agenda item no renfrewshire council - south ayrshire€¦ · agenda item no..... renfrewshire...

Agenda Item No ..... Renfrewshire Council

To:

Community & Family Care Policy Board

On: 21 February 2012

Joint Report by

Chief Executive and Director of Social Work

Significant Case Review: Declan Hainey 1. Summary

1.1 The purpose of this report is to provide members with a comprehensive assessment of

an independent review into the tragic circumstances surrounding the death of Declan Hainey. The role and involvement of social work and health services in the case has been considered and progress is reported on the implementation of a range of actions arising from the review. Members are invited to scrutinise the response to the recommendations made in the independent review.

1.2 Social work services in Renfrewshire work with over 1500 children and their families.

On 27 January 2012 there were 794 children and young people looked after within Renfrewshire, 329 of whom are in foster or residential care placements with the remainder looked after in their own home or with relatives. On this date 89 children were on the child protection register. Over the past five years the number of children and young people coming into contact with social work has increased, as has the number of children on the child protection register and the number of children accommodated.

1.3 Declan Hainey was born on 17 April 2008 and he was found dead at his mother’s home

on 30 March 2010. Kimberley Hainey, Declan’s mother was found guilty of his murder at the High Court in Glasgow on 16 December 2011. On 12 January 2012 she was sentenced to a mandatory life sentence with a minimum term of 15 years. Ms Hainey has indicated that she intends to appeal her conviction

1.4 Following the discovery of Declan’s body Renfrewshire Social Work and Renfrewshire Community Health Partnership reviewed the involvement of both agencies in this tragic case. Given the circumstances surrounding the untimely death of a young child the independent chairperson of Renfrewshire Child Protection Committee consulted with the Child Protection Committee‘s Chief Officers Group and agreed to initiate an independent significant case review in relation to Declan Hainey. The independent chairperson and the Chief Officers Group were clear that they wished the significant case review to be commissioned quickly. This was to ensure that full consideration of the circumstances relating to Declan were investigated and allow any recommendations made to be actioned quickly. It was recognised that to await the outcome of any criminal process would significantly delay the implementation of action in any areas that required to be strengthened.

1.5 The commissioning of an independent significant case review prior to the conclusion of criminal proceedings is unusual in Scotland and required negotiations with the Procurator Fiscal’s Service. Agreement was reached that the significant case review could proceed at an early stage and prior to the conclusion of the criminal proceedings recognising that in these circumstances the report would be subjudice. However it was essential to ensure that any areas for improvement could be progressed quickly despite the restrictions that would apply. This has been achieved and described in the action plan which sets out how each of the recommendations within the report is being addressed. The action plan is attached as Appendix 1.

1.6 Dr Zoe Dunhill, a consultant paediatrician and Mr Jim Cameron, a former Chief Social Work Officer were appointed to conduct a significant case review into the death of Declan Hainey. Dr Dunhill and Mr Cameron conducted their work following the Renfrewshire Child Protection Committee’s Procedure for Conducting a Significant Case Review in Renfrewshire and the Protecting Children and Young People: Interim Guidance for Child Protection Committees for conducting a Significant Case Review published by the Scottish Executive.

1.7 A copy of the significant case review, with minimal redaction of personal data, is

attached as Appendix 2 for the consideration of Board members. The redactions have been made in line with data protection legislation and every effort has been made to disclose as much of the report as is lawfully possible. The redactions do not impede a reader’s comprehension or understanding of the circumstances of Declan’s life or the involvement of agencies in his life and the 16 recommendations contained within the significant case review report are printed in full.

1.8 The significant case review identified a number of key themes including:

• Risk assessment and review processes. • Interagency communication and information sharing. • Identification of non-engagement/non compliance with services resulting in

the child not being seen.

1.9 The recommendations contained within the significant case review were presented to senior officers from the Child Protection Committee in November 2010 allowing an agreed action plan to be developed to respond to the recommendations. The Child Protection Committee‘s Chief Officers Group, chaired by the Chief Executive of the Council with representatives of the Chief Constable of Strathclyde Police and the Chief Executive of NHS Greater Glasgow and Clyde Health Board, has ensured the action taken has strengthened the interagency working arrangements in Renfrewshire. The action plan has been regularly reviewed by the Chief Officers Group and Renfrewshire Child Protection Committee. The action plan incorporating details on the progress made in relation to the recommendations is attached as Appendix 1.

1.10 Elected members were advised of Declan’s death following the Council meeting on 1

April 2010. Since then Senior Elected Members have been briefed at the Cross Party Sounding Board in September 2010, June 2011 and October 2011 prior to the significant case review and its findings being considered formally at the Community and Family Care Policy Board.

1.11 Officials from the Scottish Government and the Care Inspectorate were also advised of Declan’s death in April 2010. Scottish Government officials and the Care Inspectorate have been kept informed of the key issues identified by the authors of the significant case review and the progress made in implementing the recommendations. This was important in ensuring that issues which were not only Renfrewshire specific but of national significance were highlighted at an early stage. The Care Inspectorate has been invited to review the action taken in response to the recommendations.

1.12 The Child Protection Committee was able to consider the significant case review report

at the conclusion of the criminal trial. The significant case review was based on the findings of interviews, undertaken in 2010 conducted with a number of staff involved in working with Declan and his mother. The criminal case held at the end of 2011 was also able to considered evidence from a wider range of witnesses and medical evidence not previously available to the authors of the significant case review.

1.13 At the High Court in Glasgow Lord Woolman sentenced Kimberley Hainey to a

mandatory life sentence with a minimum term of 15 years after she was found guilty of the murder of Declan Hainey. Lord Woolman’s sentencing statement summarised the key findings in the case against Kimberley Hainey and an extract is attached at appendix 3.

1.14 At the conclusion of the trial of Ms. Hainey, the Crown Office indicated that the case

would be reported to the Scottish Fatalities Investigation Unit to consider whether a Fatal Accident Inquiry should be held. The decision to hold a Fatal Accident Inquiry into the death of Declan Hainey was announced on 26 January 2012.

1.15 Given the involvement of services in this case it was appropriate to investigate the role

of individual members of staff in their work with the family with further action being taken where appropriate. As the action plan details an operational instruction on non-engagement has been issued to staff and briefings on this and on the National Child Protection Guidance published by the Scottish Government in 2010 has been delivered to staff. In addition Scottish Training on Drugs and Alcohol (STRADA) has been engaged to review the Getting Our Priorities Right (GOPR) process in Renfrewshire and provide further training on an interagency basis. This process relates to the management of risk posed to the children of parents who have addiction problems.

2. Recommendations

2.1. The Community and Family Care Policy Board is asked to note that:

[a] on the instruction of the Independent Chair of Renfrewshire Child Protection

Committee an independent significant case review was undertaken, following the death of Declan Hainey;

[b] an action plan was developed to address the 16 recommendations contained within the report;

[c] the Child Protection Committee’s Chief Officers Group has overseen the progress made in relation to each of the recommendations to strengthen interagency working in Renfrewshire;

[d] practice and procedures have been put in place to address each recommendation;

[e] regular liaison has taken place with relevant government and regulatory agencies since the completion of the significant case review and the Care Inspectorate has been invited to review the inter-agency response to the action taken to address the recommendations contained within the significant case review; and

[f] further reports will be submitted to the Community and Family Care Policy Board and Council as appropriate.

3. Background

Renfrewshire Child Protection Committee

3.1. Renfrewshire Child Protection Committee is a multi-agency partnership forum established in line with statute and government guidance to provide the strategic planning mechanism for interagency child protection work in each local authority area. It has 3 principal functions.

• Public Information • Continuous Improvement • Strategic Planning.

3.2 The guidance also requires that Chief Officers work collectively to identify and

commission interagency activity with respect to child protection. The Chief Officers Group and Committee is made up of representatives from Renfrewshire Council, NHS Greater Glasgow and Clyde, Strathclyde Police, the Scottish Children’s Reporter Administration, the Procurator Fiscals Office and members of the Voluntary Sector.

3.3 The Chief Officers Group appointed an Independent Chairperson in 2004, providing

independent scrutiny of the work of the Committee. A number of other areas in Scotland have since followed this approach.

3.4 Where criminal proceedings are outstanding the normal practice has been to await the

outcome of those before initiating a significant case review. As noted in paragraph 1.5 negotiations with the Procurator Fiscal’s service allowed the commissioning of an independent review of the case in advance of the criminal case being concluded. The significant case review was commissioned by the Independent Chair on behalf of the Child Protection Committee. The Procurator Fiscal’s Office agreed that the independent significant case review could proceed but that the content and findings of the report would remain subjudice during the criminal trial. Agreement was secured that the recommendations could be shared on a confidential basis allowing the Child Protection Committee to respond to them quickly making changes to processes or procedures as required.

3.5 The significant case review was undertaken during 2010 by Dr Zoe Dunhill and Mr Jim

Cameron. A copy of the significant case review, with minimal redaction is attached at Appendix 2. To ensure data protection compliance it has been necessary to redact some personal data, such as sensitive personal data from Ms Hainey’s medical records and some personal information about third parties. The action plan incorporating details on the progress made in relation to the recommendations is attached as Appendix 1.

3.6 The authors of the significant case review noted concerns in relation to the interface

between GOPR and the formal Child Protection Procedures; the quality and robustness of the assessment of the risk presented to Declan by his mother; completion of records (quality and timeousness); levels of contact with Declan; the application of judgment and understanding of thresholds of risk; a focus on Ms Hainey’s needs and failure to fully consider potential risks to Declan; an overly optimistic view of progress; quality of information sharing between professionals; lack of understanding of agreed actions and lack of clarity at handovers and closure of involvements.

3.7 The significant case review contains 16 recommendations for consideration on a single

and multi-agency basis. Of the recommendations 6 were multi-agency, 3 were for action by social work and the remaining 7 by health. The recommendations can be summarised as actions required in relation to: how referrals for pregnant women with substance misuse concerns should be made and responded to; staff training; contact levels with children; recording; sharing information; monitoring practice and steps to be followed when a case is closed. Since the significant case review was completed in November 2010 individual agencies have taken action to respond to the recommendations that apply to them. These actions and those for the multi-agency partnership have been taken forward and reported to the Child Protection Committee and the Chief Officers Group.

3.8 The response to the recommendations has been co-ordinated by a RCPC Case Review

Group chaired by the Independent Chair of the Child Protection Committee ensuring multi-agency agreement and a shared action plan to address the recommendations. The Child Protection Committee’s Chief Officer Group has ensured that all of the recommendations have been responded to and has closely monitored progress on the action plan. The action plan showing progress in relation to addressing the recommendations is attached at Appendix 1.

3.9 The social work service has taken action in relation to the three specific

recommendations. These actions have ensured that all of the required agency representatives contribute to meetings considering the circumstances of children who may be vulnerable. The arrangements for the assessment of parents with drug and alcohol problems have been reinforced and a change in the management arrangements in social work service in the Royal Alexandra Hospital (RAH) has strengthened services there.

3.10 In the last year social work has modernised and redesigned children’s services resulting

in a further enhancement to the dedicated children’s services management structure in each locality. This included action to address the recommendation in relation to the management of child care work in the RAH at an early point. Where opportunities have been available further developments to enhance children’s services have been taken including the introduction of a Family Assessment and Contact approach and the development of an early years team in each locality. The resourcing of social work services remains under review on a regular basis to seek to ensure that it is able to meet the demands placed upon it.

Issues of national relevance 3.11 Officials from the Scottish Government and the Care Inspectorate were advised of

Declan’s death in April 2010. Scottish Government officials and the Care Inspectorate have been kept informed of the key issues identified by the authors of the significant case review and the actions taken to change and strengthen services.

This was important in ensuring that issues of national significance were highlighted at an early stage. The Care Inspectorate has been invited to review the action taken in response to the recommendations.

3.12 The significant case review identified areas which have relevance and implications for

child protection services across Scotland: • non-engagement and avoidance of contact; • risk assessment and risk management in child protection; • working with substance misusing parents: • information sharing across agencies; and • the role of General Practitioners in Child Protection.

3.13 Non-engagement and avoidance of contact is identified in the report as a risk factor in

relation to the protection of children. The National Guidance for Child Protection in Scotland, issued in December 2010 contains a section on non-engagement and the related risks for children. All child protection committees across Scotland will now be required to amend their local procedures to ensure that this area is addressed. Renfrewshire social work service and Greater Glasgow and Clyde NHS has responded to the recommendation in the significant case review, considered the National Guidance and introduced procedures to address this issue.

3.14 The National Guidance for Child Protection in Scotland sets out a process for assessing

risk, conducting investigations into potential risk and the arrangements for convening child protection case conferences in relation to unborn children. The National Guidance recognises a need to retain professional judgement based on robust risk assessment tools. Work is being taken forward at a national level in relation to the development of risk assessment tools for use by professionals working in child protection. Renfrewshire social work service has reviewed the issue of risk assessment and risk management and action taken to ensure all staff are aware of their responsibilities in this area. Social work contributed to the development of the Renfrewshire Child Protection Committee’s Risk Management Framework: Assessing and Managing Risk within the Child Protection Setting published in June 2010.

3.15 Working with substance misusing parents has also been addressed in the National

Guidance. In addition a review and update of Getting Our Priorities Right (GOPR) is being progressed at a national level which will be considered within the Renfrewshire updated procedures. The importance of professionals understanding the impact of parental substance misuse on children is highlighted as a priority for action. The national guidance emphasises the need to integrate the assessment of the risk posed by adults to children into the Getting it Right for Every Child Assessment Framework. Within Renfrewshire work has been taken forward to ensure that GOPR is embedded in the integrated assessment framework tool.

3.16 The National Guidance contains a chapter on information sharing. The guidance sets

out the principles for information sharing, addresses issues of confidentiality and consent, the principles of recording and analysing information and concludes on how records should be stored and retained. The Renfrewshire Child Protection Committee developed interagency guidance on effective communication between agencies and professionals in response to the recommendation contained within the significant case review. The guidance was issued by each individual agency and highlighted at the interagency child protection briefings.

3.17 The significant case review highlights issues in relation to the role of General

Practitioners in child protection work. These issues need to be addressed at a national level ensuring that General Practitioners across Scotland are supported in discharging their essential role in child protection work.

3.18 It is clear that whilst the recommendations contained within the significant case review

have implications for child protection practice at a national level the National Guidance issued in December 2010 has already addressed some of the issues. Child Protection Committees across the country will take action to ensure their procedures and training cover these areas. However the issues concerning the training, expectations and support of General Practitioners may also benefit from consideration by the Scottish Government.

3.19 In addition to the areas of national relevance contained within the report there are two

other areas of local practice which other child protection committees may wish to consider. The first concerns the appointment and role of an independent chairperson for the Child Protection Committee. There are significant strengths in this approach particularly holding the partner agencies to account for their practice in child protection work and the scrutiny of policies and procedures. As indicated earlier in this report the independent chairperson in Renfrewshire was able to commission a significant case review into the death of Declan prior to the conclusion of the criminal process. In most circumstances the significant case review is not commissioned until the end of any criminal procedures.

3.20 The second area which is of significance at a national level is the introduction of “An

Unseen Child” protocol. It is suggested that the Scottish Government consider supporting all child protection committees to have a detailed response in place to ensure situations where a child is not seen on a regular basis are addressed.

3.21 The significant case review made 16 recommendations which the Child Protection

Committee has accepted. Since November 2010 action has been taken to review and improve processes and procedures in Renfrewshire to assist in mitigating the risk for vulnerable children. The partnership approach to delivering child protection services has been reviewed and actions taken to develop and build practice. The protection of children remains the highest priority for agencies across Renfrewshire and future reports on the improvement plan will be presented to future meetings of the policy board.

Implications of this report 1. Financial Implications – none. 2. HR & Organisational Development – The role of the individual members of staff in

their work with the family has been investigated and further action has been taken where appropriate. Training and development has taken place in respect of the key findings of the significant case review.

3. Community Plan/Council Plan Implications Safer and Stronger – Recommendations from the Significant Case Review have been

implemented in order to strengthen and develop child protection services in Renfrewshire.

4. Legal Implications – The significant case review is attached as appendix 2 with

minimal redaction of personal data to ensure compliance with the Data Protection Act 1998.

5. Property Implications – none. 6. Information Technology Implications – none. 7. Equal Opportunity Implications – none. 8. Health and Safety Implications – none. 9. Procurement Implications – none. 10. Risk Implications – In response to the recommendations arising from the Significant

Case Review changes have been implemented in relation to risk assessment and management arrangements.

11. COSLA Policy Position – none.

Appendix 1

Significant Case Review Recommendations and Action Plan, updated for RCPC 25th January 2012

Recommendation Outcome Action Taken Evidence Monitoring arrangements

1. When a substance misusing mother-to-be is being referred to maternity services this should be done using a pro forma which includes information on their substance misuse and any other relevant issues.

Pregnant women with substance misuse problems are referred to SNIPS and the appropriate information is shared.

SNIPS (Special Needs in Pregnancy Service) pro forma is used by social work and midwifery staff and includes information on their substance misuse and other relevant issues. Currently other health and partner agency staff refer to SNIPS through use of a referral letter which includes details of maternal substance misuse. It has been agreed that the SNIPS Proforma will now be used as the standard referral paperwork. Where the initial referral to SNIPS is made by phonecall , this will be followed up in writing by completion of the proforma. Given the number of referral sources to this service , implementation of the standardised referral paperwork will take place during February and March 2012 RCHP Children and Families Team Leaders attend regular scheduled joint meetings with the SNIPS Team to discuss current SNIPS cases. When appropriate, Team Leaders will pass on information to the attached Health Visitor (HV) and the patient’s GP Practice for any necessary follow up action. Team

• Copy of blank pro forma • Evidence of communication with

staff • Examples of completed pro

forma/ confirmation from SNIPS service that it is being used.

• List of meetings between SNIPS and Team Leaders, minute and actions arising.

• Team Leader review role as part of caseload management supervision to ensure actions completed with input to support improvements if required.

• A review noted that 244 referrals were received by SNIPS over a 12 month period (September 2010 – September 2011)

• Maternity pathway has been shared with all HVs and Midwives as part of joint development sessions.

• Initial report from Team Leaders on the implementation of the Care Pathway due in January

Health has implemented a review by Clinical Services Manager (CSM) quarterly commencing December 2011. New care pathway will be reviewed by Head of Midwifery and CSM (children and families). STRADA have been contracted by the Alcohol and Drugs Partnership (ADP) to review the existing pregnancy protocol, the results of which are due March 2012.

Leaders actively monitor this as part of Caseload Management Supervision. A new care pathway between midwifery and Health Visiting has been jointly developed and implemented from May 2011. This pathway is designed to ensure seamless care for vulnerable mothers to be. Team Leaders actively monitor this as part of Caseload Management Supervision. SNIPS team meet with the Senior social worker, child care, RAH (Royal Alexandra Hospital) fortnightly to discuss referrals, review cases and share information.

2012 and thereafter on a quarterly basis.

2. There should be an initial child protection case conference arranged in all cases of children being born to drug-using parents

The needs of and risks to children being born to substance misuse parents are assessed.

In line with National Guidance for Child Protection in Scotland (2010) and the West of Scotland Child Protection procedures, an assessment is completed in all cases of children being born to substance misusing parent(s) (for both drugs and alcohol misuse). A Child Protection Assessment (CP1) is completed in addition to a ‘Getting Our Priorities Right’ (GOPR) assessment (in line with the RCPC Inter agency working with children affected by Drug and Alcohol misuse protocol). This is completed in all cases which are then reviewed by the Social Work Fieldwork Manager. The RCPC has adopted the position of the National Guidance for Child Protection (published in December 2010) for this recommendation which was made in advance of the National Guidance being published.

• Copy of Memorandum • A review of cases between

1/1/11 and 6/10/11 confirmed that CP1s were being routinely being completed in accordance with the memorandum.

• Multi agency RCPC case file audit November 2011 noted that CP1 was completed where appropriate

• SW audit of 27 children who had been subject to pre birth GOPR process noted 25 had GOPR/CP1 assessments completed, a further two had been subject to GOPR initial assessment and were continuing as open social work cases.

Social Work has developed a rolling programme of internal audit and will audit GOPR practice as part of this in spring 2012.

3. A Health Visitor or School Nurse from the GP practice should be invited to all meetings concerning substance abusing parents and their child (ren).

• •

To ensure that there is appropriate health representation at meetings and all relevant health information is available.

Social work use a standard invite list to ensure that health visitors (HV) and school nurses (SN ) are invited to all meetings concerning substance misusing parents and their children.

Further Guidance is being developed which will make clear the responsibilities regarding content of the CP reports from health visitors and school nurse sand their responsibilities around the co-ordination of information from other health professionals> this will be completed by January 2012.

The Child Protection Unit (CPU) at Yorkhill Hospital provide an early sharing and collation of information system.

• Social Work review of 271 case conferences ( for period 1/1/11 to 6/10/11) which examined invitations to health visitors and school nurses

A further audit will be carried out in February 2012.

4. The GOPR care plan should include specific reference to the level of direct contact to take place with the child(ren), who is responsible for maintaining this contact and, in the event of any significant

All GOPR (getting our priorities right) assessments have a SMART intervention plan including details about direct contact with parent and child(ren) and contingency plan Significant changes to the GOPR plan trigger a review GOPR

Social Work Operational Instruction issued February 2011 requires that there is a SMART care plan which identifies the level of face to face contact expected and contingency arrangements including where contact is not being achieved in line with the plan.

It further instructs that where there is significant change of circumstances including failure to engage or co-operate a review should be held involving appropriate partners.

• An audit of GOPR cases at Royal Alexandra Hospital, was undertaken in 2010 which found good practice to be in place.

• RCPC case file audit November 2011 noted that where there was a GOPR assessment, direct contact arrangements were specifically noted.


RCPC has carried out regular multi agency case file audits (June 2009/ June 2010/ November 11). The GOPR process is a key aspect to the audit and areas for improvement are

variation from the programme of planned contact, the requirement for an urgent review be arranged.

meeting and review of the care plan.

noted and incorporated into the self evaluation plan.

5. NHS GG&C should introduce an Unseen Child protocol in conjunction with its partner Local Authorities.

Ensure that any risks to the safety and ongoing wellbeing of children are identified as early as possible.

The Clinical Services Manager (CSM), Renfrewshire CHP, submitted a draft protocol (Unseen Child) to the NHS GG&C Child Protection Unit Autumn 2010. This has been incorporated into the draft NHSGGC ‘Non-Attendance Policy’. Renfrewshire CHP (Community Health Partnership) issued a letter to all primary care staff highlighting the need to ensure compliance with best practice regarding all unseen children in September 2011 The new GG&C Policy was approved - pending minor amendments - by NHS GG&C Child Protection Forum,on 17 January 2012. A robust staff awareness and implementation plan will commence within Renfrewshire March 2012 following issue of the final policy.

• Copy of letter issued by Head of Primary Care and Community Services, date of issue, confirmation by staff members re receipt, understanding and application.

• GG&C Draft Policy indicative implementation date is end of January 2012.

• Multi-Agency RCPC case file audit, November 2011 noted that all cases had specific reference to the child being seen.

Review of the application of this policy is integral to Caseload Management Supervision and outcomes per HV. Reviewed by Clinical Services Manager quarterly. Audit reports are reviewed by respective management teams, clinical governance group and RCPC An implementation report will be available 6 months after implementation.

6. Cases coming under the GOPR umbrella should be the subject of

Cases are not closed or transferred without full information and assessment of the

Social Work issued an Operational Instruction in February 2011 to ensure that childcare cases are subject to review within agreed timescales. It further instructs that where a case is being transferred or closed the relevant assessment should be updated, the child seen and a closing

• The inter agency audit of cases in November 2011 noted that where there was a GOPR assessment there was regular review.

• Evidence of sample of care plans


regular review and should not be closed or transferred without such a review taking place, including updating the Parental Substance Misuse Report.

circumstances

summary completed within one week. Guidance for Addiction Services Staff stipulates that prior to case closure consultation must take place with Children and Families services. All staff are required to comply with best practice as outlined in Child Protection West of Scotland Procedures and National Guidance for Child Protection in Scotland (2010).

RCPC has carried out multi agency case file audits (June 2009/ June 2010/ November 2011). The GOPR process is a key aspect to the audit and areas for improvement are noted and incorporated into the Self Evaluation plan.

7. There should be put in place a monitoring system, such as exists in respect of Child Protection, to ensure that the process of completing GOPR Full Assessment Reports and conducting reviews can be tracked, and speedy action taken where there is significant variation from the prescribed timescales.

To ensure that active monitoring is in place

Social work has reviewed and implemented an enhanced monitoring system. Fieldwork managers review key GOPR assessment activity on a monthly basis (previously undertaken quarterly). Data quality of Initial meetings and GOPR contacts are being tracked on a weekly basis. As at 13/1/12, 30 assessments are being progressed.

• Business Object reports from SW information system

Social Work has developed a rolling programme of internal audit and will audit GOPR practice as part of this in spring 2012. SW performance information is monitored through the senior management meeting structure.

8. Given that GP records are likely to be the most accurate and comprehensive source of the medical history of a substance-misusing parent, it is recommended that it be made the responsibility of the GP to ensure that such information is made available to case discussions either by direct presentation by her/himself, or a representative of the practice eg a Health Visitor, or by the provision of a written report.

•

When requested by Social Work, GPs will submit a written report to all meetings. All relevant information about the child will be shared by the GP and, when appropriate, his/her primary carers.

Social Work use a standard invite list to ensure that health visitors and school nurses are invited to all meetings concerning substance misusing parents and their children. The Child Protection Nurse Specialist based at Child Protection Unit (CPU) at Yorkhill Hospital is also invited to all child protection meetings.

Data on attendance and reports received at Child Protection meetings is being reviewed on a regular basis to monitor invites/ attendance / reports received and quality of reports.

• SW audit noted that, between 1/1/11 and 6/10/11, 124 Initial Case Conference took place. GPs were invited on 120 occasions, 3 GPs attended and 1 also submitted a report, 37 reports were submitted where no GP in attendance

• RCPC case file audit November 2011 noted that, where there was case discussions, most cases had relevant information in report

A further SW survey will be carried out February 2012. RCPC has carried out multi agency case file audits (June 2009/ June 2010/ November 2011). The GOPR process is a key aspect to the audit and areas for improvement are noted and incorporated into the Self Evaluation plan.

9. It should be

mandatory for all staff and managers involved in this area of work, either directly or indirectly, including GPs and consultants within the RDS, to undergo GOPR training, and each agency should maintain a GOPR training record, either on a stand alone basis, or as part of any existing training record.

To ensure the competence and confidence of staff, (including managers) in working with or managing cases in line with the GOPR protocol

Inter agency GOPR training has been delivered since 2006. All GPs have been issued with GOPR protocol and laminated flow chart (March 2010). GOPR training is mandatory for relevant SW staff and monitored as per SW Supervision Policy. All RCHP staff working in Children’s Services, Addiction Services and relevant adult Mental Health Services have been trained in the implementation of GOPR. A specific training session was devised and delivered to medical staff and consultants working in Addiction Services in August 2011. As a matter of routine, all new staff joining the CHP in the above services, are trained in GOPR as part of the staff induction process. RCHP staff groups involved in GOPR training are HVs, School Nurses, Support Workers, All Specialist Children’s Services Staff, GPs, Addictions and Adult Mental Health, AHP staff working with children. GPs are individually responsible for their continuing education and the CHP cannot mandate GPs to undertake GOPR Training. However the CHP is actively promoting and facilitating:

• Attendance of GPs at GOPR training events specially tailored to GP Practice staff;

• Awareness raising of GOPR training through the LMC Newsletter;

• Use of GP Protected Learning Time and targeted Health Centre based training sessions for GPs on GOPR.

• STRADA carried out research on the GOPR training delivered from 2006 to 2010. The numbers of staff who attended, the number of training events and agencies of participants is evidenced in the report.

• 2996 staff have attended GOPR training from 2006 to April 2011 including the following numbers from agencies:

Social Work Services, 1069; Health, 622; Education and Leisure Sevices, 676; Housing and Property Services, 199; Voluntary sector, 198; Drug and alcohol services, 45

• Health Team Leaders have confirmed that all 80 staff in C&F team have completed this training and this is evidenced in individual staff training record submissions. 23 Addiction Team staff have been trained.

• HMIe, Jan 2011, notes as an example of good practice ‘preparing staff to meet the needs of children and young people affected by parental substance misuse’

• RCPC annual GOPR Training Plan and reports on attendance at GOPR training.

STRADA are undertaking a review of the GOPR training as part of their contracted work for the Alcohol and Drugs Partnership. SW CPD system maintains an overview of staff training and development. RCPC GOPR training management information is reported to RCPC. Health professionals attendance is monitored as part of individual personal development plans as mandatory training. To date this is a paper based system however an electronic data base will be in place from March 2012 for each staff group.

10. A simple paper or electronic form of communication should be introduced to ensure that there is clarity of language and intent when staff from one agency are asking staff from another agency to carry out a specific task.

Effective communication between staff to protect children

RCPC issued Communication Guidance in November 2011. This has been implemented by all agencies instructing that, where staff from one agency is asking staff from another agency to carry out a specific task, they are required to provide additional written secure communication. This is in addition to current professional responsibility in relation to case recording. Application of the Guidance has been discussed with staff at RCHP locality Team meetings and this continues on an ongoing basis through caseload supervision. The Guidance will be included in CHP staff induction packs and also for sharing with staff returning from long term leave. The RCHP Clinical Director will, in consultation with the RCHP GP Forum, advise on the most efficient way to implement this Guidance within GP Practices by March 2012. Education and Leisure services (ELS) have circulated the Guidance and RCPC letter to all staff and discussed at Head Teachers meeting in November 2011. SW has issues an operational instruction from Head of Service to all child care staff regarding the RCPC Communications Guidance. This was discussed at a Senior Social workers (SSW) meeting in November 2011. Fieldwork managers have discussed the implementation with staff at supervision and team meetings.

• RCPC Guidance • RCPC information sharing

protocol • Renfrewshire GIRFEC policy • Single agency information sharing

policies • CHP was issued RCPC Guidance to

all CHP staff in November 2011. Managers have a record which demonstrates each member of staff has read and understood the content of the Guidance

• CHP minutes of locality meetings and induction packs

• Police briefing paper for RCPC December 2011

• ELS note to staff and head teacher meeting minute

• SW operational instruction and SSW meeting minutes

• RCPC minutes • Housing services implementation

report

All agencies have reported to RCPC on the process of implementation. Audits will be carried out by each agency in 2012.

Police (K Division) have an implementation and training plan for relevant staff Housing will incorporate the communications protocol into CP procedures in January 2012

11. There should be a review of guidance for Health Visitors on interagency working, including their responsibilities under recommendation 7, and consideration of a short period of “shadowing” as part of the induction programme for new staff.

Health Visitors are fully briefed and understand their specific and joint responsibilities as described within the West of Scotland Procedures Health Visitors new to the CHP will have a working knowledge of local Social Work staff and structures and associated local child protection /welfare issues.

RCHP staff will comply with best practice as outlined in Child Protection West of Scotland Procedures and National Guidance for Child Protection in Scotland (2010). All CHP staff working directly or indirectly with children will attend RCPC Briefings on CP procedures and Guidance by March 2012. All newly appointed HVs within RCHP will undertake a one day experiential placement within social work as part of their induction programme (weeks 1- 12 in post). This will commence November 2011.

• RCPC interagency case file audit • Evaluation of induction and

impact assessment on future practice

• Numbers of new staff in CHP matched to number who have been offered a shadowing placement with Social Work within first 3 months of joining CHP.

• Number of staff attending briefings

Evaluation of induction and impact on practice.

12. Guidance should be introduced for Health Visitors on case handover

Improved continuity of care and ongoing risk assessment for children subject to a change in

Introduction of RCHP HV Case Load Handover Guidance developed in partnership with HV’s and School Nurses. This includes :

• HV to HV at times of sick leave , mat leave or vacancy

• HV to School Nurse – transition to

• Guidance introduced and implemented in September 2010

• RCHP Guidance for case handover

Team Leader monitoring report to CSM quarterly. Senior Nurse Review early 2012.

practice, including an entry in the patient record, at least in all “additional” and “intensive” cases, of key issues and the date of handover.

Health Visitor.

school

Ongoing monitoring of the Guidance will take place through Team Leader caseload supervision. The CHP Senior Nurse will regularly review service wide implementation of this Guidance.

13. There should be a review of clinical and management supervision arrangements for Health Visitors with reference to frequency, recording of content and formalising sessions for all staff.

All Health Visitors have access to a sustainable system of timeous clinical support and caseload management supervision by a Team Leader.

Case Load Management Supervision has been implemented for all Health Visitors and School nurses working in C&F teams in RCHP. This is monitored and reviewed by Team Leaders and CSM. Clinical Supervision has been reviewed and reintroduced by the Senior Nurse to ensure effectiveness and support to all staff.

• Monitoring and review by team leaders and CSM

• Quality improvement plan

This will be monitored as part of the CHP Quality Improvement Plan. An excel datasheet provides a progress report to Managers on a monthly basis.

14. There should be a review of the nurse management structure to ensure that health visitors and other nursing staff receive appropriate support and supervision.

All Health Visitors have access to a sustainable system of timeous clinical support and caseload management supervision by a Team Leader

The responsibilities and capacity of Team Leaders in Children and Family services have been rigorously reviewed to ensure equity, quality of support and rigorous staff and clinical governance. This is actively supported and reviewed on an ongoing basis by the CSM Children and Families; Senior Nurse and Head of Service. Additional Team leader resource has been in place since April 2010.

• Review completed resulting in 15 additional hours of Team Leaders capacity as of April 2011. In addition numbers of HVs in each team have been reviewed and realigned on an equitable basis.

Monitoring by CSM with Team Leaders and Senior Nurse.

15. Steps should be taken to ensure that GPs are familiar with RCGP/SG guidance on the management of substance abusers.

GPs in Renfrewshire have awareness and increased knowledge in relation to the UK Health Dept’s Guidance ‘Drug Misuse and Dependence – UK Guidelines on Clinical Management 2007.

RCHP GP Forum has discussed GP awareness of RCGP/SG guidance. Over the last 12 months the Clinical Director has issued Guidance with reminders and will continue to do so with additional support from targeted training to GP Practices.

• Agenda, discussion and outcomes from RCHP GP forum

• Outcome of meeting with Chair

of RCPC/ Clinical director/ Head of Service •

Monitor issue of Guidance and communications between Clinical Director and GP practices. Monitor uptake, delivery and impact of GP target training programme.

16. Management of Social Work child care practice within the RAH should sit within Child Care rather than Community Care.

Child care staff, including managers, from RAH based social work services sit within the child care line management structure.

Social Work has reviewed and implemented changes to staffing arrangements within the RAH. Dedicated social workers are managed by an experiences child care senior social worker. Senior staffing structures have changed to ensure that a child care Fieldwork Manager has overall responsibility for child care practice within the RAH.

A review of GOPR pre birth cases at the RAH in October 2011 has found CP1 reports have been completed and reviewed by Fieldwork Manager in every case

Action has been implemented.

Appendix 2

Significant Case Review relating to Declan Hainey Explanatory Note This document contains the Significant Case Review relating to Declan Hainey. This was written by two independent authors, commissioned by the Renfrewshire Child Protection Committee. In the interests of transparency, every effort has been made to disclose as much of the SCR as is lawfully possible. The only editing prior to disclosure is the redaction of personal data, disclosure of which cannot be justified under the Data Protection Act 1998 (“the DPA”). Although there has been a criminal trial and extensive media coverage of this case, and a significant amount of both personal data and sensitive personal data is, as a result of this, publicly available, disclosure of the personal data contained in this report must still comply with the DPA. This means that even though some of the redacted information may already be publicly available, or it may be considered to be in the public interest to disclose, it cannot automatically be disclosed, as the DPA contains certain conditions which must first be met. The process of redacting the SCR has involved careful consideration of:-

• The need for transparency and the overall purpose of the SCR in the identification of any lessons learned.

• The public interest in disclosure.

• Considering whether information is sensitive personal data, (for example, because it is information about a person’s physical or mental health or condition, his/her sexual life, or the commission or alleged commission of an offence) and whether its inclusion in the SCR complies with the Data Protection Act 1998.

Notes on Redaction 1. Paragraphs 16, 4.6.3 and 4.9.8 relate to a family incident and contain the

sensitive personal data of Ms Y and third party data which cannot be disclosed.

2. The chronology contained in Appendices 1 and 2, referred to in paragraphs 2.2, 4.1.1 and 4.7.2 has been withheld in its entirety as this contains extracts from medical and other confidential records.

3. Redaction in Glossary of Terms relate to actual medication and medical procedures and are sensitive personal data.

Renfrewshire Child Protection Committee

A Significant Case Review into the Death of Baby X

Jim Cameron and Zoë Dunhill November 2010

agenda item no renfrewshire council - south ayrshire€¦ · agenda item no..... renfrewshire...

Documents