CONFIDENTIAL
LOCAL SAFEGUARDING CHILDREN BOARD
SERIOUS CASE REVIEW
Executive Summary
Ashley
******
Contents
1
INTRODUCTION
1
2
REVIEW PROCESS
4
3
SUMMARY OF PROFESSIONAL INVOLVEMENT
6
4
KEY ISSUES ARISING FROM THE CASE
11
5
PRIORITIES FOR LEARNING & CHANGE
20
6
RECOMMENDATIONS
24
1
INTRODUCTION
1.1
BACKGROUND
1.1.1
A 4 months old baby, called ‘Ashley’ for the purposes of this report, was taken to the local
hospital by ambulance in January 2011 after his mother called emergency services. It is
understood that his father had sole care of him for a short period that morning, and called
Ashley’s mother as their baby was unwell. Ashley was transferred to the Paediatric Intensive
Care Unit at a specialist hospital where he subsequently died a week later.
1.1.2
Medical and pathological examinations determined that Ashley had suffered a brain
haemorrhage as a result of violent shaking and the police treated the death as suspicious.
His father has been charged with manslaughter.
1.2
INITIATION OF SERIOUS CASE REVIEW
1.2.1
Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 requires Local
Safeguarding Children Boards (LSCBs) to undertake reviews of serious cases in
accordance with procedures set out in chapter 8 of Working Together to Safeguard Children
HM Government 2010.
1.2.2
A serious case review (SCR) should be initiated when a child has died and abuse or neglect
is known or suspected to be a factor in that death. Its purpose is to:
•
•
•
‘Establish what lessons are to be learned from the case about the way in which local
professionals and organisations work individually and together to safeguard and
promote the welfare of children
Identify clearly what those lessons are both within and between agencies, how and
within what timescales they will be acted upon, and what is expected to change as a
result and
Improve inter-agency working and better safeguard and promote the welfare of children’
1.2.3
On 28.02.11 the SCR panel was convened and determined the criteria in Working Together
2010 were satisfied i.e. ‘a child dies and abuse or neglect is known or suspected to be a
factor in the death’. The panel’s recommendation was accepted by Oena Windibank, Local
Safeguarding Children Board (LSCB) interim independent chair on 14.03.11.
1.3
SUMMARY OF FINDINGS
1.3.1
In 2001/ 2002 mother and maternal grandmother communicated to the health visitor
concerns about the elder sibling’s safety arising from the domestic violence episodes within
the home. The health visitor should have shared these concerns with the GP and sought
consultation within the service and/or made a referral to children’s social services. The
reasons for her failure to do so are not known as she has not been able to contribute to this
serious case review as she has now retired from employment.
1.3.2
One or more members of the public are to be commended for having made anonymous
referrals to CSS and expressing concerns at the school. These reports described
deteriorating home circumstances in 2009, largely relating to neglect but also to the risk of
physical abuse. By 2010, the concerns expressed related to the impact on the elder sibling
of the earlier concerns.
1
1.3.3
The response to these concerns in 2009 of an initial assessment through appointment and
seeing the child in the presence of her family did not enable adequate assessment of the
circumstances within the home, particularly in response to the third well informed referral
pointing out the flaws to such an approach. It is possible that insufficient consideration was
given to the details of the referral because of its anonymous nature.
1.3.4
Mother was provided with good support from mental health services for her depressive
illness. However, what was missing was the consideration of her child’s welfare, especially
in the face of her expressions of anger towards others and fantasies of acting on this
emotion.
1.3.5
There was good information sharing by midwifery during mother’s pregnancy in 2010,
alerting colleagues to mother’s low moods and making appropriate referrals.
1.3.6
The joint investigation in 2010 ended without a thorough investigation about the truthfulness
or otherwise of the allegations that father had as a teenager repeatedly raped and physically
assaulted a primary school aged child. Whilst it may not have been possible to obtain
enough evidence for a criminal prosecution, further efforts should have been made to
evaluate the risk to other children in contact with this man. Whilst not possible to be
conclusive without further audit of cases, this may be an indication of systemic weaknesses
in investigative practice, following a decision by the police to end the criminal investigation
on the basis that a prosecution was unlikely.
1.3.7
Even with the failure to adequately investigate the allegations relating to historical abuse,
there should have been sufficient concerns about the father in 2010 for at a minimum further
assessment involving consideration of how to enable the sister to speak openly. Moreover, a
child protection conference should have been held to facilitate multi-agency understanding
and assessment of the potential risk and the best way this should be managed.
1.3.8
The fathers in this case were not included in any assessments, despite allegations of their
behaviour being central to the concerns. In the case of the police investigation a decision
was made to end the criminal investigation without any interview of the alleged perpetrator
of very serious crimes against a young child. In the same instance a child protection enquiry
was also completed without seeing the man concerned or observing the relationship
between him and the child in the home.
1.3.9
As in all serious case reviews there were examples of poor information sharing. In this case
it was perhaps less about the fact of communication per se, rather the content of the
exchange. This was most telling in the manner children’s social services sought information
from other agencies during the assessment of concerns. By not sharing the cause for
concern, there is evidence that pertinent information was not identified as relevant.
1.3.10
Following a delayed new birth visit, despite knowledge of maternal mental health and
father’s reported childhood experience of abuse, no follow up health visiting home visits
were offered. It is understood that resource availability and team dynamics issues
contributed to this decision.
1.3.11
The agency responses following the 999 call were sound, with a fast response from the
ambulance crew, responsive medical assessments at both the local and specialist hospital
and a largely well run CSS and police investigation, demonstrating good joint work.
1.3.12
The joint investigation in 2011 suffered from a lack of appropriate multi-agency input to the
initial strategy discussions. The omission of the school at this stage compounded by poor
information sharing resulted in a well intentioned, but insensitive contact with the elder
sibling at the school on the day of the injury.
2
1.3.13
Much thought was given to the sibling’s immediate care subsequent to her brother’s
hospitalisation and her wish to be with her family. The subsequent actions taken did not
adequately address her immediate and ongoing emotional and therapeutic needs or the
need for a timely assessment of the family carers.
1.3.14
The Ofsted inspection report of 2010 said that:
‘In approximately half of cases seen by inspectors, there were significant concerns about the
quality of practice and management; in the worst of these cases, children were left
unprotected and were at risk of significant harm’.1
1.3.15
This was the case for the children in this family, particularly around the assessment of
concerns and evaluation of risks.
1.3.16
Whilst it may not have been possible to predict the exact nature of the tragedy that occurred,
the likelihood of harm to children in the care of mother’s partner should have been
recognised. Had this happened, the probability of safeguarding the children and preventing
Ashley’s death would have increased.
1.4
REPORT CONSTRUCTION
1.4.1
The remainder of this report is laid out as follows:
•
•
•
•
•
An explanation of the review process
A summary of the agencies involvement
An overview of the key issues arising from the case
The priorities for learning and change
The recommendations for action
1.5
PUBLICATION
1.5.1
It is anticipated that this review will be published once all parallel legal processes have been
completed.
1.5.2
In order to preserve anonymity for the children in the family, the decision was taken by the
LSCB manager to:
•
•
•
•
Use pseudonyms for the names of the children in the family (‘Ashley’ and sibling ‘Jo’)
Describe all adults in terms of their relationship to ‘Ashley’
Avoid the use of exact dates
Avoid any identification of the locality
1 County Council inspection of safeguarding and looked after children, Ofsted 19.11.10
3
2
REVIEW PROCESS
2.1
SCOPE
2.1.1
The SCR panel determined that learning could be maximised by reviewing the period from
01.01.01 to 31.03.11. This commences with mother’s first pregnancy and extends beyond
Ashley’s death to include the subsequent arrangements made for the care of his elder sister.
2.1.2
Terms of reference were agreed by the panel and identified the following as key issues to be
considered:
•
•
•
•
•
•
•
Quality of information sharing, assessments, planning, intervention and joint working
between agencies
Quality of assessments of parents' attachments to both children, level of care, impact of
any substance misuse, domestic abuse, sexual abuse and any learning difficulties
How the older siblings views were ascertained, and recorded and how race, cultural,
religious, linguistic issues were recorded and addressed
Involvement of senior colleague
Whether KSCB practices and procedures were followed
Any lessons learnt and how they were acted upon
Highlight examples of good practice
2.2
SCR PANEL MEMBERSHIP
2.2.1
Members of the serious case review panel, was determined as follows:
•
•
•
•
•
•
•
•
•
•
•
•
2.2.2
Ghislaine Miller (Independent Chair)
LSCB Manager
Designated Nurse Safeguarding & LAC [for meeting on 05.07.11] and subsequently
Associate Director of Safeguarding, Primary Care Trust
Head of Safeguarding, Children’s Social Services (CSS)
Designated doctor
Superintendant Public Protection Unit (PPU) local Police
Senior Probation Officer
Standards Manager, Education (local authority)
Named GP
Named Nurse Safeguarding Children, Mental Health Trust
Head of Service, DAAT
District Manager, CSS
The work of the SCR panel was managed by the LSCB manager.
4
2.3
INVOLVEMENT OF LOCAL AGENCIES
2.3.1
The following local agencies were identified as having potential information and opinions of
relevance to the SCR and were asked to provide an Individual Management Review:
•
•
•
•
•
•
•
•
•
•
Children’s Social Services
Police
Probation
Education
Community Health
General Practitioners
Primary Care Trust
Acute Hospital Trust
Ambulance Trust
Children and Adult Mental Health Services
2.3.2
Additionally letters were requested from the paediatric intensive care unit of a major city
hospital, from NHS direct and from a local housing association.
2.4
INDEPENDENCE
2.4.1
The need for sufficient independence to enable objective debate and challenge was
recognised and it was ensured that IMR authors were not involved in the case or in its line
management and panel members had had no prior involvement with, or line management
responsibility for, Ashley and his family.
2.4.2
The SCR panel chair was Ghislaine Miller, an independent consultant, with significant
experience in the work of Local Safeguarding Children's Boards and serious case reviews.
2.4.3
An overview report was commissioned from Edi Carmi, an independent consultant, who has
extensive experience as a serious case review author and chair.
2.5
INVOLVEMENT OF FAMILY
2.5.1
The mother, the father, maternal and paternal grandmothers and paternal aunt were all
offered the opportunity to meet with the independent chair and overview author, so as to be
able to provide their perspective on the lessons to be learnt for agencies involved with the
family. The mother and maternal grandmother chose to accept the offer. Their views have
been included within the body of the report where relevant.
2.6
INVOLVEMENT OF STAFF
2.6.1
The Individual Management Review author of each agency undertook interviews with
relevant staff.
2.7
RECOMMENDATIONS & ACTION PLANS
2.7.1
Recommendations arising from the multi-agency perspective are provided at the end of this
report, along with the individual management review recommendations for improving service
delivery. Each agency has produced its own action plans for implementation of its
recommendations, stating how each has been or will be implemented, identifying the
responsible person, the progress made and the timescale for its achievement. These have
been incorporated into an integrated action plan including the recommendations arising from
the multi-agency analysis in the overview process.
5
3
SUMMARY OF PROFESSIONAL INVOLVEMENT
3.1
INTRODUCTION
3.1.1
This chapter provides a narrative account of involvement by agencies since 2001. Earlier
history is provided to give contextual information.
3.2
BACKGROUND INFORMATION AVAILABLE TO AGENCIES
3.2.1
At the age of 17 the mother commenced a five year relationship with the father of her first
child, who was born in 2001. Prior to this there was very little information on mother and her
family, although it has since been learnt that the mother’s father died when she was 16
years old.
3.2.2
There is more background information relating to the father of her second child, Ashley.
Early records show that he had behaviour and learning difficulties as a child and complained
of being bullied at school. Following his parents’ divorce as a teenager he was described as
displaying violent behaviour within the home to his mother and siblings. He also spoke of
being physically abused himself by a previous stepfather.
3.3
2001 – 2006
3.3.1
Jo was born in 2001 and lived with both her parents. There were no concerns identified
during mother’s regular antenatal care, during the labour and delivery or during the postnatal
care on the ward or at home. Some months later the health visitor was aware of mother’s
low mood, which was assessed using the Edinburgh postnatal depression scale as ‘mild
postnatal depression’ and mother was offered ‘listening visits’.
3.3.2
The first indications of difficulties in the parental relationship occurred soon after this, with
mother telling the health visitor of an incident of domestic violence (to property) when her
partner was looking after his daughter. Mother reported that maternal grandmother was now
looking after the baby to ensure her safety.
3.3.3
In subsequent months, the health visitor was told, once by mother and once by maternal
grandmother, about Jo’s father’s difficulties in managing his temper, the fragile parental
relationship, mother’s low mood and that maternal grandmother cared for the baby, to
prevent father being on his own with his daughter. There is no evidence these concerns
were shared with any colleagues within health or reported to children’s social services.
3.3.4
Meanwhile Jo was seen by the GP and very occasionally by the health visitor; there were no
concerns about her development. At Jo’s second development check in 2003 a student
health visitor noted ongoing relationship problems, that Jo’s father resented Jo’s lack of
interest in him, that they were homeless and that the daughter sensed her father’s anger.
3.3.5
During the next 3 years little is known about Jo, except that she started school in 2005. It is
not known if she experienced any education or nursery prior to this date. She had one
hospital presentation during this period for what was understood to be an accidental injury.
3.3.6
Her mother is understood to have ceased working around 2004 and continued to feel low.
Her health deteriorated with a prolonged condition which lasted over 2 years, caused
considerable discomfort, back pain and led to hospital admissions and surgery.
3.3.7
Jo’s father had two separate A&E presentations in 2004 with a self inflicted injury to his
hand, causing pain and swelling. On both occasions he reported he had punched a wall.
6
3.3.8
It is not known exactly when the father left the household; the first records mentioning the
separation suggest it was around 2005 or 2006, although mother’s later accounts refer to
the break as even earlier.
3.4
2007 – 2009: EMERGING CONCERNS
3.4.1
During 2007-2009 mother struggled with depression and was prescribed regular antidepressants. In July 2007 she requested and was referred for counselling to discuss her
father’s death 9 years previously.
3.4.2
The first evidence of parenting problems emerged in January 2008 when mother was
concerned about her daughter’s angry outbursts and a referral was made from the school for
parenting group sessions, which mother reported to find positive. These were provided via
community health.
3.4.3
Around the autumn / winter 2008/2009 she became friendly with the father of Ashley and by
early 2009 referrals were being made to children’s social services about the care of her
daughter.
3.4.4
During 2009 three anonymous referrals were received by children’s social services. The first
two came via the NSPCC and expressed concern that mother’s parenting had deteriorated,
the home was a ‘pigsty’, mother was under the influence of drugs or alcohol and neighbours
were having to step in to care for the child, Jo. This deterioration in conditions was said to
have occurred following an older man moving into the home in autumn 2008 and a new
relationship with a younger boyfriend. The referrer also spoke of the change in Jo: the
‘happy bubbly little girl’ had become withdrawn. The second referral indicated further
deterioration, mother drinking heavily and a violent dispute between mother and daughter
the previous day, requiring neighbours intervention to remove Jo to a ‘place of safety’
overnight.
3.4.5
In response children’s social services undertook an initial assessment, visiting the home
twice, seeing the child once (with mother and grandmother) and checking with police, the
school and the GP. None of these actions provided evidence to support the concerns
expressed, except that the school were aware from other parents of several men going in
and out of the family home.
3.4.6
The third referral was received via Ed Balls, the Children’s Minister at the time. This
anonymous letter pointed out the social worker had visited the home by appointment, the
mother had cleaned up, got the men to remove their belongings and was able to ‘drill the
child in what to say and what not to say’. In response to this letter children’s social services
checked with the school, who said the girl remained ‘bright and bubbly’ and that they had no
concerns, except once mother had arrived ‘a little worse for wear’ and alcohol was queried.
It was agreed that the school would monitor and the case was closed within social services.
3.4.7
During the same period mother had gone to her GP to request help. She reported
deterioration in mood swings and being unable to manage her temper, requesting anger
management courses. In particular she identified anger with her daughter and partner as a
problem.
3.4.8
When being assessed by a community psychiatric nurse for the anger management course
mother spoke of an incident when she got drunk, became verbally aggressive, punched
walls and threatened others. She said she did not misuse drugs, was an occasional social
drinker, avoiding regular drinking as it could cause her to be paranoid and aggressive.
Whilst she stated she was never violent to others, she did admit to imagining hurting
someone who annoys her.
7
3.4.9
Mother was referred for an anger management course and to see a psychiatrist. At the
course a continuing theme was her lack of ‘empathy’, getting angry with her partner, child
and others in her flat. She was diagnosed by the psychiatrist with dysthmia2, not depression,
a change in medication agreed and a follow up arranged.
3.4.10
Mother seemed open with professionals, telling the social worker about her appointment
with mental health services, and the mental health services of her contact with the social
worker. However, the practitioners in each agency did not communicate with each other.
The social worker therefore never learnt about the details of mother’s angry feelings.
3.5
JANUARY – AUGUST 2010: RISK TO SISTER AND UNBORN CHILD
3.5.1
This period is marked by mother’s improved mental health and pregnancy but possible
deterioration in the welfare of her daughter.
3.5.2
In January 2010 mother saw her GP and was noted to be ‘very happy’. From that point she
ceased to collect any prescriptions for anti-depressants.
3.5.3
In contrast to this positive description of mother, there were indications that her daughter’s
care had deteriorated. It was noted at school that she was de-hydrated and not well looked
after ‘on a basic level’ and mother was asked to provide a drink as her daughter would not
drink water at school. In February mother informed the school her daughter had a sore
bottom and may have problems sitting down, probably caused by constipation.
3.5.4
Specific child protection risks were investigated in Spring 2010 due to allegations made
about mother’s new partner. These concerned his alleged repeated and serious physical
and sexual abuse of his sister some years earlier, when she was at primary school. Paternal
grandmother also confirmed she had seen strangle marks around her daughters neck
allegedly caused by her son and that he used to hit her too. Paternal aunt remained in touch
with her brother and had told his partner of these allegations some months previously.
3.5.5
These allegations led to two joint child protection investigations by police and social
services, the first relating to paternal aunt and the second to the unborn baby [Ashley] and
Jo.
3.5.6
The first child protection investigation was concluded after the allegations because paternal
aunt did not wish to pursue a prosecution. Neither police nor social services spoke with
mother’s partner, nor with the friend to whom paternal aunt went on one occasion when she
allegedly escaped from her brother. Whilst she did not at that point disclose the alleged
rapes, she did speak about being ‘beaten up’.
3.5.7
Children’s social services concluded the concerns against the sister were substantiated and
initiated a joint child protection investigation with regard to Jo. At this point mother’s partner
was on bail for an alleged violent assault and robbery in December 2009, with bail
conditions not to speak to his partner as she was a witness; however there was information
he was living at her property. (He was subsequently convicted for this crime and received a
custodial sentence in 2011).
3.5.8
A social worker and police officer visited the family home and spoke with mother and Jo.
Mother, who was by this point pregnant with Ashley, would not allow her daughter to be
2
Dysthymia is a chronic type of depression in which a person's moods are regularly low. However, symptoms
are not as severe as with major depression. Dysthymia is characterized by depressed mood experienced most
of the time for at least two years.
8
seen on her own and rejected the allegations, saying her partner’s sister was attention
seeking. Her daughter was described as happy to be living with her partner, who she called
‘dad’. Jo mentioned that he took her out to his friends.
3.5.9
The agency ‘checks’ undertaken with the school and the GP, led to no concerns about Jo,
although mother was reported to have a mental health condition of depression and anger.
The reason for the child protection investigation was not disclosed to the agencies
concerned, and the school did not raise the issue of daughter’s possible constipation
problems and difficulty sitting down. The case was closed within children’s social services
and the police investigation concluded.
3.5.10
Mother’s partner was not seen by either agency as part of their investigations.
3.5.11
The school referred Jo in July 2010 due to changes noted in her behaviour; she was
described as lethargic, lacking motivation, having relationship problems with peers and ‘a
recent slowing in learning’. It was noted that she was disappointed when mother’s partner
collected her as she did not like him. Another parent wanted concerns reported to children’s
social services that Jo was hungry, mother’s partner was dealing in drugs and there was no
money or food in the home. Jo had allegedly said she wanted to stay with her grandmother.
3.5.12
Children’s social services suggested the school discuss the concerns with mother, note
further concerns and undertake a Common Assessment or re-refer if concerns persist. By
the next term Jo seemed fine so no assessment or re-referral was made.
3.5.13
The mother attended her antenatal appointments regularly. In recognition of her previous
postnatal depression the midwife alerted the health visitor via a Midwifery Concern and
Vulnerability form and made a referral to Maternal and Infant Mental Health Services.
Mother’s psychiatric appointment did not raise any ‘risk concerns’ despite mother ceasing to
use anti-depressants. Her relationship with her daughter was explored, with mother stating
she had never hit or hurt her as a result of her anger or irritability. The treatment plan was
recorded to restart antidepressants if mother’s mood deteriorated post delivery.
3.6
TWO CHILD HOUSEHOLD: AUTUMN 2010 – JANUARY 2011
3.6.1
There was little professional contact with the family when there were 2 children in the
household, from Autumn 2010 to the time of Ashley’s fatal injury in mid January 2011.
3.6.2
Ashley was born prematurely and discharged home at 11 days old from the Special Care
baby Unit. During the time in hospital his mother visited regularly several times a day,
undertaking his care and his father visited at least once daily. Both parents were seen to
cuddle their son, be involved in his care and there were no recorded observations to give
any concerns.
3.6.3
Ashley was seen at home the day after discharge by the community midwife. Both parents
were home, Ashley was recorded as thriving and transferred to health visitor care. The
health visitor undertook a new birth visit 10 days after discharge and saw mother and baby,
aged 3 weeks. The baby was making good progress and mother spoke openly about her
history including children’s social services involvements. She denied any drug or alcohol
misuse and planned to access the Sure Start clinic.
3.6.4
The health visitor learnt the case was closed when she checked with children’s social
services the next day. She allocated Ashley to the universal health visiting service as there
were high caseload numbers and she was moving to a new team. Mother agreed to access
the Sure Start clinic.
9
3.6.5
Mother continued to be co-operative and responsible in her care of Ashley and there were
no concerns arising from his contacts with health practitioners. Mother cancelled her
appointments at the mental health clinic following Ashley’s birth, but at her post natal
appointment with the GP it was noted that she was ‘emotionally well’ and a mutual decision
made that anti-depressants were not required.
3.7
ASHLEY FATALLY INJURED: JANUARY 2011
3.7.1
Professional involvement on the day of the injury was initiated via a call to the ambulance
service from mother to attend an unresponsive baby. Mother explained she had taken her
daughter to school and received a call from her partner to return. She described their four
month old baby as ‘all limp’.
3.7.2
The ambulance crew transported Ashley to hospital. On arrival Ashley showed no signs of
life. Artificial ventilation was continued, a consultant paediatrician called and the retrieval
service from a specialist hospital were called, to facilitate a neurosurgical opinion. A CT scan
demonstrated bilateral subdural haemorrhages and evidence of hypoxic-ischaematic injury,
consistent with prolonged arrest.
3.7.3
Police attended the home, which was described as having a strong smell of cannabis.
Father was not fit for interview initially as he was under the influence of drugs.
3.7.4
Ashley died 7 days after the injury. Medical opinion was that he had suffered a shaking
injury inflicted by an adult. The mother has had difficulty understanding or believing this; she
has maintained a relationship with her partner and believes in his innocence on the charge
of manslaughter.
3.7.5
Jo was accommodated overnight by children’s social services, whilst police undertook
interviews with family members, before moving to her grandmother’s the next day, under a
written agreement which prohibits contact with mother’s partner. Her mother also stayed in
the grandmother’s home until she was re-housed.
3.7.6
Jo was made the subject of a child protection plan under the category of neglect in February
2011. Since the death of her brother, Jo has demonstrated signs of missing her brother and
of emotional trauma.
10
4
KEY ISSUES ARISING FROM THE CASE
4.1
INTRODUCTION
4.1.1
This serious case review analyses the professional practice from 2001, but particularly
focuses on the period from 2009 when concerns emerged about the welfare of the child and
the unborn baby in the family.
4.1.2
This section addresses the issues identified in the terms of reference as well as those listed
in Chapter 8, Working Together to Safeguard Children (2010)
4.2
CONTEXT
4.2.1
The issues arising from this review need to be seen within the context of this being a period
of rising referral rates for children’s social services in 2009/2010 following the death of Peter
Connelly. Locally there were vacant social work posts as well as a culture and environment
identified by Ofsted in 2010 as having ‘inadequate’ safeguarding arrangements:
‘..... There are significant differences in the quality of front-line child protection services
across the county and too many children are left without sufficient safeguards or adequate
protection arrangements. Partner agencies are failing to consistently raise concerns in these
circumstances.’ 3
4.2.2
It was not just children’s social services experiencing resource problems at the time. The
health visiting team were also suffering capacity issues which impacted on this case.
4.2.3
Overall the findings of this case support Ofsted’s judgment of practice. Within this context, it
is not surprising that much of the systemic learning from this case has already been
identified by that inspection and is already subject to improvement and change, as well as
scrutiny of delivery.
4.3
INFORMATION SHARING
4.3.1
Poor information sharing and communication is a recurrent theme from national research
studies of serious case reviews 4 5 . This case provides some examples of good practice and
others of poor information sharing, both in ongoing work and in response to specific
incidents of concern. Examples of good practice are cited in 4.17, whilst this section
considers weaknesses in practice.
4.3.2
Major shortcomings in information sharing (giving or seeking) are illustrated by:
•
•
•
In 2001 the health visitor did not inform colleagues or children’s social services of
mother’s depression and the domestic violence within the family
In 2009 there was no communication between children’s social services and mental
health services, although mother told both about the involvement of the other
In 2010 the father’s GP was not contacted as part of the s.47 enquiries and the family
GP was not invited to the 2011 child protection conference
3 Letter of 09.12.10 from Juliet Winstanley, Divisional Manager, Children’s Services Assessment Ofsted to the Managing Director of
Children, Families & Education Directorate
4 Improving safeguarding practice, study of serious case reviews 2001-2003, Rose & Barnes, DCSF 2008
5 Analysing child deaths and serious injury through abuse and neglect: what can we learn, A biennial analysis of serious case reviews
2003-2005, Brandon et al (2008)
11
4.3.3
A particular feature of the weakness in information sharing arrangements in this case was in
the way agency ‘checks’ were undertaken in both the 2009 initial assessment and the 2010
child protection enquiries. In particular, when seeking information, the social workers did not
explain the reason for the concern, contrary to the Local Safeguarding Children Procedures
Manual (2007) which states at 7.7.6:
‘ The relevant agency should be informed of the reason for the enquiry, whether parental consent has
been obtained and asked for their assessment of the child in the light of information presented.’
4.3.4
This omission is likely to have resulted in at least one occasion, during the 2010 child
protection enquiry, with the school not identifying all pertinent information.
4.3.5
Furthermore these ‘checks’ did not include all relevant agencies. It excluded father’s GP,
mental health services. Moreover in 2010 it occurred after the decision that there was no
role for children’s social services.
4.3.6
Both in 2009 and 2010 the system of seeking information from other agencies seems to
have been a mechanistic process driven exercise as opposed to being part of a clear
strategy designed to explore the risks relating to a child linked to specific suspicions /
allegations.
4.4
ASSESSMENTS IN RESPONSE TO SPECIFIC CONCERNS
Assessment of domestic abuse
4.4.1
The links between domestic violence and child abuse have been well established in the
professional literature in the UK since the late 1990s and the national analysis of SCR
findings consistently feature domestic abuse as a background factor.
4.4.2
In this case there was a background of domestic violence which was not perceived to be an
issue within the professional network.
4.4.3
It is not known why the health visitor in 2001/2002 did not recognise the need for an
assessment into the risk to the baby given that family members clearly identified such risks
to her. The health visitor has now retired and was not available for interview, but she had
been mother’s own health visitor when she was a baby. It may be that this long standing
relationship was a factor. Additionally the emotional harm to the child through witnessing
such violent episodes was only recognised in law in 2002 when Section 120 of the Adoption
and Children Act 2002 amended the Children Act 1989 by expanding the definition of "harm"
to include this. The health overview points out that health visitors are now required to have
domestic violence training and likely to be more proactive in assessing risk.
4.4.4
What is less clear in terms of changed practice are the professional responses to other
indicators of risk in 2004 and 2009, as illustrated by hospital and mental health staff when
hospital staff did not enquire about the circumstances of father’s injuries in 2004 (i.e. who he
lived with and who was present at the time) and mental health clinicians in 2009 did not
consider the need for assessment of the risks to her child (when mother described her angry
emotions, destruction of property, threatening others and imagining hurting others).
Assessments of anonymous referrals
4.4.5
A striking feature of this case was the 3 anonymous referrals about the care of the sister in
2009. These were particularly detailed, well informed and almost certainly from the same
source.
12
4.4.6
This unknown member of the public is to be commended on her/his efforts to safeguard Jo
and that s/he persevered in the face of an inadequate response to the first 2 referrals by
writing to the Children’s Minister. It is also likely that s/he mentioned concerns to school staff
as in 2009 the head teacher referred to ‘ concerns from other neighbours’ and in July 2010 a
parent’s concerns were contributed to the school’s referral about the change in the child.
4.4.7
The extent to which children’s social services response was affected by the anonymous
nature of the referral is not known, but an internal audit was commissioned by the director of
the local Children's Services in May 2010 to review thresholds. The main findings in respect
of the referrals from anonymous sources have been provided to the serious case review and
refers to:
‘The second largest source of referrals was from relations or neighbours (including anonymous who
largely fell into this category) they comprised 21% of the sample audited and they were a high
proportion of the referrals that did not progress to initial assessment.
There was some evidence that some workers if they deemed the referral to be malicious did not
undertake a full assessment. To some degree this was because they were aware of the distress that
such an investigation could cause families if the motivation of the referrer was suspect. There is
however significant evidence from serious case reviews to show that relatives and friends are often
aware of issues of concern sooner than professionals and any such referrals should always be
investigated fully.’
4.4.8
The Local Safeguarding Children Procedures Manual recognise the danger of such an
approach and instructs at 6.2.10 that ‘Any anonymous referral from the public must be
investigated thoroughly by Children’s Social Services / Children’s Social Care and treated
with the same rigor as a professional referrer’6.
Assessment in response to specific child protection concerns
4.4.9
During the period under review there were 3 separate episodes when child protection
concerns (including the anonymous referrals above) were brought to the attention of
children’s social services, the last 2 also involving the police.
4.4.10
The incident that received a good quality response was when Ashley was fatally injured in
January 2011. All agencies recognised this was an emergency and reacted accordingly with
immediate medical assessments and intervention, a criminal investigation initiated and a
s.47 enquiry.
4.4.11
In 2009 the anonymous referrals portrayed a deteriorating environment with a particular
acute incident when the child was kept with a neighbour overnight. These child protection
issues were not adequately addressed through the initial assessment process due to a
delayed response, lack of unannounced visits, seeing the child in the presence of family and
a lack of follow up of the men said to be living in the 2 bedroomed flat. The children’s social
services response also did not take account of the possibility of compensatory care
reportedly provided by neighbours: this may well have led to the impact on the child of the
alleged abuse being less noticeable.
4.4.12
The process driven initial assessment response lost the purpose of the intervention i.e. how
best to discover the truth about what was happening in this household and assess the risk to
the child. In such circumstances this would have been most likely through a longer
assessment involving unannounced visits, trying to identify the referrer via the school, with
the school staff maybe able to negotiate direct communication with her / him.
6 Safeguarding Children Procedures Manual (2007)
13
4.4.13
The most significant challenge in these circumstances is how to facilitate a child to speak
openly. It is unlikely that this would happen in the home even if the child was seen alone or
by an unknown social worker. It may be other approaches would be more successful e.g. by
involving the school pro-actively in deciding the strategy of how to assess the child’s welfare,
sharing fully the referrals and considering if a teacher may be in a better position to enable a
child to speak.
4.4.14
It is possible that the weaknesses of the 2009 assessment were linked to it not having the
status of a child protection enquiry. However, the enquiries undertaken in 2010 demonstrate
a similar lack of focus on the purpose of the investigation. Both ended without adequate
investigation of the serious allegations and evaluation of the risks. The weaknesses in the
enquiries included inadequate ‘checks’, lack of multi-agency strategy discussions, seeing
the child with mother in the family home, not seeing mother’s partner, not seeing paternal
aunt’s friend, and generally not challenging mother’s contradictory assertions about her
partner’s role in the household.
4.4.15
The allegations made by paternal aunt of repeated rape, beatings and an attempted
strangulation were extremely serious and indicated ongoing risk to herself and to any
children in contact with her brother. The seriousness of the assault and robbery in 2009
provided additional indicators of his potential for violence.
4.4.16
The joint investigation should have resulted in an informed evaluation of the risk to the
children concerned, regardless of whether or not a prosecution was viable. Although core
assessments were undertaken following both enquiries, these did not undertake further
investigative work. In the case of Jo, the core assessment did not involve any further work
with the child, or consideration of the risks to her and her unborn sibling.
4.4.17
It would seem that the current joint investigation process, as represented in this case, is one
where police involvement is based on a narrow basis of the possibility of criminal
prosecution and the social care element around process driven tasks (strategy discussion
and checks) and general welfare arrangements. The need for an investigative and risk
evaluation function within the enquiry appears to be lost. The crux of the matter is whether
this view of joint investigations is shared between agencies and if this is the best
arrangement in terms of outcomes for children. In the view of the author, such investigations
have to involve fully investigate allegations regardless of the likelihood of prosecution so as
to enable informed decisions about the risk to children.
4.4.18
Nevertheless, given the very serious allegations made by paternal aunt, together with the
allegations of 2009, it is difficult to understand why this case did not proceed to further
assessment or an initial child protection conference.
Assessing substance misuse
4.4.19
Not much is known about parental substance or alcohol misuse other than in 2009 a
neighbour alleged that mother was misusing alcohol and that father used drugs. The mother
consistently denied drug or alcohol misuse, although spoke to health clinicians about binge
drinking and becoming violent on one occasion (to property). Whilst checks with other
agencies were limited, in this case not much further information was available over and
above what mother had told the social worker.
4.4.20
Given that mother never admitted to misusing drugs or alcohol, the use of screening tools as
part of any assessments undertaken would have been extremely difficult to negotiate and
ultimately unlikely to have been effective. However, any impact on parenting was not
assessed in the face of mother’s denials. This is a challenge when assessments are
restricted to isolated observations of a parent, especially if relying on appointments.
14
Assessing Ashley’s condition following the 999 call
4.4.21
There are no issues relating to the medical assessments undertaken following the 999 call.
There was though delay in the provision of cardio-pulmonary resuscitation (CPR) due to
individual error, with a contributory factor being mother’s unusual calm presentation in such
circumstances.
4.4.22
The incident also highlighted issues with the recognition of key words in the software. This
has been raised with the software company but as the ambulance trust are no longer under
licence to the software provider the request to review the call was declined. A
recommendation has been made to address this.
4.4.23
The health overview report concludes that it is impossible to state whether the delay in
commencing cardio-pulmonary resuscitation affected Ashley’s tragic outcome. The
designated paediatrician on the panel advised that it is difficult to predict the outcome in
these cases as it is usually ‘multfactorial’.
Post mortem assessments
4.4.24
The police investigation faced difficulties in obtaining expert opinion on ‘Shaken Baby
Syndrome’, due to a lack of willingness by pathologists and medical professionals to
undertake this work, associated to both a lack of trained expertise and a reluctance to be
involved in contentious cases. The result is that in this case body parts were sent to various
areas of the country in order to obtain this essential evidence.
4.5
PROFESSIONAL CHALLENGE
4.5.1
Laming7 recognised the importance in child protection practice for professional challenge,
albeit his focus was on ‘child protection officers’ who he recommended must be equipped by
training ‘with the confidence to question the views of professionals in other agencies,
including doctors’. Since that time there has been ever increasing focus on the need for
policies and procedures on professional challenge.
4.5.2
In this case the school did not challenge children’s social services decision in July 2010, so
there was no follow up of the ongoing concerns. When interviewed for the management
review the head teacher spoke of her feelings of powerlessness and frustration at that point.
The education IMR author has confirmed that this is not a systemic issue as his
safeguarding team provide a consultation service to schools and this particular school takes
advantage of this.
4.6
STEP UP / DOWN FROM CHILDREN’S SOCIAL SERVICES
4.6.1
In both 2009 and 2010 children’s social services undertook a brief assessment and then
closed the case asking the school to monitor the situation. On both occasions the school did
subsequently try to re-refer but this was not accepted. Whilst the judgment of children’s
social services to close the case without a core assessment in 2009 and without further
assessment / child protection conference in 2010 was flawed in the opinion of the author,
there remains the question of other adequate safeguards elsewhere in the system in such
circumstances.
4.6.2
An alternative for the school would have been to have undertaken a CAF, and then to rerefer if appropriate, as advised by children’s social services in 2010. In practise this was
7
The Victoria Climbie Inquiry report, Lord Laming, DH 2003
15
unlikely to occur as the end of term was imminent and then after the summer the child’s
presentation improved.
4.6.3
The health visitor could also usefully have undertaken a CAF, given the knowledge of
mother’s mental health problems. However, there is no indication that this would have
identified the risks to the children in the family.
4.6.4
What perhaps may have been helpful following the episode of social services involvement in
2009 would have been a more structured ‘step-down’ process than just asking the school to
‘monitor’, for example providing Jo with an identified individual in the school for regular oneto-one sessions. In 2010 the risks to the children were too high and needed further input, so
this would not have been appropriate on its own.
4.7
CHILDREN’S WISHES & FEELINGS
Interviews as part of assessment process
4.7.1
When seen in 2009 by a social worker and in 2010 by a social worker and police officer, Jo
was spoken to in the presence of her mother. This did not provide the child with the
opportunity to speak openly. How to do this safely for the child is a real challenge in such
circumstances as discussed in 4.4.16-17.
4.7.2
The lack of an adequate core assessment in these years (the one in 2010 merely covered
the s.47 enquiry) severely limited the potential for giving the child the opportunity to be able
to express her feelings.
Sensitivity in a crisis
4.7.3
On the day of Ashley’s injuries, children’s social services formulated well intentioned plans
to inform Jo of her brother’s injury, through using a social worker she had previously met.
Unfortunately she did not recognise the social worker from 2010 and was alarmed at being
asked to get into a stranger’s car. She had not been prepared by school staff (who
themselves were unaware of the circumstances) nor offered an escort from school.
4.7.4
Such occasions are never easy, but in order to consider how best to manage such
situations, school staff should be told the circumstances, as part of strategy discussions and
consulted on how best to manage the difficult situation.
4.8
DIVERSITY ISSUES
4.8.1
This is a white British family, whose language is English. Performance varied between
agencies to the extent that these were recorded and the extent to which the management
reviews commented on this.
4.8.2
The maternal grandmother’s home is a terraced house within a stable ‘village’ environment
out of the town. This is the house mother grew up in. From the little known of father, his
background is also geographically stable, with his family in the area and he still has the
same GP as in his childhood.
4.8.3
It is understood from the father’s GP records and from his school records, that he had
learning difficulties. As none of the agencies were ever in direct contact with him this did not
affect the input of professionals. Mother’s GP records refer to her being dyslexic whilst at
school, but there is no indication she now has any difficulties with literacy.
16
4.9
CARE PLANNING
4.9.1
There was no child protection plan prior to Ashley’s injury. Following Ashley’s injuries, there
was immediate consideration of the care needs of Jo with foster care arranged the first
night, and a move to maternal grandmother the next day.
4.9.2
The local Kinship Care Policy & Procedures (2010) specify a core assessment be
undertaken when children are placed with family or friends, unless the child is ‘Looked After’
by the local authority, in which case the carer would be assessed as a foster carer.
4.9.3
Jo was not considered to be Looked After, as she was accommodated for less than 24
hours. However, the requisite core assessment was not undertaken during the period of the
serious case review (i.e. within the next eight weeks). In such circumstances when a Local
Authority have intervened to arrange a family placement, it is though unlikely that a core
assessment would in fact provide an adequate assessment of the carer’s ability to provide
safe care over the longer term.
4.9.4
It has been clarified that the intention of the current procedures is for the child to be
accommodated when the local authority ‘broker’ the arrangement. However, this was not
understood by the District team, and consequently the grandmother was not referred to the
fostering service for assessment. The Interim Director (children’s social services) issued a
memo on 19.08.11 clarifying this, but the procedures need to make it clear so as to avoid
such misunderstandings in the future.
4.10
THERAPEUTIC NEEDS
4.10.1
This case has shown a marked difference in the health response to the therapeutic needs of
an adult as opposed to a child.
4.10.2
Mother was able to articulate her feelings and was considered to have insight into her
needs. She received a good standard of service for herself, although there was a failure
within this to consider the potential negative impacts on her daughter of her mother’s health.
The health overview report comments that this is an historic problem and strategies are
already in place or to be implemented to rectify this.
4.10.3
In contrast her daughter at a young age experienced a particular traumatic bereavement,
accompanied by a major change in family dynamics and circumstances. It has been evident
since Ashley’s death that his sister feels his loss acutely. Her behaviour has demonstrated
her emotional turmoil, with her avoidance of school. Whilst there has been planning for her
emotional needs at the strategy meetings, at the child protection conference and at the core
group meetings, what remains less clear is to what extent, if at all, the sister’s therapeutic
needs have been understood and met.
4.10.4
She was not ‘not afforded the opportunity to say ‘goodbye’ to her brother in a supported way
prior to his death. Whilst this well intentioned advice to mother attempted to protect Jo from
inappropriate responsibility to support her family, it was not necessarily in her best interests.
4.10.5
Subsequently, there was a delay in the making of the referral, and a long wait for an
assessment for therapy. The reasons for this are complex and involve resource issues (no
school nurse at the core group), then lack of clarity about which clinic was most appropriate
and a delay in providing an assessment. However, by the time of the referral, Jo had already
been waiting for 3 months since the death of her brother, longer than the 4 weeks ‘watchful
waiting’ recommended in the NICE guidelines for Post Traumatic Stress Disorder, so by that
point her need for support should have received a prompt assessment.
17
4.11
PARENTAL / PROFESSIONAL RELATIONSHIP
4.11.1
One of the factors that appear to have influenced the professionals concerned was a belief
in the credibility of the mother and in her ability to ensure her children’s safety. This was
critical within children’s social services, but practitioners there were by no means alone in
this trust and faith in mother’s responsible care of her children. The continuing and complex
challenge for professionals is to retain ‘a mindset’ of ‘professional uncertainty’ as described
by Laming8 and repeated in Brandon et al9 :
‘Building strong relationships with children and families and compassion is crucial to reducing
maltreatment, but trust needs to be placed with care, and ‘respectful uncertainty’ towards families,
and interest and curiosity in their narratives, needs to be part of the practice mindset.
4.12
MANAGEMENT ISSUES
4.12.1
The notable management issues raised in this case related to the inappropriate use of a
student health visitor in 2003 and supervision weaknesses within children social services in
2009 / 2010. The latter reflected a general issue within the County of the common use of
‘directive’ as opposed to ‘reflective’ supervision, compounded by a ‘threefold increase in
referrals’ and an agency drive to prepare for an Ofsted inspection with an unfortunate
consequent focus on process as opposed to practice. Quality of supervision has already
been identified as being in need of improvement and subject to training and audit.
4.13
CONSISTENCY WITH POLICY & PROCEDURE AND WIDER PROFESSIONAL
STANDARDS
4.13.1
There were many examples of a lack of consistency with local procedures, but the
significant issues in this case are about agencies understanding the nature of the
investigative task and the need to evaluate the risk to the children. This is an example of
what Munro10 calls single as opposed to double loop thinking, defined by Drucker as ‘A
concern with doing things right versus a concern for doing the right thing’.11
4.14
ROLE OF MEN
4.14.1
In line with repeated research findings from serious case reviews12, practice by all agencies
in this case failed to include the men within the household in assessments, despite concerns
in 2009 and 2010 centring on the welfare of Jo since father’s involvement in the family.
4.14.2
Remarkably mother’s assertion of a positive relationship between her partner and Jo was
accepted without observation of this relationship. There was a lack of consideration of the
nature of grooming, especially in relation to child sexual abuse. The contradiction of him not
being left alone and Jo saying, in front of her mother, that he took her to his friends, was not
explored. Nor did the latter comment seem to suggest to staff a potential risk.
4.15
RECORDING
4.15.1
The IMRs identify detailed recording issues that are addressed by the
recommendations, but are not significant in terms of the outcome of this case.
IMR
8 The Victoria Climbie Inquiry report, Lord Laming, DH 2003
9 Brandon et al (2010) Building on the learning from serious case reviews: a two-year analysis of child protection database notifications 2007-2009
10 The Munro Review of Child Protection – Part One: A Systems Analysis, Professor Eileen Munro, DfE 2010
11 Peter Drucker (1909-2005), writer, management consultant, and ‘social ecologist’
12 Brandon et al (2009) Understanding serious case reviews and their impact, a biennial analysis of serious case reviews 2005-07
18
4.16
KEY POINTS IN DECISION MAKING AND IF CHANGES IN THESE MAY HAVE
IMPACTED ON OUTCOME?
4.16.1
There were several key points when agencies could have intervened earlier, most
significantly the child protection concerns in 2009 and 2010 provided opportunities which
may have impacted on the outcomes for this family.
4.16.2
Had there been pro-active multi-agency response to the referrals in 2009, involving a core
assessment and a practitioner developing an individual relationship with Jo, she may have
spoken about the changes in her household and the impact on her. Had the school been
involved in discussions about the anonymous referrer, it may have been possible for the
school to have obtained further information from the parent/s expressing concerns [which
may be the referrer] and facilitation of direct contact of referrer with social services.
4.16.3
The main opportunity for intervention was in 2010. If the enquiries had focused on
investigating what had happened to paternal aunt regardless of the possibility of prosecution
and if those involved had considered what was known of father (allegations made in 2005 as
well as the violent assault in 2009), there should have been sufficient recognition that he
was a potential risk to children in his care, a child protection conference convened and multiagency involvement in considering if and how best to protect Jo and the unborn baby.
4.16.4
The further concerns of the school and the neighbour in July 2010, should have been seen
in the context of the earlier allegations and prompted re-assessment.
4.16.5
Following the tragic death of Ashley there were delays in undertaking the necessary
assessments to ensure Jo receives consistent and nurturing parenting to provide her with
the safe care she requires, along with having her therapeutic and educational needs met.
4.17
GOOD PRACTICE
4.17.1
There have been examples of good practice in this case including:
•
•
•
•
•
•
•
The Ambulance Service demonstrated their learning from a previous incident of the
need to refer to the police once confirmed the incident was a paediatric cardiac arrest
The police investigation into Ashley’s death recognised the need for the operation to be
commanded by an officer trained and experienced in both homicide and child protection
procedures
The community midwife in 2010 pregnancy was proactive in gathering information from
GP records, identifying the family’s vulnerability, regularly assessing and documenting
mother’s mood, communicating the concerns via a Concerns & Vulnerability form to the
health visitor and making a referral for Maternal & Infant Mental Health Services
The specialist hospital evidenced improved record keeping and observations of parental
interactions and behaviour in accordance with learning from previous SCRs: the quality
of information gathering within the paediatric intensive care unit has impressed local
Designated Nurses and consent has been obtained to replicating its use locally
The head teacher and Family Liaison Officer at the school have continued to try to
support the sister’s return to school since January 2011, with occasional home visits
The provision by children’s social services of the initial assessment record to the school
in 2009 was good practice
Since Ashley’s death the social worker has visited Jo regularly and attempted to provide
her with the opportunity to speak openly
19
5
PRIORITIES FOR LEARNING & CHANGE
5.1
LESSONS THAT APPLY TO MORE THAN ONE AGENCY
5.1.1
Overall practice demonstrated an emphasis on following individual agency processes, as
opposed to understanding the nature of the task from the perspective of safeguarding the
children’s welfare. In all such interventions staff and managers need to understand the
priority of ‘doing things right versus a concern for doing the right thing’13.
5.1.2
This case reflects a striking absence of men in assessments, despite the concerns centring
the man’s presence in the household. Research findings from serious case reviews14 show
this to be a widespread failing in practice. Further work needs to be undertaken locally to
change the culture about working with men.
5.1.3
There is an urgent need to ensure that information sharing in response to specific concerns,
known as ‘agency checks’ by CSS, is based on a shared understanding of the concerns
prompting the ‘check’.
5.1.4
Without such multi-agency involvement in strategy discussions, the needs of the child are
unlikely to be adequately considered and suitable child centred strategies formulated for
how to best undertake an assessment. This is already contained within the local
Safeguarding Children Procedures Manual (2007), so the challenge is to effect a change in
the understanding of professionals about this key process, through cultural change.
5.1.5
This case illustrates the danger of incomplete investigations once a police decision has been
taken that a prosecution is not possible, even though further investigation is required to
evaluate the risks to children. Clarity is required by the LSCB about the nature of
investigative practice in these circumstances and the responsibilities of each agency.
5.1.6
Practitioners working with adults need to maintain an inquisitive nature about the impact of
their patient / client’s behaviour on those around her/him, especially children.
5.1.7
There is a need to ensure consistent recording of ethnic and religious details. The lack of
such information may reflect the fact that this was a white British household, and family
members all came from the locality. However, the significance of the individual culture could
have usefully been explored. The local Safeguarding and Looked After Children
Improvement Plan addresses the need for work in this area with regard to CSS.
5.1.8
There is a multi-agency responsibility to ensure that children’s long term therapeutic needs
are met: this should involve professional challenge for any delays in the delivery of service
planned as part of a child protection plan.
5.1.9
A recurring theme in serious case reviews is the impact on professionals of the presentation
of parents. In this case mother was perceived to be open and having insight into her
difficulties, whilst being able to be trusted to put the needs of her children first. However,
research has demonstrated such factors should be treated with caution and that the focus
has to be ‘professional uncertainty’ with decisions based on full assessments that focus on
the child and not on parental interpretation of the child’s wishes and feelings.
13 Peter Drucker (1909-2005), writer, management consultant, and ‘social ecologist’
14 Brandon et al (2009) Understanding serious case reviews and their impact, a biennial analysis of serious case reviews 2005-07
20
5.2
LESSONS FOR CHILDREN’S SOCIAL SERVICES
5.2.1
In accordance with existing local procedures anonymous referrals need to consistently
receive the same evaluation as those coming from professionals. Consideration should be
given to the possibility of being able to identify the referrer within the professional network
and hence, if appropriate, negotiating direct contact so as to better evaluate the risks to the
child.
5.2.2
Practice in this case demonstrates the priority of process over purpose when assessing
specific safeguarding concerns in initial assessments and s.47 enquiries. To provide a
greater focus on the investigative nature of the task involves recognition that this may take
time, involve unannounced visits, include developing relationships with children out of the
home and/or by using school staff. Skilled social workers, adequately trained to undertake
this investigative task may be part of the challenge, but the staff in this case were trained in
the police Specialist Child Abuse Investigator Development Programme. This suggests that
the challenge is more complex than purely one around training, but one around
understanding purpose, role, investigative strategy and planning.
5.2.3
The children’s social services management review indicates that the importance of seeing a
child alone and their voice being effectively heard and that this has already been identified
and is being addressed. Training and practice tools in communicating with children should
assist in improving standards, however, unless attention is paid to the ability of a child to
speak ‘in safety’ outside of the family home with trusted adults, such skills may be wasted.
5.2.4
There is a need to ensure a timely response to referrals, effective management of the
assessments and good quality reflective supervision. The local Safeguarding and Looked
After Children Improvement Plan addresses all these areas.
5.2.5
A contributory factor to the shortcomings in service provision arose due to resource
shortages. The local Safeguarding and Looked After Children Improvement Plan addresses
the need for a ‘compelling workforce strategy’ and effective recruitment.
5.2.6
The lack of timely and adequate assessment of family carers in this case indicates that
when the Local Authority is directly involved in making arrangements and agreeing
conditions, the child should be considered as Looked After and the kinship carers assessed
as foster carers. This is in line with the intention of current procedures, but the latter were
misunderstood by the District at the time and should be made clearer.
5.2.7
There is a need for strategy discussions and child protection conferences to involve
consideration, and if need be expert advice, for the management and support of children
during periods of trauma. Such consideration to be effective has to involve those staff from
agencies with knowledge of the child and her/his needs.
5.3
LESSONS FOR EDUCATION, LEARNING & SKILLS
5.3.1
The importance of schools having information about family and household composition,
including male partners and fathers of children is highlighted by this case.
5.3.2
The case reinforces the vital role of school staff in being in the prime position to develop a
trusting relationship with children and enable them to speak about their worries. In this case
the IMR is clear the school has an open door pastoral policy for children to access, however
how information obtained is subsequently stored and responded to could be better
evidenced, by demonstrating clarity of content and action taken.
21
5.3.3
Despite a well used consultation process for schools, this case has indicated the need for
further awareness raising within schools regarding the use of consultation, the escalation
process and complaints procedures, where appropriate.
5.4
LESSONS FOR HEALTH AGENCIES
Community health
5.4.1
This serious case review has identified serious concerns about provision of an acceptable
level of health visiting care in the area involving a combination of capacity issues and
operational stressors and challenges arising from internal team dynamics. These factors led
to a failure to deliver an acceptable standard of care to this family over a period of time.
5.4.2
Work is already underway to address health visiting capacity on a local and national basis.
The health overview report author has escalated the key concerns within the organisation
and requested urgent contact to plan performance management meetings with this provider.
5.4.3
The Ofsted / CQC inspection of 2010 identified the limited development of preventative and
early intervention services, the CAF and ‘Team Around the Child’ approach.
Local Mental Health Trust
5.4.4
Children of service users and any children with whom they have contact need to be
considered from the first point of contact and throughout the therapeutic process. This is
particularly significant for any parent / carer attending anger management therapy.
5.4.5
The health reports for this review indicate that this failure to identify the negative effect of
mother’s behaviour on her child is mainly a ‘historic’ issue with the introduction of clinical
audit and a review of training provision and supervision. Improvement will be performance
managed by normal performance management routes.
5.4.6
There is a need to ensure that information is shared with health colleagues and referrers,
including the outcomes and needs of those attending group therapy.
5.4.7
This case suggests that adult therapeutic needs receive a more timely assessment and
service in contrast to children’s. It is understood that a contributory factor to the delay was
some uncertainty about the nature of the service required and its urgency. In such
circumstances contact needs to be made with referrers so as to clarify the needs of the
child. If an assessment is required to determine this, these should receive priority.
5.4.8
It appears that there are further systemic obstacles to receiving timely services for children,
which need to be addressed urgently. In 2010 the national support team visited and
identified significant waiting lists. This was also noted by the joint Ofsted /CQC inspection. A
robust plan is in place to address shortfalls and significant investment has been made to
improve services. The health overview report refers to the plan to raise this case with the
commissioner of the service.
Local Acute Hospital NHS Trust
5.4.9
There is scope for hospital staff to be more aware of children’s welfare by eliciting and
recording children’s wishes and feelings, observing their interaction with their carers and
noting pertinent information.
5.4.10
Hospital staff need to ensure that best practice guidelines are followed with regard to
resuscitation of children.
22
GP involvement
5.4.11
This case demonstrates the pivotal role of the GP within health services. Integral to this is
the need for the GP to take responsibility for pro-active communication with health
colleagues and holistic consideration of children’s welfare on the basis of all available
information. This is best undertaken via regular and clearly documented multidisciplinary
meetings between GPs and universal public health service providers, as emphasised in the
locally revised Royal College of General Practitioners toolkit. As training for practice
managers and child protection leads is already being planned to support GPs embed such
best practice and meet CQC registration requirements, no recommendation will be made.
5.4.12
The child’s records did not flag the poor mental health of the mother. Such flagging linking
vulnerable family members enables a GP to specifically reflect on interaction with parent/s
during contacts.
Ambulance Service
5.4.13
This case highlighted the difficulty experienced by non-clinical staff faced with atypical
presentations during 999 calls and the importance of adhering to the scripted prompts
presented by the call software, regardless of the caller’s presentation. This individual error
has been addressed via intensive training and increased performance management.
5.4.14
It was concluded that the software prompts might be able to have picked up the patient’s
condition more quickly if the key words were different. The Trust had recently moved to a
new system and this will be tested rigorously to ensure appropriate key words trigger the
system to prompt call takers actions. The Ambulance Trust have attempted to follow up this
potential national safety issue with the providers of the software, requesting they check the
software prompts, but that software provider declined the request. A national
recommendation has been made to address potential risks to other users of this software.
5.5
LESSONS FOR LOCAL HOUSING ASSOCIATION
5.5.1
The housing association have identified that they were not aware of changes in the
household composition and although this would not have been relevant to the outcome of
this family, it may be in other cases. The tenancy audits that were introduced in 2010 will be
extended to include unannounced visits if there are any safeguarding concerns.
5.6
LESSONS FOR LOCAL POLICE
5.6.1
The 2010 police investigation did not sufficiently address the primary objective of protecting
children and would have benefitted by formally putting the allegations to the father. The lack
of follow up of a friend able to provide corroboration of the sister’s earlier allegations of being
beaten by her brother may not have provided evidence regarding the more serious sexual
offence allegation, but may have provided evidence in relation to a lesser offence and / or
contributed to protecting children.
5.6.2
The investigation into Ashley’s death has highlighted the difficulties in acquiring the services
of paediatric pathologists and other experts able to make evidential comment on ‘Shaking
baby Syndrome’, resulting in body parts being sent to various parts of the country to obtain
this essential evidence.
5.6.3
The police do not currently have the resources to either follow up all police intelligence about
relatively minor drug offences or research whether addresses identified in these
circumstances are associated with a previous child protection concern. Such information
would have been relevant as providing support of the 2009 anonymous allegations.
23
6
RECOMMENDATIONS
6.1
INTRODUCTION
6.1.1
Recommendations to the Local Safeguarding Children Board emerging from this serious
case review include those requiring action by:
•
The Local Safeguarding Children Board
•
Individual member agencies
6.1.2
The recommendations from the Individual Management Reviews are in section 7.3. Section
7.2 provides the recommendations arising from the multi-agency perspective and which
have not already been indentified within the Individual Management Review
recommendations.
6.1.3
The accompanying action plan provides details of how the recommendations have been /
will be implemented and the completion dates.
6.2
OVERVIEW REPORT RECOMMENDATIONS
National LSCB recommendations
6.2.1
The LSCB to raise with the DOH and the National Ambulance Safeguarding Group the
issues raised in this case with respect to the software and potential risk to other Trusts.
6.2.2
The LSCB to raise with the Home Office the difficulties acquiring the services of paediatric
pathologists and the impact on the family of such delays in the criminal investigation
Local LSCB recommendations
6.2.3
All agencies to assure the LSCB that the following elements of sound safeguarding practice
are consistently communicated and applied to ensure risks to children are assessed and
needs are effectively met:
•
•
•
•
•
•
•
6.2.4
‘Professional curiosity’ & ‘respectful uncertainty’
Avoiding ‘assumptions’ about the welfare of children based on perceived qualities of
openness and insight of parent / carers
Engagement with and observation of children as part of any child assessment process
Use of consultation and escalation processes within each agency
Importance of providing reason for enquiry when requesting information sharing i.e.
7.7.4-7.7.6 of local Safeguarding procedures
Engagement of all significant people for the children, including fathers and all carers
and an understanding of their background history
An understanding of the child’s experience of parental substance misuse, mental health
issues, domestic violence
The LSCB to establish if the investigative practice in this case is indicative of systemic
weaknesses.
24
Children’s Social Services
6.2.5
Children’s Social Services to provide evidence of a robust response to anonymous referrals
from material from July 2011 onwards.
6.2.6
Children’s Social Services to ensure staff understand the need for children to be considered
as ‘Looked After’ when placed with family and friends in circumstances when the Local
Authority ‘brokers’ the arrangements.
6.2.7
Children’s Social Services to ensure that GPs are consistently invited to child protection
conferences.
Health agencies
6.2.8
The Local Mental HealthTrust to assure the LSCB that CAMHS provides a responsive
service to referrals for children, involving a timely process to determine the urgency of need
via discussion with referrers and assessment appointments. In all cases feedback should be
provided to referrers within 2 weeks.
6.3
IMR RECOMMENDATIONS
Children’s Social Services
1. The quality of supervision delivered to be reviewed.
2. Ensure that children are seen (alone where appropriate) and heard as part of any assessment
undertaken.
3. To ensure that all adults who are present in a household are invited to participate in the
assessment process.
4. To ensure that District teams are reminded of the procedures to follow when placing children
and young people with extended family.
Education, Learning and Skills
1. Review of Schools Admission Form
2. Support to school to enable improved recording of all relevant safeguarding information
3. Reinforce need to challenge decision making of other agencies if unhappy with response to a
referral
Local Housing Association
1. Housing Association to ensure that unannounced visits are used as part of the tenancy audits
when the organisation is aware of safeguarding concerns.
Health Agencies
Health overview recommendations
1. It is recommended that the LSCB Safeguarding Health Group will consider and address the
challenges to the production of timely high quality individual management reports.
2. It is recommended that lessons for the local PCT cluster associated with the process of
managing the serious case review process within health will be identified and addressed.
25
3. It is recommended that the concerns identified in relation to lack of health visiting capacity
and poor working practices that contributed to this service failure should be addressed. A plan
that describes the new health visiting service and the expected outcomes of that service,
described in terms of benefits to children at risk of harm, should be developed and delivered.
4. The caseload of the deceased child’s health visiting team will be audited and omissions of
care to other children will be rectified.
Local Community Health NHS Trust
1. A case vignette be prepared concerning the poor practice of HV2 in her duties to the elder
sibling, this could be used in a variety of training opportunities including, Safeguarding
Children Group 2 training, HV updates on Maternal mental health, Training on the importance
of the Family needs assessment tool.
2. Awareness raising concerning the importance of acting upon and understanding the contents
of the Concern and Vulnerability forms.
3. Following the strategic review of CAF, a comprehensive training and implementation plan to
be devised to ensure CAF becomes embedded in clinical practice.
4. Review local plans concerning “Action on Health Visiting” to ensure that existing resources
are optimally applied using national guidance on weighted childhood deprivation.
5. Explore with commissioners how “Action on Health Visiting” could be accelerated within the
locality.
6. Devise and implement a year long campaign within the Public Health nursing service entitled
“The child first and always”.
7. Audit current practices regarding assessment of race, cultural, religious and linguistic needs.
8. Within existing record keeping training and safeguarding training, review the time spent /
importance of ensuring practitioners fully understand their role and responsibilities with regard
to information sharing.
Local Mental Health Trust
1. Children should be considered at the first contact with all adult clients. All frontline staff will be
provided with the new assessment checklist in the form of a flowchart. All clinical/professional
training delivered must ensure that the importance of thorough documentation is emphasised.
2. The Mental Health Trust must sustain annual safeguarding children training updates for all
frontline staff who regularly undertake assessments. This will ensure that all staff are aware
of current legislation, policy, and process and keep the importance of safeguarding children in
the forefront of their practice.
3. Acute/Recovery Services must strengthen their clinical/professional information-sharing
protocols where there is multi-professional engagement with an individual.
Local Acute Hospital NHS Trust
1. To improve how children and their families are assessed with regard to race, cultural,
religious and linguistic issues.
2. To improve recording keeping in relation to parental interaction for all children
26
3. To ensure that national best practice guidelines are followed with regard to resuscitation of
children
Local NHS GP involvement
1. The local PCT cluster will review all current flagging systems within GP practices and best
practice guidance across the area. Consideration will be given to flagging vulnerable
children.
2. The specific GP who reviewed mother postnatally will be required to provide evidence of up to
date child protection training at level three within three months to his appraiser.
Ambulance Service
1. Continued monitoring of the individual member of staff through audit and managerial support
as detailed in the EDC senior management report.
2. Details of reflective study undertaken by the call taker to be shared (suitably anonymised)
with all EDC staff across all EDC sites within the ambulance trust.
3. 999 calls to be externally audited for compliance.
4. External 999 scrutiny to assess the use of key words, which may indicate a need for
resuscitation in a paediatric patient, are included and lead to appropriate instructions.
5. Thorough testing of new call taking software is undertaken to give assurance around the use
of key words and appropriate instruction being given promptly given the same, or similar
response.
Local Police
1. When it is alleged a child has been raped or sexually assaulted and a suspect has been
named, that person should, in most circumstances, be interviewed under caution. In cases
where the victim has not retracted the complaint, but declined to support a prosecution, the
suspect should still be interviewed and given the opportunity to respond to the allegations. If
the suspect is a member of the victim’s family then such an interview may expose further child
protection issues and assist in identifying risks to vulnerable persons.
2. The Police must record on a prescribed ‘Crime Report’ document, allegations of rape reported
by the victim, even though the case may not be prosecuted.
3. In cases relating to vulnerable children, those responsible for inputting information reports
(5x5x5) on to the Genesis database, must ensure this is done swiftly and accurately. In
particular, information regarding a child’s name, address and any specific vulnerabilities must
be accurately recorded and linkages with other nominal’s clearly identified.
Those
responsible for child protection cases should also ensure information reports are completed
and submitted, and they are clear, up to date and accurate.
4. Consideration should be given to the introduction of an improved method of assessing
Information Reports (5x5x5) that relate to premises habitually used for the supply or
consumption of drugs, and which may also be occupied by children. Addresses should be
researched in an attempt to identify any vulnerable children who may be present on those
premises. In some cases, further investigative action by the Public Protection Unit may be
appropriate, which may result in a Section 47 enquiry or a Child in Need referral to Social
Services.
27