Lessons Learned from Case Reviews Cases of

Lessons Learned from Case Reviews & Cases of Concern 2011 to 2013

Learning Outcomes • Raise awareness of how case reviews are carried out in Salford • Understand the key themes and recurring themes from Salford’s Case Reviews • Recognise what has been done so far and what still needs to be done • Discuss how to keep you informed about case review recommendations and implementation

CRSG Membership The following agencies/services are represented: • Children’s Services- Head of Safeguarding, Head of CIN & CP (Vice Chair), Assistant Director for Universal Services and the Deputy Head of the Youth Offending Service • Health Services- Designated Nurse for Safeguarding Children (Chair), CMFT Head of Psychology, GMW Safeguarding Children Practitioner, NHS Salford Consultant in Public Health and SRFT Safeguarding Supervisor • Housing- Safeguarding Lead • Greater Manchester Police- Serious Case Review Team • Greater Manchester Probation- new representative to be identified • SSCB Business Manager • SCC Legal Services

SSCB Case Review Policy Revised in September 2012. Changes made include: • One referral form for all case reviews • Guidance on seeking the views of the family members • Guidance on the use of SCIE Systems Methodology Case of Concern review criteria made more explicit“an agency raises a serious concern about the way a service has managed/is managing a case. The case should be where a child/children have been at risk of serious harm but an incident (or incidents) has not occurred which takes it to the level of an SCR. The case should be one where lessons can be learned and practice improved for the benefit of other children and families”.

Case Referral Process Any agency can refer a relevant case Referral form included in policy CRSG considerations: • Is a Screening Panel required? • Does the case meet the criteria for a Case of Concern review? • Review methodology • Other actions required e. g. single agency actions.

Criteria for Serious Case Review Working Together to Safeguard Children 2013 SCR criteria: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (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.

Case 1 Lindsay Barrett, Safeguarding Lead Officer (Housing) & Pat Dugdale, Safeguarding Childrens Team Supervisor (Health)

Background • Oct 06 – Couple approved as foster carers, with one biological child. Mr A was the main foster carer as Mrs A had physical health problems • From Nov 06 to Mar 10 – 5 children were fostered • Aug 07 – the 2 nd foster child placed, male aged 2 days • Dec 07 – incident Mr A angry towards birth mother of foster child no. 2 • Jan 08 – Mr & Mrs A wants to be considered for adopting foster child no. 2 • Feb 08 – incident Mr A displayed aggressive behaviour towards the birth mother of foster child no. 2

Background • Jun 09 – Approved to adopt foster child no. 2 • Jun 09 – Mrs A reports behaviour changes in Mr A, query epilepsy? • Oct 09 – Self harm incident by Mr A, subsequently admitted to mental health in patient unit • Dec 09 – Mr A re-admitted to inpatient unit 2 nd time • Feb 10 – Mr A re-admitted to inpatients unit for 3 rd time • Jun 10 – Mr A arrested after attempting to suffocate Mrs A and re-admitted to inpatient unit • Jul 10 – Mr & Mrs A de-registered as foster carers

Methodology • Decision to use the ‘systems’ model to analyse the case - SCIE (Social Care Institute of Excellence) Systems Approach • Sub-group members formed the review team • Case group members were all practitioners directly involved in the case • Initial introductory meeting • Conversations with case group members • Follow-on meetings • Recommendations & action plan

Key Practice Episodes • Foster Panel approve Mr and Mrs A as Foster Carers – not all information available to the Panel • Foster Panel re-approves Mr and Mrs A as Foster Carers – not all Childrens Services information was collated • Adoption and Permanence Panel approves Mr and Mrs A as Adoptive Parents for foster child no. 2 – incidents of anger issues not explored • Incident in which concerns about Mr A’s behaviours resulted in an admission to an inpatient mental health unit – no formal multi-agency risk assessment and appropriate safeguarding of the children

Lessons learned • Practice was not sufficiently child focussed i. e. the full impact of Mr A’s deteriorating mental health on the children • Assessments lacked comprehension • Overly optimistic assessment of the carers • Over-reliance on self–reporting without verification • Lack of appropriate communication and information sharing

Recommendations and Action Plan • 12 single agency recommendations for: Childrens Services Health Services Adult Mental Health Services • 1 multi-agency recommendation • Themes – assessments, communication & information sharing • All recommendations on the action plan have now been completed and signed off accordingly

Discussion Forum 1. Prior to today were you aware of this case? 2. Were you aware of the recommendations and action plan from this case review? 3. Can you see if any of these actions have been implemented in your agency?

Case 2 Sharon Hubber, Head of Safeguarding, Salford City Council & Julie Moss, Head of Child in Need & Child Protection, Salford City Council

• Female • DOB – 9/05/2001 • White British • Lived with 3 Adults • Adult 1 – Mother • Adult 3 - Maternal Grandfather • Adult 4 – Maternal Grandmother Adult 1 – requested support with daughters self esteem and bullying.

School Joint visit Educational Welfare Officer & School Nurse This visit upset all the family and further arranged meetings then cancelled by Adult 1 Bullying GP Numerous appointments Poor school attendance 2007 (CAF) Moved Primary School OCD EWO Adult 1 banned from school premises due to behaviour Shouting swearing Spill things Remove clothing Nervous breakdown SHA HS M CA DNA (closed in line with old policy) Adult 1 unhappy with seeing a trainee psycologist

Clinical meeting held (no safeguarding discussion (EIP) FAM Unhappy about psychology wanted psychiatry (DNA closed in line with old policy) CAMHS GP Food intolerance Viral Food refusal Not leaving home Poor self esteem Bullying Adult did not attend 2009 SHA Professionals’ meeting held Referral to CSC Core Assessment (but no other professional involved) Poor School attendance Refused to allow information sharing Surgery discussed issues but no outcome logged Home educated (end of 2009) never returned to mainstream education

Unhappy about discussing child’s 2 weight GP CAMHS Self esteem 2010 Unhappy given appointment to see psychiatrist Did not want to see a male psychiatrist Bullying? CSC Section 47 Removed 4 appointments 2 seen by adults 2 child/4 th appointment child gave abuse allegation

Safeguarding never really on agenda No risk assessment No escalation of same presenting problem Poor response in 2009 Inadequate Core Assessment Challenging aggressive adults Voice of child not in the case Barriers No follow up of Professionals’ Meeting Refused to allow information sharing Complexity of Health Services DNA Policy CAMHS Fabricated and induced illness not considered Removed from mainstream education left her vulnerable Some delay following allegation

Detailed Multi Agency Chronology Mum not allowed to intimidate Good Multi Agency response following allegation Good Practice Escalated appropriately following case conference Procedure followed when Manager in CAMHS became aware of allegation

Discussion Forum 1. Prior to today were you aware of this case? 2. Were you aware of the recommendations and action plan from this case review? 3. Can you see if any of these actions have been implemented in your agency?

Break

Case 6 Melanie Hartley, Designated Nurse for Safeguarding Children, NHS Salford Clinical Commissioning Group

Case 6 Review This complex case was referred to the CRSG by Greater Manchester Police in November 2012 Complex family unit formed in 2007 Family comprised of 2 adults caring for 5 children: • 1 aged under 2 years- birth child of the 2 adults • 2 teenage children- birth children of one adult from a previous relationship • 2 teenage children- second adult was the legal carer of these children. Referral followed a serious assault by 1 teenager on another teenager in the family unit.

Agency Involvement Child F – Victim of Incident Agencies involved: School 2 GP Child G Agencies involved: HV GP Child D Agencies involved: School 2 GP Adult A: Legal Carer of Child E and F and mother of Child G Adult B: Father of Child C and D and Child G Child E Agencies involved: School 2 School Nurse GP Child C – Perpetrator of Incident. Agencies involved: School 1 CAMHS IYSS EIP School Health Advisor Community Paediatricians GP

Case 6 Review • Case discussed at a Screening Panel meeting in November 2012 • Recommendation made to SSCB Chair that the case did not meet the criteria for a Serious Case Review and that a Case of Concern review should be undertaken • SSCB Chair agreed to this and decision made to undertake this review through an externally facilitated Multi-agency Learning Event • Event held in February 2013 • Action plan from this case review currently being implemented.

Case 6 Review Methodology • Innovative “whole system” review methodology • Externally facilitated • Full day Learning Event • Representatives from all agencies working with the family involved • Detailed chronology reviewed, agency involvement discussed and lessons learnt identified.

Case 6 Review - Lessons Learnt Communication/Information sharing: • Some examples of good communication and information sharing • Cross border issues • No practitioner had a full understanding of the concerns held by all the agencies • No practitioner had a full understanding of the complex history of the family.

Case 6 Review- Lessons Learnt Challenge and escalation: • Individual practitioners did challenge both the parents/carers and other agencies • Attempts to escalate were complicated by the information sharing issues • Agency attempts to escalate were based only on the information and concerns known to them about the family members they were working with.

Case 6 Review- Lessons Learnt Voice of the Child: • Practitioners working with the individual teenagers listened to and believed them • Trusting relationships were established • Disclosures did not result in escalation of the case. Why? • - some retraction of statements • - number of different practitioners involved.

Case 6 Review- Lessons Learnt Emotional abuse thresholds: • Further clarity required about thresholds Risk management of complex cases where there are no child protection plans in place: • Case managed at TAC level • Multi-agency level of risk not determined and no risk management plan in place.

Practitioner Feedback • “It was a useful event for me. It was very useful learning further information on the case and how we can improve some of the services”. • “It was a draining and exhausting day listening to very disturbing information regarding the children and the family dynamics. The staff needed to express their emotions. However they did appreciate the event and recognised the importance of bringing agencies together”.

Practitioner Feedback • “Lot of agencies involved, very sad and information there that I didn’t know” • “Lot I didn’t know, one piece of information is a surprise and should have known about it” • “Professionals go to homes not knowing what situation they may find. They take the information given by mother as truth”.

SCRs AND ENHANCING CHILD PROTECTION RAY JONES PROFESSOR OF SOCIAL WORK 35

SCRs AND ENHANCING CHILD PROTECTION • MY EXPERIENCE • SOME OF THE BARRIERS • SOME OF THE ENABLERS • WHAT MAKES FOR GOOD CHILD PROTECTION 36

SCRs AND ENHANCING CHILD PROTECTION MY EXPERIENCE • • • SOCIAL WORKER AND MANAGER DIRECTOR OF SOCIAL SERVICES 1992 -2006 INQUIRIES X 3 LSCB CHAIR CIB CHAIR X 5 RESEARCH 37

SCRs AND ENHANCING CHILD PROTECTION BARRIERS TO LEARNING FROM SCRs • • • TOO MANY SCRs TOO TIME CONSUMING AND COSTLY THE BLAME CULTURE AND DEFENSIVENESS CASE RATHER THAN CONTEXT WHAT RATHER THAN WHY 38

SCRs AND ENHANCING CHILD PROTECTION BARRIERS TO LEARNING FROM SCRs • • • TOO MANY RECOMMENDATIONS ACTION PLANS NOT SMART TOO MUCH FOCUS ON PROCEDURES NOT PRACTICE NOT REACHING WHERE IT NEEDS TO REACH MOVING ON TO THE NEXT SCR LEARNING AND IMPROVEMENT NOT EMBEDDED 39

SCRs AND ENHANCING CHILD PROTECTION ENABLERS FOR LEARNING AND IMPROVEMENT • • PRACTITIONER PARTICIPATION THROUGHOUT REFLECTION NOT ONLY DESCRIPTION CONVERSATIONS AND COMPREHENSION SMART RECOMMENDATIONS/ ACTION PLANS THEMES AND MESSAGES SYNTHESISE AND SIMPLIFY REALISTIC AND RELEVANT 40

SCRs AND ENHANCING CHILD PROTECTION ENABLERS FOR ENHANCEMENT AND IMPROVEMENT • • TARGETING MESSAGES AND LEARNING FOR PRACTITIONERS AND MANAGERS FOR DIFFERRENT AGENCIES AND WORKERS BUT ALSO LEARNING TOGETHER PROCEDURES AND TRAINING BUT ALSO CULTURE AND BEHAVIOURS LEADERSHIP AND CHAMPIONS 41

SCRs AND ENHANCING CHILD PROTECTION ENABLERS FOR LEARNING AND IMPROVEMENT • THE IMPORTANCE OF SUPERVISION • THE PRIMACY OF FRONT-LINE MANAGERS • PROMOTE PROFESSIONAL IDENTITY AND VALUES • REPEAT AND EMBED • AUDIT AND CHECK ON IMPACT 42

SCRs AND ENHANCING CHILD PROTECTION WHAT MAKES FOR GOOD CHILD PROTECTION • • • A STABLE FRONTLINE COMPETENT AND CONFIDENT PRACTITIONERS WHO KNOW EACH OTHER ACROSS AGENCIES RELATIONSHIPS, RELATIONSHIPS! WHO KNOW THEIR LOCALITIES AND NETWORKS WITH ALL SERVICES CHILD AWARE AND FOCUSED 43

SCRs AND ENHANCING CHILD PROTECTION WHAT MAKES FOR GOOD CHILD PROTECTION • STABLE FRONT-LINE MANAGERS • WHO ARE EXPERIENCED AND SUPPORTIVE • WITH REFLECTIVE AND CHALLENGING SUPERVISION • APPRAISING OPTIONS 44

SCRs AND ENHANCING CHILD PROTECTION WHAT MAKES FOR GOOD CHILD PROTECTION ALL THE ‘I’s • • INVESTIGATIVE INQUISITIVE INTRIGUED IMAGINATIVE • INGRAINED [ TO BE CHILD-FOCUSED] • INSPIRED AND INFUSED [TO THINK AND TO ACT] 45

SCRs AND ENHANCING CHILD PROTECTION WHAT MAKES FOR GOOD CHILD PROTECTION • TOP MANAGERS STAYING CLOSE TO THE FRONT LINE • WHO THEMSELVES : – – HAVE EXPERIENCE AND EXPERTISE HAVE CONFIDENCE AND WISDOM ARE OPEN TO FEEDBACK AND SEEK TO STAY INFORMED RECOGNISE A COLLECTIVE ENTERPRISE WITHIN AND ACROSS AGENCIES 46

SCRs AND ENHANCING CHILD PROTECTION WHAT MAKES FOR GOOD CHILD PROTECTION EMOTIONAL INTELLIGENCE AS WELL AS INTELLECTUAL INTELLIGENCE 47

SCRs AND ENHANCING CHILD PROTECTION WHAT MAKES FOR GOOD CHILD PROTECTION AND TIME AND SPACE TO PRACTICE WELL! 48

Discussion Forum How can we cascade the lessons learned more effectively to front line practitioners?

Lessons Learned from Case Reviews & Cases of Concern 2011 to 2013 Thank you for your participation today Please complete the Post-Evaluation and collect your certificate