Tameside SCB

Tameside Safeguarding Children Board has published a Serious Case Review Executive Summary, re child C, completed in February 2010.

1.            Introduction

1.1 This report summarises the findings from a Serious Case Review that was held in order to consider agency involvement with Child C.  Following a serious incident whereby Child C was made the subject of an Emergency Protection Order, Tameside Safeguarding Children Board made a decision to conduct a Serious Case Review. The Serious Case Review was held to give consideration as to how well each agency had responded to any known safeguarding concerns, as well as to how well agencies had worked together to promote the welfare of Child C and  complied with safeguarding procedures to take protective action in a timely manner.           

1.3 The Serious Case Review established the facts and analysed the practice of the professional activity undertaken in relation to services provided to Child C.

1.4 The Serious Case Review was conducted in accordance with the Working Together to Safeguard Children guidance issued by the Department for Education and Skills in 2006.

2. Membership and scope of Serious Case Review Panel

2.1 The Serious Case Review Panel was comprised of the following:

• Independent Chair
• DCI, Greater Manchester Police
• Associate Director, NHS Tameside and Glossop Provider Division
• Principal Education Welfare Officer
• Service Manager, Quality Assurance, Children’s Social Care

2.2 Additionally the Development Manager, Tameside Safeguarding Children Board and the Independent Author of the Overview Report have been in attendance at each panel meeting.

2.3 The review considered information from all health, children’s social care,   education and police forces that have had contact with Child C since birth. A significant amount of historical information from another Local Safeguarding Board area was considered as contextual information; information from agencies in Tameside was received as Individual Management Reviews.

3. The Terms of Reference for the Serious Case Review are as follows:

3.1 To establish the facts of the case in relation to what was known to each agency in respect of Child C;

3.2 The Serious Case Review will cover the time period when services in Tameside first had contact with Child C and her family in 2001 until the point when Child C became looked after by the local authority on 20^th March 2009;

Historical information from before 2001 will also be considered within the Serious Case Review process in order to ensure that the review is informed about any previous allegations or concerns.

3.3 The key lines of enquiry are as follows:

• Establish what services were provided for and to what extent they identified and met the assessed needs of the child;
• Identify any gaps in inter agency working with regard to the duty to safeguard and promote the welfare of the child;
• Examine whether services acted appropriately in identifying the potential risk of sexual abuse to Child C and whether adequate safeguarding measures were put in place;
• Examine the effectiveness of mechanisms and practice in determining thresholds and systems for referral of cases of neglect between Schools, Education Welfare and Children's Social Care;
• Establish good practice by highlighting any learning points from the case and making recommendations to the Local Safeguarding Children Board as appropriate;
• Identify any shortfalls in communication and information sharing between agencies in relation to the family moving from another Local Authority area.

3.4 Each agency that had knowledge of an identified family member was asked to complete an Individual Management Review (IMR), giving consideration to any decisions and actions taken, and making recommendations based on the analysis of the information. IMR authors were asked to identify any issues of diversity, including race, culture, linguistic factors.

3.5 To invite the parents of Child C to contribute to the review process and agree a process by which they will be informed of the progress and outcome of the review.

3.6 For all public, family and media enquiries to be managed by the Independent Chair of Tameside Safeguarding Children Board before, during and after the review.

4. Brief Summary

4.1 Child C is the only child born within the relationship of her parents. Both parents had children within previous relationships although none of those children lived with the mother or father of Child C during childhood. Child C moved to Tameside at approximately two years of age.

4.2 Following the birth of Child C, the Children’s Services of the local authority area where the family was living conducted an assessment to ensure that Child C’s needs could be fully met by the parents. This assessment was conducted because the local authority was made aware that both parents had contact with child welfare agencies when parenting their children with previous partners. The assessment identified no significant concerns and Child C continued to be monitored through standard child health services.

4.3 The Serious Case Review found that the assessment following the birth of Child C was overly optimistic about the parent’s ability to parent Child C without the provision of services to support the mother in particular. Furthermore, the assessment did not give sufficient focus to the potential of risk from the father about whom there had been previous allegations of inappropriate behaviour towards children. The Review noted that all assessments completed subsequently relied on the findings of the first assessment as an accurate assessment of potential risk from either parent.

4.4 Whilst in the care of both parents, Child C was described as well cared for; a bright child who met developmental milestones with ease. Child C started school and was considered to be a bright and sociable child.

4.5 The mother and father of Child C separated when Child C was five years old. Child C lived very briefly with the mother in another local authority area, but moved back to Tameside with the father where Child C continued to live. It is known that Child C was made subject of a Residence Order in favour of the father. Child C had no ongoing contact with the mother.

4.6 Over the following four year period, a range of concerns were expressed about Child C’s welfare.  The early concerns related to standards of parenting and school attendance, with continued concern about head lice, tiredness and hygiene. Child C changed schools during this period, and similar concerns were expressed at each school. Children’s Social Care responded to several referrals by undertaking an Initial Assessment, however, good interagency communication was not always evident at the point of assessment and closure. This was particularly evident by the fact that Children’s Social Care undertook an Initial Assessment with regard to a potential risk of sexual abuse from a young person but did not share the facts and potential risks with other agencies.

4.7 Each school worked closely with the Education Welfare Service and tried to engage the father in addressing the concerns that existed. The School Nurse was also alerted to concerns on occasions, and also tried to support and engage the father in parenting advice. In 2006, the school convened a Child and Family Meeting with School Nurse and Education Welfare in attendance as well as the father. This meeting met twice, and after some improvement in school attendance it was agreed that no further meetings or action would be taken.

4.8 The following year in 2007, Child C was attending a different primary school, who expressed similar concerns to the Education Welfare Officer. The Serious Case Review noted that from 2006 onwards the father began withdrawing active co-operation with agencies, and in late 2007 through non co-operation he was able to prevent a Core Assessment being completed as well as prevent specific keeping safe work with Child C. The review was concerned about the apparent ease that the father was able to prevent Child C’s needs being fully assessed or met and noted that the impact of the father’s decisions on Child C was never fully considered or addressed.

4.9 In April 2008, the school expressed continuing and similar concerns about Child C to the Education Welfare Officer. The Education Welfare Officer communicated the concerns to Children’s Social Care, although it was noted that this was not formalised through a commonly applied interagency referral process. Children’s Social Care advised the Education Welfare Officer to complete a CAF (Common Assessment Framework) and convene a further Child and Family Meeting. The review considered this to be unhelpful advice given that such an action relies on the father’s co-operation and Health, Education and Children’s Social Care had all experienced his withdrawal from services.

4.10 The Serious Case Review found that within the borough, there is no inter- agency protocol with regard to neglect which would have assisted the professionals in determining whether Child C should have received a more specialist service. A commonly applied protocol which addressed expected standards of care could have enabled the Education and Health Services to confidently and assertively advocate for specialist services for Child C.

4.11 The review perceived a lack of challenge between agencies about thresholds of intervention for services, and considered that a more challenging culture should be developed to promote the best outcomes for children.

4.12 No further meeting or assessment took place until 2009 when Child C was tested positively with a disease which is commonly, and in all probability sexually transmitted. The Serious Case Review found significant deviation from safeguarding procedures within the process of identifying and responding to an indicator of sexual abuse. The Serious Case Review was further concerned about the process of joint police and Children’s Social Care investigation, which acted to see Child C and alert a parent to an investigation before all historical facts and information was considered.

4.13 The Serious Case Review considered that as a consequence of this and other reviews, the Tameside Safeguarding Children Board needed to pro-actively review the policies, guidance and training with regard to sexual abuse to ensure that staff across all safeguarding agencies are well equipped to identify, respond and investigate sexual abuse in a manner that places the child as paramount whilst ensuring any potential suspect is identified and subject to ongoing risk management procedures

5. Identified Learning

The agencies each contributed to the Review process by completing a critical analysis of the work of their agency. The following recommendations were made by the individual agencies:

5.1  NHS Tameside and Glossop (including General Practice) and Tameside Hospital Foundation Trust

5.1.1 Each Health agency will review its safeguarding training plan and its implementation to ensure it is on target and audited for compliance. With consideration to be given to a multi-agency audit looking at effectiveness in practice or the above named training;

5.1.2 Specific Protocol/Guidance will be produced by the Tameside and Glossop Acute Foundation Trust looking at diagnosis of sexually transmitted diseases by culture or otherwise in children under the age of 16 looking specifically at how quickly the diagnosis is made, confirmed, and shared with other professionals;

5.1.3 Both Trusts will review safeguarding record keeping standards and their implementation with regular audits to be fed back to TSCB on this issue to give assurance of the accurate recording of information and the way in which it is shared;

5.1.4 Tameside Primary Care Trust will revise the protocol on parents opting out of the school health program to ensure that information of parents who opt out is notified to the school.

5.2  Tameside Services for Children and Young People, Achievement and Learning

5.2.1 It is recommended that welfare officers working in partnership with schools both reiterate the roles and responsibilities set out in the Children’s Needs Framework and ensure that Child and Family meetings are convened when appropriate and that the role of Lead Professional is adopted for the completion of CAF;

5.2.2 The regular use of the local Information Sharing Agreement will be essential in supporting the practice recommended above which may be audited in relation to the Lead Professional role;

5.2.3 That Education Welfare reviews the recording of case information to ensure consistency of good practice;

5.2.4 It is recommended that welfare managers consult staff to determine suitable criteria (length of involvement; number of referrals; agencies involved, etc) that ensures appropriate cases are reviewed;

5.2.5 It recommended that the wider context of the family and the integration of information are incorporated into regular case work supervision.

5.3 Tameside Services for Children and Young People, Specialist Services and Safeguarding        

5.3.1 Specialist Services and Safeguarding should ensure that all historical information is included in assessments and that cumulative evidence of risk of sexual abuse is considered;

5.3.2 Specialist Services and Safeguarding should ensure that where a second or subsequent referral is made indicating risk of sexual abuse consideration is given to holding a Child Protection Conference and that this is recorded;

5.3.3 Specialist Services and Safeguarding should issue further guidance to managers in relation to triggers for Child Protection Conferences to sit alongside the Tameside Safeguarding Children Board Safeguarding Framework;

5.3.4 Specialist Services and Safeguarding should ensure that reasons for closure are recorded by managers for all referrals and assessments;

5.3.5 Specialist Services and Safeguarding should ensure that when Initial Assessments are considered the child is always seen or reasons for not doing so are recorded.

5.4  Greater Manchester Police

5.5  Greater Manchester Police did not make any specific recommendations.

6. Recommendations made by the Serious Case Review Panel

6.1 When undertaking Initial Assessment, reliance should not be placed on the validity of previous assessments without undertaking a full analysis of all existing current and historical information. Over reliance should not be placed on conclusions and outcomes of previous assessments as a reason for no further action;

6.2 All Initial Assessments should ensure there is consultation with all other agencies working with a child, and that each agency is informed of the outcome and reasons in accordance with section 5.45 of Working Together to Safeguard Children 2006;

6.3 In circumstances where an adult is alleged to have sexually offended against a child, whether the outcome is proven or inconclusive, the need to convene a child protection conference in respect of any child potentially at risk should always be considered, with a clear and written risk assessment that analyses the reasons taken;

6.4 In circumstances where it is necessary to undertake a core assessment to assess the needs of a child, and a parent refuses to co-operate with the assessment, consideration should routinely be given to the possibility of invoking child protection procedures and/or the use of a Child Assessment Order;

6.5 That the LSCB introduce an inter agency referral form which should be used for all referrals to Children’s Social Care;

6.6 That the Local Safeguarding Board ensure an interagency protocol on neglect is put in place which will provide a reference point for professionals to identify and respond to any concerns about neglect;

6.7 That the LSCB ensure an interagency Escalation Policy is in place to assist practitioners and agencies to escalate unresolved difference in a professional and constructive manner;

6.8 That all personnel in both Children’s Social Care and the Police who have responsibility for the management of sexual abuse investigations are advised immediately of the need to plan any investigation through the use of a Strategy Meeting prior to undertaking the investigation;

6.9 That the Local Safeguarding Board creates a task group to consider the Boards priorities and responsibilities in respect of responding to sexual abuse. This should include a review of procedures, training,  and ongoing monitoring of the local indicators against the national indicators in relation to sexual abuse;