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Southampton Safeguarding Children Board Serious Case Review Child F Executive Summary

Panel Chair: Donald McPhail Report author: Laura Eades

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1. Background and Review Process The reasons for conducting the SCR 1.1 In 2011 Child F, who was then aged 2 years was admitted to hospital in an emergency, with a wheezy chest which progressed to respiratory distress, had pinpoint pupils and was very drowsy and disorientated. Her mother was with her but gave no explanation for her condition. Urine toxicology screening one day later, indicated that Child F had ingested methadone. The child subsequently made a full recovery. Child F and her older sister child C were removed from their mothers care and placed together with foster carers.


The case was presented to a Consideration Meeting of the Southampton LSCB Serious Case Review sub-committee. It was agreed by the Panel that the central issue of concern was the access of Child F to methadone in the home and that this in itself constituted serious neglect by the parents.


It was also agreed that gaps in multi-agency practice could be identified and that the criteria as laid out in Working Together 2010 Chapter 8 were met for a Serious Case Review. The serious nature of the concerns was underlined by information that this incident was preceded by the death of a man, Mr G, mother’s partner, who had died from a methadone overdose in the family home only weeks before the admission of Child F to hospital and that at the time of both incidents, Child F and Child C were subject to a Child Protection Plan. Ofsted were informed of this decision by a letter from the Independent Chair of the LSCB on 25th March 2011.


Scope, focus and terms of reference of the SCR. 1.5 While the main subject of the SCR concerns, Child F, it is impossible to review the circumstances of her life without setting it firmly within the history and context of her older siblings Child A and Child B (who were removed to care and adopted before Child C’s birth) and particularly of Child C, her elder sibling who was living in the same household at the time of the critical incident. Hence the LSCB decided that the scope of the review should extend to encompass events from the antenatal period for Child C onwards. The Terms of Reference for the SCR are included as Appendix 1.
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Appointment of the SCR panel, the SCR panel chair and the appointment and role of the independent overview report author


The SCR Panel was agreed at the Consideration Meeting. The Independent Chair of the LSCB, Donald McPhail chaired the Panel and other members were as follows; Service Manager, Children’s Services & Learning (retired mid way through the process) Interim Service Manager attended 1 further meeting Head of Housing Management, Southampton City Council Senior Inspector, Education, Commissioning & Inclusion Southampton LSCB Board Manager Head of Safeguarding, Southern Health Foundation Trust Hampshire Probation Trust Designated Doctor, NHS Southampton Public Protection Serious Case Reviewer, Hampshire Constabulary Designated Nurse, NHS Southampton


The overview report author, Laura Eades was appointed following consideration of potential authors by the SCR Panel Chair. The overview author is a current Chair of two LSCBs and has chaired, project managed and written a number of Serious Case Reviews. She has a professional background in social work and has held posts of Assistant Director and Project Director within Children’s Services Neither the Chair the Overview author or any panel member had any prior involvement with the family. IMRs were requested from the following agencies; Southampton City Council Children’s Social Care Southampton University Hospital Trust NHS Southampton City Solent NHS Trust Southern Health Foundation Trust Southampton City Council Early Years and Education Services Southampton City Council Housing Services



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Southampton City Council Independent Domestic Violence Advocacy service Hampshire Probation Hampshire Police South Central Ambulance Trust Society of St James (Drug Treatment Services – voluntary sector organisation) CAFCASS 1.10 In addition a health overview report was commissioned and additional information was sought about the commissioning of substance misuse services for the Southampton Drug Action Team (DAT)


The SCR Panel met on 10 occasions. Involvement of the children and other family members


The Panel informed the parents and maternal grandmother of this SCR by letter from the chair on 18th May 2011. The overview author contacted Ms D Mr E and Ms H by letter in mid September. Ms D and Ms H were interviewed by the overview author on October 12th 2011. Mr E was in prison during much of the time the SCR was being conducted. Following his release he was hard to track down and eventually was found sleeping rough in a local town. The overview author made a decision not to interview him in this context as he would very likely be under the influence of drink or drugs. It was agreed by the Panel that Child F and Child C who were in foster care but still with contact with mother and grandmother, would not benefit from involvement in the Review. However it was stressed that they should be made aware of the Review at an appropriate stage and arrangements made to support them to access it if they wished.

2. Summary of the case 2.1 Child F was the fourth child of the family. She was admitted to hospital in 2011 at the age of 2 years with potentially life threatening symptoms following ingestion of methadone in the family home. The methadone had been prescribed for her mother. The children’s father was also accessing services to address his illicit drug use and was on a methadone prescription but at the time of the incident, he was not living in the family home. Mother was in a new relationship with Mr G.

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The mother had a 10 year history of drug misuse and in 2009 as a result of her increased use of heroin and occasionally crack cocaine, had asked for help from drug treatment services to get off illicit drugs and reduce her alcohol use. At the time of Child F’s hospital admission, mother had been in receipt of a prescription for methadone for over a year. She was taking the methadone at home and had been given advice on how to store it safely. It is still not clear how Child F accessed the methadone although mother believes that the child must have found a discarded bottle or bottles in the rubbish bin and drunk the liquid remaining in them. Child C was in the house at the time. At the time of the hospital admission, both Child F and Child C were subject to Child Protection Plans. The children and their parents were well known to a number of agencies across Southampton and this had been the case since the birth of two previous children of the parents, Child A and Child B who had been removed to care under Care Orders just before the birth of Child C and were subsequently adopted. The concerns for all the children had been about neglectful care by the parents due to alcohol and drug abuse, domestic violence, unstable relationship and criminal activity. Neither Child C nor Child F have had any contact with these older siblings. The review looked in detail at seven time periods in the history of the family and evaluated the effectiveness of multi agency work to safeguard the children. In addition the review explored practice across a number of themes; domestic violence, management of substance misuse issues, use of policies and procedures, management of neglect, focus on diversity, staff competency, management and supervision of practitioners and engaging with parents.



3. Key Findings 3.1 Assessment practice in this case lacked a child focus. Assessments were focussed far too much on the parent’s capacity to parent rather than on the intrinsic impact of their behaviours on the children. The pre birth assessment of Child C and the lack of a pre birth assessment of Child F illustrates how the focus was on supporting mother in her expressed desire to look after her children and her apparent compliance with the requirements made of her. The assessments of both children failed to fully take into account the information available to them from the previous court proceedings which highlighted mother ‘s inconsistent care, disguised compliance and neglectful care of Child A and Child B. These were factors that required rigorous monitoring and immediate action if similar
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behaviours were evidence in respect of Child C and then Child F. This was not the case. 3.2 The case was not identified and managed as one of chronic neglect. Even though key features of neglect were in evidence, the case was dealt with as a series of incidents rather than an accumulation of negative experiences for the children. The GPs were the professionals who received all the information about the parents and children in this case and were the least practice in assessing the impact on the children of all the parental issues. There are significant issues for GP practices in understanding their crucial role and in making arrangements to ensure that such information is carefully considered. Substance misuse services were not effectively engaged in multi agency work with this family despite their awareness of the involvement of social care and the Police at certain points. There was poor communication with them from statutory partners but the organisations also lacked confidence and expertise in working with risk to children for parental substance misuse. The Police were a critical agency in all senses in this case as they had involvement in 3 main areas; i) response to and communication about domestic violence and appropriate identification of risk, ii)responses to and overview of the criminal behaviour of both parents and awareness that much of this was linked to their drug and alcohol abuse as was the domestic abuse iii)the participation in the child protection process. The lack of join up between these areas of work ensured that they failed as an agency to properly identify assess and respond to the risk posed to these young children by the criminal and violent behaviour of their parents. The investigation regarding Mr G was a missed opportunity to fully identify the risks posed to the children by Ms D’s chaotic lifestyle. The Police and social care’s protracted response to the death of Mr G and their missed opportunity to work together as agencies with responsibility for protecting children was a significant weakness in this case. The Acute health services modelled good practice in relation to the physical well being of the children and response to chronic illness. The hospital services acted in good faith to respond to the health issues including the significant medical crises in Child F’s life. They made every attempt to identify child protection concerns amidst the tasks of providing critical care and in a sense had far less opportunity to see the whole picture as their interventions were episodic.
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Domestic violence processes and services tended to operate in isolation from other risks and the IDVA service’s focus on support to the victim did not always assist the multi agency understanding of risks to the children. However, the IDVA worker’s direct involvement with Ms D was effective in helping her make changes that impacted positively on the children. The risk posed by prescribed methadone use by a parent of young children was not identified within the context of this family. The presence of drug in the home, including illicit drugs at times posed an ever present possibility that the children may access them. The lack of clarity by workers visiting the home about what methadone looked like and the arrangements for safe storage and disposal did not provide any sort of safety net. The lack of interagency consideration of risk following the death of Mr G from methadone overdose only two months before the critical incident is a key issue in assessing whether the ingestions of the drug by Child F was preventable.


4. Conclusion 4.1 The critical incident leading to the review of Child F’s ingestion of methadone was probably not predictable in the light of what agencies (individually and collectively) knew and understood about the parents drug use and other risk factors. However the pattern of chronic neglect in the family and the agencies pattern of responding to individual incidents does suggest that the sad event was an accident waiting to happen. Even the death of Mr G had not prompted robust action to protect the children and so it seems inevitable that only evidence of physical harm to one or other of the children was going to prompt a robust response. The question as to whether the incident was preventable lies in the early stages of the lives of both Child C and Child F and the decisions that were made about the risks posed to them in the care of their mother. Even the limited risks that were identified and which resulted in clear plans, were not responded to. This left Ms D and Mr E in the position of parenting Child C and Child F without a clear understanding of expectations and thresholds. It allowed Ms D even now when she has had four children who are no longer in her care, to believe that she has done all that it required of her to be a good and successful parent. The conclusion to be drawn is that Child F and Child C should not have been subjected to neglect and placed at risk from other forms of significant harm in the same way that their older siblings Child A and Child B had. It is poignant that they were of similar ages to these children when they were removed from Ms D’s care.
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5. Recommendations 5.1 There are a considerable number of recommendations from this review. All the recommendations from the IMRs and the Health Overview Report were considered by the Panel is determining those that should made by the overview report author. The SCR panel on behalf of Southampton LSCB considered that this review highlighted some new areas of concern for the Board particularly with regard to the commissioning of substance misuse services. All recommendations have been reviewed and where the recommendation is broader than for a single agency, these have been added to those in the overview report.

6. Overview Report recommendations 1. Southampton children’s social care should ensure that the rich information about risk factors that is available from the care proceedings of older siblings/other children is used to formulate care plans for other children/unborn children of those parents. 2. Southampton SSCB should ensure that where there is care order or supervision order on a child who is placed with parents or where there is a pre-birth assessment on a child where other children in the family have been subject to care proceedings there should be a very robust framework around the management of the case. Information about factors which prompted the removal of other children from the family should be made available to core agencies to assist in the monitoring of the safety and well being of the children. The possibility of using Child Protection processes during this period should be considered. 3. Southampton SSCB should ensure that the management of cases where the child is subject to a supervision order takes full account of the powers available to them under such a court order. 4. Southampton SSCB should require all agencies to use the escalation policy when challenge to an agency fails to result in protective action. 5. Southampton Children’s social care should improve management oversight of complex cases. 6. Southampton Children’s Services must ensure that whenever cases are closed and where there is a management project to close cases which are open and inactive, that robust criteria for closure are applied which include giving particular attention to cases where there have been Care Proceedings, child protection plans and a combination of significant risk factor and should ensure that in such cases, there is consultation with those agencies working with key aspects of risk.

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7. Southampton SSCB should ensure that guidance to professionals about abuse and neglect reflects the fact that some children express distress and difficulty in over compliance, eagerness to please and an over concern for others. 8. NHS Southampton should ensure that where patients present with serious injuries allegedly inflicted by someone else and where children are present during such incidents, the Walk in Clinic and GP practices contact the Police. 9. NHS Southampton should ensure that all GP practices are addressing issues of chronic asthma in young children though providing a chronic conditions management service. 10. Hampshire Police and social care must ensure that appropriate discussions are held following an unexplained death in a household where there are young children to share relevant information to inform plans to safeguard them. 11. Ambulance crew should always be interviewed by Hampshire Police should they have been involved in an investigation into a suspicious death in the home. 12. Children’s social care should always ensure that drug treatment services are advised of any significant or serious events concerning drugs in any open case and consult them as to any relevant safeguarding issues such as the need for supervision of methadone doses. 13. Senior Management in Hampshire Constabulary should ensure that there is sufficient capacity within the service to support processes which provide information and analysis of risk in respect of repeated incidents of domestic abuse in the same family. 14. MARAC action plans must address the need to progress target hardening as soon as the need for them is identified and not wait for the notification of release from custody of an offender. Panic alarms should be installed within clear timescales. 15. Her Majesty’s Prison Service is advised by Southampton SSCB of the need to develop a means for communicating release dates of violent offenders to local Police forces 16. Southampton SSCB should ensure all core agencies have systems in place to assess the risk that domestic violence poses. 17. Southampton SSCB should ensure that there are clear referral pathways to specialist services when risk is high. 18. Southampton LSCB should ensure that all agencies understand the links between MARAC and Child Protection Conferences and what their respective roles and responsibilities are and the expected outcomes. Southampton Domestic Violence Forum should review systems in place for sharing information about domestic violence incidents across the city. 19. The safe storage and the safe disposal of methadone must be discussed at each new referral to drug services with the service user.
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20. Southampton SSCB should advise the Southampton Drug action team of the findings of this SCR in relations to safe storage and disposal of methadone and request a revision of the guidance and a clear protocol outlining which agency is primarily responsible for providing advice and guidance and whether there is a secondary responsibility for agencies visiting the family home to check on arrangements . 21. The LSCB should ensure that commissioners agree a protocol on the commissioning of a timely response for drug testing where a child is subject to child protection processes or care proceedings and that arrangements are detailed in local procedures. 22. Commissioners should ensure that SSMS are able to fully engage with child protection activity and are confident about the use of local protocols and local safeguarding procedures, knowing who to contact and who to seek advice from. 23. Southampton SSCB should ensure that substance misuse services are fully compliant with the LSCB safeguarding standards for commissioning. 24. Southampton SSCB should ensure that all agencies working with children and families where substance misuse is a known risk factor provide practitioners with information and training in understanding the effects, prescribing options, and safe/lethal doses of commonly used drugs and being able to identify prescribed methadone. 25. Southampton SSCB should require agencies to provide assurance that when there is a critical incident such as a death, accident or serious crime involving people who are actively using drug treatment services, that information is shared with substance misuse services to ensure that they can take action to protect children and vulnerable people with e.g. supervised dosing. 26. Southampton LSCB should conduct a systematic review of how agencies identify and respond to chronic neglect. 27. Southampton Children’s Services should ensure that all assessments and reports to Child Protection Conferences address issues of children’s attachment, the impact of domestic abuse and parental substance misuse 28. Southampton Children’s Services should ensure that social work staff are equipped to undertake such assessments. 29. Southampton Children’s Services must ensure that Child Protection Plans for children subject to neglect, address the need for high quality dental care. 30. Southampton SSCB should ensure that commissioners are engaging with and ensuring dentists have appropriate safeguarding arrangements in place and are able to identify their role in identifying neglect. 31. Southampton LSCB should consider how it can monitor progress in relation to the inclusion of information about the child’s experience in all assessments and plans.
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32. NHS Southampton should provide guidance and support to GP practices in the establishment and monitoring of standards of practice re safeguarding children. This should provide clarity about the expectations regarding safeguarding supervision/consultation. Internal Management Review Recommendations GP s 1. Increase awareness issues of Domestic Violence, potential effects on children and families. 2. Increased knowledge of the joint working protocol and increased implementation within daily practice. 3. Increased knowledge of the CAF process and increased implementation within daily practice. Increased awareness and interaction with other key agencies. 4. New patient registration forms to have an additional section requesting information on over the counter medications, alternative medication and illicit drugs. 5. Improve performance management of Primary Care services. 6. Increase awareness GP role and responsibility in engaging in child protection conferences. 7. Practice undertaking methadone prescribing should ensure ALL practitioners have a basic knowledge and understanding of the client group and potential side effects of the medication including those of overdose. 8. Ensure regular robust communication systems are in place between health visitors and practices. Solent Healthcare 1. Walk in Centre/ Unscheduled care service documentation to be amended to include ‘children’s view’ domain 2. Raise awareness among staff of protocol for transition of children of concern from health visiting to school nursing service. 3. Continue to embed use of neglect toolkit in practice. 4. Complex substance misuse training should be provided to health visitors and other key groups of practitioners. 5. Review safeguarding supervision model for health visitors and ensure that agreed actions have a time limit identified. 6. Initiate pilot of enhanced communication system between GPs and health visitors. 7. Raise awareness of system for managing professional disagreements/ escalation policy. 8. Common assessment process that may be used across all Solent Health Services is developed.
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9. The non engagement protocols for each service in Solent NHS Trust should be audited. 10. Ethnicity should be routinely recorded on all Solent NHS Trust records.

Southern Health 1. The role of Drug Worker Lead for Child Safeguarding coordinates jointly with Southampton Children’s Services to share good practice in working together and develop ways in which improvements can be made to communication 2. SHFT provide awareness for all staff groups of the recently developed Domestic Abuse Policy including the availability of domestic abuse training throughout SHFT 3. The use of DICE is reviewed and replaced/amended to consider the risk of domestic abuse and the effects domestic abuse may be having on any children of the client 4. SHFT (HPFT) KW’s and prescribing Drs will provide information to clients regarding the safe storage, consumption and disposal of prescribed methadone and other drugs and substances for the following groups: • Clients who are under the Care of the Substitute Prescribing Service in situations were children may come into contact with the drugs. • Clients under the care of the Substitute Prescribing Service when requesting ‘holiday prescriptions’ • Other clients whose lifestyles, health problems or disability may mean there is a heightened risk to children from unsafe storage, taking or disposal of drugs 6 When a client is a member of a family and one client is under Care Coordination from SHFT and another under SSJ and they are in a household with children or one of them is pregnant, there will be regular joint meetings to consider risks concerning children between SHFT and SSJ 7 Substance misuse Manager at NRC will review SHFT workers child protection and domestic abuse training records and develop a bespoke programme that allows for development of staff with multi agency training in accordance with Intercollegiate guidance (Royal College of Paediatricians (2010). Record of all training are provided to SHFT training department 8 The quality of assessments received by SHFT substance misuse workers is considered as part of the case note supervision, missing information identified and challenged with the referrer if needed 9 KWs will ask clients at care plan reviews if there are changes in the family situation, including potential new partners that may have an impact on any children in the household
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NRC to review attendance of KWs at Child Protection Case Conferences and planning/core group meetings and identify what prevents KW’s from attending and work with Children Services to increase attendance This IMR and its recommendations are reviewed by the SHFT Heads of Safeguarding Adults to see if lessons learned for children apply to vulnerable adults under the care of SHFT.


SUHT 1. That for all adult parents or carers who presents to ED where there are risk factors present, ED staff with complete a child protection/safeguarding risk assessment or refer as a child protection case if at that threshold. 2. That all ED staff access SUHT child protection/safeguard Topic Specific training on risk factors or/and the ED targeted awareness raising training sessions on risk factors. 3. That ED undertake a review of the Concern Form system and associated administrative process. Ambulance Trust 1. SCAS staff member who raised verbal concerns learns from this incident 2. All SCAS staff learns from this incident 3. Evaluate lessons learned from the West Berkshire pilot scheme Society of St James 1. That better records of interagency meetings are produced and retained 2. That the Society will develop an overarching client database to track children at risk
across projects

Health Overview 1. NHS Southampton as a partner in the Drug Action Team should review commissioning arrangements of substance misuse services to ensure the use of consistent assessment processes which routinely and reliably consider all children and clients who may be at risk. 2. NHS Southampton City should review commissioning arrangements to Substance Misuse Services to ensure that an appropriate and child friendly facility is available for children when they attend appointments with parents.

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3. NHS Southampton City should require all substance misuse services (not just those named in this overview report) to review their arrangements for advising clients on the safe storage and disposal of prescribed and as far as is possible, other medication or ‘street’ drugs. 4. NHS Southampton City should ensure that all providers are aware of the requirement to provide child protection or safeguarding supervision, and that this requirement is included in contract monitoring arrangements. 5. NHS Southampton City should ensure robust arrangements for regular liaison between General Practitioners and health visiting teams through the establishment of link health visitors who meet practice safeguarding leads on a regular basis to discuss families causing concern 6. NHS Southampton City should work with Solent NHS Trust should ensure capacity in the health visiting service for effective liaison with General Practitioners 7. NHS Southampton should reform systems for providing support to GP practices in relation to safeguarding children standards. Intensive support should be provided to enable practices to achieve auditable compliance with Care Quality Commission and Royal College of General Practitioners standards by April 2012. 8. NHS Southampton City primary care team should work with the safeguarding children professionals to ensure there is sufficient capacity within practices to enable GPs to effectively fulfil their safeguarding responsibilities. 9. NHS Southampton City should ensure that health services are developed and commissioned to ensure that arrangements are compliant with Department of Health Guidance ‘commissioning NHS services for women and children who are victims of violence or abuse – a guide for health commissioners (2011). 10. NHS Southampton City should ensure that health services are developed and commissioned to ensure that arrangements are compliant with Department of Health Guidance ‘commissioning NHS services for women and children who are victims of violence or abuse – a guide for health commissioners (2011). 11. NHS Southampton City should require local health providers to submit the findings of their annual audit of record-keeping and identify the proportion of records which have ethnicity recorded. 12. NHS Southampton supports the continuing development of multiagency triage of CYP reports

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Housing 1. Staff working in homelessness to flag up on the housing computer system risk factors that may affect the management of at tenancy. 2. To make sure that Housing Management Officers and Income Officers are sharing information on known support needs and risk factors. 3. Staff working in homelessness to be reminded of the importance of completing pre-tenancy assessments. 4. To review the sign up procedure and the level of appropriate follow up work by Housing Management Officers following the completion of the personal checklist / vulnerability form. 5. To remind Housing Management Officers to generate a pop up box on IWORLD at the time of sign up to indicate that a tenant is vulnerable. 6. To remind Housing Management Officers of the importance of completing settling in visits, particularly where there are vulnerabilities 7. To carry out a briefing session with staff on the Income Team explaining the MARAC process and wider issues around domestic violence. IDVA 1. As part of the strategic co-ordination of multi-agency responses to DV in Southampton ensure all core agencies have systems in place to risk assess DV and knowledge of appropriate responses based on that risk – including referral pathways to specialist DV services. 2. As part of the strategic co-ordination of multi-agency responses to DV in Southampton ensure and facilitate awareness between core mainstream services and specialist DV services of respective roles and functions when working with families where DV is a risk factor 3. Ensure MARAC systems are in place and meetings conducted in a way that leads to clear, SMART and accurate risk identification and actions that are clearly recorded – including details of attendees at each MARAC 4. Ensure safety planning and measures to reduce risk to victims is not based around or dependent upon offender custody release dates where custody is short-term and timely information about release dates is highly unpredictable.


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1. Training to all frontline staff in risk to children and CYPR submission should be updated 2. The force should have in place processes to identify repeat victims and serial perpetrators and identify a method of managing these problems. 3. Police to be considered as participants in core groups if they are actively engaged with the family. 4. Any proactive police intervention such as an unannounced visit should be part of the documented child protection (or MARAC) plan. If this is considered outside of the meeting structure then children social care should be consulted before any visit takes place. 5. Police to monitor closely actions arising from meetings and ensure they are completed in a timely fashion. 6. That a review is conducted of minute taking at MARACs and improvements should be made to better reflect discussion and actions taken. 7. That all minutes and notes from MARAC meetings are available on the police Records Management System to be available and searchable in a retrievable format. 8. CA12 forms should either be legibly written or typed. 9. Police should participate in agency training/awareness raising about parents who misuse drugs and the risk to children. 10. MARAC administration should be reviewed with a view to gaining support from all MARAC

Probation 1. HPT to incorporate revised guidance on home visits to offenders who live with or who have contact with children subject to a child protection plan or where there are other concerns or evidence that a child(ren) may be at risk. 2. Where there is evidence of domestic abuse behaviours, irrespective of the age of evidence, offender managers will ensure the evidence informs risk assessments and risk management. 3. HPT to improve recording of any contact with children and/or offender family members. 4. HPT to improve recording of all case discussions and meetings held with other agencies concerning child safeguarding. Children’s Social Care 1. Training in Assessment skills that advance understanding of the focus of assessment; how to gather and consider information; consider risk in the family and in the family’s cultural experience; and how to make robust judgement should be provided on a rolling basis. 2. Assessment practice and the supervision of assessment should be reviewed in order to promote the focus on including men.

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3. Senior managers should consider the embedding of a specific approach or methodology to support assessment practice and include this in training. 4. A comprehensive training package for social workers around parental substance misuse alongside treatment workers and its impact should be commissioned and be supported by the joint protocol and by ongoing group supervision / action learning groups. 5. Social workers should further engage in domestic violence training to include the new domestic violence procedures within the Safeguarding Children Procedures (2011). 6. Training should be provided on an on-going basis regarding working with the child, both in assessment and in social work intervention skills, that is based in forming supportive and ‘therapeutic’ relationships with children living with their families 7. Explicit consideration should be given in supervision and in planning meetings to the nature of engagement by families. 8. Social workers should be given time to access and familiarise themselves with new procedures and guidance 9. The supervision policy should be revised to allow a more reflective style of supervision for each worker as per CWDC model for NQSWs and Early phase development social workers 10. That group supervision is held regularly and in a planned way to reflect on practice improvement and achievement. 11. That the ongoing development of senior practitioners as managers and decision makers is continued 12. That transfer points and policy for recording and receiving management instruction is reviewed. 13. The case decision of the weekly allocation meeting that is emailed to manager is placed on the individual child’s PARIS file and read by social workers. 14. That practice guidance is issued by senior managers to ensure that the child protection
system and the Public Law Outline are used when appropriate.

Education 1. Termly training for Child Protection Lead Officers (CPLO) includes training on the importance of contextualised records in relation to the child’s demeanour, well being and all issues related to safeguarding, particularly for those children subject to a Child Protection Plan

Drug Action Team

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1 That the Drug Action Team (DAT) will ensure that safeguarding is built into the commissioning agreement and that all service specifications include the key policy that drug treatment providers will focus on the families where parents misuse drugs, intervening early to prevent harm to children, prioritising parents' access to treatment where children are at risk and sharing information appropriately with other treatment providers and statutory agencies as required under the Joint Working Protocol (see 4lscb website). 2 Service specifications will include the 7 standards for treatment services working with adults as set out in the Southampton Safeguarding Children’s Board Standards for Commissioning i.e: Standard 1: Written policy on keeping children and young people safe. Standard 2: Putting policy into practice Standard 3: Recording and Reporting Standard 4: Safer recruitment Standard 5: Managing allegations Standard 6: Training for keeping children safe Standard 7: Agencies contribution to and learning from serious case reviews. 3 That Southampton Drug Action Team (DAT), together with all commissioned drug treatment services for Southampton City, agree a joint protocol outlining the processes and responsibilities to be undertaken by each service when dealing with service users who are parents, carers or who live in a household where there are children or vulnerable adults. The DAT will work with all drug treatment providers to review the current paper based case recording systems and agree protocols for the appropriate sharing of case records in advance of re-commissioning of existing services. Southampton DAT to work jointly with drug treatment providers and with Southampton Children’s and Adults services to share good practice in working together and improve communication. Southampton DAT will work with drug treatment providers to ensure that the seven standards are adopted, in particular in relation to providing attendance at Child Protection Case Conferences. To review the use of DICES as a tool for risk assessment and actively investigate the availability of alternative risk assessments that are fit for purpose.
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To train managers and staff to use the replacement tool and to be confident in asking challenging and difficult questions, practising “respectful uncertainty” and developing an investigative approach. To work with drug treatment providers to ensure that staff are offered regular and challenging supervision which will enable them to develop their interview skills in relation to asking difficult and challenging questions of service users. DAT to purchase on a “one off” basis lockable boxes for the safe storage of methadone and leaflets to inform parents/carers of the dangers of methadone to children and ways in which methadone can be stored and disposed of safely. Thereafter, the provision of lockable storage boxes to be built into the service specification of prescribing services. DAT to implement a series of quality audits of drug treatment services as part of the commissioning arrangements.




CAFCASS 1 I recommend that the Child Protection Manager should refer the issue of the supervision arrangements of SECs to the Director of Policy with a view to establishing whether these are sufficiently robust; and, if not, how these are to be strengthened. The use of the CAADA/DASH risk assessment tool should be mandatory in all cases where domestic abuse is a feature. Ensure that all teams receive training incorporating key learning derived from this IMR, to include: The dynamics of parental substance abuse. The timeliness of decision-making for children. Risk assessment and the role of the Children’s Guardian in influencing care planning. Understanding family/professional dynamics – e.g. ‘mirroring’ and the rule of optimism. 4 Ensure, through supervision and audit, that the management arrangements in respect of Self-Employed Contractors are robust; and that work undertaken by Self- Employed Contractors is of the required standard (i.e. at least ‘met’) Ensure that staff attendance at Core Training is tracked through review of the training calendar at monthly management meetings.
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