hertfordshire safeguarding children board · 2018-08-22 · hertfordshire safeguarding children...

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Serious Case Review: Hertfordshire LSCB

Hertfordshire

Safeguarding Children Board

Serious Case Review:

Child A

Episode that triggered the review March 2013

LSCB adoption of the review findings September 2014

Publication November 2016

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Chapter Page

1 Introduction to the Review Process

Reason for the Serious Case Review 4

Timescale for the SCR 5

Child A’s family 5

Child A’s family background – A brief summary 5

Succinct summary of case 7

Timeline of significant incidents 7

The lead reviewers 13

The review team 14

The case group 15

Family member involvement 15

Structure of the review process 15

Sources of data 16

About Hertfordshire 16

2 Professional practice

Summary appraisal 17

Narrative of professional involvement 18

3 The Findings:

Analytical process for establishing systems findings 24

Finding 1: A failure to use expertise within the professional

network as to how children with different or complex

communication needs express themselves, leads to the child’s

voice not being heard

26

Finding 2: There is multi-agency confusion in Hertfordshire

about the child in need processes for disabled children leaving

them without effective outcome focussed plans and multiagency

reviews

30

Finding 3: There is a professional unwillingness to label the

early signs of poor quality care provided to disabled children as

neglect leaving those children’s needs unaddressed

33

Finding 4: A parent or carer not taking a child to health

appointments, particularly where the child is additionally

vulnerable, should be an indicator that the child may be at risk

resulting in proactive follow up

35

Finding 5: There is a pattern of uncritical acceptance of parental 39

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self report by professionals in all agencies which leaves

children’s needs and circumstances un-assessed

Finding 6: The meaning given by one agency to a phrase about a

client does not necessarily have the same meaning for all

agencies meaning that risk may be wrongly assessed by others

42

Finding 7. There is a pattern whereby non-resident Fathers are

routinely excluded from assessments and decision making about

their children

44

4 Additional Matters

Escalation process 47

Re-commissioned services maybe vulnerable 47

Assessing the risk an “adult” issue poses to children 48

5 References and Bibliography 49

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1: Introduction to the Review Process

Reason for the Serious Case Review

1.1 In March 2013 Child A (who was eight at the time) was taken to hospital by

ambulance because of a reported allergic reaction to hair dye. The attending

ambulance crew noticed some bruising and large ‘O’ shaped marks on Child A’s

body. This prompted a full child protection medical which revealed that Child A had

sustained multiple unexplained injuries. There was also evidence of human bite

marks, fractures to this ribs and a head injury. Child A received medical

intervention and his Mother and Stepfather were arrested and they were

subsequently bailed pending further investigations. In 2014 Child A and his two

siblings were living with their maternal grandparents, and they had contact with

their Mother, but not Stepfather. Child A was referred to the Hertfordshire SCR sub

group by East and North Herts NHS Trust on 25th March 2013 and a decision to

undertake an SCR was made on 24th April 2013. A member of the extended family

was convicted of offences arising from the severe physical abuse of Child A in mid-

2016.

1.2 Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out

the requirement for Local Safeguarding Children’s Boards to undertake reviews of

serious cases where: (a) abuse or neglect of a child is known or suspected; and (b)

either — (i) the child has died; or (ii) the child has been seriously harmed and 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.

1.3 Working Together was reissued in 2013 and provided new guidance for

undertaking a serious case review which requires that they should be conducted in

a way which:

recognises the complex circumstances in which professionals work together to

safeguard children;

seeks to understand precisely who did what and the underlying reasons that led

individuals and organisations to act as they did;

seeks to understand practice from the viewpoint of the individuals and

organisations involved at the time rather than using hindsight;

is transparent about the way data is collected and analysed; and

makes use of relevant research and case evidence to inform the findings.

1.4 LSCBs may now use any learning model which is consistent with the principles in

the guidance, including the systems methodology recommended by Professor

Munro. Hertfordshire LSCB agreed to undertake a review using the SCIE Learning

Together methodologyi.

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Time scale for the SCR

1.5 The period under review is from 2nd March 2012 and concluded on 16th March

2013 when Child A’s injuries were discovered by medical professionals. Child A has

been known to a range of services throughout his life and the review takes account

of some aspects of this historical context.

This review was commissioned in August 2013 and completed in September 2014.

Publication of the report was delayed until 2016 in order to ensure that it did not

prejudice the criminal investigation or trial.

Child A’s Family

1.6

Relationship to Subject Ethnicity

Child A Subject White/

British

Mother Mother of Child A, sibling 1 and 2.

Father Father of Child A

Stepfather Father of sibling 1 & 2

Sibling 1 Half sibling same Mother – different Father White/

British

Sibling 2 Half sibling same Mother – different Father White/

British

Child 1 Child of Stepfather NK

Child 2 Child of Stepfather NK

MGM Maternal Grandmother of all siblings White/

British

Step MGF Step Maternal Grandfather of all siblings White/

British

Child A Family Background – A Brief Summary

1.7 Child A was born prematurely at 30 weeks gestation when his Mother was in her

teens and living at home with her Mother and Stepfather. Child A has cerebral

palsy, profound neural deafness and he is currently a wheelchair user. Child A has

been known to the Disabled Children Team since birth. He was referred by medical

staff to the hearing impairment advisory team at 4 months old. He started at a

school for physically and neurologically impaired young people in the September

following his third birthday and support has been provided via the school ever

since. Child A was assessed regarding special educational needs, and his Mother

requested a place at a specialist school for pupils with physical and neurological

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difficulties. Child A has attended this school for a number of years, and is provided

with high quality educational and physical support.

1.8 When he was five, Child A’s mother was referred to a physical disabilities team

because she was struggling with the physical care needs of Child A and his 18 month

old sibling 1. She had her own physical heath difficulties, specifically a back injury

which was exacerbated by the level of lifting and handling required to care for Child

A. At this time she was assessed as being entitled to Direct Payments of £90 per

week, which she never claimed.

1.9 Child A’s Father was in his late teens when Child A was born. He did not have

parental responsibility until recently. He told the reviewers that when Child A was

born he asked Mother about registration of the birth, he was told this had been done

and that he was not named on the birth certificate. He was not able to challenge this

in court for financial reasons. Child A’s Father said that he has provided financial

support every month since Child A was born and that he has had regular contact

every weekend, with overnight stays every other week. He was in contact with Child

A’s school in the early days.

1.10 It is not clear when Child A’s Mother met Stepfather, but their first child was born in

2008. They had a second child in 2012 (sibling 2). There were differing reports

regarding their relationship, and Mother told some professionals that they were in a

relationship, but did not live together, and told others that they lived together for

part of the week, so he could help out with the care of the children. Stepfather had a

brief relationship with another woman, and she had a baby in 2009. This baby was

made subject to a child protection plan before its birth, because of Stepfather’s

domestic violence and this child is currently in care. He also has another older child

with whom he has no contact.

1.11 Stepfather has a long criminal history, with offences for theft, violence to a partner,

members of the public and the police. He also has long term alcohol and drug use,

and he has misused heroin, crack cocaine and cannabis in the past. He is prescribed

methadone, and he tested positive for class A drugs in the period under review.

There has been a police marker regarding him for violence and mental health issues,

but when assessed by a psychiatrist in the period just before this review he was said

to have no diagnosed mental illness.

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Succinct summary of case

1.12 Child A has been in contact with a range of services since he was born. This includes

social work, occupational therapy, school, and speech and language services. He

attends a specialist school, and requires specialist equipment to enable him to

participate fully in education, supported by speech and language therapy and the

wheelchair service. Child A has attended school regularly, and the main area of

concern has been missing and lost equipment. Child A is a child with a disability

and as such has been a child in need since birth. There were no concerns regarding

the care he received or family difficulties until March 2012 when his Mother was

arrested for assault. .

1.13 His Stepfather was arrested and charged with endangering his own child and drink

driving in September 2012. An assessment was undertaken, but led to no further

action. Mother gave birth to her third child in December 2012. Child A continued to

attend school, who became concerned about a burn to Child A which required

medical attention and caused them concern. Child A remained in contact with

those agencies that supported him through school, and lost equipment, issues

about him being unkempt and small injuries became of increasing concern. These

concerns were emailed to his social worker, and she tried to visit the family home

without success. At this time Stepfather started to disengage from his contact with

probation and the drug and alcohol agencies. The escalation of worries about child

A and his family circumstances was not fully understood by any one agency.

Timeline of significant incidents

1.14

Review Period Starts

Date Incident

2 March 2012 Police report that Mother assaulted a woman because she

believed the woman was seeing her boyfriend/Stepfather.

Both were said to be drunk.

6 March 2012 Child A was not at school. Discussion that the week before

Child A had not brought his hearing equipment,

communication book, boots and mouth pointer to school.

Mother was reported to have been a little agitated when

she came to school.

7 March 2012 Occupational therapist (OT) undertook a home visit. She

discussed this with the Practice Manager of the Disabled

Children’s Team who asked the allocated social worker and

the OT to go back to the house. A home visit was

undertaken and Stepfather was looking after Child A and

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his sibling. The Practice Manager was informed of this, and

she asked the allocated DCT (Disabled Children’s Team)

social worker to let the out of hours Duty Team know about

the situation, which she did.

8 March 2012 The allocated DCT social worker spoke to Mother, who said

she had not been charged, and did not want to talk about

the incident.

8 March 2012 Child A did not attend his speech and language session

because he was late into school.

9 March 2012 The Police told the allocated DCT social worker that Mother

had been interviewed regarding a charge of Actual Bodily

Harm (ABH) and was bailed for ten days pending further

investigations.

18 and 29 March 2102 Telephone calls between Mother and social worker

regarding practical matters.

8 May 2012 School meeting, Mother attended.

22 May 2012 Stepfather was sentenced at Crown Court to a Community

Order of 200 hours of unpaid work for handling stolen

goods.

13 June 2012 Mother visited G.P. and was found to be pregnant.

9 July 2012 Stepfather started on a methadone programme.

2 August 2012 Stepfather was seen by his new drug and alcohol team

where he reported that he had ceased using heroin and

crack cocaine, but smoked cannabis. Stepfather told the

drugs worker that his partner was pregnant with their

second child, and he had another older child who was in

care, and he was taking steps to have contact with her.

3 August 2012 The drug and alcohol team sought information from

Children’s social care as a result of Stepfather sharing

information about his children.

6 August 2012 The Duty team from children’s social care contacted the

disabled children’s team to inform them that Mother and

Stepfather had applied to care for Stepfather’s daughter

who was currently in care.

7 August 2012 There was a case discussion between the allocated (DCT)

social worker from the disabled children’s team and her

team manager regarding Stepfather’s drug use and

Mother’s pregnancy. Agreed that a core assessment should

be carried out. This was progressed in October.

17 August 2012 Stepfather’s Community Order was terminated because he

had breached the requirements and a new Community

Order of 18 months with supervision and drug

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rehabilitation requirements was made in its place. New

probation officer allocated.

20 August 2012 During testing as part of his order Stepfather tested

positive for opiates.

4 September 2012 The Probation officer made a referral to Children’s referral

to Children’s social care regarding Child A, sibling 1, child 1

and the unborn baby. Probation officer said Stepfather does

not pose “an imminent” risk.

4 September 2012 The Probation officer spoke to allocated social worker for

child 1 who told her that the current plan for child 1 was

adoption.

9 September 2012 The police received an anonymous call regarding an

allegation that Stepfather had been drinking and smoking

marijuana, and was riding a motorcycle along the street

with a small child on the handlebars. The Police attended

and Stepfather was arrested for drunk driving, it was noted

that Mother was obstructive.

10 September 2012 Referral to Children’s social care from the Child Abuse

Investigation Unit (Police) regarding Stepfather’s offences.

10 September 2012 The probation officer contacted Children’s social care to let

them know that Stepfather had been arrested and to check

whether the child protection referral had been received.

12 September 2012 Children’s social care decided that the assessment of the

unborn baby and sibling 1 would be undertaken by the

assessment team, and the assessment of Child A by the

disabled children’s team.

12 September 2012 Stepfather told the probation officer that his stepson, Child

A, had been allocated a social worker. He told the probation

officer that he had been charged with “Exposing a Child to

Danger” and drunk driving, as he had been 2 times over

legal limit.

13 September 2012 Probation officer telephoned the allocated social worker

(DCT) and left a message regarding the new offences.

13 September 2012 Telephone call from the Head Teacher to allocated social

worker (DCT) expressing concern that Child A was coming

to school without the necessary equipment, which was

impacting on his ability to access the curriculum.

19 September 2012 Stepfather tested positive for cocaine following a routine

urine test.

19 September 2012 The allocated social worker from the disabled children’s

team and social worker from the assessment team met

together to share information.

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20 September 2012 The drug and alcohol team made a referral to Children’s

social care regarding concerns for Stepfathers children

because of his continued drug use and drug related

offences.

20 September 2012 Strategy discussion held regarding Child A.

25 September 2012 Strategy discussion held regarding sibling 1 and 2.

26 September 2012 Professionals meeting organised by Children’s social care

to discuss the risk posed by Stepfather. The school

recorded that they thought the meeting concluded that

there would be a child protection conference in the next

few weeks.

27 September 2012 Meeting at school with Mother and Stepfather. Concerns

were expressed about lack of equipment coming into

school for Child A and also Mothers lack of contact with the

wheelchair services.

15 October 2012 The allocated social worker (DCT) for Child A contacted

probation to ask about curfew requirements. She was told

that Stepfather could not stay away from home.

15 October 2012 Stepfather brought Child A to school because the family had

stayed at stepfather’s home the previous night because

Mother’s fridge had broken.

16 October 2012 Stepfather asked the CRI drugs agency he was attending for

help with his alcohol misuse.

17 October 2012 Child A was found at school to have 4 small marks on his

side – described as like carpet burns. Recorded in the

schools records.

17 October 2012 Stepfather received a 4 month sentence suspended for 18

months, for the charge of endangering a child. Sentence

included attending a Drinkwise programme.

23 October 2012 Stepfather had session with Probation. He reported that he

had missed Drinkwise programme because of Court

Hearing regarding child 2. Alcohol consumption addressed

and he acknowledged he had a drink that morning.

30 October 2012 Child protection enquiries completed. Concerns were

substantiated, but children not judged to be at continued

risk.

6 November 2012 Stepfather reported to the drug and alcohol agency, CRI,

that his alcohol misuse was out of control, and he requested

help. Group work was offered.

8 November 2012 Mother saw the midwife and told her that her partner, the

child’s stepfather, was on a methadone programme.

8 November 2012 The Core assessment was completed regarding Child A and

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sibling 1 and the unborn baby. Both recommended no

further action.

20 November 2012 Stepfather told his key worker at CRI reports that he is

struggling with the methadone reduction programme,

drinking excessively and he was unaware that he was due

to attend the Drinkwise programme via probation. He

reported that he was on a final warning because of non

attendance. He was encouraged to speak to Children’s

services.

20 November 2012 Neighbour of Stepfather telephoned police to express

concern that Stepfather was smoking crack cocaine at home

and that he has a court order not to drink alcohol or take

drugs. Police find no trace of an order or conditions and so

closed the incident with no action taken.

13 December 2012 Sibling 2 born at 30 weeks. Kept in special care unit.

18 December 2012 Stepfather reported to probation. Told of birth of son,

prematurity and that he had drunk four pints to celebrate.

Discussion about drug use and interventions.

2 January 2013 Stepfather attended group session under influence of

alcohol.

4 January 2013 Stepfather reported to Probation. He admitted using crack

cocaine and drinking. His lapse was discussed and he said it

peer pressure and that he found it difficult to refuse.

6 January 2013 Speech and language service contacted the allocated social

worker to express concerns about equipment. Social

worker agreed to talk with Mother. Appointment had been

cancelled.

7 January 2013 Children’s social care contacted Probation to discuss

stepfather’s progress. Assessment social worker said she

was pleased with his engagement and compliance. It was

discussed that the case was likely to close. It is not clear if

the drug use disclosed on 4 January 2013 was discussed.

15 January 2013 School nurse saw a burn on Child A’s foot. They were

concerned and asked Mother to take him to hospital.

Allocated social worker informed.

15 January 2013 Child A taken to A&E by Father. Injury considered by the A

and E Doctor and Nurse to be consistent with explanation

given. Which was the foot had been trapped between bed

and radiator.

17 January 2013 Health visitor undertakes a new birth visit with Mother and

sibling 2.

23 January 2013 Speech and Language service expressed concern to school

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about missing equipment. Head teacher attempted to

contact the allocated social worker (DCT) and emailed her

explaining concerns, Child A looking unkempt, lost or

broken equipment and a bruise on the left cheek of Child A.

30 January 2013 There was a discussion between the Head teacher and the

allocated social worker (DCT). Concerns discussed and

social worker reported that she would see Mother next

week.

31 January 2013 Speech and language service emailed their concerns

regarding lost and broken equipment to the allocated social

worker (DCT).

11 February 2013 School nurses noticed graze on Child A’s forehead which

was healing, but there was no explanation in the home-

school diary. Teacher phoned Mother who was not sure

what had happened but thought he might have grazed his

head on his bed. Allocated social worker (DCT) informed.

12 February 2013 Meeting at school regarding equipment. Mother revealed

informally that Stepfather was at the house everyday even

though he should not be, because she could not manage the

children alone. School notified the allocated social worker

(DCT) regarding this. Social worker agreed to visit and

raise concerns.

27 February 2013 Teacher emailed the allocated social worker regarding

home visit to Mother and was told it had not happened

because Mother was out.

28 February 2013 Stepfather gets a new probation officer. His attendance at

the drug agency had become sporadic only attending 9 out

of 19 drug testing appointments.

7 March 2013 The teacher emailed the allocated social worker to ask if

she had done a home visit. She did not receive a reply

before the critical incident nine days later. This was due to

the allocated social worker being part time.

16 March 2013 Child A taken to hospital.

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Methodology

1.15 This serious case review has been undertaken using the SCIE Learning Together

methodology. The focus of a case review using a systems approach is on multi-

agency professional practice. The goal is to move beyond the specifics of the

particular case – what happened and why – to identify the underlying patterns that

are influencing practice more generally. It is these generic patterns that count as

‘findings’ or ‘lessons’ from a case, and changing them should contribute to

improving practice more widely. Data comes from semi-structured conversations

with the involved professionals, case files, contextual documentation from

organisations and the young person and their family who are the subject of the

review. A fundamental part of the approach is to talk with staff to understand what

they thought and felt at the time they were involved in the case, avoiding hindsight

as much as possible. It is vital to try and make sense of what factors contributed to

their understanding at the time and to the decisions they made. This is known as

the ‘local rationality’. Any appraisal of practice is then made in the context of those

contributory factors.

The Lead Reviewers

1.16 This review was undertaken by Jane Wiffin and Dave Peplow, both of whom are

SCIE accredited Lead Reviewers.

1.17 Jane Wiffin is a qualified social worker who has extensive experience of working in

safeguarding. She is an experienced serious case review author and chair, having

undertaken 18 reviews. She is an accredited SCIE Learning Together Reviewer and

has undertaken a number of reviews using this methodology. She is currently

engaged in work developing tools and frameworks for addressing childhood

neglect and she is an experienced auditor and safeguarding trainer. She is

independent from all the agencies involved in this review.

1.18 Dave Peplow served 25 years as a police officer. He was the Essex Police lead

for safeguarding matters and Head of Child Abuse Investigations. He has extensive

experience of multi-agency working across three local authority areas. He left the

police in 2012 and became an accredited Learning Together reviewer in July 2012.

He is the Independent Chair of Thurrock and Warwickshire LSCBs and sits on a

fostering panel. Dave is independent of all the agencies involved in this.

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The Review Team

1.19 The review was conducted by a team of senior representatives from local agencies

who had had no direct dealings with the case. They shared in the conversations, the

analysis of documents, the identification of key practice episodes and contributory

factors. This report is the shared responsibility of the Review Team in terms of

analysis and conclusions, but was written by the joint lead reviewers.

Name Agency/Role

Geoff Core Hertfordshire Social Care.

Head of Child Protection (to December 2013)

Andy Lawrence Hertfordshire Social Care.

Head of Disabled Children Services and Children’s

Brokerage Team (from December 2013)

Deborah Brice East and North Herts CCG and Herts valley CCG

Designated Nurse, Safeguarding Children and Looked

After Children (to 2015)

Jemima Burnage Hertfordshire Partnership University Foundation Trust

Head of Social Work and Safeguarding (to 2015)

Liz Hanlon Hertfordshire Police

Detective Chief inspector (to 2015)

Roz Frampton Services for Young People, Education and Early

Intervention

Educational Psychology Team Manager

Steve Johnson-Proctor Hertfordshire Probation (now National Probation

Service)

Director of Operations

Sue Smith Crime Reduction Initiatives

Regional Children and Families Lead

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The Case Group

1.20 The members of the Case Group are the professionals who worked with or made

decisions about the family, and who had individual conversations with members of

the Review Team ( in this case the therapists and the school nurses met as small

groups with Review Team members). The Case Group comprised of over 22 people

(although not all these people attended case group meetings). Most were briefed on

the methodology and then met with the Review Team on four further occasions to

share in the analysis, the identification of contributory factors, and to comment and

contribute to the report.

Social workers x 2

Social Work practice manager x 3

Head teacher

Classroom teacher

Occupational Therapist

Physiotherapist

Dietician

Speech and Language Therapist

School nurse x 3

Substance Misuse workers x 3

Health visitor

Police officer

Probation officer

Accident and Emergency Doctor

Accident And Emergency Nurse

Family Member Involvement

1.21 The Birth Father of Child A, The maternal GrandMother and her partner

contributed to the Review by meeting with the Reviewer during the process. It was

not possible to include Mother or Stepfather because of the ongoing police

investigation.

Structure of the Review Process

1.22 The Review Team met on six occasions, including four times with the Case Group,

and worked on a range of issues including the information from conversations,

identification of the Findings and issues for LSCB consideration.

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Sources of data

1.23 Conversations: The semi-structured conversations between members of the

Review Team and members of the Case Group; semi-structured conversations with

family;

Documentation: All necessary documentation was made available to the review

ranging from case files, procedures, assessments and police attendance records.,

About Hertfordshire

1.24 Hertfordshire borders London to the north and covers 643 square miles, having a

population of over one million people, making it the most densely populated shire

county in the East of England. Hertfordshire has approximately 278,300 children

and young people under the age of 19 years. This is 24.9% of the total population.

The proportion entitled to free school meals is lower than the national average.

School-aged children and young people from minority ethnic groups account for

24.1% of the total population, compared with 25.4% in the country as a whole.

2011 Census information shows that the largest minority ethnic groups in

Hertfordshire are Asian (6.5%), Black African and Black Caribbean (2.8%) and a

notable Eastern European population (1.3%). The proportion of pupils with English

as an additional language is below the national figure with the main languages

other than English being Urdu, Polish and Gujarati. Hertfordshire has 5,458

Children in Need of which 1,207 (22.1%) had a recorded disability.

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2: Professional Practice

Summary Appraisal

2.1 This case involved the response of agencies to a disabled child (Child A) and his

family over the period from March 2012 to March 2013. During this time there

were a large number of professionals involved and the focus of professional

attention was divided between meeting Child A’s developmental needs in the

context of his disabilities, supporting his Mother who was perceived incorrectly to

be a single parent who was trying her best in difficult circumstance and addressing

the Stepfather’s offending behaviour and drug and alcohol misuse. During the

period under review Child A’s own Father was not seen or acknowledged by any

agencies. This was contrary to effective practice and the reasons for this are

discussed in Finding 7. There was a lack of a holistic approach to the needs of Child

A, exacerbated by the lack of any multi-agency Child in Need Processes (see Finding

2), inadequate assessment practice inappropriately shared between two social

workers, unclear information sharing between agencies, an overreliance on Mother

and Stepfather’s own views of their circumstances (Finding 5) and a lack of

escalation (see Additional Matters) of concerns about early signs of neglect

(Finding 3 and 4) and potential physical abuse. It is clear that the services focussed

on Stepfather did not always recognise the significance of the information they held

or the potential impact of Stepfather’s deteriorating behaviour on the children in

the family (See Finding 6). Outside of school, Child A was given few opportunities to

communicate with professionals about his own needs and circumstances (See

Finding 1).

During the time of the Review the social worker for the Disabled Children Team

told the Review Team that she held over 35 cases and worked a two and half day

week. This was an unmanageable caseload/workload which meant that even

routine and regular tasks could not adequately be covered. The Team Manager

supervised over 600 cases and this impacted on her ability to have management

oversight of all these cases. These concerns were raised with senior managers

throughout this time. There was a change in Drug and Alcohol Services provided to

Stepfather. This agency experienced a shortfall in personnel and high sickness

levels which had an impact on the consistency of response to Stepfather and

capacity to carry out appropriate assessments. The Health Visiting Service were

experiencing higher than average caseloads.

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Narrative of Professional Involvement

2.2 Child A attended a school which was equipped to meet his needs and where he was

happy and progressing. The school held regular in house planning meetings which

brought together education staff, nursing care, speech and language and nutritional

experts. The Disabled Children Team (DCT) social worker for Child A did not attend

these meetings because of the reported shortfall in capacity which, given the lack of

any other regular multi-agency meetings, was a missed opportunity for Child A.

2.3 The school had a reasonable working relationship with Mother, she attended

meetings and there was a well established communication process using the home

school diary. Despite this, the school and speech and language service had concerns

regarding the equipment Child A needed to hear and to communicate, which was

often lost, broken or missing as well as worries about whether Mother was

responding appropriately to the need to attend wheelchair service appointments.

These issues were addressed with Mother, she responded and there were short

term changes, however the problem remained and got worse in the longer term.

The lack of actual change was not recognised by the school as a potential early

indicator of child neglect which needed action – this is discussed in Finding 3 and

Finding 4. Towards the end of the period under review the school communicated a

series of individual concerns about missing equipment, Child A being unkempt and

unexplained bruising to the allocated social worker (DCT) without providing any

context or analysis. These concerns were not responded to in a timely manner, in

part because of the working pattern of the allocated social worker and in part

because of the reported shortfall in capacity in the Disabled Children Team. The

school did not escalate their concerns or seek any formal meeting or process to

address the lack of response from the Disabled Children’s Team as would be

expected.

2.4 Child A was known to the Disabled Children Team (DCT) team from birth. Over an

eight year period there were no concerns about the care that Child A received from

his Mother, but historically there were worries about how she was coping with the

physical care of Child A and a toddler. She was reluctant to make use of direct

payments, social work services or Occupational Therapy support, and as a result a

pattern of contact developed where Mother was telephoned by the allocated social

worker (DCT) on a regular basis regarding practical matters. Child A was never

subject to any planning or review processes and he was not seen regularly, all of

which was outside agreed standards of practice.

2.5 It is of concern that there appears to have been confusion across the professional

network about what it actually meant that Child A’s was a “child in need”.

Hertfordshire procedures highlight that there is a distinction between disabled

children who require services over a long period of time to support their wellbeing,

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and those disabled children who are “children in need” because of their family

circumstances and who require a qualified social worker, sometimes referred to as

complex child in need cases. This confusion meant no one professional was clear

about what to expect from the social worker, or what review and planning should

have been in place.

2.6 In March 2012 Child A’s Mother was arrested for the assault of a woman whilst

both of them were under the influence of alcohol. Stepfather looked after Child A

and his siblings whilst Mother was held at the police station. The allocated social

worker (DCT ) became aware of this and visited. She alerted the Emergency Duty

Team, but the incident was not analysed or followed up. As a “child in need” it

would be expected that there would have been a review of Child A’s circumstances

and consideration of the impact on him of his primary carer being unexpectedly

unavailable and an exploration of the role of Stepfather.

2.7 There was considerable professional confusion about what role Stepfather played

in family life, despite being the Father of sibling 1 and professionals being aware

that Mother was pregnant with sibling 2 in June 2012. This was in part because he

was not living permanently in the family home, but also because both Mother and

Stepfather gave conflicting accounts of their relationship to different professionals.

It was important for Child A and his siblings that all professionals understood the

role of Stepfather because he had a long history of violence and offending,

influenced by drugs and alcohol and therefore represented a potential risk.

2.8 In August 2012 Stepfather was transferred to a new drug and alcohol agency and as

part of the initial assessment of his needs he told the drug and alcohol worker that

his partner was pregnant with their second child, he had a child who was in care,

and another older child who he had no contact with. It was good practice that the

drug and alcohol worker contacted the social worker for child 2 to share

information about Stepfather, and this information was subsequently shared with

the allocated social worker (DCT) for Child A. However, because of a shortfall in

available staff a full parenting assessment was not undertaken, nor a home visit as

would be expected.

2.9 The allocated social worker (DCT) discussed the concerns raised regarding

Stepfather’s drug and alcohol use, violence and domestic abuse to child 2’s Mother

with her Team Manager and it was agreed that a core assessment would be

undertaken. Capacity issues within the Children with Disability Team meant that

there was a delay in this starting and two weeks later Stepfather’s Probation Officer

appropriately made a referral to Childrens Social Care because she had also been

told by him about his children.

20


2.10 Soon after this referral was made Stepfather was arrested for driving a motorbike

on the road whilst drunk, with sibling 1 on the handlebars. The Police responded

immediately to an anonymous referral and Stepfather was arrested. Mother was

noted to be angry and hostile to the Police Officer. Stepfather was charged with

drunk driving offences having been twice over the legal limit and endangering a

child. The police made an appropriate and clear referral to Children’ Social Care

and Probation also made contact with Children’ Social Care to ensure they knew of

this new offence. Two strategy discussions were held and a professionals meeting

to share information. The conclusion was that a child protection Core Assessment

(Sec 47) would be completed, some 6 weeks after the original plan to undertake an

assessment of Child A.

2.11 The allocated social worker (DCT) was tasked with completing the assessment of

Child A and a social worker from the Assessment Team would undertake the

assessment for sibling 1 and unborn sibling 2. This was outside normal procedures

where it would be expected that the social worker from the disabled children’s

team would have undertaken assessments on all three children. This was caused

by the high caseload held by the allocated social worker (DCT) and her

inexperience in carrying out complex assessments. This separation had a

significant impact. It meant that only one of the social workers had contact with

Maternity Services and once the case was closed regarding sibling one and two the

connection with early year’s services was lost. It also meant that there was

confusion about who to contact when Child A was brought to hospital with a burn

to his foot.

2.12 The two social workers liaised with each other and individually they sought

information from all appropriate agencies. Probation and the Drugs agency were

not asked to reflect on the implications of Stepfather’s behaviour and

circumstances on his ability to parent or on the implications for the safety of two

young and vulnerable children. The information provided focussed on Stepfather’s

positive engagement and the improvements that he had made from their

perspective. The Drug and Alcohol Team reported that Stepfather had been free

from class ‘A’ drugs since testing positive for crack cocaine in August 2012. He also

tested positive in the middle of September 2012, but this information does not

appear to have been available to the assessment. The assessments drew the overly

optimistic conclusion that Stepfather had made changes to his drug use and

criminal activity, without acknowledging that the incident with his son was caused

by excessive alcohol use. School provided a positive view of the engagement of

Mother, but also shared information about missing equipment.

2.13 Although two separate assessments were completed much of the information is

exactly the same in both, information having been “cut and pasted” from one to the

other. This is of concern given that each assessment is intended to focus on the

21


particular needs of each child, in the context of their family circumstances. Child A’s

needs are very different from that of his younger brother, and the issue of Child A’s

disability is described but not anlaysed.

2.14 Appropriately Sibling 1 was spoken to as part of the assessment process and Child

A was observed at school, but it is poor practice that there is no evidence that

attempts were made to use the expertise within the school to communicate with

Child A directly. (This is discussed in Finding 1)

2.15 It is poor practice that Child A’s Father was not informed that a Child Protection

assessment had been undertaken and Mother provided information about changes

in Child A’s behaviour when he returned from contact with his Father, and that

neither Father nor paternal grandparents had showed an interest in Child A. These

issues were never clarified directly with Father, who provided a different story as

part of this review.

2.16 The conclusion of both assessments was over optimistic and lacked a clear analysis

of all the existing risk factors. Both assessments relied heavily on self report from

Mother and Stepfather who both provided inaccurate and misleading information,

for example Stepfather was allowed to dismiss the issue of domestic abuse and hold

his previous partner responsible. Mother gave a false account of the incident when

Father was arrested for child endangerment. She said she was not present when it

happened, but the referral from the Child Abuse Investigation Unit made clear that

she was hostile and unhelpful to the police.

2.17 The assessment for the siblings recommended no further action and the

assessment for Child A recommended the continuation of the child in need plan, but

there was no plan formulated and because both assessments “cut and pasted”

information from one to another, the conclusion of Child A’s assessment incorrectly

stated that there would be no further action. In effect, this is largely what

happened.

2.18 In December 2012 Mother gave birth to her third child, who was born prematurely

and spent some time in special care. On the day of discharge from hospital the

health visitor went to the family home, she did not know any of the family history

as she had not received any written notification. The social worker who had liaised

with maternity services was not the allocated worker for Child A, and the

conclusion of the assessment for the siblings recommended no further action. The

Health Visitor saw only Mother and the new baby. Mother was described as

welcoming and the house was appropriate for the needs of a new baby. Discussion

covered feeding, safe sleeping and contraception. Mother was keen to attend clinic

for baby weight checks. There were no concerns and Mother provided no

information about the recent assessments.

22


2.19 From November 2012 onwards Stepfather’s probation Officer reduced the

reporting and drug testing requirements for stepfather to below what was

expected, because he said he was having contact with his children, although this

was not the case. In November 2012 Stepfather told the drug and alcohol agency

that he was drinking excessively and wanted help. In January 2013 he attended a

group work session whilst under the influence of alcohol. This information was not

shared with any other agency. The capacity issues for the Drug and Alcohol agency

meant that Stepfather had contact with a number of staff over time and this

inconsistency meant that no one person was able to reflect on the implications of

this escalation for Child A and his siblings.

2.20 The Core assessment of sibling 1 and 2 was updated by the social worker from the

assessment team in January because sibling 2 had been born. The Probation Officer

was reported to have said she remained happy with Stepfather’s engagement and

progress. A Drug Worker said that Stepfather was engaging well and had been drug

free since August 2012. This was incorrect; he had proved positive for class “A”

drugs in September, had asked for help with his drinking and had missed 9 out of

19 drug testing appointments since the end of November. The updated assessment

for siblings 1 and 2 concluded that there was a “robust plan of support for the

family”. This was clearly not the case.

2.21 In January 2013 Child A arrived at school with a burn to his foot. Mother had

recorded in the home school diary that he had burnt his foot on the radiator the

previous week. This explanation was passed to Father who later reported the same

when he took his son to hospital. The school nurse was very concerned about the

look of the injury, which was reported by her as swollen and Child A, when asked,

said that it hurt. The nurse contacted Mother and asked her to take Child A to

hospital. She in turn asked Father to take Child A and he arrived at school and Child

A was taken to the hospital. The school contacted the hospital to inform them that

Child A was coming to the accident and emergency department, and provided

information about the recent child protection enquiry. The Child Protection nurse

was called and she sought information about the family from the assessment team

social worker and not from the allocated social worker from the Disabled

Children’s team because of the confusion caused by two social workers undertaking

the Core Assessment. The outcome of the assessment was shared along with the

Family history, the conclusion from Children’s Social Care being that there were no

current concerns. Child A was medically assessed by a triage nurse who was a

specialist in burns and plastic surgery, and a registrar. It is poor practice that Child

A was not given any opportunity to communicate what had happened by any

professional involved. The outcome was that the injury was not considered

medically serious, was considered to be consistent with the explanation provided

by Mother and the delay in seeking medical attention understandable. Given the

23


lack of concerns expressed by Children’s Social Care, a safeguarding referral was

not considered necessary. A differential diagnosis of Child Maltreatment should

have been more carefully considered, and contact made directly. The confusion

about who was the allocated social worker meant that the hospital were unaware

that they had not spoken to the right person. It is inappropriate that this incident

led to no review of Child A’s circumstances. A Child in Need meeting should have

been convened by the allocated social worker (DCT) and because most of the

professionals seemed unaware of Child A’s Child In Need status, no one questioned

why this was the case.

2.22 Over the next two months the school had increasing concerns about missing and

broken equipment, small bruises and grazes and that Child A looked unkempt. The

school communicated each issue to the social worker individually, and they became

frustrated by the delayed response caused by the social worker being part time.

This frustration did not lead to any action, and the school appeared unaware of the

escalation policy in the Hertfordshire procedures. The allocated social worker

(DCT) did agree to undertake a home visit, but this was unsuccessful. This meant

that the allocated social worker (DCT) had not seen Child A or any of his family

since the Core Assessment had been completed in November 2012. Given the birth

of a new baby who need special care, a trip to hospital and issues raised by the

school, this was not appropriate.

2.23 Child A’s Mother called an ambulance in March 2013 reporting that he had had an

allergic reaction to red hair dye. He was taken to hospital, where Mother repeated

the same story. Child A was found to have a number of injuries, which were

assessed as non accidental. Child A was admitted to the hospital. Initially the

injuries seen were bruising to the face, body and buttocks. More detailed

examination revealed three fractured ribs, a possible human bite and a subdural

haematoma. Mother could provide no explanation for how these injuries had

occurred. Mother and Stepfather were arrested on suspicion of having caused, or

allowed to cause the injuries. This came as a surprise to all the professionals

involved with Child A, and was a measure of the lack of awareness of potential

safeguarding issues across the whole period under review.

24


3: The Findings

Analytic process for establishing systems findings

3.1 The aim of a Learning Together case review is to use a single case as a ‘window on

the system’, to uncover more general strengths and weaknesses in the child

protection system. A four-stage process of analysis is used to articulate how features

of the case can lead to more general systems learning. The first is to look at how the

issue manifested in the case specifics, this will often be presented as one example,

even if there are several such examples. This evidence comes from the analysis of

the reconstruction of the unfolding case, documentation and an examination of the

key practice episodes.

3.2 The second step is to consider whether the issue observed in this case is

‘underlying’. That is, that it is not a ‘quirk’ of the case, but is likely to represent

practice in other cases and by other practitioners. The third step is to consider how

geographically widespread and numerically prevalent the issue is within the system.

Sometimes it is not possible within the scope of a review to collect this data. The

sources for these steps will be information from the Review Team and Case Group,

any performance data, national research and other reviews in a variety of

combinations. In this review, it has not been possible to obtain some of the data

requested to populate these steps – this has been highlighted where relevant.

3.3 The last step is to articulate why this issue matters, what are the risks to the

safeguarding system. Based on this finding, questions and considerations for the

LSCB are formulated.

Categories of underlying patterns

3.4 The systems model that SCIE has developed includes 6 broad categories of

underlying patterns. The ordering of these in any analysis is not set in stone and

will shift according to which is felt to be most fundamental for systemic change.

Not all the typologies will have a finding associated with them but they are

designed to allow for structured enquiry as to what the data has revealed:

Human biases (cognitive and emotional):

Are there common errors of human reasoning and judgement that are not

being picked up through current case management processes?

Family-professional interaction:

What patterns are discernible in the ways that professionals are interacting

with different family members, and how do they help and or hinder good

quality work?

25


Communication & collaboration in responses to incidents:

Are there particular good or bad aspects to the patterns of how professionals

respond to specific incidents (e.g. allegations of abuse)?

Communication and collaboration in longer term work:

Were any good or bad patterns identified about ways of working over a longer

period with children and families?

Tools:

What has been learnt about the tools and their use by professionals?

Management system:

Are any elements of management systems a routine cause for concern in any

particular ways?

3.5 This review has prioritised 7 findings for the Board to consider:

Finding Category

Finding 1: A failure to use expertise within the

professional network as to how children with

different or complex communication needs

express themselves, leads to the child’s voice

not being heard.

Communication and

Collaboration in

response to incidents.

Finding 2: There is multi-agency confusion in

Hertfordshire about the child in need processes

for disabled children leaving them without

effective outcome focussed plans and

multiagency reviews.

Communication and

Collaboration in longer

term work.

Finding 3: There is a Professional unwillingness

to label the early signs of poor quality care

provided to disabled children as Neglect leaving

those children’s needs unaddressed.

Communication and


term work.

Finding 4: A parent or carer not taking a child to

health appointments, particularly where the

child is additionally vulnerable, should be an

indicator that the child may be at risk resulting

in proactive follow up.

Family-Professional

interaction.

26


Finding 5: There is a pattern of uncritical

acceptance of parental self report by

professionals in all agencies which leaves

children’s needs and circumstances unassessed.

Family-Professional

interaction.

Finding 6: The meaning given by one agency to

a phrase about a client does not necessarily

have the same meaning for all agencies

meaning that risk may be wrongly assessed by

others.

Communication and


term work.

Finding 7. There is a pattern whereby non-

resident Fathers are routinely excluded from

assessments and decision making about their

children.

Family-Professional

interaction.

Finding 1: A failure to obtain an understanding as to how children with different or

complex communication needs express themselves and communicate, from those

with the expertise, leads to the child’s voice not being heard.

How did it manifest in this case?

3.6 Through the period under review it is striking how few opportunities were

provided to Child A to communicate with professionals about his own needs and

circumstances.

3.7 The exception was the professionals at the school who were very skilled at

communicating with him, but were never asked by any other professionals to help

or discuss his communication needs. During the core assessment, Child A was

visited by his social worker at school and she observed his behaviour in class.

There is no evidence that she discussed with school the best way to communicate

with him about the purpose of the assessment, or to seek his views to include in the

assessment.

3.8 One example of this was when in January 2013 the Learning Support Assistant from

Child A’s class asked the school nurses to check his foot as Mother had recorded in

the school diary that Child A had burnt his foot on the radiator. Mother said that he

had been lying on the bed watching a DVD and she heard him scream. She realised

the radiator had been on but she did not know how long the foot had been against

the radiator.

3.9 The school nurse looked at Child A’s foot and recorded in detail what she saw

because she was concerned that it looked swollen and inflamed. She asked Child A

27


about the injury and he said that it hurt. . The school asked Mother to take Child A

to the hospital Accident and Emergency. This was arranged and in fact Father

provided the transport and arrived ahead of Mother. No member of staff from the

school went to the hospital with Child A.

3.10 The school nurse telephoned the Child Protection (CP) Nurse at the hospital. She

provided information about the injury, that there had been previous child

protection concerns, but did not discuss Child A’s communication needs or that he

had a communication passport in the pocket of his wheelchair.

3.11 The CP nurse was aware of Child A’s disability, and she spoke to Mother and Father.

One of them explained that Mother had found the child with his foot stuck between

his bed and radiator after he screamed. Mother said that it had not looked too bad

and had been cleaned and covered at the time.

3.12 The CP nurse spoke to the social worker from the assessment team who had

recently undertaken the assessment of Child A’s siblings. She provided information

about the new baby who she said had been in special care until recently,

Stepfathers previous drug use and recent conviction for endangering a child. This

social worker had no direct responsibility for Child A and would not be able to

provide a clear picture of his individual needs.

3.13 The Accident and Emergency Doctor saw Child A and was given the same history

from Mother. He examined the wound, a burn on the foot reported as 7 days old. He

dressed the wound, prescribed antibiotics and discharged for GP follow up. He

made no attempt to communicate with Child A or seek help to ensure that someone

else could do so on his behalf.

What makes this an underlying pattern rather than a one off incident in this

particular case?

3.14 The repeated occasions on which Child A’s communication needs were not

explored, suggest that this a common element of practice, rather than a one-off. For

example, when Child A was admitted to hospital as a result of the injuries he

received in March 2013 there was no discussion about how Child A could

communicate what had happened to him until the Police questioned whether an

ABE interview with Child A, would be possible. This was not considered to be a

viable option.

3.15 The nurses and Doctor who treated Child A’s burn injury acknowledged that no

attempt was made to communicate directly with him or to establish if this could

have been achievable. The Hospital Doctor said in conversation that there would be

an attempt to obtain an independent history from a child over eight if they spoke a

28


language other than English but there was no system in place to assist in speaking

to children with a disability.

3.16 The review team and case group provided information that this was not an issue

unique to this case.

How widespread is the pattern

3.17 There is nothing to suggest the pattern in Hertfordshire is any different to the

national picture. The Ofsted report “The Voice of the Child: Learning lessons from

serious Case Reviews”ii examined 67 serious case reviews involving 93 children.

This report notes that: “Serious case reviews involving disabled children

commented on the importance of practitioners using appropriate means of

communication.”

How prevalent is the issue?

3.18 Local data was provided by speech and language therapists in Hertfordshire being

asked.

A) How many of the pupils on your caseload would need help or an interpreter to

facilitate communication?

Answer: 228

B) How many would benefit from being provided with symbols in A and E?

Answer: 171

C) How many have communication passports?

Answer: 38

Responses came from 19 placements. There are a number of other issues which

need to be taken into account but this data gives a good sense of the number of

children who have different and complex communication needs.

3.19 From the literature this can be seen to be a national issue. This issues manifests in

both the child protection system and in criminal justice. Stalker et al in “Child

protection and the needs and rights of disabled children and young people: A

scoping studyiii”, reported that disabled children were less likely than other

children to be seen as credible witnesses, fewer cases involving disabled children

went to court and courts sometimes failed to meet disabled children’s needs, with

insufficient use of video recording and intermediaries. This is despite research

clearly indicating that children with learning disabilities can provide forensically

relevant information if appropriate methods are employed (Aarons N M, Powell M

B. 2003)iv.

29


Why does it matter?

3.20 Ascertaining how a child communicates and what they are “saying” is key to

safeguarding them whatever their level of difficulty and the Report of the National

Working Group on Child Protection and Disability (NSPCC in association with The

National Working Group on Child Protection and Disability 2003v), makes clear that

practitioners need to ensure their definitions of communication are inclusive and

not discriminatory. Practitioners must plan for and ensure effective communication

with an approach adapted to suit the individual child.

3.21 The Children Act 1989 places a duty on local authorities to ascertain the wishes and

feelings of a child before making any decisions concerning him or her and to give

due consideration to those wishes. The Children Act 2004 (Part 5 section 53)

amended The Children Act 1989 and placed a new duty on local authorities to

ascertain a child's wishes and feelings and give due consideration to them, (with

regard to age and understanding). This must be done in relation to assessments of

children in need under section 17 and in relation to child protection investigations

under section 47 of The Children Act 1989.

3.22 Just because a child does not use oral language it does not mean they have nothing

to say. It has become more straightforward to work with children and young people

who do not have English as a first language; it is much more complex to be able to

provide the wide range of communication aids that are tailored to individuals with

a whole range of needs

3.23 Some children and young people with cognitive difficulties or learning disabilities

may have a limited use of language, both in terms of what they understand and

what they can communicate to others. They may communicate using objects, signs

or symbols through systems such as Makaton and Picture Exchange

Communication System (PECS) an understood ’formal code’ A small number of

children and young people, such as those with multiple difficulties do not

communicate using a shared and agreed system, they communicate using a system

that is individual to them such as using gestures, non-verbal body language,

vocalisation or sounds and changes in mood and routine.

3.24 The voice of the child is a familiar theme for professionals working with children;

this voice should be heard from all children regardless of the communication

method. It is for professionals to make enquiry as to how they might best attempt

communication, familiarise themselves with a communication passport or establish

if there is another professional who is able to communicate with the child or

advocate on their behalf.

30


Finding 1: A failure to obtain an understanding as to how children with different or

complex communication needs express themselves and communicate, from those

with the expertise, leads to the child’s voice not being heard.

Ascertaining how a child communicates and what they are “saying” is key to safeguarding

them. Practitioners must plan for and ensure effective communication with an approach

adapted to suit the individual child, drawing on the skills of others in the professional

network as appropriate.

Does the Board recognise this as an issue?

Given the National prevalence of this as an issue in past Serious Case Reviews is

there a pool of good practice that could be drawn upon?

Is there an opportunity to learn from practices used within the adult disability

teams and Speech and Language Service to assist in better communication with

children?

Is the Multi-agency network sufficiently aware of the use and meaning of

“communication passports”?

Speech and Language Service reported to the review that they were training more

people and raising awareness. Was the board aware of this change and how might

the Board support this work?

How might the Board monitor the impact and progress of action taken?

Finding 2: There is multi-agency confusion in Hertfordshire about the child in need

processes for disabled children leaving them without effective outcome focussed

plans and multiagency reviews.


3.25 Child A was known to the Disabled Children Team from birth as a child in need.

The Hertfordshire procedures make clear that for every child in need there should

be a child in need plan in place, a working agreement drawn up with parents,

regular child in need multi-agency meetings and reviews. There are also clear

guidelines for how often children in need should be visited by their social worker.

For disabled children the procedures make a distinction between those disabled

children who are children in need, but require package of support services in the

long term to ensure their well being, and those disabled children who are children

in need because of their family circumstances, who are also known as complex child

in need cases. Those needing services will be allocated to a professional assistant

31


rather than a qualified social worker, and their package of support should be

reviewed twice yearly.

3.26 During the period under review there was no evidence that there was a child in

need plan with outcomes and services associated with it for Child A. There were no

child in need reviews, and therefore there was no opportunity to consider the

significant changes in Child A’s circumstances or the concerns raised by school.

3.27 In March 2012 Child A’s Mother was arrested for assault whilst drunk, and he was

left in the care of Stepfather, someone whom the services knew little about. He was

made subject to a child protection enquiry in October 2012, but this led to no plan

or review. When he was found to have a burn to his foot, concerns were expressed

initially about how this had happened, and whether Mother had sought medical

help quickly enough. The hospital decided that the injury was consistent with the

explanation provided, and there were no safeguarding concerns. However, this

should have been considered in the context of the child in need process.

3.28 Over the period of the review Child A was only seen sporadically and there were no

visits to school or home to see him from November 2012 to March 2013. This was a

period when the school became increasingly concerned about small injuries

without explanation, missing equipment and Child A looking unkempt, something

school communicated to the social worker, but without being clear what they

wanted to happen next.

3.29 At this time Mother also had a baby, born prematurely in December 2012 and who

stayed in special care for a period of time.

3.30 The absence of any multi-agency child in need meetings meant that this

information was not connected together, and the needs of Child A were lost as a

result.


particular case?

3.31 There were no child in need processes across the whole review period. There was

no evidence that this absence was discussed within social work supervision.

Conversations with the review team and case group also suggested that child in

need processes for disabled children are not well embedded in the multiagency

network because no one agency was clear about whether there should have been

“child in need” meetings, reviews or plans or sought to explore why child in need

processes were not taking place.

32


How widespread and prevalent is the pattern?

3.32 It has not been possible to establish how widespread or prevalent a pattern it is in

Hertfordshire. The absence of “child in need” meetings, effective outcome focussed

plans and reviews were highlighted as a national issue in the Ofsted thematic

inspection of the protection of disabled children. The confusion about who should

ensure that all services for disabled children are coordinated across the multi-

agency network has been highlighted by Every Disabled Child Matters review of

Key Working processesvi and is part of the Government proposals “Support and

aspiration: A new approach to special educational needs and disability”vii where

the importance of clear key working arrangements for disabled children is

highlighted as of critical importance to their wellbeing in the long term.

Why does it matter?

3.33 The child in need process is a critical factor in ensuring the wellbeing and outcomes

of vulnerable children and young people, and the Children Act 1989 made clear that

Disabled Children (in the context of the local authorities definition of disability)

would automatically be considered as children in need, because of the importance

of services to promote their positive wellbeing and outcomes.

3.34 The critical issue here is determining what the needs of a disabled child are. Good

quality assessment is crucial. For some children the outcome of the assessment will

be services focussed specifically around the nature of their disability and for others

it will be needs arising from both their disability and family circumstances, much

like any other child in need. It is therefore important that there is a clear plan in

place. The purpose of this is to set a plan of action, based on the assessed need. This

makes clear to young people how the Local Authority plans to support them and

ensures that parent’s/carers know what is required of them to promote their

children’s outcomes. It also creates the framework for multi-agency work. The

ultimate aim is to improve children’s outcomes and so the review mechanism is an

essential part of the process. This enables progress to be marked, and services

provision to be amended if necessary.

Finding 2: There is multi-agency confusion in Hertfordshire about the child in need

processes for disabled children leaving them without effective outcome focussed

plans and multiagency reviews.

“Life chances for the approximately two million children in England identified with SEN or

who are disabled are disproportionately poor”. Department of Education 2011viii

Effective outcome focussed child in need plans, which are regularly reviewed, in a multi-

agency context and where necessary revised in the light of changing circumstances are

33


essential to ensure positive outcomes for disabled children. The child in need processes for

non-disabled children are clear, but for disabled children in Hertfordshire there are

different pathways depending on their family circumstances. It is essential that all

professionals are clear about what the “child in need “status means and the multi-agency

network are aware of what should be expected for disabled children and their families.

Does the Board recognise that this is an importance issue for disabled children and

their families?

Are the Board aware that there is potential for agencies to have a misunderstanding

of when Child in Need processes should be applied for disabled children and their

families?

Is there more the Board members could do to establish the extent of this issue, e.g.

case audit?

What can the Board do to address the confusion identified in this review?

How will the Board know that the partnership have been successful in ensuring that

Child in Need processes is embedded in multi-agency practice?

Finding 3: There is a Professional unwillingness to label the early signs of poor

quality care provided to disabled children as Neglect leaving those children’s needs

unaddressed


3.35 Child A is dependent on a range of equipment to help him hear and communicate.

This equipment is vital to enable him to take part in family life and engage

effectively with education and other activities. There were concerns over a long

period of time about Child A arriving at school with broken or missing equipment,

or reports that the equipment was not being used at home. This meant that in

effect, Child A could not hear and could not communicate. There were additional

concerns about his wheelchair and missing wheelchair appointments.

3.36 The school addressed this directly with Mother, and in the short term some aspects

of this changed. In the longer term this remained a “persistent” problem. These

concerns were communicated to the disabled children team social worker over

time as each individual concern was raised, but without any analysis of what the

issues might mean for child A or without the school communicating that it was

concerned that his needs were not being effectively met and this might be the early

signs of neglect.

3.37 These concerns were also raised as part of the Child Protection Core Assessment

that was undertaken in September 2012 but they were not sufficiently analysed in

34


the context of Child A’s individual needs. There was no clear plan developed as part

of the conclusion of the assessment and the absence of any multi-agency meeting

meant that they were dealt with incident by incident, rather than being seen

collectively as early evidence of neglect, which required a proactive response.

3.38 Child A also appeared at school with a number of small injuries which were

unexplained and in January he was seen at school with a burn. Mother was not

always entirely clear about how these injuries were caused, but they were not

named as part of a wider pattern of neglectful care.


particular case?

3.39 The case group told the Review team that there was a reluctance to label concerns

about the quality of care received by disabled children as neglect in the early

stages, partly because of concerns about having sufficient evidence to do so, and

partly because they were aware of the pressures on parents and families. There

was concern that labelling early difficulties as neglectful might be unfair on parents

and not be respectful of the additional challenges facing families as they saw it. The

case group said that they were not unwilling to address the difficulties, just

unwilling to label concerns of neglect at an early stage. This is also recognised as a

national concernix.


3.40 It has not been possible to establish the number of disabled children in

Hertfordshire about whom there are early concerns about neglectful care.

Nationally research shows that disabled children are more likely to be neglected

but less likely to be assesses or recognised as being neglected.

Why does it matter?

3.41 Childhood neglect is a significant issue which has the potential, to damage

children’s well-being and developmental outcomes in the short and long

term. Recent research suggests that early identification and early help is essential

to prevent the development of chronic neglect. The paradox is that researchx

suggests those professionals are often reluctance to name “neglect” in these early

stages.

3.42 Disabled children are more likely than non disabled children to be neglected and

children with communication and sensory impairments are particularly vulnerable.

A recent thematic review by Ofsted suggests that although disabled children are

more likely to be abused, they are less likely to be subject to safeguarding processes

35


and that professionals are reluctant to identify disabled children as experiencing

neglect.

3.43 The work of Wonnacott and Kennedy (2012)xi suggest that professionals can adopt

an approach whereby they feel sorry for parents because of the perceived burden

of caring for a disabled child. Parents can be seen as struggling to meet the needs of

a disabled child because the disability places pressures which cause

understandable stress, which accounts for the poor quality of care seen. This can

lead to inappropriate professional practice which accepts a poor standard of

parental care for disabled children and which does not focus on parental attitude to

children’s needs in the context of their disability.

Finding 3: There is a Professional unwillingness to label the early signs of poor

quality care provided to disabled children as Neglect leaving those children’s needs

unaddressed

Disabled children are less likely to achieve as much in a range of areas as their non-disabled

peers. Improving their outcomes..... will help them to achieve more as individuals. It will also

reduce social inequality, and allow communities to benefit from the contribution that disabled

children and their families can make, harnessing their talent and fostering tolerance and

understanding of diversity. Aiming High for Disabled Childrenxii.

Disabled children are more likely to be neglected than non disabled children and neglect

has a profound impact on the outcomes for all children. The recognition of neglectful care

at an early stage is essential, so that plans can be put proactively in place to promote

disabled children positive outcomes and for lack of progress to be noted and addressed.

Do the Board recognise that this is an important issue?

What has been the impact of work previously done to address this issue?

Is the Board aware of specialist assessment tools and frameworks that could aid

professional practice in this area?

What other strategies could the Board adopt to encourage all professionals to be

proactive in recognising and addressing early neglect for disabled children?

How will the Board know that the partnership has been successful in addressing

this issue?

Finding 4: A parent or carer not taking a child to health appointments, particularly

where the child is additionally vulnerable, should be an indicator that the child may

be at risk which should result in proactive follow up


36


3.45 Child A is a wheelchair user. In October 2011 the Occupational Therapy services

was contacted by the wheelchair services regarding a missed appointment. When

asked at school about this, Mother said she had not received a letter and was not

sure if they held her new address. School suggested she contact the service

regarding this and to make a new appointment. It is unclear if this happened, but

later that month Mother told the school via a note in the diary that Child A’s wheel

chair had tipped over and Child A had hurt his face. School again advised Mother to

contact wheelchair services. There was no response for three days from Mother.

3.46 The Wheelchair services analysed the records and reported to the review along

with a chronology of events. The records indicate that during 2011 there were

several appointments and that letters were sent to parents, the appointments were

subsequently not attended. The letters sent to parents as a result of the DNA were

vague in that they did not offer another appointment but advised that if they had

reasons of ill health then they would hold a place on the waiting list and reschedule.

The policy was that if the child did not attend 2 appointments then they were

removed from the list. Subsequently it also came to light that two of these

appointments were sent to the wrong address. The net result was that Child A was

discharged from the wheelchair services in July 2012 because Mother had not been

in touch.

3.47 The next appointment sent to new address however was also not attended and

there continued to be a delay because of re-scheduling of appointments. In the

interim however Child A was regularly seen at school by the Occupational

Therapist (OT) whom the wheelchair service maintained contact. The OT advised

that under normal circumstances the client would have an annual assessment so it

does not appear that there was felt to be any urgency in assessing him.

3.48 The first recorded assessment therefore was in January 2012 a year after the first

recorded request. Although the chair itself was assessed by the wheelchair service

at school following a referral from the OT because it was noted to be tipping and

was subsequently checked for safety and stability. A new prescription was finalised

in March 2013.

3.49 Thereafter maternal access to the service became regular and there was continuity

of care because Child A was seen by the same core of therapists. There were several

face to face assessments so he was monitored for the impact of growth on his

wheelchair usage. Concerns that he may have outgrown the chair were unfounded

and in part due to poor positioning. Repairs were undertaken in a timely way.


particular case?

37


3.50 Records confirm that efforts made by the service to make contact via other

professionals (OT) and in writing. These additional efforts recognised the need for

attendance but still resulted in discharge in accordance with the policy. Given the

overall family context in which this was happening a more proactive investigation

may have been warranted.

3.51 There was some discussion amongst the case group professionals that such “was

not taken” events are treated differently by different agencies and that there was

no uniform approach, so for example non- attendance at a speech and language

session would lead to a more proactive investigation as to the reason for missing

the appointment than was the case with the wheelchair services. There was

recognition that this was an issue and that there should be a uniform approach.

How widespread is the pattern

3.52 This has been and remains a National issue, a recent paper by Catherine Powell and

Jane Appletonxiii (2012) discusses the notion that missed healthcare appointments

by children and young people should be reconceptualised as “was not brought”. It is

noted that this is not a new concept citing a number of early publications which

allude to this same issue.


3.53 In discussion with the review team the heath representative suggested that the

data would be available for each service but not across the diversity of services

provided, it was also the case that this data would not show if the person in

question also had additional vulnerability or emergent concerns. This picture is

reflected nationally.

3.54 Across the whole population and health economy this is a very big issue. It is

estimated that missed appointments have a financial cost of around £700 million

(BBC report March 2012xiv) with up to six million appointment slots wasted. In

many cases this is simply adults forgetting to attend their own appointments.

3.55 It is the case that Powell and Appletonxv note that more work needs to be done to

determine the missed appointment rates for the whole child population as well as

in cases where there maybe emergent concerns.

Why does it matter?

3.56 The issue of non attendance or “DNA” at medical appointments is a significant

national issue and much work has been undertaken to understand and reduce the

level of non attendance. However, there remains a routine response by providers

38


when individuals fail to attend for health appointments. The current national

approach is that if two appointments (occasionally three) are failed, the patient is

discharged from care and referred back to their GP.

3.57 There is little recognition within this policy of the vulnerability of children and

young people. For children and young people access to health care is a fundamental

right (UN Convention on the rights of the child) yet they are often dependant on

parents and carers to ensure they have access to this. It has also been recognised

that the failure of parents/ cares to ensure that their children attend health

appointments is connected to issues of child neglect and emerges as a significant

issue in serious case reviews. Children and young people’s right to health care is an

issue which the current “DNA” policy does not address.

3.58 Missed appointments are a prominent feature in previous serious case reviews.

Thinking about missed appointments in the terms of “was not taken” encourages

child focused practice. Failing to ensure a child’s access to health care is within the

statutory definition of neglect.

3.59 In the 2008 study by Rose and Barnesxvi of a selection of 40 serious case reviews

Critical incidents such as missed appointments were often noted, but there was a

failure to be proactive in following this up or seeing it in the context of what else

was happening for the child and family. Neglect was noted to be a significant feature

in the cases, alongside parental substance misuse and adult mental health

difficulties. Several of the children had outstanding health needs due to disability,

chronic health problems and/or being born pre-term.

3.60 The National Institute for Health and Clinical Excellence Guidance (2009) When to

suspect child maltreatment.xvii Says that professionals should ‘consider neglect if

parents or carers repeatedly fail to attend essential follow-up appointments that are

necessary for their child’s health and well-being.’

3.61 There does not seem to be consistency across different services or areas and

perhaps in response to previous review findings some areas have policy regarding

Children and Young Person “DNA”. East London NHS has a current policyxviii which

in summary states:

“The staff member has an individual professional responsibility to respond to failure

to attend an appointment in a manner based on an assessment of the service user’s

risk and need status.”…

“In accordance with the Trust policy discharge from care should only occur

after careful consideration and in the context of safeguarding and child

protection concerns.”

39


Finding 4: A parent or carer not taking a child to health appointments, particularly

where the child is additionally vulnerable, should be an indicator that the child

maybe at risk resulting in proactive follow up

Missed appointments have been a prominent feature in previous serious case reviews.

Changing the terminology from Did Not Attend (DNA) to Was Not Brought (WNB),

alongside raising professional awareness of the implications for children and young people.

encourages child focused practice

Failing to ensure a child has access to health care is within the statutory definition of

neglect.

Has the Board responded to this issue previously following a Review?

Does the Board have access to data which would inform the prevalence of the issue?

Does existing policy in this regard take sufficient account of the needs of children

and vulnerable people to be taken to appointments?

Do all those working with children have a consistent proactive approach to

following up missed appointments?

Could the Board adopt policy and procedures being used elsewhere that would

assist in encouraging a child focus to missed appointments across all services?

Finding 5: There is a pattern of uncritical acceptance of parental self report by

professionals in all agencies which leaves Childrens needs and circumstances

unassessed

3.62 Partnership practice with parents is important where there are concerns about

children’s welfare. Munroxixin her review of the child protection system highlighted

the importance of developing effective relationships with parents, to achieve better

outcomes for children. The concept of partnership practice has recently been

defined as “Authoritative Practice” where professionals treat parents/carers with

respect and empathy, but are also clear about appropriate and positive challenge.xx


3.63 Two Core Assessments were carried out as part of the Child Protection response to

concerns about Stepfather’s history of violence, drug and alcohol problems and his

conviction for endangering his own child. On both occasions, parental self report

about incidents and behaviour were accepted without critique.

3.64 For example, Stepfather was asked about the incident which had led to the current

assessment. He was reported to the police for being drunk and driving on the road

40


on a motorcycle with sibling 1 on the handlebars. Stepfather said that “he had one

beer” although the information provided as part of the Child Abuse Investigation

Unit referral (CAIU) said that he was twice over the legal limit for driving. This

minimisation of what were serious concerns about alcohol use and the impact on

Stepfather’s behaviour was accepted without comment. He was said to be

remorseful, and to have learnt his lesson. This does not chime with the “no

comment” interview he provided to the police, or his being found positive for using

cocaine two and a half weeks later.

3.65 Mother told the assessing social worker that she had not been present when

Stepfather had left the house with sibling 1, and that she had been angry with him

for putting sibling 1 at risk. In fact the referral from the Joint Child Protection

Investigation Team made clear that Mother was present had been hostile and

aggressive when the police had called at the house regarding this incident, and this

was something they were concerned about.

3.66 The level of self report was not recognised within the assessment and the

conclusion was that Mother and Stepfather had been fully cooperative and this

cooperation and apparent openness influenced outcome of the assessment.


particular case?

3.67 The case group told the review team that a reliance on parental self report was a

key issue in their work. They told us that giving parents a voice in records and

assessments was important, but they reflected that this might lead to a lack of

healthy scepticism and respectful uncertainty (Laming 2003xxi).

How common and widespread is this?

3.68 It is unclear how common and widespread this issue is as no data is collected about

the extent of parental self report and its influence on decision making. This is a not

an issue which is part of current auditing practice.

Why is it important?

3.69 Assessments are the cornerstone to effective practice with children, young people

and their families. The forward to the practice guidance regarding the assessment

framework makes clear

“we cannot begin to improve the lives of disadvantaged and vulnerable children

unless we identify their needs and understand what is happening to in order to take

appropriate action”xxii.

41


3.70 Research shows that good assessments matter, they help to improve planning and

are linked to positive outcomes for children and young people.

3.71 The assessment framework is the national tool used to identify whether children

are in need of services or in need of safeguarding. It was developed to provide a

systematic way of analysing, understanding and recording what is happening to

children and young people within their families and the wider context of the

community in which they live. The specific process for undertaking assessments

where there are safeguarding concerns is the Core Assessment which is defined as

“as an in-depth assessment which addresses the central or most important aspects of

the needs of a child and the capacity of his or her parents or caregivers to respond

appropriately to these needs within the wider family and community contextxxiii”

3.72 The Assessment framework emphasises the importance of the assessing social

worker accessing information from a range of sources, the child themselves, the

parents and extended family as well the multi-agency group. The expectation is,

however that it is the assessing social worker who makes a professional judgement

about the meaning of the different information in the context of the needs of the

child or young person.

“Working with family members is not an end in itself; the objective must always

be to safeguard and promote the welfare of the child. The child, therefore, must be

kept in focus”xxiv”

3.73 Partnership practice with parents and building relationships is an important part of

the assessment process, as parents are often experts in their child’s life. However, it

is critical that professionals maintain a level of healthy scepticism and respectful

uncertainty (Laming 2003xxv). There should be an active process of triangulating

the information from different sources, and establishing ether there are

discrepancies and what those discrepancies might mean for the child.

Finding 5: There is a pattern of uncritical acceptance of parental self report by

professionals in all agencies which leaves children needs and circumstances

unassessed.

It is much safer for children, young people and their families if challenge of what is

reported by parents is built into processes such as supervision and decision making, but

also into cultural expectations which recognise that asking questions and seeking

explanation from parents is something to be valued. A high reliance by professionals on

self- report by parents brings with it significant risks of proceeding on false information.

Arrangements put in place to recognise when there is insufficient challenge, and to increase

the value given to challenge, are in the interests of families and professionals. Such

arrangements can include ensuring time for in depth supervision, ensuring an independent

42


uninvolved voice at key decision making meetings, managers modelling that challenge is

acceptable, and showing how it can be done in a constructive way so that workers have

more confidence in challenging parents.

Is there a collective view at the LSCB about the prevalence of this issue and the scale

of change needed around challenge with families?

Is enough known about the perspectives of the workforce on this issue? Is there a

view that to challenge parents is to be judgemental?

How could the LSCB promote a culture where professionals are supported to be

challenging when necessary?

Is there clarity about when assessments can and should be shared with multi-

agency colleagues?

Finding 6: The meaning given by one agency to a phrase about a client does not

necessarily have the same meaning for all agencies meaning that risk may be

wrongly assessed by others.


3.74 In August 2012 the new drug agency for Stepfather became aware that he had a

partner who was pregnant with their child and that there were two other children

in the family. Stepfather also told them that he had two other children by two

different partners, one who was in care and one he had no contact with. The drug

agency appropriately made a referral to Children’s social care because of

Stepfather’s long history of offending, violence, drug and alcohol problems.

Stepfather’s probation officer also became aware that he had children by three

different partners, and also made a referral to Children’s social care because of his

history of violence and class A drug use.

3.75 A core assessment was agreed but did not start until October 2012 when Stepfather

had been charged with endangering a child and driving whilst under the influence

of alcohol. A strategy discussion led to agreement that a core assessment would be

undertaken regarding Child A, sibling 1 and unborn sibling.

3.76 Information was sought from probation and they provided a clear outline of

Stepfathers offending history. Probation reported that they were pleased with

Stepfather’s progress, and that he had engaged well with all that was required of

him. The view from Probation related to their own reporting requirements and in

the context of other offenders. It was not a view about whether he could

successfully parent, meaning that he could manage his own alcohol and drug

problems, in the context of caring for children. Something he had recently failed to

do.

43


3.77 The Drug agency also provided information about Stepfather’s long history of drug

and alcohol problems. They also reported that they were pleased with Stepfather’s

level of engagement and that had complied with the testing requirements. He had

tested positive for opiates in August, but had been clean since and would be

reducing his methadone prescription. The positive progress reported was in the

context of adults who misuse drugs and alcohol, and in that context Stepfather was

doing reasonably well.

3.78 The positive view from Probation and the Drug agency led to a mistaken belief that

Stepfather was making progress, and that his long term difficulties were behind

him. Neither Probation or the drug agency were asked about the implications for

the future, or the implications of his long history of violence and drug and alcohol

abuse on his ability to be an effective parent. The core assessment analysis was not

shared with either agency, and they did not ask to see it. This meant there was no

opportunity to reflect on the overly positive analysis that Stepfather had made

progress which meant that there were no concerns.


particular case?

3.79 The case group recognised that there is often misunderstandings or confusion

about what information is required from agencies focussed on adult issues, in the

context of children’s needs. It is clear in this case that although the Drug agency and

Probation felt positive about an adult’s progress, this was not a reflection on how

they were likely to be in another context or whether this meant they posed no risk

to children.


3.80 It is unclear how widespread a problem this is, but the case group told the review

team that this was something they encountered on a regular basis. This is also an

issue seen nationally across a number of serious case reviewsxxvi.

Why does it matter?

3.81 Parental drug, alcohol, offending and violent behaviour all have the potential to

impact negatively on children’s lives. It is clear from research and serious case

reviews that all of these adults concerns have the potential individually to cause

risks to children’s lives and wellbeing, but collectively the coexistence of serious

drug and alcohol problems, violence and offending behaviour with concerns about

adult mental health, known as the “toxic trio” are known to be a serious risk factor.

44


Finding 6: The meaning given by one agency to a phrase about a client does not

necessarily have the same meaning for all agencies meaning that risk may be

wrongly assessed by others.

Good quality assessments of children rely on effective information about the risks and

strengths that the adults in their lives pose. It is important to be clear with all agencies the

purpose of assessments, and to be clear what information is needed to assess that risk. One

agencies “positive progress” cannot be automatically translated into a more generalised

belief that this progress relates to another context.

Are the Board aware of this as an important issue?

Have the Board done any work on this previously in relation to other serious case

reviews?

Are the Board aware whether professionals providing services to adults are aware

of the purpose of assessment of children and young people and what information

they should be providing?

Are the Board aware of whether professionals understand the importance of

sharing assessments where there is an ongoing role for that agency?

How will the Board know it has made progress in this area?

Finding 7: There is a pattern in Hertfordshire whereby non-resident Fathers may be

excluded from assessments and decision making about their children.


3.82 Child A’s birth Father was seen by the lead reviewer as part of the review process.

It was a brief meeting as he had no involvement with professionals during the

period of the review. He was aware that his existence and role in his son’s life was

known of by children’s social care and the school. The assessments record that he

had contact with Child A’s, however the school believed that he was not part of the

child’s life and until the trigger incident had no knowledge that Father regularly

had Child A to stay, and as a result this part of his life was absent from his

communication book. Both were clear that Child A’s birth Father did not have

parental responsibility. Since the commencement of other proceedings Father has

obtained Parental Responsibility.

3.83 The extent of his involvement according to Mother is recorded within assessments.

There is no evidence that he was contacted or consulted at any time nor was his

home assessed for suitability for contact which was frequently overnight. He was

and had been throughout the child A’s life a financial contributor, supported

Mother and Child A by assisting with transport on some occasions and had planned

45


regular contact. There is a difference between the amount of contact reported by

Mother as part of an assessment and that reported by Father to the reviewer.

However whatever the precise truth he was having care of his son overnight at

least once a month, probably more, and contact of at least one day most weekends.

3.84 There was no record of social workers attempting to contact Father and an

expressed belief that this was not possible due to the fact that he did not have

parental responsibility. In review meetings this seemed to be a major factor in the

decision not to involve him or speak to him, but of course the Stepfather who also

did not have parental responsibility was spoken to. Not having parental

responsibility limits the decisions Fathers can make on behalf of their children.

3.85 The difference in how these two men were treated and viewed is difficult to

understand. Aside from the matter of parental responsibility being a barrier to

speaking to Father it could be that his absence from the home and life of Mother

together with the fact that he was not readily accessible to professionals also

influenced his lack of involvement in assessments.

3.86 Early in Child A’s school career Father had some information shared but as he did

not have parental responsibility this stopped at Mothers request. There was an

assumption that Father played no other role in the Child A’s life until the trigger

incident when it was realised by the school that he was still a significant part of

Child A’s life.

How do you know it is an underlying pattern?

3.87 The case group recognised that it is common for Fathers to be marginalised,

particularly when there are concerns about them. Research and serious case

reviews support that this is an underlying pattern nationally.

How widespread is the pattern?

3.88 This is a national issue and was one recognised by the review team as being present

in Hertfordshire.


3.89 No numbers relating to the prevalence of this issue within Hertfordshire have been

adduced however nationally the role of Fathers continues to surface as an issue in

serious case reviews and within research.

46


Why does it matter?

3.90 The parenting tasks undertaken by fathers or father figures should be addressed

alongside those of mothers or mother figures. In some families, a single parent may

be performing most or all of the parenting tasks. In others, there may be a number

of important caregivers in a child’s life, each playing a different part which may

have positive or negative consequences

3.91 The Children Act 1989 and the Human Rights Act 1998 makes clear that fathers

must be involved in decision making, planning and services regarding their

children. Fathers have a significant role to play in children’s lives and in Lord

Laming’s 2009 review of the child protection system he said "Particular mention

should be made of the part to be played by fathers, not least as good role

modelsxxvii”. There is also significant evidence that men are often not included in

maternity care, services to support families and where children are subject to child

protection processes (Featherstone, B et al 2010xxviii). Scourfield’s research

suggests that practitioners’ perceptions of men in child protection work was as

either threat, no use, irrelevant or absent (Scourfield 2001xxix, 2006xxx).

3.92 The basic rule about working with Fathers of children, who are receiving services

concerning their safety and well-being from the local authority children’s services,

is that they should be consulted and involved in all planning and decision-making

processes, irrespective of whether or not they have parental responsibility. This

can be problematic if the Mother does not agree to his involvement. Clearly she can

prevent it by withholding the name and address. However, the local authority

should endeavour to work with her to assist her to consider the potential impact,

including the benefits to the child of having his/her Father involved in the planning

process. (Featherstone B et al 2010xxxi)

3.94 The Government launched its Fathers Matter campaign in 2008, and they have

since launched a best practice framework to help agencies and LSCB develop

effective practice.

Finding 7:There is a pattern in Hertfordshire whereby non-resident Fathers may be

excluded from assessments and decision making about their children.

Fathers of Children who are receiving services concerning their safety and well-being from

any agency should be consulted and involved in all planning and decision-making

processes, irrespective of whether or not they have parental responsibility. The parenting

tasks undertaken by fathers or father figures should be addressed alongside those of

mothers or mother figures. This case has suggested that this does not always occur,

particularly when fathers do not have parental responsibility, or are not present in the

47


family home.

Does the Board recognise this as an issue?

Does the Board ask member agencies to monitor the attendance of Fathers at

meetings or know of any blockers to making the invitation or to attendance?

Are policy and procedures clear around what not having parental responsibility

means in terms of decision making as distinct from involvement in assessments and

meetings?

How will the Board know that Fathers and Father figures are integrated into

assessment process at all levels of intervention?

4: Additional matters.

4.1 The Hertfordshire serious case review sub group raised some additional matters

which they wished to bring to the attention of the LSCB. These were not considered

in detail with the case group and review team. There is no evidence as to how

widespread or prevalent the issue is and they maybe case specific. These matters

are not presented in the learning together “anatomy of a finding” format.

Escalation process

4.2 There were occasions when the school raised concerns with other agencies,

particularly with social care. They were not always satisfied with the response they

received. However there is no evidence that this dissatisfaction was at anytime

escalated by use of existing policy and procedure. It is not clear why this would be

and as stated above this issue was not explored with the review team and case

group.

4.3 Such policy is formulated and agreed when there are no issues and are intended to

provide a clear professional framework for when issues do exist. This case seemed

to be an occasion where the policy should have been “taken off the shelf”. Whilst

only speculation, perhaps some consider that the use of a formal policy could

damage relationships with those they have to do daily business with.

4.4 The LSCB may wish to do further work to understand what the underlying pattern

is and if it was a circumstance that pertains to just this case or if it is a more

widespread issue. In either case it would be prudent to reinforce with the multi-

agency partnership the fact that the policy exists and that practitioners should feel

free to revert to the policy.

48


4.5 It is recommended that the LSCB remind all agencies that policy and procedures

provide a professional framework which staff must not be reluctant to use.

Re-commissioned services may become vulnerable

4.6 This issue came to light in relation to services provided to an adult, Stepfather.

Changes to the drug and alcohol service happened in August 2012 and Stepfather

was transferred to a new drug and alcohol agency, as part of the initial assessment

of his needs he told the drug and alcohol worker about his family. Because of the

lack of staff at this time, a full parenting assessment was not undertaken, nor a

home visit as would be expected. The capacity issues for the Drug and Alcohol

agency meant that Stepfather had contact with a number of staff over time and this

inconsistency meant that no one person was able to reflect on the implications of

this escalation for Child A and his siblings. In conversation one worker said that the

changes of staff that Stepfather encountered would not have suited his personality

type and was unsettling for him.

4.7 This is a complex issue for LSCB’s to be able to tackle, particularly in instances

similar to this case where it is a re-commissioning of an adult service which may

have some impact on children if they are part of the service user’s life. Clearly as

part of the commissioning process there will be regard to business and service user

continuity plans. It is these plans that the LSCB may wish to be reassured about.

4.8 There is a challenge for the LSCB in firstly being notified of a plan to re-commission

services and secondly to be sighted on the continuity plans, this could be

particularly challenging when the service in question is adult focused. Even

without a re-commissioning process there are challenges in assessing the risk that

adults presenting with their own issues, such as substance abuse, may pose to a

child.

4.9 The LSCB may wish to explore a mechanism for being notified of any re-

commissioning of services that could have an impact on children and to be

reassured as to the effectiveness of the service user continuity plan.

Assessing the risk an “adult” issue poses to children

4.10 It is well recognised that working effectively with parents with mental health

problems (which may include substance abuse) requires an holistic approach,

often referred to as a ‘think family’ approach. This is in two main ways. Firstly, the

impact of parenting on a parent’s mental health must be considered; the stresses of

parenting can precipitate or exacerbate mental health issues. Secondly, it is

important to consider the impact of the parent’s mental health on the child’s safety

and wellbeing, including the possibility that the parent may harm their child. The

49


implications of “Think Family” are far reaching and extend to both universal and

targeted services working with adults, children and families and working across all

sectors (Think Family Toolkit. DCS 2009xxxii)

4.11 There may be a pattern in which key professionals may not be ‘thinking family’,

meaning that a full understanding of mental health and substance misuse issues

and their impact on parenting capacity may not be reached, and potential

safeguarding issues not identified.

4.12 It is recommended that the LSCB further explore how embedded the “think

family” agenda is and take remedial action as appropriate.

References

i Fish, S. Munro, E. and Bairstow, S. (2008) Learning Together to Safeguard Children:

developing a multi-agency systems approach for case reviews. SCIE: London

ii Ofsted (April 2011) The voice of the child: learning lessons from serious case reviews: Athematic report of Ofsted’s evaluation of serious case reviews from 1 April to 30 September2010. Ofsted London

iii Stalker, Kirsten and Green Lister, Pam and Lerpiniere, Jennifer and McArthur, Katherine(2010) Child protection and the needs and rights of disabled children and young people: Ascoping study. University of Strathclyde, Glasgow.

iv Aarons N M, Powell M B (2003), “Reports of abuse from children with an intellectualdisability. Current Issues in Criminal Justice, Vol 14, 3, pp257-268

v NSPCC in association with The National Working Group on Child Protection and Disability(2003), It Doesn’t Happen to Disabled Children: Child Protection and Disabled Children,NSPCC. London.

vi Every Disabled Child Matters (2012) Unlocking key working: information andtransparency for families with disabled children.http://www.edcm.org.uk/media/41865/unlocking_key_working.pdf

vii Department of Education (2011) Support and aspiration: A new approach to specialeducational needs and disability - A consultation:http://webarchive.nationalarchives.gov.uk/20130401151715/https://www.education.gov.uk/publications/standard/publicationdetail/page1/cm%208027

viii Department of Education (2011) Support and aspiration: A new approach to specialeducational needs and disability - A consultation:http://webarchive.nationalarchives.gov.uk/20130401151715/https://www.education.gov.uk/publications/standard/publicationdetail/page1/cm%208027

50


ix Gardner (2008) Developing an effective response to neglect and emotional harm tochildren: NSPCChttp://www.nspcc.org.uk/Inform/research/nspccresearch/completedresearch/DevelopingAnEffectiveResponseToNeglect_wda56702.html

x Action for Children (2011) Neglecting the issue: impact, causes and responses to childneglect in the UK. London: Action for Children.

xi Wonnacott and Kennedy (2005) Kennedy, M. and Wonnacott, J. (2005) Neglect ofdisabled children. In: Taylor J. and Daniel B. (eds) Child neglect: practice issues for healthand social care. London and Philadelphia: Jessica Kingsley Publishers. pp. 228-248.xii Department of health (2012) Aiming High for Disabled Children:

http://webarchive.nationalarchives.gov.uk/20130401151715/http://www.education.gov.

uk/publications/eOrderingDOwnload/PU213.pdf

xiii Powell, C., Appleton, JV (2012) Children and young people’s missed health careappointments: reconceptualising ‘Did Not Attend’ to ‘Was Not Brought’ – a review of theevidence for Practice. Journal Research in Nursing 17:2, 181-192

xiv http://www.bbc.co.uk/news/health-17298612

xv Idem

xvi Rose, W and Barnes, J. Improving Safeguarding Practice: Study of Serious Case reviews2001-2003. HM Government DCSF. 2008

xvii National Collaborating Centre for Women’s and Children’s Health Commissioned by theNational Institute for Health and Clinical Excellence (2009). When to suspect childmaltreatment. RCOG Press., London.

xviii http://www.eastlondon.nhs.uk/About-Us/Freedom-of-Information/Trust-Policies-and-Procedure/Clinical-Policies/DNA-Policy-Childrens-Services.pdf

xix Department for Education (2011) Munro review of child protection: final report - achild-centred system: https://www.gov.uk/government/publications/munro-review-of-child-protection-final-report-a-child-centred-system

xx The term authoritative practice is referred to in the most recent biennial review andspecifically in the Baby Peter executive summary which describes the approach aschallenging and confronting about parenting, setting clear targets with short timescalesand discovering motivation and capacity to be aresponsible parent

xxi Laming , H. (2003) The Victoria Climbie Inquiry: report of an inquiry by Lord Laminghttps://www.gov.uk/government/publications/the-victoria-climbie-inquiry-report-of-an-inquiry-by-lord-laming

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xxii Department of Health (2000) Framework for the Assessment of Children in Need andtheir Families:http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdf

xxiii Department of Health (2000) Framework for the Assessment of Children in Need andtheir Families:http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdf

xxiv Department of Health (2000) Framework for the Assessment of Children in Need andtheir Families:http://webarchive.nationalarchives.gov.uk/20130401151715/https:/www.education.gov.uk/publications/eOrderingDownload/Framework%20for%20the%20assessment%20of%20children%20in%20need%20and%20their%20families.pdf

xxv Laming , H. (2003) The Victoria Climbie Inquiry: report of an inquiry by Lord Laminghttps://www.gov.uk/government/publications/the-victoria-climbie-inquiry-report-of-an-inquiry-by-lord-laming

xxvi Department of education (2009) Understanding serious case reviews and their impact:a biennial analysis of serious case reviews between 2005 and 2007:https://www.gov.uk/government/publications/understanding-serious-case-reviews-and-their-impact-a-biennial-analysis-of-serious-case-reviews-between-2005-and-2007

xxvii The Lord Laming. The Protection of Children In England: A Progress Report. HMGovernment 2009.

xxviii Featherstone, Brid; Fraser, Claire; Lindley, Bridget; Ashley, Cathy (2010) FathersMatter: Resources For Social Work Educators. Family Rights Group.

xxix Scourfield, J. (2001) Constructing men in child protection work, Men and Masculinities,4, 1: 70-89

xxxScourfield, J. (2006) The Challenge of Engaging Fathers in The Child Protection Process.Critical social Policy, 26, 2: 440-449

xxxi Idem

xxxii Department for Children, Schools and Families. 2009. Think Family Toolkit, ImprovingSupport For Families at Risk, Strategic Overview. Department for Children, Schools andFamilies. 2009

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