Learning from Serious Case Reviews & Case Reviews

1. Learning from Serious Case Reviews & Case Reviews

2. North Somerset Serious Case Reviews Three historic Serious Case Reviews in North Somerset, in the public domain: • October 2009 – in respect of Children B and C • December 2009 - Primary School aged child – C • January 2012 - The Abuse of Pupils in a First School One from February 2014 ‘Alice’ not yet published

3. 1. Children B and C: the circumstances • Children B and C were primary school aged children who were seriously injured by their mother - their wounds required hospitalisation. Their mother was convicted of wounding with intent to cause grievous bodily harm in October 2009 • Specialist assessments did not fully consider the impact of the mother’s mental health and substance misuse problems on her parenting capacity • Concerns raised by the family were not fully considered by two key agencies involved • Mother disclosed she considered harming the children: however the assessors relied on the view of professionals who knew her well that she wouldn’t harm the children • Specialist services working with the children were not given sufficient information about the parent’s behaviour or disclosures to interpret and analyse the children’s behaviour and risk.

4. Recommendations and Learning • All managers and staff in all agencies working with children and the adults who care for children should have an understanding of the impact of domestic abuse, mental health and substance misuse on children’s safety and welfare • Strategy discussion procedures should promote multi-agency working between early years settings and other agencies and between social care teams and the Special Educational Needs co-ordinators • All agencies should share information in line with the ‘Information Sharing Guidance for Practitioners and Managers’ GOV 2008 • Managers should ensure sufficient case oversite through effective supervision • Thorough holistic assessment of need required to understand impact of long term emotional abuse

5. Changes made to practice • ‘Toxic Trio’ training is now provided to multi-agency staff covering how to assess the risks to children living in households where there is domestic abuse, substance misuse and Mental Ill health. • Single Assessment has been introduced which allows for more in depth initial assessments. • Single assessment and signs of safety strengthen the risk assessments made • Supervision, audit and case mapping has strengthened management oversight of cases • All training references the Information Sharing Guidance • Best Practice Guidance produced on Strategy Discussions

6. 2. Child C - Circumstances • Child C lived with his mother following separation with the child’s father in the previous year. Relationships between the parents were acrimonious. The child was subject to a safeguarding plan because professionals were concerned about the impact of the domestic disputes between parents’ on the child’s emotional well-being. The Court was involved to consider issues of contact between the father and the child. The child died whilst in his father’s care. The Coroner’s Court has recorded an open verdict • The father also killed himself

7. Recommendations and Learning • Thresholds for referral to children’s social care were not well understood by other agencies. The response by children’s social care to notifications of domestic abuse was slow. • Inter-agency communication in this case was not as well developed as it should have been. Key agencies did not attend the initial conference • The concerns of the case conference were never directly communicated to CAFCASS, the Court Welfare Service. • A comprehensive assessment of the risks posed to the child by the parental discord after separation of the parents was never fully completed because those involved thought the separation had reduced the risks to the child. • In spite of this, no evidence has been found to suggest that the outcome was predictable

8. Changes made to practice • Threshold document developed and widely promoted • Ongoing programme of Domestic Abuse training available that reflects up to date assessment frameworks and knowledge • Regular meetings involving senior managers from Children’s Social Care and CAFCASS have been set up, and a protocol between CAFCASS and Children’s Social Care introduced • Research – Filicide – Suicide: Common factors in parents who kill their children and themselves – Susan Friedman et all (2005) distributed

9. 3. The abuse of pupils in a First School • The sexual abuse of children took place over a number of years prior to a disclosure in December 2010 • The perpetrator was a male teacher who had taught for 15 years • Photos and videos found on the teacher’s computer and other devices were taken in school and showed the teacher abusing pupils • Teacher pled guilty to 36 sexual offences including 22 counts of sexually assaulting children under the age of 13 with 8 counts of sexual assault by penetration, one count of attempted rape, one count of voyeurism and one charge of causing a child under 14 to commit sexual activity. • There were 30,500 indecent photographs mostly from the internet and 720 indecent movies in his possession.

10. Circumstances • 30 known incidents of inappropriate or unprofessional conduct by the teacher. Ranging from inappropriate lesson content, to over familiarity with children and indecent touching. 11 reported formally within the school and none reported outside the school or to the chair of governors • It was noticed that he had favourite pupils who were girls, who were given tasks viewed as privileges, he was known to speak and joke with them in an inappropriately adult manner • All incidents were dealt with in isolation with no consideration to the cumulative significance of previous concerns • Observations of his teaching were made, but no action relating to concerns about possible inappropriate involvement with pupils • Ofsted inspected three times - latest report stated: ‘pupils feel exceptionally safe and secure’

11. Recommendations and Learning • Historic concerns – Essential for schools to keep accurate records of all incidents and concerns • All allegations need to be treated with ‘respectful uncertainty’ and all evidence carefully recorded • Child protection training should aim to raise awareness of grooming behaviour • Staff should be aware of how to make complaints and how these can be pursued externally. • Use rigorous recruitment processes such as value based interviewing • It is important to not only provide training but to monitor attendance and impact

12. Changes made to practice The NSCB required that the whole of the Children’s Workforce should: • Know about the role and contact details of the LADO • Know about the allegations procedures for schools and the wider workforce • Be able to recognise the signs of Grooming behaviour • Know about and use the ‘Guidance for Safer Working Practice’ • Follow Safer Recruitment practices including the use of value based interviewing • Have policies for safe use of digital technology

13. The following slides provide information that is not in the public domain

14. Case Reviews in North Somerset LSCB’s should conduct reviews of cases which do not meet the criteria for a Serious Case Review, but which can provide valuable lessons about how organisations are working together to safeguard children (Working together to Safeguard Children 2013).

15. Case Reviews In North Somerset • “Alice” • NSFII14 – August 2014 • L12/13

16. 1. “Alice” - Circumstances • Alice, 10 month old was admitted to hospital following a seizure episode. A CT scan showed at least one subdural haemorrhage and possibly one older subdural injury. The brain injury was consistent with her having been shaken • Mum’s two previous partners known to have a history of violence • Alice’s father had made threats to kill her brother • Mum’s most recent partner also alleged to have assaulted his previous partner when she was pregnant

17. Adult’s circumstances Police involvement with Mum and her different partners indicates a complex picture of minor crime, involvement with drugs, existence of domestic abuse issues and animosity between past and present partners as well as mental health issues

18. Lessons for learning: Children’s Social Care • More active attention to the risks of a pattern of very violent relationships and management of cases to protect very young children • Danger of underestimating the risks to young children and babies where there is a history of high levels of violence • Risk of treating each incident separately and relying on the relationship ending to protect children • To ascertain whether the non- violent partner has accessed support to reduce the risk of developing further relationships • It may be prudent to visit even if all the information regarding risk and past behaviour is not known

19. 2. NSFII14 August 2014 • On 12th July 2013 Children’s Social Care received a referral of suspected Fabricated and Induced Illness relating to a 11 year old twin (SC1) • At that point SC1 had not attended school since December 2010, it was believed by the school that SC1 was being cared for by the Children’s Hospice since October 2012 and that SC1’s mother was terminally ill • SC1 received medical treatment for: Asthma, Laryngeal Papilloma, von Willebrand disease and hay fever • SC1 was treated at: Great Ormond Street Hospital, Bristol Children’s Hospital, GP, Respiratory Medicine Outpatients, ENT Outpatients • During home visits SC1 was in his mother’s bed downstairs in a room set up with monitors and oxygen tanks

20. The review established: SC1 did not have a terminal illnessSC1’s mother did not have a terminal illness School viewed managing SC1’s illness as a single agency responsibility The mother’s alleged illness shifted the practitioners focus from SC1 The school nurse was not involved in SC1’s health care plan The Health Visitor believed the mother’s information about her child’s illness and did not check with GP or School Nurse The review meeting felt that the extent of information held in GP records should have prompted discussions with other professionals

21. Practice and Organisational Learning • Use the Early Help Assessment when two or more agencies need to be involved • Health Care plans in educational settings involve qualified Health Care Professionals • All practitioners receive training on recognition and management of Fabricated Induced Illness • The importance of communication between health professionals • The importance of maintaining an individual record of each child in school • The importance of supervision and support for those offering pastoral care in schools

22. Changes to Practice • Early Help Training provided to all agencies • Reference to Fabricated Induced Illness in all basic awareness courses

23. 3. L12/13 • L12/13 Was a Looked After Child in North Somerset under Section 20 aged 16 following a violent assault by her boyfriend • Prior to this she had been homeless and living on the streets with a boyfriend who had been physically and sexually violent towards her, referrals made whilst she lived with her mum did not result in a service - she has since alleged she was sexually abused by her step dad • She had 12 placement breakdowns in 2 months, because they could not care for her extreme behaviours including self-harm and ‘promiscuous’ behaviour • Between 19th Sept 2012 and May 2013 she was assessed on 8 occasions as not having a mental illness. During this time she made a number of allegations of rape that were unsubstantiated, and made attempts to overdose, jump off a bridge and reported feeling unsafe and suicidal

24. 24th May 2013 she was admitted to an Adult Mental Health Ward in Taunton where she stayed until 2nd June when she requested discharge - the Social Worker had made numerous attempts to find appropriate provision during this time • She was readmitted on 3rd June saying she had overdosed on 50 paracetamol and would overdose again if discharged. • 17th June she was discharged and moved to a placement – since diagnosed with post-traumatic stress disorder and now in a ‘secure environment for patients with a forensic history and/or challenging behaviour’

25. Groups involved in discussions to achieve suitable placement included • CAMHS in Somerset • CAMHS in North Somerset • Director of Patient Safety – Somerset • Somerset Partnership NHS Trust • Assistant Director Children’s Services, North Somerset • North Somerset Children Commissioner • North Somerset Adult Mental Health Commissioner • Adult Mental Health Services in North Somerset

26. Practice and Organisational Learning • Somerset Partnership NHS Trust should review their Protocol for Admitting Young People Under 18 Years to Adult Mental Health Wards • The Role of the Responsible Commissioner for Looked After Children should be Communicated to Managers in relevant services • Commissioners across agencies should review the arrangements for provision of services 0-25 years • Commissioners across agencies should review provision of mental health services for Looked After Children – who have a high level of need • Practitioners should be reminded that they must always act in the best interest of the child or young person • The social workers has ‘shown considerable tenacity in this complex case’

27. Changes made to practice • Separate pathway is in place for looked after children who require support from specialist CAMHS • Additional post to support the specialist nurse for looked after children has been created to support the emotional health and well -being needs of looked after children • Meetings held between North Somerset and Somerset to clarity cross broader working and protocol for CAMHS

28. For Future Learning • Serious Case Review Training – available via CPD online • 8th January 2016, morning session – Rickford Room, Town Hall • 22nd January 2016, morning session – Castlewood • Resources • http://www.northsomersetlscb.org.uk/serious-case-reviews.htm

29. Think About! • Do the circumstances in these scenarios resonate with any of your cases? • Are there any areas of learning that you want to explore in more detail? • Where we have described changes made, is this true for your practice?