Discovery of multiple injuries resulting from the severe physical abuse of Child A, aged eight, in March 2013. Mother and stepfather were arrested and bailed. A member of the extended family was convicted of offences arising from Child A's physical abuse in 2016. Child A was born prematurely when his mother was in her teens. He suffers from cerebral palsy and is profoundly deaf. Due to his disability, he had been a child in need since birth, receiving services from children's social care, occupational therapy, speech and language services and he attended a specialist school. Stepfather had a history of domestic abuse, drug and alcohol problems and criminality; mother had physical health problems and was arrested for assault. The police, stepfather's probation officer and his drug and alcohol service made referrals to children's social care. Following child protection enquiries, concerns were substantiated but Child A and his siblings were not judged to be at continued risk. Findings include: there is multi-agency confusion about the child in need processes for disabled children leaving them without effective outcome-focussed plans and multiagency reviews; there's an unwillingness to label the early signs of poor quality care provided to disabled children as neglect leaving those children's needs unaddressed. Uses the Social Care Institute for Excellence (SCIE) learning together systems model and poses questions for the local safeguarding children board (LSCB) based on the findings. Recommendations include: the LSCB should explore how embedded the "think family" agenda is and take remedial action as appropriate.
      
 Title:  Serious case review: Child A. LSCB: Hertfordshire Safeguarding Children Board Author: Jane Wiffin and Dave Peplow Date of publication: 2016  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           1Serious Case Review: Hertfordshire LSCBHertfordshireSafeguarding Children BoardSerious Case Review:Child AEpisode that triggered the reviewMarch 2013LSCB adoption of the review findingsSeptember 2014PublicationNovember 20162Serious Case Review: Hertfordshire LSCBChapterPage1Introduction to the Review ProcessReason for the Serious Case Review4Timescale for the SCR5Child A’s family5Child A’s family background – A brief summary5Succinct summary of case7Timeline of significant incidents7The lead reviewers13The review team14The case group15Family member involvement15Structure of the review process15Sources of data16About Hertfordshire162Professional practiceSummary appraisal17Narrative of professional involvement183The Findings:Analytical process for establishing systems findings24Finding 1: A failure to use expertise within the professionalnetwork as to how children with different or complexcommunication needs express themselves, leads to the child’svoice not being heard26Finding 2: There is multi-agency confusion in Hertfordshireabout the child in need processes for disabled children leavingthem without effective outcome focussed plans and multiagencyreviews30Finding 3: There is a professional unwillingness to label theearly signs of poor quality care provided to disabled children asneglect leaving those children’s needs unaddressed33Finding 4: A parent or carer not taking a child to healthappointments, particularly where the child is additionallyvulnerable, should be an indicator that the child may be at riskresulting in proactive follow up35Finding 5: There is a pattern of uncritical acceptance of parental393Serious Case Review: Hertfordshire LSCBself report by professionals in all agencies which leaveschildren’s needs and circumstances un-assessedFinding 6: The meaning given by one agency to a phrase about aclient does not necessarily have the same meaning for allagencies meaning that risk may be wrongly assessed by others42Finding 7. There is a pattern whereby non-resident Fathers areroutinely excluded from assessments and decision making abouttheir children444Additional MattersEscalation process47Re-commissioned services maybe vulnerable47Assessing the risk an “adult” issue poses to children485References and Bibliography494Serious Case Review: Hertfordshire LSCB1: Introduction to the Review ProcessReason for the Serious Case Review1.1In March 2013 Child A (who was eight at the time) was taken to hospital byambulance because of a reported allergic reaction to hair dye. The attendingambulance crew noticed some bruising and large ‘O’ shaped marks on Child A’sbody. This prompted a full child protection medical which revealed that Child A hadsustained multiple unexplained injuries. There was also evidence of human bitemarks, fractures to this ribs and a head injury. Child A received medicalintervention and his Mother and Stepfather were arrested and they weresubsequently bailed pending further investigations. In 2014 Child A and his twosiblings were living with their maternal grandparents, and they had contact withtheir Mother, but not Stepfather. Child A was referred to the Hertfordshire SCR subgroup by East and North Herts NHS Trust on 25th March 2013 and a decision toundertake an SCR was made on 24th April 2013. A member of the extended familywas convicted of offences arising from the severe physical abuse of Child A in mid-2016.1.2Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets outthe requirement for Local Safeguarding Children’s Boards to undertake reviews ofserious cases where: (a) abuse or neglect of a child is known or suspected; and (b)either — (i) the child has died; or (ii) the child has been seriously harmed and thereis cause for concern as to the way in which the authority, their Board partners orother relevant persons have worked together to safeguard the child.1.3Working Together was reissued in 2013 and provided new guidance forundertaking a serious case review which requires that they should be conducted ina way which:recognises the complex circumstances in which professionals work together tosafeguard children;seeks to understand precisely who did what and the underlying reasons that ledindividuals and organisations to act as they did;seeks to understand practice from the viewpoint of the individuals andorganisations 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.1.4LSCBs may now use any learning model which is consistent with the principles inthe guidance, including the systems methodology recommended by ProfessorMunro. Hertfordshire LSCB agreed to undertake a review using the SCIE LearningTogether methodologyi.5Serious Case Review: Hertfordshire LSCBTime scale for the SCR1.5The period under review is from 2nd March 2012 and concluded on 16th March2013 when Child A’s injuries were discovered by medical professionals. Child A hasbeen known to a range of services throughout his life and the review takes accountof some aspects of this historical context.This review was commissioned in August 2013 and completed in September 2014.Publication of the report was delayed until 2016 in order to ensure that it did notprejudice the criminal investigation or trial.Child A’s Family1.6Relationship to SubjectEthnicityChild ASubjectWhite/BritishMotherMother of Child A, sibling 1 and 2.FatherFather of Child AStepfatherFather of sibling 1 & 2Sibling 1Half sibling same Mother – different FatherWhite/BritishSibling 2Half sibling same Mother – different FatherWhite/BritishChild 1Child of StepfatherNKChild 2Child of StepfatherNKMGMMaternal Grandmother of all siblingsWhite/BritishStep MGFStep Maternal Grandfather of all siblingsWhite/BritishChild A Family Background – A Brief Summary1.7Child A was born prematurely at 30 weeks gestation when his Mother was in herteens and living at home with her Mother and Stepfather. Child A has cerebralpalsy, profound neural deafness and he is currently a wheelchair user. Child A hasbeen known to the Disabled Children Team since birth. He was referred by medicalstaff to the hearing impairment advisory team at 4 months old. He started at aschool for physically and neurologically impaired young people in the Septemberfollowing his third birthday and support has been provided via the school eversince. Child A was assessed regarding special educational needs, and his Motherrequested a place at a specialist school for pupils with physical and neurological6Serious Case Review: Hertfordshire LSCBdifficulties. Child A has attended this school for a number of years, and is providedwith high quality educational and physical support.1.8When he was five, Child A’s mother was referred to a physical disabilities teambecause she was struggling with the physical care needs of Child A and his 18 monthold sibling 1. She had her own physical heath difficulties, specifically a back injurywhich was exacerbated by the level of lifting and handling required to care for ChildA. At this time she was assessed as being entitled to Direct Payments of £90 perweek, which she never claimed.1.9Child A’s Father was in his late teens when Child A was born. He did not haveparental responsibility until recently. He told the reviewers that when Child A wasborn he asked Mother about registration of the birth, he was told this had been doneand that he was not named on the birth certificate. He was not able to challenge thisin court for financial reasons. Child A’s Father said that he has provided financialsupport every month since Child A was born and that he has had regular contactevery weekend, with overnight stays every other week. He was in contact with ChildA’s school in the early days.1.10It is not clear when Child A’s Mother met Stepfather, but their first child was born in2008. They had a second child in 2012 (sibling 2). There were differing reportsregarding their relationship, and Mother told some professionals that they were in arelationship, but did not live together, and told others that they lived together forpart of the week, so he could help out with the care of the children. Stepfather had abrief relationship with another woman, and she had a baby in 2009. This baby wasmade subject to a child protection plan before its birth, because of Stepfather’sdomestic violence and this child is currently in care. He also has another older childwith whom he has no contact.1.11Stepfather has a long criminal history, with offences for theft, violence to a partner,members of the public and the police. He also has long term alcohol and drug use,and he has misused heroin, crack cocaine and cannabis in the past. He is prescribedmethadone, and he tested positive for class A drugs in the period under review.There has been a police marker regarding him for violence and mental health issues,but when assessed by a psychiatrist in the period just before this review he was saidto have no diagnosed mental illness.7Serious Case Review: Hertfordshire LSCBSuccinct summary of case1.12Child A has been in contact with a range of services since he was born. This includessocial work, occupational therapy, school, and speech and language services. Heattends a specialist school, and requires specialist equipment to enable him toparticipate fully in education, supported by speech and language therapy and thewheelchair service. Child A has attended school regularly, and the main area ofconcern has been missing and lost equipment. Child A is a child with a disabilityand as such has been a child in need since birth. There were no concerns regardingthe care he received or family difficulties until March 2012 when his Mother wasarrested for assault. .1.13His Stepfather was arrested and charged with endangering his own child and drinkdriving in September 2012. An assessment was undertaken, but led to no furtheraction. Mother gave birth to her third child in December 2012. Child A continued toattend school, who became concerned about a burn to Child A which requiredmedical attention and caused them concern.Child A remained in contact withthose agencies that supported him through school, and lost equipment, issuesabout him being unkempt and small injuries became of increasing concern. Theseconcerns were emailed to his social worker, and she tried to visit the family homewithout success. At this time Stepfather started to disengage from his contact withprobation and the drug and alcohol agencies. The escalation of worries about childA and his family circumstances was not fully understood by any one agency.Timeline of significant incidents1.14Review Period StartsDateIncident2 March 2012Police report that Mother assaulted a woman because shebelieved the woman was seeing her boyfriend/Stepfather.Both were said to be drunk.6 March 2012Child A was not at school. Discussion that the week beforeChildAhadnotbroughthishearingequipment,communication book, boots and mouth pointer to school.Mother was reported to have been a little agitated whenshe came to school.7 March 2012Occupational therapist (OT) undertook a home visit. Shediscussed this with the Practice Manager of the DisabledChildren’s Team who asked the allocated social worker andthe OT to go back to the house. A home visit wasundertaken and Stepfather was looking after Child A and8Serious Case Review: Hertfordshire LSCBhis sibling. The Practice Manager was informed of this, andshe asked the allocated DCT(Disabled Children’s Team)social worker to let the out of hours Duty Team know aboutthe situation, which she did.8 March 2012The allocated DCT social worker spoke to Mother, who saidshe had not been charged, and did not want to talk aboutthe incident.8 March 2012Child A did not attend his speech and language sessionbecause he was late into school.9 March 2012The Police told the allocated DCT social worker that Motherhad been interviewed regarding a charge of Actual BodilyHarm (ABH) and was bailed for ten days pending furtherinvestigations.18 and 29 March 2102TelephonecallsbetweenMotherandsocialworkerregarding practical matters.8 May 2012School meeting, Mother attended.22 May 2012Stepfather was sentenced at Crown Court to a CommunityOrder of 200 hours of unpaid work for handling stolengoods.13 June 2012Mother visited G.P. and was found to be pregnant.9 July 2012Stepfather started on a methadone programme.2 August 2012Stepfather was seen by his new drug and alcohol teamwhere he reported that he had ceased using heroin andcrack cocaine, but smoked cannabis. Stepfather told thedrugs worker that his partner was pregnant with theirsecond child, and he had another older child who was incare, and he was taking steps to have contact with her.3 August 2012The drug and alcohol team sought information fromChildren’s social care as a result of Stepfather sharinginformation about his children.6 August 2012The Duty team from children’s social care contacted thedisabled children’s team to inform them that Mother andStepfather had applied to care for Stepfather’s daughterwho was currently in care.7 August 2012There was a case discussion between the allocated (DCT)social worker from the disabled children’s team and herteammanagerregardingStepfather’sdruguseandMother’s pregnancy. Agreed that a core assessment shouldbe carried out. This was progressed in October.17 August 2012Stepfather’s Community Order was terminated because hehad breached the requirements and a new CommunityOrderof18monthswithsupervisionanddrug9Serious Case Review: Hertfordshire LSCBrehabilitation requirements was made in its place. Newprobation officer allocated.20 August 2012During testing as part of his order Stepfather testedpositive for opiates.4 September 2012The Probation officer made a referral to Children’s referralto Children’s social care regarding Child A, sibling 1, child 1and the unborn baby. Probation officer said Stepfather doesnot pose “an imminent” risk.4 September 2012The Probation officer spoke to allocated social worker forchild 1 who told her that the current plan for child 1 wasadoption.9 September 2012The police received an anonymous call regarding anallegation that Stepfather had been drinking and smokingmarijuana, and was riding a motorcycle along the streetwith a small child on the handlebars. The Police attendedand Stepfather was arrested for drunk driving, it was notedthat Mother was obstructive.10 September 2012Referral to Children’s social care from the Child AbuseInvestigation Unit (Police) regarding Stepfather’s offences.10 September 2012The probation officer contacted Children’s social care to letthem know that Stepfather had been arrested and to checkwhether the child protection referral had been received.12 September 2012Children’s social care decided that the assessment of theunborn baby and sibling 1 would be undertaken by theassessment team, and the assessment of Child A by thedisabled children’s team.12 September 2012Stepfather told the probation officer that his stepson, ChildA, had been allocated a social worker. He told the probationofficer that he had been charged with “Exposing a Child toDanger” and drunk driving, as he had been 2 times overlegal limit.13 September 2012Probation officer telephoned the allocated social worker(DCT) and left a message regarding the new offences.13 September 2012Telephone call from the Head Teacher to allocated socialworker (DCT) expressing concern that Child A was comingto school without the necessary equipment, which wasimpacting on his ability to access the curriculum.19 September 2012Stepfather tested positive for cocaine following a routineurine test.19 September 2012The allocated social worker from the disabled children’steam and social worker from the assessment team mettogether to share information.10Serious Case Review: Hertfordshire LSCB20 September 2012The drug and alcohol team made a referral to Children’ssocial care regarding concerns for Stepfathers childrenbecause of his continued drug use and drug relatedoffences.20 September 2012Strategy discussion held regarding Child A.25 September 2012Strategy discussion held regarding sibling 1 and 2.26 September 2012Professionals meeting organised by Children’s social careto discuss the risk posed by Stepfather. The schoolrecorded that they thought the meeting concluded thatthere would be a child protection conference in the nextfew weeks.27 September 2012Meeting at school with Mother and Stepfather. Concernswere expressed about lack of equipment coming intoschool for Child A and also Mothers lack of contact with thewheelchair services.15 October 2012The allocated social worker (DCT) for Child A contactedprobation to ask about curfew requirements. She was toldthat Stepfather could not stay away from home.15 October 2012Stepfather brought Child A to school because the family hadstayed at stepfather’s home the previous night becauseMother’s fridge had broken.16 October 2012Stepfather asked the CRI drugs agency he was attending forhelp with his alcohol misuse.17 October 2012Child A was found at school to have 4 small marks on hisside – described as like carpet burns. Recorded in theschools records.17 October 2012Stepfather received a 4 month sentence suspended for 18months, for the charge of endangering a child. Sentenceincluded attending a Drinkwise programme.23 October 2012Stepfather had session with Probation. He reported that hehad missed Drinkwise programme because of CourtHearing regarding child 2. Alcohol consumption addressedand he acknowledged he had a drink that morning.30 October 2012Child protection enquiries completed. Concerns weresubstantiated, but children not judged to be at continuedrisk.6 November 2012Stepfather reported to the drug and alcohol agency, CRI,that his alcohol misuse was out of control, and he requestedhelp. Group work was offered.8 November 2012Mother saw the midwife and told her that her partner, thechild’s stepfather, was on a methadone programme.8 November 2012The Core assessment was completed regarding Child A and11Serious Case Review: Hertfordshire LSCBsibling 1 and the unborn baby.Both recommended nofurther action.20 November 2012Stepfather told his key worker at CRI reports that he isstruggling with the methadone reduction programme,drinking excessively and he was unaware that he was dueto attend the Drinkwise programme via probation. Hereported that he was on a final warning because of nonattendance. He was encouraged to speak to Children’sservices.20 November 2012Neighbour of Stepfather telephoned police to expressconcern that Stepfather was smoking crack cocaine at homeand that he has a court order not to drink alcohol or takedrugs. Police find no trace of an order or conditions and soclosed the incident with no action taken.13 December 2012Sibling 2 born at 30 weeks. Kept in special care unit.18 December 2012Stepfather reported to probation. Told of birth of son,prematurity and that he had drunk four pints to celebrate.Discussion about drug use and interventions.2 January 2013Stepfather attended group session under influence ofalcohol.4 January 2013Stepfather reported to Probation. He admitted using crackcocaine and drinking. His lapse was discussed and he said itpeer pressure and that he found it difficult to refuse.6 January 2013Speech and language service contacted the allocated socialworker to express concerns about equipment. Socialworker agreed to talk with Mother. Appointment had beencancelled.7 January 2013Children’s social care contacted Probation to discussstepfather’s progress. Assessment social worker said shewas pleased with his engagement and compliance. It wasdiscussed that the case was likely to close. It is not clear ifthe drug use disclosed on 4 January 2013 was discussed.15 January 2013School nurse saw a burn on Child A’s foot. They wereconcerned and asked Mother to take him to hospital.Allocated social worker informed.15 January 2013Child A taken to A&E by Father. Injury considered by the Aand E Doctor and Nurse to be consistent with explanationgiven. Which was the foot had been trapped between bedand radiator.17 January 2013Health visitor undertakes a new birth visit with Mother andsibling 2.23 January 2013Speech and Language service expressed concern to school12Serious Case Review: Hertfordshire LSCBabout missing equipment. Head teacher attempted tocontact the allocated social worker (DCT) and emailed herexplaining concerns, Child A looking unkempt, lost orbroken equipment and a bruise on the left cheek of Child A.30 January 2013There was a discussion between the Head teacher and theallocated social worker (DCT). Concerns discussed andsocial worker reported that she would see Mother nextweek.31 January 2013Speech and language service emailed their concernsregarding lost and broken equipment to the allocated socialworker (DCT).11 February 2013School nurses noticed graze on Child A’s forehead whichwas healing, but there was no explanation in the home-school diary. Teacher phoned Mother who was not surewhat had happened but thought he might have grazed hishead on his bed. Allocated social worker (DCT) informed.12 February 2013Meeting at school regarding equipment. Mother revealedinformally that Stepfather was at the house everyday eventhough he should not be, because she could not manage thechildren alone. School notified the allocated social worker(DCT) regarding this. Social worker agreed to visit andraise concerns.27 February 2013Teacher emailed the allocated social worker regardinghome visit to Mother and was told it had not happenedbecause Mother was out.28 February 2013Stepfather gets a new probation officer. His attendance atthe drug agency had become sporadic only attending 9 outof 19 drug testing appointments.7 March 2013The teacher emailed the allocated social worker to ask ifshe had done a home visit. She did not receive a replybefore the critical incident nine days later. This was due tothe allocated social worker being part time.16 March 2013Child A taken to hospital.13Serious Case Review: Hertfordshire LSCBMethodology1.15This serious case review has been undertaken using the SCIE Learning Togethermethodology. The focus of a case review using a systems approach is on multi-agency professional practice. The goal is to move beyond the specifics of theparticular case – what happened and why – to identify the underlying patterns thatare influencing practice more generally. It is these generic patterns that count as‘findings’ or ‘lessons’ from a case, and changing them should contribute toimproving practice more widely. Data comes from semi-structured conversationswith the involved professionals, case files, contextual documentation fromorganisations and the young person and their family who are the subject of thereview. A fundamental part of the approach is to talk with staff to understand whatthey thought and felt at the time they were involved in the case, avoiding hindsightas much as possible. It is vital to try and make sense of what factors contributed totheir understanding at the time and to the decisions they made. This is known asthe ‘local rationality’. Any appraisal of practice is then made in the context of thosecontributory factors.The Lead Reviewers1.16This review was undertaken by Jane Wiffin and Dave Peplow, both of whom areSCIE accredited Lead Reviewers.1.17Jane Wiffin is a qualified social worker who has extensive experience of working insafeguarding. She is an experienced serious case review author and chair, havingundertaken 18 reviews. She is an accredited SCIE Learning Together Reviewer andhas undertaken a number of reviews using this methodology. She is currentlyengaged in work developing tools and frameworks for addressing childhoodneglect and she is an experienced auditor and safeguarding trainer. She isindependent from all the agencies involved in this review.1.18Dave Peplow served 25 years as a police officer. He was the Essex Police leadfor safeguarding matters and Head of Child Abuse Investigations. He has extensiveexperience of multi-agency working across three local authority areas. He left thepolice in 2012 and became an accredited Learning Together reviewer in July 2012.He is the Independent Chair of Thurrock and Warwickshire LSCBs and sits on afostering panel. Dave is independent of all the agencies involved in this.14Serious Case Review: Hertfordshire LSCBThe Review Team1.19The review was conducted by a team of senior representatives from local agencieswho had had no direct dealings with the case. They shared in the conversations, theanalysis of documents, the identification of key practice episodes and contributoryfactors. This report is the shared responsibility of the Review Team in terms ofanalysis and conclusions, but was written by the joint lead reviewers.NameAgency/RoleGeoff CoreHertfordshire Social Care.Head of Child Protection (to December 2013)Andy LawrenceHertfordshire Social Care.Head of Disabled Children Services and Children’sBrokerage Team (from December 2013)Deborah BriceEast and North Herts CCG and Herts valley CCGDesignated Nurse, Safeguarding Children and LookedAfter Children (to 2015)Jemima BurnageHertfordshire Partnership University Foundation TrustHead of Social Work and Safeguarding (to 2015)Liz HanlonHertfordshire PoliceDetective Chief inspector (to 2015)Roz FramptonServices for Young People, Education and EarlyInterventionEducational Psychology Team ManagerSteve Johnson-ProctorHertfordshire Probation (now National ProbationService)Director of OperationsSue SmithCrime Reduction InitiativesRegional Children and Families Lead15Serious Case Review: Hertfordshire LSCBThe Case Group1.20The members of the Case Group are the professionals who worked with or madedecisions about the family, and who had individual conversations with members ofthe Review Team ( in this case the therapists and the school nurses met as smallgroups with Review Team members). The Case Group comprised of over 22 people(although not all these people attended case group meetings). Most were briefed onthe methodology and then met with the Review Team on four further occasions toshare in the analysis, the identification of contributory factors, and to comment andcontribute to the report.Social workers x 2Social Work practice manager x 3Head teacherClassroom teacherOccupational TherapistPhysiotherapistDieticianSpeech and Language TherapistSchool nurse x 3Substance Misuse workers x 3Health visitorPolice officerProbation officerAccident and Emergency DoctorAccident And Emergency NurseFamily Member Involvement1.21The Birth Father of Child A, The maternal GrandMother and her partnercontributed to the Review by meeting with the Reviewer during the process. It wasnot possible to include Mother or Stepfather because of the ongoing policeinvestigation.Structure of the Review Process1.22The Review Team met on six occasions, including four times with the Case Group,and worked on a range of issues including the information from conversations,identification of the Findings and issues for LSCB consideration.16Serious Case Review: Hertfordshire LSCBSources of data1.23Conversations: The semi-structured conversations between members of theReview Team and members of the Case Group; semi-structured conversations withfamily;Documentation: All necessary documentation was made available to the reviewranging from case files, procedures, assessments and police attendance records.,About Hertfordshire1.24Hertfordshire borders London to the north and covers 643 square miles, having apopulation of over one million people, making it the most densely populated shirecounty in the East of England. Hertfordshire has approximately 278,300 childrenand young people under the age of 19 years. This is 24.9% of the total population.The proportion entitled to free school meals is lower than the national average.School-aged children and young people from minority ethnic groups account for24.1% of the total population, compared with 25.4% in the country as a whole.2011 Census information shows that the largest minority ethnic groups inHertfordshire are Asian (6.5%), Black African and Black Caribbean (2.8%) and anotable Eastern European population (1.3%). The proportion of pupils with Englishas an additional language is below the national figure with the main languagesother than English being Urdu, Polish and Gujarati.Hertfordshire has 5,458Children in Need of which 1,207 (22.1%) had a recorded disability.17Serious Case Review: Hertfordshire LSCB2: Professional PracticeSummary Appraisal2.1This case involved the response of agencies to a disabled child (Child A) and hisfamily over the period from March 2012 to March 2013. During this time therewere a large number of professionals involved and the focus of professionalattention was divided between meeting Child A’s developmental needs in thecontext of his disabilities, supporting his Mother who was perceived incorrectly tobe a single parent who was trying her best in difficult circumstance and addressingthe Stepfather’s offending behaviour and drug and alcohol misuse. During theperiod under review Child A’s own Father was not seen or acknowledged by anyagencies. This was contrary to effective practice and the reasons for this arediscussed in Finding 7. There was a lack of a holistic approach to the needs of ChildA, exacerbated by the lack of any multi-agency Child in Need Processes (see Finding2), inadequate assessment practice inappropriately shared between two socialworkers, unclear information sharing between agencies, an overreliance on Motherand Stepfather’s own views of their circumstances (Finding 5)and a lack ofescalation (see Additional Matters) of concerns about early signs of neglect(Finding 3 and 4) and potential physical abuse. It is clear that the services focussedon Stepfather did not always recognise the significance of the information they heldor the potential impact of Stepfather’s deteriorating behaviour on the children inthe family (See Finding 6). Outside of school, Child A was given few opportunities tocommunicate with professionals about his own needs and circumstances (SeeFinding 1).During the time of the Review the social worker for the Disabled Children Teamtold the Review Team that she held over 35 cases and worked a two and half dayweek. This was an unmanageable caseload/workload which meant that evenroutine and regular tasks could not adequately be covered. The Team Managersupervised over 600 cases and this impacted on her ability to have managementoversight of all these cases. These concerns were raised with senior managersthroughout this time. There was a change in Drug and Alcohol Services provided toStepfather. This agency experienced a shortfall in personnel and high sicknesslevels which had an impact on the consistency of response to Stepfather andcapacity to carry out appropriate assessments. The Health Visiting Service wereexperiencing higher than average caseloads.18Serious Case Review: Hertfordshire LSCBNarrative of Professional Involvement2.2Child A attended a school which was equipped to meet his needs and where he washappy and progressing. The school held regular in house planning meetings whichbrought together education staff, nursing care, speech and language and nutritionalexperts. The Disabled Children Team (DCT) social worker for Child A did not attendthese meetings because of the reported shortfall in capacity which, given the lack ofany other regular multi-agency meetings, was a missed opportunity for Child A.2.3The school had a reasonable working relationship with Mother, she attendedmeetings and there was a well established communication process using the homeschool diary. Despite this, the school and speech and language service had concernsregarding the equipment Child A needed to hear and to communicate, which wasoften lost, broken or missing as well as worries about whether Mother wasresponding appropriately to the need to attend wheelchair service appointments.These issues were addressed with Mother, she responded and there were shortterm changes, however the problem remained and got worse in the longer term.The lack of actual change was not recognised by the school as a potential earlyindicator of child neglect which needed action – this is discussed in Finding 3 andFinding 4. Towards the end of the period under review the school communicated aseries of individual concerns about missing equipment, Child A being unkempt andunexplained bruising to the allocated social worker (DCT) without providing anycontext or analysis. These concerns were not responded to in a timely manner, inpart because of the working pattern of the allocated social worker and in partbecause of the reported shortfall in capacity in the Disabled Children Team. Theschool did not escalate their concerns or seek any formal meeting or process toaddress the lack of response from the Disabled Children’s Team as would beexpected.2.4Child A was known to the Disabled Children Team (DCT) team from birth. Over aneight year period there were no concerns about the care that Child A received fromhis Mother, but historically there were worries about how she was coping with thephysical care of Child A and a toddler. She was reluctant to make use of directpayments, social work services or Occupational Therapy support, and as a result apattern of contact developed where Mother was telephoned by the allocated socialworker (DCT) on a regular basis regarding practical matters. Child A was neversubject to any planning or review processes and he was not seen regularly, all ofwhich was outside agreed standards of practice.2.5It is of concern that there appears to have been confusion across the professionalnetwork about what it actually meant that Child A’s was a “child in need”.Hertfordshire procedures highlight that there is a distinction between disabledchildren who require services over a long period of time to support their wellbeing,19Serious Case Review: Hertfordshire LSCBand those disabled children who are “children in need” because of their familycircumstances and who require a qualified social worker, sometimes referred to ascomplex child in need cases. This confusion meant no one professional was clearabout what to expect from the social worker, or what review and planning shouldhave been in place.2.6In March 2012 Child A’s Mother was arrested for the assault of a woman whilstboth of them were under the influence of alcohol. Stepfather looked after Child Aand his siblings whilst Mother was held at the police station. The allocated socialworker (DCT ) became aware of this and visited. She alerted the Emergency DutyTeam, but the incident was not analysed or followed up. As a “child in need” itwould be expected that there would have been a review of Child A’s circumstancesand consideration of the impact on him of his primary carer being unexpectedlyunavailable and an exploration of the role of Stepfather.2.7There was considerable professional confusion about what role Stepfather playedin family life, despite being the Father of sibling 1 and professionals being awarethat Mother was pregnant with sibling 2 in June 2012. This was in part because hewas not living permanently in the family home, but also because both Mother andStepfather gave conflicting accounts of their relationship to different professionals.It was important for Child A and his siblings that all professionals understood therole of Stepfather because he had a long history of violence and offending,influenced by drugs and alcohol and therefore represented a potential risk.2.8In August 2012 Stepfather was transferred to a new drug and alcohol agency and aspart of the initial assessment of his needs he told the drug and alcohol worker thathis partner was pregnant with their second child, he had a child who was in care,and another older child who he had no contact with. It was good practice that thedrug and alcohol worker contacted the social worker for child 2 to shareinformation about Stepfather, and this information was subsequently shared withthe allocated social worker (DCT) for Child A. However, because of a shortfall inavailable staff a full parenting assessment was not undertaken, nor a home visit aswould be expected.2.9The allocated social worker (DCT) discussed the concerns raised regardingStepfather’s drug and alcohol use, violence and domestic abuse to child 2’s Motherwith her Team Manager and it was agreed that a core assessment would beundertaken. Capacity issues within the Children with Disability Team meant thatthere was a delay in this starting and two weeks later Stepfather’s Probation Officerappropriately made a referral to Childrens Social Care because she had also beentold by him about his children.20Serious Case Review: Hertfordshire LSCB2.10Soon after this referral was made Stepfather was arrested for driving a motorbikeon the road whilst drunk, with sibling 1 on the handlebars. The Police respondedimmediately to an anonymous referral and Stepfather was arrested. Mother wasnoted to be angry and hostile to the Police Officer. Stepfather was charged withdrunk driving offences having been twice over the legal limit and endangering achild. The police made an appropriate and clear referral to Children’ Social Careand Probation also made contact with Children’ Social Care to ensure they knew ofthis new offence. Two strategy discussions were held and a professionals meetingto share information. The conclusion was that a child protection Core Assessment(Sec 47) would be completed, some 6 weeks after the original plan to undertake anassessment of Child A.2.11The allocated social worker (DCT) was tasked with completing the assessment ofChild A and a social worker from the Assessment Team would undertake theassessment for sibling 1 and unborn sibling 2. This was outside normal procedureswhere it would be expected that the social worker from the disabled children’steam would have undertaken assessments on all three children. This was causedby the high caseload held by the allocated social worker (DCT) and herinexperience in carrying out complex assessments.This separation had asignificant impact. It meant that only one of the social workers had contact withMaternity Services and once the case was closed regarding sibling one and two theconnection with early year’s services was lost.It also meant that there wasconfusion about who to contact when Child A was brought to hospital with a burnto his foot.2.12The two social workers liaised with each other and individually they soughtinformation from all appropriate agencies. Probation and the Drugs agency werenotaskedtoreflectontheimplicationsofStepfather’sbehaviourandcircumstances on his ability to parent or on the implications for the safety of twoyoung and vulnerable children. The information provided focussed on Stepfather’spositive engagement and the improvements that he had made from theirperspective. The Drug and Alcohol Team reported that Stepfather had been freefrom class ‘A’ drugs since testing positive for crack cocaine in August 2012. He alsotested positive in the middle of September 2012, but this information does notappear to have been available to the assessment. The assessments drew the overlyoptimistic conclusion that Stepfather had made changes to his drug use andcriminal activity, without acknowledging that the incident with his son was causedby excessive alcohol use. School provided a positive view of the engagement ofMother, but also shared information about missing equipment.2.13Although two separate assessments were completed much of the information isexactly the same in both, information having been “cut and pasted” from one to theother. This is of concern given that each assessment is intended to focus on the21Serious Case Review: Hertfordshire LSCBparticular needs of each child, in the context of their family circumstances. Child A’sneeds are very different from that of his younger brother, and the issue of Child A’sdisability is described but not anlaysed.2.14Appropriately Sibling 1 was spoken to as part of the assessment process and ChildA was observed at school, but it is poor practice that there is no evidence thatattempts were made to use the expertise within the school to communicate withChild A directly. (This is discussed in Finding 1)2.15It is poor practice that Child A’s Father was not informed that a Child Protectionassessment had been undertaken and Mother provided information about changesin Child A’s behaviour when he returned from contact with his Father, and thatneither Father nor paternal grandparents had showed an interest in Child A. Theseissues were never clarified directly with Father, who provided a different story aspart of this review.2.16The conclusion of both assessments was over optimistic and lacked a clear analysisof all the existing risk factors. Both assessments relied heavily on self report fromMother and Stepfather who both provided inaccurate and misleading information,for example Stepfather was allowed to dismiss the issue of domestic abuse and holdhis previous partner responsible. Mother gave a false account of the incident whenFather was arrested for child endangerment. She said she was not present when ithappened, but the referral from the Child Abuse Investigation Unit made clear thatshe was hostile and unhelpful to the police.2.17The assessment for the siblings recommended no further action and theassessment for Child A recommended the continuation of the child in need plan, butthere was no plan formulated and because both assessments “cut and pasted”information from one to another, the conclusion of Child A’s assessment incorrectlystated that there would be no further action.In effect, this is largely whathappened.2.18In December 2012 Mother gave birth to her third child, who was born prematurelyand spent some time in special care. On the day of discharge from hospital thehealth visitor went to the family home, she did not know any of the family historyas she had not received any written notification. The social worker who had liaisedwith maternity services was not the allocated worker for Child A, and theconclusion of the assessment for the siblings recommended no further action. TheHealth Visitor saw only Mother and the new baby. Mother was described aswelcoming and the house was appropriate for the needs of a new baby. Discussioncovered feeding, safe sleeping and contraception. Mother was keen to attend clinicfor baby weight checks. There were no concerns and Mother provided noinformation about the recent assessments.22Serious Case Review: Hertfordshire LSCB2.19From November 2012 onwards Stepfather’s probation Officer reduced thereporting and drug testing requirements for stepfather to below what wasexpected, because he said he was having contact with his children, although thiswas not the case. In November 2012 Stepfather told the drug and alcohol agencythat he was drinking excessively and wanted help. In January 2013 he attended agroup work session whilst under the influence of alcohol. This information was notshared with any other agency. The capacity issues for the Drug and Alcohol agencymeant that Stepfather had contact with a number ofstaff over time and thisinconsistency meant that no one person was able to reflect on the implications ofthis escalation for Child A and his siblings.2.20The Core assessment of sibling 1 and 2 was updated by the social worker from theassessment team in January because sibling 2 had been born. The Probation Officerwas reported to have said she remained happy with Stepfather’s engagement andprogress. A Drug Worker said that Stepfather was engaging well and had been drugfree since August 2012. This was incorrect; he had proved positive for class “A”drugs in September, had asked for help with his drinking and had missed 9 out of19 drug testing appointments since the end of November. The updated assessmentfor siblings 1 and 2 concluded that there was a “robust plan of support for thefamily”. This was clearly not the case.2.21In January 2013 Child A arrived at school with a burn to his foot. Mother hadrecorded in the home school diary that he had burnt his foot on the radiator theprevious week. This explanation was passed to Father who later reported the samewhen he took his son to hospital. The school nurse was very concerned about thelook of the injury, which was reported by her as swollen and Child A, when asked,said that it hurt. The nurse contacted Mother and asked her to take Child A tohospital. She in turn asked Father to take Child A and he arrived at school and ChildA was taken to the hospital. The school contacted the hospital to inform them thatChild A was coming to the accident and emergency department, and providedinformation about the recent child protection enquiry. The Child Protection nursewas called and she sought information about the family from the assessment teamsocial worker and not from the allocated social worker from the DisabledChildren’s team because of the confusion caused by two social workers undertakingthe Core Assessment. The outcome of the assessment was shared along with theFamily history, the conclusion from Children’s Social Care being that there were nocurrent concerns. Child A was medically assessed by a triage nurse who was aspecialist in burns and plastic surgery, and a registrar. It is poor practice that ChildA was not given any opportunity to communicate what had happened by anyprofessional involved. The outcome was that the injury was not consideredmedically serious, was considered to be consistent with the explanation providedby Mother and the delay in seeking medical attention understandable. Given the23Serious Case Review: Hertfordshire LSCBlack of concerns expressed by Children’s Social Care, a safeguarding referral wasnot considered necessary. A differential diagnosis of Child Maltreatment shouldhave been more carefully considered, and contact made directly. The confusionabout who was the allocated social worker meant that the hospital were unawarethat they had not spoken to the right person. It is inappropriate that this incidentled to no review of Child A’s circumstances. A Child in Need meeting should havebeen convened by the allocated social worker (DCT)and because most of theprofessionals seemed unaware of Child A’s Child In Need status, no one questionedwhy this was the case.2.22Over the next two months the school had increasing concerns about missing andbroken equipment, small bruises and grazes and that Child A looked unkempt. Theschool communicated each issue to the social worker individually, and they becamefrustrated by the delayed response caused by the social worker being part time.This frustration did not lead to any action, and the school appeared unaware of theescalation policy in the Hertfordshire procedures.The allocated social worker(DCT) did agree to undertake a home visit, but this was unsuccessful. This meantthat the allocated social worker (DCT) had not seen Child A or any of his familysince the Core Assessment had been completed in November 2012. Given the birthof a new baby who need special care, a trip to hospital and issues raised by theschool, this was not appropriate.2.23Child A’s Mother called an ambulance in March 2013 reporting that he had had anallergic reaction to red hair dye. He was taken to hospital, where Mother repeatedthe same story. Child A was found to have a number of injuries, which wereassessed as non accidental. Child A was admitted to the hospital. Initially theinjuries seen were bruising to the face, body and buttocks. More detailedexamination revealed three fractured ribs, a possible human bite and a subduralhaematoma. Mother could provide no explanation for how these injuries hadoccurred. Mother and Stepfather were arrested on suspicion of having caused, orallowed to cause the injuries.This came as a surprise to all the professionalsinvolved with Child A, and was a measure of the lack of awareness of potentialsafeguarding issues across the whole period under review.24Serious Case Review: Hertfordshire LSCB3: The FindingsAnalytic process for establishing systems findings3.1The aim of a Learning Together case review is to use a single case as a ‘window onthe system’, to uncover more general strengths and weaknesses in the childprotection system. A four-stage process of analysis is used to articulate how featuresof the case can lead to more general systems learning. The first is to look at how theissue manifested in the case specifics, this will often be presented as one example,even if there are several such examples. This evidence comes from the analysis ofthe reconstruction of the unfolding case, documentation and an examination of thekey practice episodes.3.2The second step is to consider whether the issue observed in this case is‘underlying’. That is, that it is not a ‘quirk’ of the case, but is likely to representpractice in other cases and by other practitioners. The third step is to consider howgeographically widespread and numerically prevalent the issue is within the system.Sometimes it is not possible within the scope of a review to collect this data. Thesources for these steps will be information from the Review Team and Case Group,any performance data, national research and other reviews in a variety ofcombinations. In this review, it has not been possible to obtain some of the datarequested to populate these steps – this has been highlighted where relevant.3.3The last step is to articulate why this issue matters, what are the risks to thesafeguarding system. Based on this finding, questions and considerations for theLSCB are formulated.Categories of underlying patterns3.4The systems model that SCIE has developed includes 6 broad categories ofunderlying patterns. The ordering of these in any analysis is not set in stone andwill shift according to which is felt to be most fundamental for systemic change.Not all the typologies will have a finding associated with them but they aredesigned to allow for structured enquiry as to what the data has revealed:Human biases (cognitive and emotional):Are there common errors of human reasoning and judgement that are notbeing picked up through current case management processes?Family-professional interaction:What patterns are discernible in the ways that professionals are interactingwith different family members, and how do they help and or hinder goodquality work?25Serious Case Review: Hertfordshire LSCBCommunication & collaboration in responses to incidents:Are there particular good or bad aspects to the patterns of how professionalsrespond to specific incidents (e.g. allegations of abuse)?Communication and collaboration in longer term work:Were any good or bad patterns identified about ways of working over a longerperiod with children and families?Tools:What has been learnt about the tools and their use by professionals?Management system:Are any elements of management systems a routine cause for concern in anyparticular ways?3.5This review has prioritised 7 findings for the Board to consider:FindingCategoryFinding 1: A failure to use expertise within theprofessional network as to how children withdifferent or complex communication needsexpress themselves, leads to the child’s voicenot being heard.Communication andCollaboration inresponse to incidents.Finding 2: There is multi-agency confusion inHertfordshire about the child in need processesfor disabled children leaving them withouteffective outcome focussed plans andmultiagency reviews.Communication andCollaboration in longerterm work.Finding 3: There is a Professional unwillingnessto label the early signs of poor quality careprovided to disabled children as Neglect leavingthose children’s needs unaddressed.Communication andCollaboration in longerterm work.Finding 4: A parent or carer not taking a child tohealth appointments, particularly where thechild is additionally vulnerable, should be anindicator that the child may be at risk resultingin proactive follow up.Family-Professionalinteraction.26Serious Case Review: Hertfordshire LSCBFinding 5: There is a pattern of uncriticalacceptance of parental self report byprofessionals in all agencies which leaveschildren’s needs and circumstances unassessed.Family-Professionalinteraction.Finding 6: The meaning given by one agency toa phrase about a client does not necessarilyhave the same meaning for all agenciesmeaning that risk may be wrongly assessed byothers.Communication andCollaboration in longerterm work.Finding 7. There is a pattern whereby non-resident Fathers are routinely excluded fromassessments and decision making about theirchildren.Family-Professionalinteraction.Finding 1: A failure to obtain an understanding as to how children with different orcomplex communication needs express themselves and communicate, from thosewith the expertise, leads to the child’s voice not being heard.How did it manifest in this case?3.6Through the period under review it is striking how few opportunities wereprovided to Child A to communicate with professionals about his own needs andcircumstances.3.7The exception was the professionals at the school who were very skilled atcommunicating with him, but were never asked by any other professionals to helpor discuss his communication needs. During the core assessment, Child A wasvisited by his social worker at school and she observed his behaviour in class.There is no evidence that she discussed with school the best way to communicatewith him about the purpose of the assessment, or to seek his views to include in theassessment.3.8One example of this was when in January 2013 the Learning Support Assistant fromChild A’s class asked the school nurses to check his foot as Mother had recorded inthe school diary that Child A had burnt his foot on the radiator. Mother said that hehad been lying on the bed watching a DVD and she heard him scream. She realisedthe radiator had been on but she did not know how long the foot had been againstthe radiator.3.9The school nurse looked at Child A’s foot and recorded in detail what she sawbecause she was concerned that it looked swollen and inflamed. She asked Child A27Serious Case Review: Hertfordshire LSCBabout the injury and he said that it hurt. . The school asked Mother to take Child Ato the hospital Accident and Emergency. This was arranged and in fact Fatherprovided the transport and arrived ahead of Mother. No member of staff from theschool went to the hospital with Child A.3.10The school nurse telephoned the Child Protection (CP) Nurse at the hospital. Sheprovided information about the injury, that there had been previous childprotection concerns, but did not discuss Child A’s communication needs or that hehad a communication passport in the pocket of his wheelchair.3.11The CP nurse was aware of Child A’s disability, and she spoke to Mother and Father.One of them explained that Mother had found the child with his foot stuck betweenhis bed and radiator after he screamed. Mother said that it had not looked too badand had been cleaned and covered at the time.3.12The CP nurse spoke to the social worker from the assessment team who hadrecently undertaken the assessment of Child A’s siblings. She provided informationabout the new baby who she said had been in special care until recently,Stepfathers previous drug use and recent conviction for endangering a child. Thissocial worker had no direct responsibility for Child A and would not be able toprovide a clear picture of his individual needs.3.13The Accident and Emergency Doctor saw Child A and was given the same historyfrom Mother. He examined the wound, a burn on the foot reported as 7 days old. Hedressed the wound, prescribed antibiotics and discharged for GP follow up.Hemade no attempt to communicate with Child A or seek help to ensure that someoneelse could do so on his behalf.What makes this an underlying pattern rather than a one off incident in thisparticular case?3.14The repeated occasions on which Child A’s communication needs were notexplored, suggest that this a common element of practice, rather than a one-off. Forexample, when Child A was admitted to hospital as a result of the injuries hereceived in March 2013 there was no discussion about how Child A couldcommunicate what had happened to him until the Police questioned whether anABE interview with Child A, would be possible. This was not considered to be aviable option.3.15The nurses and Doctor who treated Child A’s burn injury acknowledged that noattempt was made to communicate directly with him or to establish if this couldhave been achievable. The Hospital Doctor said in conversation that there would bean attempt to obtain an independent history from a child over eight if they spoke a28Serious Case Review: Hertfordshire LSCBlanguage other than English but there was no system in place to assist in speakingto children with a disability.3.16The review team and case group provided information that this was not an issueunique to this case.How widespread is the pattern3.17There is nothing to suggest the pattern in Hertfordshire is any different to thenational picture. The Ofsted report “The Voice of the Child: Learning lessons fromserious Case Reviews”ii examined 67 serious case reviews involving 93 children.This report notes that: “Serious case reviews involving disabled childrencommented on the importance of practitioners using appropriate means ofcommunication.”How prevalent is the issue?3.18Local data was provided by speech and language therapists in Hertfordshire beingasked.A) How many of the pupils on your caseload would need help or an interpreter tofacilitate communication?Answer: 228B) How many would benefit from being provided with symbols in A and E?Answer: 171C) How many have communication passports?Answer: 38Responses came from 19 placements. There are a number of other issues whichneed to be taken into account but this data gives a good sense of the number ofchildren who have different and complex communication needs.3.19From the literature this can be seen to be a national issue. This issues manifests inboth the child protection system and in criminal justice. Stalker et al in “Childprotection and the needs and rights of disabled children and young people: Ascoping studyiii”, reported that disabled children were less likely than otherchildren to be seen as credible witnesses, fewer cases involving disabled childrenwent to court and courts sometimes failed to meet disabled children’s needs, withinsufficient use of video recording and intermediaries. This is despite researchclearly indicating that children with learning disabilities can provide forensicallyrelevant information if appropriate methods are employed (Aarons N M, Powell MB. 2003)iv.29Serious Case Review: Hertfordshire LSCBWhy does it matter?3.20Ascertaining how a child communicates and what they are “saying” is key tosafeguarding them whatever their level of difficulty and the Report of the NationalWorking Group on Child Protection and Disability (NSPCC in association with TheNational Working Group on Child Protection and Disability 2003v), makes clear thatpractitioners need to ensure their definitions of communication are inclusive andnot discriminatory. Practitioners must plan for and ensure effective communicationwith an approach adapted to suit the individual child.3.21The Children Act 1989 places a duty on local authorities to ascertain the wishes andfeelings of a child before making any decisions concerning him or her and to givedue consideration to those wishes. The Children Act 2004 (Part 5 section 53)amended The Children Act 1989 and placed a new duty on local authorities toascertain a child's wishes and feelings and give due consideration to them, (withregard to age and understanding). This must be done in relation to assessments ofchildren in need under section 17 and in relation to child protection investigationsunder section 47 of The Children Act 1989.3.22Just because a child does not use oral language it does not mean they have nothingto say. It has become more straightforward to work with children and young peoplewho do not have English as a first language; it is much more complex to be able toprovide the wide range of communication aids that are tailored to individuals witha whole range of needs3.23Some children and young people with cognitive difficulties or learning disabilitiesmay have a limited use of language, both in terms of what they understand andwhat they can communicate to others. They may communicate using objects, signsorsymbolsthroughsystemssuchasMakatonandPictureExchangeCommunication System (PECS) an understood ’formal code’ A small number ofchildren and young people, such as those with multiple difficulties do notcommunicate using a shared and agreed system, they communicate using a systemthat is individual to them such as using gestures, non-verbal body language,vocalisation or sounds and changes in mood and routine.3.24The voice of the child is a familiar theme for professionals working with children;this voice should be heard from all children regardless of the communicationmethod. It is for professionals to make enquiry as to how they might best attemptcommunication, familiarise themselves with a communication passport or establishif there is another professional who is able to communicate with the child oradvocate on their behalf.30Serious Case Review: Hertfordshire LSCBFinding 1: A failure to obtain an understanding as to how children with different orcomplex communication needs express themselves and communicate, from thosewith the expertise, leads to the child’s voice not being heard.Ascertaining how a child communicates and what they are “saying” is key to safeguardingthem. Practitioners must plan for and ensure effective communication with an approachadapted to suit the individual child, drawing on the skills of others in the professionalnetwork as appropriate.Does the Board recognise this as an issue?Given the National prevalence of this as an issue in past Serious Case Reviews isthere a pool of good practice that could be drawn upon?Is there an opportunity to learn from practices used within the adult disabilityteams and Speech and Language Service to assist in better communication withchildren?Is the Multi-agency network sufficiently aware of the use and meaning of“communication passports”?Speech and Language Service reported to the review that they were training morepeople and raising awareness. Was the board aware of this change and how mightthe Board support this work?How might the Board monitor the impact and progress of action taken?Finding 2: There is multi-agency confusion in Hertfordshire about the child in needprocesses for disabled children leaving them without effective outcome focussedplans and multiagency reviews.How did it manifest in this case?3.25Child A was known to the Disabled Children Team from birth as a child in need.The Hertfordshire procedures make clear that for every child in need there shouldbe a child in need plan in place, a working agreement drawn up with parents,regular child in need multi-agency meetings and reviews.There are also clearguidelines for how often children in need should be visited by their social worker.For disabled children the procedures make a distinction between those disabledchildren who are children in need, but require package of support services in thelong term to ensure their well being, and those disabled children who are childrenin need because of their family circumstances, who are also known as complex childin need cases. Those needing services will be allocated to a professional assistant31Serious Case Review: Hertfordshire LSCBrather than a qualified social worker, and their package of support should bereviewed twice yearly.3.26During the period under review there was no evidence that there was a child inneed plan with outcomes and services associated with it for Child A. There were nochild in need reviews, and therefore there was no opportunity to consider thesignificant changes in Child A’s circumstances or the concerns raised by school.3.27In March 2012 Child A’s Mother was arrested for assault whilst drunk, and he wasleft in the care of Stepfather, someone whom the services knew little about. He wasmade subject to a child protection enquiry in October 2012, but this led to no planor review. When he was found to have a burn to his foot, concerns were expressedinitially about how this had happened, and whether Mother had sought medicalhelp quickly enough. The hospital decided that the injury was consistent with theexplanation provided, and there were no safeguarding concerns. However, thisshould have been considered in the context of the child in need process.3.28Over the period of the review Child A was only seen sporadically and there were novisits to school or home to see him from November 2012 to March 2013. This was aperiod when the school became increasingly concerned about small injurieswithout explanation, missing equipment and Child A looking unkempt, somethingschool communicated to the social worker, but without being clear what theywanted to happen next.3.29At this time Mother also had a baby, born prematurely in December 2012 and whostayed in special care for a period of time.3.30The absence of any multi-agency child in need meetings meant that thisinformation was not connected together, and the needs of Child A were lost as aresult.What makes this an underlying pattern rather than a one off incident in thisparticular case?3.31There were no child in need processes across the whole review period. There wasno evidence that this absence was discussed within social work supervision.Conversations with the review team and case group also suggested that child inneed processes for disabled children are not well embedded in the multiagencynetwork because no one agency was clear about whether there should have been“child in need” meetings, reviews or plans or sought to explore why child in needprocesses were not taking place.32Serious Case Review: Hertfordshire LSCBHow widespread and prevalent is the pattern?3.32It has not been possible to establish how widespread or prevalent a pattern it is inHertfordshire. The absence of “child in need” meetings, effective outcome focussedplans and reviews were highlighted as a national issue in the Ofsted thematicinspection of the protection of disabled children. The confusion about who shouldensure that all services for disabled children are coordinated across the multi-agency network has been highlighted by Every Disabled Child Matters review ofKey Working processesvi and is part of the Government proposals “Support andaspiration: A new approach to special educational needs and disability”vii wherethe importance of clear key working arrangements for disabled children ishighlighted as of critical importance to their wellbeing in the long term.Why does it matter?3.33The child in need process is a critical factor in ensuring the wellbeing and outcomesof vulnerable children and young people, and the Children Act 1989 made clear thatDisabled Children (in the context of the local authorities definition of disability)would automatically be considered as children in need, because of the importanceof services to promote their positive wellbeing and outcomes.3.34The critical issue here is determining what the needs of a disabled child are. Goodquality assessment is crucial. For some children the outcome of the assessment willbe services focussed specifically around the nature of their disability and for othersit will be needs arising from both their disability and family circumstances, muchlike any other child in need. It is therefore important that there is a clear plan inplace. The purpose of this is to set a plan of action, based on the assessed need. Thismakes clear to young people how the Local Authority plans to support them andensures that parent’s/carers know what is required of them to promote theirchildren’s outcomes. It also creates the framework for multi-agency work. Theultimate aim is to improve children’s outcomes and so the review mechanism is anessential part of the process. This enables progress to be marked, and servicesprovision to be amended if necessary.Finding 2: There is multi-agency confusion in Hertfordshire about the child in needprocesses for disabled children leaving them without effective outcome focussedplans and multiagency reviews.“Life chances for the approximately two million children in England identified with SEN orwho are disabled are disproportionately poor”. Department of Education 2011viiiEffective outcome focussed child in need plans, which are regularly reviewed, in a multi-agency context and where necessary revised in the light of changing circumstances are33Serious Case Review: Hertfordshire LSCBessential to ensure positive outcomes for disabled children. The child in need processes fornon-disabled children are clear, but for disabled children in Hertfordshire there aredifferent pathways depending on their family circumstances. It is essential that allprofessionals are clear about what the “child in need “status means and the multi-agencynetwork are aware of what should be expected for disabled children and their families.Does the Board recognise that this is an importance issue for disabled children andtheir families?Are the Board aware that there is potential for agencies to have a misunderstandingof when Child in Need processes should be applied for disabled children and theirfamilies?Is there more the Board members could do to establish the extent of this issue, e.g.case audit?What can the Board do to address the confusion identified in this review?How will the Board know that the partnership have been successful in ensuring thatChild in Need processes is embedded in multi-agency practice?Finding 3:There is a Professional unwillingness to label the early signs of poorquality care provided to disabled children as Neglect leaving those children’s needsunaddressedHow did it manifest in this case?3.35Child A is dependent on a range of equipment to help him hear and communicate.This equipment is vital to enable him to take part in family life and engageeffectively with education and other activities. There were concerns over a longperiod of time about Child A arriving at school with broken or missing equipment,or reports that the equipment was not being used at home. This meant that ineffect, Child A could not hear and could not communicate. There were additionalconcerns about his wheelchair and missing wheelchair appointments.3.36The school addressed this directly with Mother, and in the short term some aspectsof this changed. In the longer term this remained a “persistent” problem. Theseconcerns were communicated to the disabled children team social worker overtime as each individual concern was raised, but without any analysis of what theissues might mean for child A or without the school communicating that it wasconcerned that his needs were not being effectively met and this might be the earlysigns of neglect.3.37These concerns were also raised as part of the Child Protection Core Assessmentthat was undertaken in September 2012 but they were not sufficiently analysed in34Serious Case Review: Hertfordshire LSCBthe context of Child A’s individual needs. There was no clear plan developed as partof the conclusion of the assessment and the absence of any multi-agency meetingmeant that they were dealt with incident by incident, rather than being seencollectively as early evidence of neglect, which required a proactive response.3.38Child A also appeared at school with a number of small injuries which wereunexplained and in January he was seen at school with a burn. Mother was notalways entirely clear about how these injuries were caused, but they were notnamed as part of a wider pattern of neglectful care.What makes this an underlying pattern rather than a one off incident in thisparticular case?3.39The case group told the Review team that there was a reluctance to label concernsabout the quality of care received by disabled children as neglect in the earlystages, partly because of concerns about having sufficient evidence to do so, andpartly because they were aware of the pressures on parents and families. Therewas concern that labelling early difficulties as neglectful might be unfair on parentsand not be respectful of the additional challenges facing families as they saw it. Thecase group said that they were not unwilling to address the difficulties, justunwilling to label concerns of neglect at an early stage. This is also recognised as anational concernix.How widespread and prevalent is the pattern?3.40It has not been possible to establishthenumberofdisabledchildreninHertfordshire about whom there are early concerns about neglectful care.Nationally research shows that disabled children are more likely to be neglectedbut less likely to be assesses or recognised as being neglected.Why does it matter?3.41Childhood neglect is a significant issue which has the potential, to damagechildren’s well-being and developmental outcomes in the short and longterm. Recent research suggests that early identification and early help is essentialto prevent the development of chronic neglect. The paradox is that researchxsuggests those professionals are often reluctance to name “neglect” in these earlystages.3.42Disabled children are more likely than non disabled children to be neglected andchildren with communication and sensory impairments are particularly vulnerable.A recent thematic review by Ofsted suggests that although disabled children aremore likely to be abused, they are less likely to be subject to safeguarding processes35Serious Case Review: Hertfordshire LSCBand that professionals are reluctant to identify disabled children as experiencingneglect.3.43The work of Wonnacott and Kennedy (2012)xi suggest that professionals can adoptan approach whereby they feel sorry for parents because of the perceived burdenof caring for a disabled child. Parents can be seen as struggling to meet the needs ofadisabledchildbecausethedisabilityplacespressureswhichcauseunderstandable stress, which accounts for the poor quality of care seen. This canlead to inappropriate professional practice which accepts a poor standard ofparental care for disabled children and which does not focus on parental attitude tochildren’s needs in the context of their disability.Finding 3: There is a Professional unwillingness to label the early signs of poorquality care provided to disabled children as Neglect leaving those children’s needsunaddressedDisabled children are less likely to achieve as much in a range of areas as their non-disabledpeers. Improving their outcomes..... will help them to achieve more as individuals. It will alsoreduce social inequality, and allow communities to benefit from the contribution that disabledchildren and their families can make, harnessing their talent and fostering tolerance andunderstanding of diversity. Aiming High for Disabled Childrenxii.Disabled children are more likely to be neglected than non disabled children and neglecthas a profound impact on the outcomes for all children. The recognition of neglectful careat an early stage is essential, so that plans can be put proactively in place to promotedisabled children positive outcomes and for lack of progress to be noted and addressed.Do the Board recognise that this is an important issue?What has been the impact of work previously done to address this issue?Is the Board aware of specialist assessment tools and frameworks that could aidprofessional practice in this area?What other strategies could the Board adopt to encourage all professionals to beproactive in recognising and addressing early neglect for disabled children?How will the Board know that the partnership has been successful in addressingthis issue?Finding 4: A parent or carer not taking a child to health appointments, particularlywhere the child is additionally vulnerable, should be an indicator that the child maybe at risk which should result in proactive follow upHow did it manifest in this case?36Serious Case Review: Hertfordshire LSCB3.45Child A is a wheelchair user. In October 2011 the Occupational Therapy serviceswas contacted by the wheelchair services regarding a missed appointment. Whenasked at school about this, Mother said she had not received a letter and was notsure if they held her new address. School suggested she contact the serviceregarding this and to make a new appointment. It is unclear if this happened, butlater that month Mother told the school via a note in the diary that Child A’s wheelchair had tipped over and Child A had hurt his face. School again advised Mother tocontact wheelchair services. There was no response for three days from Mother.3.46The Wheelchair services analysed the records and reported to the review alongwith a chronology of events. The records indicate that during 2011 there wereseveral appointments and that letters were sent to parents, the appointments weresubsequently not attended. The letters sent to parents as a result of the DNA werevague in that they did not offer another appointment but advised that if they hadreasons of ill health then they would hold a place on the waiting list and reschedule.The policy was that if the child did not attend 2 appointments then they wereremoved from the list. Subsequently it also came to light that two of theseappointments were sent to the wrong address. The net result was that Child A wasdischarged from the wheelchair services in July 2012 because Mother had not beenin touch.3.47The next appointment sent to new address however was also not attended andthere continued to be a delay because of re-scheduling of appointments. In theinterim however Child A was regularly seen at school by the OccupationalTherapist (OT) whom the wheelchair service maintained contact. The OT advisedthat under normal circumstances the client would have an annual assessment so itdoes not appear that there was felt to be any urgency in assessing him.3.48The first recorded assessment therefore was in January 2012 a year after the firstrecorded request. Although the chair itself was assessed by the wheelchair serviceat school following a referral from the OT because it was noted to be tipping andwas subsequently checked for safety and stability. A new prescription was finalisedin March 2013.3.49Thereafter maternal access to the service became regular and there was continuityof care because Child A was seen by the same core of therapists. There were severalface to face assessments so he was monitored for the impact of growth on hiswheelchair usage. Concerns that he may have outgrown the chair were unfoundedand in part due to poor positioning. Repairs were undertaken in a timely way.What makes this an underlying pattern rather than a one off incident in thisparticular case?37Serious Case Review: Hertfordshire LSCB3.50Records confirm that efforts made by the service to make contact via otherprofessionals (OT) and in writing. These additional efforts recognised the need forattendance but still resulted in discharge in accordance with the policy. Given theoverall family context in which this was happening a more proactive investigationmay have been warranted.3.51There was some discussion amongst the case group professionals that such “wasnot taken” events are treated differently by different agencies and that there wasno uniform approach, so for example non- attendance at a speech and languagesession would lead to a more proactive investigation as to the reason for missingthe appointment than was the case with the wheelchair services. There wasrecognition that this was an issue and that there should be a uniform approach.How widespread is the pattern3.52This has been and remains a National issue, a recent paper by Catherine Powell andJane Appletonxiii (2012) discusses the notion that missed healthcare appointmentsby children and young people should be reconceptualised as “was not brought”. It isnoted that this is not a new concept citing a number of early publications whichallude to this same issue.How prevalent is the issue?3.53In discussion with the review team the heath representative suggested that thedata would be available for each service but not across the diversity of servicesprovided, it was also the case that this data would not show if the person inquestion also had additional vulnerability or emergent concerns. This picture isreflected nationally.3.54Across the whole population and health economy this is a very big issue. It isestimated that missed appointments have a financial cost of around £700 million(BBC report March 2012xiv) with up to six million appointment slots wasted. Inmany cases this is simply adults forgetting to attend their own appointments.3.55It is the case that Powell and Appletonxv note that more work needs to be done todetermine the missed appointment rates for the whole child population as well asin cases where there maybe emergent concerns.Why does it matter?3.56The issue of non attendance or “DNA” at medical appointments is a significantnational issue and much work has been undertaken to understand and reduce thelevel of non attendance. However, there remains a routine response by providers38Serious Case Review: Hertfordshire LSCBwhen individuals fail to attend for health appointments. The current nationalapproach is that if two appointments (occasionally three) are failed, the patient isdischarged from care and referred back to their GP.3.57There is little recognition within this policy of the vulnerability of children andyoung people. For children and young people access to health care is a fundamentalright (UN Convention on the rights of the child) yet they are often dependant onparents and carers to ensure they have access to this. It has also been recognisedthat the failure of parents/ cares to ensure that their children attend healthappointments is connected to issues of child neglect and emerges as a significantissue in serious case reviews. Children and young people’s right to health care is anissue which the current “DNA” policy does not address.3.58Missed appointments are a prominent feature in previous serious case reviews.Thinking about missed appointments in the terms of “was not taken” encourageschild focused practice. Failing to ensure a child’s access to health care is within thestatutory definition of neglect.3.59In the 2008 study by Rose and Barnesxvi of a selection of 40 serious case reviewsCritical incidents such as missed appointments were often noted, but there was afailure to be proactive in following this up or seeing it in the context of what elsewas happening for the child and family. Neglect was noted to be a significant featurein the cases, alongside parental substance misuse and adult mental healthdifficulties. Several of the children had outstanding health needs due to disability,chronic health problems and/or being born pre-term.3.60The National Institute for Health and Clinical Excellence Guidance (2009) When tosuspect child maltreatment.xvii Says that professionals should ‘consider neglect ifparents or carers repeatedly fail to attend essential follow-up appointments that arenecessary for their child’s health and well-being.’3.61There does not seem to be consistency across different services or areas andperhaps in response to previous review findings some areas have policy regardingChildren and Young Person “DNA”. East London NHS has a current policyxviii whichin summary states:“The staff member has an individual professional responsibility to respond to failureto attend an appointment in a manner based on an assessment of the service user’srisk and need status.”…“In accordance with the Trust policy discharge from care should only occurafter careful consideration and in the context of safeguarding and childprotection concerns.”39Serious Case Review: Hertfordshire LSCBFinding 4: A parent or carer not taking a child to health appointments, particularlywhere the child is additionally vulnerable, should be an indicator that the childmaybe at risk resulting in proactive follow upMissed appointments have been a prominent feature in previous serious case reviews.Changing the terminology from Did Not Attend (DNA) to Was Not Brought (WNB),alongside raising professional awareness of the implications for children and young people.encourages child focused practiceFailing to ensure a child has access to health care is within the statutory definition ofneglect.Has the Board responded to this issue previously following a Review?Does the Board have access to data which would inform the prevalence of the issue?Does existing policy in this regard take sufficient account of the needs of childrenand vulnerable people to be taken to appointments?Do all those working with children have a consistent proactive approach tofollowing up missed appointments?Could the Board adopt policy and procedures being used elsewhere that wouldassist in encouraging a child focus to missed appointments across all services?Finding 5: There is a pattern of uncritical acceptance of parental self report byprofessionals in all agencies which leaves Childrens needs and circumstancesunassessed3.62Partnership practice with parents is important where there are concerns aboutchildren’s welfare. Munroxixin her review of the child protection system highlightedthe importance of developing effective relationships with parents, to achieve betteroutcomes for children. The concept of partnership practice has recently beendefined as “Authoritative Practice” where professionals treat parents/carers withrespect and empathy, but are also clear about appropriate and positive challenge.xxHow did it manifest in this case?3.63Two Core Assessments were carried out as part of the Child Protection response toconcerns about Stepfather’s history of violence, drug and alcohol problems and hisconviction for endangering his own child. On both occasions, parental self reportabout incidents and behaviour were accepted without critique.3.64For example, Stepfather was asked about the incident which had led to the currentassessment. He was reported to the police for being drunk and driving on the road40Serious Case Review: Hertfordshire LSCBon a motorcycle with sibling 1 on the handlebars. Stepfather said that “he had onebeer” although the information provided as part of the Child Abuse InvestigationUnit referral (CAIU) said that he was twice over the legal limit for driving. Thisminimisation of what were serious concerns about alcohol use and the impact onStepfather’s behaviour was accepted without comment.He was said to beremorseful, and to have learnt his lesson. This does not chime with the “nocomment” interview he provided to the police, or his being found positive for usingcocaine two and a half weeks later.3.65Mother told the assessing social worker that she had not been present whenStepfather had left the house with sibling 1, and that she had been angry with himfor putting sibling 1 at risk. In fact the referral from the Joint Child ProtectionInvestigation Team made clear that Mother was present had been hostile andaggressive when the police had called at the house regarding this incident, and thiswas something they were concerned about.3.66The level of self report was not recognised within the assessment and theconclusion was that Mother and Stepfather had been fully cooperative and thiscooperation and apparent openness influenced outcome of the assessment.What makes this an underlying pattern rather than a one off incident in thisparticular case?3.67The case group told the review team that a reliance on parental self report was akey issue in their work. They told us that giving parents a voice in records andassessments was important, but they reflected that this might lead to a lack ofhealthy scepticism and respectful uncertainty (Laming 2003xxi).How common and widespread is this?3.68It is unclear how common and widespread this issue is as no data is collected aboutthe extent of parental self report and its influence on decision making. This is a notan issue which is part of current auditing practice.Why is it important?3.69Assessments are the cornerstone to effective practice with children, young peopleand their families. The forward to the practice guidance regarding the assessmentframework makes clear“we cannot begin to improve the lives of disadvantaged and vulnerable childrenunless we identify their needs and understand what is happening to in order to takeappropriate action”xxii.41Serious Case Review: Hertfordshire LSCB3.70Research shows that good assessments matter, they help to improve planning andare linked to positive outcomes for children and young people.3.71The assessment framework is the national tool used to identify whether childrenare in need of services or in need of safeguarding. It was developed to provide asystematic way of analysing, understanding and recording what is happening tochildren and young people within their families and the wider context of thecommunity in which they live. The specific process for undertaking assessmentswhere there are safeguarding concerns is the Core Assessment which is defined as“as an in-depth assessment which addresses the central or most important aspects ofthe needs of a child and the capacity of his or her parents or caregivers to respondappropriately to these needs within the wider family and community contextxxiii”3.72The Assessment framework emphasises the importance of the assessing socialworker accessing information from a range of sources, the child themselves, theparents and extended family as well the multi-agency group. The expectation is,however that it is the assessing social worker who makes a professional judgementabout the meaning of the different information in the context of the needs of thechild or young person.“Working with family members is not an end in itself; the objective must alwaysbe to safeguard and promote the welfare of the child. The child, therefore, must bekept in focus”xxiv”3.73Partnership practice with parents and building relationships is an important part ofthe assessment process, as parents are often experts in their child’s life. However, itis critical that professionals maintain a level of healthy scepticism and respectfuluncertainty (Laming 2003xxv). There should be an active process of triangulatingtheinformationfrom differentsources,and establishing ether therearediscrepancies and what those discrepancies might mean for the child.Finding 5: There is a pattern of uncritical acceptance of parental self report byprofessionals in all agencies which leaves children needs and circumstancesunassessed.It is much safer for children, young people and their families if challenge of what isreported by parents is built into processes such as supervision and decision making, butalso into cultural expectations which recognise that asking questions and seekingexplanation from parents is something to be valued. A high reliance by professionals onself- report by parents brings with it significant risks of proceeding on false information.Arrangements put in place to recognise when there is insufficient challenge, and to increasethe value given to challenge, are in the interests of families and professionals. Sucharrangements can include ensuring time for in depth supervision, ensuring an independent42Serious Case Review: Hertfordshire LSCBuninvolved voice at key decision making meetings, managers modelling that challenge isacceptable, and showing how it can be done in a constructive way so that workers havemore confidence in challenging parents.Is there a collective view at the LSCB about the prevalence of this issue and the scaleof change needed around challenge with families?Is enough known about the perspectives of the workforce on this issue? Is there aview that to challenge parents is to be judgemental?How could the LSCB promote a culture where professionals are supported to bechallenging when necessary?Is there clarity about when assessments can and should be shared with multi-agency colleagues?Finding 6: The meaning given by one agency to a phrase about a client does notnecessarily have the same meaning for all agencies meaning that risk may bewrongly assessed by others.How did it manifest in this case?3.74In August 2012 the new drug agency for Stepfather became aware that he had apartner who was pregnant with their child and that there were two other childrenin the family. Stepfather also told them that he had two other children by twodifferent partners, one who was in care and one he had no contact with. The drugagency appropriately made a referral to Children’s social care because ofStepfather’s long history of offending, violence, drug and alcohol problems.Stepfather’s probation officer also became aware that he had children by threedifferent partners, and also made a referral to Children’s social care because of hishistory of violence and class A drug use.3.75A core assessment was agreed but did not start until October 2012 when Stepfatherhad been charged with endangering a child and driving whilst under the influenceof alcohol. A strategy discussion led to agreement that a core assessment would beundertaken regarding Child A, sibling 1 and unborn sibling.3.76Information was sought from probation and they provided a clear outline ofStepfathers offending history. Probation reported that they were pleased withStepfather’s progress, and that he had engaged well with all that was required ofhim. The view from Probation related to their own reporting requirements and inthe context of other offenders. It was not a viewabout whether he couldsuccessfully parent, meaning that he could manage his own alcohol and drugproblems, in the context of caring for children. Something he had recently failed todo.43Serious Case Review: Hertfordshire LSCB3.77The Drug agency also provided information about Stepfather’s long history of drugand alcohol problems. They also reported that they were pleased with Stepfather’slevel of engagement and that had complied with the testing requirements. He hadtested positive for opiates in August, but had been clean since and would bereducing his methadone prescription. The positive progress reported was in thecontext of adults who misuse drugs and alcohol, and in that context Stepfather wasdoing reasonably well.3.78The positive view from Probation and the Drug agency led to a mistaken belief thatStepfather was making progress, and that his long term difficulties were behindhim. Neither Probation or the drug agency were asked about the implications forthe future, or the implications of his long history of violence and drug and alcoholabuse on his ability to be an effective parent. The core assessment analysis was notshared with either agency, and they did not ask to see it. This meant there was noopportunity to reflect on the overly positive analysis that Stepfather had madeprogress which meant that there were no concerns.What makes this an underlying pattern rather than a one off incident in thisparticular case?3.79The case group recognised that there is often misunderstandings or confusionabout what information is required from agencies focussed on adult issues, in thecontext of children’s needs. It is clear in this case that although the Drug agency andProbation felt positive about an adult’s progress, this was not a reflection on howthey were likely to be in another context or whether this meant they posed no riskto children.How widespread and prevalent is the pattern?3.80It is unclear how widespread a problem this is, but the case group told the reviewteam that this was something they encountered on a regular basis. This is also anissue seen nationally across a number of serious case reviewsxxvi.Why does it matter?3.81Parental drug, alcohol, offending and violent behaviour all have the potential toimpact negatively on children’s lives. It is clear from research and serious casereviews that all of these adults concerns have the potential individually to causerisks to children’s lives and wellbeing, but collectively the coexistence of seriousdrug and alcohol problems, violence and offending behaviour with concerns aboutadult mental health, known as the “toxic trio” are known to be a serious risk factor.44Serious Case Review: Hertfordshire LSCBFinding 6: The meaning given by one agency to a phrase about a client does notnecessarily have the same meaning for all agencies meaning that risk may bewrongly assessed by others.Good quality assessments of children rely on effective information about the risks andstrengths that the adults in their lives pose. It is important to be clear with all agencies thepurpose of assessments, and to be clear what information is needed to assess that risk. Oneagencies “positive progress” cannot be automatically translated into a more generalisedbelief that this progress relates to another context.Are the Board aware of this as an important issue?Have the Board done any work on this previously in relation to other serious casereviews?Are the Board aware whether professionals providing services to adults are awareof the purpose of assessment of children and young people and what informationthey should be providing?Are the Board aware of whether professionals understand the importance ofsharing assessments where there is an ongoing role for that agency?How will the Board know it has made progress in this area?Finding 7: There is a pattern in Hertfordshire whereby non-resident Fathers may beexcluded from assessments and decision making about their children.How did it manifest in this case?3.82Child A’s birth Father was seen by the lead reviewer as part of the review process.It was a brief meeting as he had no involvement with professionals during theperiod of the review. He was aware that his existence and role in his son’s life wasknown of by children’s social care and the school. The assessments record that hehad contact with Child A’s, however the school believed that he was not part of thechild’s life and until the trigger incident had no knowledge that Father regularlyhad Child A to stay, and as a result this part of his life was absent from hiscommunication book. Both were clear that Child A’s birth Father did not haveparental responsibility. Since the commencement of other proceedings Father hasobtained Parental Responsibility.3.83The extent of his involvement according to Mother is recorded within assessments.There is no evidence that he was contacted or consulted at any time nor was hishome assessed for suitability for contact which was frequently overnight. He wasand had been throughout the child A’s life a financial contributor, supportedMother and Child A by assisting with transport on some occasions and had planned45Serious Case Review: Hertfordshire LSCBregular contact. There is a difference between the amount of contact reported byMother as part of an assessment and that reported by Father to the reviewer.However whatever the precise truth he was having care of his son overnight atleast once a month, probably more, and contact of at least one day most weekends.3.84There was no record of social workers attempting to contact Father and anexpressed belief that this was not possible due to the fact that he did not haveparental responsibility. In review meetings this seemed to be a major factor in thedecision not to involve him or speak to him, but of course the Stepfather who alsodid not have parental responsibility was spoken to. Not having parentalresponsibility limits the decisions Fathers can make on behalf of their children.3.85The difference in how these two men were treated and viewed is difficult tounderstand. Aside from the matter of parental responsibility being a barrier tospeaking to Father it could be that his absence from the home and life of Mothertogether with the fact that he was not readily accessible to professionals alsoinfluenced his lack of involvement in assessments.3.86Early in Child A’s school career Father had some information shared but as he didnot have parental responsibility this stopped at Mothers request. There was anassumption that Father played no other role in the Child A’s life until the triggerincident when it was realised by the school that he was still a significant part ofChild A’s life.How do you know it is an underlying pattern?3.87The case group recognised that it is common for Fathers to be marginalised,particularly when there are concerns about them. Research and serious casereviews support that this is an underlying pattern nationally.How widespread is the pattern?3.88This is a national issue and was one recognised by the review team as being presentin Hertfordshire.How prevalent is the issue?3.89No numbers relating to the prevalence of this issue within Hertfordshire have beenadduced however nationally the role of Fathers continues to surface as an issue inserious case reviews and within research.46Serious Case Review: Hertfordshire LSCBWhy does it matter?3.90 The parenting tasks undertaken by fathers or father ﬁgures should be addressed alongside those of mothers or mother ﬁgures. In some families, a single parent may be performing most or all of the parenting tasks. In others, there may be a numberof important caregivers in a child’s life, each playing a different part which mayhave positive or negative consequences3.91The Children Act 1989 and the Human Rights Act 1998 makes clear that fathersmust be involved in decision making, planning and services regarding theirchildren. Fathers have a significant role to play in children’s lives and in LordLaming’s 2009 review of the child protection system he said "Particular mentionshould be made of the part to be played by fathers, not least as good rolemodelsxxvii”. There is also significant evidence that men are often not included inmaternity care, services to support families and where children are subject to childprotection processes (Featherstone, B et al 2010xxviii). Scourfield’s researchsuggests that practitioners’ perceptions of men in child protection work was aseither threat, no use, irrelevant or absent (Scourfield 2001xxix, 2006xxx).3.92The basic rule about working with Fathers of children, who are receiving servicesconcerning their safety and well-being from the local authority children’s services,is that they should be consulted and involved in all planning and decision-makingprocesses, irrespective of whether or not they have parental responsibility. Thiscan be problematic if the Mother does not agree to his involvement. Clearly she canprevent it by withholding the name and address. However, the local authorityshould endeavour to work with her to assist her to consider the potential impact,including the benefits to the child of having his/her Father involved in the planningprocess. (Featherstone B et al 2010xxxi)3.94The Government launched its Fathers Matter campaign in 2008, and they havesince launched a best practice framework to help agencies and LSCB developeffective practice.Finding 7:There is a pattern in Hertfordshire whereby non-resident Fathers may beexcluded from assessments and decision making about their children.Fathers of Children who are receiving services concerning their safety and well-being fromany agency should be consulted and involved in all planning and decision-makingprocesses, irrespective of whether or not they have parental responsibility. The parentingtasks undertaken by fathers or father ﬁgures should be addressed alongside those of mothers or mother ﬁgures. This case has suggested that this does not always occur, particularly when fathers do not have parental responsibility, or are not present in the47Serious Case Review: Hertfordshire LSCBfamily home.Does the Board recognise this as an issue?Does the Board ask member agencies to monitor the attendance of Fathers atmeetings or know of any blockers to making the invitation or to attendance?Are policy and procedures clear around what not having parental responsibilitymeans in terms of decision making as distinct from involvement in assessments andmeetings?How will the Board know that Fathers and Father figures are integrated intoassessment process at all levels of intervention?4: Additional matters.4.1The Hertfordshire serious case review sub group raised some additional matterswhich they wished to bring to the attention of the LSCB. These were not consideredin detail with the case group and review team. There is no evidence as to howwidespread or prevalent the issue is and they maybe case specific. These mattersare not presented in the learning together “anatomy of a finding” format.Escalation process4.2There were occasions when the school raised concerns with other agencies,particularly with social care. They were not always satisfied with the response theyreceived. However there is no evidence that this dissatisfaction was at anytimeescalated by use of existing policy and procedure. It is not clear why this would beand as stated above this issue was not explored with the review team and casegroup.4.3Such policy is formulated and agreed when there are no issues and are intended toprovide a clear professional framework for when issues do exist. This case seemedto be an occasion where the policy should have been “taken off the shelf”. Whilstonly speculation, perhaps some consider that the use of a formal policy coulddamage relationships with those they have to do daily business with.4.4The LSCB may wish to do further work to understand what the underlying patternis and if it was a circumstance that pertains to just this case or if it is a morewidespread issue. In either case it would be prudent to reinforce with the multi-agency partnership the fact that the policy exists and that practitioners should feelfree to revert to the policy.48Serious Case Review: Hertfordshire LSCB4.5It is recommended that the LSCB remind all agencies that policy and proceduresprovide a professional framework which staff must not be reluctant to use.Re-commissioned services may become vulnerable4.6This issue came to light in relation to services provided to an adult, Stepfather.Changes to the drug and alcohol service happened in August 2012 and Stepfatherwas transferred to a new drug and alcohol agency, as part of the initial assessmentof his needs he told the drug and alcohol worker about his family. Because of thelack of staff at this time, a full parenting assessment was not undertaken, nor ahome visit as would be expected. The capacity issues for the Drug and Alcoholagency meant that Stepfather had contact with a number of staff over time and thisinconsistency meant that no one person was able to reflect on the implications ofthis escalation for Child A and his siblings. In conversation one worker said that thechanges of staff that Stepfather encountered would not have suited his personalitytype and was unsettling for him.4.7This is a complex issue for LSCB’s to be able to tackle, particularly in instancessimilar to this case where it is a re-commissioning of an adult service which mayhave some impact on children if they are part of the service user’s life. Clearly aspart of the commissioning process there will be regard to business and service usercontinuity plans. It is these plans that the LSCB may wish to be reassured about.4.8There is a challenge for the LSCB in firstly being notified of a plan to re-commissionservices and secondly to be sighted on the continuity plans, this could beparticularly challenging when the service in question is adult focused.Evenwithout a re-commissioning process there are challenges in assessing the risk thatadults presenting with their own issues, such as substance abuse, may pose to achild.4.9The LSCB may wish to explore a mechanism for being notified of any re-commissioning of services that could have an impact on children and to bereassured as to the effectiveness of the service user continuity plan.Assessing the risk an “adult” issue poses to children4.10It is well recognised that working effectively with parents with mental healthproblems (which may include substance abuse) requires an holistic approach,often referred to as a ‘think family’ approach. This is in two main ways. Firstly, theimpact of parenting on a parent’s mental health must be considered; the stresses ofparenting can precipitate or exacerbate mental health issues. Secondly, it isimportant to consider the impact of the parent’s mental health on the child’s safetyand wellbeing, including the possibility that the parent may harm their child. The49Serious Case Review: Hertfordshire LSCBimplications of “Think Family” are far reaching and extend to both universal andtargeted services working with adults, children and families and working across allsectors (Think Family Toolkit. DCS 2009xxxii)4.11There may be a pattern in which key professionals may not be ‘thinking family’,meaning that a full understanding of mental health and substance misuse issuesand their impact on parenting capacity may not be reached, and potentialsafeguarding issues not identified.4.12It is recommended that the LSCB further explore how embedded the “thinkfamily” agenda is and take remedial action as appropriate.Referencesi Fish, S. Munro, E. and Bairstow, S. (2008) Learning Together to Safeguard Children:developing a multi-agency systems approach for case reviews. SCIE: Londonii Ofsted (April 2011) The voice of the child: learning lessons from serious case reviews: Athematic report of Ofsted’s evaluation of serious case reviews from 1 April to 30 September2010. Ofsted Londoniii Stalker, Kirsten and Green Lister, Pam and Lerpiniere, Jennifer and McArthur, Katherine(2010) Child protection and the needs and rights of disabled children and young people: Ascoping study. 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London.vi Every Disabled Child Matters (2012) Unlocking key working: information andtransparency for families with disabled children.http://www.edcm.org.uk/media/41865/unlocking_key_working.pdfvii Department of Education (2011) Support and aspiration: A new approach to specialeducational needs and disability - A consultation:http://webarchive.nationalarchives.gov.uk/20130401151715/https://www.education.gov.uk/publications/standard/publicationdetail/page1/cm%208027viii Department of Education (2011) Support and aspiration: A new approach to specialeducational needs and disability - A consultation:http://webarchive.nationalarchives.gov.uk/20130401151715/https://www.education.gov.uk/publications/standard/publicationdetail/page1/cm%20802750Serious Case Review: Hertfordshire LSCBix Gardner (2008) Developing an effective response to neglect and emotional harm tochildren: NSPCChttp://www.nspcc.org.uk/Inform/research/nspccresearch/completedresearch/DevelopingAnEffectiveResponseToNeglect_wda56702.htmlx Action for Children (2011) Neglecting the issue: impact, causes and responses to childneglect in the UK. 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HM Government DCSF. 2008xvii National Collaborating Centre for Women’s and Children’s Health Commissioned by theNational Institute for Health and Clinical Excellence (2009). When to suspect childmaltreatment. RCOG Press., London.xviii http://www.eastlondon.nhs.uk/About-Us/Freedom-of-Information/Trust-Policies-and-Procedure/Clinical-Policies/DNA-Policy-Childrens-Services.pdfxix Department for Education (2011) Munro review of child protection: final report - achild-centred system: https://www.gov.uk/government/publications/munro-review-of-child-protection-final-report-a-child-centred-systemxx The term authoritative practice is referred to in the most recent biennial review andspecifically in the Baby Peter executive summary which describes the approach aschallenging and confronting about parenting, setting clear targets with short timescalesand discovering motivation and capacity to be aresponsible parentxxi Laming , H. (2003) The Victoria Climbie Inquiry: report of an inquiry by Lord Laminghttps://www.gov.uk/government/publications/the-victoria-climbie-inquiry-report-of-an-inquiry-by-lord-laming51Serious Case Review: Hertfordshire LSCBxxii Department of Health (2000) Framework for the Assessment of Children in Need andtheir Families:http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdfxxiii Department of Health (2000) Framework for the Assessment of Children in Need andtheir Families:http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdfxxiv Department of Health (2000) Framework for the Assessment of Children in Need andtheir Families:http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdfxxv Laming , H. (2003) The Victoria Climbie Inquiry: report of an inquiry by Lord Laminghttps://www.gov.uk/government/publications/the-victoria-climbie-inquiry-report-of-an-inquiry-by-lord-lamingxxvi Department of education (2009) Understanding serious case reviews and their impact:a biennial analysis of serious case reviews between 2005 and 2007:https://www.gov.uk/government/publications/understanding-serious-case-reviews-and-their-impact-a-biennial-analysis-of-serious-case-reviews-between-2005-and-2007xxvii The Lord Laming. The Protection of Children In England: A Progress Report. HMGovernment 2009.xxviii Featherstone, Brid; Fraser, Claire; Lindley, Bridget; Ashley, Cathy (2010) FathersMatter: Resources For Social Work Educators. Family Rights Group.xxix Scourfield, J. (2001) Constructing men in child protection work, Men and Masculinities,4, 1: 70-89xxxScourfield, J. (2006) The Challenge of Engaging Fathers in The Child Protection Process.Critical social Policy, 26, 2: 440-449xxxi Idemxxxii Department for Children, Schools and Families. 2009. Think Family Toolkit, ImprovingSupport For Families at Risk, Strategic Overview. Department for Children, Schools andFamilies. 2009