SERIOUS CASE REVIEW FAMILY T/S EXECUTIVE SUMMARY

23 OCTOBER 2012

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Introduction 1. This is the Executive Summary for the Serious Case Review commissioned by Lincolnshire Safeguarding Children Board into the case of two white twin babies (C6) and (C5) born in March 2011. 2. C6 was admitted to hospital on 8th May 2011 with life-threatening head injuries. Her twin brother, C5, was subsequently found to have a healing fracture to the left clavicle. The babies were 7 weeks old and both were the subjects of Child Protection Plans as a result of decisions at an Initial Child Protection Conference held, pre-birth, on 25th February 2011. C5 and C6 have been in local authority care since May 2011. The Court has agreed an adoption plan and the twins will move to their permanent home in October. 3. Their mother, A1, has previously had four children removed from her care and received a two year custodial sentence in 2005 for wilful neglect and Grievous Bodily Harm to her eldest son, C1. The twins father, A2, is a care leaver from Leicestershire. 4. At a meeting of the Lincolnshire Safeguarding Children Boards (LSCB) Serious Case Review Sub-Group, on the 23rd May 2011, it was agreed unanimously that this case met the criteria to undertake a Serious Case Review (SCR) and this was subsequently confirmed by the Independent Chair of the LSCB. Background and timetable 5. The purpose of a Serious Case Review is to identify what can be learned from the case about the way professionals and agencies work together in order to improve inter-agency working and to better safeguard and promote the well-being of children. It is not an inquiry into how a child was injured, or who was culpable which is a matter for the criminal courts. A criminal prosecution was initiated and those charged were acquitted in May 2013. 6. Terms of Reference for the SCR were set when the original Review was commissioned and were subsequently in revised in March 2012. These set out the purpose, subjects, scope and governance for the Review and identify those agencies requested to provide Internal Management Reviews (IMRs). 7. Agencies have already considered some of the action points established from their IMRs and taken appropriate and prompt management action to address obvious shortfalls in process and operational capacity. This is positive and appropriate to ensure that learning and improvement does not wait on the completion of the formal serious care review process. Actions already taken include an audit in Childrens Social Care to examine the recording and risk analysis at Strategy Meetings and a resulting action plan;

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the establishment of an annual CSC programme of Action Learning Sets for supervisors and chairs of Child Protection Conference, to develop skills to probe, evaluate and seek evidence to challenge biased thinking and over optimism a review of FAST teams by CSC (December 2011 to February 2012) to look at practice and decision making lessons illustrated by this case; changes to CSC guidance to clarify the aims set for Child Protection Plans; an audit by the LSCB of Child Protection Plans which has led to the review of interagency training and the continued audit of CP Plans; a requirement for the Resource Panel of senior managers in CSC which reviews high risk and complex cases, to consider all cases involving parent(s) with previous involvement in proceedings or with a conviction for harm of a child; where a person is investigated for possible offences against children a requirement for police to liaise with the investigating officer(s) or at least consult the crime files, for any previous investigation.

8. The Serious Case Review Panel has met on four occasions to consider key themes, review the quality and coverage of Internal Management Reviews (IMRs) completed by each agency, and to consider the Overview Report prepared by an independent author. The Final Overview Report was presented to a meeting of the LSCB Senior Management Group on 4 October and approved following discussion and consideration of the key learning points identified from this Serious Case Review. 9. The SCR Panel has representation from all the partner agencies involved with this case. The Panel has provided constructive and reflective criticism of the SCR reports as they have been presented, and has maintained a clear focus on establishing the learning from this case. The Panel also notes that there are examples of good practice in aspects of this case. 10. The timeframe for the SCR is the period from 23 August 2010 (when A1 consulted her GP about pregnancy) to 23 May 2011 (when the Police confirmed to the LSCB that the injuries to the children were considered to be non-accidental). 11. However, the SCR Panel considered that the history of previous involvement for A1 and her children with Lincolnshire agencies provided critical information and this needed to be evaluated in order to understand how this history informed assessment, decision-making and the management of risk for C5 and C6. It was also clear that the care history of A2 and his involvement with Leicestershire County Council Childrens Services was significant. All agencies were therefore asked to consider all records relating to A1 and A2, and those for A1s previous children (C1, C2, C3 and C4). Summary of key events 12. A full integrated chronology of the case has been compiled from the details supplied
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by each agency. This section highlights the key events that were examined in the Review. The chronology illustrates how there was parallel contact between A1 and different agencies and that much of the contact was concurrent. This highlights the missed opportunity to draw these strands together into a comprehensive assessment of the situation until a late point in A1s pregnancy. 13. During 2003 and 2004 there was evidence of injuries caused to C1, which culminated in his accommodation in foster care from November 2004 and care proceedings. A1 was convicted in January 2006 of willful neglect and Grievous Bodily Harm to her son and sentenced to 2 years imprisonment. A7 received an 18-month custodial sentence. C2 was born in June 2005 and placed in the care of her paternal grandparents, A3/4. In December 2005 she contracted pneumococcal meningitis that resulted in significant disabilities. 14. In September 2005 a specialist psychological assessment of A1 concluded that the risk of physical abusive parenting was significant without therapeutic work and that considerable parenting support would be required to offset the continuing potential risk to children. 15. Whilst in prison A1 gave birth to C3 in May 2006 who was immediately placed in foster care. C1, C2 and C3 are now all cared for by their paternal grandparents, A3 and A4. 16. A1 was released from prison in January 2007 and formed a new relationship with A8. No work had taken place with A1 on her offending behavior in prison. 17. A strategy discussion and S47 enquiries resulted in an ICPC in September 2007 where professionals agreed that C4 (unborn) was likely to suffer physical harm. A pre-birth assessment was completed, together with a further specialist psychological report and legal advice sought. A review CPC in November agreed that the threshold for care proceeding had been reached, C4 was born in December 2007, and was placed in the long term care of his maternal great aunt and uncle. 18. The 2007 Psychologists report concluded the level of risks in this case are significant and I would have great concerns were A1 to be in a position of caring to care for a new born child. 19. A1 had a relationship with A8 from early 2007 until early 2010, and with A9 from early 2010. Both relationships involved domestic violence and A1 was referred to MARAC in April 2009 and April 2010. Her relationship with A2 appears to have started in mid 2010. 20. The domestic violence and continuing depression and anxiety are recorded in her contacts with her GPs through 2008 and 2009. Whilst the GP continued to prescribe antidepressants, A1 was also referred for counseling to LPFTs Improving Access to
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Psychological Therapies service for work on past abuse in September 2009 although she is discharged in February 2010, and referred to a psychological wellbeing practitioner for anxiety management (5 sessions to November 2010). 21. A1 presented to her GP and her pregnancy was confirmed on 23rd August 2010. 22. At this time A1 was concerned about threats from her ex-partner A9, and was in contact with Womens Aid and the police in respect of these. She was also staying with a same-sex couple who appeared controlling of her movements and contacts, and cancelled some of her appointments. One of this couple had a conviction for child cruelty. 23. A1 attended her booking appointment with the midwife on 9 th September, and subsequent antenatal appointments. Her pregnancy was confirmed as twin on 13th October. As a result of disclosing that none of her previous children reside with her MW1 completed a CAF on 9th November, with A2. There is no record of this CAF form faxed to the FAST team. A1 continued to attend her antenatal appointments to March 2011 and there appeared to be no serious concerns about her pregnancy, 24. A1 alleged that A9 raped her and told the Independent DV Advisor that she was staying with friends as she was too frightened to remain at her own flat, and that she was suffering from depression and panic attacks. A MARAC meeting on 18 th November considered A1 as a high-risk individual as a result of her previous relationship with A9. 25. On 29th October and 1st November respectively A3/4 and A5/6 contacted CSC to advise that A1 is pregnant as they have concerns about this, and the implications for future care of the children. 26. On 13th December the case was allocated to SW1 for Initial Assessment after the midwife followed up on previous contact on which no action had been apparent. Previous files are secured and the IA was completed on 21 st December. 27. On 20th December the case was referred by Maternity to Health Visiting and arrangements made for an antenatal visit at 32 weeks (February 2011). 28. On 6th January the IDVA and SW1 assisted A1 in moving back to her own flat from the house of the couple she had been staying with. 29. On 9th February SW1 and PP4 discussed the case briefly with TM1, initially proposing that it should be dealt with as a Child in Need case and a support plan prepared for A1/A2 to parent the twins. TM1 concluded that the case should proceed to a Child Protection Conference. On the same day a phone conversation took place between PP4 and the police. This confirmed that the case will proceed to ICPC, but was not a multi-agency strategy discussion to share the information now known to several
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agencies. 30. SW1 discussed a request for support with the Strengthening Families Service, although this is not recorded. It appears from interviews with staff that this raised concerns about the plan for the twins to remain in the care of A1 given the history and severity of previous abuse of C1. 31. An Initial Child Protection Conference (ICPC) was held on 25 th February. The professionals did not reach a clear consensus on whether the twins were at risk of significant harm and the chair made the decision that a Child Protection Plan was required. The Child Protection Plan (CPP) included a community based assessment; a high level of visits to monitor parenting; engagement by parents with health visits and clinics; continued work with A1 from Womens Aid, and work to address depression and anxiety A1 to consider continuing counseling and therapy when she is ready. 32. C5 and C6 were born on 22 March 2011, twenty days prior to the expected date of delivery. A1 had had a Caesarean and subsequently her wound became infected requiring additional treatment. 33. Thirty-five day time visits were undertaken by a team of social workers and Strengthening Families workers on four occasions no one was at home. A proposal to reduce the number and frequency of visits to three visits a week was agreed at a core group meeting on 4th April. 34. There is a gap of recording visits between 18th and 25th April when it is not clear any visits by CSC took place. 35. On 8th May East Midlands Ambulance Service attended in response to a 999 call and C6 was admitted to hospital with injuries. Internal Management Reviews (IMRs) 36. IMRs were requested from and completed by the following agencies: Lincolnshire County Council, Childrens Social Care (CSC) Leicestershire County Council, Childrens Services Lincolnshire Police Lincolnshire Partnership Foundation Trust (LPFT) United Lincolnshire Hospital Trust (ULHT) Lincolnshire Community Health Services (LCHS) NHS Lincolnshire (General Practice) Health Overview Report City of Lincoln Council East Midlands Ambulance Service (EMAS) NACRO
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Lincoln Integrated Domestic Abuse Services (LIDAS) MARAC: Domestic Abuse Management 37. In addition, a summary report for information was requested from Queens Medical Centre, Nottingham, relating to the investigations and treatment of C6 in May 2011. Involvement of Family 38. A1 and A2 were informed at an early stage that the Serious Case Review was being undertaken and offered the opportunity to meet with the Overview Author to answer a number of questions and to make any observations that they wish. To date there has been no response to this offer. 39. The Independent Overview Author met with A3/4 and A5/6 in order to ask for their comments on the case, to put specific questions to them and to identify any observations as learning for the Serious Case Review process. A3 and A4 care for the three children of A1 and A7, and A5 and A6 care for C4. 40. The involvement of these family members in the Serious Case Review has been valuable, and raised challenging questions about the decision-making that occurred during November 2010 to May 2011. Summary of Conclusions 41. Throughout the case the focus of professional attention remained on A1, and to a certain extent A2, rather than on the safeguarding of the twins, C5 and C6. A stronger focus of the twins as the subjects of the safeguarding process was required. Effective safeguarding needs to be proactive in the interests of the child(ren) concerned. A proper professional scepticism and robust evaluation of the evidence available needs to be deployed particularly when there are no precipitating incidents. 42. A1 had never provided safe, long-term care to any child. She had been convicted of serious child cruelty offences, and was not allowed unsupervised access to her older children. The carers of her children had contacted childrens services because of their anxieties about her caring for new babies, particularly the pressures and demands of twins. She had contact with others with a history of offences against children. She had experienced a number of relationships, some of them involving violence. She had placed herself and the unborn babies in a dominated and controlling relationship with others. Her pregnancy was unplanned and her new partner said that it had taken three months to come to terms with it. The relationship with A2 was recent, and there were disputed claims for paternity of the twins from A9. A thorough assessment in 2007 had reached the conclusion that C4 should be removed from her care, and this had been supported through the courts. Her three older children had been removed from her care as a result of her actions
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as a perpetrator of abuse, not as a victim. Her continuing contact with all four children was limited and supervised. 43. It is remarkable that it was assumed that, even with a robust and closely monitored support plan, she was likely to find it easy to provide safe care for the twins. The focus in most assessments from the agencies she was in touch with is on her separate presenting issues or on her relationships with partners rather than examining her parenting capacity. The acknowledged pressures that she had found difficult to deal with when caring for C1, and which had been accepted as risk factors against her care for C4, were undoubtedly increased in looking after twin babies. The specific therapeutic work to address her parenting capacity, identified in 2005 and 2007 by the specialist psychological reports, had never been undertaken. Her mental health support had been patchy and no specific programme of work had been completed. She was also recovering from her labour and Caesarean, with a wound requiring continuing treatment; still establishing her relationship with A2, who also had caring responsibilities for his grandfather; and was dealing with housing and benefit issues which must have increased the pressures on her. There is little evidence of a strong and supportive family or community support network on which she could draw. She had little practical experience of childcare, and had admitted in the care of C1 that she had controlled her behaviour towards C1 in public and in front of family and partner, but could lash out and lose her t emper. The evidence of the injuries to C1 demonstrates a sustained period of cruelty and premeditated and controlled previous abuse. Even if there had been secure evidence of therapeutic intervention there was little foundation in 2010/early 2011 on which to establish safe and secure parenting for C5 and C6. 44. It is clear from the evidence in the IMRs that A2 had conflicting care responsibilities. Although these are retrospectively acknowledged in the evidence collected in the IMRs, these were never properly assessed at the time nor the tensions and demands that arose addressed. The evidence of his Leicestershire LCSW suggests that A2 sincerely wished to support his new partner and the twins but he was also committed to continue caring for his grandfather. The ICPC records that he had taken three months to come to terms with the pregnancy. The ULHT IMR highlights that A2 was not visible during the antenatal period. There were complex benefit and housing implications for him and his new family that are not satisfactorily addressed during November 2010 to March 2011. All this suggests that the protective role of A2 should have been evaluated more critically. 45. The practical experience of child care of both A1 and A2 was limited and expectations of parenting on them were not clear. The core assessment records that the focus of work with them should be to educate them in managing difficult and challenging situations as the twins develop; to provide engaging and stimulating activities; and to sustain realistic expectations of children, but it not clear how this was to be achieved, nor what expectations of parenting behaviours and practical

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competencies they were expected to demonstrate. The visits set out in the Child Protection Plan were largely to monitor, rather than to provide practical assistance. 46. The social worker formed a view of this case at an early stage of her involvement in December 2010. This carried through into the core assessment. This perspective minimised the severity and length of the injuries to C1, failed to recognise the extent to which these were hidden by A1, and read back the context of domestic violence that was prevalent in 2010 to correlate this to the harm done to C1. Despite the ample evidence available in the files, the availability of colleagues who had worked on the case before, the concerns flagged by family members, and the complex engagement with other professionals that suggested a number of different presentations and scenarios to be examined, this was not adequately evaluated or analysed in preparing the case for conference. The view formed by the social worker suggested that things had changed and that the parents could be supported to look after the twins. It did not examine critically the triggers that were known and recorded as contributing to A1s previous behaviour. This was the wrong judgement, and was not effectively probed and challenged by supervision or by other professionals. The lack of an effective strategy discussion, or multi-agency S47 enquiries, meant that the discussion at ICPC was inhibited by the missed opportunity to link and share information and to test apparently contrasting evidence. 47. My conclusion on this case is that there was a failure by the Social Worker responsible to assess and evaluate fully the information available, both from the history of C1 and the decision-making concerning C2, C3 and C4; and from the multiagency involvement with A1 and A2 from August 2010 to May 2011. This occurred in a context where there was a lack of curiosity and challenge from other professionals and agencies. Key opportunities to inform a more comprehensive picture of the situation were missed across all agencies, and A1 rather than the twins became the focus for attention. At critical points there was a failure to provide challenge and evidence was too readily accepted at face value. Each agency had a different picture and this was never brought together to allow the contrasting evidence to be tested and assessed. Each agency involved was focussed on delivering the service for which it was responsible, rather than asking the critical questions that might have safeguarded the twins. The accounts of professional involvement in this case are not complacent or unconcerned, but appear to trust in the process and do not seek to extend the responsibility for safeguarding beyond the remit of the given agency or service. This is seen most clearly in the absence of robust challenge to the presumptions presented at the Child Protection Conference. 48. In the light of what is known about A1s history and behaviour, and taking into account the varying extent to which she engaged with agencies on different issues during the period of this SCR, I believe that there were strong grounds to suspect possible harm to the twins, and that therefore the outcome of significant harm was predictable. This could have been assessed at a much earlier stage.

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49. It is not clear that any level of intensive support would have been sufficient to offset these risks, and therefore it is not certain that any action would have made the injuries to C5 and C6 preventable. A decision to seek the removal and protection of C5 and C6 should have been sought. It is clear that there was sufficient evidence available, although a failure to collate and assess it, for the decision to have been reached at a much earlier point than late February. 50. As identified in paragraph 7 above, there have been prompt and appropriate management actions to review the issues raised by this case, and to strengthen the management and oversight of key processes. An Action Plan has been prepared to take forward the recommendations identified in each IMR. The Overview Report recommends that the LSCB should take responsibility for two specific actions that have cross-partnership relevance. 50.1. The LSCB to consider developing and implementing an integrated multiagency pre birth protocol which includes arrangements for Child Protection Conferences for unborn babies 50.2. LSCB to develop a Lincolnshire-wide protocol for the management of suspected Mongolian blue spot and possible indications of bruising.

David Ashcroft Independent Author 23 October 2012

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