Head injury to 11-week-old baby boy admitted to hospital in November 2012. The injury was later found to be a skull fracture believed to be due to a non-accidental head injury. Baby W and his 3-year-old brother Child Z were taken in to care, and later adopted, following the incident. Child Z had previously been identified as a Child in Need due to concerns about neglect. A decision for this case review was sought retrospectively since Sunderland Children Safeguarding Board was not notified in 2012 about the incident. Mother, who was 17-years-old when she first became a parent had been living with her grandparents, who were seen by professionals as a supportive factor. She moved into her own accommodation following the birth of Baby W. Mother had a history of: concealment of pregnancies, lack of engagement with professionals and neglectful parenting. The father was not known to any services. Issues identified include: lack of detailed awareness of Unborn Baby Procedures and their relationship to Child Protection Procedures; limitation to professionals' understanding of the impact of neglect on children's development; poor record keeping; and a lack of supportive opportunities to reflect on practice. Recommendations include: practitioners should have access to information about the tools to use in assessment; partner agencies should ensure chronologies of 'significant events' are used and maintained; and a Multi-Agency Neglect Strategy should be developed.
      
 Title:  Serious case review: Baby W and Child Z: overview. LSCB: Sunderland Safeguarding Children Board Author: Linda Richardson 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.                             1          Serious Case Review     Baby W and Child Z (The SSCB has used a pseudonym to protect the identity of the child and family)          Publication Date: 6 September 2016         2  Contents           Page No   1. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews (SCRs)   3  2. The decision to hold a Serious Case Review        3  3. The approach used          3  4. The family’s perspective          5  5. The family as known to agencies         6  6. Analysis of Practice (ASP)         11   ASP 1:   Undertaking Effective Assessments      12 • Unborn Baby Procedures and Pre-Birth Assessments  • Quality of Initial and Core Assessments • The extent to which professionals considered parental neglect • Understanding Professional Reasoning   • The importance of chronologies and quality recording  ASP 2:  The extent to which professionals communicated and worked   21  collaboratively  ASP 3:   Working with Parents who are resistant      24  ASP 4:   Supervision and Managerial Oversight     26  ASP 5:  The SCR Process         28  7. Findings and Recommendations        29 8. Concluding Comments         33    Appendix 1: Summary of Recommendations for Sunderland Safeguarding Children Board  34 Appendix 2: Single Agency Learning        35 Appendix 3: How has the learning from this SCR improved practice?    37 Appendix 4: Learning and Improvement Workshops – Impact as described by staff  41                      31. Local Safeguarding Children Boards (LSCBs) and Serious Case Reviews 1.1. The main responsibilities of Local Safeguarding Children Boards (LSCBs) as set out in section 14 of the Children Act 2004, are to co-ordinate and quality assure the safeguarding children activities of member agencies. The statutory guidance1 which accompanies legislation and which underpins the work of LSCBs is very clear in its expectation that when things go wrong for children, through death or serious injury from maltreatment, there needs to be a rigorous, objective analysis of what happened and why, so that important lessons can be learnt and services improved in order to reduce the risk of future harm to children. There is an expectation that these processes known as Serious Case Reviews (SCRs) should be transparent with findings of reviews shared publicly. 2. The decision to hold a Serious Case Review (SCR) 2.1. Baby W was admitted to hospital in November 2012 aged 11 weeks. He was later found to have sustained a skull fracture believed to be the result of a non-accidental injury. Both Baby W and his three year old brother, Child Z were placed with foster carers until further enquiries were made. The local authority began Care Proceedings in December 2012 and both children were adopted together in 2014.   2.2. The injury to Baby W in November 2012, should have led Children’s Services to notify Sunderland Safeguarding Children Board (SSCB) at that time that a serious child care incident had occurred so a decision could be taken about whether the circumstances met the criteria for a SCR. This did not happen.  When the Chair of the Adoption Panel learnt of the circumstances under which these children had been removed from the care of their mother, she queried with SSCB why a Serious Case Review had not taken place at the time of the injury to Baby W.  It was only at this point that it became apparent that SSCB had not been notified of the serious incident relating to Baby W and a decision was sought retrospectively as to whether a SCR should be undertaken.     2.3. The Independent Chair of SSCB took advice from the Learning and Improvement in Practice Sub-committee2 and the National Panel and concurred with their view that the circumstances, which led to the injuries sustained by Baby W, met the criteria for a Serious Case Review and despite the lengthy delay, commissioned this review in 2015.  The further delay in the commencement of the SCR was a result of practical considerations arising from other SCRs being undertaken by SSCB during 2015.  3. The approach used  3.1. A Review Team of senior professionals, representing the agencies that had been involved with the family was established.  Their role was to provide strategic information about their agencies’ involvement and to identify learning for their agency through the submission of an Agency Learning Report.   The members of the Review Team were: Linda Richardson    Lead Reviewer                                                  1 Working Together to Safeguard Children 2015 DFE 2 This is a sub group of SSCB, which reviews practice and takes the lead on ensuring continuous learning and development across all agencies.    4Lynne Thomas     SSCB Business Manager  Team Manager    Northumbria CRC Head of Lifelong Learning and   Sunderland City Council  Educational Attainment  Strategic Manager    Sunderland City Council Named Nurse     City Hospitals Sunderland Operations Manager   Community Safety & Safeguarding-Gentoo  Safeguarding Children Lead Nurse  Sunderland CCG and Designated Nurse LAC Acting Head of Community    Sunderland City Council and Family Wellbeing Lay Member       SSCB  Deputy Head of Safeguarding    Northumberland Tyne & Wear NHS &Public Protection  Detective Inspector     Northumbria Police  Lead Nurse Safeguarding    South Tyneside NHS Foundation Trust  Named Professional for Safeguarding   North East Ambulance Service NHS Trust  Vulnerable Groups  3.2. Members of the Review Team also identified frontline practitioners and first line managers who were known to, or had worked with the mother of Baby W and Child Z. These practitioners formed the ‘Practitioner’s Group’ and they met on three occasions. Given the significant time delay of this SCR, not all the practitioners who had been in contact with the family were still in post. However, all the practitioners who attended the meetings accessed agency records and offered useful insights to practice and systems in place at the time.   Practitioners involved in the SCR were as follows:  Midwife 1     City Hospitals Sunderland Midwife 2      City Hospitals Sunderland Contraceptive Services Nurse   City Hospitals Sunderland Art of Living Manager,     Gentoo Neighbourhood Enforcement Officer  Gentoo Practice Manager    GP Surgery Health Visitor 1      South Tyneside NHS FT Nursery Nurse 1    South Tyneside NHS FT Social Worker 2     Sunderland City Council Social Worker 5     Sunderland City Council Operational Manager    Sunderland City Council Principal Social Worker    Sunderland City Council  Early Years Worker    Sunderland City Council  Team Manager 1 (conversation only)  Sunderland City Council  Team Manager 2 (conversation only)  Sunderland City Council   3.3. The Review Team was faced with several challenges in scoping this SCR, both in terms of timescales and identifying key lines of enquiries. The period which appeared the most obvious to consider was the involvement of professionals from late 2009 when the mother became pregnant with her first child through to November 2012 when both children were removed from her care. Current thinking suggests the most valuable lessons for agencies are identified when the SCR process examines practice less than two years old as looking further back carries the risk that the SCR identifies issues which have since been addressed by agencies. The Review Team was mindful of this and of the context in which the review was taking place.    53.4. During the last three years, SSCB has undertaken six SCRs, which relate to the death or serious injury to babies under the age of 1 year old.  These SCRs had all been concluded, although not published, at the point at which the decision was taken to undertake this SCR.  The Review Team were therefore left to consider how best to identify learning from this SCR and concluded that the starting point should be an acknowledgment of previous findings and an exploration and identification of any systemic failings which were still not being addressed.  However, the context in which this review took place was also an important consideration for the Review Team.  In July 2015, Ofsted found ‘serious and widespread’ failings in the care of vulnerable children in Sunderland. The authority was judged to be inadequate and commissioners were appointed to oversee improvements across Children’s Services. Inevitably, some of the findings in this SCR resonate not only with previous SCRs, but also with the findings from the Ofsted report. Where this became evident to the Review Team, references are made in the corresponding text.   3.5. The Review Team was particularly mindful of the potential and actual impact of the Ofsted findings on staff morale in Children’s Services and the difficulties many practitioners can experience working in an authority during such challenging times. Every effort was made to ensure that the practitioners who were involved in the SCR process had access to support and clearly understood the purpose and remit of the SCR.  4. The family’s perspective   Mother    Marie      Child Z    SUBJECT   Baby W    SUBJECT   Maternal Grandmother  MGM     Maternal Great Grandmother  MGGM      Maternal Great Grandfather MGGF  4.1. The Lead Reviewer met with Marie and both of her grandparents as part of the SCR process and discussed with them their views about professional involvement when Child Z and Baby W were living in the family.   4.2. Both Marie and her grandmother (MGGM) did not agree that professional concerns about Marie’s lifestyle and her care of Child Z were justified. They insisted that the information presented during court proceedings was inaccurate and untrue. Specifically, Marie and MGGM said that the accounts of Marie drinking, taking drugs, and not properly caring for Child Z were false and disputed the facts surrounding many of the reported episodes contained in professional records. Marie said that when her grandparents went away for weekends, she and Child Z would usually stay at her mother’s house a few minutes away or they and her younger brother would go with her grandparents to their caravan. MGGM confirmed this information. 4.3. Marie said that allegations which had been made about her care of Child Z were always found to be untrue and were made either by family members when they fell out or by friends. Marie pointed out how unfair it was that the [previous] friend who was responsible for the injury to Baby W now had her own child and yet she, Marie, had both her children removed from her care. Both MGGM and MGGF agreed with this view. The family had tried to appeal against the decision to place the children for   6adoption but were given legal advice that in the absence of any new information, an appeal was not likely to be granted.    4.4. Marie said she was appreciative of the support she had received from the midwife (MW1) and her health visitor (HV2). However, she said that when she moved to live independently with her children, she did not get the support she was expecting but she did not pursue this with her health visitor. MGGM said she had not been concerned when Marie  moved out to live independently, she said that Marie needed more space than could be provided at their home and she knew she would keep in close contact with her family. Marie went on to explain that she was waiting for furniture to be delivered to the home and had only been there for a couple of weeks when the injury to Baby W happened. Marie again stated it was her friend who had caused the injury but did not give any more details and MGGM explained what had happened, although she acknowledged that she wasn’t present when Baby W was hurt.  4.5. Neither Marie nor her grandparents were able to say what services might have helped. MGGM said they all looked after Child Z and Baby W and were very distressed about the decisions that were taken in respect of the children. The family still have regular contact with other children in the family and photographs were produced of Marie’s niece. Marie said she had no contact at all with her sons and was not able to send them cards. 4.6. The Reviewer explained the next stage of the SCR process to the family and contact details were shared in the event they wanted more information. Marie pointed out it was over three years ago now and it was not easy revisiting everything again, she was advised that she would be contacted prior to the final report being published so she was aware of its contents and could be offered support if she felt it was needed. Marie said she was still well supported by her grandparents.  5. The family as known to agencies Background 5.1. Children’s Services were involved with Marie and her family for several years from 1997 until 2008.  Marie has lived with her grandparents for most of her life and although she has contact with her mother and sister, there are often arguments and fall-outs with these family members.  Marie’s younger brother has also lived in the grandparent’s home from a young age. October 2009- December 2009 5.2. Marie was still living with her grandparents and attending college when she became pregnant at 17. She told no one about her pregnancy and in October 2009, attended a clinic for a termination. After a scan, Marie was found to be 23 weeks pregnant; she was given counselling about her options and advised to tell a member of her family that she was going to have a baby. Two referrals were made to Children’s Services around this time, one from the Contraceptive Services Nurse (CSN) and the other from the Midwife (MW1) who completed an Antenatal Vulnerability Assessment for Marie, a few days later.  Both referrals centred on Marie’s age, her late pregnancy and wish for a termination and the apparent lack of any family support. Marie offered no information about the father of the baby and indicated there was no longer any contact between them.    75.3. An Initial Assessment (1) 3 was undertaken by a duty social worker (SW1) later that month which concluded there was no need for Children’s Services involvement as Marie had support from her grandparents, had agreed to work with a Children’s Centre and was engaging well with midwifery services.  Marie was allocated a health visitor (HV1) who visited late November and discussed with Marie the support she would receive from a Child and Family Support Worker (CFSW) and other professionals from the Team around the Family (TAF)4 process. Marie advised HV1 she would like to return to college after the birth.   5.4. The first TAF meeting was organised for early December 2009 although the midwife was not notified of the meeting and HV1 health visitor (HV1) was unable to attend on the selected date.  Marie did not attend but the meeting went ahead and CFSW and the Connexions officer devised a 7-week support plan, which they later shared with Marie.  This included Marie attending parenting classes and accessing services at a Children’s Centre.   Agency Involvement 2010 - 2011 5.5. Child Z was born in early 2010 and mother and baby were discharged to the home of MGGM and MGGF. Marie and MGGM attended two TAF meetings, both of which indicated she was managing well. Marie continued to attend the Children’s Centre on an ad hoc basis. HV1 noted Marie to be unresponsive to her advice and comments and Marie later asked for, and was given, a change of health visitor when she objected to HV1 offering her feeding advice after she had been observed ‘prop feeding’ Child Z. Although there were one or two occasions when Marie appeared to be more receptive to HV2, she more often than not rescheduled or failed to keep appointments and was frequently described as being dismissive and disinterested in any advice offered.  5.6. There were three contacts made with Children’s Services during 2010 all of which alleged that Marie was neglectful in her care of Child Z. The first, made by family members in March 2010, led to a request for Marie to call into the office. Having met with Marie, MGGM and having seen Child Z, the duty social worker (SW2) concluded that the allegation of neglect was malicious and no further action was taken. The second contact was made anonymously several weeks later and again alleged neglect of Child Z. The caller told Children’s Services that Marie had a party where property was damaged and she was using drugs and alcohol. The caller also stated that the police had been called to the property. Marie was again called into the office and she attended with baby Child Z and MGGM. Records suggest that SW3 checked with Police and decided no further action was considered necessary.  5.7. A third allegation was made to Children’s Services in July 2010 by a friend of Marie who reported that she looked after Child Z for most of the time and that Marie would leave him with anyone if she, the friend, was not available. The friend also expressed concern that Marie was not allowed to remain in her grandparent’s house most weekends as they went to their caravan and would not let Marie stay alone in the house. The caller said that Marie had to often find somewhere for her and Child Z to stay and alleged that Marie would usually pass Child Z to any adult willing to look after him. She also described Child Z, as usually being dirty and disheveled and that, at 6 months old, he was still not                                                  3 Initial Assessments are short assessments of each child referred to Children’s Services to find out whether the child is in need of services or whether there is reasonable cause to suspect that the child is suffering, or is likely to suffer significant harm. 4 A TAF meeting involves parents and professionals who are working with the family to offer additional support. The term ‘Team around the Family’ (TAF) replaced ‘Team around the Child’ (TAC) but the terms continue to be used interchangeably an agency records.    8weaned. The caller was advised to speak with Marie and share her concerns. Later that day, the caller again contacted the office to confirm that Child Z was in her care as she had been asked by Marie to look after him as she was going away for ‘a while’. 5.8. This information led to a second Initial Assessment (2), in which SW4 highlighted concerns about Marie’s parenting commitment and abilities. The assessment noted that Marie still lived with her grandparents and although they were considered supportive, a more in-depth assessment was recommended. SW5 began a Core Assessment5 in September 2010 and Child Z, who was then aged 8 months, was subsequently identified as a Child in Need following concerns about his lack of stimulation, slow development and a view that Marie’s lifestyle placed him in ‘potentially dangerous situations’. Marie was allocated an Early Years worker (EY1) to help with parenting skills. Towards the end of 2010, HV2 recorded concerns about Marie’s ability to care for Child Z when his 9-12 month developmental assessment continued to highlight delayed development.  Agency Involvement 2011 -2012 5.9. EY1 concluded her work with Marie in January 2011 after two visits indicating that Marie had a  ‘positive assessment and had demonstrated that she was able to meet Child Z’s needs’. The Review Team was unable to locate any records, which offered evidence to support this assessment or any indication that the information and analysis about Marie’s parenting abilities was shared with HV2.   5.10. In January 2011, HV2 records indicate a conversation with Marie and MGGM about a small round bruise on Child Z’s bottom. The explanation given was accepted and HV2 shared the information with SW4 who contacted her a few days later and advised that no further action was considered necessary and Children’s Services would be withdrawing their involvement with the family  ‘as Marie has engaged and completed work with the Early Years worker and is able to meet Child Z’s needs’.  There was no challenge by HV2 who told the Review Team she had no reason to question this decision as she had no significant concerns about Marie’s parenting capacity and was reassured knowing the young parent was living with her grandparents. 5.11. During a home visit by HV2 in May 2011, Child Z was described as clean and well dressed and the home was tidy. Child Z was playing with MGGM, who was singing nursery rhymes.  Marie was observed to hold and cuddle Child Z who responded by smiling.  His fine and gross motor skills were described as age appropriate although HV2 noted he was not using words or language, suggesting developmental delay. MGGM and MGGF were recorded as being supportive of Marie.  5.12. Towards the latter part of the year, Marie was taken to hospital by ambulance on two occasions following assaults on her person. She was discharged without further treatment but hospital records suggest she was intoxicated on both occasions. Neither Police nor Children’s Services were involved or notified and there are no references to Child Z in these records.  In December 2011, Child Z attended A&E following a burn to his fingertips where he had apparently touched the glass panel of a gas fire. Marie and her grandparents were given advice by HV2 about safety measures and accident prevention in the home.  Agency Involvement 2012                                                   5 A Core Assessment is an in-depth assessment carried out by a social worker.  Its purpose is to clarify and identify the needs of the child by gathering information to gain a greater understanding of a child’s circumstances.   A Core Assessment usually starts at the point at which an Initial Assessment ends.   95.13. Between January and October 2012, the health visiting team undertook fourteen home visits to help Marie learn how to stimulate Child Z and improve his language and development. Child Z’s two-year developmental assessment had highlighted continuing delay with speech and language and there were growing concerns about his fine motor skills. HV2 continued to find it difficult to engage Marie but they did agree that HV2 should pursue a request through CAF6 in order that a nursery place for Child Z could be secured.  Child Z subsequently started at nursery in April 2012 where his speech and language delay was noted. His attendance was recorded as good and Marie regularly brought nappies and changes of clothing for Child Z although it was recorded that he often arrived at nursery with a soaking wet nappy, which had to be changed immediately.  5.14. Marie did not take Child Z for his Speech and Language appointment later that month and at a follow-up appointment declined any offer of support as she said it wasn’t needed because Child Z had started nursery.  Following a conversation with MGGM and Marie, HV2 agreed to arrange for a nursery nurse (NN1) to support Marie with parenting and managing Child Z’s behaviour, which Marie said was becoming very difficult and had been noticed by Nursery.  5.15. In late June 2012, an anonymous referral was received by nursery staff alleging that Child Z had bruising to his ribs and back. Children’s Services were contacted and an immediate visit was made by SW6 as part of an Initial Assessment (3).  SW6 visited the nursery and according to nursery records ‘no bruise was found to be present’.  The assessment indicates that a conversation was held with Marie but there are no case notes, which provide detail of that conversation, or the conversation, which according to the assessment document, took place with the HV2.  In conversation with the Lead Reviewer, Marie said she was contacted by SW6 and told to meet her at the nursery where she was asked to strip Child Z to see if any bruises were evident. Marie said she informed SW6 that this was a malicious allegation probably made by a family member and reiterated that no bruises or marks were found.  At the time, SW5 was working with the member of Marie’s family who had allegedly raised the concerns about bruising. The Review Team could find no record, which suggested any conversation had taken place with this member of the family or that any liaison had occurred between SW6 and SW5.    5.16. The visits by NN1 continued - there were 9 between June and November 2012 - and records indicate that Marie appeared at times to be happy to engage with NN1.  During the summer, Marie said that she was waiting to secure her own accommodation with Gentoo. MGGM stated to NN1 that she felt the proposed property was too far away from her family and she wasn’t sure how Marie would manage.  Marie was described as being open and honest with the NN1 with strong eye contact and openly acknowledging her difficulty in accepting advice by other people, which she saw as ‘interfering’.  Marie continued to complain about Child Z’s behaviour and did not attend any further Speech and Language appointments for Child Z.  5.17. At the end of July 2012, Sunderland Midwifery services submitted a child protection referral when a scan found that Marie was 32 weeks pregnant. Marie said she had not known she was pregnant and declined to give any details about the father. A copy of the referral was forwarded to HV2 who alongside NN1 was unaware that Marie was pregnant. At this time the Initial Assessment was still                                                  6 The Common Assessment Framework (CAF) is a process for gathering and recording information about a child for whom a practitioner has concerns. It was and in some area still is, used to identify needs of the child and agree how those needs can best be met.   10open to SW6 on the system and the team manager  (TM1) appears to have directed SW6 to pursue further enquiries, as an ‘assessment for Marie’s unborn baby could be required’. The Review Team could find no evidence that any further assessments were undertaken.  5.18. According to the integrated chronology SW6 received an email from a worker in August 20127 at the Children’s Centre advising that other parents had made allegations about Marie’s care of Child Z and had passed on information, which related to an offensive image of Child Z being placed on social media by Marie and a suggestion that he was drinking from a bottle Marie used for amphetamines. The information contained in these allegations was serious but there is no evidence that they were investigated or discussed with Marie. The information was not shared with HV2.   5.19. On the 16 August, NN1 undertook a home visit. Marie, her sister and MGGM were present.   Marie was described as being very angry, although the notes do not offer any further details. Marie told NN1 that she would not take Child Z back for any speech and language appointments, as ‘there was nothing wrong with him’ and said she would not take advice from anyone about Child Z ‘still drinking from a bottle’. MGGM said Marie was often angry these days and that she and MGGF were suffering from poor health and they wanted Marie to move out.  Marie said she was waiting for a property from Gentoo to be allocated. She was asked about the father of the baby, but she said he still lived with his mother and she had no intention of sharing a house with him.  This information and the observations of NN1 were not shared with HV2 at the time.   5.20. SW6 had case supervision on 22.8.12 with a team manager (TM3) who signed off the Initial Assessment, significantly out of timescale, a few days later. There was no reference made to Marie’s pregnancy or to the request seemingly made by TM2 to SW6 to explore the need for a pre-birth assessment.  5.21. HV2 made a home visit in late August, having tried on three previous occasions to see Marie. On one visit, MGGM told the HV that she did not know where Marie would live after the birth of the baby. Marie however told HV2 that she would be moving back in to her grandparent’s home after the birth of the baby.  Marie also told HV2 about the allegations that had been made but stressed these had been shown to be ‘lies and that Child Z did not have any bruises’. HV2 was unaware of these allegations and contacted SW6 for more information. SW6 later returned the call to confirm the allegations and advise that an Initial Assessment had been undertaken but the allegations had been found to be ‘malicious and probably instigated by [a family member]’.  5.22. MW1 made three attempts to chase up the outcome of her referral made in July and was left a message by Children’s Services in August that there would be no further action taken on their part. There was no discussion about or reference to the need for a pre-birth assessment under Unborn Baby procedures.   Baby W was born in early September 2012 and was discharged into mother’s care at the address of MGGM and MGGF. MW1 called when Baby W was two days old and she noticed a small red mark on the baby’s back, which Marie said was a birthmark. The midwife accepted this although there was no documentation of such a mark on Baby W’s birth records.  MW1 did not contact HV2 to advise her about the visit.                                                   7 The Review Team were unable to clarify who sent this email. There are no records relating to this incident held at the Children’s Centre although some members of staff could recall ‘something’ from a few years previous.    115.23. HV2 made an antenatal visit and learnt that Marie had given birth a few days previously. Marie was described as ‘receptive, chatty and willing to accept support’. Marie said she was managing well and had the support of her grandparents. She confirmed she had a tenancy and was doing up the property before moving in sometime around the end of the month.   Several days later, Marie agreed to HV2 starting a CAF to allow Marie to have access to a Family Support Worker when she moved into her own accommodation.  She stated she would not be allowing family members or other people to stay in her home once she moved.   5.24. There are references in Children’s Services records to the Initial Assessment being ‘completed on 12 September 2012’ despite the apparent signing off in August. The records refer to the allegations relating to bruising of Child Z, (June 12), Marie not registering her pregnancy (unknown date) and the comments made by parents at the Children’s Centre (August 12) as all being malicious.  The records also state that neither HV2, nor nursery staff had any concerns about Child Z and that Marie was said to be working ‘positively with professionals’. There is no reference to a pre-birth assessment.  The Review Team were puzzled by the conflicting dates and entries contained in the assessment document as it appeared that the allegations were added to the Initial Assessment document retrospectively but were not actually explored as part of that assessment.   5.25. During visits by NN1 in October 2012, Marie was noted to be more engaging and receptive but admitted she did wonder how she would cope being on her own with two children and ‘having to do everything herself’.  The first complaints to Police and Gentoo of parties, noise and anti-social behavior in Marie’s property began to emerge during November 2012, although Marie and her two children were thought to have been still living with her grandparents in their home and had not yet fully moved to the new property.   5.26. In November 2012, Marie called an ambulance to her own address just before midnight. The ambulance crew noted the poor and ‘unclean’ conditions in the home and that another child was seen ‘lying on the floor’.  Baby W was admitted to hospital where he was found to have a fractured skull.  Marie’s friend accepted responsibility for the injury, which she and Marie both claimed was an accident, although the explanations given were not consistent and it remains unclear how the injury was caused.  Child Z and Baby W were subsequently taken into police protection before being placed with foster carers.  6. Analysis of Practice    6.1. It is important to be aware how much hindsight can distort judgment about the predictability of an adverse outcome. Munro (2011)8 suggests that once we know about a serious injury to a child it becomes too easy to look back and conclude that certain assessments or actions were critical in leading to that outcome. Woods (2010)9 writes that this ‘hindsight bias’ oversimplifies or trivialises the situation confronting practitioners and masks the processes affecting practitioner behaviour…. Hindsight bias blocks our ability to see the deeper story of systematic factors that predictably shape human performance’. The Review Team were mindful of the dangers of hindsight bias but wanted to understand why certain actions and decisions would have made sense at the time and importantly, what systemic factors in place then were still impacting upon practice in 2016.                                                    8 Munro E. A child-centred system DfE 2011 9 Woods D (2010) Behind Human Error   126.2. From studying key documents and listening to the views and experiences of front line practitioners involved in this SCR process, the Review Team identified ‘areas of significant practice’ (ASPs).  These areas were used to explore in detail the actions and decisions of professionals working with this family to help the Review Team understand why professionals acted as they did or why they may not have acted at all. Given that this SCR is not only historical but covers the same period as several other SCRs, there are references to previous learning throughout this section. Where appropriate, reference is also made to recent developments in agencies. Five areas of significant practice (ASP) were identified and these are discussed in more detail in the related sections below.   ASP 1:   Undertaking Effective Assessments  • Unborn Baby Procedures and Pre-Birth Assessments  • Quality of Initial and Core Assessments • The extent to which professionals considered parental neglect • Understanding Professional Reasoning   • The importance of chronologies and quality recording  ASP 2:  The extent to which professionals communicated and worked     collaboratively  ASP 3:   Working with Parents who are resistant   ASP 4:   Supervision and Managerial Oversight  ASP 5:  The SCR Process   6.3. ASP1: Undertaking Effective Assessments  Unborn Baby Procedures and Pre-Birth Assessments   6.3.1. Marie attended a Contraceptive Services clinic in mid-October 2009 asking for a termination of her pregnancy. She was 17 years old and already 23 weeks pregnant but had not told anyone including her grandparents, with whom she lived, about her pregnancy. The implications of concealment of pregnancy are wide-ranging and represent a real challenge for professionals in safeguarding the welfare and the wellbeing of the unborn child and the mother. Whilst by its nature, concealment limits the scope of professional help, experience shows that better outcomes can be achieved by co-ordinating an effective inter-agency approach once the fact of the pregnancy is established. The Contraceptive Service Nurse (CSN) upon learning of Marie’s pregnancy acted appropriately and after contacting Children’s Services, submitted a child protection referral. This was copied to the Health Visiting and Maternity services, and their associated Safeguarding Teams together with a completed ‘Health Information-Sharing Notification Form’ 10. Appointments were made for Marie with her GP and a midwife a few days later.  6.3.2.  The midwife (MW1) was aware of Marie’s family background, having supported the births of other family members. She completed an Antenatal Vulnerability Assessment when she met with Marie and although aware that a referral had already been submitted by the CSN a few days earlier, submitted another child protection referral to highlight her concerns. The responses of both CSN and MW1 demonstrated an awareness of the potential risks for Marie and her unborn baby and their response to these was appropriate. Neither practitioner referred to SSCB Unborn Baby procedures nor were they advised to do so by their respective safeguarding leads. The procedures clearly state that where there is evidence of late or concealed pregnancies, the need for pre-birth assessments should be considered. Marie was 23 weeks pregnant and had told no-one about her pregnancy, this                                                  10 This is a form used, as the name implies, to share concerns an/or specific information between health professionals.   13together with her family history and the fact she had wanted a termination, should have alerted health professionals, including the safeguarding leads, to consult the Unborn Baby procedures.   6.3.3. The response of Children’s Services to these referrals was to instigate an Initial Assessment and not a pre-birth assessment. Children’s Services held significant information about Marie’s childhood and being informed of the circumstances surrounding Marie’s pregnancy, should have also alerted them to the Unborn Baby Procedures which would in turn have highlighted the need for a Pre-Birth assessment. A Pre-Birth assessment differs from an Initial Assessment in that key professionals are brought together from the outset so that potential risks can be explored from a multi-agency perspective and plans agreed.  6.3.4. The Review Team were mindful of the dangers of placing too much emphasis on whether procedures were followed rather than whether good decisions were made but the team was unable to locate any records which referred to the rationale for the decision to undertake an Initial Assessment rather than a Pre-Birth assessment or even why one did not lead to the other. The outcome of this decision was a missed opportunity to gather and assess information from a multi-disciplinary perspective, especially in relation to the sharing of background information. The Review Team considered that the view that MGGM and MGGF were strong supportive factors for Marie began at this point and prevailed without question throughout the period professionals were involved.   6.3.5. Some of the social work practitioners and team managers involved with the family at the time are no longer working for Sunderland, but the professionals involved with the SCR suggested that the Unborn Baby procedures are probably considered more often when there are specific child protection concerns rather than being used to respond to more general ‘concerns’ around an impending birth. The view was also expressed that an Initial Assessment could always recommend a Pre-Birth assessment but it was acknowledged by professionals during the SCR process that the details of the Unborn Baby procedures were not well understood.  6.3.6. The Review Team was curious to explore why the details of these very specific procedures were not familiar to practitioners and especially to hospital staff. Health professionals informed the Review Team during this and a previous review, that they were of the view that if the Unborn Baby procedures were relevant then Children’s Services as the lead agency would instigate them. Both Marie’s pregnancies led to referrals into Children’s Services and whilst acknowledging that social workers and their managers should have been aware of these procedures, the Review Team was also of the view that as they are ‘multi-agency’ procedures, health professionals should be equally familiar with these processes.  6.3.7. There were no challenges to Children’s Services from the CSN or MW1 or their safeguarding leads when the Unborn Baby Procedures were not followed and during discussions it became apparent that none of the professionals at that time understood the circumstances under which Pre-Birth assessments could take place and how and where they differed from Initial Assessments, but importantly, neither did they see the need to refer to any procedural guidance.  6.3.8. During individual and group discussions, professionals for this review were asked about ‘when do professionals access procedures’. Suggestions were offered that when a practitioner is faced with a situation which requires professional judgement and they are uncertain about the best course of action, they are more likely to consult with an ‘experienced’ professional or someone ‘in the know’   14rather than refer directly to the procedures themselves. Some practitioners described trying to access procedures as time consuming and not always being sure about where to look– especially in times of transition. Professionals also said there was an expectation that social workers would know the procedures ‘inside out’ as they were ‘the experts’, a somewhat misguided view which has been highlighted in previous SCRs in Sunderland.  Finding 1: Children’s Social Care and health professionals were unaware of the specific detail of the Unborn Baby procedures and how these related to Child Protection procedures. This was a finding in previous SCRs in Sunderland which reviewed practice during the same period.    Quality of Initial and Core Assessments  6.3.9. Four Assessments were undertaken by Children’s Services during this period, three Initial Assessments, and one Core Assessment. The Review Team had sight of the Core Assessment dated January 2010 and the Initial Assessment which began in June 2012 but which was not completed until September 2012. Copies of the other assessments could not be located on the CCM11 system.   6.3.10. The quality of these assessments was poor: there was missing information such as the fact that Marie’s sibling also lived with the grandparents; information which conflicted with health records, no reference or exploration of relevant concerns or incidents and little to suggest that there had been meaningful exchanges of information and views with other professionals. The risks to Child Z were neither identified nor documented and allegations of poor parenting and neglect were deemed malicious, without sufficient evidence to suggest they had been thoroughly investigated.  6.3.11. The assessments, all of which were out of timescale, appeared as a collection of statements but no depth of analysis was evident. Poor analysis has been a continued and consistent theme and was identified in the recent Ofsted Inspection and other SCRs in Sunderland, suggesting that lessons have not been learnt or embedded into front line practice.   6.3.12. Undertaking assessments involves judgement and balance, with social workers needing to consider the value and likelihood of the possible benefits of a particular decision against the seriousness and likelihood of possible harm. Harm can however never be totally prevented and decisions need therefore to be judged by the quality of the decision making, not by the outcome. The Review Team were unable to determine how or why certain decisions were taken following these assessments and whilst this calls into question the practice of some frontline practitioners in Children’s Services, it also highlights shortcomings in supervision and managerial practice, a point further discussed under ASP4.  Finding: Robust assessment and decision-making depends on good internal and cross-agency practice and this was not evidenced in this SCR, a finding identified in previous SCRs. The Review Team was informed that improving the quality and managerial oversight of assessments are issues currently being addressed as part of the Improvement Plan in Sunderland. These findings also raised questions as to why poor quality assessments had not also been picked up through LSCB audit arrangements.                                                    11 Children’s Case Management   (CCM) is a recording and data collection system used in Children’s Services     156.3.13. The fact that assessments had been undertaken by Children’s Services served to reassure health professionals who told the Review Team they saw no need to challenge any of the decisions taken by Children’s Services. They believed that Children’s Services had fully assessed Marie’s situation and concluded that there were no identified risks. Health professionals did not enquire about the rationale or seek to understand the decisions taken by Children’s Services as they told the Review Team, they did not have any ‘significant’ concerns, which would merit a challenge and they were reassured because Marie lived with her grandparents. This perspective that, if Children’s Services were not concerned, other professionals could  be reassured, was also evident in a more recent SCR published in 2015.  6.3.14. Information from the Practitioners Group and the Review Team suggests that in this authority like others, there continues to be diminishing budgets and competing priorities. At the time the authority was also experiencing difficulties in recruiting staff. Research by Brandon et al (2008)12 suggests that these factors along with pressures of work can impact on the acceptance of referrals for further intervention and that ‘speed practices’ or ‘short cuts’ to manage referrals or contacts can easily emerge during these critical times. Marie was asked to call into the office on two occasions following allegations that her care of Child Z was poor. On both occasions the duty social worker considered no further action was necessary.  6.3.15. Using hindsight and knowing the eventual outcome for Baby W, the Review Team concluded it would be too simple to say home visits should have been made at the time. The Review Team were of the opinion that given other pressures in the workplace, the response to the two initial contacts would have ‘made sense at the time’ and the fact that both Marie and MGGM attended both appointments and the child was seen to be well, would have been reassuring to the social workers. The assessment that occurred after the third contact however, should have taken into account not only those original contacts but also the historical information known about the family and the very significant involvement Children’s Services had at the time with another family member.  6.3.16. There is considerable research13, which suggests that without the use of tools to assess risk, professional judgment can too often be flawed, with assessments being ‘only slightly better than guessing’.  The risk indicators in this family were not recognised by Children’s Services workers or by health professionals and consequently opportunities to challenge and manage those risks were lost. When concerns about a child are identified, professionals working with parents and families need to take account of not only current circumstances, but also past history and the potential for future harm. This means that professionals have to investigate and explore family circumstances in some detail in order to understand how the needs of a child may go unmet and how and where risk circumstances may emerge. Had professionals used tools such as the Graded Care Profile, Signs of Safety or the Sunderland Risk Assessment model14 to inform their professional judgment, they may well have been better equipped to identify areas of concerns and strengths and measure where, when and if any progress was being made.                                                   12 Brandon, M ET al:(2008) Analysing Child Deaths and Serious Injury through Abuse and Neglect: What Can We Learn? A biennial analysis of serious case reviews 2003-2005. Research Report DCSF-RR023. University of East Anglia. 13 www.rip.uk 14 The model used in Sunderland is the Bruce Thornton Risk Assessment model.    166.3.17. At the heart of good social work practice is the ability to make sound decisions about the safety of children. Decision-making tools are helpful and should only ever be used to assist in decision-making and only where the validity of such tools have been seriously explored. The Review Team was informed that the Bruce Thornton Risk Assessment model adopted for use in Sunderland is however not routinely used and neither are other similar tools used on a regular basis. Good decisions still depend upon frequent and high quality dialogue with expert practice supervisors to help develop and test hypotheses about what is happening within families but the use of tools as part of single agency and multi-agency processes can support decision-making and lead to more structured professional judgments about risks and the safety of children.  6.3.18. The Review Team was informed by practitioners that not enough information is provided to professionals about when and how to use tools to support decision-making, especially within a multi-agency setting. Time and workload pressures tend to increase the reliance upon professional intuition to make decisions and if opportunities for reflective supervision are not available, professional biases are more likely to happen.  Finding:  Without the use of shared and standardised tools to assess risk, professional judgement and decision-making is more likely to be flawed and this can leave children vulnerable. This finding was recognised by professionals as being a current issue and not just specific to this SCR.  The extent to which professionals understood parental neglect  6.3.19. From late 2009 through to early 2012, Marie appeared to have what can best be described as having an ambivalent and dismissive attitude towards professionals. She frequently ‘forgot’ about appointments, including those made for Child Z to explore his speech and language, and records suggest she ignored much of the advice given to her. There were also corroborated examples of Marie leaving Child Z, with inappropriate young people or with a particular friend for days at a time. Both health visitors noted concerns about Child Z’s development and that he was not being ‘properly stimulated’, evidenced by his poor speech and language and the delay in him reaching his developmental milestones.  6.3.20. The evidence of neglectful parenting was not however recognised by the professionals working with Marie. The approach towards Marie as a ‘stroppy teenager’ was a significant aspect of professional’s attitude towards her and seems to have led more often than not, to her being given the benefit of the doubt about her care of Child Z. There were frequent reports about Marie’s lifestyle and social life, which may not have been untypical for an eighteen year old, but should have generated greater concern about her as a young parent. It is in the interaction between the parent and child that indicators of neglect are best observed and there were several occasions recorded which refer to Marie appearing disinterested in Child Z, ‘prop’ feeding him, being left in soaking wet nappies, and being ignored by Marie when he demanded or needed her attention. At these times, Marie had to be ‘encouraged’ to see to his needs. The allegations that Marie left Child Z at weekends with ‘anyone who would look after him’ were not unfounded but there is little to evidence that this behaviour raised concerns about parental neglect.   6.3.21. Research 15 suggests that professionals most readily recognise neglect in terms of poor home conditions, rather than in terms of poor parent-child relationships. The home of the grandparents                                                  15 Brandon et al. DFE Neglect Missed opportunities  (2014)   17was described as being clean and comfortable and Child Z as he grew older, was often described as ‘well presented.’ In families where neglect is recognised as a concern, it is often the appearance of the child and the home conditions, which first catch the attention of professionals, and traditional views of neglected children have tended to rely on these physical signs. There were many recorded incidents where Marie’s behaviour clearly demonstrated the extent to which she placed her own needs above those of her child but there is little to evidence that  her  ‘neglectful’ behaviours were purposefully challenged or that issues around Child Z’s attachment to Marie were assessed or explored in any depth.  6.3.22. Marie, as an adolescent mother, was noted to have lacked the maturity and skills necessary for giving appropriate care to Child Z. Although, maternal age alone has not been shown to be a singular risk factor for injuries to children, factors such as alcohol and substance abuse are known to impact on parental behaviours in young adolescent mothers16 and Marie’s lifestyle should have been regarded as a significant risk factor, which may have suggested neglect.  6.3.23. Although limited resources or insufficient training may act as obstacles to recognising neglect and taking effective action, there is evidence to suggest (not least from analyses of Serious Case Reviews, for example Brandon et al., 2009; 2013) that there are a number of professional assumptions, or mind-sets, which prevent indicators of neglect from being acknowledged or acted upon. These include fears about being judgemental or appearing overly critical and this can lead professionals to focus more on the parent than the child. What was evident to the Review Team was that professionals did not consider in any depth Child Z’s lived experiences and what it was like for him to be passed around carers, moving from house to house when he and Marie could not stay in the grandparents’ home or what happened to him when Marie was out drinking with friends. There are few records, which describe the relationship between Child Z and Marie or any commentary, which explores Child Z’s attachment behaviours towards his mother.  6.3.24. The professionals in the TAC meetings appeared to view the TAC process as one which needed to support Marie, yet early intervention services, even at that time, were intended to be extra support for the child’s additional needs. It is difficult to see what impact the TAC and Child in Need meetings actually had on improving outcomes for Child Z, much of the recording relates to Marie’s needs rather than her child’s and the issue of her non engagement did not increase concerns about her parenting capacity or raise issues about parental neglect.   6.3.25. It appears that at the time, there was no multi-agency neglect strategy in place, in Sunderland. The Review Team was informed that a neglect strategy is currently being formulated and progressed by a senior manager in Children’s Services, although a draft could not be made available to the Review Team and none of the managers from other agencies had, to their knowledge, been asked to contribute to its development.   Finding: There was a limitation to professionals’ views of neglect, which prevented them from seeing Marie as a ‘neglectful’ parent.                                                      16 Substance Use among Adolescent Mothers: A Review Shawna L. Carroll Chapman1 and Li-Tzy Wu1 (2013)   18Understanding Professional Reasoning  6.3.26. Reference has already been made to the dangers of hindsight bias, but the Review Team was curious to understand why risk indicators were not more carefully considered and addressed by professionals. Research tells us that there are ranges of behavioural biases, which affect a professional’s ability to make objective judgements. These include, making judgements based on how easy it is to think of similar examples, (availability bias), only looking for evidence that confirms pre-existing views (confirmation bias) and the tendency to judge cases on their relative rather than objective merits. There is evidence of these biases in the work that was undertaken with Marie.  6.3.27. Munro (2010)17 argues that professionals should always take time to step back and question the assumptions, which underpin their actions and decision-making, a form of reflection she describes as ‘double loop’ learning.  The Review Team questioned some of the assumptions made by Health and Children’s Services professionals in relation to their work with Marie and the progress they perceived to be taking place. Despite the input of a nursery nurse, a child and family support worker and regular visits from the health visiting service, Child Z’s fine motor skills at 2 years old were notably delayed, he was not able to build a tower nor turn the pages of a book and he remained significantly behind in his speech and language. As he grew older, Child Z’s behavior was highlighted by Marie and nursery staff as a concern. Yet, there was no attempt by professionals to find out more about what was happening in the home or to explore in greater detail Marie’s relationship with her grandparents and importantly, the relationship they had with their great grandson.  6.3.28. The Review Team were unable to locate any assessments of Marie’s grandparents; their ability or willingness to support Marie and the extent to which they could be relied upon to protect Child Z, if they felt him to be at risk.  Our cultural vision of grandparents is informed by both myths and misconceptions that shape thinking without conscious awareness. Conventional images of grandparents tend to focus on these adults as providing care and nurturing their grandchildren. The Review Team concluded that this perception or bias was evident in the assessments and work undertaken with Marie; there were many references to the ‘support’ that Marie received from her grandparents but this ‘support’ was neither specified nor assessed, but was assumed ‘because they were grandparents ’.   6.3.29. There was little known about their views of Marie’s parenting capacity, although MGGF did share some concerns with Children’s Services because he was worried that Marie was  ‘taking drugs and drinking alcohol’. The requirement that Marie and Child Z should sometimes find somewhere to stay when they went to their caravan was never fully explored and the Review Team was unable to determine how often this happened and for how long. Professionals did not appear to be curious about these arrangements and to what extent the grandparents ‘not trusting’ Marie included her care of Child Z. The Review Team could not access any information, which described where Marie and Child Z went when they could not remain in the home of the grandparents.  Yet, the fact that Marie lived with her grandparents continued to reassure professionals and left them believing Marie and therefore Child Z, was well supported.                                                   17 Munro, Eileen (2010) Learning to reduce risk in child protection. British Journal of Social Work   196.3.30. The ‘rule of optimism’ that can affect assessment and decision-making in child welfare and child protection work is well documented.18   The descriptions of Marie as, defiant, self-centered, avoiding eye contact and not believing adults had anything to offer could be applied to many teenagers, but it appeared to the Review Team that Marie was ‘managed’ as a difficult teenager to be coaxed and cajoled rather than as young parent to be challenged about non-engagement and held responsible for the welfare of her child.  6.3.31. At the time Child Z was born, Marie was still a child herself and the view was expressed by professionals that they may have made allowances for her in that respect and perhaps placed too much emphasis on small improvements, even when these were not sustained. Professionals also highlighted that Marie could be volatile and intimidating and challenges to her behaviour or attitude often needed to be carefully managed. The Review Team considered that professionals focused on Marie’s strengths but played less attention to what was not working well and the impact this was having on Child Z. Marie did not inform professionals that she was pregnant with Baby W until she was 32 weeks and then announced that she was intending to live independently once the baby was born. This did not raise any alarm bells, despite MGGM’s view that she worried how Marie would manage living on her own. 6.3.32. There were as many as 6 different social workers who had contact with Marie during the period under review and this brings particular challenges for those workers as each one revisited incidents or allegations and appeared to ‘start again’. The ‘start again syndrome’, has proved a helpful way of conceptualising practice and decision making especially in cases of neglect. In these circumstances knowledge of the past is put aside with a focus on the present and on short-term thinking and there is evidence on work with Marie that background factors and history were not taken into consideration when considering potential risks to Child Z and later to Baby W. Practitioners also acknowledged that ‘because’ she had looked after Child Z and he remained in her care, concerns about how she would care for Baby W were minimised.  6.3.33. Professionals involved in the SCR reflected on their role in working with Marie and repeatedly concluded that because she was living with her grandparents, any risks to Child Z or later Baby W would be identified by them and reported. They persisted in their view that Marie’s grandparents were supportive, despite some evidence to the contrary. Despite this view, even when health professionals became aware that Marie was intending to live on her own after the birth of Baby W, they did not revise their assessment of risk and continued to support Marie move towards greater independence. Practitioners recognised the importance of demonstrating ‘healthy scepticism’ and revising their judgements in the light of changing circumstances but also acknowledged a reality that in times of increasing caseloads and fewer staff, opportunities to reflect on their practice and were limited. HV2 also shared with the Review Team that opportunities to  just ‘talk over’ cases was influenced by the quality  of the working relationship between a worker and the supervisor and in her case, a struggling relationship with her line manager impacted upon her decision not to talk over her work with Marie.                                                   18 Humphreys C.  And Stanley N. (eds) 2006. Ofsted 2011. Ages of concern: learning lessons from serious case reviews: A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011   20Finding:  Without supportive opportunities to reflect on their practice, professional biases can occur and without challenge these can develop and adversely influence professional judgement and decision-making.  This is an issue which has been identified in recent SCRs.   The importance of chronologies and quality recording 6.3.34. The Review Team could find no evidence of any chronologies being used and the absence of these made it difficult for the social workers to see any emerging pattern so each allegation or agency contact with Children’s Services was viewed as an isolated incident. Various studies have found that without a full social history and/or chronology, it is difficult for professionals to develop a properly contextualised understanding of the child and family’s needs and circumstances thus making the production of effective plans less likely. Chronologies have become one of the most talked about and perhaps least understood tools in work with families. The Review Team found little evidence to suggest they were in place or used effectively to support professional thinking and decision-making in Sunderland.   6.3.35. The chronologies shared or produced for this SCR demonstrated inconsistencies in terms of what was recorded and shared between agencies and highlights the importance of producing both single and multi-agency chronologies for families where there are concerns about children. The response by Children’s Services to the allegations and referrals during the period under review were dealt with on an incident-by-incident basis and without easily accessible and readable chronologies, patterns and the cumulative impact of neglectful parenting was overlooked.  6.3.36. According to records, Child Z was subject to three Initial Assessments - only one of which can be located on the CCM system - and one Core Assessment during the period under review. There is information contained in these documents, which does not always correspond with what is recorded in child health records. The Review Team concluded that this not only suggested minimal collaboration between agencies but also minimum input to these assessments by health professionals despite the fact that HV2 was the only consistent professional working with this family. Although Child Z was identified as a Child in Need,19 following the Core Assessment, the Review Team was told that no CIN plan could be found on the CCM system. The Review Team found other significant gaps in case records and little evidence that Children’s Services professionals viewed recording as an essential and intrinsic part of the intervention process. Neither did it appear that recording practices were routinely monitored or audited by team managers. The issue of poor record keeping in Children's Services and a lack of rationale for key decisions that were made was a recurring feature in this review and a feature in the Ofsted inspection in July 2015.  6.3.37. The Review Team was informed that at the time under review, the case management system in Children’s Services made it difficult for ‘significant events’ to be merged into a chronology. The lack of a ‘fit for purpose’ chronology as part of the electronic recording system undermines the critical importance such a tool has for practitioners in understanding the past and its implications for the present.                                                  19 Under S17 of the Children Act 1989, a child is deemed to be ‘in need’ if without the input of services by the local authority, their health or development will be impaired. All children subject to child in need status should have a Child in Need plan which identifies their needs, the local authority’s response to those needs and the outcome of services provided.    216.3.38. However, four years later, this issue remains a significant challenge in Sunderland and a sustainable solution has yet to be found. A major task for social workers is the need to interact with information technology systems known as the Integrated Children's System (ICS) that implements both record keeping and reporting functions. ICS was one of the specific areas that Eileen Munro was asked to look at in her 2010 review of child protection systems in England and Wales, yet the systems used by local authorities across the UK continue to inhibit rather than support effective record keeping. The Review Team was informed that the procurement for a new data management system in Sunderland is underway.  Finding: Poor record keeping in some agencies and the absence of succinct chronologies, in others, impaired the ability of professionals to consider the relevance of historical information or to recognise patterns of neglectful parenting. This finding was recognised by professionals as being a current issue and not just specific to this family.   6.4. ASP 2: The extent to which professionals communicated and worked collaboratively 6.4.1. The practice of the CSN in sexual health services was good, as not only did she complete a referral to Children’s Services, she verbally contacted the midwife and the GP, informing them of the referral and late booking of pregnancy. The CSN recalls that Marie was upset that she was pregnant and unable to have a termination and she spent some time reassuring her and encouraging her to inform her grandmother of the pregnancy. The CSN did not receive any direct communication from Children’s Services regarding her referral but was kept informed through her contact with MW1 and HV1. Whilst this is a good example of effective information sharing between health professionals, the importance of professionals taking responsibility for following up on their referrals to Children’s Services was discussed in some depth with practitioners who asserted that time and workload issues remained a constant challenge in terms of ‘checking up ‘ on colleagues in Children’s Services. This issue repeats findings in previous SCRs.  6.4.2. There was evidence within health documentation of prompt written information sharing between the midwifery service and the health visiting service when Marie presented late with both pregnancies. Information was shared by the midwifery service with regard to indicators of vulnerability when Marie was pregnant with Baby W but HV1 did not receive a copy of this assessment until 4 weeks later. The system for sharing information has since been revised and health visitors now receive these assessments within 48 hours.  6.4.3. Although MW1 contacted HV1 by telephone to share this information, it did not alert HV1 to the need for a visit to Marie. At the time it was usual practice for Health Visitors to wait until mothers were at least 36 weeks pregnant before making a primary visit. This was a missed opportunity as a visit around this time may well have alerted HV1 to Marie’s situation and offered scope for an early discussion about her pregnancy and the extent to which she understood the needs of babies and infants. The delay in health visitors contacting pregnant mothers has been raised in previous reviews and resulted in a change of practice across the health visiting service during 2015. Health visitors now no longer wait until a mother is 36 weeks before their initial visit, they now make contact at the earliest opportunity especially with parents with identified vulnerabilities.   6.4.4. The Review Team questioned why a referral was not submitted to the Family Nurse Partnership (FNP) which is a NHS service targeted specifically for vulnerable teenage mothers to-be, pregnant   22with their first child. Marie’s background, circumstances, and vulnerabilities would suggest she clearly met the criteria for referral. However, further exploration suggested that the FNP programme was still being considered in Sunderland at the time and was not well known to professionals or well embedded into services at that time.   6.4.5. There was a lack of communication from Children’s Services to MW1 with no initial invites to the TAC, or copies of minutes forwarded to her. The midwife eventually became involved when Marie was 36 weeks pregnant but earlier involvement would have supported the parenting assessment and better consideration of Marie’s attachment to her baby during pregnancy.  6.4.6. There was evidence of some information sharing between HV2 and the health visitor of another family member, although given what was happening with other children in the wider family, greater collaboration would have been of benefit to both families. Equally, there is little evidence that professionals in Children’s Services collaborated despite different social workers working with other family members at the same time. Records indicate that during the period under review, health professionals often had to contact Children’s Services to access or confirm information, which should have been shared with them as a matter of course.  6.4.7. MW1 completed the referral to Children’s Services on Baby W and demonstrated persistence in chasing up the outcome to her referral, due to her concerns that the pregnancy was well advanced at 32 weeks and there was ‘concealment of pregnancy’. There was however no challenge when she was informed that the case was closed. MW1 told the Review Team that she knew Marie’s family very well and that she was always able to ‘get on’ with Marie, and she reflected that perhaps this influenced, to a degree, why she did not think to contact her safeguarding lead to discuss the outcome of her referral. There was little evidence of effective communication between HV2 and MW1 in relation to Marie’s pregnancy with Baby W and this was a missed opportunity which may have changed the decision not to hold a discharge-planning meeting when Baby W was discharged from hospital even though an Initial Assessment was still open on the CCM system.  6.4.8. The Review Team was not able to access any documentation, which suggested that health professionals had requested or indicated a need for such a meeting or challenged the fact that one did not take place. A discharge-planning meeting would have allowed multi-agency information sharing and ensured that a discharge package of care and support was in place to a young mother with two children under the age of 2. At this point Marie was already talking of living independently. The importance of discharge meetings and the need for clarification as to when they should occur has been identified in a recent SCR and is being addressed by SSCB.  6.4.9. Child Z had begun to attend nursery in April 2012 and concerns began to emerge, in addition to his speech and language delay, about his behaviour. His key worker contacted NN2 who was working with Marie at the time, to exchange information, whilst this would be expected practice, communication would have been further enhanced by joint collaboration and planning.  6.4.10. In June 2012, the nursery informed Children’s Services when they received an anonymous allegation that Child Z had bruising to his back and ribs. SW6 is recorded as attending the nursery and records are vague but indicate that ‘no bruise was found to be present’. This suggests the child was examined. This is not in accordance with child protection procedures and should have been   23escalated if these accounts are accurate. If the reports are inaccurate then this highlights the dangers of careless recording and offers further scope for learning.  6.5. In response to the concerns raised by parents at the Children’s Centre, the Early Years worker sent an email to SW6 rather than making contact or submitting a CP referral. If a conversation took place before the email was sent then this is not recorded. The Review team could find no details or records pertaining to these allegations either in the Children’s Centre records or in Children’s Services records. Conversations with staff at the Children’s Centre suggested some recall about something ‘a few years ago’ but they were unable to provide further details. The Review Team was advised that systems are in place now which are far more robust and any actions taken in respect of safeguarding concerns are discussed with the safeguarding lead and recorded.  6.5.1. HV2 was not however aware of these allegations until the SCR process began and this again highlights a lack of communication and information sharing between professionals working with this family. Practitioners who were involved in the SCR process acknowledged this failing but were keen to point out that they each had evidence of good collaborative working between agencies but it was becoming noticeably difficult with so many staff changes at operational and managerial levels in Children’s Services.  6.5.2. Information was shared with the GP surgery when Marie presented for a termination in October 2009 and CSN submitted a referral to Children’s Services. There was no response to this information being received and neither were Marie’s records ‘flagged’ to indicate any risks or concerns. This meant that during the following two years, Marie’s relatively frequent contacts with her GPs in relation to Child Z’s minor ailments, [her] accidents, assaults upon her person, and her usual volatility at these times, were not seen within an overall context and were responded to on an incident by incident basis. Marie’s second concealed pregnancy registered at 32 weeks was not picked up by the GP as being significant. During the time under review Marie was seen by five different GPs and this highlights the importance of effective recording systems so that patterns and concerns can be more easily identified. It is vital that GPs understand the significance of what has been shared and can contribute to the breadth of responses required across the spectrum of health services. GPs unlike teachers or other health professionals often see multiple family members and can identify risk factors in parents not always observed by other professionals.  6.5.3. A review of practice in the GP surgery at the time of both Marie’s pregnancies highlights difficulties with communication and information-sharing between health professionals and particularly so between GPs and midwives. Since 2012 different systems have been introduced and when concerning information or any child protection concerns are notified, the information is now ‘flagged’ up on mother’s records and discussed at the regular Multi-Disciplinary Meetings (MDMs) which take place at the surgery. There are improved relationships with midwives although they do not always attend the MDMs. 6.5.4. During the process of this review, the GP also highlighted the difficulty in reading the Antenatal and Postnatal Vulnerability forms when these are scanned and sent electronically. The Review Team shared this view and was advised that the forms were redesigned in 2015 making scanned copies easier to read. Copies are also forwarded to GPs through the post under confidential cover.     246.5.5. There were two periods of multi-agency working. Marie received support from TAF between December 2009 and March 2010 and then as part of the Child in Need process between October 2010 and January 2011. The notes from the TAF meetings suggest some partnership working; the meetings were attended by key professionals; joint visits to Marie took place and tasks were identified for professionals and Marie to accomplish before the next meeting. The notes give the impression that Marie and MGGM positively engaged with the TAF process but there is little evidence of challenge or any details recorded about Marie’s observed or assessed parenting of Child Z.  6.5.6. There are limited records relating to the brief period when Child Z was a Child in Need and no Child in Need Plan could be located. The Review Team was of the view that there was little consideration given by any professionals to the benefits of a multi-agency meeting when Child Z was in nursery and it became known that Marie was pregnant. Discussions also took place about the importance of practitioners making contact with housing providers. Once it was known that Marie had accepted a tenancy, contact with Gentoo to see what support could be offered could have led to useful collaboration and early discussions may have led to greater scrutiny about Marie’s intentions in accepting the tenancy agreement. Within the practitioner’s group, there was an acknowledgement that calling a multi-agency meeting was perceived to be the responsibility of social workers and, unless there was a significant need to do so, other professionals were less likely to instigate such a meeting.  Finding: Without a clear framework for multi-agency collaboration, opportunities to share, analyse and explore concerns were lost. The issue of multi-agency working has been picked up by the Ofsted Inspection in 2015 and in recent SCRs.    6.6. ASP 3:  Working with Resistant Parents   6.6.1. Descriptions of Marie suggest she was an unwilling participant in a process she clearly resented and according to research by C4EO20 this response is not uncommon and suggests that as many as 75% of parents do not co-operate with services and simply ‘tell workers what they want to hear’.  6.6.2. The dilemma of how to work to a strengths-based approach, whilst also maintaining a critically evaluative focus on whether parental avoidance is happening is highlighted in several research studies21 . These suggest that professionals can place too much reliance on what parents say and do not always consider that families can be resistant to contact from professionals and able to develop skillful strategies for keeping them at arms length. The possibility that this could be the case with Marie does not appear to have been considered in any of the assessments undertaken or in the records of the health professionals and highlights the importance of access to good supervision, which asks professionals to explore and reflect on whether parental engagement is genuine and leading to improved outcomes for their child.   6.6.3. The Review Team found no evidence that Marie’s experiences as a child and adolescent were considered in either the assessments or in the work undertaken with Marie. Professionals should                                                  20 C4EO Knowledge Review 2010 21 Horwath J and Morrison T ‘Assessment of Parental Motivation to Change’ (2001); Assessing Parental Capacity to Change DfE June 2014   25have been aware of the significant body of research evidence from a wide range of disciplines showing that without strong protective factors, adverse childhood experiences are likely to have long-term consequences for the adult we become. Negative impact of childhood experiences has been shown to continue throughout adolescence and unless provided with opportunities to build and develop resilience, they can leave a young person and especially a young parent, with little confidence and inconsistent and ineffective parenting behaviours.  6.6.4. The extent to which these factors impacted on Marie’s capacity as a parent was never explored and significantly neither was her capacity or motivation to change what surmounted to neglectful parenting behaviours. This latter issue is an important one as there is considerable evidence that Marie did not accept the concerns expressed by professionals and neither was she committed or motivated to change the way in which she parented Child Z.  This should have been identified as a risk when professionals learnt she was pregnant again. There is evidence that what Marie did do was to avoid professionals or tell them what they wanted to hear.  6.6.5. Research highlights that professionals need to understand how behavioural change occurs, in order to be able to identify where parents are at in terms of changing their parenting behaviours so interventions can be targeted accordingly. Changing behaviour is not easy, but it is even harder for those parents who are struggling with an interlocking web of problems and perhaps even more so for the young parent, such as Marie, moving as an adolescent through her own periods of rapid biological, psychological, and social change. Change is a complex process, and although it can be supported and promoted through effective interagency interventions, it cannot be imposed and importantly it will not happen unless a parent is proactively engaged.  6.6.6. Given her childhood experiences, it is probable that Marie did not know very much about child development and how important she was to her babies as they were growing. Her resistance to the advice offered may have stemmed from just being an adolescent or as a result of not wanting to accept her responsibility as a young parent.  Nevertheless, there was clearly a resistance to change how she cared for or related to Child Z, often insisting that ‘there was nothing wrong’. The context of working with parents when there are concerns about their children is in itself likely to create resistance, which can be a response to professional involvement in the family rather than to change itself, but the Review Team could find no evidence of any exploration as to why things had not improved for Child Z and why at 2 and a half years, living with Marie and his great grandparents there were still concerns about his development and him being under-stimulated.    6.6.7. Brandon et al (2009) noted that ‘many… families are not straightforwardly voluntary or co-operative, which provides considerable challenges for making voluntary systems [such as TAC and Child in Need] work.’ These systems only succeed in helping and protecting children if professionals are confident about working with and supporting parents, but importantly also maintaining a focus on the needs of the children. Professionals must be able to recognise when it is necessary to step-up to a different framework for intervention, and how to put this across when there is no obvious change in presenting circumstances. The Review Team concluded that the risks to Child Z and later to Baby W from Marie’s non-engagement and neglectful parenting were not only underestimated and unassessed they were also left unchallenged. 6.6.8. Professionals do need to consider that sometimes when changes cannot be evidenced, it can be that the service is not right service for the family, or the individual professionals themselves exacerbate   26resistance particularly through the way in which they approach a young parent.  There is evidence that when Marie wanted a change of Health Visitor (HV1), this was agreed, but the Review Team was not confident that the reason for wanting the change of worker was fully explored and compliance with Marie’s wishes was not necessarily in the interests of Child Z, given Marie intimated that HV1 was challenging her all the time.  6.6.9. Records suggest that Marie engaged to some extent with CFSW and NN1, but the summary of their work and the detail of any achievements and progress made by Marie are not recorded in sufficient detail.  What is clear however, is that during 2011, there were no concerns recorded in relation to Child Z’s development or Marie’s parenting and it was not until July 2012, when Marie presented to midwifery services at 32 weeks, that a third child protection referral was submitted, again by MW1. Although health records suggest that Marie seemed to demonstrate a greater degree of maturity and appeared more receptive to NN1 around this time, it is not clear exactly what Marie was doing differently and whether she was accepting the concerns expressed by health professionals. There is certainly little to indicate any professional concerns when Marie indicated her intention to move from the home of her grandparents to live independently following the birth of Baby W.  Finding:  When beginning work with a family, without any assessment to determine whether parents are able, willing, or motivated to change their behaviours, professionals can be mistaken in their assumptions that parents are co-operating and working towards better outcomes for their child. This can lead not only to drift but can also leave children vulnerable and without access to services.  This finding has been identified in a previous SCR.  6.7. ASP 4: Supervision and Managerial Oversight 6.7.1. During this review it was revealed that there was not a thorough understanding by frontline professionals and managers of the Unborn Baby procedures. The referrals made in relation to Marie’s pregnancies in 2009 and again in 2012 were copied to the Safeguarding Teams in respective agencies but neither they nor the operational managers in Children’s Services picked up the significance of the information shared and highlighted the need to refer to these procedures. 6.7.2. At the time, it was noted there were capacity issues in 2011 – 2012 within the safeguarding teams in both STNHSFT and CHSFT. However two recent SCRs in Sunderland, published in 2015 would suggest this continues to be a challenge and is exacerbated by the growing number of referrals being passed to Safeguarding Leads. The Review Team were made aware through recent SCRs that the STNHSFT Safeguarding Team still do not have an electronic system to support the Named Nurse and the supervisors in their daily work – this was a recommendation in the Child X SCR in 2010, and reportedly remains high on the STNHSFT Risk Register.  6.7.3. The Review Team was told that midwives do not routinely have case supervision but are encouraged to contact their Safeguarding Lead, if they have concerns or require support to liaise with agencies. MW1 was satisfied with the response to her referral to Children’s Services in October 2009 and when she received no response to the referral she made on 1.8.2012, was persistent in her attempts to find out what had happened. There was however no response to her messages, although a social worker had been allocated to undertake an Initial Assessment. MW1 visited Marie and Baby W at home but took no further action in relation to her referral. She did not raise the lack of response by Children’s Services with her safeguarding lead.    276.7.4. Neither HV1 nor HV2 saw any need to contact their safeguarding leads. As an experienced health professional, HV2 said that with hindsight, it might have been wise to do so, but at the time, Marie was living with what she regarded as ‘supportive’ grandparents, Child Z was later at nursery and Marie was engaging with the NN1. With a caseload of over 200 families, the Review Team were told by HV2 that only ‘child protection’ cases could realistically be discussed in supervision and although aware of Marie’s vulnerability and the inconsistent care afforded to Child Z, HV2 said she did not consider that her concerns would meet the threshold for  ‘child protection’. Other professionals who contributed to the SCR process concurred with this view.     6.7.5. Assuring the quality of both professional practice and organisational processes depends on robust audit and quality assurance systems. The Review Team found that these processes were missing in the work undertaken by Children’s Services. The assessments undertaken were not completed within the required timescales, and offered little in the way of analysis of the presenting issues. There was evidence that child protection procedures were not followed, case notes and records were not updated or completed and where evidence of poor practice emerged this was not challenged. The Review Team was concerned to note that in response to allegations of bruising to Child Z in June 2012, SW6 appeared to have visited the nursery and concluded that ‘no bruises were present’ but this practice was not questioned or challenged by a team manager.   6.7.6. During the period covered by this review, the local authority recruited social workers from overseas to support the work of Children’s Services and SW6 was included in this cohort. Practice issues relating to SW6 and other similar appointments were highlighted in the SCR for Baby A and Child C.  The Review Team was informed by team leaders in post at the time that these overseas workers had different ideas about how to do assessments and had a different understanding of the social work role in general. The Review Team was told these workers had an intensive 10 week induction programme, although different views were expressed about the quality of that experience but some problems in relation to their practice later began to emerge.  6.7.7. The Review Team found no evidence that SW6’s actual work with this family was discussed in supervision or subject to managerial scrutiny yet it clearly fell short of expected professional standards. SW6 had it seems, initially impressed managers with her confidence, but following a conversation with a member of the Review Team, one team manager recalled that SW6 had her own system for recording information and did not always transfer records to the CCM system. This was not challenged at the time as team managers were themselves under considerable pressure having to cope with staff shortages and increasing workloads. The Review Team was told that managerial oversight at that time was not as robust as it should have been.  SW6 left the authority when her visa was not reviewed. 6.7.8. Records from the Children’s Services chronology refer to the occasions where managers made decisions to ‘close the case’ following assessments or enquiries in response to allegations. In the records made available to the Review Team the rationale for these decisions is not recorded and highlights the points made previously about the importance of effective recording and sturdy chronologies. The Review Team was informed that Sunderland Children’s Services are on version 29 of their CCM system and problems with recording and accessing key information continue.  6.7.9. Significantly, team managers from Children’s Services did not attend practitioners meetings for this review. The Review Team was told this was due to sickness and workload pressures but the absence   28of their contributions to the SCR process was a source of concern and therefore individual conversations were held with two team managers towards the end of the SCR process. These conversations  were illuminating and while they highlighted how the absence of  robust managerial oversight impacts on poor assessments and decision-making, the Review Team also learnt  of the difficulties experienced by team leaders who were struggling with increasing workloads and without supervision and strong leadership,  found it difficult to do their work effectively.  Finding:  The Review Team was left with questions about whether team managers in Children’s Services had adequate time and support to lead practice, read and reflect on case files and had sufficient knowledge to analyse the quality of work and decision-making undertaken by practitioners.   6.8. ASP 5:  The SCR process  6.8.1. That this review has taken place is due to the Chair of the Adoption Panel who queried why  given the background of Baby W and Z, no SCR had taken place. The Review Team were told that SSCB had not been notified at the time of the ‘serious incident’ relating to Baby W and were unaware of his injury or the circumstances that led to it. 6.8.2. Where a serious childcare incident occurs and meets the definition of a ‘notifiable incident’22 the local authority must, within 5 working days, complete a Serious Incident Notification  form and forward this to Ofsted and to the Department for Education. (DFE) A copy of the form should also be forwarded to the Chair of LSCB so a discussion can take place as to whether the death or serious injury of the child meets the criteria for a Serious Case Review. Sunderland’s procedures clearly identifies this process. 6.8.3. Sunderland LSCB was not informed either in writing or verbally about what had happened to Baby W. The Review Team learnt that following enquiries from DFE, during 2015, three other serious incidents related to children came to light about which the SSCB was unaware. The Review Team was told that this was a lack of oversight and unfamiliarity with the procedures by managers in Children’s Services responsible for sharing information with SSCB. The failure to inform SSCB has significant consequences in relation to their responsibilities to undertake SCRs, which need to be timely and relevant to current practice. The lessons from SCRs conducted two or three years later can be immaterial as the process revisits practice and systems, which may have changed over the space of time.  The Lead Reviewer wrote to the independent chair of SSCB and requested that this issue was raised formally with the Chief Executive and the Interim Director of Children’s Services. This action was promptly undertaken and all parties immediately acted to address this issue.  6.8.4. There was good participation and commitment shown by key agencies to this SCR. There was however no practitioner involvement from the nursery or the Children’s Centre. Follow up by the Review Team highlighted problems with communication and a lack of understanding by these agencies about the expectation of their involvement. These views were not addressed by their                                                  22 A notifiable incident is an incident involving the care of a child which meets any of the following criteria: • A child has died (including cases of suspected suicide), and abuse or neglect is known or suspected; • A child has been “seriously harmed” and abuse or neglect is known or suspected • A looked after child has died (including cases where abuse or neglect is not known or suspected); or  a child in a regulated setting or service has died      29respective agency leads on the Review Team; and this issue, even with the Information Pack provided to all participants in the SCR process, should be more carefully addressed at the outset of all future SCRs.  6.8.5. Further work is required to assist partner agencies involved in SCRs improve and audit their action plans and understand how to demonstrate how their actions will impact upon children and drive forward improvements in services.   6.8.6. Children’s Services in Sunderland are undergoing significant and momentous changes and the impact on staff must be considerable. The changes inevitably impact on partner agencies and colleagues and the challenge for SSCB is how learning from SCRs can, in times of transition, transfer to frontline practice in single agency and multi-agency work. Having had sight of various action plans and had access to the work undertaken by SSCB over the last two years, it seems that further deliberations will be required to minimise the chance of the same errors in practice reoccurring in the future. From the author’s experience, the key factors which inhibit learning across organisations are poor communication, lack of clarity about what needs to change, the absence of review mechanisms and limited opportunities for practitioners to discuss what is changing and why, and importantly, what they are now required to do differently.    7. Findings and Recommendations 7.1. Understanding Procedures  Finding (Page 14): Children’s Social Care and health professionals were unaware of the specific detail of the multi-agency Unborn Baby procedures and how these related to Child Protection procedures. This was a finding in previous SCRs in Sunderland, which reviewed practice during the same period.   Why these Findings are important Procedures, including those developed for multi-agency use, offer a framework for good professional practice and outline sensible actions that might be taken to protect and support vulnerable children and unborn babies. Their purpose is to ensure that all professionals are clear about what is expected of them and to offer clarity with regard to who does what, in what order, when and to what standard. Procedures also clarify at what point practitioners should collaborate with other agencies in areas of work, which demands a high level of skill and professional commitment. Whilst they are not a substitute for professional judgement and it is recognised that each case must be considered individually, procedures are produced to support and not complicate practice and deviations from procedures and especially those which relate to the safety and wellbeing of children should always be justified and recorded.  Procedures are also in place so organisations can ensure compliance with statutory requirements such as the requirement for the local authority to notify key agencies when a child has died or has sustained a serious injury and abuse or neglect is thought to be a factor.      30Recommendation 1: Understanding Procedures    a) SSCB must ensure that the recommendations previously identified in SCRs relating to Unborn Baby Procedures have been actioned by each agency and that agencies understand through audit how well frontline practitioners and their managers access and apply the Unborn Baby Procedures.   7.2. Ensuring Quality Assessments    Finding (Page 15) Robust assessment and decision-making depends on good internal and cross-agency practice and this was not evidenced in this SCR, a finding identified in previous SCRs. The Review Team was informed that improving the quality and managerial oversight of assessments are issues currently being addressed as part of the Improvement Plan in Sunderland. These findings also raised questions as to why poor quality assessments had not been picked up through SSCB audit arrangements.   Finding (Page 17):  Without the use of shared and standardised tools to assess risk, professional judgement, and decision-making is more likely to be flawed and this can leave children vulnerable. This finding was recognised by professionals as being a current issue and not just specific to this SCR.  Finding (Page 25): Without a clear framework for multi-agency collaboration, opportunities to share analyse and explore concerns were lost. The issue of multi-agency working has been picked up by the Ofsted Inspection in 2015 and in recent SCRs.   Finding  (Page 27):  When beginning work with a family, without any assessment to determine whether parents are able, willing, or motivated to change their behaviours, professionals can be mistaken in their assumptions that parents are co-operating and working towards better outcomes for their child. This can lead not only to drift but can also leave children vulnerable and without access to services.  This finding has been identified in a previous SCR.  Finding (Page 22): Poor record keeping in some agencies and the absence of succinct chronologies, in others, impaired the ability of professionals to consider the relevance of historical information or to recognise patterns of neglectful parenting. This finding was recognised by professionals as being a current issue and not just specific to this family.   Why these Findings are important  Good assessments, lead to better outcomes for children, and require a knowledgeable, highly skilled and confident workforce, supported by appropriate education, training and continuing professional development. Front line practitioners have to make decisions almost daily about risks, parenting and the safety and well-being of children, often under considerable time and workload pressures. Under such conditions they can too easily rely on their intuitive judgements about what is happening in a family and without the right sort of supervision and support, judgements can be prone to biases. Agencies must be confident that their professionals are trained and well supported to think critically and analytically when undertaking or supporting assessments and are able to process information rigorously and methodically to inform unbiased and professional judgements.  Recording systems, which do not include tools to build, maintain and share chronologies hamper practitioner’s attempts to understand a family’s history, which is particularly significant where neglect is of concern.  Without chronologies and summaries of progress and interventions, practitioners can too easily resort to a ‘start again’ approach and this leaves children vulnerable to poorly understood risks.    31 Recommendation 2: Ensuring Quality Assessments  a) SSCB should ensure that practitioners have access to information about the  tools available to them within their own professional context and on a multi-agency basis to use in assessments and opportunities to develop skills in their use; these should include tools to assess risk, neglect and assess parental capacity to change; and tools to build and maintain single and multi-agency chronologies,   b) SSCB should also ensure that practitioners are supported by their own agencies and within a multi-agency context to increase their understanding about what ‘good assessments’ looks like.  c) SSCB must develop its performance and quality assurance framework to ensure that key assessments are routinely and randomly audited on a single and multi-agency basis and the learning from these are fed back to the Board and its partners. d) SSCB should assure itself that all partner agencies  ensure that their staff use and maintain chronologies of ‘significant events’ in families, and effective systems are in place which specifies when and how multi-agency chronologies should be established  7.3. Developing a Multi-Agency Neglect Strategy Finding (Page 18):  There was a limitation to professionals’ views of neglect, which prevented them from seeing Marie as a ‘neglectful’ parent. Drift was caused by a range of factors, including inadequate assessments, poor planning, the parent failing to engage, and a lack of understanding by professionals of the cumulative impact of neglect on children’s development.  Why this Finding is important There is a considerable body of research, which demonstrates the damage done to young children living in situations of neglect; this includes the impact of a lack of stimulation, resulting in delayed speech and language, and the development of poor adult/child relationships. The pervasive and long-term cumulative impact of neglect on the well-being of children of all ages is also well documented. All aspects of children’s development can be, and are, adversely affected by neglect, including physical and cognitive development, emotional and social well-being and children’s mental health and behaviour. For professionals working with children and families this is one of the most challenging areas of their work. Research also indicates that practitioner’s knowledge of child development is not always well developed and as a result they can be less likely to understand the impact of parental neglect on children and the importance of timely decision-making to avoid significant harm.  Each local authority needs a multi-agency Neglect Strategy to increase local understanding of the prevalence of neglect and to improve the identification of, and responses to neglectful parenting. At the time of writing SSCB has yet to finalise its own Neglect Strategy which would allow the Board to have access to data and quality assurance information to enable it to monitor the quality of practice in relation to neglect across early help, child in need and child protection interventions.      32Recommendation 3: Progressing the Multi-Agency Neglect Strategy   SSCB should as a matter of some urgency, ensure that the work to develop a multi-agency Neglect Strategy is being addressed and progressed. This strategy should include information and guidance about the specific tools to be used to inform assessment of Neglect as well as the training requirements, standards and competences required of frontline staff.  7.4. Managerial Oversight and Supervision  Finding (Page 20):  Without supportive opportunities to reflect on their practice, professional biases can occur and without challenge these can develop and adversely influence professional judgement and decision-making.  This is an issue, which has been identified, in recent SCRs.   Finding (Page 29): The Review Team was left with questions about whether team managers in Children’s Services had adequate time and support to lead practice, read and reflect on case files and had sufficient knowledge to analyse the quality of work and decision-making undertaken by practitioners  Why these Findings are important  Professionals need to keep their judgements under review and good supervision should provide a safe but challenging space to oversee and review decisions, actions, and progress. In this way practitioners can be supported to use and develop their intuitive and analytical skills. Supervisors reading case files before, and maintaining curiosity during and outside of, supervision helps the process.   Line managers are an essential and powerful resource to help practitioners and protect their wellbeing, but they too need support and access to quality supervision. This is clearly a challenge under current working conditions - many line managers are juggling scarce resources while also needing to maintain safe service levels. Managers at all levels must ensure a ‘learning culture’ with an ethos in which reflective practice and self-questioning are accepted and actively promoted – a non-judgemental acceptance that errors are inevitable makes it easier to recognise, acknowledge and learn from them. The culture of an organisation is critical in setting the tone, values and behaviours that are expected and supervision has a key role in delivering good services and outcomes for children and families.    Recommendation 4: Managerial Oversight and Supervision  a) SSCB must be confident that in key agencies, quality supervision of frontline practitioners and their managers is not compromised by broader organisational issues such as time constraints, capacity issues, and workload pressures. The Board must ensure that when partner agencies undergo significant organisational change, it is provided with reports from those agencies, which demonstrate how risks to existing safeguarding practices and processes have been assessed and how they will be and are being managed.  b) SSCB should require key agencies to evidence how they provide a structured learning environment to their practitioners and managers and what frameworks for reflective ‘clinical’ supervision (individual and/or group) and other forms of case-based consultations are in place.     338. Concluding Comments  8.1.1. Whilst this review has highlighted the need for professionals to be persistent, curious, and child-centred when pursuing concerns about the welfare of children, the injury to Baby W cannot be attributed to any failings on the part of professionals who knew the family. This review is however a stark reminder for all agencies of the need for robust assessments and dogged challenges to young parents whose lifestyles have the potential to place their children at increased risk of harm.      34Appendix 1  Summary of Recommendations  Recommendations for Sunderland Safeguarding Children Board  Recommendation 1: Understanding Procedures   a) SSCB must ensure that the recommendations previously identified in SCRs relating to Unborn Baby Procedures have been actioned by each agency and that agencies understand through audit how well frontline practitioners and their managers access and apply the Unborn Baby Procedures.  Recommendation 2: Ensuring Quality Assessments a) SSCB should ensure that practitioners have access to information about the  tools available to them within their own professional context and on a multi-agency basis to use in assessments and opportunities to develop skills in their use; these should include tools to assess risk, neglect and assess parental capacity to change; and tools to build and maintain single and multi-agency chronologies b) SSCB should also ensure that practitioners are supported by their own agencies and within a multi-agency context to increase their understanding about what ‘good assessments’ looks like  c) SSCB must develop its performance and quality assurance framework to ensure that key assessments are routinely and randomly audited on a single and multi-agency basis and the learning from these are fed back to the Board and its partners d) SSCB should assure itself that all partner agencies  ensure that their staff use and maintain chronologies of ‘significant events’ in families, and effective systems are in place which specifies when and how multi-agency chronologies should be established Recommendation 3: Progressing the Multi-Agency Neglect Strategy  (a) SSCB should, as a matter of some urgency, ensure that the work to develop a multi-agency Neglect Strategy is being addressed and progressed. This strategy should include information and guidance about the specific tools to be used to inform assessment of Neglect as well as the training requirements, standards and competences required of frontline staff  Recommendation 4: Managerial Oversight and Supervision a) SSCB must be confident that in key agencies, quality supervision of frontline practitioners and their managers is not compromised by broader organisational issues such as time constraints, capacity issues, and workload pressures. The Board must ensure that when partner agencies undergo significant organisational change, it is provided with reports from those agencies, which demonstrate how risks to existing safeguarding practices and processes have been assessed and how they will be and are being managed b) SSCB should require key agencies to evidence how they provide a structured learning environment to their practitioners and managers and what frameworks for reflective ‘clinical’ supervision (individual and/or group) and other forms of case-based consultations are in place     35Appendix 2   Single Agency Learning  1. Sunderland Children’s Services  • Sunderland Children’s Services were judged inadequate by Ofsted in 2015. An improvement plan was immediately put in place and is currently being implemented  • Managers will ensure that all case files transferring from MASH to other teams within Children’s Services will have a chronology and genogram attached • Management capacity has increased during 2015 and the size of supervision groups has been reduced • There is training on new risk templates • Procedures are being updated by Tri-X and will be discussed in supervision   2. South Tyneside NHS Foundation Trust (STNHSFT) • The risks associated with the ‘rule of optimism’ and ‘disguised compliance’ will be embedded in all STNHSFT training presentations • Briefing sessions will be provided to STNHSFT Health Professionals with regard to the learning from this case with specific focus on ‘disguised compliance’ and ‘rule of optimism’ • The role of the safeguarding team in dealing with all cases which raise concerns regarding infants and children should be revisited with all STNHSFT professionals  3. City Hospitals Sunderland NHS Foundation Trust  • The sharing of information between the Midwife and HV needs to be timely and effective to ensure all risks are identified and action taken • Midwives need to escalate cases where safeguarding procedures are not being followed and seek supervision from the Safeguarding Midwives • Contact should be made with the father’s GP to ascertain any unknown risks to improve information sharing between agencies regarding ‘invisible’ fathers • In view of the concealment of pregnancy and concerns in mother’s engagement with Child Z’s health needs a discharge-planning meeting should have been held • A baby with a mark that is not documented within health professional records and a parent states it is a birthmark should be confirmed • There were and still are capacity issues within the Maternity Safeguarding Team resulting in lack of oversight of all cases and this needs to be addressed as a matter of urgency  4. General Practitioners • All GPs will receive training and briefings on the lessons from this SCR • The six-weekly baby check template currently in use will be reviewed and adapted to include a section for social history, domestic violence and depression   36• When mother present to GPs with a concealed pregnancy, the GP will take a full social history and make a referral to Children’s Services in line with UBB procedures  5. Gentoo • Roll out staff training to all front line housing staff regarding safeguarding and support of customers, encompassing the outcomes of this and other SCRs  6. Little Angels Nursery  • Importance of entry assessment of children when they arrive at nursery (IEPs are now used so progress can be measured.) •  Supervision session with the Safeguarding lead are now firmly embedded • Safeguarding is now a regular item at team meetings  • More training and greater awareness about CP procedures where there are allegations of physical abuse • Importance of keeping logs for children     37 Appendix 3  How has the learning from this SCR improved practice?  Sunderland Children’s Services • The chronology and genogram to be a mandatory requirement as without this information there may be a significant impact on informed decision making particularly at the initial referral stage o Historical information from the chronology and a genogram to identify family members should always be incorporated into assessments. In this case a family member who lived with the maternal grandparents was overlooked. o The Initial Response Team (IRT) is now a MASH. An action plan has been written and discussed with MASH Senior Managers on 3/3/16 to address the issue of chronologies & genograms being on every case and this has been agreed. The impact of this will be that the initial stages of assessment take the family history into full consideration and there is a good understanding of who is in the family before making decisions • Management oversight of cases and clearly recorded decision making and the reasons why the decision is being made was an issue in this case. It was sometimes difficult to determine why decisions had been made. There was also a delay in completing assessments o Sunderland have doubled or trebled the management capacity in all Teams.  The impact of this action is to ensure that supervision will be reflective, track the progress of cases and have more focus on the individual Social Worker’s performance and development • Assessments were not evidenced based o Children’s Services have introduced a risk framework and are launching the Graded Care Profile. The Sunderland Neglect Strategy is now a document. Child in Need workshops have commenced and the CIN procedures and processes have been rewritten, issued and presented in the workshops. All procedures are now in Tri-X and are easily accessible. The impact for families will be that assessments will be timely and child/risk focussed preventing drift and delay and the need for multiple assessments o The Serious Case Review (SCR) and Child Death Co-ordinator in Children’s Services is presenting the SCR findings and recommendations to the five Child Protection Teams, this is a more personal approach that will allow the teams to raise practice issues, training and developmental needs in their own environment, rather than being part of a larger group. The first session is on 11th May 2016. These events will complement the mandatory briefings/ training delivered by SSCB.  The same presentation is being presented to the Team Managers Group in May 2016  South Tyneside NHS Foundation Trust (STNHSFT) • Briefing sessions will be provided to STNHSFT Health Professionals with regard to the learning from this case with specific focus on ‘disguised compliance’ and ‘rule of optimism’ • Lessons Learned briefing sessions are being developed and made available to health practitioners who work predominantly with children and their families. Lessons from this SCR will focus on recognition of disguised compliance and professional ‘rule of optimism’  Outcome: All health staff working predominantly with children and their families will recognise when parent’s/families are demonstrating disguised compliance and challenge parental/carer behaviours in the safeguarding of children.  • The risks associated with the ‘rule of optimism’ and ‘disguised compliance’ will be embedded in all STNHSFT training presentations.  The risks associated with the ‘rule of optimism’ and ‘disguised compliance’ are currently included into level three training and discussed in safeguarding supervision. Presentations will be reviewed to update this topic area   38 Outcome: In safeguarding training, emphasis will be given to ‘rule of optimism’ and ‘disguised compliance’, evaluating learning through group work during sessions.  • The role of the safeguarding team in dealing with all cases which raise concerns regarding infants and children should be revisited with all STNHSFT professionals • The role of the safeguarding team currently discussed in level 1, 2 and 3 safeguarding children training will be reviewed through update of the current presentations  Outcome: Training delivery will capture the role of the safeguarding team.  City Hospitals Sunderland • The sharing of information between the Midwife and HV needs to be timely and effective to ensure all risks are identified and action taken  A VAP task and finish group has been set up to improve the tool and ensure a pathway is in place with a set timeline of sharing with HV and GP. The VAP is shared with GP and HV currently and the impact of this being shared more timely will ensure risks identified quicker for early intervention • Midwives need to escalate cases where SSCB Unborn Baby Procedures are not being followed and seek supervision from the Safeguarding Midwives This is included into safeguarding level 3 training and the impact will be to support staff in escalating and seeking advice from the safeguarding team in order to ensure unborn safety • Contact should be made with the father’s GP to ascertain any unknown risks to improve information sharing between agencies regarding ‘invisible’ fathers This will improve information gathering on father’s involvement and impact will be to identify risk and provide early intervention • In view of the concealment of pregnancy and concerns in mother’s engagement with Child Z’s health needs a discharge planning meeting should have been held Staff awareness of SSCB Unborn Baby Procedures will improve challenge and ensure discharge planning takes place • A baby with a mark that is not documented within health professional records and a parent states it is a birth mark should be confirmed There is a marks and bruises protocol in place which is now embedded and at the time of this case was utilised. To reinforce this body maps are all in maternity records and all babies have one completed prior discharge • There were and still are capacity issues within the Maternity Safeguarding Team resulting in lack of oversight of all cases and needs to be addressed as a matter of urgency  The Named Midwife has submitted a Job description to the CCG and Directorate Manager for a full time Named Midwife post and awaiting outcome  Sunderland CCG (GP) • The six week baby check template which is currently used by GPs to be reviewed and adapted to include a section for social history, domestic violence and depression o This will improve information gathering and will create more opportunities for routinely screening for social history, domestic violence and depression o There will be a standardised process for undertaking the six week baby check o A more robust assessment may highlight domestic violence and depression as risk factors • When mothers present to GPs with a concealed pregnancy the GP to undertake a full assessment of her history and make a referral to Children’s Services following the UBB procedures o Following the Unborn Baby Procedures will enable a robust pre-birth antenatal assessment to be undertaken in order to identify possible risks to the baby   39o The impact of this will be reflected in such cases being discussed at MDTs which will improve information sharing between GPs, Midwives and Health Visitors o This has been included in the level 3 GP Safeguarding Locality Briefings, Time in Time Out Sessions, the CCG Quarterly Safeguarding Newsletter for Primary Care and the quarterly support sessions with GP Safeguarding Leads  Gentoo • All staff should display a degree of professional curiosity that encourages them to question and challenge to ensure that they have sufficient factual information, in order that decisions can be made around facts rather than assumptions.  Timely communication with other agencies is therefore essential, in order to gather the facts so that the right decisions are made and the involvement of the necessary agencies is sought • Non-engagement from some customers can be an issue, and “engaging the disengaged” is a factor we sometimes come across whilst carrying out our housing management functions.  Gentoo recognise that this could be a training gap, and will incorporate guidance on how to try to engage customers (who might not want to accept help and/or support in the first instance) into training for safeguarding and community safety • As a result of these points, we have identified one main action for this SCR which is to provide staff training to all relevant front line housing staff regarding safeguarding and support of customers, encompassing the outcomes of this and other SCRs.  This will include extra guidance on how to challenge if they have a professional disagreement, discussions around professional curiosity, and tips and guidance on how to encourage engagement from customers when they are particularly disengaged from accepting any help or support • The training will be rolled out with a particular emphasis on how it fits in with our role as a housing provider, with some of the learning that has been picked up from this and other reviews like serious case reviews for children, serious adult reviews and domestic homicide reviews from the region • After a recent restructure within Gentoo (due to redundancies and efficiency savings) the date to achieve this has been changed to 30 September 2016 in order to fit in with the wider training requirements for new and reorganised staff  Little Angels Nursery • The supervision process has been reviewed and one-to-one supervision sessions are held with all staff on a termly basis  • The safeguarding policy has been reviewed  • The national introduction of the integrated assessment for 2 year olds has improved the information sharing between the nursery staff and the health visiting service  • The introduction of a tracker has improved the focus on children’s progress  Sunderland Safeguarding Children Board  • The SSCB has reviewed and updated the Safeguarding the Unborn Baby Procedures to strengthen the requirement for the Pre-Birth Child in Need Assessment to include information from other professional assessments including the Vulnerability Assessment Protocol.  The assessment will therefore be multi-agency, include the expertise of partners and will be based on a shared understanding of risk and need.  The Pre-Birth Child in Need Assessment must also be copied to all professionals working with the family to ensure a shared understanding of what the child’s plan is based on.  The planned impact of this is that all parties to the child’s plan will be clear about actions, responsibilities, timescales and impact of the work undertaken with the family • The SSCB has implemented a Concealed Pregnancy Procedure to support practitioners to deal with families where there are concealed pregnancies.  Practitioners will use the procedures to recognise and address potential issues in these situations • Reviewed and updated the SSCB Vulnerable Baby Training.  This training is delivered to multi-agency staff and includes the learning from SCRs.  This training has evaluated very well,  comments from attendees indicate that they are now aware of what can make a child vulnerable; what services work   40together with vulnerable babies and how to interact with parents who have vulnerable babies/children • The SSCB has delivered Learning and Improvement Workshops since May 2015 and 104 multi-agency staff have attended the SSCB Learning and Improvement Workshop to learn about the findings of the SCRS in Sunderland.  Staff attending the sessions report that they have learnt from the sessions and are applying this to their practice (Appendix 4) • An  audit of  the quality of  Children's Services assessments in terms of both professional practice and organisational processes will be undertaken in the 2016-2017 multi-agency audit cycle  • The Board has consulted on its draft SSCB Multi-Agency Neglect Practice Guidance including the implementation of the Graded Care Profile   • The SSCB has developed and implemented a model of reflective audit in the 2016 -2017 SSCB audit cycle which will offer the practitioners involved the opportunity to reflect on their casework within multi-agency settings supported by independent facilitators.  This will strengthen multi-agency practice and model the type of reflective practice the SSCB expects as standard • Whilst not a specific recommendation from this SCR, learning has highlighted the need to strengthen the SSCB so the SSCB has strengthened its approach to obtaining assurance about the safeguarding system in Sunderland and its partner agencies through: o Undertaking a Section 11 audit in 2015-2016 which evidenced compliance by partner agencies in respect of their staff supervision arrangements23 o The SSCB Chair is undertaking assurance work through requesting Board partners to provide assurance of their current safeguarding arrangements and their agency annual safeguarding report for 2015-2016.  This will be one element contributing to strengthening the SSCB’s understanding of how effective the safeguarding system in Sunderland is o Refocusing on the behaviours, values etc, that the SSCB wants to be embedded into safeguarding practice in Sunderland o Implemented a learning and improvement monitor which is providing robust scrutiny and high challenge on the implementation of all recommendations from all SCRs the Board is undertaking                                                   23 Section 11 of the Children Act 2004 places duties on a range of organisations and individuals to ensure their functions, and any services that they contract out to others, are discharged having regard to the need to safeguard and promote the welfare of children.  This includes ensuring they have safe recruitment practices for individuals whom the organisation will permit to work regularly with children, including policies on when to obtain a criminal record check; appropriate supervision and support for staff, including undertaking safeguarding training.      41Appendix 4  Learning and Improvement Workshops – Impact as described by staff attending  Please give one example of how you will embed the content of this training into your role:  • I will continue to encourage care team members to be vocal, and for their opinion to be sought and heard • Making sure that when we have concerns and do not get the response required, that we take it further • Knowing areas which agencies have failed on previously and making others aware and challenge decisions • I have recently been given more responsibility within Gentoo's Safeguarding Team and the training gave me invaluable knowledge • Awareness of children at home when dealing with parents with mental health or drug issues • To be mindful of safeguarding issues in families where this might not be as obvious on initial meeting  • In core groups - to use and build on the existing plan • Ensure I challenge professionally during Core Groups and that I chase up any no responses from referrals in a reasonable time • Further awareness of my role within the core group • Working with other agencies to not be afraid to question decisions and to make challenges. To ensure that this is followed up and THAT THERE IS AN OUTCOME • Enable me to get child protection plans earlier • The impact of poor practice on the outcome of safeguarding cases • More proactive at child protection meetings • Ensure staff are offered supervision.  Ensure staff are  enabled and supported during professional challenge  • Sharing Information and partnership working is crucial  • Professional challenge and not leaving all work to the social worker  • Support colleagues to correct channels  • Enforce training in safeguarding young people  