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Leicester, Leicestershire and Rutland Safeguarding Children Board
Executive Summary Serious Case Review Child W
1. Introduction 1.1 A Serious Case Review was undertaken after Child W, who was 2 years old, was killed by his father. Mr W immediately admitted causing his son’s death and a criminal investigation followed. This resulted in Mr W being charged with murder, to which he eventually pleaded guilty. Mr W was sentenced to life imprisonment. The judge ordered that he serve a minimum term in prison of just over 16 years. The Serious Case Review could not be completed until after Mr W’s trial. 1.2 This Executive Summary reflects the findings of the Serious Case Review which was carried out in line with government guidance. Local Safeguarding Children Boards (LSCBs) must consider whether to carry out a review when a child is killed by a parent. The focus of this review was the history of mental health problems of Child W’s parents, the domestic violence in their relationship and the impact of their difficulties on the care of their son. 1.3 Leicester, Leicestershire and Rutland Safeguarding Children Board is committed to learning lessons from reviews in order to develop and improve how children are safeguarded through the work of professionals and agencies and the way in which they work together. It is equally important to learn from good practice and to build on this. The review has tried to identify any changes which need to be made for the future. 2 . The Serious Case Review 2.1 Each agency that had worked with Child W and his family was asked to do a review, called an Individual Management Review. The reviewer had to be someone who had not worked directly with the family or been the line manager of any worker who had been involved. The reviewers read all the records relating to the family and spoke to some of the workers and their managers. The reviewer’s responsibility was to be thorough, objective and critical in order to identify practice which did not meet the required standards as well as good practice. It was also important to understand why certain actions were taken and decisions made. The reviewer then produced a chronology, (what happened and when), of the agency’s involvement and wrote a report of their findings. 2.2 The Serious Case Review Group, made up of representatives of the Safeguarding Children Board and the Individual Management Reviewers, considered all the reviews and analysed the professional practice and the way in which the agencies worked together. The group was joined by an independent person, the Overview Author, who was not employed by any of the agencies. Their responsibility was to look critically at the reviews and work with the group to draw conclusions from the information and analysis and then to write an Overview Report. The Children and Young People’s Service, Housing Services, the Police and the Health Services were represented on the Serious Case Review Group.
3. Background information 3.1 Mr W and Ms W1 both had childhoods where they experienced disruption and unhappiness. As adults they had mental health problems and met whilst receiving mental health services. Ms W1’s children from her marriage went to live with their father and his family when she was particularly unwell but she was able to keep in touch with them and for many years they have had regular contact with her. Ms W1 has continued to receive treatment and support from her GP and the mental health services as well as treatment for a number of physical health problems. Mr W was discharged from the mental health services and then had no further contact. 3.2 Mr W and Ms W1 wanted to have a child and were living together by the time Child W was born. Ms W1 had spoken to professionals on occasions about Mr W’s controlling and abusive behaviour towards her but at the time of Child W’s birth there was nothing which caused the agencies concern. 3.3 When Child W was 6 months old Ms W1 separated from Mr W. She spoke of him getting drunk and that his behaviour was threatening towards her and members of her family. She said there were concerns about his conduct towards an ex-partner’s child from a previous relationship. Ms W1 described Mr W as having some obsessional worries about his son, leading to very controlling behaviour towards him. 3.4 Ms W1 and Child W were in contact with the Children and Young People’s Service and the police at the point of the separation. They lived in hostel accommodation and then supported housing before moving to their own tenancy. They were in close contact with housing support services. Mr W remained in touch with Ms W1 and Child W throughout. He began to visit and then stay regularly, so that he was spending a significant proportion of each week with them. 3.5 The family lived in Sure Start areas both before the separation and after they left the hostel. Health visiting services and, later, other child and family support services were provided through the Sure Start Children’s Centres. There was brief contact with the Children and Young People’s Service and the police after Ms W1 had taken an overdose in response to problems she was having with Mr W and again with the Children and Young People’s Service when Child W was assessed for a place at a nursery. 3.6 The only serious concern about Child W was that he was very slow to be able to bear his own weight, to sit and then to walk. He was referred to the community paediatrician who gave advice and after some time he caught up in his physical development. Ms W1 had not told the workers from the agencies in touch with her and her son the full extent of Mr W’s contact with them. They thought that Child W went to a family member for contact with his father once a week. Ms W1 did speak on occasions of Mr W’s intimidating and violent behaviour towards her. She also told workers that he insisted Child W should stay in his buggy and not be put on the floor.
3.7 In the few weeks before his death Child W began to attend nursery and had settled well. Mr W had been working but Ms W1 said that he had become increasingly depressed and she had made an appointment for him to see the GP. Mr W put Child W to bed on the night of his death and he had seemed better that evening. In the night he woke Ms W1 to say he had killed his son. He had also caused injuries to himself. The appointment with the GP had been for later that week. 4. Findings from the review 4.1 The review considered whether, with the benefit of hindsight, different decisions or actions by the professionals and agencies working with Child W and Ms W1 might have led to an alternative course of events. The evidence from the review did not indicate that Child W’s death could have been predicted. There were no previous reports that Mr W had ever been violent to Child W. In the six months before his death there is no recorded information that Ms W1 had raised further concerns about Mr W’s behaviour towards him. 4.2 There were examples of good practice. When Ms W1 said she wanted to leave Mr W there was a swift response by the agencies and she and her son’s immediate safety was assured by their move to the hostel. Ms W1 received good support from Housing Services to move on from the hostel and then to manage her own tenancy. Ms W1 has spoken of how helpful she found the health visitors and how much support she received from the workers at the Children’s Centre to help her feel confident to take Child W to nursery, as she found if difficult to go out alone. 4.3 The review found that there were a number of lessons to be learned which have led to recommendations for the future. These are grouped under headings. Recognising parental mental illness and assessing what this means for the child 4.4. From when Child W was 6 months old Ms W1 spoke about how Mr W’s anxieties and fears about his son affected Child W’s care and development. This information was not linked with the knowledge some agencies had about Mr W’s earlier mental health problems and how he had behaved at that time. There was no direct contact with Mr W by either the police or the Children and Young People’s Service so he was not challenged about his behaviour and beliefs. If he had been there may have been a clearer picture of his mental state. The concerns were more about the risk from domestic violence and it is not clear why mental illness was not considered as a possible reason for Mr W’s behaviour. There were opportunities for discussion between professionals and workers from agencies involved with the family. Even if these had been used more fully it would still have required workers to consider the possibility of mental illness in the first place.
Involving non-resident fathers 4.5. Mr W was not known personally to most people working with Child W and Ms W1. Their separation was seen as a solution to any risk he might pose to his son. In fact he spent much more time in the family home than any of the professionals realised. His level of control over Ms W1 meant it would have been very difficult for her to be open about their situation and in public he was able to put on a ‘good face’. The review felt it was very important to always include the fathers of children in any assessment, even if they are not actually living in the home. How professionals work with parents 4.6. Ms W1 was given very positive support to help her to separate from Mr W in the first place. After this when she told workers about some of the problems she was having with Mr W she was usually advised to seek legal advice. This was sensible but is not a sufficient answer to managing a separated parent’s requests for contact with their child, particularly when there is domestic violence. Ms W1 was grateful for the help she was offered and it seems that she may not have been persistent in asking for further help or explaining the full extent of her concerns. Those working with her did not then look deeply enough at what lay behind what she was saying and how she expressed herself. Family support and child protection 4.7. Ms W1 was very committed to caring for Child W and having regular contact with her older children. She did benefit from the support services she received. Child W also benefited from his contact with children’s workers and then from going to nursery. The focus of the work of the agencies was on family support. When Ms W1 spoke about her concerns about Mr W and the effect of his behaviour on Child W the implications for his safety were not fully recognised. With hindsight it is apparent that Ms W1 was finding it harder than was realised to withstand the pressures from Mr W. There were, however, occasions when what she was saying should have triggered a referral for assessment of Child W’s needs for protection. There was uncertainty about whether the ‘threshold’ was met for a referral. The family support services have made a number of recommendations about how they work in the future to ensure that children’s safety is fully taken into account when support services are provided to families. Management oversight, supervision, advice and consultation 4.8. When Ms W1 separated from Mr W there was little active involvement by Children’s Social Care after she was supported to move to the hostel. It has been acknowledged that there were particular workload pressures at that time which contributed to the service not remaining clear that an assessment of Child W’s needs was required. Within a very busy service there is pressure on managers to close cases as soon as it appears a situation has been resolved. However, the review has stressed the importance of the organisation ensuring checks and balances are in place to make sure that decisions about case closure are not made prematurely.
4.9. In community based teams which offer family support, professional staff have contact with many families. The review recognised that careful supervision is needed to support staff in working quite informally with families but to recognise when there is potential risk to children. 4.10. Child W’s family situation was not straightforward, particularly in terms of recognising his father’s mental health problems and the effect of both his parents’ backgrounds on their capacity to keep him safe. The review emphasised the importance of supervision in all agencies to support frontline workers to keep their focus on the needs of the child and to look at what might be below the surface. 4.11. Professionals in all agencies need to be confident to seek advice and guidance, about whether to make a referral, to question the reasons for a case being closed if they still have concerns, or to consider whether new information should be shared. Those working with the family did not always do this, and further work is needed to build relationships between agencies so that all feel confident to seek advice, question and challenge. Information sharing, retrieving information and the use of the Assessment Framework. 4.12. There are systems and procedures for keeping information about children and their families in order that the background knowledge can be taken into account when decisions are made. On the whole the systems and procedures were in place. There were a number of occasions, across the agencies, when information that had a bearing on the protection of Child W was not looked at and taken into account. 4.13. The “Assessment Framework” guides social workers in their assessment of children’s needs. Assessments can be at different levels, Initial and Core. Core Assessments consider the child and their family situation in more depth and are used when there are concerns about a child’s safety. The assessments need to be carried out within tight timescales to ensure there is no delay in understanding and meeting the child’s needs. All agencies who know the child and the parents are expected to contribute to assessments. There were occasions when Children’s Social Care should have used their existing information and current concerns to assess Child W’s needs more fully. There would then have been a clearer understanding of the risks to him, to what extent the family could safeguard him, and about how those working with the family could best safeguard Child W. 4.14 Lastly, the review highlighted that the GP practices had significant information about Child W and his family but there was little communication with the other agencies involved. The GP practices did not appear to feel they had information to give and they were not contacted by the agencies for information. The review has recommended that there is exploration of the GP’s role in interagency work to safeguard children.
Recommendations from the overview report
Recommendations linked with Mental Health (Conclusions 5.4-5.8) 5.1.The LSCB will incorporate the findings of this review into the existing LSCB Business Plan work-stream, Strengthening Links with Adult Services. In this instance this refers to Adult Mental Health Services. Actions will include: • • Review the content of LSCB training courses to ensure that parental mental illness is always included in considering sources of risk to children. To consider whether the findings from this review in respect of raising awareness to indicators of serious mental illness, the links with substance misuse and domestic violence and the risk to children can be incorporated into the Action Plan which will be developed following the LSCB conference, Crossing the Divide. The LSCB should ensure the implications for children are always taken into account in any mental health assessment, inpatient, outpatient or with pregnant women. To enable this to happen the Leicestershire Partnership Trust recommendations regarding use of multi-agency meetings should be incorporated into an inter-agency Action Plan. Consideration of the role of the adult mental health social worker in providing a pathway with the CYPS and other relevant children’s services, particularly in respect of lower level concerns.
Recommendations linked with thresholds 5.2.The LSCB to take steps to assure itself that agencies are confident to make referrals in line with thresholds. Actions will include: • • The LSCB to ensure that the guidance on the thresholds for referral to the Children and Young People’s Services are clear. The LSCB to take steps to assure itself that agencies are confident to use the agreed processes to challenge decisions by the CYPS relating to referrals and case closure if they feel that there are outstanding child protection concerns.
The LSCB should ensure that targeted intervention with families complies with CAF/Lead Professional guidance in respect of assessments, thresholds and recording, to ensure a smooth transition from targeted intervention to the use of child protection processes. This is consistent with the Early Prevention Services recommendations.
Recommendations linked with information systems 5.3.The LSCB, using the issues raised in this review, to agree with all agencies a process by which they review their systems to ensure that staff are clear and confident about: • • • identifying and recording significant information, retrieving information using existing information when new information is received or cases transfer between workers.
Inter-agency links with GP practices (Conclusion 5.20) 5.4.The LSCB, using the findings of this review, to facilitate a process to the role of GPs in inter-agency work to safeguard children. explore
Use of CAF and the Framework for the Assessment of Children in Need
5.5.The LSCB should ensure all agencies: • • contribute fully to Initial and Core Assessments raise their awareness of fathers and partners who may be less visible to agencies but who should be involved in all assessments.
This is consistent with the recommendations from Leicester City CYPS and the Early Prevention Service relating to the application of the Framework for the Assessment of Children in Need and the Common Assessment Framework. 6. Recommendations made in the Individual Management Reviews Leicestershire Constabulary .1.The Leicestershire Constabulary Child Abuse Investigation Unit should review its working practices to ensure that in addition to existing requirements, investigating officers are required to: a) Review all related domestic abuse referrals and intelligence to identify and mitigate predictable risk factors. b) Review previous outstanding investigations relating to the parties involved in the case to ensure that new information is used to progress these where appropriate and that they are factored into the current risk assessments. c) Collate and share with partner agencies all relevant convictions and intelligence necessary to protect a child. d) Conduct risk assessments at the conclusion of an investigation whether there is a prosecution or not. This should include a recorded summary of
the potential risks to the victim or siblings or other parties from any perpetrators or other risky adults. The record created should be linked to the enquiry records and also detail any action taken to mitigate the risks. 2. Leicestershire Constabulary should review its record keeping systems to develop a method of linking all requests for information and the information given, to each child abuse investigation record. 3. Leicestershire Constabulary should develop agreements with its partner agencies to clarify the limited SPOC / department channels through which they will normally make requests for information. Housing services 1. Protocols between STAR and Children’s Centres should be reviewed in line with information sharing within the CAF Services and furthermore include all housing services 2. All Hostel staff to be trained in Domestic violence and in particular the impact this has on children (STAR and Housing Family Support have already received this training). 3. Discussions should take place with health services regarding the transfer of information on families in the homeless families hostels between health visitors. 4. Housing staff to contact the Head of Hostels Services / Service Director Accommodation and Tenancy Support when they have concerns about a response they have received from Children’s and Young Person’s Services (case closure). Leicester City CYPS 1. The Duty and Assessment Service should review and ensure that systems are now in place • to prevent inappropriate allocation where there are unresolved risk assessment issues, and • to ensure that assessments are completed in line with the Assessment Framework. 2. Practice lessons from this case should focus on • the potential risk to children and young people when parents separate and there are contact issues and where there are issues of domestic violence, sexual abuse, alcohol misuse and mental health problems intertwined. • the importance of social history in assessing current risk • that it should never be assumed that the fact that parents have separated will minimise risk. 3. Previous referrals where concerns have been identified should be recorded as such on Care First. All such records should be read when dealing with a new referral.
4. Where Children’s Social Care is advised of potential risk to any future children, this information must be shared with the local Primary Care Team Leicester City CYPS (Early prevention) 1. Policy and Procedure will be developed to ensure that all families receiving targeted intervention have an assessment of their needs, a planned intervention, and recording systems that provide appropriate and accessible information to all professionals involved. This should consider C.A.F. as the appropriate framework and case recording should be subject to annual audit linked to the annual Performance Assessment. 2. All Children’s Centres will ensure that staff are able to identify and record significant information and that there are systems in place for retrieving this information and ensuring that existing information is built upon when new information is received. These systems should also ensure that information is made available when cases are transferred between workers, both within individual Children’s Centres and across the city when families move. 3. A multi-agency approach to supervision for children’s centre staff undertaking targeted work with families will be developed across the city. The approach will clarify line management and supervision responsibilities, both within the children’ Centres and externally where professional supervision is provided by other agencies or departments. 4. Children’s Centres will work with the LCSB to ensure that all Children’s Centres staff have a clear understanding of threshold criteria and the requirement to refer appropriately to Duty and Assessment, particularly where issues of domestic violence and mental health are impacting upon parenting. 5. Centres will audit current staff attitudes to information sharing at a preventative level and then respond to the outcomes of that audit in a manner which improves how, and what information is shared. 6. Early Prevention will work with the safeguarding and family support division to establish procedures for appropriate information sharing with Children’s Centres Staff. In particular, access to Care First and case records for appropriate staff should be in place at each Children’s Centre. 7. Existing protocols between Children’s Centres and STAR should be reviewed and extended to address all housing services and in particular information sharing within the CAF services. Leicestershire Partnership Trust Recommendations 1. Leicestershire Partnership Trust will take responsibility for holding a separate Multi Agency meeting, separate to the Ward Round, when any Child Protection concerns past or present are raised and produce a clear Strategy, Action Plan and Responsibilities.
2. Leicestershire Partnership Trust (LPT) Named Nurse, Midwifery Specialist Nurse (UHL), Named Nurses for Leicester City Community Health Services / Leicestershire County and Rutland will meet monthly to raise concerns and discuss any issues concerning mothers or their unborn babies. This will included Mothers who have had Learning Disabilities, previous Mental Health or substance misuse issues or it is felt that they are currently in need of services. 3. Leicestershire Partnership Trust will provide support and advice to any one reporting Domestic Violence. This will include giving contact details about specialist services, assisting contact with an independent Domestic Violence Advisor or making a referral to a MARAC (Multi Agency Risk Assessment Conference). All reported cases of Domestic Violence where there are Children or Vulnerable Adults within the household will be referred to Social Care. 4. Where it is known that one or more Adults or Parents in a household have mental health issues, information will be shared with the General Practitioner (GP) and other Clinicians who are involved to ensure the safety of any Children or vulnerable people in the household. NHS Leicester City 1. Safeguarding Training (including response and targeting safeguarding) should be made mandatory for all staff within all provider service contracts (including NHS Trusts, Independent, Private and Voluntary providers) appropriate to role and responsibilities. This will need to be evidenced by inclusion of compliance within organisations annual reports. This should also be introduced to all new or reviewed job descriptions. Leicester City Community Health Services 1. Children and families living in hostel accommodation should have access to health visiting provision that is specifically targeted and resourced to meet the additional needs of this vulnerable group. CAFCASS 1. The Serious Case Review supports the agreement CAFCASS has reached with ACPO (Association of Chief Police Officers) that all checks will involve information in addition to PNC convictions and recommends that this is implemented and operated at a local level at the earliest opportunity. 2. It is recommended that CAFCASS reviews current practice in respect of agency check on parents’ new partners to ensure that information which may have a bearing on the overall assessment is gathered.
Leicestershire CYPS Children’s Social Care 1. Staff should be reminded to make every effort to trace historic information relating to alleged abuse, record the outcome of the search and include any information in any relevant assessment.
Susan Nash -Independent Overview Author
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