police, and observed her to be 45  NCSCB / Child G / Publication January 2015   cooperative, welcoming, and entirely appropriate in terms of her interactions with her children.  She was never perceived to be a risk to her children. 7.57. The Initial Assessment completed by Social Care indicated a parent focussed discussion and a reliance on that which was self-reported by M. Assumptions were made that F was aggressive, was harassing M and was controlling of her. The Initial Assessment was found to be detailed and descriptive but weak in terms of analysis and did not contain any information from agencies other than the Health Visitor. Had enquiries been made with the GP or Probation Services, this may have shed light on the parents mental health and drug misuse issues.  Had the Health Visitor and Social Care been privy to this information and the evident trilogy of risk factors in this case, this may have led to a more robust risk assessment.  7.58. In addition, the focus appeared to be upon the domestic abuse incidents, without acknowledging other parenting issues, particularly in relation to the emotional unavailability of the parents to the children. It is clear that there was evidence of neglect of the children’s emotional needs yet a lack of identification and response to this. 7.59. The Heath Visitor did not have any knowledge of M’s prior mental health issues. The incident of M’s attempts to harm herself as reported by F as well as her own comments regarding self-harm made whilst in Police custody, could have prompted consideration of a mental health assessment. This would have been more likely had professionals pieced this information together with the information from her teenage years. 7.60.  There is little evidence within the records to suggest that the Health Visitor and Social Care professionals spoke to M regarding the impact of domestic abuse upon the children. Professionals did urge M to ensure that her children were protected although it is not evident that how she would do this was ever explored with M. There appeared to be a degree of satisfaction with her ability to protect her children based upon her assertions that the relationship with F was over and that she had taken legal action. In addition M’s assertion that the children were not in the same room or were asleep during incidents appeared to satisfy professionals and it is questionable as to whether this reduced the perception of risk. This questions how reasonable it was to expect the mother to recognise the impact of the domestic discord upon her children if the professional themselves struggled to do so.   7.61. The initial view taken by Cafcass was that, based upon the mothers’ application, the case concerned domestic abuse and the mother was the protective parent.  However the enquiries undertaken suggested a potentially different perspective given the mothers’ impending charges of child cruelty. A 16A risk assessment should have been completed but it appeared that the FCA was unclear about what triggered a s16A risk assessment. 46  NCSCB / Child G / Publication January 2015   7.62. The Probation Service was not aware of the issue of domestic abuse, although they were aware of there being relationship difficulties and work on this became one of the supervision objectives. Despite this, there is little recorded regarding M or mention of the children when the home situation was checked.  It was not until January 2012, some two years into their involvement with F, that the probation service became aware of domestic abuse issues following the F’s breech of the Non Molestation Order.  7.63. Since the events of this case, there have been some significant developments in the multi-agency management of domestic abuse. The City Domestic Abuse Panel (CDAP)8 was set up in May 2012. This Panel manages medium risk cases of domestic abuse. CDAP will accept referrals from any partner agencies if it meets the following criteria: anyone who is deemed to be at medium risk of harm due to domestic abuse and has suffered 3 incidents in a 12 month period (as long as they have not been to MARAC or CDAP in the previous 6 months). The CDAP currently have representation from the Police, Nottingham City Homes, Nottingham CityCare Partnership, Children’s Services, Adult Social Care, the Nottinghamshire Healthcare Trust, Victim Support, Shine, and Community Protection. The CDAP meets monthly and covers the North, South and Central localities of the city. Typical actions from CDAP can involve Police Beat Teams getting further information, visits from housing patch managers, joint visits between children’s services and Police, letters to be written to GP's (when there are concerns regarding mental health or alcohol issues) and contact by Victim Support.  7.64. It is evident that Child G’s family would have met the criteria for CDAP and would have therefore benefited from this multi agency collation of information and management of risk.  7.65. The Domestic Abuse Referral Team (DART) was established in June 2012. This multi agency team will deal with cases where a DASH risk assessment has been completed for a vulnerable adult, a pregnant woman or a mother with children.  The aim of the team is to provide a streamlined process that can access multi agency information seamlessly and assess risk in a more timely and coordinated way. The potential outcomes of this service are to refer to CDAP; Family and Community Teams for a CAF; to MARAC or to Social Care for an Initial Assessment. The risk assessments completed in respect of M would now be dealt with via DART. Given that the case met the criteria for CAF and for CDAP, it is envisaged that similar cases would now be provided with a much earlier preventative response, or in cases of repeat notifications (such as this case), a more robust risk assessment would be undertaken in order to determine the threshold for intervention.                                              8 See addendum on Page 61 for updated position in respect of CDAP. 47  NCSCB / Child G / Publication January 2015   7.66. There is currently a monthly DART multi agency sustainability meeting to review the progress of the new arrangements. A decision has been made to review the effectiveness of DART twelve months after implementation (June 2013). Anecdotally the group has received a lot of positive feedback from across the partnership with regard to the new arrangements.  The identification and understanding of risk in relation to information received 7.67. Inadequate risk assessment is a significant feature within this case. This includes identification of risk, compliance with statutory and procedural requirements for a risk assessment to be completed and the rigour of assessments that were completed.  7.68. The home alone incident should have triggered s47 enquiries. It would appear that since the children were in a safe place, professionals did not consider the need to place this within an s47 process nor did they follow statute in relation to responses to children who are made subject of Police Protection. This then meant that a Core Assessment was not completed. The Initial Assessment that was completed was not thorough, did not include all of the multi-agency information available, and lacked adequate risk analysis. Although focus was given to who was responsible for leaving the children at home alone, little regard was given to the risks to which this exposed the children and what it told professionals about the dynamics within the family and specifically within the parents’ relationship. Significantly, no risk assessment was completed when the children returned to M’s care and the Initial Assessment was not updated with this significant development. The assessment indicated that there were no concerns in respect of M; a view formed on the basis of her self-reported information; from discussions with the Health Visitor and from the M’s ability to meet the children’s physical needs. There was insufficient thought given to environmental and parental factors and to what lay behind the presenting behaviours of the parents and what this meant for two very young vulnerable children in their care.  7.69. The Nottingham City Safeguarding children Board (NCSCB) Inter agency practice guidance in relation to children and domestic violence contains the DASH risk assessment tool and it is stated that: Practitioners are expected to use the DASH Risk form in all cases of suspected DV in order to assess the level of risk and determine the course of action.   • Explain purpose to the survivor   • Ensure safe and private space with enough time to complete the form (not in front of the children)   • If in doubt record concerns and use professional judgement   • Use the classification grid to determine whether the survivor is at high, medium or standard risk 48  NCSCB / Child G / Publication January 2015   7.70. Despite this being a multi-agency tool, the DASH risk assessment tool was not used by the Health Visitor or by the Duty Social Workers involved in the case. It would appear that it is not current practice for Social Care staff to use this tool despite the NCSCB practice guidance. Health professionals will generally usually use the DASH risk assessment when a disclosure is made directly to them rather than using it as a dynamic risk assessment tool. When used by the Police, the risk assessment is incident specific and is not a risk assessment of the family in the fuller sense.  7.71. The NCSCB practice guidance provides detailed guidance with regard to how to work with families experiencing domestic abuse in order to protect non abusing partners and children. It does not appear that this guidance was utilised in this case by the agencies involved. 7.72. It has been shared within the SCR Panel that risk assessment and risk management are not key components of the core training within the Health Visiting. Work is going to take place to address this deficit (see section 8). 7.73. Despite the criteria for a 16A Risk Assessment being met this was not completed by Cafcass. It is possible that this assessment, had it been completed, would have been more rigorous than the Initial Assessment as the Family Court Advisor appeared to recognise that the situation may not be that which was presented by M and that she may pose a risk herself to the children. The 16A risk assessment could have acted as a safety net in this case. This did not happen and the Cafcass IMR would suggest that this was a case of practitioner error, although recognises that there has been confusion regarding the use of 16A risk assessments and that this needs to be addressed within the service. 7.74. Understanding of domestic abuse and the risk to infants does not appear to be understood by the professionals involved in the case. In many respects the professionals felt that there was no evidence of negative impact upon the children or risk of harm. This is likely to have been due to the children’s ages where the only outward sign would be with regard to their physical development, which was known to be good. There would not have been evidence of significant harm in relation to their emotional development at such a young age, however research tells us there is an emotional impact for very young children exposed to domestic abuse. In fact, research indicates that infants and toddlers through to age three may be at higher risk of permanent impairment than older children due to the plasticity of their developing brains (Moffatt 2006). This would appear to be a key area for development and training. 7.75. As it stands the multiagency system does not readily allow for the use of expertise or research to predict future harm. Interventions are evidence based, and the difficulty in evidencing emotional harm within infants is a clear inhibitor to full risk assessments. In some respects the wider safeguarding system does not support interventions until children, especially those that are very young, display the impact of significant harm.  49  NCSCB / Child G / Publication January 2015   7.76. Nottingham City Social Care and Family Community Teams have been implementing the Signs of Safety model within their assessment and intervention practice over the last year. The Signs of Safety model is a strengths based approach to child protection work which expands the investigation of risk to encompass strengths and signs of safety to make an overall judgment using a safety scale. It is designed to always undertake risk assessments with the full involvement of all professionals involved and family members. The individual scoring of safety opens up discussions between agencies on their views and differences of opinion to provide a greater understanding of risk. In addition, the Signs of Safety model strives to keep the focus upon the child and their experience of the situation throughout the assessment and planning process through the use of a number of specific assessment tools which require practitioners to provide descriptors of the child’s experiences.  7.77. Signs of Safety would have provided the professionals involved in this case with a clear set of assessment tools for measuring risk and mapping out historical information along with the current circumstances surrounding the children in the family.  It would have enabled professionals to be clear about their worries (risks- past, current and future harm) what was going well (strengths and safety factors); the factors that may make it harder for the  parent to look after the child; the areas that they needed to know more about and what needed to happen. The model would have provided a robust structure for considering differing professional views, ensuring involvement of all family members such as F, and focusing upon the experiences of Child G and her sibling.  The sharing of information appropriately and in a timely fashion 7.78. Although there is evidence of information sharing between agencies, this was not always timely or purposeful. Examples of this include: • The Police DASH Risk assessments were routinely sent to the Health Safeguarding team and the Social Care, but often several weeks after the event. In any case, these notifications did not generally result in action/prompt action being taken by the receiving agency.  Where the notifications were delayed, this may have contributed to the agencies responding with less concern, almost assuming that the crisis had passed. It is clear that this process of information sharing was not fit for purpose and has been replaced via the creation of DART. In similar situations now, the DASH Risk assessment will be forwarded to DART who will decide whether a Social Care referral is required or the initiation of a CAF.   • The Police did not always respond to requests for information from Social Care in a timely manner, and this should have been escalated as a concern within the organisations. • Agencies did not always share the full information that was known to them i.e. the Probation Service  liaised with agencies following the  home alone incident but were not made aware of the concerns in respect of domestic abuse. 50  NCSCB / Child G / Publication January 2015   • Police information sharing with the Probation Trust in connection with community orders was problematic and there was no clear process for the Police to share information with Probation following arrests.  • With regard to the GP, there was evidence of limited discussion about the family taking place between the GP and a Health Visitor at the GP practice’s red card meetings (held in GP practices, red card meetings discuss cases were there are concerns, usually of a safeguarding nature). However the Health Visitor who attended these meetings was not the allocated Health Visitor working directly with the family, as she was not attached to the GP practice attended by the family. The Health Visitor system in place at the time was that Health Visitors were responsible for a geographical area rather than GP attached. There were no direct conversations between the allocated Health Visitor working with the family and the GP. The process has now changed to ensure that each GP has an assigned Health Visitor. Whether this would have ensured information was shared in this case is unlikely given how M was perceived by the Health Visitor.  • The Health Overview Report helpfully identifies that pre scope there was a lack of appropriate information sharing regarding increased vulnerability, for example, previous domestic abuse, overdoses, self-harm, between the GP for F and the Nottinghamshire Healthcare Trust (in respect of GP referrals made regarding F) and the GP for M and Nottingham University Hospitals Trust (in respect of GP referrals made regarding M). It is not clear if the GP recognised the significance or importance of this information in the context of the referrals made.   Whether the issues identified above have resonance with other similar cases. 7.79. The impact of domestic abuse, adult mental health and substance use upon children has been highlighted by a number of Serious Case Reviews nationally. NCSCB has undertaken one previous SCR where this learning was identified in relation to a young child, although the focus of this impact was in the physical risks presented. In this SCR, the emotional impact of the trilogy of risk factors was not acknowledged or understood. These issues present complex challenges for the NCSCB and partner agencies.  7.80. The NCSCB has also undertaken a Significant Incident Learning Process (SILP) for a case where interventions were being provided during the same timescale as those for Child G. The complexity of domestic abuse is highlighted by both cases, identifying a need for practitioners working with families to undertake full assessments informed by all family members. Both cases highlighted the complexity of adult relationships and the need to clearly identify where the risk to children lies.  51  NCSCB / Child G / Publication January 2015   7.81. A lack of information sharing across agencies has also been identified by a number of local and national SCRs and learning reviews. Use of the Common Assessment Framework or a Core Assessment would have enabled information to be shared and understood in a multi-agency framework in all of these cases.   7.82. The recommendations made as a result of this SCR are anticipated to have far reaching implications for all services working with children and families that exhibit similar issues and/or cause for concern.  What the case can tell us about any underlying patterns that either support good practice or create conditions in which problematic practice is more likely. 7.83. A particular factor that has been identified by the SCR Panel has been the young age of children. The children appeared safe, well fed, well cared for and they were unable to tell professionals what their life was like. The focus upon the child and the assessment of the emotional impact of unstable parenting in cases where children are preverbal may well be compromised. 7.84. The perceived status of the case, i.e. not meeting the threshold for CAF or Social Care involvement, alongside viewing incidents in isolation, may have stopped professional inquisitiveness and dulled professional responses. The volume of incidents in this case did not appear to increase concern. Indeed, a rule of optimism appears to have been a significant theme in this case, combined with a lack of challenge to M in particular and a lack of engagement with F. The point at which fathers are engaged by professionals working with mothers who are experiencing domestic abuse, within the context of universal and targeted service provision, requires further consideration by NCSCB.  7.85. Perceptions of the mother and father in this case appeared to have been based on self-reported information and fell very neatly into the stereotypes of the woman as the survivor and the man as the abuser. It was would appear that the dynamics of the relationship were far more complex than this, yet neither parent was effectively assessed in terms of the risk they presented.  7.86. It is clear from this SCR that the Family Support Strategy is not fully embedded within frontline practice. This would question the effectiveness of the Family Support Strategy Implementation Plan. A scorecard has been drafted to enable performance reporting on outputs and outcomes for the Family Support Strategy with emphasis on the section to monitor the ‘Effectiveness of Early Help’.  This will include CAF data. The impact of this reporting upon early intervention has yet to be tested.  Experience of the child   7.87. Child G was a very young child who presented as being well cared for by M. Her physical development was not of concern and her basic care needs were met. However, it is clear from this SCR that Child G was 52  NCSCB / Child G / Publication January 2015   living in an environment characterised by domestic discord and extreme parental behaviours. This is highly likely to have been a very frightening environment for the child, with a lack of predictability of care and comfort. The conflict between the parents will undoubtedly have impacted upon the parents’ availability to meet her needs. 7.88. Research from the Committee on Early Childhood, Adoption, And Dependent Care (as cited by Moffatt 2006) tells us that during the first few years of life a child learns how to cope with his/her environment and these skills become fixed response patterns in the brain. A child who experiences chronic threat can respond with apathy and withdrawal while a child experiencing acute stress may resort to tantrums and aggression. Although Child G was too young to display these behaviours, it is evident from this SCR that she was exposed to highly stressful events.  7.89. Domestic abuse can lead to the parents experiencing stress and these effects could reduce their ability to parent effectively. This can lead to neglect, poor parent-child interactions, and measurable effects in the child’s developing brain. A significant result of stress and/or maternal depression in infancy is its effects on attachment. Even if the child is unaware of violence occurring in the home, the resulting stress could produce results in the infant as if the child had, in fact, witnessed violence. (Johnson, Browne, & Hamilton-Giachristis, 2006). 7.90. More recently, research completed in the United States has indicated that being exposed to arguing parents is associated with the way babies' brains process emotional tones of voice. The study found that infants respond to angry voice tones, even when they are asleep and that infants from high conflict homes showed greater reactivity to very angry tones of voice in the brain areas linked to stress and emotion regulation. According to the researchers, the findings show that babies are not oblivious to parental conflicts, and exposure to them may influence the way babies' brains process emotion and stress (Mikulak 2013).  7.91. The relevance of this research when completing assessments of infants where domestic abuse is a factor cannot be underestimated. It is imperative that practitioners feel empowered to use research as evidence of harm and predictor of future harm when considering the risks posed to very young children whose physical care needs appear to be being met. Identified examples of good practice  7.92. Although some of the IMRs have identified aspects of good practice, it would appear that these are generally incidents of expected practice and procedural compliance.   8. Changes in Practice and Actions Already Taken How is the wider multi-agency system operating now? (May 2013)  8.1. The most significant change now is the introduction of DART as described above. Once DART risk assessments are received by the 53  NCSCB / Child G / Publication January 2015   team, a decision is made regarding whether they require a referral to Social Care or for a CAF to be initiated.  8.2. If, as in this case, it is clear that a CAF is required and the lead professional is likely to be the Health Visitor, this will be logged on the electronic system that underpins health visiting services and entered into a CAF tracker. If the CAF is not actioned within a certain timescale, an alert will be sent to the relevant manager.  8.3. Given that the case met the criteria for CAF, it is envisaged that similar cases would now be provided with a much earlier preventative response, or in cases of repeat notifications (such as this case), a more robust risk assessment would be undertaken in order to determine the threshold for intervention. 8.4. The following bullet points outline the many changes in practice that have now occurred. Within Social Care: • Action has been taken to ensure that where three Initial Contacts are made to Social Care detailing reports of Domestic Abuse, however minor they appear, an Initial Assessment should be undertaken. There is an electronic system in place, which now highlights multiple referrals and contacts in relation to the same family.  • A bespoke training session for the Social Care Duty and Screening team has been developed in respect of risk assessment and the threshold for significant harm. A supervision audit is also to take place given the volume of referrals received by the team and the need to satisfy any concern regarding management oversight.  • All home alone incidents involving young children under 5 years of age will now be managed within the child protection arena and section 47 enquiries should be undertaken unless there are compelling reasons not to do this. If there are, these must be clearly recorded and signed off by a Social Care Team Manager who has oversight of the investigation. This change in practice needs to be embedded within NCSCB procedures and the Family Support Pathway.  8.5. Within Cafcass several local level changes have been made to working practices: • A tracking system to ensure that cases for which hearings take place on days when a duty Family Court Advisor is not in attendance at court are followed up and reviewed. • In those section 8 applications where the court has not followed Cafcass’ advice, the allocated Family Court Advisor  will actively review whether the court’s decision is compatible with Cafcass’ assessment of the safety and welfare of the children and will take any necessary action (in line with the Cafcass Child Protection policy). 54  NCSCB / Child G / Publication January 2015   • Schedule 2 letters need to be written as “stand alone” documents which do not rely on further discussion between the court duty Family Court Advisor and the Judges. • The introduction of “reflective circles” into Team meetings to provide a means of critically challenging practice. These are formal sessions which revisit practice regularly to ensure that pertinent aspects of the work are not overlooked and to reinforce policies and procedures.  • The introduction of small group workshops to develop and refine skills in writing succinct and analytical Schedule 2 letters. • A reminder of Cafcass’ guidance on escalation where, in the Family Court Advisor’s opinion, a Local Authority’s response to a child protection referral leaves a child unsafe (in line with the Cafcass Child Protection Policy). • Nationally, Cafcass Legal Services have issued additional clarification and guidance on s16A risk assessments.  8.6. Within Health:  • GP referrals to secondary care must contain appropriate safeguarding information.  Following a recent Serious Case Review in Nottingham, a referral form to paediatrics has been developed and is due to be implemented.   • Within Nottingham University Hospitals NHS Trust, there has been an increase in staff attending domestic abuse training and significant numbers of staff in the key areas of the Emergency department and midwifery services are trained to complete the DASH risk assessment form. • Improved information management systems have been introduced within CityCare which has enabled access to all patient electronic records, both adult and child, if they are known to a CityCare service; more streamlined information sharing where safeguarding concerns exist and the development of a CAF tracker as outlined above.   • Changes to the previous model of safeguarding supervision within CityCare have already occurred but this is an on-going process over the next 6 months. Newly Qualified Health Visitors continue to discuss all their safeguarding families at supervision in order to build confidence and competence in managing safeguarding cases.  Experienced practitioners are now encouraged to bring 3 or 4 cases for an in depth discussion and analysis, in the expectation that this will empower practitioners to transfer the learning to cases with similar issues and facilitate the opportunity to reflect on the emotional impact of managing these cases. • The CityCare Domestic Abuse Nurse Specialist is developing a RAG rating system which will enable practitioners to prioritise DART information. Once information regarding a Domestic Abuse incident is placed on a child’s record, the relevant team is sent a task to let them know that there is information that needs attention. A quarterly 55  NCSCB / Child G / Publication January 2015   audit is being completed which dip tests a number of incidents to ascertain the action taken by CityCare staff. • As part of the Safeguarding review that CityCare began in October 2013 following a request by NHS Nottingham City, additional resources have been requested to facilitate the development of a CAF service.  The service will maintain a database of CAF’s, provide support to health practitioners regarding the CAF process and monitor the CAF tracker. • CityCare have recently reviewed all essential training and devised a new training matrix and are now working to develop ‘core’ skills associated with individual roles and the introduction of risk assessment skills for practitioners working with complex families. • The lead commissioner for Children’s Services in Nottingham City Clinical Commissioning Group is currently reviewing IT systems within the health community to ensure pertinent safeguarding information is easily accessible and documented clearly in each health record.    8.7. Within Probation:  • The domestic abuse policy has been reviewed and re-launched with a particular emphasis on home visits and info sharing.  • A new Quality Assurance framework has been developed through which practitioners' work is quality assured through case file reviews, observations, line and peer supervision and reflective supervision.  9. Conclusions: 9.1. The outcome of this case was not only tragic but highly unusual. However the characteristics of the case, in particular issues of domestic abuse, substance misuse and concerns regarding mental health are very similar to those raised in a number of other Serious Case Reviews.   9.2. Within this case there was a prevailing sense of chaos and parents that were preoccupied with their own needs and the ongoing difficulties within their relationship. Although there was evidence of some good parenting skills, it is likely that this preoccupation took their focus away from the care of their children and led to the parents, and especially the mother, acting unpredictably. Assessment skills and supporting tools need to be sufficiently developed to enable recognition of these factors and for appropriate protective action to be taken.   9.3. The SCR has identified that there was a failure to recognise the combined impact of the parent’s relationship, their mental health history, potential substance misuse and the level of violence and conflict that the children were facing. Despite mounting information and evidence of concern, professional responses were superficial and incidents were viewed in isolation. There were occasions where practitioners failed to comply with procedural requirements and 56  NCSCB / Child G / Publication January 2015   information sharing lacked purpose. There were several occasions, in particular that of the home alone incident and the inter-familial domestic abuse incident, that should have triggered a far more robust response. There were numerous indicators that something was amiss and yet decisive action was not taken to safeguard the children.   9.4. This appeared to be due to the agencies responsible for the children having made a hypothesis regarding M and not wavering from this view despite information to suggest the opposite being known to them. A lack of professional curiosity led to light touch interventions and the absence of an adequate multiagency risk assessment compounded this position. There were very many occasions that should have triggered an assessment of need or assessment of risk. Linked to the lack of risk assessment was a failure to understand the impact of domestic abuse, chaotic relationships and unpredictable parenting upon young children and to see beyond their physical presentation.   9.5. The systems in place at the time did not assist in the management of concerns or support the effective sharing of information.  It is clear that the different agencies involved all had valuable information that would have informed an effective risk assessment of the family. This information was never pulled together and as such, the hypothesis made regarding the family remained unchallenged.   9.6. The implementation of the DART in June 2012 has led to significant developments in the management of children experiencing domestic abuse within Nottingham City. The evaluation of DART due in June of this year will hopefully provide assurance to NCSCB that processes are improving agency responses and therefore outcomes for children.   9.7. The challenge for NCSCB and partner agencies now is twofold: firstly to ensure that risk assessments for the most vulnerable age group of children are robust, effective and research based, and secondly, that practitioners are appropriately skilled and confident to undertake them.   10. Recommendations 10.1. Each agency that has undertaken an Individual Management Review has developed recommendations and Individual Action Plans for their agencies. These are included within the Combined Action Plan and the implementation of these is being monitored through the Serious Case Review Standing Panel of the NCSCB . 10.2. As agreed within the scope for this SCR, the analysis of the case enabled consideration of the wider multi-agency system in which agencies were operating at the time of Child G’s death. The learning from the case was presented to the SCR Standing Panel to enable them to consider the issues within the broader work of the NCSCB and partner agencies and make appropriate recommendations that would support this work. As a result, the recommendations made are aimed 57  NCSCB / Child G / Publication January 2015   at system change rather than being case specific. The main areas of work required and the recommendations are as follows: The management of cases where children are left home alone.  10.3.    Significantly in this case, two young children were found home alone in  the middle of the night but this did not result in a robust assessment or understanding of the risks within a child protection framework. Whilst there is no evidence to suggest there are wider system failures, the NCSCB Strategic Board wanted assurance of this.            The management of domestic abuse  10.4.  The SCR Standing Panel and NCSCB Strategic Board agreed that as a number of reviews undertaken locally have highlighted areas for development in relation to the management of domestic abuse, these should be considered together. The specific findings of this review were in relation to the need to understand the dynamics of parents relationships; the impact of this on the children and a full assessment of where the risks lay. In addition, there was a delay in sharing information about domestic abuse and a lack of response as a result of the information being shared, along with a focus on individual incidences without taking an overall view of the situation and potential risk. Whilst the implementation of the DART is seen to be having a positive impact on all of these issues further assurance of this is required.          SCR Recommendation 1: Incidents of children being left home alone, or those where powers of Police Protection are used must be managed within an appropriate safeguarding framework, therefore: • The NCSCB Safeguarding Procedures are to be updated to clarify the risks associated with young children being left home alone and the appropriate action to be taken as a result • Awareness raising on the responsibility to initiate Section 47 enquiries when powers of Police Protection have been used will be undertaken. • Nottingham City Council Social Care are to provide assurance to the NCSCB on the management of other home alone incidents / cases where powers of Police Protection are used.   SCR Recommendation 2: To ensure a full review and development of robust responses to domestic violence, the NCSCB consider the learning from this SCR alongside the learning from all local Domestic Homicide Reviews and SCRs where domestic abuse is a feature. The focus should be on the development of: • Consideration of the effectiveness of the Domestic Abuse Referral Team (DART) and the impact of this on outcomes for children and young people • A robust model and supporting tools for domestic abuse to ensure the risk to children, young people, vulnerable adults and families is identified and managed.  • Consideration of how to engage with and assess offenders of domestic abuse and developing links between the DART and Nottinghamshire Probation. 58  NCSCB / Child G / Publication January 2015   Early Help and thresholds for intervention  10.5.  The SCR has identified that, in line with the Nottingham City Family Support Strategy, this family should have been supported within a model of early intervention. A Common Assessment Framework should have been undertaken to allow a full assessment, information sharing and multi-agency interventions to take place. The NCSCB has new responsibilities under Working Together 2013 in relation to the monitoring and evaluation of early help and the development and publication of a threshold document. The SCR Panel and NCSCB agreed that further implementation of the Family Support Strategy and Common Assessment Framework was a requirement of this work.         Development of assessment practice across all agencies 10.6. A thorough, robust assessment, taking into account historical issues  and perspectives of all family members would have supported appropriate interventions in this case and helped practitioners understand the children’s lives and the risks presented to them. The NCSCB Strategic Board agreed that the development of assessment practice must be considered alongside the implementation of the Common Assessment Framework and the Signs of Safety model that have been agreed as the tools to be used by all NCSCB partner agencies in Nottingham City.               SCR Recommendation 3: In implementing Working Together 2013, the NCSCB should consider the governance of the Family Support Strategy and Pathway with a view to ensuring it is fully implemented across all partner agencies. In addition, the Children’s Partnership Board must undertake an evaluation of the impact and effectiveness of early help to report to the NCSCB.   SCR Recommendation 4: The Signs of Safety approach is adopted by all NCSCB partner agencies and embedded into practice across the partnership. Within this and further implementation of the Common Assessment Framework, practice across all partner agencies is developed to support practitioners working with complex families particularly in the following areas: • Inclusion of all appropriate family members within an assessment, including specific consideration of the child’s perspective  • Using historical information, evidence, research and analysis within assessments   • Understanding the trilogy of risks, and any cumulative concerns and the impact of these upon children    59  NCSCB / Child G / Publication January 2015   10.7.  A Strategic Action Plan has been agreed that provides the detail on  how these recommendations will be implemented to ensure that services are developed as a result of the learning from this case. This will also be monitored through the NCSCB SCR Standing Panel, with further assessment of the evidence and impact on practice being undertaken by the NCSCB Quality Assurance Group.    References  Moffatt, G (2006) Childhood exposure to conjugal violence: Developmental considerations and consequences for behavior and neural development. Johnson, R., Browne, K., & Hamilton-Giachristis, C. (2006). Young children in institutional care at risk of harm. Trauma, Violence & Abuse, 7, 34-60. Mikulak, A (2013) What Sleeping Babies Hear: A Functional MRI Study of Interparental Conflict and Infants’ Emotion Processing"                       60  NCSCB / Child G / Publication January 2015     Glossary of Terms  Term  Definition  SCIE  Social Care Institute for Excellence LSCB Local Safeguarding Children Board NCSCB Nottingham City Safeguarding children Board SCR Serious Case Review IMR Individual Management Review NDVF Nottingham Domestic Violence Forum  SDVC Specialist Domestic Violence Court MARAC Multi Agency Risk Assessment Conferences SARC Sexual Assault Referral Centre IDVA Independent Domestic Violence Advocate DART Domestic Abuse Referral Team MASH Multi Agency Safeguarding Hub IOM Integrated Offender Management DASH Domestic Abuse, Stalking and Harassment, Honour Based Violence  CAMHS Child and Adolescent Mental Health Services SCIMT Safeguarding Children Information Management Team DASU Police Domestic Abuse Support Unit EDT Emergency Duty Team FHDRA First Hearing Dispute Resolution Appointment CSC Children’s Social Care CDAP City Domestic Abuse Panel FCA Family Court Advisor NUH Nottingham University Hospitals SILP Significant Incident Learning Process ADHD Attention Deficit Hyper Activity Disorder   61  NCSCB / Child G / Publication January 2015     Addendum to SCR Report – January 2015 The following points should be considered in respect of the content of this     report. 1. With reference to point 3.1 the development of a Multi-Agency Safeguarding Hub (MASH) planned for 2013. Nottingham City has made a decision not to join the MASH at this stage, but to continue to operate our local arrangements through DART. These arrangements have been subject to a comprehensive review and evaluation with positive findings. In addition these arrangements received positive comments in our Ofsted inspection and have further strengthened our position not to join the MASH at this stage.   2. With reference to point 7.63 The City Domestic Abuse Panel (CDAP) was set up in May 2012. This panel is no longer in operation as this work is covered by the Domestic Abuse Referral Team (DART)  