Serious injuries to a 20-month-old boy in 2018. Child L and his half-brother were made subject to an interim care order. Learning includes: there was no shared understanding of mother's learning needs or her emotional needs, and there were differing perceptions of her; when extended family are providing support it is important to balance the strengths alongside the risks and to understand the nature of the relationships between family members; all behaviours must be viewed as potential trauma and the impact of this trauma on the lived experience of the child. Recommendations include: to build on the multi-agency understanding of risk for children under a child in need plan to include dynamic risk assessments and challenge from partner agencies; to explore how a list of children on a child in need plan can be shared with the multi-agency safeguarding network; ensure that private pre-schools and nurseries are meeting the required standards of safeguarding, and to consider raising the issue with Department for Education to bring private providers under the same guidance as statutory services.
      
 Title:  Report of the serious case review regarding Child L. LSCB: Hertfordshire Safeguarding Children Partnership Author: Ann Duncan Date of publication: 2021  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.                                               Report of the Serious Case Review Regarding Child L    Author: Ann Duncan                 26 October 2021    2  Contents    Circumstances that led to this SCR                                                        Page 3  Terms of Reference   Page 4  Brief Summary of the Case                               Page 5 - 8  Areas of Practice Learning   Page 8 - 16   Conclusion and Recommendations                                                        Page 17   Appendix 1: Acronyms                                        Page 18   Appendix 2: Methodology                                   Page 18 – 20  Appendix 3: Learning event programme   Page 20                                                                                                                                                                                                     3 1.0.  Circumstances that led to this Serious Case Review  1.1. This Serious Case Review (SCR) concerns the serious injury of Child L, then aged 20 months whilst in the care of his1 mother.  In the month leading up to the injuries, a Child Protection (CP) medical had been performed on Child L. The outcome of this CP medical was that there were no safeguarding concerns and Child L was referred to the Accident and Emergency Department at the local General Hospital due to a swollen and painful scrotum. An ultrasound identified fluid around the testicle, which along with blood test results, was suggestive of infection so Child L was admitted.  1.2. Over the next month, his mother brought Child L back to the family GP and the hospital presenting with marks and rashes in the scrotal area and feet and fading bruising to the back. He was treated with antibiotics. A joint medical review by two senior doctors took place on the afternoon of 29.06.18; the mother and maternal grandmother were present. The examination revealed extensive bruising and excoriation2 and it was noted that Child L was restless and difficult to examine but did not seem to be in pain. The doctors did not feel able to make a definitive diagnosis. They thought that there was a possibility that the injuries were being inflicted but were also concerned about possible vasculitic3 or a malignant process. The doctors felt a prolonged period of observation would be helpful, but the mother was reluctant for Child L to be admitted over the weekend; it was agreed that he would be admitted on the following Monday.  1.3. Child L was brought to hospital by his mother on the Sunday (01.07.18) with extensive and superficial injuries including: a large number of bite marks, bruises, lesions and scratches around the heels and squashed toes. There were injuries to the nipples and scrotum, the latter requiring insertion of a catheter in order for Child L to pass urine.   1.4. Child L was taken into police protection on the 01.07.18, his sibling was medically examined the following day which identified a smaller number of similar injuries. It was noted that his half-brother was aggressive towards staff during the medical. Both Child L and his half-brother were made subject to an Interim Care Order4 on the 02.07.18.  1.5. The mother of Child L had a history of mental health concerns (depression and suicidal thinking) during her first pregnancy and some learning needs identified during her adolescence. She also had a history of domestic abuse (victim and perpetrator) from both Child L’s father and the father of Child L’s half-brother.  1.6. At the time of Child L’s and his half-brother’s injuries there were a number of agencies involved with the family.  Child L and his half-brother were subject to a Child in Need Plan.   1.7. The case was considered by the Serious Case Review Panel (SCRP) on four occasions between 04.07.18 and 18.09.18. Following these meetings, the panel made a recommendation to the Hertfordshire Safeguarding Children Board (now the Hertfordshire Safeguarding Partnership) to conduct a SCR.  The chair of HSCB  1 To protect children’s anonymity all the children are referred to using the male pronoun 2 A raw irritated lesion of the skin / the skin is scraped or abraded 3 Inflammation of blood vessel or blood vessels 4 The Local Authority obtains parental responsibility and decides where and with whom the children will live   4 accepted the recommendation to conduct a SCR on the 28.09.18, in line with Chapter 4, Working Together5.  1.8. The criminal case has now concluded, and the mother’s partner was found guilty on four counts and received a long custodial sentence. The mother was found guilty on one count and received a suspended prison sentence, community service and a period of rehabilitation.   2.0.      Terms of Reference  Full details of the review process are included in Appendix 2. In summary, an    independent lead reviewer worked alongside a review team, composed of senior managers and facilitated by an independent chairperson. The purpose of the SCR was to review the involvement of the agencies involved with the family to understand how professionals had understood the cause and nature of the family’s difficulties, and how effectively professionals had responded. The focus of the review was to learn about how local safeguarding systems are operating and if any changes may be required as a result of the wider lessons from the case. The SCR considered the work of the following Hertfordshire agencies:  • Health agencies (including: General Practice services, Health Visiting, Community Paediatric Services, Acute Paediatric Services Mental Health) • Local Authority Services (including Children’s Services (CS), Family Safeguarding Team (FST), Early Childhood Services and Education) • Domestic Violence Services • Hertfordshire Constabulary • Children’s Centres • Housing Services  The timeframe for the review was from June 2017 (when the children were removed from a Child Protection Plan and placed on a Child in Need Plan) to early July 2018 (when Child L was admitted into hospital with significant injuries).  2.1.  The Serious Case Review panel identified two key lines of enquiry that the review should address:  • Were existing identified risks to Child L and his half-brother understood and managed effectively? • How effective was the response to suspicions of physical abuse of Child L, allegations of domestic abuse and reported contact with men who may have posed a risk?  .       3.0. Family involvement.   The involvement of key family members in a review can provide particularly helpful insights into the experience of receiving or seeking services. In this case due to the ongoing criminal proceedings it has only been possible to speak with the family members prior to the publication of the SCR. The independent reviewer had  5 Working Together to Safeguard Children, HM Govt 2015. This SCR was commissioned while LSCB was still in statute    5 telephone conversations with the mother, maternal grandmother and father Child L’s half-brother, and an MST meeting with the father of Child L.    4.0. Brief Summary of the Case   4.1. The family had been working with Children’s Services (CS) from October 2014 when Child L’s half-brother was made subject to a Child Protection Plan (CPP) due to domestic abuse between his mother and father and the mother’s reported mental health concerns (depression and suicidal thinking) during her pregnancy. She also had some learning needs. These difficulties had not been resolved and the half-brother remained subject to a CPP.    4.2. In May 2016 the mother was pregnant with Child L (by a different partner) and the unborn child was made the subject of a pre-birth protection plan under the category of emotional abuse. The conference noted that the mother had problems of global delay in development, Attention Deficit Disorder (ADD) and Obsessive, Compulsive Disorder (OCD) all of which had been assessed by Child and Adolescent Mental Health Services (CAMHS) when the mother was a teenager.  4.3. The professionals described concerns about the mother’s care of Child L’s sibling (lack of routine and ability to manage his behaviour). The mother’s engagement in the existing protection plan was noted to have been limited.   4.4. In December 2016 Child L’s father was subject to bail conditions following an allegation made by the mother of a sexual assault which meant that he had no contact with his son. The father of Child L’s half-brother had not had contact with his son for over a year and it was reported that he had abandoned his application through the family court stating that he had no faith in social care, the courts or police.  4.5. In June 2017 the children were stepped down from a Child Protection Plan to a Child in Need Plan. Social worker 1’s report recommended removal from the Child Protection Plan ‘not without reservations’ and recognised that there would need to be a long period of Children’s Services and Families First6 involvement. It was noted that if there was a deterioration in the case then a Child Protection Plan would be needed, and legal advice would be sought. The case was allocated to a children’s practitioner working with other members of the Family Safeguarding Team7, and received regular supervision from the Consultant Social Worker.  4.6.        In September 2017 the first Child Protection (CP) medical was requested for Child L’s half-brother due to the nursery notifying Children’s Social Care (CSC) of two bruises (on cheek and ear) and scratch marks. The outcome of the CP medical was that the injuries were believed to be ‘non-specific.’ A referral was made to the Child Development Team for community follow up. It was noted that Child L’s half-brother had uncontrollable behaviour and was using foul and abusive language. The case continued to be managed under a Child in Need plan.   6 https://www.hertfordshirefamiliesfirst.org.uk 7 The new arrangements focus on a whole family approach and make it easy for parents to access all the support they need from within one team, to help them deal with the complex issues of domestic abuse, mental health and drug/alcohol abuse that harm their lives and those of their children: Hertfordshire family safeguarding model | Hertfordshire County Council      6 4.7.  In December 2017 there was a domestic incident in the family home (between the mother and father of Child L) which resulted in the mother attending a local hospital where a head injury required stitches. This triggered a Section 47 inquiry8 because the children were present in the home and thought to have witnessed the incident. The Section 47 enquiry ended on the 19.01.18. It was also reported that the perpetrator of this DA had forcibly shaved Child L’s half-brother’s hair off as he did not like the haircut. It was thought that the perpetrator was staying or living near the family. This led to concern and activity by the police and discussion at a Multi-Agency Risk Assessment Conference (MARAC)9 on the 23.01.18. (An independent review of MARAC meetings has been commissioned).   4.8. In early February 2018 a professionals’ meeting was convened when it was agreed that there would be joint work with the child practitioner and family support worker to work on the recommendations made by the Family Safeguarding psychologist. Two days later a request was made by social worker 2 for health visitor (HV) 1 to complete the Graded Care Profile10 (GCP) as part of the multi-agency actions, it was not clear as to why the request for the GCP was made to the HV as CS could equally have completed the tool. The graded care profile was never completed (HV1 left the service).    4.9. Over the next few months it was reported by professionals that the situation within the family was deteriorating: Child L’s half-brother was reported to be soiling in his bedroom and he was finding it difficult to cope with transitions and became anxious when he was due to be collected from school. His attendance at pre-school and nursery became erratic and he was often late.  Child L’s half-brother also made disclosures at pre-school that Child L’s father (naughty ****) had locked him in a coat cupboard and “he didn’t give me any food or drink, he put plastic on my door, and I couldn’t get out but mummy let me out”. In the middle of May he said, “mummy hurt me last night, she kicked me”. Although the pre-school had reported other incidents there is no record of these being explicitly shared with CSC.  4.10.      During a routine planned home visit by the child practitioner at the end of May, the mother disclosed that she was in a new relationship and that the partner had been in her house the previous evening when the police attended the property. The new partner had fled from the family home. Neither the mother nor maternal grandmother had voluntarily given this information to CSC despite the fact that it was part of the Child in Need Plan. Bruises were noticed on Child L’s face and the mother was unable to account for the injuries. A strategy meeting was held between CSC and the police and it was agreed that a CP medical should be undertaken; this was arranged for later the same day. The view of the paediatrician was that there were no safeguarding concerns but advised that Child L should be taken to the local general hospital due to a red and swollen scrotum and he appeared to be in  8 A Section 47 enquiry means that CSC must carry out an investigation when they have 'reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm   9 A MARAC, or multi-agency risk assessment conference, is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, probation, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other specialists   10 Graded Care Profile (GCP) structured tool developed by Jane Wiffin. The current tool being used in Hertfordshire has been adapted by Islington which, was initially developed by Jane Wiffin on behalf of Hounslow LSCB and has been further refined by Brent LSCB. The original concept came from work undertaken by Dr Leon Polnay and Dr O.P. Srivastava at Bedfordshire and Luton Community NHS Trust and Luton Borough Council.     7 pain. There was no formal referral made to the hospital by the examining paediatrician. Child L was admitted to hospital following examination by a junior doctor who referred the case to the consultant on duty. Child L was discharged two days later, his condition had improved, and his mother was advised to return to the hospital if his condition deteriorated.  4.11.      Health Visitor 2 made a home visit on the 12.06.18 and observed two bruises to Child L’s face, he was observed to be pale.  There were small blisters on his right foot and the underneath of his foot was red and he was reluctant to stand on his feet. The HV contacted SW2 using the HSCP bruising flowchart11. The duty social worker and child practitioner visited the home and photographed the bruises and arranged for a CP medical to take place later that day. The mother was unhappy about this decision and contacted the Designated Doctor who agreed that Child L could be examined at the hospital. This was not a CP medical. Child L was examined by a junior paediatric doctor and then by the Named Doctor. A referral was made to dermatology, following examination and discussion with the named doctor it was felt that it was a continuation of the skin infection. Treatment was prescribed and a follow up appointment given. The Named Doctor contacted CS about the medical opinion and reported that there were no immediate safeguarding concerns.   4.12.      A strategy telephone discussion booked for the 15.06.18 did not happen due to the unavailability of the social work manager and was not re-arranged; we do not know why this did not happen.  4.13.     Over the next two weeks there were a number of occasions whereby the mother sought medical advice and intervention for Child L. The doctors considered whether this was a case of fabricated or induced illness12.  He was admitted for further tests and observations over a weekend in June (22/23). At this point the focus was on finding a medical cause for the presentation of Child L but safeguarding was also still being considered. The mother and maternal grandmother repeatedly stated that no other adult had care of either of the two children and that there had been no reported trauma to the area.  4.14.      Child L was reviewed again on the 29.06.18 by two experienced paediatricians at a local child development centre. They wanted to admit him on to the paediatric ward for a prolonged period of observation to exclude whether the injuries were inflicted. The mother was reluctant to agree to his admission as she had previously been resident on the ward with Child L and stated that she knew that nothing would happen during this time. The mother agreed that Child L would be admitted after the weekend.  There was no communication with CS at this point because a specific child protection diagnosis had not been made, the doctors did not feel that there was enough evidence to support a finding of non-accidental injuries at this point.  The consequence of this was that the doctors did not consider the need for a  11  Bruising Flowchart and Multi-Agency Protocol for the Management of Bruising, Bites and Suspicious/Unexplained Marks in Children (0-17)  https://hertsscb.proceduresonline.com › pdfs › bruising_suspicious_marks  12  is a rare form of child abuse It occurs when a parent or carer, usually the child's biological mother, exaggerates or deliberately causes symptoms of illness in the child. https://hertsscb.proceduresonline.com/chapters/p_fab_ill.html       8 strategy discussion between the police and CS as they had been reassured that the mother would bring Child L back to the hospital as agreed. The view from CS was that had they known that the mother had refused to allow Child L to be admitted this would be a change in her compliant behaviour.  4.15.     The significant injuries to Child L occurred sometime between the Friday (when he was last examined) and Sunday (29.06-01.07.18.) when he was admitted to the hospital and taken into Police Protection. His half-brother was medically examined on the following day and found to have a smaller number of similar injuries. Both children were made subject to an Interim Care Order.  .  5.0.       Areas of Practice Learning  5.1. Introduction This section of the Review assesses the quality of multi-agency practice at the key points that are considered to provide the most significant learning. In doing so, the Review considers both the contemporary required standards and the information that was known, or could have been known, at the time of the events. Where there is information about why practice may not have met required standards, this is explained. By understanding why things happened in the way that they did, rather than simply what happened, the SCR is seeking to achieve a greater depth of learning about safeguarding systems within Hertfordshire, and beyond this individual case.  5.1.2.     Child L and his half-brother were being seen regularly by CS, health and the nursery as part of the Child in Need Plan and the plan was being implemented.  5.1.3.     The child protection procedures that the HSCP and its member agencies had put in place to implement ‘Working Together 2015’, had been implemented in the way they had envisaged, throughout the involvement with the family. With some important exceptions, agencies coordinated their work, shared information and came together to implement the Child in Need Plan. There was a systematic approach to evaluating risks using the Strengthening Hertfordshire Families Approach to conferencing.  5.1.4.     Despite robust systems being in place, there were some gaps in practice which need to be considered in order to learn from them. It must be remembered that the five areas of practice learning identified in this review overlap with one another and should not be viewed in isolation.  5.2.        Were the mother’s specific learning needs fully understood by the professionals working with the family?    5.2.1      It is well documented that children may be at increased risk where a parent/ carer has a learning need/disability. Professionals need to carefully consider the implications of relying on individual parents to follow through on advice or recommendations, bearing in mind that they may be unwilling or unable to do so. Professionals should consider whether the failure of the individual to follow through on advice or recommendations is an additional level of concern. The staff working in the hospital were unaware of the mother’s learning needs and reflected that the mother presented well and appeared to understand the possible causes of Child L’s condition. SW1 who knew the mother best told the SCR that “sometimes it wasn’t obvious of her learning need but at other times it was, it was inconsistent, and I was unsure if it was a learning need or an emotional need.”     9 5.2.2.    The professionals used directive instruction rather than strength-based or motivational interviewing when working with the mother. This was based upon advice provided following a Psychological assessment, which was completed as part of the Public Law Outline (PLO) process completed in September 2016.  Advice was given to professionals to use simple language when explaining and demonstrating what she was required to do, and to follow it up with written instruction. The child practitioner and family support worker were supporting the mother with practical parenting, setting clear boundaries for the children and promoting regular routines. The mother received a large amount of assistance from the various agencies and her family. However, this information was not shared with the wider network and professionals within the hospital setting were unaware of her learning difficulties.   5.2.3.     The SCR was told that there were a variety of different views about the mother which ranged from being vulnerable to highly manipulative and she ‘played the little girl.’. The professional network including the DA worker from the Family Safeguarding Team who provided input and support to the mother but also the professional network in terms of scaling risk.  The mother behaved and responded differently towards different professionals within the network. The differing response by the client can lead to a split in the network and needs to be identified early in order to present a unified position.  5.2.4.     Professionals, especially those in targeted services, routinely work with adults who are distressed and needy, who have been traumatised by their history. Professionals have to strike a balance between being supportive and positive towards the family in the steps that they have taken but must maintain “healthy scepticism” and “respectful uncertainty” (Laming 2003). In this case the mother continued to require a level of support and intervention in order to meet the needs of her children, but she was not consistent in accepting or engaging with the services. There were periods when overall care of the children was positive, and professionals could see positive change. Risk was assessed by the professionals in terms of the level of engagement by the mother and the absence of contact with her ex-partners.  5.2.5.    The conclusion of the panel was that there was no shared understanding of mother’s learning needs or her emotional needs and there were differing perceptions of her. These differing views needed to be brought together into a coherent picture so that a unified response could be achieved. The opportunity to achieve this kind of Multi-Agency (MA) unity can be missed when working with families under Section17 (Child in Need CIN) as the nature of this service provision is consent based and this can lead to an understandable view that professionals cannot meet without the parents being present. However, when attempting to provide a coherent MA response to a Child in Need Plan, opportunities to bring the network together to explore perceptions and provide challenge must be sought.         5.3.        The maternal grandmother was viewed as supportive to both her daughter and grandchildren despite the fact that they had a difficult and volatile relationship. Was there a level of collusion and deceit between them that hoodwinked the professionals?  5.3.1.     The mother and maternal grandmother had a difficult and at times volatile relationship. The professionals found it difficult to engage the mother about her relationship and their understanding was informed by the report prepared by the   10 clinical psychologist.13 The maternal grandmother was known to have experienced mental health issues over a long period of time. However, the maternal grandmother did offer support to the mother and in particular looked after Child L’s half-brother to give her a break.  5.3.2.     The Child in Need plan was explicit in that there was an expectation and understanding that the mother and maternal grandmother would work with CS in an open and honest way and would inform CS if and when the mother commenced a new relationship. This clearly did not happen on one known occasion as it is now known that the mother had commenced a new relationship in April 2018.  5.3.3.     The maternal grandmother would often accompany her daughter to the hospital, and it was recorded that the maternal grandmother would often be the one to do all the talking and asking the questions. The maternal grandmother and mother repeatedly denied to the hospital staff (over the weekend of 22-23 June 2018) that any other adult had care of the children.   5.3.4.     The conclusion of the panel was that when extended family are providing support to a family it can be from a strengths-based perspective and may not always strike the right balance between the strengths and the vulnerabilities   The learning from this is that; it is important to balance the strengths alongside the risks, to understand the nature of the relationships between family members (based on an understanding of historic family relationships stemming from childhood) and to continually reassess the changing and emerging picture of the family situation to allow strengths and risks to be adequately analysed so that the totality of the situation is understood.   5.4.        It was viewed that the risks could be managed safely on a Child in Need plan. Was this an over optimistic view?  5.4.1.     Child protection planning frameworks (such as child protection conferences) can   provide an opportunity to routinely bring the multi-agency network together under the leadership of an experienced independent chair to robustly review progress and provide challenge, equally the CP process can be felt to be overly formal and judgemental and push families away from working with professionals. The conference held in June 2017 recommended that the children were provided           with services under Section 17 of the Children Act 1989 (Child in Need CIN). In circumstances where there has been significant progress in reducing harm to children and achieving plans, this can be the appropriate decision. However, working with families under this legislative framework requires a partnership with families characterised by consent and a willingness to engage; this was not always evident with the mother missing / forgetting appointments and not always being truthful about her contact with the fathers of her two children There had been eight child protection conferences with three different chairs.  The view of SW1 was that the risks could be manged under a Child in Need Plan but with “reservations” as the mother tended to put her own needs before those of her children particularly around her relationships with men.  5.4.2.    Shortly after this decision was taken SW1, who had worked with the family for the              past three years left, and the case was allocated to a child practitioner.              The family had a complex history, chaotic lifestyle and periods of non-compliance                  with agreed interventions. The focus for the professional network was practical parenting and helping the mother establish a routine and boundaries for Child L and his half-brother. The allocated child practitioner was experienced; she was viewed  13 Psychological and Cognitive Report 2016.    11 as being able to highlight relevant cases of concern and would ask for support when required. The mother was inconsistent with how she cared for the children and there were on-going concerns about different men friends visiting the flat and staying late.     The Ofsted inspection in October 201814  identified an area for improvement was achieving the right balance between support and challenge with all parents. A review of Child in Need practice across Hertfordshire Children’s Services identified that there were different practices in place whereby not all children on a Child in Need Plan had an allocated social worker. Children’s practitioners bring a skilled and vital part of the work undertaken with families at both CP and Child in Need and this will continue. The change is to ensure that there will be an allocated SW involved in all Child in Need casework. This has been implemented.   5.4.3.    Following a domestic abuse incident in December 2017, which resulted in the mother requiring stitches to a wound on her head a Section 47 inquiry was started. This was ended a month later as the mother had worked with CS and the decision was made not to escalate at this time.  During a team consultation in early February the case was reviewed (due to escalating concerns) with the team manager and her supervisor, the outcome was that the mother was given a period of six weeks to engage, if she failed to do so then the case would be escalated. There were some positives in the changes to the behaviour of the children and the mother was given a further four weeks to carry on with the improvements, the mother was doing ‘just enough’ to reassure the professionals that she ‘was trying her hardest to do what was required.’ The decision taken was that the risks could still be managed under the Child in Need Plan at this point.    5.4.4. The mother was given ‘another chance’ to parent her two children. There is a process in place within Hertfordshire which allows professionals to escalate concerns about any Child in Need Plan if they feel that the plan is not keeping children safe15. This escalation was not used by any of the professionals involved who were working with mother as there was evidence that improvements were being achieved. There are many factors16 which lead professionals to adhere to a supportive and helpful plan, where there is sometimes unwarranted optimism about outcomes, and find it difficult to change course. Supervision becomes paramount to ensure that professionals are supported and challenged. In this case group supervision within Family Safeguarding took place monthly (apart from March and April). Brandon and Colleagues (2008) stress the importance of effective and accessible supervision. This helps staff put into practice the critical thinking required to understand cases holistically, complete analytical assessments, and weigh up interacting risk and protective factors. The assessment was that the mother was in the contemplation stage17 characterised by ambivalence and conflicted emotions whilst both fathers were assessed as pre-contemplation - characterised by denial and ignorance of the problem. The supervision recordings suggest that the analysis and understanding of impact on the children was lacking.  5.4.5. At each CIN professional meeting the risks were reviewed: the RAG18 rating remained at amber for the entire period on the Child in Need plan. The risks identified included: the mother associating with ‘unsafe people,’ inconsistent engagement, lack of routine and boundaries for the children, domestic abuse, not  14 www.gov.uk/government/organisations/ofsted 15 Hertfordshire Multi-Agency Children in Need Protocol Children and Procedures  16 Reder et al (1993) 17 The 6 Stages of Behaviour or Transtheoretical Model James Prochaska and Carlo DiClemente (1970’s) 18 Risk Assessment rating: Red, Amber or Green (Red significant risk & Green low risk)   12 always being open and honest with the professionals and Child L’s half-brother’s challenging behaviour. There was no evidence that domestic abuse issues had increased or that there was a new partner (it is now known that the mother had a new partner around April 2018). However, at the time, the professional network did not have evidence of unsafe people or DA being a current issue for the children.   5.4.6.    Although the SCR was told that all professionals within the network were concerned  about the family and in particular Child L’s half-sibling, the contingency plan made when the children were removed from the child protection plan was not triggered. An optimistic view is more likely to develop when the difficulties faced by a parent (or prospective parent) are considered and measured by specific practical steps, with professionals not taking an overall view of the challenges faced by someone who has had some extremely bad experiences.  5.4.7.  The conclusion of the panel was that although it was deemed at the time that the risks could be managed safely on a Child in Need Plan, the risk remained that the mother had a history of putting her own needs before those of her children and that there was a high risk that the mother would enter into another abusive relationship. An open and honest relationship between the mother and agencies was key to the plan being implemented. The challenge when cases are stepped down with “reservations” is to ensure that the work includes dynamic risk assessment, evaluation and re-evaluation so that the correct safeguards are in place.    5.5 The behaviour of Child L’s half-brother was of particular concern; harm should be measured by what the child is telling us.  5.5.1.    Child L’s half-brother was described as a “challenge but charming” He was  desperate for adult attention and found it difficult to play alongside or with other children within the pre-school and nursery setting. His attendance was erratic and would often arrive late and still dressed in his pyjamas and hungry. The mother said it was because she couldn’t get him to go to bed and then he wanted to sleep in the morning. Child L’s half-brother found transition from one setting to another difficult and the Lead Reviewer was told during a conversation with a member of staff, as part of this SCR, that he would become anxious when it was time for his mother to collect him and one professional commented: “we were always worried about this little boy, right from the beginning.”  5.5.2.     Child L’s half-brother used extreme language and the Lead Reviewer was told that it was used in context. The professionals working within the Early Years setting told the Lead Reviewer that they thought he had heard this from the Child L’s father. Child L’s half-brother talked about different males in the house and in particular “naughty ****” (Child L’s father) who had locked him in a cupboard as well as in his bedroom and “didn’t give me any food or a drink.”  The Lead Reviewer was provided with an e-mail trail of communication between the private pre-school provider and CS. However, there was no evidence of the specific language used by Child L’s half-brother being shared. This is of concern and requires immediate follow up. The requirements placed on a privately-run nursery/ pre-school are very different from those in statutory services.    5.5.3.     The question that arises is: how was significant harm being determined? Child L’s half-brother’s behaviour was of concern, he used foul and abusive language in context and towards women. Professionals needed to be curious as to whether he was repeating what he had heard being said to his mother.  He told professionals about what was happening to him and also talked about ‘willies and bums’. Professionals needed to be curious as to whether this was sexualised behaviour?   13 His attendance at the pre-school and nursery was erratic, he often arrived late and sometimes still dressed in his pyjamas, hungry and thirsty.   5.5.4.     Child L was too young to be able to verbalise what he was experiencing but his half-brother did tell professionals about what was happening, sadly there is no evidence to suggest that this was acted on. The voice of the child was not heard. It is important that the focus of any assessment or work with a family has the child or children at its core.   5.5.5.    The conclusion of the panel was that not all of the specific incidents were reported to CS by the pre-school provider which meant that opportunities to gain a better understanding of the lived experiences of the children was lost.  Although information was shared at the Child in Need meetings, the specific language used by Child L’s half-brother and the context it was used in, was not. The learning from this is that all behaviours must be viewed as potential trauma and the impact of this trauma on the lived experience of the child.  5.6.        The mother had reported domestic abuse over a sustained period of time; how did the safeguarding network assess the risk and impact for the children?  5.6.1.     Multi-Agency Risk Assessment Conferences are multi-agency meetings where statutory and voluntary agency representatives share information about high risk victims of domestic abuse in order to produce a co-ordinated action plan to increase victim safety19.  The mother had been in two abusive relationships over the last four years and the family had been the subject of seven Multi-agency Risk Assessment meetings (MARAC) over a two-year period. When reviewing the minutes, it was not possible to determine whether the ‘core’ agencies were present at all of them. This of course may have an impact upon the effectiveness of MARAC outcomes and the quality of the information being shared, and the subsequent risk identification or action planning. There were a number of risks including: stalking/ harassment, child contact/witness, separation, substance misuse, mental health, threats of or actual harm that were not reflected in the risk/identification/safety planning of the MARAC.                MARAC was fully reviewed by SafeLives20 in early 2019 and was given generally very positive feedback. No concerns were raised as the way cases with children were managed and in fact Children’s Services are consistently present at all MARAC meetings ensuring information sharing and multi-agency approach. The structure of the meeting has been amended so that all cases with children are given extra time and heard at the start to always ensure there is sufficient time. Children are listed on all cases and their needs and the impact on them is discussed from a multi-agency perspective during the meeting.   5.6.2.    The mother’s learning difficulty was shared at the third MARAC, neither this nor the ongoing mental health concerns within the subsequent referrals were explicitly considered in the identification of risks or safety/action planning. It was noted that some of the information contained within the minutes remained the same throughout, alongside agency’s presenting differing or conflicting information from one MARAC to another. This could indicate gaps in recording and/or inadequate research.  19 Multi-Agency Risk Assessment Conference (hertssunflower.org)  20 UK-wide charity dedicated to ending domestic abuse, for everyone and for good.    14 5.6.3.     The number of possible or evident risks recorded in the minutes were not always reflected in the safety planning actions that were put in place. Some of the risks: strangulation, threats to kill, threats of suicide are on their own immediate high-risk indicators and it is unclear as to how these risks were responded to. There was an opportunity for the agencies to work jointly to try to better engage and work with the family.   5.6.4.     Over time, the number of reported domestic abuse incidents reduced and the focus of the work moved to ensuring that there were safe contact arrangements for both Child L and his half-brother due to the past domestic abuse, and the impact that any conflict between parents, whether emotional or physical, would have to the children's safety and well-being. Of equal importance was the damage that may already have been done to the children and in particular the worrying behaviour of Child L’s half-brother. All children living with domestic abuse experience stress that may manifest in a number of ways including aggression or bullying, problems in school, truancy, speech problems, difficulties with learning, attention seeking and bed-wetting.  5.6.5.    The conclusion of the panel was that the safeguarding network were reliant on the mother and maternal grandmother working openly and honestly with them. If this trust is broken there is a danger that professionals do not have a clear understanding of what is happening within a family and as a consequence may be unaware of increased risk. They also understood that the mother was a vulnerable adult with low self-esteem and a history of difficulties in making and maintaining healthy relationships. All of her relationships had been with men who were both physically and emotionally abusive to her. The risk remained that the mother would enter into an abusive relationship in the future. The professionals also understood that when there were no men in the mother’s life then the care that she provided, with support from the professionals and the extended family, was adequate. The learning from this case is that without considerable therapeutic intervention past behaviour is the best predictor of future behaviour.    5.7.        Is there an over-reliance on the medical view and a definitive diagnosis of non-accidental injury, that as a consequence leaves the safeguarding network overly reassured?   5.7.1.    The presentation of Child L was highly unusual and experienced paediatricians had never seen anything like this case before. The mother appeared genuinely concerned about Child L and appeared to cooperate with the requests made by the medical profession. However, the mother presented at a time or a place that avoided too much scrutiny e.g. attending the hospital late in the evening rather than daytime and going to the hospital rather than attending the local child development centre for a CP medical (see p 4.11).   5.7.2.     The first CP medical was carried out on the 31.05.18 following a home visit by the child practitioner when bruising was observed.  Mother reported that she was in a new relationship and that the police had made a home visit the previous evening (the man had left the flat evading the police).  We now know that the mother had been in this relationship since April and had failed to divulge this information to any of the professionals working with her. The maternal grandmother was also aware of this new relationship and also failed to inform CS.   5.7.3.    The CP medical concluded that there were no safeguarding concerns, but the mother was advised to take the child to the hospital due to his swollen scrotum.  The fact that the doctor stated there were ‘no safeguarding concerns’ does not   15 mean that there are no concerns. Professionals need to continue to monitor and analyse the situation and must feel comfortable about working with uncertainty. Following the completion of the child protection medical SW2 accompanied Child L and his mother to the local hospital, where it was reported that Child L was currently on a Child in Need Plan and that he was sent by the paediatrician who had undertaken the child protection medical earlier in the day.  The hospital staff were informed about the mother’s former partners and domestic abuse. When Child L attended the hospital there was an active Section 47 as the Strategy meeting had taken place and there had been a CP medical, but the Section 47 had not been concluded. The hospital staff knew that the mother had cared for the child since his birth and that there had never been any previous concerns about physical injuries or bruising. Child L was admitted to the paediatric unit and was discharged two days later having responded well to the prescribed treatment.  5.7.4.     A second CP medical was arranged on the 12.06.18, but Child L did not have a CP medical (see P 4.11). Instead, the examination that did happen had a medical focus rather than a safeguarding or child protection focus and a referral was made to dermatology due to the presenting skin condition. There was no SW present at this time. Child L attended the dermatology clinic, the consultant contacted the named doctor (who was at another hospital in a busy clinic) because of concern about increasing bruising and red marks to the feet. The advice given by the named doctor was for Child L to be taken to the emergency department of the hospital. The mother did not do this, so the named doctor called the mother and asked her to attend the hospital which she did after some delay arriving at about 8pm. The strategy phone-in was unable to proceed in June due to the un-availability of the Social work team manager.   5.7.5.    Child L attended with his mother and maternal grandmother, it was recorded that maternal grandmother did most of the talking and was forceful; demanding answers as to what was wrong with her grandson. Child L was admitted over the weekend and discharged on the Sunday; CS were informed. A week later mother presented Child L at the hospital, it was noted that there were increasing lesions, healing scabs around the nipple area and also red semi-circular marks around the nipples and on his arms. The consultant felt uneasy about the case: “altogether it wasn’t making sense.”  The named doctor and designated doctor agreed to review Child L the next day at the local child development centre. The outcome of the consultation was that they wanted to admit Child L for an extended period of observation as there was a view that they could be inflicted injuries, but they could not ‘make a definitive diagnosis.’ The mother was reluctant to agree to a weekend admission but agreed to return on the Monday. There was no discussion with CS at this point and a strategy discussion was not requested as the doctors had not specifically made a “child protection diagnosis.” The decision of this medical examination was made on the basis of a clinical medical decision rather than on a multi-agency basis. The challenge for the partnership is how the agencies work together to share decision making in these circumstances and jointly own the risk.  5.7.6.    The medical examination initially left doctors unclear about the cause of Child L’s symptoms. The definitive examination on the Sunday (two days after the joint review) identified extensive and superficial injuries including multiple bite marks that had been inflicted over the previous 24-48 hours. Following this medical examination and diagnosis of non-accidental injuries, the child protection procedures were instigated and followed.  5.7.7.    The conclusion of the panel was that diagnostic uncertainty, and the fact that experienced doctors did not feel that there was enough evidence at the time of their   16 examination to support a diagnosis of non-accidental injury, resulted in a decision that Child L would be admitted three days later (on the Monday following the weekend) for observation. There was no attempt to achieve multi-agency collaboration about the question of risk.  Risk can only be determined by the multi-agency group, for professionals to feel that they must be in position of certainty about risk is an untenable position. Uncertainty is a feature of safeguarding work and as E. Munro21 states; to suggest or act only on the basis of certainty has no place in safeguarding work. The learning from this is how the safeguarding network can work in partnership to share and own risk particularly in times of uncertainty.    6.0.      Learning Event               A Learning Event was held for key staff and managers at the end of February 2020, to share the key findings from the case and identify any additional learning (20 professionals and 7 panel members). The full details of the event can be seen in Appendix 3. The Learning Event was an holistic process which allowed staff to reflect and challenge one another in both a positive and safe environment.               The independent reviewer would like to acknowledge the honesty and contributions that all attendees made in difficult and emotional circumstances. The learning that emerged was:  • The benefits of a Schwartz Round22 in order to discuss the case once the criminal and care proceedings had been concluded, which allowed staff to discuss in a safe environment how this case had impacted on them and how it had made them feel. • The participants of the learning event expressed that they now felt more confident in sharing uncertainties with other professionals. • The importance of asking the right questions that will allow the network to review and risk assess the current situation within the family. • The benefits of multi-agency meetings and listening to all the views of the professionals working with the family.   7.0.      Areas of good practice  • The child practitioner was mindful of the risks posed by adult males in the household, she promptly and efficiently completed police checks on anyone that she encountered at the flat and informed mother of the outcome.  • The Named Doctor was determined and persistent when mother failed to bring Child L back to hospital. • Paediatric Consultants determination to seek advice from the Designated Doctor over the weekend.    21 Decision – making under uncertainty in child protection: Creating a just and learning culture. E. Munro Child & Family Social Work Vol.24, Issue 1 July 2018   22 Schwartz Rounds are an evidence-based forum for hospital staff from all backgrounds to come together to talk about the emotional and social challenges of caring for patients. The aim is to offer staff a safe environment in which to share their stories and offer support to one another.    17 8.0.  Conclusion             This was a difficult and emotive case that had, and continues to have, an impact on all of the professionals and managers involved.  A safe child protection system needs to deal proficiently with risk and probability; it is not enough to respond reactively after an incident of harm has been caused to a child. The multi-agency partnership must understand that if children are subject to a Child in Need plan this means there is a level of concern about the safety of the child/ren which requires a statutory social work intervention. This area of practice learning was identified in a recent SCR undertaken in Hertfordshire.             The assessment of the extended family on their ability to provide care and support to the family needs to adequately balance strengths with risks in order to understand the nature of the relationships between family members which should include historical relationships stemming from childhood.             Private providers within the Early Years setting require statutory guidance (from Central Government) that brings them in line with the statutory guidance for schools. MARAC needs to strengthen information sharing and analysis of short- and long-term vulnerabilities and risks in order to achieve multi-agency collaboration in the uncertain world of safeguarding children.                     As already stated, that areas of practice learning overlap and as a result there will not be specific recommendations for each of the practice learning areas.   8.0. Recommendations:             To build on the recommendation from a previous SCR on the multi-agency understanding of risk for children under a CIN plan to include dynamic risk assessments and challenge from all partner agencies.               To explore how a list of children on a CIN plan can be shared with the multi-agency safeguarding network as is the case with children subject to a CPP using Child Protection Information Sharing Project.                 Hertfordshire Children Safeguarding Partnership requires assurance that private pre-school and nurseries are meeting the required standards of safeguarding, and to consider raising the issue with DoE to bring private providers under the same guidance as statutory services.            HCSP to receive assurance that the changes implemented following the MARAC review, are identifying all risks and vulnerabilities of children and young people and shared with the Multi-agency Safeguarding network.                To develop both guidance and the necessary actions to be taken, where a child referred for a Child Protection medical does not go on to have one because the child is taken to another health provider.         18 Appendix 1:  Acronyms   ADD  Attention Deficit Disorder  CAMHS  Child and Mental Health Services  CP  Child Practitioner  CPC  Child Protection Conference  CIN  Child in Need  CPP  Child Protection Plan  CS  Children’s Services  DD  Designated Doctor  FST  Family Safeguarding Team  GP  General Practitioner/ Family Doctor  HV  Health Visitor  HSCB/P  Hertfordshire Safeguarding Children Board/Partnership  IDVA  Independent Domestic Violence Advisor  MARAC  Multi Agency Risk Assessment Conference  ND  Named Doctor  OCD  Obsessive, Compulsive Disorder  PLO  Public Law Outline  TM  Team Manager  SCR  Serious Case Review  SW  Social Worker  Appendix 2:  Methodology  2.1.1.  Statutory guidance within Working Together requires Local Safeguarding Children Boards to have in place a framework for learning and improvement, which includes the completion of Serious Case Reviews. The guidance establishes the purpose as follows: Reviews are not ends in themselves. The purpose of these reviews is to identify improvements, which are needed, and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action, which lead to sustainable improvements, and the prevention of death, serious injury or harm to children. (Working Together, 2013:66)   19 2.1.2.   The statutory guidance requires reviews to consider: “what happened in a case, and why, and what action will be taken”. In particular, case reviews should be conducted in a way which:  ➢ recognises the complex circumstances in which professionals work together to safeguard children ➢ seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; ➢ seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; ➢ is transparent about the way data is collected and analysed; and, ➢ makes use of relevant research and case evidence to inform the findings  2.1.3.  In order to meet these requirements, the model adopted in undertaking this review uses a ‘systems approach’, which draws significantly on the work undertaken by Professor Munro23 and SCIE [Social Care Institute for Excellence]. A ‘systems approach’ to learning recognises the limitations inherent in simply identifying what may have gone wrong and who might be ‘to blame’. Instead it is designed to identify which factors in the wider work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely. The purpose therefore is to move beyond the individual case to a greater understanding of safeguarding practice more widely.  2.1.4. An independent lead reviewer worked alongside a review team (Panel), and composed of senior managers, and facilitated by an independent chairperson. The review team met on six occasions and considered the following documentation:  • A merged chronology from all the agencies providing care to the family of Child L • Child Protection Conference Minutes • Copies of CIN, Group Meeting • Copies of Group Supervision • Access to Social Work Electronic Records • MARAC minutes • Workbook Children’s Practitioner • Public Law Outline minutes • Fathers Risk assessments • Psychological and Cognitive Assessment Report prepared by Clinical Psychologist in Family Safeguarding • Domestic Abuse Intervention Report   • Conversations with 16 key professionals.  2.1.5.  The author of this SCR, Ann Duncan, was commissioned by HCSP to write the overview report; she was independent of the case and all agencies involved.  2.1.6.  The Review Team was comprised of the Independent Lead Reviewer, and the following senior managers/senior professional leads who were independent of the case:      23 Social Care Institute for Excellence (Fish et al, 2008)   20 Job Title / Role  Organisation Bridget Griffin  Independent Chairperson Team Manager: LADO & CPSLO Hertfordshire County Council (HCC) Director of Operations, Children and Families  Hertfordshire Children Services Strategy Manager, Early Childhood Services, Family Services Commissioning Hertfordshire Children Services Designated Nurse Safeguarding/LAC & Care Leavers East &North Hertfordshire Clinical Commissioning Group & Herts Valley Clinical Commissioning Group Named Nurse Safeguarding Children Hertfordshire Community Trust Consultant Community Paediatrician  East & North Hertfordshire Trust Lead Nurse Safeguarding, Named Nurse Safeguarding Children West Hertfordshire Hospitals Trust Partnership Manager Domestic Abuse, Strategic Partnership Business Manager HSCB DCI, Safeguarding Partnerships and Policies Hertfordshire Constabulary Minute Taker HSCP Business Unit Ann Duncan Independent Reviewer  2.1.7.  The time frame under consideration for this Review was: June 2017 – June 2018  The period under review covers the period of time from when the children were stepped down from a Child Protection Plan to a Child in Need Plan in June 2017 and finishes a year later when Child L was admitted in to hospital with significant injuries.   Appendix 3:   Serious Case Review – Child L Learning Event Programme  1 pm   Refreshments on arrival 1.30 pm  Welcome and Introductions: Bridget Griffin and Ann Duncan  1.40 pm  Research Questions Key Lines of Enquiry  1.50 pm  Brief Overview of the Case Professional Curiosity  3 pm  Break and refreshments 3.10 pm Areas of Practice Learning Questions to Consider Areas of Good Practice  4.15 pm  Recommendations 4.30 pm Close   