Blaenau Gwent LSCB Serious Case Review January 2010

1.2 A medical examination of Child A identified 22 separate injuries. These included multiple bruises over his face, cheeks, chest-wall, back and right arm. A spiral fracture of his right wrist was highly suggestive of non accidental injury.

1.3 In October 2009 mother and her partner were found guilty of cruelty and were given a community order and a 9 month custodial sentence respectively.

1.4 Health professionals, police officers, social workers and independent child care organisations were involved with Child A and his family throughout the period from his birth in April 2005 to the time was he was removed from his mother’s care in June 2008

Duties of the Local Safeguarding Board

1.5 Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires Local Safeguarding Children Boards (LSCBs) to undertake reviews of serious cases in accordance with procedures set out in chapter 10 of Safeguarding Children: Working Together under the Children Act 2004.

1.6 When a child dies, or is injured and abuse or neglect is known or suspected to be a factor in the death, the LSCB should conduct a serious case review into the involvement that organisations and professionals had with that child and their family.

Outline of the Terms of Reference

1.7 Aim of the Individual Agency Reviews was to look openly and critically at individual and organisational practice to see whether the case indicates that changes could and should be made and if so, to identify how these changes will be brought about.

1.8 The overview report, on which this summary is based brought together and relate the information and analysis contained in the individual agency reviews, together with reports commissioned from any other relevant interests (parents, court evidence, Judge etc) in order to:

• Establish whether there are lessons to be learned from the case about the way in which local professionals and agencies work together to safeguard children
• Identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result and
• Improve inter-agency working and safeguarding children

Process of the Review

1.9 The Serious Case Review Panel was chaired by an independent professional with significant experience of working with children and families in Blaenau Gwent. The chair had no previous involvement with the management of Child A’s case.

1.10 The overview writer is a qualified social worker with 35 years experience in statutory children’s services. He has experience of undertaking serious case reviews as the Chair of an Area Child Protection Committee, as chair of serious case review panels, as a writer of individual management reports and as a writer of overview reports.

1.11 The writers of independent agency reviews for Health, Police and Social Services were experienced and qualified professionals who had no involvement in the management of Child A’s case nor managerial responsibilities for the practitioners involved.

1.12 The Panel members were committed and knowledgeable which greatly assisted the efficiency and effectiveness of the process.

1.13 The writer met separately with both the child’s mother and maternal grandmother in their homes.

2. Key Issues

2.1 Mother was 18 years old at the time of Child A’s birth, and in additional to her comparative youth, was identified as having a number of other actual or potential vulnerabilities. Professionals and her family are recorded as suggesting she had a learning disability (although there was no formal assessment). At the time of Child A’s birth Mother was living with her natural mother, step father and her brother. Child A has had no contact with his father. Mother’s vulnerability is a thread that runs throughout this case over the review period. The roots of her vulnerability are identified as her age, intellectual capacity and social experience.

2.2 When Mother moved to live independently she appears to have developed basic practical parenting skills but any gaps in her parenting had been covered by Maternal Grandmother. Mother told the health visitor that she would manage as extended family was very supportive. The barriers later created by Mother’s Partner meant that this support was increasingly less available whilst concerns were being raised about poor home conditions and Child A’s need for stimulation.

2.3 An increasing pattern of aggression and control within the household by her partner was emerging. This included physical threat and violence, separating Mother from her family and controlling the impact and effect of professionals who become involved. Even when not directly physically harmed, exposure to domestic violence is distressing for children and can lead to serious anxiety and longer term psychological distress. The risks of children being directly physically or sexually abused are markedly increased where children are living with domestic violence.

2.4 The impact of neglect on children’s growth, development and health – physical and emotional are increasingly central to children safeguarding concerns. In Child A’s case there were a number of practical indicators of neglectful parenting. Taken alone each of these may not be significant but over time would amount to a perceptible impact on Child A’s growth and development.

2.5 During the time when Child A was living with his mother and her partner he was observed to have bruises on different occasions. Mobile toddlers do get bruises for accidental reasons and most of Child A’s bruises were explained by Mother as being a result of falls. The indicators of domestic violence and a comment by Child A should have led to more robust questioning of Mother’s explanations.

3. Would different decisions or actions have led to an alternative course of events?

3.1 Early in Child A’s life there was consideration given to convening a strategy meeting in response to the perceived threat of his 13 year old uncle’s aggressive behaviour. It is reasonable to state that this meeting should have taken place. Whether the actions that followed a meeting would have changed the direction of agency involvement cannot confidently be deduced.

3.2 The circumstances surrounding the strategy discussion which took place in April 2008 in addition to the historical information available to the meeting suggests that there were grounds to proceed to a child protection conference. Had this taken place and Child A’s name placed on the Child Protection Register the focus and robustness of the agency involvement that followed may have either exposed the level of risk or delivered interventions that reduced it. Consideration of action through the court may have then followed.

3.3 A strategy discussion in response to the receipt of the Nursery referral in May 2008 may not have resulted in a different response to that of a visit by the case holding worker. However, it would have established the status of the response and should have resulted in following the guidance in the All Wales Child Protection Procedures. To have done so may have shifted the direction of travel in the case

3.4 The underlying themes of this case is not that professionals were unaware of the circumstances of Child A’s early life, nor that they did not react to concerns, but the extent and nature of the potential concerns were not recognised nor systematically explored in order to be either discounted or addressed.

3.5 There is no evidence to suggest that the information available to the local authority would have allowed it to take action to separate Child A from his Mother through the Family Court before the defining incident in June 2008.

3.6 Whilst there were opportunities missed to intervene earlier in Child A’s life there are a number of examples of good professional practice:

• With a few exceptions the responses to contacts and referrals by agencies were timely and addressed the immediate concerns.
• During the review period Social Services completed three Initial assessments that were completed in a timely correct way, recorded within the appropriate format.
• Visits to the home when the child was not seen were the exception. Where appropriate he was examined without his clothes on.
• There are many examples of prompt referrals and good working relationships and only a few examples where inter-agency communications were not as good as they might have been.
• Some services that would have supported Mother and assisted Child A were identified and offered
• The Health Visitor’s response to concerns of the Nursery by following these up herself.
• Case recording was generally good across all the agencies
• The strategy meeting held in April 2008 was appropriately convened and attended, well recorded with a clear plan of action
• The Police response on 17th June 2008 demonstrated best practice on the part of the officers who attended the home on an unrelated matter.

4. Conclusions and recommendations

4.1 The assessment of the impact of a parents’ cognitive capacity is one of a number of needs / problems that require specialist input which include parents with chronic problems arising from drug and alcohol misuse and mental health disorders. These can only be assessed with input from the relevant specialist adult services.

Recommendation 1: The LSCB gives consideration to clarifying the local cross-agency arrangements for (a) delivering multiagency assessment and services for children in need; and (b) engagement with adult services in assessing parents who have identifiable needs or problems that impact on their capacity to provide safe nurturing care for their children with a view to delivering clear referral pathways and effective joint working.

Violence in the Home

4.2 Child A lived with domestic conflict and violence throughout his life. In the home of his maternal grandmother there was tension and aggressive behaviour displayed by his Mother’s younger brother. Following the move with his mother to a home of their own, the controlling violence and outbursts of the Mother’s Partner was evident, if not fully recognised, from the earliest observations by professionals. Subsequently Child A was subjected to direct physical violence.

Recommendation 2: The LSCB should (a) review its training plan and contents of courses to ensure that the significance of domestic abuse as a key indicator and cause of harm to children is both explained and (b) support individual agencies in embedding it into individual professional’s practice

Neglect

4.3 Professionals working with families have to make judgements about thresholds for neglect on a daily basis. It is not a simple quantitative exercise and is influenced by general standards in peer families and perceptions of parents endeavour set against the personal challenges they face and overcome. There is no easy guide or immediate solution to achieving more informed and effective responses to poor and chronically neglectful parenting.

Recommendation 3: The LSCB should review its strategy and professional tools to identify, assess and address neglectful parenting to ensure that it is capable of delivering improvements for children in need in Blaenau Gwent

Physical Abuse

4.4 We know that Child A was subject to a number of bruises to which explanations were given when he lived with Mother and her Partner. Professionals see children with bruises every day and make judgements based on their knowledge and training.

Recommendation 4: The LSCB should review multi-agency training with a view to ensuring professionals are equipped to recognise the significance of bruising in the context of a child’s age, the previous history and explanations given

Assessment

4.5 In retrospect it is clear that there were three critical areas that did not receive the level of assessment and attention they required:

• Mother’s parenting capacity
• The propensity for violence of the two young men in the homes, in particular Mother’s Partner
• The developing history of indicators of harmful behaviour

4.6 There appears to have been an awareness of these issues but no assessment identified the pattern or cumulative impact. Whether this was a matter of the application of thresholds that were too high, or that the key information was not sufficiently well located in one place is difficult to ascertain. These are possibly two factors amongst a number of others, for instance professional capacity that influenced the assessments.

Recommendation 5: The LSCB should review the arrangements for professional assessment of needs and risks with a view to ensuring the best possible practice in relation to:

1. obtaining and collating information
2. understanding the meaning of the information
3. recognising the limitations of the assessment
4. making decisions based on sound judgements

Organisations’ Safeguarding Duties

4.7 Earlier sections have identified shortfalls in agencies’ application of the statutory frameworks for delivering multi-agency child protection and there are implicit indicators that the professional’s responses reflected what they thought they knew. Adherence to set child protection process reduces the chances of this happening by ensuring measured, multiagency consideration of the available facts. If procedures are followed we may not always get it right but we significantly reduce the chances of getting it wrong.

Recommendation 6: The LSCB uses audit processes to check compliance and quality in respect of initiating child protection procedures on new referrals and open case with particular focus on those cases which did not proceed to section 47 enquiries being made.

4.8 Agencies’ roles and responsibilities for safeguarding and promoting the welfare of children under section 28 of the Children Act 2004 state that each person and body to whom the section applies must make arrangements for ensuring that:

1. their functions are discharged having regard to the need to safeguard and promote the welfare of children; and
2. any services provided by another person pursuant to arrangements made by the person or body in the discharge of their functions are provided having regard to that need.

Recommendation 7: The LSCB and member agencies review their arrangements for commissioning services from non-statutory providers to ensure that their policies and procedures are consistent with the requirements of the All Wales Child Protection Procedures and that the procedures are robustly implemented

Challenge

4.9 The protection of individual children from significant harm, as well as the broader requirement for safeguarding and promoting children’s welfare, depends fundamentally upon effective sharing of information, collaboration and understanding between agencies and professionals. This includes challenging decisions made by agencies when individual professionals are concerned that necessary protective action has not been taken.

Recommendation 8: The LSCB should (a) ensure that its policies, procedures and training emphasise the importance of practitioners rights and duties in respect of challenging decisions that they consider fail to protect children from harm or risk of harm; and (b)encourage agencies to put in place clear management support to facilitate this

Supervision

4.10 The importance of supervising and monitoring the work of practitioners working with individual children and families is stated in section 7.34 of Safeguarding Children: Working Together under the Children Act 2004

Recommendation 9: The LSCB should consider how it can develop a common set of standards which inform agencies arrangements for supervising and advising staff who work with vulnerable children