Death of two sisters aged 3 years and 17 months respectively in November 2015. Mother was found guilty of murder of both girls and was sentenced to life in prison. Child 1 and Child 2 lived with both parents. On 16 November 2015 mother contacted police reporting that she had been a victim of domestic violence. Police visited the family home while father was at work; mother and girls were moved to a women's refuge. The following morning the mother stabbed both girls to death. Mother pleaded guilty to manslaughter on the grounds of diminished responsibility. Father denies allegation of domestic violence and has never been charged. The deaths were completely unexpected by any of the professionals who had had contact with the family; there were no concerns about the couple's relationship prior to mother's disclosure to a family worker on 30 September, or mother's mental health. Father is white British with Italian heritage; mother is white Italian. Learning includes: families can and do hide relationship problems and professionals should adopt an attitude of respectful uncertainty in their interaction with them; alleged victims of domestic abuse are vulnerable and at risk of depression and mental health, and are likely to be scared of the alleged perpetrator. Recommendations include: where it is known that there has been a family breakdown agencies should not hold meetings involving both parents unless it is clear that both parents want to and a risk assessment has been carried out.
      
 Title:  Serious case review concerning two sisters who died at 3 years and 17 months of age. LSCB: Kirklees Safeguarding Children Board Author: Peter Ward Date of publication: 2017  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.                              Kirklees Safeguarding Children Board  Serious Case Review concerning two sisters who died at 3 years and 17 months of age  Overview Report   5 December 2016  Overview Report  5 December 2016    Page 2 of 37  Table of Contents    Page 1. Child 1 and Child 2 and the circumstances leading to decision to carry out a Serious Case Review  3 2. The Statutory Basis for Conducting a Serious Case Review   3 3. The Review Process  4 4. The Facts - Summary of Agency Involvement  6 5. Analysis 13  6. Learning from the Review 28  7. Recommendations  28     Appendices Appendix 1 – Key Lines of Enquiry Appendix 2 - Abbreviations Appendix 3 – Recommendations from Agency Reports   Overview Report  5 December 2016    Page 3 of 37  1. Child 1 and Child 2 and the circumstances leading to the decision to carry out a Serious Case Review  1.1 This Serious Case Review concerns two sisters who were 3 years and 17 months old respectively at the time of their deaths.  Throughout this report the older girl is referred to as Child 1 and her sister is referred to as Child 2.  Their parents are referred to as the mother and the father.    1.2 Child 1 and Child 2 were the only children of their mother and father and lived with both parents throughout their short lives.  The girls’ father is white British, with an Italian grandmother, and was 30 years old at the time of his daughters’ deaths.  He lived in the UK for the first 15 years of his life before moving to Italy to live with his paternal grandparents.  The girls’ mother is white Italian and was 24 years old at the time of their deaths.  The parents had been in a relationship with one another since 2011.  Child 1 was born in Italy and the family moved to Kirklees in March 2013.  Child 2 was born the following year.  At the time of the girls’ death their father was working full time and their mother was caring for them on a full time basis.  1.3 On 16 November 2015, whilst the girls’ father was at work, their mother contacted West Yorkshire Police and reported that she been a victim of domestic violence from her partner.  Police officers visited the family home whilst the father was at work and the girls and their mother were moved to a women’s refuge outside Kirklees.  The following morning the mother stabbed both girls to death in the flat they had been allocated within the refuge.  The mother was arrested and charged with the murder of both children.  She pleaded guilty to manslaughter on the grounds of diminished responsibility but was found guilty of two counts of murder and sentenced to life in prison with a minimum of 24 years. The father denies the allegation of domestic violence and has never been charged in connection with the allegation.  2. The Statutory Basis for Conducting a Serious Case Review  2.1 This review was commissioned in compliance with Regulation 5 of the Local Safeguarding Children Boards (LSCBs) Regulations 2006 which came into effect on 1 April 2006.  Regulation 5 sets out the functions of LSCBs including the requirement for them to undertake reviews of serious cases in specified circumstances.  Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely:   5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.    (2) For the purposes of paragraph (1) (e) a serious case is one where:    (a) abuse or neglect of a child is known or suspected; and    Overview Report  5 December 2016    Page 4 of 37  (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.  2.2 The relevant guidance for conducting Serious Case Reviews is contained within Chapter 4 of Working Together to Safeguard Children (HM Government 2015).  Kirklees Safeguarding Children Board and the Lead Reviewer have followed that guidance in conducting this Serious Case Review.   3. The Review Process  3.1 Chapter 4 of Working Together to Safeguard Children states that “reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed”.   3.2 In accordance with this principle Kirklees Safeguarding Children Board commissioned Peter Ward as the Lead Reviewer for this Serious Case Review.  Mr Ward has a background in social care and has worked in management and front line social work.  He is qualified to degree level in social work and has a post-graduate diploma in management studies.  Since 2005 he has been involved in several Serious Case Reviews as an Independent Overview Report Author, Individual Management Review Author or Panel Chair.  Mr Ward has undertaken training in respect of using systems approaches1 when undertaking Serious Case Reviews and he is an accredited Lead Reviewer with Review Consulting having successfully completed the SILP2 Lead Reviewer training in 2016.  3.3 A Serious Case Review Panel with the following membership was established to oversee the review:  Service Manager, Children’s Social Care (Chair)  Lead Reviewer   Kirklees Safeguarding Children Board Manager  Assistant Head of Service, Children & Young Peoples Services   Director of Quality, Locala Community Partnerships CIC  Designated Doctor for Safeguarding Children, Kirklees  Designated Nurse for Safeguarding Children North Kirklees and Greater Huddersfield Clinical Commissioning Groups  Director, The Refuge   Teacher in Charge, Early Years SEN Support, Kirklees Education Services   Superintendent, West Yorkshire Police  Nursery Manager - Proprietor  3.4 Chapter 4 of Working Together to Safeguard Children 2015, states that Serious Case Reviews and other case reviews should be conducted in a way which:                                             1 The systems approach “focuses on a deeper understanding of why professionals have acted in the way they have, so that any resulting changes are grounded in practice realities” (Munro, 2011).  It “looks for causal explanations of error in all parts of the system not just within individuals” (Munro, 2005). 2 SILP (Significant Incident Learning Process) is a specific approach to carrying out a review which has been developed and is owned by Review Consulting. Overview Report  5 December 2016    Page 5 of 37   Recognises the complex circumstances in which professionals work together to safeguard children.    Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did.   Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight.   Is transparent about the way data is collected and analysed.   Makes use of relevant research and case evidence to inform the findings.  3.5 In order to meet these requirements this Serious Case Review has been undertaken using a ‘systems approach’, as recommended by Munro (2011) and authorised within Chapter 4 of Working Together to Safeguard Children 2015.  3.6 Organisations which had been involved with the family between September 2013, when health services became aware of them and 17 November 2015, when the children died were asked to provide chronologies and brief reports of their involvement including relevant background information which pre-dated this time period.  In analysing their involvement the organisations were asked to consider seven key lines of enquiry agreed by the Lead Reviewer and Serious Case Review Panel (appendix 1).  3.7 Reports were provided by the following organisations:  Calderdale and Huddersfield NHS Foundation Trust  Kirklees Early Intervention & Targeted Support Service  Kirklees Education Services   Locala Community Partnerships CIC   Mid Yorkshire Hospitals NHS Trust  North Kirklees Clinical Commissioning Group   Private Nursery  The Refuge   West Yorkshire Police   3.8 The chronology and report from Mid Yorkshire Hospitals NHS Trust showed that the organisation had not had any involvement with the family that was of relevance to this review.  Consequently it was agreed that the Trust would not take any further part in the review.  3.9 Chapter 4, paragraph 10 of Working Together to Safeguard Children 2015 lists seven “principles for learning and improvement” that should be applied to all reviews.  One of these is that “professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith”.  In carrying out this review the Lead Reviewer held a ‘Practitioner Event’ to which front staff and their managers were invited.  The event was attended by staff from all the organisations which have contributed to the review with the exception of Mid Yorkshire Hospitals NHS Trust and provided an opportunity for those present to discuss and reflect upon their involvement with the family.  Towards the end of the review process a follow up event was held with the same group of practitioners who were given an opportunity to comment on a draft of the overview report.  These practitioners’ events helped the Lead Reviewer to gain a greater understanding of the context in which practitioners worked with the family and the reasons for the decisions they made Overview Report  5 December 2016    Page 6 of 37  and the actions they took.  This in turn has assisted with drawing out relevant learning and recommendations for action and as such has been an important part of the systems approach that has been used.   3.10 Another principle is that “families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively”.  After the conclusion of the mother’s trial the Lead Reviewer and Panel Chair met the father with the children’s paternal grandparents, grandfather’s partner, paternal uncle and uncle’s partner.  The Lead Reviewer and Panel Chair subsequently met with the mother.  These meetings were used to clarify some points of uncertainty and to ascertain the family members’ opinions of the services they received from the agencies involved in this review.  Where appropriate views expressed by the family members have been incorporated into the main body of this report.    4. The Facts - Summary of Agency Involvement   4.1 This section of the report provides a factual summary of key episodes of agency involvement with the family.  It is not a comprehensive record of all contacts with the family but focuses on those episodes that are considered to be significant to the way the case developed.  It is divided into four time periods which coincide with changes in the family’s situation and the support they received.  Period 1  4.2 Period 1 describes the period from 10 December 2013 when health visitor 1 carried out a movement in contact visit in respect of Child 1 until 4 September 2014 when Child 2 received her eight week medical examination.  During this period the mother was pregnant with and gave birth to Child 2 and consequently received maternity care.  The family also had their first contacts with Health Visiting Services.    4.3 No health, development or social concerns were identified in relation to Child 1 during the movement in visit on 10 December 2013 but speech was to be reviewed.  It was also noted that mother was four months pregnant and was to register herself with a GP and midwife.  The following week mother was seen by a nurse at the GP practice for a new patient examination.  On 9 January 2014 she was seen at home by a midwife when it was recorded that she was 16-18 weeks pregnant and therefore a late booking.  During the pregnancy the community midwife carried out two home visits, four foetal scans were undertaken and mother attended one ante-natal clinic and missed one other.  There were no health concerns for her or the unborn child during the pregnancy and Maternity Services had no social concerns regarding the family.  4.4 On 28 February 2014, health visitor 1 undertook a two year development review of child 1 who was found to be meeting all her developmental milestones.  No concerns were identified either through the health visitor’s observation or in discussion with the parents, who were both present and said they had a network Overview Report  5 December 2016    Page 7 of 37  of supportive friends and family and no concerns about their daughter’s behaviour.  4.5 Six weeks later, on 9 April 2014, health visitor 2 carried out an ante natal visit.  The mother and child 1 were both present but the father was not present although, at his request, the appointment had been made for a time when he could attend.  It was recorded that the mother felt emotionally well with no past history of depression, self-harm or anxiety and that she felt physically and emotionally prepared for the birth of her second child.   4.6 Child 2 was born in the early hours of 26 June 2014 and later that day she and her mother were discharged home.  During the next two weeks the community midwife undertook four home visits and identified no health concerns.  Towards the end of that two week period health visitor 2 carried out a primary birth visit and undertook a full health assessment of the mother and child 2.  No unmet health or social needs were identified and it was determined that the health visitor would continue to visit as per the healthy child programme.  4.7 On 2 September 2014, the mother was seen by the GP for her six week post natal check.  Edinburgh Post Natal Depression screening was carried out with a score of zero which indicated that there were no concerns in relation to post natal depression.  Two days later the eight week examination of Child 2 was normal and she was given her first course of vaccinations.  On 29 September 2014, health visitor 2 carried out another home visit.  She assessed mother’s mental health by asking postnatal screening questions.  No concerns were identified and the mother reported that she was well supported by her partner.  Health visitor 2 also found that Child 2 was feeding and developing well.  The mother informed the health visitor that the family were due to move home before Christmas.    Period 2  4.8 Period 2 describes a period from 27 November 2014 when the parents took Child 1 to the GP practice and expressed concern about her behaviour and speech development until the end of June 2015 when they informed the health visitor that they were imminently moving home from South to North Kirklees.   During this period the significant contacts were in respect of the concerns raised about the behaviour of Child 1.  4.9 On 27 November 2014, Child 1, accompanied by both parents, was seen by GP3, a trainee GP.  The parents expressed concern about Child 1’s behaviour, describing it as uncontrollable and also about her speech development as she was only saying the occasional words.  GP3 referred Child 1 to a paediatrician who saw her five weeks later, on 31 December 2014, and noted that she was difficult to engage, prone to screaming and difficult to examine.  The paediatrician recommended that Child 1 be reviewed by the Child Development Team for a Schedule of Growing Skills Assessment with a plan to be seen again by the paediatrician after the assessment.   4.10 The Child Development Team saw Child 1 six weeks later, on 11 February 2015, but was unable to complete the assessment because Child 1 would not engage.  The Child Development Team made a referral to Speech and Language Therapy Overview Report  5 December 2016    Page 8 of 37  for further assessment and informed the GP Practice and health visitor 1 of the outcome of the assessment.  Paediatrician 1, who had planned to see Child 1 again after the Schedule of Growing Skills Assessment did not see the report from the assessment and the planned follow up appointment was not arranged.  4.11 Having been contacted by the Child Development Team, health visitor 1 contacted the father and arranged a home visit for 9 March 2015.  Both parents were at home for the home visit.  They told the health visitor that Child 1 had struggled since the birth of her sister and needed constant attention around her.  The father stated that he felt he was being passed from pillar to post as he had now been asked to make an appointment with Speech and Language Therapy.  The health visitor advised that they make the appointment to avoid being discharged.  The parents also said that they were reluctant to register Child 1 with a local nursery because they hoped that they would soon be moving to North Kirklees.  Health visitor 1 emphasised the potential benefits of an early years placement and strongly recommended registration at a local nursery as a moving date had not been confirmed.  Health visitor 1 subsequently visited the family home on both 24 April 2015 and 29 May 2015 with the intention of carrying out a pre-one assessment of Child 2.  The family had been notified of both these visits but they were not at home on either occasion and the health visitor left a calling card advising the parents to contact the Health Visiting Service if a visit was required    4.12 The family made an appointment for Child 1 to see a speech and language therapist on 5 May 2015 but forgot to take her to the appointment.  This was rearranged for 1 June 2015 when they did take her.  Advice was given regarding vocabulary development and play and a plan was made for Child 1’s care to be transferred to therapy services in North Kirklees as the family was moving home.  4.13 Having had no contact from the family since her attempted visit on 29 May 2015, health visitor 1 reviewed the records on 5 June 2015 and saw that Child 1 had been seen by Speech and Language Therapy and would benefit from further support to access nursery provision.  Health visitor 1 also noted that a house move was imminent.  Having tried, unsuccessfully, to contact the family health visitor 1 undertook an opportunistic home visit on 22 June 2015 and was told by the mother that the family was moving home the following week and arrangements had been made for Child 1 to have follow-up from Speech and Language Therapy in North Kirklees.  Health visitor 1 informed the mother that Child 2 was due a pre-one assessment and that information would be passed to the Health Visiting Team in the family’s new area.  The following week health visitor 1 reiterated these points to the father in a phone call.  Period 3   4.14 Period 3 describes a period from 17 July 2015 after the family had moved to North Kirklees until 12 November 2015 after the mother told a family worker from the Early Intervention and Targeted Support Service that she wanted to leave her partner and needed help securing benefits.  During this period the mother and Child 2 attended a ‘One Stop Shop’ whilst Child 1 started to attend a local day nursery.  Overview Report  5 December 2016    Page 9 of 37  4.15 Health visitor 3 tried to visit the family at home on both 17 and 20 July 2015 having informed them of her intention to do so but she was unable to gain access on either occasion.  On 23 July 2015, the father phoned the health visitor and asked that the visit be rearranged for a different day when he could be at home as his partner was Italian and spoke little English.  It was agreed that health visitor 3 would visit the following day.  4.16 When health visitor 3 carried out the agreed visit on 24 July 2015 the father was not present.  Health visitor 3 offered the use of Language Line3 but the mother did not want this and the visit went ahead without the use of an interpreter.  Full universal health needs assessments were undertaken for both children.  It was noted that Child 1 had very delayed speech but was seeing a speech and language therapist.  No other concerns were observed in respect of Child 1’s behaviour or development although the mother discussed concerns about her ability to play and share toys with other children.  No concerns were raised or observed regarding Child 2.  Health visitor 3 gave the mother information about local resources, including nurseries and said she would discuss it with the father.  The mother told the health visitor that she felt settled and supported now she had moved home and she was observed to be smiling and maintaining good eye contact.  The health visitor’s assessment was that there were no unmet health or social needs and that future contacts should be as per the healthy child programme unless the parents contacted the Health Visiting Service.    4.17 On 12 August 2015 the mother attended a local ‘One Stop Shop’ session run by the Early Intervention and Targeted Support Service.  She was supported with finding a nursery place for Child 1 and encouraged to continue to attend the One Stop Shop’ sessions, which she did.  4.18 On 24 August 2015, the mother made an initial visit to a local nursery.  She made the nursery manager aware that she had been to the GP regarding Child 1’s development and was concerned about her speech.  The manager explained that if deemed appropriate the nursery could refer Child 1 to Kirklees Early Years Special Educational Needs (SEN) Support for extra support.  Child 1 started to attend regularly from 7 September 2015 and continued to do so throughout the remainder of her short life.  4.19 On 14 September 2015, the nursery referred Child 1 to Kirklees Early Years SEN Support, this referral was allocated within the team on 19 October 2015 and a meeting arranged for parents, nursery staff and an inclusion officer from Kirklees Early Years SEN Support staff to take place at the nursery on 17 November 2015.  4.20 On 30 September 2015, the mother spoke to a family worker at a ‘One Stop Shop’ session about issues to do with her relationship with her partner and said that she felt isolated and lacked confidence.  She was referred onto a ‘Steps programme4’, commencing in January and it was agreed that the family worker would continue to support her in the interim.  She was asked if there had been any domestic violence in the relationship and she responded that there had not.                                             3 Language Line is a telephone based interpreting service 4 The Steps programme is aimed at improving motivation, confidence and self-esteem Overview Report  5 December 2016    Page 10 of 37   4.21 On 26 October 2015, the nursery phoned the Speech and Language Therapy Service in North Kirklees who appear to have had no record of Child 1 despite the plan for the South Kirklees service to transfer her care.  The nursery requested that the referral be classed as urgent.  4.22 On 9 November 2015, the mother told the family worker from the Early Intervention and Targeted Support Service that she wanted to leave her partner and wanted advice regarding benefits.  She said again that there had not been any domestic violence in the relationship.  The family worker discussed this with her manager later in the week and planned to contact the mother during the week beginning 16 November 2015.  Period 4  4.23 Period 4 describes a period of approximately 27 hours from shortly before 09:00 hours on 16 November 2015 when the mother dialled 999 and made an allegation of domestic violence against her partner until she was arrested on suspicion of the murder of both children the following day.  During this period the mother and children were admitted to a women’s refuge, both parents had several phone calls with West Yorkshire Police and staff from Kirklees Early Years SEN Support attended the nursery for a planned meeting with both parents.  4.24 The mother told the West Yorkshire Police call handler that her partner had hit her the previous day and she thought something bad was going to happen to her the following weekend.  The father was not in the house and was thought to be at work so the mother was advised to lock all her windows and doors and was told that police officers would be with her within an hour.  4.25 Police officers attended the address at 10:11 and spoke to the mother who said that she was in fear of suffering significant harm and that she wished to leave the address.  PC3 carried out a Domestic Abuse, Stalking, Harassment and Honour Based Violence (DASH) report which assessed the risk as medium5.  The DASH form allows officers to comment on the demeanour of children in the household and PC3 recorded having no concerns for the welfare of the children or the mother’s care of them.  PC2 made a referral to a refuge in another city which specialises in provision for black and minority ethnic victims of domestic violence who have children.  The mother and both children were accepted after a member of staff from the refuge spoke to the mother over the phone and completed a referral form and a needs assessment.  The police officers took them to the refuge.  4.26 Both children were unwell with coughs and colds when they arrived at the refuge and during the afternoon the mother took them to a ‘Walk in Centre’ local to the refuge where a Locum GP prescribed antibiotics. Also during that afternoon, the mother expressed concern about being in a refuge in this city due to members of                                             5 Medium Risk is defined on the DASH form as: ‘There are identifiable indicators of risk of serious harm. Offender likely to cause serious harm if change in circumstances, i.e. failure to take medication, relationship breakdown, substance misuse, if bailed after Court appearance etc.’ Overview Report  5 December 2016    Page 11 of 37  the father’s family working there.  She was given reassurance about security around the refuge.  Refuge staff phoned refuges in other local cities to enquire about the possibility of the mother and children moving but there were no vacancies and at around 16:30 it was decided that the mother and children would stay the night in the refuge.    4.27 Also on 16 November 2015, the father phoned the nursery manager at 09:30 to say that Child 1 would not be attending as she was unwell.  It was agreed that the meeting with Kirklees Early Years SEN Support would go ahead the following day as planned.  At 12:00 the father phoned the nursery manager again.  He said that he and the mother were on the verge of splitting up as they had been having problems for a few months and he enquired about the availability of a full time nursery place for Child 1 when they did split up.  He also reiterated that both he and the mother wanted the meeting planned for the following morning to go ahead.  At 17:15 he phoned nursery for the third time that day and told the deputy manager that he had got home from work and realised that his partner and both children were missing.  He asked for nursery to phone the mother and find out where she was but he was advised to report them missing to the police if he was concerned.  After the call ended the deputy manager tried to phone the mother to ask whether she wanted to cancel the meeting planned for the following day but the mother did not answer.  4.28 At 23:22 a female caller dialled 999 and stated she was calling on behalf of her brother-in-law to report a missing woman and two children.  The Police call handler then spoke to the children’s father who stated that he had last seen his partner and children that morning.  He was asked directly if his partner had any medical or mental health conditions and he stated that he suspected that she may have “a bit of depression mixed with paranoia”.  He expressed concern for the welfare of his partner and children on the basis that she has no friends or family in the UK and no money.  Having checked records, the operator notified the father that all she can state is that they are safe and well.  4.29 At 23:38 the father’s brother phoned the police wanting to know where the mother and the children were.  He was also told that they were safe and well but that no other information could be provided.  4.30 Just before 03:00 hours on the 17 November 2015, the father phoned the Police again and said that he believed the mother was “on the verge of a nervous breakdown”.  He stated that he was concerned for the safety of her and the children and that she gets high levels of paranoia.  The father also described the mother as a “a very good mum” who “looks after them like nobody else would”.  The call handler informed the father that his partner and the children were safe and well and advised him to speak with social services and a solicitor.  The call handler also updated the log with information about the father’s concerns about his partner.  4.31 At 07:30 a supervisor from the nursery tried to make contact with the mother to find out if she wanted the meeting to go ahead but did not receive an answer.  The supervisor then phoned Kirklees Early Years SEN Support and stated that there had been a family breakdown but both parents still wanted to attend the planned meeting. Overview Report  5 December 2016    Page 12 of 37   4.32 PC4 was instructed by Inspector 1 to contact the refuge and ensure that the mother and children had stayed the night and were safe and well.  PC4 first tried to phone at 08:00 but received no answer.  This is because the refuge is only staffed from 09:00 to 17:00 each day.  At 08:43, PC4 phoned the father who repeated his concerns for the mother’s mental health.  PC4 provided general advice about the father contacting the mother’s GP, social services and a solicitor.  At 09:15 PC4 spoke to refuge staff who informed him that the mother and children were settled and assumed to be safe and well although they had not been seen yet that morning.  4.33 Between 08:37 and 08:48 the mother contacted the Police three times by dialling 999.   On the first two occasions she was told that her issue was not an emergency and she should redial on 101 but on the third occasion the call handler engaged in a discussion with her which lasted nearly 10 minutes.  The mother explained that the police had visited her the previous day and she had been taken to a place of safety. She requested that the police accompany her to a doctor’s appointment with her daughter as she was concerned her boyfriend would be there and would take her children from her.  The operator explored options and concluded by saying that police could not help.  4.34 The nursery manager arrived at the nursery at 09:15 on 17 November 2015 by which time the father was already there and was talking on the phone to the mother trying to persuade her to come for the meeting.  The inclusion officer and her manager from Kirklees Early Years SEN Support arrived around the same time and the nursery manager started to talk to them about the events of the previous day.  4.35 The father had several phone conversations with the mother and at one stage he told staff that she said she would attend the meeting but had to wait until 10:00 before she could be let out from where she was.  A nursery supervisor also spoke to the mother who said she knew it was an important meeting but she was scared.  Early Years SEN Support staff and nursery manager decided that the meeting should be cancelled and rearranged.  The father spoke to the mother on the phone in Italian and then told staff that they had agreed to meet that afternoon to discuss access to the children.  He also told the nursery manager that he had spoken the Police the previous evening and had been told that the mother and children were safe.  After the decision had been taken to cancel the meeting the father stayed at the nursery for some time talking to the nursery manager.  4.36 At 09:55 CW2 from the refuge passed the mother and Child 2 in a corridor, on the phone and crying.  CW2 informed CW1 who decided to go and ring the mother’s doorbell to ask how she and the girls were.  CW1 rang the doorbell at 11:05; mother was with Child 2 and said that Child 1 was sleeping and she would come down in 10 minutes.  CW2 told her there was no rush.  At 11:15 SW5 from the refuge rang the doorbell and the mother came downstairs crying on phone and saying she had killed the girls.  At around the same time the mother phoned father, who was still at the nursery and told him she had killed the children by stabbing them.  The police and ambulance were called and the mother was arrested on suspicion of murder. Overview Report  5 December 2016    Page 13 of 37   5. Analysis   Key Line of Enquiry 1 To what extent was mother’s Italian heritage a factor in this case; in particular, was her level of English language a barrier to effective communication?  Did agencies pay sufficient regard to cultural issues and possible language difficulties?  5.1 Everyone who worked with the mother was aware that she was of Italian origin and that English was not her first language.  This is reflected in agency records of their contacts with the family.      5.2 Of the individuals who have contributed directly to this review, no-one who had direct contact with the mother thought that her level of English language was a barrier to effective communication.  Health visitor 1 observed the mother to be less confident speaking English than listening to it but found that her confidence speaking improved over time.  Furthermore, on an occasion when the father was also present, health visitor 1 was of the opinion that he did not act as an interpreter for his partner.   5.3 The members of the paternal family who contributed to this review were of the opinion that the mother understood English fairly well although maybe not as well as she thought she did. The father explained that he ensured that he was present during the early visits by the health visitor but as the mother’s English improved he was confident that she could manage these visits without him being there.  5.4 On two occasions, firstly before the ante natal visit in April 2014 and secondly before the ‘movement in’ visit in July 2015, the father told health visitors that he wanted to be present for their visits because of his partner not having English as her first language.  Visits were arranged to accommodate this request but on both occasions the father was not at home when the visit took place.  The visits went ahead and it was the view of the health visitors that the mother spoke and understood English sufficiently well to communicate with them.  5.5 The Serious Case Review Panel queried whether the Edinburgh Post Natal Depression screening tool contains questions that require good understanding of English and if so whether an interpreter should have been used when this was carried out.  The panel was reassured that the questions are straight forward and do not require particularly good or precise understanding of spoken English.  5.6 When the Health Visiting Service and the refuge asked the mother if she wanted to use an interpreter from Language Line she declined this offer.  It was good practice on the part of these services to offer this service.  Records show that prior to mother’s discharge home from hospital following the birth of Child 2 information was given via an interpreter although there is no record as to why a decision was taken to use an interpreter and there was no other time when one was used.  5.7 The police officers who attended the house have both stated that although the mother spoke to them in English she interchanged between English and Italian.  Overview Report  5 December 2016    Page 14 of 37  Nevertheless they believed that they were fully able to obtain a verbal account from her of her allegation of assault and her fears for her future safety.  They were also of the view that the mother’s command of English was insufficient for a formal witness statement to be taken from her and that a fuller and more accurate account would be obtained if an interpreter was used.  This is good practice and commensurate with guidance to officers.    5.8 In a letter referring Child 1 to the hospital it was written that mother’s English was poor.  It is not known whether this was based on GP3’s own observation or something said by one of the parents.  However, both GP practices with whom the family were registered have access to Language Line and neither used it in their dealings the mother.  5.9 One question on the ‘needs assessment form’ completed by the refuge prior to admission  asks if there is anyone else involved with the family of whom the refuge should be aware.  When asked this question the mother named the family worker from the Early Intervention and Targeted Support Service.  She did not tell refuge staff that Child 1 attended a nursery and elsewhere on the form it is recorded that the mother would like help getting a nursery place for Child 1.  It is not known whether this omission in the information provided was the result of any language difficulty.    5.10 An interpreter was present for the mother’s meeting with the Lead Reviewer and Panel Chair but was not required for most of the discussion.    5.11 As an Italian woman who had only been in the UK since 2013 the mother had no family or friends of her own in the neighbourhood and therefore could potentially be isolated.  During the second half of 2014 a priority for the parents was to move back to North Kirklees to be near to the father’s family.  The health visitors who worked with the family during that time understood that the mother saw the father’s family as providing her support network and she was as keen as he was for this move to take place.  When the health visitors tried to encourage the parents to engage with services in South Kirklees they were reluctant to do so as they were in the process of arranging their move and this was their priority.  For example on 12 February 2015, the father told health visitor 1 that the mother was isolated where they were currently living so they were hoping to move nearer to his family for support.  The mother told the Lead Reviewer and Panel Chair that after coming to England isolation was a significant factor for her and caused her some depression.  This was particularly acute in Huddersfield due to the location of the home, some distance from shops and other amenities.  She acknowledged that she had not shared her feelings with midwives or health visitors and described ‘wearing a mask’ and ‘putting on a smile’ so as not to show how she was feeling.   5.12 The police officers who attended at the family home identified that the mother was socially isolated and did not have her own support network of family or friends in the UK.  This contributed to their decision to seek accommodation for her and her children in a refuge.  In view of the mother’s Italian heritage, it was good practice on the part of the police officers to contact a refuge which specifically works with people from black and minority ethnic communities.  When Overview Report  5 December 2016    Page 15 of 37  the mother was admitted to the refuge she told staff that she was very lonely with no family around and that her family was coming to see her soon.  5.13 At one session at the children’s centre the mother said that she did not get on with her partner’s family.  She was encouraged to attend the One Stop Shop every week to make friends and was also encouraged to get a nursery place for Child 1.  There is evidence that the family worker from the children’s centre was beginning to develop a positive working relationship with the mother, who was beginning to share information about her life and how she was feeling.  Key Line of Enquiry 2 What information, if any, was available to agencies before 16 November 2015 that could have raised concerns about the welfare of the children?  How appropriate was the response to any such information?   5.14 Throughout the period being considered by this review the professionals working with the family observed the interactions of one or both parents with the children and there were never any concerns that the children were not loved and appropriately cared for by both of their parents.  This review has considered a number of themes and whether these should or could have led to concerns for the welfare of the children.   Mother’s mental health  5.15 When mother registered with a GP practice in the United Kingdom she would have been asked questions about her medical history but her medical records from Italy would not have been accessed as it is not usual practice to do so.  Therefore the GPs would only know what the mother chose to disclose about her medical history, including any mental health issues.  This review has not had access to the mother’s previous medical history from when she lived in Italy and the Lead Reviewer has no knowledge of whether or not she ever suffered, or was treated for, any mental health problems prior to coming to live in the UK.  5.16 Health professionals undertook appropriate screening in respect of the mother’s mental health and never had concerns.  The midwife screened the mother for depression at the booking in appointment on 9 January 2014 and there was no indication that she was depressed.  GP4 screened the mother for post natal depression using the Edinburgh Post Natal Depression tool when Child 2 was six weeks old.  She scored 0 out of a possible 30 and guidance states that scores in the 0-9 range are generally not indicative of depression.  5.17 From April 2014 when Health Visitor 2 carried out an ante natal visit until July 2015 when Health Visitor 3 carried out a ‘movement in’ visit no concerns were identified by the health visitors about the mother’s mental health, even when specific assessments were undertaken such as on 29 September 2014 (see paragraph 4.7).  She appeared to be relaxed during contacts and positive and warm interactions between her and the children were observed.  Good eye contact and interaction with all health visitors was documented.  Similarly the midwives did not raise any concerns about her mental health at any stage during the pregnancy or in the days immediately after Child 2 was born.    Overview Report  5 December 2016    Page 16 of 37  5.18 The family worker from Early Intervention and Targeted Services met the mother one week before she made an allegation of domestic violence and eight days before she killed her children.  During this meeting the mother talked about wanting to leave her partner and wanted advice regarding benefits.  Unsurprisingly she presented as less happy than she had done on previous occasions but nothing about her presentation caused any great concern.  5.19 The paternal family told the Lead Reviewer and Panel Chair that they had had some concerns about the mother’s mental health; in particular that she had some paranoia and depression.  The paternal grandmother had talked to her about this and suggested she may benefit from seeing the doctor and taking some medication to help with this.  However, they were totally shocked by the murder of the girls.  5.20 Until the night of 16/17 November 2015, neither the mother nor any member of the paternal family expressed concern about the mother’s mental health to any of the organisations working with them.  Mother’s explanation of this is provided in paragraph 5.11 above.  On the night of 16/17 November 2015 the father did express concerns to the Police and this is addressed in paragraphs 5.65 to 5.67 of this report.   Engagement with services  5.21 On four occasions between April and July 2015 health visitors carried out pre-arranged visits to the family home but received no reply.  However health visitor 1 successfully undertook a visit on 22 June 2015 and health visitor 3 undertook one on 24 July 2015.  These missed appointments did not cause concern for the welfare of the children.  There was no requirement for the parents to engage with Health Visiting Service at that time and no sense that they were deliberately avoiding professionals.  When the children were seen they appeared to be well cared for and, notwithstanding the concerns regarding Child 1’s behaviour and speech they were developing appropriately.  5.22 The family also failed to take Child 1 for her first scheduled appointment with the speech and language therapist but once again this did not cause concern for the welfare of the children.  This is an opt-in service and the appointment had been made by the parents in the first place and they subsequently attended when it was rearranged.   Child 1’s behavioural problems  5.23 Period 2, in Section 4 of this report, describes a period of time when Child 1’s parents reported that her behaviour had deteriorated and they were concerned about delays in her speech development.  GP3, a paediatric consultant, members of the Child Development Team, a speech and language therapist and health visitor 1 all had contact with Child 1 and one or both of her parents in connection with this issue.     5.24 The GP appointment when the parents expressed concern about the behaviour and development of Child 1 was five months after Child 2 was born.  The arrival of a baby is a significant event within a family and it is not unusual for this to have Overview Report  5 December 2016    Page 17 of 37  an impact on an older child.  The father told the Lead Reviewer and Panel Chair that concerns about Child 1’s behaviour commenced prior to the birth of Child 2 but this is not evident from the records.    5.25 The parents consider that it took a long time between them raising concerns about Child 1’s behaviour and them receiving any help.  Records show that there was a gap of five weeks between their appointment with the GP and an appointment with the Paediatrician, a further six weeks until the appointment with the Child Development Team and a further three months before the first appointment with a speech and language therapist, which the family missed.  It is understandable that this feels like a long time to the family but each individual gap was of an acceptable timescale. However if the health visitor had been informed at the time of the referral to the paediatrician she could have offered support immediately, rather than three months later (see paragraph 5.38).    5.26 Health visitor 1 was responsive after being informed of the schedule of growing skills assessment, proactively visiting the family and encouraging them to initiate speech and language therapy and to enrol Child 1 at a local nursery.  The priority for the family, at that time, seems to have been to secure their move to North Kirklees to be nearer to the father’s extended family and they decided against enrolling at a nursery until they had done so.    5.27 After the family moved in July 2015, health visitor 3 carried out a comprehensive universal needs assessment in respect of Child 1 which indicated no concerns other than minimal speech.  Health visitor 3’s observation of Child 1 was that she presented the same as any other child of a similar age and did not exhibit any behavioural concerns.  The mother expressed concerns about Child 1’s ability to play and share toys with other children.  The paternal family confirmed that their concerns about Child 1 continued after the family moved to North Kirklees.    5.28 After the family moved they did secure a nursery place for Child 1.  Nursery staff were responsive to Child 1’s needs, making referrals to Early Years SEN Support and Speech and Language Therapy.  The parents worked with nursery staff and again there were no concerns about the care they were providing.    5.29 No-one from any agency ever took the view that the concerns about Child 1’s behaviour and speech were the result of her not being cared for appropriately by her parents and this review has not found any reason why agencies should have had such concerns.  Her parents initially brought the issues to the attention of the GP and they co-operated with the subsequent referrals.     Signs of domestic violence/relationship problems  5.30 The first time the mother alleged domestic abuse to anyone involved in this review was when she contacted the Police on 16 November 2015.  The father was never charged with any offence and he categorically denies the allegation.    5.31 When the mother talked to the family worker on 30 September 2015 this was the first time that anyone had been aware of any relationship problems between the parents.  The response from the family worker followed service practice for low level intervention work with a referral being made to the ‘Steps’ programme and Overview Report  5 December 2016    Page 18 of 37  the case being discussed in supervision after the mother said she was considering leaving her partner. The referral form for the ‘Steps’ programme includes a question about domestic violence.  When the mother was asked about this question she did not initially understand what was meant but when it was explained in more detail she said that there had not been any domestic violence in the relationship.  She repeated this when she met with the family worker on 9 November 2015.  At the time of the children’s death, the family worker was still working with the mother with a view to establishing whether one to one work was required.    5.32 Midwives and health visitors are expected to ask mothers questions about domestic abuse to try to establish whether there is any in their relationships.  There is no documented evidence that the midwives asked this during any of their contacts with the mother and it is not known whether the question was asked but not recorded or not asked.  During a domestic homicide review carried out in Kirklees in 2014 it was found that midwives had not always asked the victim about domestic abuse.  Further work has been carried out by Calderdale and Huddersfield Foundation Trust since the previous review regarding routine enquiry. This has now been changed on the electronic record so that a yes or no response is required and if no a reason why is given.  There are plans in place to audit the electronic records to check that the question is routinely being asked and the response recorded.   5.33 The health visitors’ professional guidelines are that it is not appropriate to ask questions about domestic abuse if another adult or a child over two years old is present.  In this case the health visitors never saw the mother without either her partner or Child 1, who was over two years old, being present and therefore the domestic abuse screening questions were never asked.  However, none of the health visitors ever had concerns about the relationship and health visitor 1, who saw the parents together, did not sense or observe any tension between them and the mother told health visitor 2 that she was well supported by her husband.  The health visitors believe that, had they had concerns about the relationship they would have made an opportunity to talk to the mother alone to give her an opportunity to open up.   5.34 When talking to the Lead Reviewer and Panel Chair the mother described being controlled by the father.  Practitioners had no sense that this was the case during their work with the family.  The father was present for some appointments but not for others and health visitor 1 reports that when he was present he did not always stay in the room.  The mother had numerous opportunities to engage with practitioners without her partner present.  She told the Lead Reviewer and Panel Chair that she hid what she was experiencing from health professionals and now wishes that she had disclosed much sooner.   Conclusion  5.35 Having considered these themes the Lead Reviewer does not consider that agencies had any reason to have concerns for the welfare of the children whilst they were in the care of their parents.  When the parents themselves raised concerns about Child 1’s behaviour and speech development there was a multi-agency response that was timely and appropriate. Overview Report  5 December 2016    Page 19 of 37   Key Line of Enquiry 3 The quality and appropriateness of inter and intra-agency communication, including any gaps in communication.  5.36 It is evident from this review that until 16 November 2015 there were no significant concerns in relation to this family and limited engagement with agencies.  Consequently there was not a need for high levels of communication within or between agencies.  Nevertheless, this review has found three specific occasions when there were gaps in communication during the period up to 16 November 2015.  5.37 Firstly, when GP3 referred Child 1 to a paediatrician on 27 November 2014 the Health Visiting Service was not made aware of this referral.  The GP practice and health visitor have a monthly link meeting where information can be shared about children where there are some concerns and this would have provided an opportunity for the GP to inform the health visitor of the concerns expressed by Child 1’s parents and the actions taken.    5.38 It is neither necessary nor appropriate for GPs to inform health visitors of all pre-school age children who are referred to a paediatrician.  The Health Visiting Service would not have a role in all such cases and would not have the capacity to follow up every child who was referred.  However, it would have been appropriate for the health visitor to have been informed about Child 1 being referred because the parents were struggling to manage her behaviour and it might be that the health visitor could have provided support and guidance, particularly whilst the family were waiting for their appointment with the paediatrician.  When the Health Visiting Service was subsequently informed of Child’s 1 attendance at the Child Development Unit, health visitor 1 visited the family promptly to assess and offer support.  Had she been informed at the time of the original referral to the paediatrician she could have visited nearly three months earlier.  It is not known why the system that is in place for communication between the GPs and health visitors did not work on this occasion but GP3’s lack of experience, as a trainee, may have been a factor.    5.39 The second occasion when there was gap in communication occurred after Child 1 had been seen by the Child Development Team.  The consultant paediatrician intended to see her again when the Schedule of Growing Skills Assessment had been undertaken but although the GP practice and Health Visiting Service received a copy of the assessment report it appears that the consultant paediatrician did not.  Records within the Child Development Team show that the child development assistant’s line manager agreed to have a conversation with the paediatrician but this appears not to have happened.  Having investigated this matter, the Child Development Team manager believes it was a one off, firstly because it is unusual for a paediatrician to wait for feedback before arranging a follow up appointment and secondly because it is usual practice for the team to inform a paediatrician of the outcome of an assessment.  Had a follow up appointment taken place the paediatrician would have considered whether or not to refer Child 1 for other specialist assessments, such as an autism assessment.  Nationally there are long waiting lists for autism Overview Report  5 December 2016    Page 20 of 37  assessments and if Child 1 had been referred she would not have received such an assessment in the time frame of this review.       5.40 Finally, in South Kirklees speech and language therapy is provided by Calderdale and Huddersfield Foundation Trust whilst in North Kirklees it is provided by Locala.  Consequently, if a person receiving speech and language therapy moves from South to North Kirklees they need to be referred to Locala to continue receiving a service.  The parents believed that the speech and language therapist who whey saw in Huddersfield was going to refer Child 1 to the Speech and Language Therapy Service in North Kirklees.  They expected to be contacted by the North Kirklees service for an appointment but this did not happen.     5.41 It was recorded by the South Kirklees Speech and Language Therapy Service that a plan had been made for Child 1’s care to be transferred to the North Kirklees.  It was further recorded that the therapist wrote to the parents at their Huddersfield address on 23 June 2015 asking for their consent for a referral to be made to the North Kirklees service.  However, no copy of this letter can be found and the parents did not receive it.  Therefore it is possible that it was never sent or that it was sent but did not arrive until after the family moved home on 29 June 2015.      5.42 This review has been unable to establish exactly what process should have been followed by the Speech and Language Therapy Service in South Kirklees when the family moved to North Kirklees or what process was followed.  However, it is evident that Child 1 was not referred to the Speech and Language Therapy Service in North Kirklees until the nursery made a referral three months after the family moved home and consequently she did not receive any speech and language therapy after they moved.  5.43 These breakdowns in communication contributed to feelings of anger and frustration expressed by both parents that they did not receive a quicker response to their concerns about Child 1’s behaviour and that they were passed from place to place with no-one taking appropriate responsibility.     5.44 There was appropriate communication between agencies throughout the time period under review.  This included the Child Development Team informing the GP Practice and health visitor 1of the outcome of the Schedule of Growing Skills Assessment, communication between different Health Visiting Teams when the family moved home, communication between the nursery and Kirklees Early Years SEN Support regarding support for Child 1 and communication within the Early Intervention and Targeted Support Service when the mother disclosed isolation and relationship difficulties.   5.45 PCs 2 and 3 expressed surprise at how little discussion the refuge staff had with them when they arrived with the mother and children on 16 November 2015, although there was no information they particularly felt they needed to pass on.  From their perspective they had spent around three hours with the family and undertaken a detailed DASH assessment and they expected to be asked for their view of the situation.  Refuge staff had had a lengthy phone conversation with the mother to carry out a needs assessment and to ensure that she wanted to be Overview Report  5 December 2016    Page 21 of 37  admitted.  Therefore, refuge staff were of the opinion that the mother had had the opportunity to provide them with any information they might want.  Had the police officers considered that they did have information that the agency needed they could have made an opportunity to do so at the time or contacted the agency by phone shortly afterwards.       5.46 Notwithstanding the possibility for police officers to provide information verbally to the refuge this review has considered whether then DASH risk assessment itself could or should have been shared.  It is currently routine practice for Kirklees Safeguarding Unit to share DASH risk assessments with agencies they make referrals to for victim support.  However, it does not appear to be common practice for the West Yorkshire Police, or other Police services, to supply a copy of the DASH assessment to refuges when accommodating victims, or indeed for refuges to request a copy.  West Yorkshire Police guidance to staff requires that the DASH is completed on to the form whenever possible directly with the victim.  However, central audit shows that it is commonly current practice in most cases for officers to actually complete the written DASH form after returning to the station.  This means that in most cases officers transporting a victim to a refuge will not have a DASH form available to supply to workers there and then as the actual report will not have been completed at that point.  5.47 West Yorkshire Police has developed the facility to create a DASH report on a handheld device which all officers are now issued with, and this should be regarded as best practice.  West Yorkshire Police is considering withdrawing Word versions of the DASH form from databases so that the report can only be completed on the device as it believes that restricting completion of the assessment to the handheld device will ensure that it is filled in the presence of the victim with a consequent increase in the quality of the report.  Creating the DASH form on the handheld device also requires officers to put an entry in the free text field which accompanies each risk factor they endorse as being identified before they can proceed with completing the form.  This would have ensured that PC3 would have had to include some qualifying free text in relation to her identification of depression/suicidal thoughts as a risk factor on the mother’s DASH form (see paragraph 5.52).  5.48 At the current time DASH assessments can only be emailed from a desktop or laptop computer, not from the handheld device.  Therefore, even when such assessments are completed on the handheld device whilst officers are away from the police station it is not possible for a copy to be given to refuge staff there and then.  However, West Yorkshire Police have instructed officers that when a person is taken to a refuge the officer who completes the DASH risk assessment should email a copy of it to the refuge before they finish their shift.   5.49 Communication on 17 November 2015 is considered in the analysis of Key Line of Enquiry 6.  Key Line of Enquiry 4 Agencies’ responses to mother’s allegation of domestic violence made on 16 November 2015.   Overview Report  5 December 2016    Page 22 of 37  5.50 West Yorkshire Police and the refuge were the only agencies that were aware that the mother had made an allegation of domestic violence.  5.51 The police response to the mother’s report of a domestic assault on 16 November 2015 was positive and supportive. Officers attended within an acceptable time frame given that the incident was not ongoing, the father was neither present at the address nor expected to imminently return and PC2 had called the mother who had asked the officers to give her time to get the children ready before arriving.  It is a consistent theme of domestic abuse training that staff should listen to and believe the victim and should give weight to the victim’s own assessment of the potential risk they face and this is what the officers did in this case, responding positively to the mother’s fear and wish to leave the property.   5.52 The DASH risk assessment form completed by PC3 is comprehensive.  It identifies several risk factors with information evidencing many of the areas identified.  Question 5 on the DASH form asks whether the subject is displaying depression or suicidal thoughts and does not differentiate between the two.  This question has been answered in the affirmative but there is no additional text to expand on this.  PC3 believes that she did not include any free text because she did not consider this factor be of particular significance in this case as the mother described herself as being in a ‘low’ mood rather than actually depressed and gave no indication that she may be suicidal.  Additionally, the officers had no concerns about the mother’s mental health. West Yorkshire Police has amended its DASH form  to include separate questions concerning depression and suicidal thoughts.   5.53 Nothing the officers saw or heard whilst they were with the mother and children gave them any concerns about the welfare of either child, who were well presented and appeared well looked after.  Indeed their assessment was that the mother was a diligent and caring parent.  5.54 The refuge also acted appropriately, completing a needs assessment form through direct discussion with the mother by phone before agreeing to admit her and the children.  The refuge regarded this as a routine admission and their priority was to ensure that the immediate needs of the family were met.  This included providing the mother with vouchers for a local supermarket and arranging appointments for the children with a GP as they were unwell.  In addition, because the mother expressed fear about the location of the refuge, time was spent providing reassurance concerning the security measures in place at the refuge and contacting refuges in other cities with a view to a possible move.      5.55 Paragraph 5.9 refers to information that the mother provided to the refuge about other agencies when the needs assessment form was being completed.  The refuge could have tried to contact the family worker on the afternoon of 16 November 2015 but as stated above, their priority was to address the family’s immediate needs and, having received them into what was believed to be a safe place, there was no reason to prioritise contacting the family worker who, it transpires, was not in work that day.  If the mother had told refuge staff that Child 1 already attended a nursery they would have either contacted the nursery to tell Overview Report  5 December 2016    Page 23 of 37  them that Child 1 would not be attending or would have encouraged the mother to do this herself.  Again, it is unlikely that this would have been done on the afternoon of 16 November 2015 as there were other priorities to address.  It is more likely that it would have been done on 17 November 2015.   5.56 Child 1 had been absent from the nursery the previous week with a cough and cold throughout the week beginning 9 November 2015 and therefore, when the father phoned the nursery on the morning of 16 November and said that she was still unwell and would not attend that day, staff had no reason to be concerned.  When the father told the nursery manager, at 12:00, that he and his partner were on the verge of splitting up this was the first indication nursery staff had of difficulties within the couple’s relationship.  The stated purpose of this phone call was to enquire about the availability of a full time place for Child 1 and again nothing was said that should have raised concerns about the welfare or safety of the children.  When the father phoned the nursery again at 17:15 the deputy manager acted appropriately by consulting with the manager and advising the father to phone the police if he had concerns about the mother and children.  The deputy manager’s purpose in trying to phone the mother herself was to ask her whether she wanted to go ahead with the planned meeting the following morning.  This was appropriate but when the mother did not answer her phone there was no further action that the nursery needed to take at that time.  Nursery staff had never had any reason to be concerned that the mother had mental health problems or might constitute a risk to her children and there was no reason why the information from the father that they were not at home and he did not know where they were should have led to concerns over their welfare or safety that required immediate action.    Key Line of Enquiry 5 The decision that a meeting with both parents planned to take place at the nursery on 17 November 2015 would go ahead after mother made an allegation of domestic violence.  How appropriate was this decision and what factors were put in place to safeguard the children whilst the meeting took place?    5.57 On the morning of 17 November 2015 the mother and children were in a refuge as a result of the mother making an allegation to the police that her partner had hit her and that she had significant concerns about her future safety.  Police officers were due to investigate a possible criminal offence allegedly committed by the father.  In that context it was not appropriate for a meeting involving both parents to take place at the nursery, or anywhere else that morning.  However, in considering the actions of the agencies involved it is necessary to consider what they knew about this situation.  5.58 The meeting was due to take place between both parents and staff from the nursery and Kirklees Early Years SEN Support.  The nursery manager and deputy manager knew, from information provided by the father the previous day, that there were relationship problems between the parents and also that the mother and children had not been at the family home when the father had returned from work the previous day.  They did not know whether the mother and children had returned home later that evening or that the mother had made an allegation to the Police of domestic violence against her partner and been admitted to a refuge.  Staff from Kirklees Early Years SEN Support had never Overview Report  5 December 2016    Page 24 of 37  met any of the family and, until the morning of 17 November 2015, did not have any information about any relationship problems between the parents.  They were also unaware that the mother and children had left the family home.  5.59 The only agencies in which staff were aware that the mother had made an allegation of domestic violence and had been admitted to a refuge with her children were the refuge itself and West Yorkshire Police and no-one from either of these agencies knew that Child 1 attended the nursery or that a meeting had been arranged for that morning with the exception of one call handler from the Police who the mother spoke to shortly before 09:00 on 17 November 2015 (see paragraphs 4.33 and 5.68).  5.60  Although the father told the nursery staff that he wanted the meeting to go ahead the staff had been unable to make contact with the mother since being told that she had left the family home and therefore had no information as to her view regarding the meeting.  The Serious Case Review Panel has carefully considered whether the nursery should have cancelled the meeting when they were unable to contact the mother on the morning of 17 November 2015.  The panel is of the view that, given the limited information available to nursery staff at that time (see paragraph 5.58), along with their knowledge that the mother had previously been very keen for this meeting to go ahead, there was not a compelling reason for it to be cancelled.    5.61 Staff were faced with an unclear situation when they arrived at the nursery and the frequent phone calls between the parents made it difficult for them to clarify this.  The phone conversations were partly conducted in Italian so staff could not always understand what the father was saying and could not hear the mother’s side of the conversation.  Consequently, their understanding of the situation was entirely dependent on what the father told them and their observations of his tone of voice and body language.  They considered him to be calm, controlled and reasonable and he did not express concern to the staff about the mother’s ability to care for the children.  During this period, nursery and Kirklees Early Years SEN Support staff remained unaware as to where the mother and children were, that an allegation of domestic violence had been made or that the Police had been involved.    5.62 The decision to cancel the meeting was taken as a result of the mother telling the nursery supervisor that she was scared to attend.  Staff from the nursery and early years understood that the father told the mother that the meeting had been cancelled but the mother told the Lead Reviewer and Panel Chair that she thought it was still going ahead and that she was expected to attend.  5.63 The decision to cancel the meeting was appropriate but it would have been good practice for the nursery manager or Early Years Inclusion Officer to have made sure that the mother knew that it had been cancelled and to have told her that she did not need to meet with the father and should only meet with him with appropriate safeguards in place.  A short while after the decision was made to cancel the meeting, early years staff left the nursery whilst the father stayed, talking to the nursery manager.  The nursery manager intended to try to contact the mother once the father left but he was still present when the mother killed the children and therefore this call was never made.     Overview Report  5 December 2016    Page 25 of 37   Key Line of Enquiry 6 Agencies’ responses to the developing situation on the morning of 17 November 2015.    5.64 Two issues arise from the phone calls that the father and others made to the police between 23:22 on 16 November and PC4’s phone call to the father at 08:43 the following morning.      5.65 The first of these is whether it was appropriate for the police to inform the father and his brother that the mother and the children were safe and well and that no other information about their whereabouts could be given.  The paternal family feel aggrieved that they were not given more information; indeed they believe that the Police should have contacted the father when they first took the mother and children from the family home and took them to a refuge in order to tell him what they had done.  The police consider that informing the father that an allegation of assault had been made against him and that the mother and children had been accommodated in a refuge might, to some extent, have provided him with the answers he was seeking.  However, they consider the decision not to do so was correct for a number of reasons.  Individual staff members were aware that they may not be in possession of all the relevant information and that a disclosure to a caller that an allegation of a crime had been made may result in the loss of evidence or lead a possible suspect to take steps to avoid arrest.  It may cause the caller to make efforts to find the victim and put her at greater risk of harm.  Finally, it would be a disclosure of personal information without the consent of the subject.  5.66 The second issue to consider from these phone calls is whether the police should have done anything in respect of the concerns that the father expressed about his partner’s mental health.  These concerns were in the general terms of her being on the verge of a nervous breakdown and paranoia.  He did not suggest that the mother had any diagnosed mental health condition, was receiving treatment or was on medication and he stated that she was a very good mother who looked after them like nobody else would.  This is consistent with the views of PCs 2 and 3 who observed nothing which caused them to think that the mother had any mental illness, were impressed by the quality of her engagement with the children and had no concerns for their welfare whatsoever.  Whilst the information from the father should not have been dismissed out of hand it was uncorroborated information received from an ex-partner who the mother was fleeing having stated that he had coerced and controlled her over a number of years and had now assaulted her.  5.67 Short of there being immediate concern for the safety of the mother or children there would be little that the police could do with this information in the middle of the night.  Staff are only in attendance at the refuge from approximately 09:00 to 17:00 hours each day and therefore a phone call would not have elicited a response.  Residents can contact a staff member by phone at any time but the Police do not have this emergency number.   Even if refuge staff had been contacted they would not have disturbed the mother and children on the basis of the information provided by the father.  It would have been good practice for the police to have passed the father’s stated concerns about his partner’s mental Overview Report  5 December 2016    Page 26 of 37  health on to refuge staff on 17 November 2015.  However, even if they had done so it is unlikely that the refuge staff would have acted differently than they did during that morning.  This is because of the generalised and qualified nature of the concerns as detailed in the previous paragraph and the refuge staff’s own observations of the mother with her children the previous evening.      5.68 The calls that the mother made to the police before 09:00 on 17 November were not emergency calls and the call handlers were quite correct in informing her that she should not be dialling 999.  Notwithstanding this, CE10 did engage in discussion with the mother who talked about an appointment she had that morning and her fear that the father may be there.  This discussion could have provided an opportunity to positively intervene in respect of the mother’s attendance at the meeting but this did not happen and CE10 gave advice to the mother but took no further action herself.  CE10 could have created a log in respect of the call and passed it to the district control room but did not do so as she did not believe that the police would attend a doctor’s appointment because of the possibility of the father turning up.  CE10 did know that the mother was in a refuge and she could have advised the mother to seek support from staff at the refuge or could have tried to phone staff herself.  This course of action did not occur to her because she had no experience of engaging with women’s refuges and did not know how they operated or what they could or could not do.  From the log of the phone conversation it also appears that CE10 did not appreciate that the father was due to attend the meeting but instead thought that the mother was worried that he might turn up and because of this she suggested that the mother tried to rearrange the appointment to a time the father did not know about.      5.69 Because CE10 only gave advice and no further action was planned by the Police it was not necessary for a log to be made of the mother’s call.  If a log had been created it would not have gone to the Kirklees hub of West Yorkshire Police as the call had not been made from Kirklees.  Therefore PC4 was unaware of the call when he phoned the refuge approximately 30 minutes later to enquire about the welfare of the mother and children and therefore there was no opportunity for him to pass the mother’s concerns on to staff at the refuge. This is not to suggest that systems did not work as they should do but is a reflection that the Police did not assess this to be an emergency situation that required a response.  5.70 It is believed that when refuge staff left on the evening of 16 November 2015 the mother was settling into the flat she had been allocated and caring for her children who both had colds.  She did not make any contact during the night and there was no urgent reason for staff to speak to her on the morning of 17 November 2015.  Consequently no contact was made with her when staff first arrived.  The only contact anyone from any agency made with the refuge that morning was when PC4 contacted them at 09:15 to seek confirmation that they had stayed there.  PC4 had been instructed to make this call so that the missing person log created as a result of the father reporting his partner and children missing could be ended.  The staff member explained that the mother and children were settled and assumed to be safe and well although they had not been seen yet that morning.  There was no reason to suspect that they might not be at the refuge or might not be safe and well and nothing was said to suggest that they should be seen immediately.  Refuge staff remained unaware of the Overview Report  5 December 2016    Page 27 of 37  planned meeting at the nursery, the discussions that were taking place with the father or the phone calls between the parents.  There was no reason for refuge staff to suspect that the mother and children were anything other than safe and well on the morning of 17 November 2016 until the moment that the mother disclosed having killed her children and there is no reason why refuge staff should have taken any other actions earlier that day.  When the mother was seen in the corridor she was on the phone and therefore it was not practical for staff to engage with her immediately.  When a staff member did try to talk to her the mother asked for a little more time to get ready and it appears that it was straight after this that she killed her daughters.  5.71 It is of note that the mother did not share her concerns about the meeting with refuge staff at any time. Staff were not present in the refuge until 09:00 hours which was after she had phoned the Police but she did have an opportunity to talk to them once they arrived and did not avail herself of this.  The mother told the Lead Reviewer and Panel Chair that she did not ask for assistance from the refuge staff because she believed that the father would take the children from her and she thought that only the Police would be able to stop him from doing so.  Key Line of Enquiry 7 Were practitioners in services aware of and sensitive to the impact of domestic abuse on women in general and more specifically to the impact of domestic abuse on BME women and the potential effects on mental health?  5.72 Research suggests that the prevalence of mental ill health amongst victims of domestic violence and other abuse is significantly higher than amongst the rest of the population (Women’s Aid).  Furthermore, domestic violence commonly results in self-harm and attempted suicide.  According to Stark and Flitcraft (1996) one-third of women attending emergency departments for self-harm were domestic violence survivors, abused women are five times more likely to attempt suicide and one third of all female suicide attempts can be attributed to current or past experience of domestic violence (in Women’s Aid).  According to Chantler K et al (2001) the figures for black and ethnic minority women are even higher: for example, 50% of women of Asian origin who have attempted suicide or self-harm are domestic violence survivors (in Women’s Aid).  5.73 Only the Police and refuge staff were ever aware that the mother had made an allegation of domestic abuse and other agencies did not have any reason to suspect that she was a victim.  As explained in the analysis of Key Line of Enquiry 2, neither the midwives nor the health visitors ever asked the mother whether there was domestic violence in her relationship.  The family worker from Early Intervention and Targeted Services did ask this question which was good practice.  5.74 The refuge to which the mother and children were admitted is a specialist refuge for black and minority ethnic women and is part of a larger organisation which specialises in supporting women around domestic abuse.  The staff who had contact with the mother during the short time she was at the refuge considered this to be a straight forward case.  They observed her to be a caring mother and had no significant concerns about her mental health.    Overview Report  5 December 2016    Page 28 of 37  5.75 As stated elsewhere in this analysis, the Police responded appropriately to the mother when she made the allegation and further enquiries were due to be made on 17 November 2015.   6. Learning from the Review  6.1 This is a tragic case and the deaths of Child 1 and Child 2 at the hands of their mother was completely unexpected by any of the professionals who had had contact with the family.  No one identified the mother as constituting a risk to her children and this review has found no reason why anyone should have expected her to harm, let alone to kill the children.  Similarly, no information has come to light to suggest that anyone should have had concern about the couple’s relationship, prior to the mother’s disclosure to the family worker, or the mother’s mental health.  Consequently the learning that can be drawn from this review is limited.  6.2 This review has, almost inevitably, found some occasions when people working with the family could have acted differently and also examples of good practice and these are identified throughout the analysis.  Agencies have taken action and made recommendations based on the findings of their individual reviews and these are included in appendix 3.  6.3 In respect of the period before 16 November 2015, the findings of this Serious Case Review serve as a reminder that families can and do hide relationship problems and other difficulties and therefore, professionals should adopt an attitude of respectful uncertainty in their interactions with families.  However, it is important to stress that, in this case, there is no suggestion that anyone should have had cause for concern regarding the welfare of the children.    6.4 It appears that the mother was scared of seeing her partner on 17 November 2015 and believed that he might take the children from her.  A key lesson from this review is that alleged victims of domestic abuse are vulnerable and at risk of depression and mental ill health.  They are likely to be scared of the alleged perpetrator and must be reassured that they do not need to have direct contact with that person.    6.5 Staff from the nursery and Kirklees Early Years SEN Support did not have a clear understanding of the family’s situation on the morning of 17 November 2015.  However, where it is known that there has been a family breakdown it would be good practice not to hold meetings involving both parents unless it is clearly evident that they both want the meeting to go ahead and a risk assessment has been carried out which considers the safety of the parents, their children and anyone else who may be present where the meeting is taking place.  7. Recommendations   Kirklees Safeguarding Children Board should:  1. Raise awareness within partner agencies that alleged victims of domestic abuse are vulnerable and at risk of depression and mental ill health.  They Overview Report  5 December 2016    Page 29 of 37  are likely to be scared of the alleged perpetrator and must be reassured that they do not need to have direct contact with that person.  This should be done by including the learning from this Serious Case Review in the next newsletter from the Safeguarding Children Board and by ensuring that this message is included within future training relating to safeguarding and domestic abuse.  The Safeguarding Children Board should consider issuing the newsletter jointly with the Safeguarding Adult Board and including the learning from recent Learning Lessons Reviews and the SCR 025 Serious Case Review, which have all been undertaken within Kirklees.      2. Work with partner agencies to instruct staff that where it is known that there has been a family breakdown agencies should not hold meetings involving both parents unless it is clearly evident that both parents want the meeting to go ahead and a risk assessment has been carried out which considers the safety of the parents, their children and anyone else who may be present where the meeting is taking place.  3. Ensure that the Speech and Language Therapy Service within Calderdale and Huddersfield Foundation Trust has a robust process in place to refer patients on to appropriate health services when they move to a different geographical area.  4. Ensure that agencies have fully implemented the recommendations made in agency reports.     Overview Report  5 December 2016    Page 30 of 37  Appendix 1 – Key Lines of Enquiry  The key lines of enquiry for the review are:   1. To what extent was mother’s Italian heritage a factor in this case; in particular, was her level of English language a barrier to effective communication?  Did agencies pay sufficient regard to cultural issues and possible language difficulties?  2. What information, if any, was available to agencies before 16 November 2015 that could have raised concerns about the welfare of the children?  How appropriate was the response to any such information?   3. The quality and appropriateness of the inter and intra-agency communication, including any gaps in communication.  4. Agencies’ responses to mother’s allegation of domestic violence made on 16 November 2015.   5. The decision that a meeting with both parents planned to take place at the nursery on 17 November 2015 would go ahead after mother made an allegation of domestic violence.  How appropriate was this decision and what factors were put in place to safeguard the children whilst the meeting took place?    6. Agencies’ responses to the developing situation on the morning of 17 November 2015.    7. Were practitioners in services aware of and sensitive to the impact of domestic abuse on women in general and more specifically to the impact of domestic abuse  on BME women and the potential effects on mental health?     Overview Report  5 December 2016    Page 31 of 37  Appendix 2 – Abbreviations  DASH - Domestic Abuse, Stalking, Harassment and Honour Based Violence  LSCB - Local Safeguarding Children Board PC – Police Constable SEN – Special Educational Needs         Overview Report  5 December 2016    Page 32 of 37  Appendix 3 - Recommendations from Agency Reports  Several agencies involved in this Serious Case Review have identified actions to undertake as a result of this case and these actions were included as recommendations in their agency reports.  Many of these recommendations have now been fully implemented.  This appendix contains a list of the recommendations made in agency reports and the actions taken to date.     Calderdale & Huddersfield NHS Foundation Trust 1. Manager of the Child Development Service to look at a system of ensuring that the referrer is notified that the SOGS assessment has taken place.   Action Taken The child development service manager confirms that a copy of the report for any child attending for an assessment is routinely sent to the Consultant who is in charge of the child’s care, the GP & Health visitor.  The manager of the service will carry out a random audit of 10 cases per quarter to check this is consistent  2. Midwives should ask a question at each contact about domestic violence (or if not appropriate they should record why it was not asked).   Action Taken The CHFT midwifery domestic violence policy based on national recommendations states that a midwife should ask at least once regarding domestic violence, ideally when the woman is alone.  There have been issues with the new Athena electronic record that the information was only able to be captured if the answer was yes, not if unable to ask. This has now been changed so that a yes or no response is required & if no a reason why given. There are plans in place to audit the electronic records to check that the question is routinely being asked & the response is recorded.  Locala 1. The voice of the child must be explicitly considered and captured in assessments undertaken by health visitors.  Action Taken It has been agreed that the safeguarding children nurses will attend all group supervision sessions in January for health visitors and school nurses to provide briefings and learning on how to capture the voice of the child in their analysis of assessments.  North Kirklees Commissioning Care Group 1. Within 3 months of this SCR all Kirklees GP Practices should include documentation of all persons present, and their relationship to the child, during any consultation with a child or young person.   2. Within 3 months all Kirklees GP Practices should ensure that the section of the patient record relating to ‘language spoken’ correctly reflects the patient’s needs. Overview Report  5 December 2016    Page 33 of 37   3.  Within 3 months all Kirklees GP Practices will be reminded of the importance to inform the family Health Visitor or School Nurse of all child referrals to secondary health services where the child or family would benefit from additional support in the interim period.  Action Taken  All recommendations to North Kirklees Commissioning Care Group have been fully implemented; see Action Plan on pages 35 and 36.  The Refuge 1. Referral and Needs Assessment form (page 6) to leave a larger space for `additional information` to be added `    Action Taken  This is now on the database (Referral Needs & Risk Assessment-Part B) and more space is allowed for detail.  2. Referral and Needs Assessment form (page 1) to have a tick box added to indicate whether or not an interpreter was required.   Action Taken This is now on the data base (Referral Form (Part A).  3. Referral Form (front page, part A)`Other Information` section: make the question about health and safety risks from client to service users and staff more prominent and leave more space.  Action Taken This is now on the database (Referral Needs & Risk Assessment-Part B).   4. Referral and Needs Assessment practice to include following up ALL the agencies (whether statutory or voluntary) listed under `Current Agency Involvement` (page 6).  prior to admission to gain further information.   Action Taken This is now embedded in practice and on the database (Referral Needs & Risk Assessment-Part B, section 6 )  5. Admission: To add to the Refuge Essential Checklist for Admissions a question aiming to minimise any risk/reduce distress by asking the client if she has any upcoming important matters or appointments or if there are any  other worries /needs/  concerns (such as feeling safe in Bradford, people known to perpetrator).  Action Taken The Essential Checklist for Admission has been amended accordingly.  6. Admission: To add to the Refuge Essential Checklist for Admissions a question  to assess their feelings of safety once they have arrived in refuge and take appropriate action (E.g. moving them on if not safe in Bradford).  Overview Report  5 December 2016    Page 34 of 37  Action Taken The Essential Checklist for Admission has been amended.  7. Admission Procedure: where possible a children’s support worker to be involved in admission to assess capacity of mother to care for children and to consider emotional wellbeing, level of distress Etc.   Action Taken The Essential Checklist for Admission has been amended to reflect this.  8. On Call Procedure: The on call worker to phone new clients in the evening between 8pm and 9.30pm to ask if they are OK.  Action Taken This is fully embedded in the refuge practice.  West Yorkshire Police  1. That the Force continue to review the DASH process and clarify the distinction between depression and suicidal thoughts in question 5;  Action Taken This has been undertaken and is being addressed by the Central Safeguarding Unit for West Yorkshire Police. The forms have been amended to reflect this.   2. That the Force continue to review the DASH process and develop the use of the handheld device to ensure that assessments are completed while speaking with the victim whenever possible and all identified risk factors are accompanied by qualifying free text entries;  Action Taken All officers across the whole of West Yorkshire Police have been advised to complete as much of the DASH as possible whilst at the scene of an incident/ whilst talking to individuals involved. The forms once completed are saved on to Niche (crime recording system for WYP). If this needs to be added to it can be at a later time.  Officers have been advised to fill in all sections of the form and to provide as much details as possible to assist with decision making.  3. That all officers and staff are reminded of the need to consider communicating information to agencies who are providing services to people referred to them by the police where that information indicates that the referred person may suffer mental ill health or harm.  Action Taken This has been undertaken. Officers have been updated and will continuously be provided with further learning.  In addition West Yorkshire Police have instructed officers that when a person is taken to a refuge the officer who completes the DASH risk assessment should email a copy of it to the refuge before they finish their shift.  The serious case review officer for West Yorkshire Police Overview Report  5 December 2016    Page 35 of 37  has also arranged for domestic abuse leads in Police Services across the country to be made aware of this action so that they can give it consideration within their own service. Overview Report  5 December 2016    Page 36 of 37   SCR 027 KSCB Ref. Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / Work Undertaken Evidence / Outcomes Date Complete RAG SCR 027 / GP Rec 1 North Kirklees Clinical Commissioning Group The children’s GP records did not always specify who accompanied them to their appointments Within 3 months of the completion of this SCR all Kirklees GP Practices should include documentation of all persons present, and their relationship to the child, during any consultation with a child or young person.   Ensure that all GP Practices are aware of the importance of specifying who accompanies the child to appointments. Named Nurse Safeguarding Children & Designated Nurse Safeguarding Children  have circulated the ‘Learning Lessons – Sharing Best Practice’ briefing paper with all GP Practices (both North Kirklees and Greater Huddersfield) in the following ways;   It has been emailed to all Kirklees GP Practices  It has been included in both the North Kirklees and Greater Huddersfield Newsletters to their respective GP Practices  It has been uploaded to both the North Kirklees and Greater Huddersfield intranet pages which are accessible to their respective GP Practices  It has been discussed    October 2016 G R E E N SCR 027 / GP Rec 2 North Kirklees Clinical Commissioning Group The mother’s GP record was completed incorrectly and did not clearly show that her 1st language was Italian  Within 3 months of the completion of this SCR all Kirklees GP Practices should ensure that the section of the patient record relating to ‘language spoken’ correctly reflects the patient’s needs.  Ensure that all GP Practices are aware of the importance of patient records clearly identifying possible additional needs e.g. language & communication. G R E E N SCR 027 / GP Rec 3 North Kirklees Clinical Commissioning Group The family Health Visitor was not initially aware that one of the children had been referred to secondary health services Within 3 months of the completion of this SCR all Kirklees GP Practices will be reminded of the importance to inform the family Health Visitor or School Nurse of all child referrals to secondary health services where the child or family would benefit from additional Ensure that all GP Practices inform the family Health Visitor or School Nurse of all child referrals to secondary health services where the child or family would benefit from additional support in the interim G R E E N Overview Report  5 December 2016    Page 37 of 37  support in the interim period.  period.  at the four GP Safeguarding Lead Meetings that took place during October and November 2016    