Tameside SCB

 1. BACKGROUND TO THE SERIOUS CASE REVIEW

1.1                   The young person who is the subject of this review is known as Child B.  Child B was thirteen years old when he first came to the attention of police and children’s social care.  Subsequent concerns about his learning and behaviours led to his being assessed by child and adolescent mental health services (CAMHS).  However, Child B’s behaviours continued to be of concern and in July 2008, the youth offending team (YOT) began to work with him.  During the period under review, there were a number of serious incidents as the result of Child B’s behaviours and a number of children were hurt.

1.2                   Child B is currently serving a custodial sentence.   This means that there are legal restrictions on the information that can be provided about Child B and his circumstances.  This will be reflected in what follows in this executive summary of the serious case review.

1.3                   The most important purposes of a serious case review are to help professionals and agencies understand what happened and to find out whether they can take steps to prevent a similar incident in the future. 

1.4                   The Government has determined when a serious case review should be undertaken and has provided guidance for Local Safeguarding Child Boards (LSCBs) and for agencies that work with children, about how a serious case review should be conducted. 

1.5                   This guidance is contained in ‘Working Together to Safeguard Children (2010)’: Tameside Safeguarding Children Board (TSCB) follows this guidance closely. 

1.6                   ‘Working Together’ describes the circumstances in which an LSCB must undertake as serious case review as well as circumstances in which an LSCB should always consider undertaking such a review.  

1.7                   According to the guidance, an LSCB must undertake a serious case review if a child dies in its area and abuse or neglect is suspected to be a factor in that child’s death.    In addition, an LSCB should always consider undertaking a serious case review when a child has been seriously hurt and the case gives rise to concerns about the way in which local professionals and services worked together.

1.8                   In this case, although no child had died as the result of abuse or neglect, Tameside Local Safeguarding Children Board had concerns, nevertheless, that children had been hurt because of Child B’s behaviour.   On the basis of early information provided, the Board also had concerns about the way in which agencies had worked together to assess Child B’s needs and to help manage the risk that his behaviours posed to other children. 

1.9                   The TSCB, therefore, appointed a Serious Case Review Panel (SCRP) to consider whether a serious case review should be undertaken, to propose terms of reference for a review, if appropriate, and to determine what should be the key lines of enquiry.  The SCRP concluded that the criteria for a serious case review were met and formed the view that it would provide learning opportunities for a range of agencies.

1.10               In August 2009, the Chair of the Board decided that a serious review case should be undertaken.  In line with guidance, the SCRP was to oversee the conduct of the serious case review on behalf of the TSCB.  An independent person had been appointed to chair the SCRP: the panel was to be assisted in its function by the TSCB Development Manager and the TSCB Administrator.

1.11          Agencies and organisations forming the SCRP were:

• Achievement and Learning, Services for Children and Young People;
• Connexions, Tameside;
• Greater Manchester Police
• Pennine Care NHS Foundation Trust (CAMHS)
• Area Support and Youth, Services for Children and Young People (YOT)
• Crown Prosecution Service
• Children’s Safeguarding Unit (representing TSCB)
• NHS Tameside and Glossop (also representing General Practice and Tameside NHS Foundation Hospital Trust)
• Specialist Services and Safeguarding, Services for Children and Young People

1.12          The terms of reference for a serious case review set out what period the review should cover, who should contribute to the review, what should be the main focus of the enquiry and what time the review should take.  In this review, the SCRP asked agencies to evaluate their involvement with Child B and his family from October 2006 until July 2009. 

1.13          The SCRP wanted to know the answers to seven main questions:

a. What was the detail of information held by agencies about Child B and his family during the period under review?

b. Were the services that Child B received based on a full assessment of his needs?

c. Did assessments properly take into account previous concerns about Child B’s behaviours?

d. Did agencies that provided services to Child B take into account consideration of Child B’s cultural, religious, language or disability related needs of Child B?

e. Did agencies fully recognise the consequences of Child B’s behaviours and were consistent safeguarding measures put in place? 

f. Were decisions made in this case reasonable and responsible? 

g. What were the gaps in inter-agency working in respect of their duty to safeguard and promote the welfare of Child B, with particular emphasis on shared risk assessment and planning?

1.14               A number of organisations contributed to the serious case review by carrying out Individual Management Review (IMRs).  IMRs are designed to provide and open and critical analysis of an organisation or agency’s work with the child and family.  All IMRs consider what lessons the agency has learnt and make recommendations and plans to avoid similar problems arising in future.

1.15          The organisations which provided IMRs were:

•  NHS Tameside and Glossop (including General Practice) and Tameside NHS Foundation Hospital Trust;
• Pennine Care NHS Foundation Trust including Tameside Child and Adolescent Mental Health Services (CAMHS);
• Greater Manchester Police (GMP);
• Tameside Connexions;
• Conference and Review Team, Children’s Safeguarding, Services for Children and Young People, Tameside Council;
• Specialist Services and Safeguarding, Services for Children and Young People, Tameside Council (children’s social care);
• Youth Offending Service, Services for Children and Young People, Tameside Council;
• Achievement and Learning Services, Services for Children and Young People, Tameside Council (Education); and,
• The Crown Prosecution Service.

1.16               The TSCB commissioned an independent author to complete the serious case review overview report.  The purpose of the overview report is to draw together the information and analysis contained in the IMRs and to consider what lessons agencies can learn for the future.

1.17               As well as IMRs, the SCRP was keen to offer the opportunity to contribute to Child B, to his mother and to the parents of the children that had been hurt. The Board and agencies very much appreciate their willingness to talk openly and frankly, in what have been very distressing circumstances.   The TSCB is grateful for the valuable insight their contributions have provided.

1.18               In February, the overview author completed her analysis of the case.  The recommendations which she made were endorsed by TSCB and an ‘action plan’ was drawn up to show how the Board and agencies are going to make sure that the recommendations are carried out. 

 2. KEY FINDINGS

2.1      In relation to the key lines of enquiry set out by the SCRP, it was found that:

a. Child B was the subject of a large number of assessments.  While some of these assessments appear to have satisfied their own particular purposes, no assessment set out Child B’s needs in full.  In addition, the review found that, although there were a large number of assessments carried out, these assessments did not, on the whole, lead to Child B receiving services.

b. In general, it was possible to see a graduated response by agencies to Child B’s behaviours.  However, a number of significant issues arose in relation to professionals’ appreciation of risk factors and how they interacted with one another.

c. Agencies generally took account of Child B’s particular disability but did not recognise sufficiently how features of this disability reinforced his behaviours. There is no indication that Child B had cultural, religious or language related needs that were not identified by agencies.

d. Overall, agencies were slow to recognise the significance of Child B’s behaviours at home, in school and in the community.  An error by children’s social care and lack of persistence by CAMHS meant that an opportunity for an earlier assessment was lost.  A joint assessment by YOT and children’s social care was weak in its conclusions.  The plan for Child B was not properly developed and there was a lack of communication between YOT and the police at key points.

e. Generally speaking, agencies followed expected work processes but outcomes were affected by some poor decision-making.

f. The quality of information sharing was variable but the quality of inter-agency work was generally poor.  On the whole, agencies appear to have recognised that working together was a fundamental requirement in this case and there are some examples of joint working and sharing of information. However, there were significant deficiencies.

g. It would not have been possible at the point that the review began to predict that Child B’s behaviours would become so persistent, although further incidents were more evidently likely as time went on.  It is not possible to conclude that agencies could have prevented Child B behaving in the way that he did.

3. LESSONS LEARNT

3.1                   The case review highlighted particular issues specific to Child B’s situation.  However, because of the complex combination of Child B’s needs, behaviours and characteristics, these issues had limited general application.  For that reason, the review focussed on the general lessons that can be learned from this case, in terms of how agencies worked separately and together to safeguard Child B and to assess and manage the risks that his behaviours posed to other children.

3.2                   Unfortunately, a number of these lessons are not new, but have been identified in research and repeated in numerous serious case reviews.  This does not, however, make them less important.

Assessments should be holistic and dynamic. 

3.3                   This means that assessments must always take into account all relevant information and that there must be consideration of how different aspects of the child’s life interact with other, for better or for worse.

3.4                   Such assessments, self-evidently, cannot be done on the basis of information held by one agency only: they must include information obtained from a variety of professionals and agencies, as well as information obtained directly from family members.   Where there are child protection concerns, multi-agency involvement should be evident from early in the assessment process: this is reflected in Tameside Safeguarding Framework.  

Assessments of the risk that a young person’s behaviour poses must give due weight to similar reported incidents, even if they cannot be proved beyond reasonable doubt.

3.5                   In this case, professionals were uncertain of the extent to which they should take into account particular reported incidents when undertaking a risk assessment.   Uncertainty is understandable, in these circumstances, as this is a complex issue for clinicians and practitioners to resolve.  For that reason, it is important that those undertaking risk assessments have access to general guidance to help them manage this process.  They should also have access to legal advice, if specific assessments rely heavily on reports of incidents which are have not been proved or which a young person denies.

When a young person’s behaviour poses a risk of harm to others, agencies need to produce a detailed risk management plan that is overseen by a suitable multi-agency group.

3.6                   An assessment that concludes that a young person’s behaviours pose a risk of harm to others is of no value unless it leads to action. In all such cases, a multi-agency risk management group should be established to share relevant information and to ensure that the risk management plan is well founded.   It is crucial that the group overseeing the risk management plan has the authority, expertise and flexibility it needs to respond to the particular issues in each case.    The level of risk posed by any young person must be reviewed regularly, to take account of new information, the impact of services and/or any further incidents.

Practitioners working with young people whose behaviours pose a risk to other children should consider whether he or she should be identified as an individual who poses a risk to children within the Council’s policy framework

3.7                   Although a specialist assessment came to the conclusion that Child B’s behaviours posed a risk to other children, no consideration appears to have been given as to whether Child B should be identified as an individual who poses a risk to children in accordance with Tameside SCB’s policy framework. (http://www.tamesidesafeguardingchildren.org.uk/publications/individuals-who-pose-a-risk-of-harm). Use of this process might have increased the effectiveness of inter-agency information sharing.  The reasons this did not happen are unknown.  However, the LSCB recognises that a review of the practical effectiveness of this policy and guidance should form part of its response to this serious case review.

Consideration must be given to providing specific services to a young person even if he or she has charges outstanding

3.8                   The importance of ensuring that a young person’s legal rights are not compromised cannot be understated.   However, in each case, there may be services that can be offered that would reduce the risk that a young person’s behaviour poses, while that young person is awaiting trial.

Every agency, organisation and school has a responsibility to ensure that it has taken adequate steps to reduce the risk of harm posed to children using its facilities from the behaviour of other young service users

3.9                   All organisations which provide or commission services for children must ensure safe environments for children and young people who use their facilities.   Policies, procedures and practices, designed with that end in mind, must be consistent with national and locally agreed standards.

There needs to be a review of cases similar to this case, in order to ensure that assessments and risk management plans are satisfactory

3.10                It is important that any shortcomings identified in this case are not replicated in current assessments or risk management arrangements.  Where problems are found, agencies should ensure that appropriate remedial action is taken.

The Youth Offending Team and children’s social care must ensure that all work, including specialist assessments and plans, is adequately managed and integrated with any concurrent assessments, plans and reviews. 

4. RECOMMENDATIONS

The lessons learnt in this serious case review led to four recommendations which have relevance to all agencies.

4.1       The first recommendation is that the TSCB should take action to improve the quality of core assessments on which child protection plans are based by:

• Increasing participation of agencies in the process at an early stage;
• Ensuring that specific lessons learnt about improving the quality of assessments are incorporated into training; and,
• Verifying that children’s social care’s actions and proposals to improve the analytical quality of core assessments are likely to bring about expected improvements.

4.2      The second recommendation is that the TSCB should ensure there are agreed, safe multi-agency processes for assessing and managing the risk posed by young people who are known to, or who are suspected to, sexually abuse other children and young people. 

4.3       The third recommendation is that TSCB require agencies providing or commissioning day or residential facilities to provide evidence that risk assessment protocols used in these facilities adequately address the potential risks that young people’s and children’s behaviours might pose to one another.

4.4       The fourth recommendation is that the TSCB require evidence that YOT and Specialist Services and Safeguarding:

• Have identified all children and young people who are currently known, or suspected, to pose a risk of sexual harm to other children;
• Have reviewed all the assessments and risk management plans that relate to these children and young people;
• Have taken any actions necessary to rectify any problems; and,
• Have clarified the arrangements for recording, managing and reviewing both current cases and cases that might arise in the immediate future, pending the completion of actions under Recommendation 2.

4.5       Agencies, with the exception of the Crown Prosecution Service, produced recommendations to improve practice in their particular organisations.  The final recommendation relates to these.

4.6       The final recommendation is that that TSCB ensure that agencies work separately and together to draw up a multi-agency action plan that clearly describes how recommendations relevant to individual agencies are to be enacted, monitored and evaluated in terms of their implementation.