Background
Child G died aged 3 years.
The family moved frequently
between various parts of
the country and the children
never had a stable home
situation. There
was agency involvement
over a number of years.
The Terms Of
Reference And Purpose
Of The Review
The overlying purpose
of a Serious Case Review
is set out at Chapter 8
of Working Together to
Safeguard Children;
“When a child dies,
and abuse or neglect are
known or suspected to be
a factor in the death,
local agencies…….
should consider whether
there are any lessons to
be learned from the tragedy
about the ways in which
they work together to safeguard
children……”
Specifically agencies
should;
-
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 as a consequence
-
To improve inter-agency
working and better safeguarding
children.
Recommendations
for Individual Agencies
Leeds Social
Services Department
Recommendation 1
Senior
Social Services management
should identify the causes
of, and solutions to, the
shortcomings highlighted
in this report. Areas
of particular focus would
include:
-
opening separate files
on individual children
in a family:
-
the gathering of information
from other agencies:
-
conducting further
checks when there is
change in a household’s
composition
Recommendation 2
When
referrals are made to family
support service providers,
the Social Services Department
should draw up a clear
specification for the expected
involvement. The
specification should include
arrangements for communication
and joint review. Where
appropriate, there should
be explicit acknowledgement
of which agency is to take
the lead or co-ordinating
role.
Recommendation 3
In any case where there
are significant differences
in the assessment of
risk by the involved
agencies, the relevant
Team Manager should act
to try to resolve those
differences. This
might include convening
a strategy meeting. The
outcome of any action
taken should be recorded
on the file, together
with the reasoning behind
the decision.
Recommendation 4
It is acknowledged that
the principal purpose
of a Section 37 report
is to investigate whether
the Local Authority should
institute care proceedings.
However, the department
should act upon all the
outcomes of such investigations,
and be prepared to consider
the implications for
other family members
of any conclusions drawn
about a particular child.
Recommendation 5
When a Team Manager post
is vacant, there should
be clear alternative
arrangements for supervision,
planning and decision
making. These should
be recorded. A
copy of that record should
be included in the file
of any case that may
be affected by the arrangements.
Area A Social Care and
Health Directorate
The Panel has made no
recommendations for Area
A Social Care and Health
Directorate.
Area B Social Services
Department
The Panel has made no
recommendations for Area
B Social Services Department.
Leeds Health
Recommendation 1
A clear protocol for the
assessment of children
when there are issues
regarding neglect should
be drawn up and available. The
protocol should include
details of both content
and process in assessment. Appropriate
training on a regular
basis should be provided
to support this.
Recommendation 2
Any assessment undertaken
in line with the Protocol
as in Recommendation
1 (see above) must be
undertaken by a professional
with an appropriate level
of training and expertise.
Recommendation 3
A clear Multi-agency Protocol
for the assessment of children
with suspicious burn or
scald injury should be
drawn up. Training should
be provided in its use.
Recommendation 4
Following any significant
injury to a young child
presented to hospital,
whether deemed to be
accidental or non-accidental,
the hospital in liaison
with the primary care
team must make appropriate
arrangements for follow
up both from the point
of view of treatment
for the injury and also
for the prevention of
future injuries.
Recommendation
5
As a result of child protection
supervision for nursing
staff, a record must be
kept in the client’s
notes of the reason for
the discussion and the
outcome.
Area A Primary Care Trust
The Panel has made no
recommendations for the
Area A Health Services.
Area B Health
The Panel has made no
recommendations for Area
B Health.
West Yorkshire
Police/Area A Police
The situation where the
Probation Service supervised
an offender for a period
of nearly two years without
being aware of any cautions
being issued for sexual
offences is concerning.
Recommendation
1
The Police and Probation
Service should explore
what action can be taken
to prevent such a situation
arising in the future and
ensure their findings are
implemented at the earliest
opportunity.
West Yorkshire
Probation Service
The Probation Service
child protection procedures
require the supervising
officer to inform Social
Services of any situation
in which an offender resides
in the same household or
has significant contact
with any child. It
would appear that despite
Child G’s Father
being the subject of regular
MAPPP’s it was ten
weeks after his release
from prison before a referral
was made to Social Services.
Recommendation
1
The Probation Service should
ensure all practitioner
staff are reminded of the
requirements regarding
liaison with Social Services
when an offender has any
significant contact with
a child.
The situation where the
Probation Service supervised
an offender for a period
of nearly two years without
being aware of any cautions
being issued for sexual
offences is concerning.
Recommendation
2
The Probation Service and
the Police should explore
what action can be taken
to prevent such a situation
arising in the future and
ensure their findings are
implemented at the earliest
opportunity.
Leeds Early
Years Service and Seacroft
Sure Start
Sure Start had the potential
to make a significant contribution
to the assessment of the
family through the level
of contact planned over
an eight month period. However,
for reasons identified
this did not prove to be
the case on this occasion. The
Panel felt unclear about
Sure Start’s commitment
to and understanding of
child protection procedures.
The Panel recommends Sure
Start review their current
practice in light of the
learning from this case. In
particular Sure Start should
plan a more comprehensive
role when working with
families in the future. The
Panel recommends the following
action points:
Recommendation 1
At the beginning of
any contact with a family,
Sure Start should undertake
a check to establish
what other agencies are
involved with the family.
Recommendation 2
At the beginning of any
contact with a family,
an intervention plan
should be drawn up identifying
issues to be addressed
to ensure contact is
focussed on a need.
Recommendation
3
All intervention plans
should identify other
agencies currently involved
with the family.
Recommendation 4
The intervention plan should
be explicit about the
level of information
exchange between different
agencies working with
the family.
Recommendation 5
All contacts with families
should be accurately recorded. Failure
to keep arranged contacts
is recognised as a risk
issue and as such should
be regarded as significant
and of value to other agencies,
in particular the referring
agency who must be informed
in such circumstances.
Recommendation 6
When working with families
where known child protection
issues exist, Sure Start
should make every effort
to observe children during
home visits and where
they fail to do so this
should be regarded as
significant and recorded.
In relation to the serious
case review report submitted
by Sure Start, the Panel
felt that greater efforts
should have been made to
follow ACPC guidelines
for report writing. The
report was very short,
contained little information
and offered little or no
analysis, conclusion or
recommendations.
NCH North East
The agency’s report
identifies a number of
appropriate recommendations. The
significant point to add
is the importance of all
NCH staff recognising the
value of an inter-agency
approach. The NCH
report recommendation does
not highlight this point
strongly enough. The
need for workers to share
information when working
with children is fundamental
to basic good practice. The
author of the agency report
describes a feeling in
the project that “to
seek background information
from others could distort
rather than inform an assessment”. This
cannot be acceptable. Similarly,
under the heading “lessons
to be learned” when
commenting on inter-agency
communication the report’s
author states “it
was not the projects role
to co-ordinate a multi-agency
approach”. This
is not a helpful contribution
given the lack of a multi-agency
approach apparent in this
case. In a situation
where the NCH worker is
the person with the most
frequent level of contact
with a family, it must
surely follow they must
take some responsibility
for liaising with and then
recording their contact
with all other agencies
involved with a family.
The Panel recommends the
following three points:
Recommendation 1
NCH consider its guidance
to staff on inter-agency
working and issues new
guidance emphasising
their responsibilities
in this area.
Recommendation 2
NCH conducts a review of
record keeping within
the agency and ensures
staff understand all
contacts regarding work
with a family must be
recorded.
Recommendation 3
NCH implements further
child protection training
for all staff to ensure
a greater awareness of
the factors associated
with child neglect.
Education Leeds/Area A
Education Directorate
The practice of forwarding
pupil records, including
issues of child protection,
when a child moves School
has made it difficult in
the case of the family,
to evaluate the effectiveness
of the Schools Child Protection
Practice. There is
no detailed information
available from Schools
in either Leeds or Area
B and the report from Area
A is written in general
terms and does not include
a chronology identifying
specific events, dates,
times, etc. The only
other information available
is a limited report from
the Education Welfare Service
in Leeds.
Recommendation 1
Schools adopt a practice
of maintaining duplicate
records of pupils where
there are child protection
concerns. The original
could be forwarded to
the new School, the copy
stored in the current
School for a time limited
period.
In the absence of any
internal report from Education
Leeds regarding the practices
at GF Primary School, it
is difficult to make any
specific recommendations. Social
Services records indicate
all contacts were initiated
by their Department and
if this is correct it would
be reasonable to acknowledge
good child protection practice
is a two-way process and
when Schools observe issues
of neglect they have a
duty to initiate contact
with the Social Services
Department and not just
respond. In this
case, the Head Teachers
observations were very
significant and needed
to be shared at the earliest
opportunity.
Recommendation 2
The recommendation in respect
of this issue is for
schools to be reminded
of the importance of
raising child protection
issues with Social Services
at the earliest opportunity.
Finally, it became apparent
during the overview process
that the Head Teacher at
GF Primary School had never
been consulted when the
serious case review was
being completed by the
Education Welfare Service. This
is far from satisfactory. The
Panel questioned whether
Education Welfare were
the most appropriate body
to conduct the review in
any event, the school’s
governing body may be more
appropriate.
Recommendation 3
The process for conducting
serious case reviews
in education needs to
be reviewed and the serious
case review sub committee
should undertake this
task at the earliest
opportunity.
Issues And Recommendations
For ACPC
Issues for ACPC
The Case Recording at
the beginning of December
described:
“a very chaotic
situation with the downstairs
of the home being in disarray. Clothes
were piled at the bottom
of the stairs, a window
was still boarded up, curtains
draped across the window,
the living room was dark
and the floor covered in
food, debris and litter. Mother
was observed to be hastily
sweeping this up. Mother
informed social worker
that S and her three children
were about to move into
a hostel on 2 December
2003. Mother said
that she could not clean
up when they were all in
the property. Social
worker suggested to Mother’s
Partner that he could help,
but he just shrugged. Social
worker’s impression
was that the tasks had
not been done, “more
concerning because of the
involvement of the Department
of Social Service and the
forthcoming Court hearing. Mother
was considered as being
unable to assert or motivate
herself, and vulnerable
to the interference of
others”. Also of
importance it was noted
that “Child G was
observed as being fractious
and seeking attention from
others.”
The Panel has become conscious
on reading and re-reading
the details of this case
that the circumstances
of the three children was
amply reflected in numerous
records from various agencies
over a protracted period
of time. Much less
clear in the records is
any reference made to the
likely or observed effects
of such adverse circumstances
on the children.
Recommendations
for ACPC
The case recording at
the beginning of December
2003 some weeks before
Child G died paints a vivid
picture of the situation
in which these children
and their family were living. It
appears however that this
situation was being tolerated
by the various agencies
who were visiting the family
on a regular basis and
implicitly therefore that
this standard of childcare
was in a sense acceptable,
although there is no doubt
that the agencies were
attempting to improve matters.
Recommendation
1
The Panel has come to the
view that central to this
case is a need for there
to be a debate within ACPC
regarding acceptable standards
of childcare and appropriate
responses when those standards
cannot be reached. The
second area which the Panel
wishes to draw attention
to is the lack of any systematic
assessment and co-ordination
within and between the
various agencies involved
with this family during
the latter period when
they resided in Leeds.
The situation with this
family parallels in some
ways that described in
the earlier Serious Case
Review for the Serious
Neglect Case (Family X)
published by Leeds ACPC
in November 2002. Very
similar comments could
be recorded of Child G
and her family except the
outcome was more serious
in this case than the Serious
Neglect Case where the
child (Child Z) did not
die.
We can do no more than
quote directly from the
Serious Neglect Case Review:
“5.8 Commentary
5.8.1 The
apparent inability of
the Social Services personnel
(and other agencies)
to recognise and respond
appropriately to neglect
and other child protection
issues and the subsequent
omission to commence
a S.47 enquiry seemed
to have maintained the
resultant Family in Need
(support) approach to
the X children.
5.8.2 Without
the co-ordinating effect
of a S.47 Child Protection
Enquiry, agencies continued
to operate in a largely
separate and unco-ordinated
manner, working within
their own departmental
silos, failing to communicate
effectively and responding
in an ad- hoc rather
than pro-active fashion.
5.8.3 This
dynamic continued right
up to the date of Child
Z’s emergency admission
to hospital and was only
stopped by the infection
nurse’s very timely
and decisive actions
which arguably saved
Child Z’s life.
The recognition of neglect
and her response stand
out as one of the few
examples of positive
practice in the chronology
of the X children’s
involvement with the
child welfare/protection
agencies.
5.8.4 A
key point emerging form
this final period of
the review concerns the
issue of thresholds in
cases of neglect and
the point at which it
becomes necessary to
intervene with a child
protection - as opposed
to children in need/family
support focus. Again,
access to the long history
of previous concerns
(the ‘Big Picture’)
would arguably have given
a more contexualised
and holistic understanding
of the children’s
needs and may have led
to a different set of
outcomes in relation
to agency response and
the welfare of Child
Z and her siblings.”
Except for para 5.83,
the Panel considered that
all the above comments
applied to this case. The
picture was complicated
by the fact that a formal
assessment of one child,
demanded by the court,
was undertaken although
it failed to speak to the
totality of the situation
for the other children.
This assessment resulted
in that single child eventually
being removed from the
family. However it totally
failed to address the needs
of the remaining children
including the child who
died.
Recommendation 2
ACPC should review the
recommendations from both
this Serious Case Review
and from the earlier Serious
Case Review to ensure they
have been fully implemented. |
