Shropshire Safeguarding Children Board Report of the Serious Case Review Regarding Children A & B Authors: Fiona Johnson, Claire Porter, Lisa Charles 1 Index Title Page 1.1 Why this case was chosen to be reviewed 3 1.2 Succinct summary of case 3 1.3 Family composition 3 1.4 Time frame 3 1.5 Organisational learning and improvement 3 2.1 Methodology 4 2.2 Reviewing expertise and independence 5 2.3 Acronyms and terminology 5 2.4 Methodological comment and limitations 5 2.4.2 Participation of professionals 5 2.4.3 Perspectives of the parents 5 2.5 Structure of report 5 3 Professional practice appraisal 7 4 The Findings 13 4.1 Introduction 13 4.2 What light has this case review shed on the 13 reliability of our systems to keep children safe? 4.3 Summary of findings 14 4.4 Findings in detail 15 6 Conclusion 33 Appendix 1: The SCR Process in detail 34 Appendix 2: Glossary 40 Appendix 3: Bibliography 41 2 1 Introduction 1.1 Why this case was chosen to be reviewed The Shropshire Local Safeguarding Children Board determined to conduct a Serious Case Review (SCR) because the circumstances of this case met the following criteria: (a) abuse or neglect of a child is known or suspected; and (b) (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. (Working Together to Safeguard Children, 2015:75)1 1.2 Summary of case 1.2.1 This review concerns the services provided by Shropshire agencies, over a period of six months, to two children who were cared for by their widowed mother who had recently returned to live in Shropshire. The children were the subject of ‘child protection plans’2 because of her neglectful parenting. During the review period the older child experienced two separate injuries. The investigations into these injuries were problematic and there were delays and insufficient follow-up on concerns. The second investigation resulted in the children becoming accommodated and care proceedings were instigated. The children are currently in foster-care and will not be returning to live with their mother. 1.3 Family composition Family member Age during review period Child A 3½ years Child B 2½ years Mother 33 years Father deceased Maternal Grandmother 63 Maternal step Grandfather 64 Aunt 25 Cousin 10 1.4 Timeframe The review period is from 18th February 2014, when the family first moved back to Shropshire until 5th August 2014 when the children were placed in foster-care. 1.5 Organisational learning and improvement Statutory guidance on the conduct of learning and improvement activities to safeguard and protect children, including serious case reviews states that: ‘Professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. Good practice should be shared so that there is a growing understanding of what works well. Conversely, when things go wrong there needs to be a rigorous, objective analysis of what happened and 1 Working Together 2015 https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 2 Where there are concerns about the well-being of a child an initial child protection conference brings together family members (and the child where appropriate), with the supporters, advocates and professionals most involved with the child and family, to make decisions about the child’s future safety, health and development it is the responsibility of all involved agencies To plan how best to safeguard and promote the welfare of the child. https://www.gov.uk/government/publications/working-together- to-safeguard-children--2 3 why, so that important lessons can be learnt and services improved to reduce the risk of future harm to children.’ (Working Together 2015:72) and ‘Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.’ (Working Together 2015:73) Shropshire Local Safeguarding Children Board (LSCB) identified that a review of this case held the potential to shed light on particular areas of practice including addressing the following questions: How effective is agency input and involvement in the child protection planning process? How effective are professionals at recognising and responding to non-accidental injuries to children? Once the review was started and it became apparent that neglect was a key feature it was also agreed that the review would explore the extent to which the SSCB Neglect Strategy had impacted on frontline practice. 2. Methodology 2.1 Statutory guidance requires reviews to be conducted in such in a way which: recognises the complex circumstances in which professionals work together to safeguard children; seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. (Working Together 2015: 74) It is also required that the following principles should be applied by LSCBs and their partner organisations to all reviews: there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice; the approach taken to reviews should be proportionate according to the scale and level of complexity of the issues being examined; reviews of serious cases should be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed; professionals should be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith; families, including surviving children, should be invited to contribute to reviews. They should understand how they are going to be involved and their expectations should be managed appropriately and sensitively. This is important for ensuring that the child is at the centre of the process (Working Together 2015: 72-73) In order to comply with these requirements the Shropshire LSCB has used a review methodology based on the SCIE Learning Together systems model (Fish, Munro & 4 Bairstow 2010). Detail of what this has entailed is contained in the Appendix 1 of this report. 2.2 Reviewing expertise and independence The review has been led by Fiona Johnson, an independent social work consultant accredited to carry out SCIE reviews with extensive experience in writing SCRs/IMRs under the previous ‘Chapter 8’ framework; and, Claire Porter and Lisa Charles, who are employed by Shropshire Council and are also SCIE accredited. All reviewers have had no significant previous direct involvement with the case under review. 2.3 Acronyms used and terminology explained Statutory guidance requires that SCR reports be written in plain English and in a way that can be easily understood by professionals and the public alike (Working Together 2015: 79) Writing for multiple audiences is always challenging. Throughout the report footnotes are provided to explain relevant aspects of professional practice. In the Appendix 2 we provide a section on terminology which aims to support readers who are not familiar with the processes and language of the safeguarding and child protection work. Shropshire LSCB is keen to improve the accessibility of SCR reports and welcomes feedback and suggestions for how this might be improved. 2.4 Methodological comment and limitations 2.4.1 This review was undertaken using the SCIE methodology but did not have supervision from SCIE and is therefore not a SCIE review. A key aspect of the methodology is the direct involvement of the frontline professionals who knew the family in the review process, assisting in developing the findings from the review. For more information regarding the methodology see appendix 1. 2.4.2 Participation of professionals The lead reviewers and the review team have been impressed throughout by the professionalism, knowledge and experience that the case group (the professionals involved with the family, from all agencies) have contributed to the review; and their capacity to reflect on their own work so openly and thoughtfully in the review process. This has given the review team a deeper and richer understanding of what happened with this family and within the safeguarding network and why, and has allowed us to capture the learning that is presented in this report. There were two groups of professionals who were less involved in the review process. The hospital staff could not attend any of the case group meetings however review team members did meet with them at the hospital and gained their perspective. Similarly there was limited involvement by the GPs and practice staff. As their involvement in this case was greater than the hospital staff this was felt by the review team to be a significant limitation. The review team was very pleased that the Practice Nurse was able to attend the second case group meeting and found her input to the review process of assistance in developing the findings further. 2.4.3 Perspectives of the family The lead reviewers wished to involve the mother and grandmother in the review but this was not possible.