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Thematic Serious Case Review

September 2019

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Foreword

The focus of this thematic review are 6 children from different families who suffered

serious non- accidental head injuries. One child sadly died as a result of these

injuries. Their injuries were sustained whilst in the care of their families; three family

members are serving prison sentences and in the remaining three cases criminal

investigations are ongoing. Three serious case reviews have already been concluded

and published in relation to three of the children. This Thematic Review reflects on the

established learning about these 3 cases and, in light of this learning, explores and

analyses the services provided to the three other children.

Learning for services has been identified and this has been positively received and

accepted by NSCB. One of the key tenets of this learning is acknowledging that multi-

agency services and practitioners safeguard children every day and improve their

outcomes, therefore it is fair to recognise that these cases are an exception rather

than a rule. However, by no means does this statement intend to infer complacency.

This report highlights the complex nature of the work undertaken by safeguarding

services and is a salutary reminder of the need to appreciate that the work is very

much a human service dealing with the tragedy of human life that does not always get

it right.

Sadly, non-accidental head injuries in young children is a feature of our society. This

review highlights the number of children across England whose lives have been

tragically ended or have sustained life changing injuries at the hands of their family or

care givers. This is not said to apportion blame: unfortunately blame is something that

too often represents a desperate attempt to simply make sense of tragedy.

This review attempts to understand the complex nature of this safeguarding issue and

appreciate the complexities of the factors involved. Safeguarding professionals have a

duty to act on behalf of society to effectively intervene and certainly there are things

that need to change to strengthen and support their work. However, it is an issue that

requires us all to take responsibility as members of this society: as politicians, policy

makers, leaders, safeguarding professionals, members of families and communities.

It is also important to be clear about the context within which safeguarding work takes

place. It is a context that features high volume, restricted resources, the sadness of

the human condition and the impact that this has on children’s lives. It is work that is

saturated with a plethora of legislation, policy, targets, performance indicators,

inspection and criticism. It is an imperfect system that requires politicians, policy

makers, leaders and the media to share the responsibilities for what gets side lined or

truncated. There are hard choices to make but the consequences belong to all.

NSCB have accepted in entirety the learning and recommendations from this Thematic

Review. Considerable work is already underway to implement the learning

underpinned by a strong commitment to the children and families of Norfolk. In

respectful partnership with politicians, policy makers, the media, leaders of

safeguarding services, safeguarding professionals and children and families Norfolk

will do its utmost to prevent harm to children and give them the very best start in life.

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Contents

Section Title Page Number

1. Why was this review undertaken? 5

2. Methodology 5 - 9

3. The Children 10

4. What happened and why? 11 (& Appx. 1)

5. Report Structure 11

6. Review Principles 11

7. Similarities & Differences – Audit Results 12 - 16

8. Research Questions 17

Parental vulnerabilities 17 - 21

Impact of violence 22 - 24

Professional curiosity 25 - 30

Assessment of risk 31 - 35

Organisational flux and impact 35 - 38

Information exchange 38 - 42

Do SCRs make a difference? 42 – 45

9. Leadership Focus Group 45 - 47

10. Summary of Key Learning 48 - 49

11. Conclusion & Recommendations 49 - 50

Appendix 1. Appraisal of Practice AF1 & AF2 51 - 62

Appendix 2. Recommendation 2. Terms of Reference 63 - 64

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1. Why was this review undertaken?

In January 2017, two serious case reviews (SCR) were published by Norfolk

Safeguarding Children Board (SCR Child S and SCR Child R) and in August 2018 a

third case (SCR Child V) was published. One child sadly died, and two children

suffered serious non-accidental head injuries which were regarded as potentially life

threatening. Since this time, 3 further cases of serious non- accidental head injuries

were referred to Norfolk Safeguarding Children Board (NSCB). Two cases (referred

to as Child AF1 and Child AF2) met the criteria for serious case reviews and it was

concluded that the third case (referred to as Child AF3) should be the subject of a

Multi-Agency Learning Review.

NSCB reviewed the circumstances of these cases, considered other serious

incidents involving infants who had suffered from non-accidental injuries and

reflected on the three relevant SCRs. It was decided that a thematic review would be

completed to consider all six cases so that a whole systems approach to learning

could be taken forward.

2. Methodological purpose & principles

NSCB decided to take an innovative approach to this review so that the greatest

possible learning could be achieved. The approach taken is rooted in statutory

guidance,1 in particular this approach recognises the limitations inherent in simply

identifying what may have gone wrong and who might be to ‘blame’. Instead it is

intended to identify which factors in the wider work environment support good practice,

and which create unsafe conditions in which poor safeguarding practice is more likely.

A central purpose therefore is to move beyond the specifics of the individual case to a

greater understanding of safeguarding practice more widely. The key principles

underpinning this review have been drawn from relevant research and literature 2

about how safety in organisations and multi-agency systems is best achieved.

Key principles

• The multi-agency safeguarding system is a complex system, when trying to

create the safest possible system, there are no quick fixes and no easy

answers.

1 Working Together to Safeguard Children – A guide to inter-agency working to safeguard and

promote the welfare of children. HMG 2015 2 Such as: Working Below the Surface. The Emotional Life of Contemporary Organisations. The Tavistock Clinic Series. The Field Guide to understanding Human Error. S. Dekker. Appreciative Inquiry: Organization Development and the Strengths Revolution. In Practicing Organization Development: A guide to leading change and transformation (4th Edition), William Rothwell, Roland Sullivan, and Jacqueline Stavros (Eds). Wiley. The Munro Review of Child Protection etc.

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• Overtime, SCRs have often repeated similar messages about the learning and

the actions required. A new set of procedures, policy, training, staff

development or new initiatives, in isolation, will not create safety.

• Systemic approaches alone, do not sufficiently get beneath the surface of the

complexities. The safeguarding system is fundamentally a human system and

the emotional experience of organisations and systems are an important

feature of how safety is achieved.

• SCRs should involve learning throughout the process and across the

hierarchies with those who are working in the system and those who are

receiving services. Frontline staff and services users are best placed to identify

vulnerabilities and strengths.

The review was led by an independent Lead Reviewer Bridget Griffin3 and NSCB

Business Manager Abigail McGarry in association with a panel, made up of relevant

agencies in Norfolk, who were fully engaged throughout the review.

Panel members:

• NSCB Business Manager

• Norfolk County Council Children’s Services

• Norfolk County Council Early Years’ Service

• Norfolk Constabulary

• James Paget University Hospital NHS Foundation Trust

• Norfolk & Norwich University Hospital NHS Foundation Trust

• Queen Elizabeth Hospital NHS Foundation Trust

• Cambridgeshire Community Services

• East of England Ambulance Service NHS Trust

• Norfolk and Suffolk Foundation Trust

• Norfolk & Waveney Clinical Commissioning Group

• Breckland District Council

3 Bridget is accredited by the Social Care Institute for Excellence in the Learning Together (systems)

methodology and has a relevant MA (Consulting and Leading in Organisations – a psychodynamic and systemic approach. The Tavistock and Portman Mental Health Trust in association with Essex University).

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Sources of information/data

This Thematic Review has reviewed and analysed:

• Integrated chronology AF1

• Individual Management Reports AF1

• Integrated chronology and multi-agency appraisal AF2

• Multi-agency case documentation for AF1 & AF2

• Relevant policy, procedure, guidance and research

• Referral to NSCB Subgroup of AF3

• NSCB. Serious Case Review Child S (2017)

• NSCB Serious Case Review Child R (2107)

• NSCB Serious Case Review Child V (2018)

Involvement of family members, front line practitioners and managers

Unfortunately, it was not possible to involve family members for Child AF1, AF2 or AF3

as criminal investigations are ongoing. In addition, it was the view of Norfolk

Constabulary that front-line practitioners and their managers should not be

approached to make a direct contribution to this review because of the sensitivities

involved in the active criminal investigations.

As a result, seven focus groups were convened across Norfolk involving multi-

agency safeguarding practitioners and managers who had no direct involvement in

the cases but who had experience of working together to safeguard children, the

participants were identified by locality or profession.

Focus groups

The focus groups were held across Norfolk in different geographic locations:

• Four involved over 60 multi-agency practitioners, clinicians and managers from

Norwich, Kings Lynn, Great Yarmouth and Dereham.

• One involved representatives from primary and secondary schools in Norfolk.

• One involved representatives from the Voluntary Sector

• One involved multi-agency senior managers/strategic leads.

A focus group with parents was planned but ultimately proved too difficult to achieve.

Three parents, who were receiving services from the Family Nurse Partnership (FNP),

met with the Independent Reviewer and Business Manager. Meetings were scheduled

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with parents who were receiving services from The Eden Team4 but unfortunately they

did not attend. Instead, a meeting was held with a staff member from this team.

Multi-agency focus groups included the following agencies /services:

• Children’s Services

• Early Help Family Focus

• Police

• Acute Trusts (midwives and paediatricians)

• Primary Care (GPs)

• Community Care (Health Visitors)

• Ambulance Service

• District Council (housing officers)

• Early Years

• Norfolk Primary and Secondary Schools

• Norfolk Voluntary Sector

Roundtable discussions, focussing on the research questions, were facilitated by the

Independent Reviewer, the NSCB Business Manager and panel representatives.

Methodological limitations

Whilst it could be argued that the group of 60 front line practitioners and managers

was a good representative sample it is important to acknowledge that this group may

well represent practitioners, managers and clinicians who, because of their voluntary

attendance at the focus groups, are a group who are highly motivated in their work

and keen to make a difference. In addition, the schools and voluntary sector groups

were a relatively small representative sample and therefore the views expressed in

these groups cannot be extrapolated as representative of these sectors.

Research Questions

Information relating to all six cases was reviewed by panel members and the following

research questions were posed at the start of the review:

• How is the impact of parental vulnerabilities assessed and understood in

relation to current and potential parental capacity? What services are needed

to support vulnerable parents? Are they available?

4 The Eden Team is a team of specialist midwives from James Paget Hospital who work alongside parents who are identified as having specific vulnerabilities.

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• How well is the impact of violence in the lives of children and adults assessed

and understood?

• What inhibits professional curiosity about injuries/reported accidental falls etc.

involving young children and what may prevent professionals from following

relevant policies/protocols/procedures? Is this due to professional deference?

• How do current systems and processes support dynamic risk assessments that

place the experience of young pre-verbal/pre-mobile child at the centre of the

assessment process?

• How well do multi-agency services understand the impact of organisational flux

and high caseloads on the services provided to children- what can be done to

recognise and mitigate this risk?

• How do current safeguarding cultures across agencies support information

exchange (supported by an active dialogue) rather than just information

sharing? What needs to be in place to promote shared ownership of

assessments and plans and support effective debate and challenge?

• Do SCRs make a difference to the services provided to children and their

families?

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3. The Children

The table below details some key features of the 6 cases including the age of the

child at the time of the significant injury, nature of injury and agency involvement at

the time of the injury. All of the children are white, five were identified as British and

one Eastern European. The children’s gender is divided equally (3 boys and 3 girls).

Child & Age of Child at time of injury/death

Nature of injury Date of incident

Agencies involved at time of injury

Type of agency involvement

Child R 9 months

Fractured skull & arm, trauma to nose, ears & facial bruising

May 2015

National Probation Service & Community Rehabilitation Company Norfolk Community Health & Care NHS Trust

Offender management Universal health care

Child S 3 years

Serious head injury and other bruising

July 2015

Early years Childminding

Child V 6 months

Serious head injury resulting in death

March 2016

Norfolk Community Health & Care NHS Trust

Health visitor & nursery nurse

AF1 23 months

Extensive bruising, abrasions & subdural haemorrhages

Dec’ 2016

Norfolk constabulary Norfolk Children’s Services Cambridge Community Services James Paget University Hospital NHS Foundation Trust

Joint Child protection investigation (Sc47)

AF2 7 months

Multiple fractures of different ages and multiple bleeds on the brain

Nov’ 2017

Cambridge Community Services Norfolk MASH

Universal health visiting Open referral

AF3 3 months

Chronic brain injury, old skull fracture and old subdural haematoma

April 2018

Cambridge Community Services

Universal health visiting

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4. What happened & why?

Serious Case Reviews SCR S, R & V contain a description and analysis of the multi-

agency work in these cases. The practice in all cases is analysed within the audit

findings and throughout this report. In line with SCR requirements, Appendix 1 details

what happened and why in cases AF1 & AF2. In this section, multi-agency practice is

analysed and appraised and factors that influenced practice/service delivery are

explored.

5. Report Structure

In the following sections, the cases will be examined using relevant audit data. In

Section 8, the research questions will be addressed using information gained from the

analysis of practice in the 6 cases and information gained from members of the panel

and focus groups. Section 10 summarises the key learning, and Section 11 & 12

concludes this report and makes recommendations.

6. Review Principles

During this review, practitioners consistently demonstrated commitment and passion

about their work and said that a key motivator was hearing about, or being part of,

things that went well for children and families. And, in the words of a parent: All I

hear is about things that don’t go well - You should bring to light things that go well, if

you did that you would build trust. The panel listened and responded to these

perspectives.

Whilst this review does not shirk from appraising the practice, or identifying barriers

to good practice, an approach has been adopted that is advocated by Eileen Munro5

and an organisational change theory known Appreciative Inquiry (AI).6

Munro emphasises the importance of identifying what works well in the safeguarding

system to improve decision making and risk management in child protection: to learn

from success as well as failures so that a just learning culture is promoted.

The AI theory is based on the principle that people in organisations construct and

enact worlds that, in turn, affect their behaviour:

To understand AI at a fundamental level, one needs to simply understand these two

points. First, organisations move in the direction of what they study. Second, AI

makes a conscious choice to study the best of an organisation, its positive

core….The first step in the AI process involves choosing the positive as the focus of

inquiry. This is because what is studied becomes reality.

5 Decision – making under uncertainty in child protection: Creating a just and learning culture. E. Munro Child & Family Social Work Vol.24,Issue 1 July 2018 6 Appreciative Inquiry Handbook. Whitney, Cooperrider & Stavros 2011

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7. Similarities and differences: Audit of 6 cases

The 6 cases were audited against set variables in order to identify any patterns in the

cases. Information gained from documents submitted for the purposes of this review

(including management reports, chronologies, agency assessments and agency case

notes/ward notes) were analysed. The audit variables were clustered into 3 broad

areas: Family, Child & Multi-Agency work. Each case had unique features and this

reflects the complexity of safeguarding work where no one child, family or

circumstances are the same.

That said, as can be seen from the audit results below, there were a number

similarities across the 6 cases. Where an audit result of Not Known (NK) is recorded,

this is either because the limited multi-agency involvement meant that the information

was not known or, in cases where there was significant multi-agency involvement,

because the information was not gathered.

Audit Findings: Family

Family Audit Result

Separation &/ or conflict in parental relationship 6

Teenage pregnancy 4

Signs of significant emotional difficulties for one or both parents

6

Evidence of violence and/or violent communication in household

6

Substance misuse 4

Evidence of parental Adverse Childhood Experiences (ACEs)

5 (1 NK)

Extended Family Involvement 6

Comment & Analysis

• In all cases the relationship between the parents (i.e. birth mother and birth

father or mother’s partner/male boyfriend) featured conflict and in all cases

there were periods when the parental couple separated/lived separately and

subsequently reunited. Reunification appeared to be a time of heightened risk;

this was a time when most of the children were injured.

• There was evidence of domestic abuse in 4/6 cases and in all cases there was

evidence of violent communication between the parental couple (such as:

coercive control/ pushing and shoving/name calling/ frequent arguments) and

on occasions this involved extended family members.

• In all cases there was evidence to suggest that one or both of the parental

couple had unresolved emotional needs. These needs included a broad

spectrum including, but not exclusive to: difficulties managing/controlling anger

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(emotional dysregulation), hostility, depression, anxiety, self-harm, suicide

attempts and criminality (including sexual offences).

• In 4/6 cases the use of substances (cannabis and/or alcohol) impacted on the

child either because of the emotional distance between mother and child

caused by excessive cannabis use and/or the use of alcohol exacerbating

existing tensions within the relationship.

• In 5/6 cases (in one case parental childhood was unknown) it was known/there

was information to suggest that one or both of the parents/ care givers had

experienced neglect and/or abuse in childhood and/or had experienced

significant family difficulties/conflict when the parent was an adolescent.

• In all cases, the involvement of extended family members was noted as a

strength, but this was not adequately assessed.

Audit Findings : Child

Child Audit Result

Previous Injuries to child 5

Prematurity 2 (1 NK)

Stressful birth/child needed intensive medical intervention at birth

4 (1 NK)

Feeding difficulties 4 (1 NK)

Difficulties noted in relationship between mother and child

4 (1 NK)

Difficulties noted in relationship between father/male partner & child

5 NK

Parents note difficulties in child’s behaviour/difficulties in meeting child’s needs

4 (1 NK)

Comment & Analysis

• The audit result of 5/6 for previous injuries is somewhat misleading; in 3/6 cases

bruising/ scratches/ swelling was previously noted, in 2/6 cases the previous

injuries were not previously known about but were found during the paediatric

assessment completed when the child was admitted to hospital with the

significant head injury.

• Two of the children were premature and in 4 cases (including the premature

births) there was evidence that the birth was stressful, with one mother

describing her child’s birth as sad and scary.

• It was significant to note that in 4 of the cases difficulties in feeding during the

early months were noted. For the children who were premature, this was a

significant issue for the parents and was accompanied by difficulties in

developing a sleeping pattern and persistent crying.

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• Overall, there was little information about the relationship between mother and

child. Where good information was available, this came from observations

made by a health visitor (AF1) during a joint visit or from midwives/ staff on the

Neo-natal Intensive Care Unit (NICU).

• The relationship between the father/male care giver received very little attention

and, as a result, this relationship was unknown in 5/6 cases.

• For the children who were premature, parents were explicit about the difficulties

in meeting baby’s needs and it was evident that this was a source of

considerable stress. However, the possibility that this may increase the risks to

the child and/or might impact on attachment, was not considered. Overall, there

were few attempts to explore this in detail.

• There was an attempt to audit whether the child’s voice had been heard by

examining case records and assessments that detailed the child’s

behaviour/characteristics and development, but this information proved too

difficult to gain. This was largely because there was very little information in all

the documents seen that profiled the child/their needs/their character/their

voice. This suggested that there is an insufficient focus on understanding the

infant’s needs/characteristics/behaviour beyond a superficial understanding of

their basic needs (food/warmth/shelter).

Audit Findings: Multi-Agency Work

Multi- Agency (MA) Work Audit Result

Evidence of good risk assessment/ decision making

0

Evidence of good collaborative multi-agency working/joint decision making

0

MA disagreements 3/6

MA escalation 0

Parental vulnerabilities known 6

Parental vulnerabilities & impact on parenting understood

0

Evidence of professional curiosity 1

Role of fathers /male partners understood 1

DA explored and understood 0

Comment & Analysis

• It is important to note that most of these cases were the subject of multi-

agency involvement some years ago, these judgements are based on

assessments completed between May 2015 and November 2017, the most

recent case (case AF3) relates to multi-agency work in early 2018. The

systemic factors that influenced the work are explored in Appendix 1 and the

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significant practice developments since this time are explored throughout this

report.

• In all cases, the appraisal of practice suggests that at various critical points of

risk there was little evidence of good multi-agency decision making. However,

at the point of the child’s admission to hospital with the serious injury there

was evidence of good multi-agency collaboration and decision making in all

cases. Members of the focus groups spoke about their experience of finding it

much easier to respond to a crisis, when there is clear unequivocal evidence

that a child has suffered NAI. However, in most cases professionals have to

make decisions and act in a context of uncertainty and this can impact on

their ability to assemble enough evidence to take statutory action (in the form

of a court order/criminal justice disposals).

• Feedback from the focus groups suggested that collaborative multi-agency

working can be achieved and case examples were provided showing when this

has worked well. Underpinning this collaboration seemed to be an established

relationship amongst the professionals characterised by respect and challenge.

The importance of relationships emerged as a key theme throughout this review

and this is explored further in Section 8.

• In one case (Child AF1), there was explicit multi-agency disagreement. In 2

other cases there was disagreement however, this was confined single agency

discussions. Although single agency escalation took place, and in one case the

Multi-Agency Resolving Professional Disagreement Protocol was followed,

decisions did not change. The view of the panel was that the current protocol

requires review and revision. Whilst protocols can be helpful, the focus groups

spoke about the importance of a working environment where debate and

challenge is an intrinsic part of safeguarding work. This requires trusted

relationships to be built on the front line and throughout the organisational

hierarchy. This is explored in Section 8 and 9.

• There was knowledge held in the key agencies about parental vulnerabilities

although there was insufficient analysis of the impact of these vulnerabilities on

parenting capacity. In all cases the impact of ACEs was not considered. This

is explored in research question 1.

• In one case there was evidence of professional curiosity. However, this did not

feature in the multi-agency response. Put simply, professional curiosity is the

capacity and communication skill to explore and understand what is happening

rather than making assumptions or accepting things at face value. The NSCB

Thematic Learning Framework identifies this as a key tenet of multi-agency

safeguarding work and the next section highlights this as a national issue.

• In all cases fathers were not adequately included in the assessments and in 4

of the cases, no questions were asked about the role of fathers or about DA.

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Whilst in one case the role of the father was partially understood, the impact of

paternal vulnerabilities combined with the vulnerabilities of the child were not.

This is explored further in research question 1.

How prevalent are these issues?

A review of the NSPCC repository7 shows that during 2018, 96 SCRs were conducted

in England and Wales. Of these, 27 (or 28%) were infants who suffered a serious

head injury.

Of the 27 reports focussing on serious injuries, a sample of 10 SCRs were randomly

selected and audited against a number of key variables. As SCRs commonly include

a summary of the significant issues it was not possible to audit these cases against all

the variables.

Audit Results: 10 SCRs published in 20188

Audit Variable Audit Result

Professional curiosity present 2

Multi-agency challenge 4

Invisible fathers 10

Evidence of parental emotional difficulties/ACE’s 10

Prematurity 2

Substance misuse 7

Evidence of Domestic abuse 6

Teenage parents 1

Voice of child heard 5

Problems with interagency collaboration 10

Comment

As the table above shows, there are a range of similarities with the 6 cases in

Norfolk and the national picture. This suggests some key features may be shared

across cases where a child suffers a non -accidental head injury, of particular note

are the findings in relation to parental ACEs and invisible fathers.

In addition, the findings related to multi-agency work (such as the absence of

professional curiosity and problems with multi-agency collaboration) suggest that

these issues are not specific to individual agencies, practitioners, or local multi-

agency safeguarding work, they appear to be systemic. The feedback from multi-

agency practitioners during this review provides insight into why this might be the

case (this is discussed later in this report).

7 https://learning.nspcc.org.uk/case-reviews/national-case-review-repository/ 8 Age of children:2 ½ weeks – 13 months

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8. Research Questions

1. How is the impact of parental vulnerabilities understood and assessed

in relation to current and potential parental capacity? What services

are needed to support vulnerable parents? Are they available?

Introduction

As can be seen from the audit results, parental vulnerabilities were identified, and

services were provided to mitigate the risks posed by substance misuse, domestic

abuse and mental health difficulties. Parental vulnerabilities linked to teenage

pregnancy were identified and 2 mothers were referred to the Family Nurse

Partnership (FNP). At the time, the team had reached capacity and as a result no

services were provided by FNP.

Parental childhood experiences were recorded in multi-agency records but there

seemed to be little understanding about what these experiences might mean in terms

of parental needs/capacity; they were not routinely identified as a vulnerability and did

not feature in the assessment of risk.

Adverse Childhood Experiences (ACEs) is a term that refers to stressful events

occurring in childhood that either affect a child directly (e.g. child abuse) or affect the

environment in which they grow up (e.g. parental substance abuse, domestic

violence). A considerable body of research suggest that ACEs are one of the strongest

predictors of poor health and social wellbeing across a life course:

Adverse childhood experiences have a strong negative impact on health and are a

significant public health concern. Adverse childhood experiences, including various

forms of child maltreatment, together with their mental health sequelae (e.g.,

posttraumatic stress disorder) also contribute to adverse pregnancy outcomes (e.g.,

preterm birth, low birth weight)… impaired or delayed bonding.9

Research suggests that the first step in supporting people who have experienced

ACEs is to be aware of impact, and to adopt a trauma informed approach across

service provision and within organisational cultures. It is recognised that this can only

be achieved when trusted relationships are built.

Public Health in Norfolk have identified ACEs as a significant issue affecting the health,

and quality of life, of children and adults. The info - graphic on the following page was

designed by Public Health in Norfolk and has recently been used in training courses,

9 Integrating Trauma-Informed Care Into Maternity Care Practice: Conceptual and Practical Issues. Sperlich M, Seng JS, Li Y, Taylor J, Bradbury-Jones C. NCBI 2017

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delivered to multi-agency staff in Norfolk, in an attempt to raise awareness about this

important issue.

Adverse Childhood Experiences (ACEs) – ‘The single biggest unaddressed public

health threat of our time’

WHAT ARE ACEs?

The Health and Wellbeing of children is

strongly related to the environmental

conditions that they grow up. A growing body

of evidence has found strong links between

‘Adverse Childhood Experiences’ (ACEs) and

multiple, long term, negative effects on

children and throughout their entire life.

The term ACEs originates from an ongoing

research project in the USA which began in

the 90s with a study of over 17,000 Californian

residents. Since then a number of studies in

the UK, particularly in Wales have explored

ACEs and their impact.

There are 10 ACEs split across 3 categories;

abuse, neglect and household dysfunction:

WHY SHOULD WE BE CONCERNED?

Four seems to be the ‘magic number’ where ACEs are concerned.

Studies have revealed children exposed to 4 or more ACEs are:

• 2x more likely to binge drink and have a poor diet

• 3x more likely to be a current smoker

• 4x more likely to have had sex under the age of 16, have been

pregnant as a teenager, or to have ever smoked cannabis

• 4x more likely to have poor mental health

• 8x more likely to have ever been incarcerated or been a victim

of violence

• 10x more likely to have perpetrated violence in the past year.

• 12.2x more likely to have attempted suicide

• 3x greater risk of cancer or stroke, and the list goes on…

THESE RISK LEVELS ARE REGARDLESS OF ‘ACE TYPE’, PURELY

QUANTITY OF ACEs EXPERIENCED PRIOR TO 18

WHAT CAN WE DO ABOUT ACEs?

Targeted, trauma-informed interventions:

We can keep ACEs in mind in all that we do by targeting enhanced

trauma-informed support to those families we can identify at

heightened risk – role of early help?

Build Trusting Relationships:

Research identified that for those children exposed to 4 or more ACEs,

having a trusted adult who they can talk to about their concerns is one

of the biggest mitigating factors for associated negative outcomes.

Build Resilience:

Encouraging children to develop coping mechanisms from a young age

but also to ask for help when they require it can empower children and

build trust.

WHY DO ACEs RESULT IN POOR OUTCOMES?

ACEs = Toxic Stress = disrupted neurodevelopment = poor outcomes

HOW COMMON ARE ACEs?

ACEs are surprisingly common!

If these findings were applied to a Norfolk

context (n=574,219, aged 18-69) this would

mean 71,203 adults have experienced 4 or

more ACEs in our county.

36% = 0 ACEs

26% 1 ACE

16% 2 ACEs

9.50%3 ACEs

12.40% 4+ ACEs

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What works well in Norfolk?

Family Nurse Partnership - Jo’s Story10

Jo grew up with her father, they moved many times across the UK. Jo’s dad was emotionally

and physically abusive to her. When Jo was 14, she was raped and by the age of 17 she had

made 37 suicide attempts. I thought I was going to die and that I wouldn’t ever get better.

When Jo was pregnant with Milo at 17, she was referred to the Family Nurse Partnership. She

quickly grew to trust her nurse – Steph. When she was in labour she said: The midwives and

all the staff were amazing – caring courteous and calm…They were on my side. They

understood my background, and they were there for me through the birth.

Jo spoke about dating a man who she described as having an enormous grip on my mind.

He had experienced a difficult childhood and posed a risk to Milo. Jo recalled Milo’s social

worker – Kate. She said she felt understood by Kate and described her as not judgemental,

honest and clear; this allowed Jo to trust her and ask for help. She was a lovely person. At the

time Steph had referred Jo to the Circle of Security Group where she met other young mums

who provided a supportive network. One of the mums enabled her to see the risk this man

posed. This friendship has been very important to Jo and Milo.

Jo has realised that she does not want Milo to have the same childhood as her: My father was

a psycho – a nut job. When I was with him, I feared for my life….I don’t want Milo to be scared

to come to me for help. I want him to come to me if he feels unsafe . Jo spoke about recently

seeing a therapist who told her she might be suffering from ‘Post-Traumatic Stress Disorder’.

This was an important point in her continued recovery, she says; she is now able to recognise

what she is feeling, describe these feelings, understand her response and mediate her

response (such as ‘hyper arousal’).

Jo explained that because of her traumatic experiences she is wary of forming trusting

relationships. She observes a person’s body language/tone of voice/facial expressions in

order to assess whether she feels safe enough to trust.

Jo explained that Steph understands the trauma she has experienced and the importance of

building positive friendships and family relationships. She said that Steph was like having a

‘professional mother’ looking out for her and Milo. Steph has been brilliant – I trust her & I have

learnt so much from her ……It was like teaching I was still terrified, but I had some clue what

10 All case studies have been anonymised

20

was going on….If it wasn’t for Steph, my mum, my brother and my sister, I would not have

come this far.

Milo is nearly 2 – Steph has been working with Jo and Milo for nearly two years. Milo is a

happy child who is reaching his developmental milestones and there is a positive attachment

between Jo and Milo. Steph has been a trusted adult and Jo now feels confident that there

are other trusted adults that she will form a relationship with as Milo gets older and seek

support from them if needed.

What works well in Norfolk? Feedback from the Focus Groups & Panel

• During the focus groups members consistently demonstrated a deep commitment

to their work. It was clear they understood that childhood experiences can impact

on parental emotional wellbeing and appreciated the importance of building trusted

relationships, they said that a key motivator in their work comes from the trusted

relationships they form with children and families.

• CAMHS provide some excellent services for young people. The two teenage mums

spoke about a trusted relationship with a clinician and how they were able to talk

about their childhood experiences and felt the impact had been understood. It

seemed that this intervention enabled trusted relationships to be formed with other

professionals.

• GPs in Norfolk often know families well and some GPs have known young parents

from early childhood. They are keen to be involved in multi-agency safeguarding

work and contribute to assessment and decision making.

• Where emotional wellbeing services are provided in schools, and the importance

of ACEs and trusted relationships with school staff is understood and valued,

children are supported to form positive relationships with adults and to strengthen

their emotional resilience.

• In Norfolk, the Family Nurse Partnership, the Eden Team, Norfolk Teenage Parent

Pathway, the Healthy Child Programme and the Perinatal Mental Health Team are

all services that offer an approach that take a trauma informed relational approach.

This kind of approach is critical when working with parental vulnerabilities linked to

childhood adversity/trauma.

• Just One Norfolk (including chat health and parent line) is an innovative service

that provides a single point of access for children and young people 0-19 and their

parents and carers to discuss health and wellbeing and provides a wide range of

accessible information to the community.

21

What are the barriers? Feedback from Focus Groups and Panel

• Adverse Childhood Experiences have only recently gained national attention. The research now available is recognised as an extensive evidential base on which to promote changes in practice so that the impact is recognised but as yet there have been no changes in the tools/policies/training/supervision to support practitioners.

• A framework for trauma informed practice including relational approaches (aimed at building trust) have only recently emerged.11 Until now, there has not been an evidenced based model on which a trauma informed response could be based.

• Traditional ways of working have not supported most multi-agency professionals to consider traumatic childhood history in assessments of risk; they have been reliant on a mental health diagnosis as a marker of possible risks, rather than considering a broader concept of Adverse Childhood Experiences/ poor emotional wellbeing/low resilience.

• Accessing emotional wellbeing services for adults and young people is difficult. The demands on CAMHS services are high and waiting lists are long.

• Evidence based services such as FNP and The Eden Team are only available to a small cohort of vulnerable (teenage) parents. Since September 2017, the Norfolk Teenage Parents’ Pathway has been a welcomed service development although there is less available for older parents who have experienced ACEs.

• There was a clear message from practitioners and managers (including schools and the voluntary sector) that whilst there are some really good emotional wellbeing services in Norfolk, access to services can sometimes feel like a post code lottery. There is a felt need for services to be mapped and as resources will never be enough to meet all needs: priorities need to be clear and resources targeted.

• Members of the voluntary sector spoke about the challenges of providing services, including as emotional wellbeing services, within a context of financial uncertainty and the difficulties that can result from short term funding agreements, such as recruitment and retention of staff and the uncertainty faced by children and families about whether they will continue to receive a service.

11 Trauma informed approaches: Research in Practice Dartington 2017

22

2. How well is the impact of violence in the lives of children and adults

assessed and understood?

Introduction

Current and/or past domestic abuse was a lived experience of the child and/or

parent in all cases. This involved domestic abuse (DA) in the history of parental

childhood and/or DA in the lived experience of the index child. Households often

featured:

• DA within the household • DA in parental childhood • conflict between the parenting couple • conflict between household members/visitors/extended family • default to violence or aggressive discourse as a mode of communication • anger management difficulties

In these cases, there appeared to be a desensitisation to physical violence and/ or

violent communication by the parents/members of the household and the impact on

the child/ren was not understood. Questions about the presence of DA, either in the

current parental relationship or in parental childhood, were rarely asked and this

contravened existing practice guidance and protocol.

People, who are violent in any context, are more likely to behave in a violent manner

with their children than someone who never uses violence as a means of coping with

difficulty.12

Children who grow up in households that feature violence are more likely to tolerate

higher levels of violence/ violent communication in adulthood. However, households

that feature violence are not confined to situations where there are acts of physical

violence. If "violent" means acting in ways that result in harm, then understanding

how families communicate is important; moralistic judgments, evaluations, criticisms,

demands, coercion, or labels of "right" versus "wrong" — could indeed be called

violent.

Unaware of the impact, we judge, label, criticize, command, demand, threaten,

blame, accuse and ridicule. Speaking and thinking in these ways often leads to inner

wounds, which in turn often evolve into depression, anger or physical violence.13

12 National Risk Framework to Support the Assessment of Children and Young People, 2012, Scottish Government) 13 Centre for non-violent communication. M Rosenberg PhD

23

What works well in Norfolk?

Leeway Domestic Violence & Abuse Service

Adolescent to parent abuse project

This service works with non- abusing parent/carer to support them in non- violent

communication with young people. Many of the young people, who have access to

this service, have previously experienced domestic abuse at home and have a range

of emotional/behavioural difficulties. They are often excluded from school because

of their behaviour.

Susan was facing exclusion from school when she was allocated a worker from

Leeway. During the 1:1 work Susan was able to understand the abuse she had

experienced when living in a household where there was domestic abuse and relate

these experiences to her own feelings and behaviour. Susan’s mother was in a

relationship with a partner who was very controlling, but she struggled to accept that

she was the victim of domestic abuse.

Susan was angry with mother about this and this affected her behaviour at home

and at school. Through the work, Susan began to understand domestic abuse, the

impact on her and her mother’s difficulties in leaving the abusive relationship. Her

behaviour began to change and through the support provided by the project worker

and school, Susan stayed in school and started to plan for her future in further

education.

What have young people said about the project?

I now think more often before I do stuff what could be bad

I am better behaved at home now and [am] a nicer person at home

It was just someone to talk to, to deal with day to day stuff, which helps

It really helped and I feel I can now control my anger better

What works well in Norfolk? Feedback from the Focus Groups and Panel

• Local policies, procedure, practice guidance and training is clear about the risks of domestic abuse to adults and children and the need to be alert to, and explore, whether households feature domestic abuse. There are a range of DA services and multi-agency panel meetings in Norfolk, and oversight is provided by a strategic body.14

• The Pandora Project course, Who’s in Charge?, offers support to mothers who have been the victim of domestic abuse to effectively parent their children once

14 Norfolk County Community Safety Partnership

24

the perpetrator has left the household: This can be a difficult time as they may not have been allowed to parent, They struggle to enforce boundaries and children can copy perpetrators’ behaviour.

• Safe Lives DASH15 risk assessments are used effectively by the DA services. This enables a good understanding of the dynamic risks and potential consequences.

• Queen Elizbeth Hospital have introduced 16-week women only appointments to better explore DA with expectant mothers.

• Some practitioners spoke about receiving regular reflective supervision which enabled them to reflect on their observations/their own anxieties, after seeing a family. They said this better equipped them to be curious about, and to explore, domestic abuse/violent communication in the household and the impact on the child.

What are the barriers? Feedback from Focus Groups and Panel

• Practitioners spoke about their experiences of being in households where

children were routinely referred to in negative ways such as ‘little shits’ or

were identified as the cause of parental conflict and/or the cause of parental

physical or emotional ill health. They spoke about being at the receiving end

of violent communication16 and of being the victim of threats or of fearing

violent acts against them.

• The focus groups discussed the impact on professionals visiting households

that are chaotic, where there is violent communication between household

members and/or where family members are hostile/aggressive towards them.

It was recognised that this can feel traumatic and stimulate feelings of

threat/danger which raises anxiety, inhibits curiosity and can stimulate a

fight/flight/freeze response. In the absence of sufficiently containing

supervision/ support from their organisation, this can remain unchecked and

have a long-term impact on their work.

• A common theme were references to feeling overwhelmed and a recognition

that this can lead to taking information at face value/ inhibiting curiosity and

leading to blind spots. In addition, there were views that there is a risk of

desensitisation to violent communication in households if there is not enough

support for practitioners, and this can result in the impact on the child /ren

being overlooked.

15 Domestic Abuse, Stalking and Honour Based Violence (2009) risk identification, assessment and management model. 16 A survey of over 2,000 SW’s by Community Care in 2017 revealed that in one day 40% had been the victim of verbal abuse by a client

25

3. What inhibits professional curiosity about injuries/reported accidental

falls etc. involving young children and what may prevent

professionals from following relevant policies/protocols/procedures?

Is this due to professional deference?

Introduction

A [national] study of 77 infants with abusive fractures of whom 32% had missed

opportunities for the diagnosis of child abuse and the most common sign on

examination at previous medical visits prior to the diagnosis of abuse was bruising or

swelling.17

In 3 out of the 6 cases , there had been previous bruising/alleged falls/accidents. There

are a range of policies/practice guidance and procedure in Health and Children’s

Services18 that guide practitioners/clinicians to be particularly alert to injuries/alleged

falls/accidents in pre-mobile children19 but in these cases whilst some professionals

followed this practice guidance, others did not.

Rather than professional deference, there appeared to be other reasons for a lack of

professional curiosity and non-compliance with policies/practice guidance:

• A lack of joined up multi-agency thinking, dialogue, assessment and decision making

• An over reliance on medical opinion to prove non- accidental injury (NAI)

• A single focus on NAI caused by commission (an act of violence)

• Lack of focus/concern about injury caused by omission (neglect leading to children being in danger of injury/ being injured)

However, these were not the only reasons. As can be noted in the SCR audit of the 10 cases in the NSPCC Repository, the absence of professional curiosity was a common finding and recommendations were made to encourage curiosity by training and supervision. In the view of the focus groups and the panel, enabling curiosity is more complex than this. Their feedback suggested that there is a connection between the emotional dimensions of safeguarding work that can act as a potential barrier to invoking curiosity and this is supported by available literature.20

17 Child Protection Evidence Systematic Review on Bruising Royal College of Paediatrics and Child Health Published: July 2017 18 Such as: Norfolk Child Protection Procedures, GP Yellow Card, Guidelines for management of unexplained injury to infants Clinical Guidance N&NUH etc. 19 There is less guidance available for police officers, the only a brief mention of NAI in the relevant national policing policy 20 Professional Curiosity in Child Protection: Thinking the Unthinkable in a Neo-Liberal World.V. Burton, L.Revell. The British Journal of Social Work, Volume 48, Issue 6, September 2018, Pages 1508–1523,https://doi.org/10.1093/bjsw/bcx123

26

What works well in Norfolk?

Eden Team – James Paget University Hospital

The Eden Team are a small team of specialist midwives, and a maternity health care

support worker, who work closely with community midwives. Vulnerable teenage

mothers, who are pregnant with their first child, are referred to the team.

There is a team approach to working with children and families; all team members

are aware of the 60 cases held in the team, a buddy system means that each family

is allocated 2 midwives. This ensures the family are always able to contact someone

who knows them. The team approach is strengthened by having regular discussions

about the children, where challenging each other about the work is expected

practice. The ethos and work is underpinned by evidence-based practice.

A member of the team told this review: We don’t turn a blind eye. That’s why we do

the job. She was asked what makes this possible and said that professional curiosity

is enabled through teamwork and regular supervision: Feeling well supported and

contained in the difficult work enables the team to and be curious about the child’s

lived world: to represent the child’s view, as they have no voice and place the child

at the centre. The team member spoke about the child who is yet to be born and the

child who is pre-verbal and the importance of working in an environment that

enables her to be attuned with the child and their needs and advocate for them,

thereby representing their voice.

Opportunities are provided to enable curiosity and reflection: We are able to cast a

fresh pair of eyes [on the situation]. This is provided through weekly team meetings

and constant reflection which avoids tunnel vision.

What works well in Norfolk? Feedback from the Focus Groups and Panel

• Focus group members from Children’s Social Care spoke highly about the systemic supervision training that has been recently provided throughout the service. Members from Breckland also spoke highly about the new model of Social Work delivery that has been introduced in Breckland where they feel their voices have been heard in the design of the service. Group supervision that enables curiosity and challenge, is part of this approach.

• Members of the focus groups often said: When in a crisis, multi-agency working works well. This was evidenced in the cases included in this review when the child was admitted to hospital with significant head injuries, at this time there was excellent multi-agency collaboration, curiosity, challenge and joint decision making.

27

What are the barriers? Feedback from Focus Groups and Panel

There is fatigue & familiarity when dealing with high risk. 21

Members from the panel and the focus groups spoke about how difficult it can be at

times to: think the unthinkable, i.e. that an infant may have been/may be very seriously

hurt/traumatised by a care giver. They spoke about times when they:

• Felt bombarded by stories of children who have suffered/are suffering pain.

• Were overwhelmed by the emotional impact of the work

• Recognised that this has eroded their thinking and inhibited curiosity.

• Understood that without the right support it might be tempting to opt for what

may seem to be a plausible explanation for a child’s injury (that it was caused

accidentally).

The most important step in diagnosing NAI is to force yourself to think of it. The biggest

barrier are our emotional blocks that can be so powerful that they can prevent the

diagnosis even in obvious cases.22

Secondary Trauma, Anxiety and Defences: Learning from SCRs,

research and literature

Providing services to children who have been harmed and with parents who often

have their own history of childhood trauma/abuse is immensely challenging work yet

the emotional challenges of this work and the inevitable impact on staff members is

rarely acknowledged in SCRs, in the workplace or indeed in public perception. This

position has been reached despite a relatively long history of psychodynamic

theories highlighting the stresses involved in working in the human services and the

inevitable impact.23 More recently, vicarious (or secondary trauma) has been

recently recognised as having a potentially serious impact on practice in the

challenging and anxiety provoking work of safeguarding professionals.

Working with children, young people and families in the context of abuse, neglect or

other adversities places high emotional demands on practitioners and may well

expose them to frightening situations where their safety may be compromised.

Responding with empathy to traumatised individuals and disturbing situations can

have an impact on workers’ personal and professional life.24

In Norfolk, SCR (Family U) published in 2018 made helpful reference to the emotional

content of the work and the impact on practice. This resulted in the following

recommendation: NSCB and Partner agencies to review the support provided to front

21 Panel Group member comment when reflecting on this research question 22 Dr E Wawrzkowicz. Consultant Paediatrician/Designated Dr Cambridge and Peterborough Foundation Trust NHS 23 The Unconscious at work: Individual and Organisational Stress in the Human Services. The Members of the Tavistock Clinic Consulting to Institutions Workshop: Eds: A.Obholzer & V.Roberts 1994 24 Henricks,2012;Figley, 2012; Biggart,2016 quoted in Developing and leading trauma – informed practice. Leaders Briefing. Research in Practice Dartington August 2018

28

line staff in the light of the learning within this Review regarding the impact of the

emotional content of child safeguarding on frontline professionals’ capacity to maintain

critical thinking in complex situations.25

Established psychodynamic literature explores the human and organisational

response to the emotional content and the anxiety inherent in the work. Studies of how

defences against anxiety are constructed by individuals and organisations have been

in existence for some time. E. Jacques suggests that organisations coalesce or ‘gel’

by sharing social defences against the anxiety that is present: The need of members

of the organisation to use it in the struggle against anxiety leads to the development

of socially structured defence mechanisms, which appear as elements in the structure,

culture and mode of functioning of the organisation. 26

Building on the work of Jacques, I. Menzies 27 produced a classic study of hospital

systems as defences against the anxieties raised by caring for people in life and death

situations and identified that the systems in place in the hospital were constructed and

used as a way of defending the nurses and the organisation against the inherent

anxieties. Jacques, Menzies, Obholzer and Roberts (1994, 2019), 28 Armstrong and

Rustin ( 2015), Hoggett ( 2010) Pengelly and Woodhouse ( 1991) extend this idea into

a range of sectors including social services and health (and interagency collaboration)

arguing that these defences can have a significant impact on the culture of an

organisation and how the organisation, and individuals within it, perform the tasks of

the organisation internally and collectively across the multi-agency safeguarding

system.

Culture involves a pattern of thought, emotion and action and all are involved in

shaping a response to problems and opportunities. It is a patterned way that an

organisation responds to its challenges whether these are explicit (for example a

crisis) or implicit ( a latent problem of opportunity ). In 2004, Westurn29 introduced the

‘Three Cultures Model’ as a way of understanding organisations and the following

typology is now widely established as a useful framework to understand an

organisational culture:

1. Pathological culture – responsibility is avoided, new ideas are actively

discouraged, failures are punished or covered up. Fear of blame encourages workers

to become defensive, avoiding using their professional judgement

2. Bureaucratic culture – information is acknowledged but not dealt with,

responsibility is compartmentalised, people are not encouraged to participate in

improvement efforts

25Recommendation from NSCB SCR Family U (S. Griffiths) Published July 2018 26 Jacques, E. (1953) ‘On the dynamics of social structure: a contribution to the psychoanalytic study of social phenomena deriving from the views of Melanie Klein’, in E. Trist and H. Murray (eds) 1990 27 Menzies, I.E.P. (1960) ‘Social systems as a defence against anxiety: an empirical study of the

nursing service of a general hospital’, in E. Trist and Murray (eds), 1990. 28 The Unconscious at work: Individual and Organisational Stress in the Human Services. The Members of the Tavistock Clinic Consulting to Institutions Workshop: Eds: Obholzer & Roberts 1994 29 Professor Westurn (2004) Three Cultures Model. BMJ Quality and Safety Journal V.13

29

3. Generative culture – able to make use of information, observations wherever they

exist in the system without regard to location or status, whistle blowers and other

messengers are trained, encouraged and rewarded - a just culture where people feel

they will be judged by reasonable standards, and what was known at the time not by

hindsight

Therefore, if we are to understand the problems and opportunities in safeguarding

work, the culture of an organisation must be understood. Recently, the work by

Research in Practice 30 and Dr K Triesman 31 has encouraged organisations to pay

attention to the significant emotional challenges faced by safeguarding professionals,

the secondary trauma that can be experienced, and the individual and organisational

defences which have an important impact on an organisational culture and how

children are safeguarded.

30 Developing and Leading trauma informed practice. Research in Practice Dartington 2018 31 Safe Hands Thinking Minds Dr K Triesman http://www.safehandsthinkingminds.co.uk/

30

Examples of responses to anxiety & secondary trauma32

32 Info graphic © Griffin Associates

Reduced critical thinking skills /think in black and

white

Retreat

Stop Listening

Stop seeing Go into flight mode Isolation (preventing

collaboration)

Experience difficulty recognising and monitoring

emotions

Low motivation and poor-quality work

Feel helpless

Become defensive and start to react rather than think

Inhibited curiosity Increased absences

Go into attack

Blame Rush around

Become desensitised Inaction/ Freeze Strict rule compliance

31

4. How do current systems and processes support dynamic risk assessments

that place the experience of young pre-verbal/pre-mobile child at the centre of

the assessment process?

Introduction

Assessments are a continuing process not an event 33

Dynamic risk assessment is a continuing assessment in a rapidly changing

environment where both static and dynamic risk variables are considered. Intervention

to mitigate risk requires a re-occurring cycle of action, review and overview. It requires

an approach that considers risks here (current), there (past), near (immediate), and

far (future). In order to understand the quality of the evidence base, the evidence

should be scrutinised to consider whether it is ambiguous, assumption based, missing

or firmly grounded and whether the critical components of multi-agency input and

collaboration have been achieved.

Placing the child at the centre of the assessment requires risk to be interpreted from

the perspective of the child. The child’s age, developmental stage, emotional, physical

and behavioural needs should be factored into any risk assessment and understood

within the context of the family in which they live, and the inter-related needs in the

family. 34

When appreciating the risks present for a very young child (i.e. pre-verbal /pre-mobile)

it is particularly important to understand the degree of protection provided by care

givers (a child’s source/s of safety). Where there is an ambivalent relationship, or

attachment difficulties between the primary care giver and the child, this has the

potential of compromising the safety of a child from danger/risks posed by the

environment or by other adults.

The assessments seen as part of this review included a number of common features;

the experiences of the child were not articulated, the likelihood of harm was rarely

considered, they were largely single agency, the risk associated with household

members/ fathers (birth/putative/step) and maternal or paternal family members was

not assessed and little attention was paid to the emotional connection between the

primary care givers and the child.

Overall, there was evidence of optimistic and polarized thinking. Whilst optimistic

thinking can support the emotional resilience of safeguarding professionals, optimism

per se (that lacks a solid evidential underpinning) can skew the reality of the risks

33 Working Together. A guide to inter-agency working to safeguard and promote the welfare of children. HMG 2018 34 Assessing risk of further maltreatment: a research-based approach. Research in Practice (Rip) 2006

32

faced by a child. On the other hand, polarized thinking is a common cognitive distortion

(a reasoning mistake) where information is incorrectly processed leading to thinking in

black and white terms/extreme simplification of reality. Both the rule of optimism and

polarized thinking are often cited in SCRs. Both are linked to errors in judgement and

a range of psychological literature suggests that both can represent an unconscious

attempt to block emotions.

In 2 of the cases, mothers described the birth of the child as ‘traumatic’ and two

children were premature resulting in admission to a neonatal intensive care unit

(NICU). In these cases, and in an additional case, mother was observed to be

emotionally distant from her infant seemingly unable to respond to the infant’s needs

to be comforted; there appeared to be little attunement. The significance of these

important factors was identified in one case but overall, the importance of the

relationship between the primary care giver and child was given scarce attention.

Traumatic birth experiences can cause postnatal mental health disturbance, fear of

childbirth in subsequent pregnancies and disruption to mother-infant bonding, leading

to impaired child development.35

At the time these assessments were completed, practitioners were not adequately supported in their assessment practice, there was insufficient training, an absence of an evidence-based practice approach and nationally, there has been insufficient focus on the emotional context of the work and its impact on thinking and decision making.

What works well in Norfolk

Becky’s story

Becky’s dad died when she was a young child, there were a lot of problems at home

and at school and when she was a teenager she started to self-harm. Becky

received therapy at CAMHS and said that she trusted her therapist ( Julie). Becky

said she could call Julie when she needed to (if I felt I was going to have a mental

breakdown) and this helped a lot.

Becky was 16 when she was pregnant with Sophie and she was referred to FNP.

Becky lived with her mum when Sophie was first born, the conditions were cramped

and there was significant conflict between the adults in the household.

There were concerns about Becky’s ability to protect Sophie, and so a referral was

made to Children’s Services. The social worker, midwife and the FNP nurse worked

hard to build a trusted relationship with Sophie and with each other; they worked

collaboratively together and supported each other. Assessments were multi-agency,

there were regular meetings to review the risks and the needs of the unborn child

were kept in focus.

35 Understanding psychological traumatic birth experiences: A literature review. Simpson M, 2016. NCBI

33

Becky said: It was hard being a mother at first. Sophie was born tongue tied and

had problems with her reflux, she cried a lot and found it hard to feed, she was

difficult to settle.

Becky was supported in gaining her own home and both she and Sophie’s dad

(Lewis) have learnt techniques that Sophie finds soothing – I have learnt that babies

love swaddling, and we have both learnt about how important it is to bond with

Sophie. Becky said she understands the importance of Lewis having a bond with

Sophie (Lewis comes around to see Sophie and plays with her) but Becky feels that

they are not full on mature enough yet to be living together. Becky says that she

feels very protective towards Sophie and says she is always checking to make sure

she is safe.

Lewis was fully included in the assessments and the services provided resulted in

the risks reducing.

What works well in Norfolk? Feedback from the Focus Groups and Panel

• There have been a number of advances in assessment practice in Norfolk resulting from focussed training,36 implementation of the Signs of Safety37 approach and improvements in the assessment format in use within Children’s Services.

• Focus group members gave some positive examples of multi-agency assessments and said that where relationships across professional boundaries and agencies are established, and trusted relationships formed, multi-agency assessments and collaboration works well.

• Practitioners in Children’s Service spoke about attending some recent Family Network training in Norfolk38 where they learnt about the importance of assessing family and kinship and how to build a child’s safety network and support this network to keep a child safe. This training and the systemic supervision training provided in Children’s Services has been helpful in exploring risk and supporting practitioners in their work.

• The joint visits completed by health visitors and social workers (HV & SW) have contributed to improved multi-agency safeguarding practice and have achieved real benefits in improving joint assessments and decision making.

What are the barriers? Feedback from Focus Groups and Panel

• The introduction of the Signs of Safety (SoS) approach has led to improvements however, at the time these cases were assessed, it was early days in the implementation of this approach. In addition, practitioners and managers spoke about inconsistencies in its implementation that, in their view, has created

36 NAI conference (2018) & an assortment of assessment training delivered by The Quality & Effectiveness Service (NCS). 37 This strengths-based and safety-focused approach to child protection work is grounded in partnership and collaboration. It expands the investigation of risk to encompass strengths and Signs of Safety that can be built upon to stabilise and strengthen a child's and family's situation. 38 Family Network Training (Norfolk County Council Children’s Service)

34

vulnerabilities. Practitioners and managers gave an example of some early training about the model where the concept of identifying safety/what works well overshadowed important aspects of the model that promotes good risk assessment.

• Practitioners spoke about feeling forced to see assessment as a single event – as an end product through the current procedural requirements (timeliness of assessments) and the workflow through teams, (for example, from MASH39 Section 47 strategy discussions to the SW teams) rather than being led by the timeliness of a child’s needs. Although recent training has promoted dynamic risk assessment, where risks are now better identified, it was argued that more training is needed to enable practitioners to put this into practice.

• The absence of a positive learning culture means that errors are not recognised as part and parcel of the work and practitioners feel worried they may be blamed, rather than understood, if a mistake is made. A practitioner commented It is not safe to be wrong and the sentiment of this statement was repeated in the focus groups across the multi-agency system. E. Munro argues that in the absence of a positive error culture, this can lead to a strict adherence to rules and policies, intolerance of uncertainty and a culture of overly strict compliance with key performance indicators (such as timeliness of assessments) and can result in compromising professional judgements.40

• Joint HV/SW visits were described as working well in some areas but there was concern that these are not consistently happening and that the monthly joint management meetings between Children’s Services and Cambridgeshire Community Services (0-19 Healthy Child Programme provider) are rarely happening. It was strongly felt that more is needed to develop this initiative so that joint assessments and decision making are facilitated.

• Members of the focus groups and the panel emphasised: it is imperative that bruising seen on a pre-mobile child is treated seriously and requires an assessment by a paediatrician but participants also recognised that it may be tempting to regard a seemingly minor mark/bruise/abrasion on a pre-mobile child as unimportant and said there needs to be better awareness (and capacity) to always consider the possibilities that something is more than ‘just a bruise’ and take action.

• It was understood that the importance of prematurity, traumatic birth or traumatic childhood history has not been routinely promoted in the assessment of risk. In addition, services that provide a trauma informed approach (before and after birth) are not readily available.

• Representatives from the police expressed a view that a disproportionate multi-agency strategic focus applied to domestic abuse (perpetrated against adults)

39 Multi-Agency Safeguarding Hub 40 Decision – making under uncertainty in child protection: Creating a just and learning culture. E. Munro Child & Family Social Work Vol.24,Issue 1 July 2018

35

is not applied to children, who are physically abused at home. It was argued that, to an extent, this translated to a lack of focus in operational delivery.

• Although multi-agency consultation is a practice and procedural requirement, the full range of multi-agency involvement is not routinely achieved.

• Social workers are not routinely supported to complete infant observation to better understand the relationship between mother and child or to understand the child’s behaviour as a representation of their emotional world. It was understood that the volume of work, and limited capacity, impacted on this time-consuming work. It was acknowledged that when there is full multi-agency involvement, this can be achieved and should be promoted.

• As discussed in the previous research question, the impact of secondary trauma and defences can affect safeguarding practice. This leads to assessments marred by blind spots, assumptions and polarized thinking and can inhibit curiosity and collaborative work.

5. How well do multi-agency services understand the impact of organisational

flux and high caseloads on the services provided to children- what can be

done to recognise and mitigate this risk?

Introduction

Working in the human services has always been stressful. Part and parcel of this

work is an ever-changing environment as organisations respond to budgetary

constraints, changes in legislation, policy, ways of working, local demographics,

inspection and the political context and, in times of change, there is a dismantling of

earlier social defence systems resulting in more uncontained anxiety until new social

defence systems evolve.41

Evidence from Norfolk SCRs Cases R, S, V and Family U suggest that

organisational change and reconfiguration can have a significant impact on service

delivery. It is often a time of uncertainty when anxieties may heighten and, as these

cases suggest, this can have a direct impact on how children are safeguarded.

Previous SCR recommendations have picked up on this:

The NSCB should explicitly develop a shared approach by which partners report on,

or seek information about, any significant changes to an agency’s function,

resources or practice which could impact on multi-agency safeguarding, in order and

to enable peer response and where appropriate, challenge. 42

41 The myth of rationality; why change efforts so often fail. Krantz & Trainor in The Unconscious at work. A Tavistock Approach to Making sense of Organisational Life. Eds: Obholzer & Roberts 2019 42 Recommendation from NSCB SCR Family U (S. Griffiths) Published July 2018

36

In the case of AF1 (June 2014 – December 2016), the Independent Management

Reviews stated the following:

• Norfolk Healthy Child Programme: A period of significant changes – a time

of national shortages in health visitors - provider organisation and personnel

changes (ECCH) separate from the rest of Norfolk until Nov’ 15 when provider

organisations changed, and service redesign commenced in 2016, leading to

significant flux (particularly in the East).43

• Norfolk Constabulary: There were significant investments in staffing of CAIU

(Child Abuse Investigation Units) over this time – although there was a 26%

increase in investigations at this time - a positive- but was the organisational

flux during these changes considered as having a potential impact on service

delivery? Do any changes need to have a risk mitigation plan considered? 44

Cases AF2 and AF3. November 2016 – April 2018

In November 2017, Norfolk Children’s Services were the subject of an inspection.45 At

these times, there can be considerable organisational anxiety and managers, in

particular, face additional demands on their time and competing priorities. This was a

particularly important inspection for Norfolk as it was a re- inspection after previous

judgements of ‘inadequate’, several service changes had been made as a result of

this grading. The re-inspection judgement of ‘requires improvement’, inevitably led to

additional service changes and organisational flux.

What works well in Norfolk? Feedback from the Focus Groups and Panel

Focus groups and panel members spoke about the importance of consistent

leadership and identified that after a long period of changes in senior management

there were recent signs of greater stability in the multi-agency senior management

group and greater cohesion at a strategic level.

That said, multi-agency practitioners, managers and panel members struggled to

identify experiences of what works well, and there were strong views that this is not

particular to Norfolk. The following suggestions were made about what might work

well in the future to demonstrate to the multi-agency workforce that the risks of

organisational flux, and high caseloads, were acknowledged.

43 Independent management Review Cambridge Community Services (AF1) 44 Independent Management Review Norfolk Constabulary (AF1) 45 Norfolk Council Re-inspection of services for children in need of help and protection, children looked after and care leavers Inspection date: 13 November 2017 to 24 November 2017 Report published: 19 January 2018

37

Leaders should have courageous conversations with each other, with

politicians and inspectors about the impact and risks of change.

Considered change = sustainable change – don’t make changes too quickly

without considering the full implications on the front line and inevitably on the

children.

Prioritise resources and work at times of change and recognise the risk and

the impact.

Openly accept that it may be a time when errors are more likely and promote a

culture that to err is human….Enable problems to be raised and discussed in a just

culture of learning – where there is no blame.

Facilitate feedback loops so that the front line, children and families can be

part of the discussion about what is working well, what is a risk and what

needs to change.

Sometimes there is a need just to say No – it is not possible to meet that need/

provide that service

Be visible to your workforce and be open to discussion

What are the barriers? Feedback from Focus Groups & Panel

• When there are changes in one agency (particularly in Norfolk Children’s Service), and the multi-agency partnership are not fully informed/engaged, the implications for partnership work are not fully considered. Examples about the communication around recent changes were cited such as the introduction of Children’s Advice and Duty Service (CADS) and the new social work delivery model in Breckland.

• Managers spoke about inspection results that have resulted in an ‘inadequate’ judgement or ‘requires improvement’ and described how this can impact on multi-agency relationships, both at the front line and at a senior level. Confidence can be eroded and there can be a long period of interim/temporary leadership.

• A view was expressed by some focus group members that some leaders have not overtly modelled supportive behaviours towards the workforce during times of change and have not explicitly acknowledged the risks they carry, or the increased risks caused by organisational change. It was acknowledged that the weight of responsibility on leadership compounded by; organisational change, poor inspection judgements and pressures on budgets and resources, may increase their anxiety and impact on their capacity and ability to effectively communicate with staff.

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• There was a strong view across the focus groups that the critical importance of professional relationships, communication, supervision and established relationships with children and families is not prioritised during organisational change/ reconfigurations.

• Focus group members and panel members spoke about the inherent anxiety

that is present during organisational change, and how this can have a negative impact on staff morale. It was their view that this has not been sufficiently recognised or contained, which increases the risk that individual and organisational defences will be constructed, adding to the risk that errors will be made/things will be overlooked. It was felt important that these potential risks were acknowledged and shared across the organisational hierarchy.

6. How do current safeguarding cultures across agencies support or

inhibit information exchange (characterised by active dialogue) rather

than information sharing? What needs to be in place to promote

shared ownership of assessments & plans and effective debate and

challenge?

Introduction

The importance of information sharing in safeguarding work is a reoccurring theme in

government guidance and statute, and SCRs frequently cite the lack of information

sharing. This research question refers to information exchange and was worded in this

way in an attempt to move away from the concept of information sharing per se (which

may unintentionally confer a passive sharing of information from one agency to

another, rather than an exchange of information where participants are an active part

of the dialogue, debate and challenge between agencies). The view of NSCB is that

this active dialogue enables a richer information exchange and invites a stronger multi-

agency debate and ownership of assessments and decision making.

The information gathered to inform an assessment of risk in the 6 cases was from a

restricted multi-agency group; requests were made to share information rather than to

exchange information and communication rarely included an active dialogue. The

assessments, plans and decision making in these cases were largely single agency

and reflected a lack of multi-agency ownership. There was little debate and challenge

and where there was challenge, it was ineffective.

As can be seen in the audit of SCRs in the NSPCC repository, collaboration between agencies was found to be absent in all cases and thus this is an issue that is not specific to Norfolk. It is a perennial issue that is raised in countless SCRs. As this research question suggests, the culture of an organisation, or the cultural

norms, may have a significant bearing on this issue. However, it is important to say

39

at the outset that information sharing is significantly hampered by the information

technology available, and the lack of integration of current systems: Systems do not

talk to each other .

The difficulties faced by safeguarding professionals as a result of this lack of integration should not be underestimated. The extent of the complexities of multiple data storage systems was raised repeatedly in the focus groups: there seems to be little that can be done about this – we have to live with this, but it is a risk. Examples were given of practitioners dealing with multiple information systems (16 data bases in one hospital and in another - 172 information systems) that have to be separately accessed to retrieve information about a patient. This context adds to the complex challenges faced by safeguarding professionals when retrieving and exchanging information about children. During the focus group meetings participants asked why schools had not been invited to participate ( they were subsequently invited to a separate focus group).It was argued that a number of parents in the cohort were teenagers and therefore these parents would have recently been at school. Participants spoke about the importance of early intervention by schools to support the emotional wellbeing/resilience of young people and of working closely with schools to exchange information for the purposes of prevention and assessment. What works well in Norfolk?

Information exchange: A Norfolk Secondary School & Police

Paul was violent towards his parents, he would attack his parents, damage property

in the home, and threaten his mother with a knife. His mum and dad would call the

police, they would visit the home and take him to school, but only limited information

was given to the school about what had happened.

Thanks to the Safer Schools Partnership with Norfolk Constabulary (Operation

Encompass) we were able to talk with the police about the incidents and gain further

information.

This active dialogue and information exchange allowed the school to better

understand what had happened and understand Paul’s needs so that adjustments

could be made in school, and services provided that effectively responded to his

needs.

Professional challenge and escalation: A Norfolk professional

A health practitioner (Mary) visited a family and observed a child who appeared

withdrawn and neglected. Mary was very worried about the child’s wellbeing and felt

she was at serious risk of harm. Mary spoke to the Children’s Social Care

practitioner but felt her concerns were being dismissed no one seemed to want to

listen, she felt ridiculed and doubted her own judgement.

But Mary was clear of her role in safeguarding children and that the child was

suffering, she understood the importance of professional challenge and that she

needed to support other professionals to understand the child’s lived world.

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I persisted and persisted. Mary ensured she was very clear about her concerns and

used relevant NSCB practice guidance and learning from SCRs to ensure her voice

was heard. Action was taken and the child was removed from a very abusive

household.

What works well in Norfolk? Feedback from Focus Groups & Panel

• The police initiative: Operation Encompass was often mentioned in the Focus

Groups. This has been described as a unique police and education early

intervention safeguarding partnership which supports information exchange

about children and young people who may have been exposed to domestic

abuse.

• The Focus Groups were well attended by GPs and it was clear that Norfolk GPs

can be ‘a family GP’, who know a family well and hold valuable information

about childhood history and family members. The GPs demonstrated an

eagerness to be an active part of the safeguarding network.

• Practitioners and managers spoke about the importance of engaging the full

multi-agency network at the earliest possible point and gave examples of when

this has worked well (Both Becky and Jo’s story illustrates this point). Case

examples were provided of good multi-agency/multi-disciplinary relationships

that have been built over time, characterised by respectful dialogue and regular

multi-agency meetings.

• Multi-agency learning events (such as the focus groups/ SCR learning events)

where active dialogue and respectful challenge is respectfully facilitated in a

containing environment was said to strengthen ongoing relationships,

particularly in the localities.

• Positive experiences were described of strong and accessible management/

leadership, who were prepared to effectively challenge and escalate where

needed, and examples were given of good supervision / access to supervision

(such as in the FNP and Eden Team). Although this was something that

seemed inconsistent and was described across agencies as: hit and miss – an

exception rather than a rule.

• Feedback from the Focus groups suggests there are early signs that the new

CADS (Children’s Advice and Duty Service) system, supports better

information exchange by facilitating a dialogue. The SCR Panel, however,

raised concerns that issues such as inconsistent responses and timeliness of

feedback are ongoing.

• Systems that enable networking and relationship building/ group supervision/

multi-agency case studies/joint learning were praised. Examples given included

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local multi-agency initiatives, local ‘Hub Meetings’ for multi-agency practitioners

and the Local Safeguarding Children Groups (subgroups of the NSCB).

• The NSCB website was described as helpful and easy to navigate, for example,

the learning from SCRs is easily accessible and the Threshold Guidance is

clear. Professionals identified that when collating information needed to make

a referral to MASH (now CADS) the Threshold Guidance is helpful and, when

needed, can assist in challenging decisions that are made.

What are the barriers? Feedback from Focus Groups & Panel

• There was a consistent message from the focus groups that multi-agency relationships are critical ; building relationships and achieving full collaboration takes time and when the working environment is characterised by high volume and high caseloads it was felt that short cuts can be made. This was described as resulting in a culture where information sharing can be compromised ( For example: requesting/providing information through fax or email without entering a dialogue that promotes information exchange, debate and challenge).

• Participants were clear: Relationships are critical to build trust, but it was felt that the importance of multi-agency relationships is not sufficiently valued. The high turnover of social workers and difficulties in recruitment in some areas was said to be a barrier and it was felt that there is not enough in place to promote/support multi-agency relationships.

• Participants spoke about multi-agency group supervision/group initiatives as being helpful but said they are often not prioritised and so do not happen. Time is needed to enable multi-agency groups to come together to discuss cases and should be facilitated to create a safe place where intuition and analysis can be shared and explored, multiple hypotheses developed, and relationships built.

• Participants spoke about the lack of courageous conversations at a senior level: Challenge and debate is not part of the multi-agency landscape. They felt strongly that this needs to be culturally embedded and modelled across the hierarchy: Leaders need to model courageous conversations with each other, and with politicians about what is possible in a climate of increased pressure and reduced resources. It was their view that there can be a fear of having courageous conversations caused by defensiveness, overly optimistic decision making, procedurally bound thinking, deflection or deference. (Reference: organisational defences as a defence against anxiety p.27)

• Whilst ‘Operation Encompass’ was identified as a clear positive there were concerns expressed by schools that these notifications only involve adult-adult domestic abuse incidents, there was a view that child - adult and adult – child incidents should be part of the notification system so that preventative measures can be put in place in schools. Given the ages of the children subject to this thematic review, the need to extend this arrangement to Early Years providers should also be considered to build on the success of Encompass.

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• Participants spoke about the difficulties that can be encountered in circumstances when it has not been possible to gain consent from parents/carers to share information. However there was a clear view that: Lack of consent can be a barrier to sharing information, but it can be just ‘red tape’. If practice is open and honest, consent can be gained.

• There were many discussions about the need to identify and engage with the full multi-agency network at the earliest possible point. Members from the voluntary sector said they were often not regarded as part of a child’s network and so not involved in information exchange and it seemed that the wealth of information held by GPs is not fully recognised (when information is gathered for the purposes of an assessment).

7. Do SCRs make a difference to the services provided to children and their

families?

Introduction

Evidence from the Focus Groups suggests that learning from SCRs in Norfolk makes a difference to the services provided to children and families. Examples were provided by practitioners illustrating how they had learnt from the SCR learning events or training commissioned by NSCB, how this had influenced their practice and how service delivery changed as a result. In the cases under review, an example of service changes resulting from a SCR (Protocol for undertaking joint visits and assessments by Social Workers, Health Visitors and Midwives, for children under 5) was evidence of good practice. However, it seemed that the experience of learning from SCRs was inconsistent

across the partnership. The reason for this seemed to be partly predicated on the

importance attached to the learning by respective agencies, line managers or

individual practitioners but importantly there was a strong view that there needed to

be more learning and publicity about when things go well/learning from good practice,

and a need to develop a positive learning culture.

Organizations that achieve a high safety record ….. have in common that they

appreciate how error is unavoidable and that achieving safer practice requires

organizations to be able to learn how the system is functioning in practice. This

requires a positive error culture where people are not afraid to report difficulties,

mistakes, and weaknesses in their practice .46

46 Decision – making under uncertainty in child protection: Creating a just and learning culture. E. Munro Child & Family Social Work Vol.24,Issue 1 July 2018

43

What works well in Norfolk?

Example: SCR Child Q Operation Encompass

Operation Encompass: is a system that provides an early notification to key

adults within a school when a pupil may have been affected by domestic abuse. It

was launched in Norfolk in 2016 following a recommendation from a Serious Case

Review (Child Q 2016:NSCB Serious Case Reviews).

In response to this notification, schools are able to ensure the appropriate support

is available for that child. There are currently 94% schools signed up to take part in

Operation Encompass in Norfolk and Encompass has now been established and

currently operates in some 33 forces in England and Wales.

Norfolk Safeguarding Board Threshold Guidance

This threshold guidance has been informed by the learning from SCRs, its format

and content allows the information to be easily accessed by multi-agency

practitioners and managers.

Learning from a front-line practitioner in Norfolk

Terry was concerned about a child who he had seen as part of a routine visit to a

family. He felt clear the child needed to be referred to Children’s Services but had

experienced difficulties making referrals in the past when he was told the referral

did not meet a threshold for statutory intervention.

He felt confused about what information he needed to provide and how to

articulate his concerns in a way that would be taken seriously. He accessed the

NSCB Threshold Guidance and carefully went through the evidence that was

needed, he spoke to a member of the MASH team and provided clear information

about his concerns.

When he was challenged, he was able to refer the worker to the NSCB Threshold

Guidance and through negotiation it was agreed that the case required the

intervention of Children’s Services.

What works well in Norfolk? Feedback from Focus Groups & Panel

• NSCB Road Shows: Practitioners spoke about attending these SCR learning

events and of integrating the learning into their practice. The NSCB

roadshows are really good – amazing and learning from SCRs through

dissemination and discussion in team meetings was said to improve practice/

strengthen safeguarding work.

• It seemed that members of the Focus Groups were very much aware of

NSCB and there was a sense that it had a clear presence in their working

lives. Many members were clear about the NSCB priorities emerging from

SCRs and felt that the website was easily accessible, relevant and

informative.

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• The established ‘Local Safeguarding Children Groups’ (LSCG’s) were felt to

be a strength enabling the learning from SCRs to be more easily

disseminated and provide an opportunity to strengthen local learning and

initiatives.

• Multi-agency learning and relationship building that is achieved when

members are part of SCR learning events/focus groups (being part of the

solution, learning from families, seeing the perspective of others and

understanding roles) was felt to improve working relationships to the benefit of

children and families.

• NSCB initiatives, such as the NSPCC ‘PANTS’ campaign (promoted by

NSCB as a result of learning from SCRs), are felt to be informative and helpful

resources when working with children.

• Feedback from the focus groups and the panel demonstrated that the

methodology in this review engendered a sense of being valued and that

there was a commitment from the various organisations, and the NSCB, to

facilitate honest dialogue, respectful learning and to make a real difference in

children’s lives.

What works well in Norfolk? Evaluation of the Focus Groups

After each of the Focus Groups, participants were invited to provide feedback

about their experience of participating in the event: 59 % strongly agreed, and 41%

agreed, that the Focus Groups met learning outcomes, were well organised,

included relevant information and increased confidence in applying SCR learning.

Thank you a very informative and enjoyable day

I learnt lots and can use this to improve practice

Well done – an excellent learning event

Good even discussions, well facilitated by knowledgeable people

There should be more learning events together

Empowering, and a reminder that we are all working together to achieve the

best outcomes for children

Inspiring ! A really brilliant day – thank you

What are the barriers? Feedback from Focus Groups & Panel

• There was a strong message that as SCRs often focus on what has not worked well: the process can feel very stressful for those involved and the detailed narrative about the case can serve as a distraction from the learning. Focus group members often spoke with a passion about their work and the challenges

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they face, and they were clear that hearing about things that go well for children was a key motivator in their work and strengthened their resilience.

• Despite the national guidance, and intention, not to apportion blame there remains a culture of seeking to attribute blame which can be fuelled by the media response. As a result there is a danger that SCRs enhance defensive behaviour within individuals and in organisations.

• There was a view that there should be a greater focus on celebrating success and good practice, this leads to feelings of being valued and it was stressed that children and families benefit from a greater awareness of what works well, which allows trust to be built.

• Whilst the Local Safeguarding Children Groups are valued, schools are not fully engaged. It was felt that LSCG’s need to find a way of engaging schools so that partnerships can be strengthened and the learning from SCRs disseminated more widely.

• The number of SCRs in Norfolk was raised and there was a view that: There is a dominant narrative in Norfolk that there are too many SCRs, rather than a narrative that embraces Norfolk’s willingness to learn from SCRs. It was felt this can inhibit the learning from SCRs.

• Throughout the various focus groups members frequently referred to a NSCB SCR learning event they had attended, and how their practice and service provision had changed as a result of this learning. However, it was clear that there is an inconsistent approach across the agencies to supporting staff attendance at these events: The importance of these events should be fully acknowledged by leaders as they promote positive relationships and build trust which has a positive impact on multi-agency front line work with children and families.

9. Leadership Focus Group Meeting

The Focus Group held with multi-agency senior leaders took place at the end of the

review. This was the first time the NSCB has included direct leadership learning as

part of a SCR methodology. The leaders were engaged in a similar learning

experience as their staff; key features of the cases, and feedback from the Focus

Groups, was shared and emerging themes discussed. Invitations were extended to

senior leaders and managers and, whilst there was good representation from some

agencies, very few agencies were represented at the most senior level. Whilst those

who attended fully engaged throughout the day, it was notable that (as opposed to

their staff groups) this group of senior managers struggled to identify what works well

in Norfolk.

It is possible that the established cultural norm, in organisations tasked with

safeguarding children, is an over-ridding focus on things that do not go well and in the

worst-case scenario when a child tragically dies. Such a tragic event is an unbearable

loss for families and communities and, as experience shows, can lead to an

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unrelenting search for who is to blame. The case of Haringey’s Director of Children’s

Services (Sharon Shoesmith) after the tragic death of Peter Connolly being a classic,

but not unique, example.

In addition, the organisational culture (including the search for who is to blame) that

can exist after a poor regulatory inspection should not be underestimated. As

previously discussed, Norfolk is currently judged as requires improvement:

For many, the judgement ‘Requires Improvement’, rather than being a catalyst for

helping to deliver improvements to services, is becoming the trap door locking behind

councils and leaving them there in perpetuity.47

That said, members of this focus group were fully engaged in the content of the day

and were keen to take forward the learning that has emerged. At the end of the event,

members were asked what learning they will be taking forward.

What will you be putting into practice?

47 A Brave New World. Is Inspection Improving Children’s Services? Local Government Association, Impower 2015

Staff wellbeing and welfare is critical – I will be making closer links to occupational

health and using a trauma informed approach

I will be having more courageous conversations with senior leaders

regarding risk sensible practice

I will be discussing the learning with the team and working to discuss at a senior

level

I want to raise awareness of a healthy leadership style and disseminating

information about a trauma informed approach

Workforce welfare and sharing risk

Valuing staff and supporting, discussing and getting engagement from

executive officers to identify local improvements and achieve further

involvement in system wide actions

Taking forward via all managers meetings focussed on risk sensible practice and

all manager training on trauma informed approaches in organisations

Focus on strengths and solutions rather than cynicism and blame

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What needs to happen next?

We (NSCB) need to model the new relationships across partners at Board

level – sharing risk, sharing leadership and ownership of safeguarding

children

We need to work more collaboratively across the partnership to share risks and

resources and create opportunities for MA staff to do this at the front line

We need to have a shared ownership and understanding of trauma informed

practice and how we create safety

We need to fully consider how we locate priorities and target resources

As senior managers we need to ensure staff are properly supported in their

risk assessments and wellbeing

We need continued feedback and co-production – with children, families, staff,

managers and leaders

We need to identify the gaps in services (such as the services for vulnerable

parents and to young fathers) and take action

We need a vision statement that defines how we support staff in SCRs and when

things go wrong to make people feel safe

We need to take the baby to the board (to ensure we are in touch with the

children and staff)

There should be joint Continued Professional Development learning events with

Board members to discuss and share how we manage the pressures on our staff

We need to focus on improving relationships rather just focus on

information sharing and communication

We need to look again at the motivators and demotivators that the focus groups

shared – take to organisational leadership and decide what we are going to do

about them

Containment reciprocity – balanced relationships -You hear me – I hear you; I see

you, I am not too busy, you’re important – model from the top down and the

children and families - be present - be genuine - be human

We need to share the clear message that we trust and value our staff who

are working well to support children and families. Also that senior leaders

are going to prioritise their wellbeing and resilience

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10. Summary of Key Learning

❖ Early involvement of trusted adults in the lives of children and adults

builds a platform on which future trusted relationships can be built.

Windows of opportunity should be harnessed, and services (such as those

provided through the voluntary sector, FNP and the Eden Team) should be

strengthened to increase capacity and gaps identified.

❖ Dynamic multi-agency risk assessments and risk sensible practice must

be strengthened, the family and the multi-agency network should be fully

engaged and the SOS model comprehensively embedded.

❖ Respectful relationships should be promoted and facilitated across

organisational hierarchies and the ownership of risk/decision making and

collective problem-solving should be improved by routinely promoting

information exchange, active dialogue,48 debate and challenge and through

specific multi-agency forums, supervision and training.

❖ Breaking the trauma cycle - the cyclical nature of family patterns and

difficulties needs to be understood. Awareness of ACEs and impact

should be strengthened (about children and parenting capacity) and a shared

multi-agency response delivered.

❖ Safeguarding children is a human service, the emotional content of the

work has a bearing on how children are safeguarded. The psychodynamic

aspects (including how defences are constructed against the inherent anxiety)

need greater attention and ways found to acknowledge the impact and mitigate

the risks to enable the workforce to think and act.

❖ The multi-agency safeguarding workforce protects children from harm

every day and improves their outcomes. This workforce is the system’s

most precious resource, opportunities to demonstrate their value should be

harnessed. Celebrate and promote good practice and what works well.

❖ A just learning culture needs to be established to support the work force in

identifying strengths and vulnerabilities so that learning and development can

be strengthened.

❖ A trauma informed approach is needed in order to respond to the needs of

children and their parents, and the needs of staff.

❖ Know your children – know your hot spots and prioritise – know your

vulnerabilities. Courageous conversations are needed, this includes

48 Active dialogue is a conversation, participants are neither passive nor dominant. It features an exchange of information and knowledge, respectful challenge, curiosity and debate.

49

conversations with families, the front line, commissioners, inspectorates and

political leaders.

❖ Be conscious about the impact of organisational flux, inspections and

SCRs and take steps to mitigate these risks.

❖ Find ways to increase energy and commitment to build partnership

working both at the front line and at a strategic level - be creative and take a

long-term view. Develop joint priorities and a shared understanding/language

and vision when responding to the learning from this review.

11. Conclusion There is much to celebrate in Norfolk. The passion and commitment of multi-agency practitioners, managers and leaders in the statutory sector, in schools and in the voluntary sector, is impressive and provides a solid platform on which improvements can be built. The resources provided and the willingness to learn from this Thematic Review demonstrated a clear multi-agency commitment by the front line and the leadership to move forward with these issues, and ultimately make a real difference to the lives of children and families. However, at this stage, it is important to return to the children who are the subject of this review. The six children suffered very serious injuries, one child sadly died as a result of these injuries and in all cases the parents/carers have been the subject of criminal investigations. This review has appraised the work of professionals and services involved and has identified learning about the wider system. It is understood that since this time there have been some considerable service improvements however it is also understood that non-accidental head injuries in very young children remains a very serious and ongoing safeguarding issue in Norfolk, and nationally.

12. Recommendations Agencies, focus group and panel members have identified single agency, service, team and practitioner learning and made recommendations that are being taken forward, these recommendations will not be repeated here. Much of the learning identified in this review is not specific to Norfolk and there is no magic wand, in the form of a series of recommendations, that provide an easy answer to the learning that has taken place. As a result only two recommendations are made: Recommendation 1: Operational A multi-agency task force should be urgently formed in Norfolk, including representatives from the front line, to collate data on serious injuries in similar circumstances to per-mobile pre- verbal children. Task force to oversee practice and better understand the extent of this critical safeguarding issue. The learning identified in this review (summarised as Terms of Reference for the task force in Appendix 2) should inform the work of this group.

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Recommendation 2: Strategic NSCB are encouraged to build on the work that has been completed during this review

and adopt a whole systems approach to the key learning (summarized in Section 10

above.) NSCB are invited to apply the Appreciative Inquiry model to plan how the

learning will be implemented.

Appreciative Inquiry Model

51

Appendix 1 : Appraisal of Practice AF1 & AF2

AF1 : Timeline June 2014 – December 2016

Significant Event Service Response Appraisal of practice Contributory factors

AF1 (6 weeks) moved to Norfolk with

mother.

Mother had been a Looked after Child

(LAC) in childhood. She described a

traumatic birth when AF1 was resuscitated,

she said she was sad & tearful at his birth.

Prompt movement in

appointment, history recorded.

Universal Health Visiting (HV)

services put in place

Contrary to expected practice/procedure

questions were not asked about Domestic

Abuse or about father/current partners. The

description of mother’s birth experience, her

previous LAC status and her young age should

have led to targeted HV services to enable a

relationship to be built, and for mother’s

parenting capacity to be assessed.

The impact of a traumatic birth and a

child’s admission to NICU is not routinely

considered as a risk factor impacting on

parenting capacity/attachment.

The records detailing mother’s previous LAC

status were not available to the HV and the

lack of inquiry about domestic abuse

(DA)/father’s is discussed in this report.

AF1 (22 months) observed at the home

of a maternal aunt with mother by HV

and Social worker (SW) whilst

conducting a visit to the household to

see AF1’s cousin. Concerns about

cannabis use & presence of unknown

males. AF1 observed to be unwashed & to

have bruises and deep scratches on his

face.

Joint HV/SW visit

Strategy meeting. Outcome :

Mother asked to live at the

home of Maternal

Grandparents (MGP’s) whilst

investigations continued.

The joint visit and observations of the SW and

HV were good & professional concerns were

clear (inc: poor attachment with mother).

AF1 was included in a strategy meeting about

his cousin but should have been the subject of a

separate strategy meeting- this resulted in these

concerns not being linked to AF1 in Children’s

Services (CS) and police recording systems and

compromised professional judgements.

A child protection medical was indicated but not

considered and this fell below expected practice

and procedure.

NSCB protocol on joint visiting is good

Confusion about process by police and CS

was not identified by managers. At this time

the Multi-Agency Safeguarding Hub (MASH)

were dealing with a high volume of referrals

and the capacity of managers was inhibited.

In Norfolk, there is a perception that child

protection medicals only take place when

child has an injury & there is suspicion that

the child has been injured as a result of non-

accidental injury (NAI) -not neglect. This

perception is incorrect.

52

Significant Event Service Response Appraisal of practice Contributory factors

AF1 (23 months) Mother moved out of

MGP’s home with AF1

Monitoring/ visiting by CS &

home-based support team

This move was contrary to the decisions of the

strategy meeting and although this was a joint

investigation with police, this was not discussed

with police or health.

Single agency risk assessment and decision-

making compromises safeguarding work.

Police had recorded that AF1 was living with

MGP under a Sc20 agreement ( legal

agreement ) this was incorrect. In the

absence of a joint approach – this was not

known about, and therefore unchallenged.

The responsibility for partnership working sits

with all partners, in Norfolk there is

insufficient emphasis on this partnership

and a deference to CS decision making –

collaborative working, including debate and

challenge, is not well embedded.

AF1 (23 months). Mother no longer

living with MGP’s.

Joint HV/SW visit AF1 observed to have a

significant facial bruise, was

‘dishevelled & dirty’, mother ‘completely

disengaged’ from AF1, lack of food, AF1

craving adult attention.

Paediatric assessment,

strategy meeting & admission

to hospital

Health professionals clear

about concerns (injuries due to

lack of supervision/neglect) &

clear about past present and

future risks.

Excellent joint visit by SW & HV – observations

good, prompt action taken.

Prompt examination admission & strategy

meeting. Excellent observations made by staff

about relationship between mother & child.

Excellent joint partnership work in response to a

crisis.

Learning from SCRs - NSCB joint protocol

Good safeguarding knowledge, supervision

and training in the hospital

AF (23 months) 2nd day in hospital

Strategy Meeting

The view of CS was that AF1

should return to maternal care

after the weekend. Health and

police opposed this decision.

Strategy meeting held promptly.

Health professionals were clear about concerns

that AF1 was at risk due to neglect. Police were

clear about birth father’s mental health needs

and vulnerabilities and the risks he posed.

53

Significant Event Service Response Appraisal of practice Contributory factors

Assessment of risk by CS was dominated by a

single focus on a need to have a medical

diagnosis of NAI, the risks father/male carers

posed & the full extent of current and future risks

were not fully considered & the views of partners

were over – ridden.

There was a high volume of cases held

within CS in the area at the time and

assessments were of a poor quality – this

severely limited professional capacity &

decision making.

CS and police are routinely dependant on a

medical diagnosis of NAI in order to take

statutory action.

Multi-agency collaborative work was not

fully embedded in assessment practice or

within the culture of wider partnership

working. Debate and challenge was not

normalised/promoted as a routine

expectation/established practice.

The challenging nature of child protection

work can result in secondary trauma which

can inhibit thinking, and in the absence of

sufficient containment ( e.g. good quality

reflective supervision) defences can be

constructed against the anxiety of the work

which can lead to polarised thinking/thinking in

concrete terms.

AF1 discharged from hospital &

returned to maternal care that day (after

maternal grandfather objected to his

continued stay in hospital)

A plan of home

visiting/monitoring &

assistance was put in place by

CS

Whilst there was escalation of the concerns

about this decision making by health, police did

not escalate. Escalation did not result in an

effective challenge of CS decision making.

There was a belief that MGP’s were protective,

however this view was not based on adequate

The responsibility for partnership working sits

with all partners, but there is often a lack of

professional debate, challenge and

escalation in safeguarding work. This is

discussed further in this report.

The escalation policy requires review and is

currently being amended - at the time an

ineffective policy was in place.

54

Significant Event Service Response Appraisal of practice Contributory factors

assessment. There was available evidence to

question this assumption.

Use of the assessment model in SOS49 at

the time was not embedded – the principle

that safety/protective factors should be

identified was understood but sensible risk

decision making was not.

6 days later, AF1 taken to hospital by

MGP’s he was unconscious and

unresponsive with extensive injuries

including a life-threatening head injury.

Mother & boyfriend are the subject of

criminal investigations

Strategy Meeting &

Emergency Protection Order

Prompt strategy meeting, excellent information

sharing, good quality professional debate and

challenge and prompt action to secure AF1’s

future safety

When partners are clear of the risks, and

have unequivocal evidence, the work

achieved can be excellent. However,

safeguarding work often features

uncertainty/unknowns/grey areas which can

pose particular challenges for safeguarding

practitioners.

49 Signs of Safety

55

Child AF2: Timeline November 2016 – November 2017

Significant Event

Service Response Appraisal of Practice Contributory factors

Booking in appointment with midwife

One month later

Childhood & history of domestic

abuse explored & clearly recorded in

notes. Decision to refer to Family

Nurse Partnership (FNP) for

targeted support.

Referral made to FNP

Good booking in appointment;

relevant history explored including

difficult childhood and current

domestic abuse perpetrated by ex-

partner. Appropriate decision to refer

to FNP.

Late referral, outcome unclear in

records. When safeguarding

children, prompt referrals and clear

recording of outcome is critical.

Experienced and well-trained midwife. Mother

seen alone. FNP is an established evidenced

based service in Norfolk that works with

vulnerable parents.

There was considerable organisational flux at

this time and caseloads were high.

Housing referral to Norfolk Children’s

Service (CS): Mother (16yrs) pregnant and

potentially homeless.

MASH referral for social work

assessment.

Appropriate referral by housing,

detailed information provided which

correctly identified mother as a child

in need in her own right.

MASH referral form clearly identified

childhood difficulties, but information

was not used in analysis of need.

Dominant focus on resolving

housing need. Notwithstanding this,

the decision to refer for a SW

assessment was correct.

Impact of Adverse childhood Experiences

(ACE’s) were not understood at the time and

the Signs of Safety approach to risk assessment

was not embedded.

FNP respond (one month after referral) FNP advised they were unable to

accept the referral due to reaching

capacity. Mother allocated to health

visiting team.

The referral to FNP was late and the

response from FNP was also late.

Early intervention is critical in order

for trusted relationships to be built

and to facilitate good information

gathering. That said, the referral and

response was provided within 6

weeks of expected due date.

FNP is a relatively small team who work to full

capacity, cases are discussed to determine

eligibility and if accepted are placed on a waiting

list. The request for services from this team is

high, and therefore thresholds are equally high.

56

Significant Event

Service Response Appraisal of Practice Contributory factors

Initial Child in Need (CiN) planning meeting

(one month after referral)

CiN plan recommended housing

provision and closure of case to CS

once SW assessment completed

CiN Meeting held promptly. Housing

were consulted during the meeting

and the actions agreed were clear.

Sole focus of meeting was on

housing needs. No other

professionals attended & it appears

they were not invited. The absence

of the full MA network and extended

family members meant that needs in

the family were not properly

considered and the plan was overly

simplistic. The needs of the unborn

child were not held in focus and the

vulnerabilities of the parents were

not adequately explored.

Recommending closure before the

baby has been born, and before the

assessment has been completed,

was optimistic.

There was a high volume of referrals into CS at

this time and a pressure to move cases through

the system to create capacity for high risk cases.

The organisation was in a state of flux after the

recent inspection and there had been

insufficient support provided to SW’s in

assessment practice.

Critical thinking can be inhibited by the

secondary trauma experienced by safeguarding

professionals – this was not recognised at the

time.

Collaborative work with the full MA group was

not embedded in assessment practice.

CS Assessment completed

( approx. 2 weeks after CiN meeting )

Case closed to CS; closure agreed

by manager. Agencies notified.

Assessment was completed

promptly but was overly focussed on

housing, not on vulnerabilities of

either mother or new partner. Mother

17rys. History of ACE’s (domestic

abuse and neglect, vulnerable to

CSE). DA was not explored, and the

case was to close before the birth of

AF2.

Management oversight is critical

when supporting practitioners in

safeguarding work and the manager

As above, and :

Poor quality assessments was later identified as a

systemic issue in CS.

The lack of reflective supervision and

organisational containment leads to reduced

critical thinking capacity.

Managers in CS deal with a high volume of

throughput and are often reliant on the information

provided in an assessment to inform their

57

Significant Event

Service Response Appraisal of Practice Contributory factors

recorded a clear reasoning behind

the decision to close. However,

greater challenge and reflection was

needed – the reasoning was overly

simplistic, and as a result –

optimistic. A decision should have

been taken for the CiN plan to

continue, or for the case to step

down to an early intervention team,

to ensure the optimism was

evidenced.

decisions. The systemic problem of poor

assessment practice has ramifications on

decision making across the system.

One week prior to birth

Joint visit SW & HV Joint SW & HV visiting is good

practice and the decision to close

the case in CS did not stop this joint

visit going ahead – this was also

good practice. The single focus on

housing remained, and as a result

optimism was again a feature.

Implementation of learning from SCRs in

Norfolk have resulted in improvements in

service delivery ( Ref: Joint HV/SW visiting

protocol)

Cognitive bias ( such as confirmation bias ) is a

common feature of safeguarding work and in the

absence of reflective supervision, this is difficult

to detect &/or challenge.

AF2 born at 28 weeks gestation. As a result of medical needs, due to

prematurity, AF2 remained in

hospital for approx. 7 weeks (52

days)

The decision for AF2 to remain in

hospital was appropriate and good

medical care was provided to meet

AF2’s needs.

Some concerns were appropriately

raised about mother’s limited visits.

It was noted that mother had a

history of DA & staff appropriately

requested a safeguarding review by

a named professional prior to

discharge .

NICU staff are experienced practitioners who

understand the impact of prematurity and are alert

to the relationship/attachment between a mother

and child. They have good access to named

safeguarding professionals.

58

Significant Event

Service Response Appraisal of Practice Contributory factors

AF2 ( 7 weeks 4 days ) discharged to

mother’s care

Safeguarding review completed by

named professional prior to

discharge concluded referral to

MASH was not indicated. Multi-

agency discharge meeting held.

Safeguarding Reviews by named

professionals are good practice and

this review was conducted promptly.

It was noted that parental visiting

had improved and there was good

analysis. The multi-agency

discharge meeting was good

practice.

The impact of AF2’s vulnerabilities,

due to prematurity, was identified by

Dr’s and a referral to MASH was

considered, this was good practice.

Mother highlighted the SW

assessment as proof of her parental

capacity and the view that there was

good support from extended family

was based on the SW

assessment/self-report – but this

had not been adequately evidenced.

The named professional is an experienced

safeguarding professional.

Prematurity, and separation from primary care

giver at this young age, was not routinely

considered as a possible risk within CS.

The SOS approach used in CS was in early

days of implementation, the principle of seeking

to identify signs of safety was understood, but the

need to fully risk assess this safety was not.

AF2 ( 7 weeks 5 days )

HV home visit A first visit took place where various

(potential) household risks were

discussed, early help services,

through the Children’s Centre, and

funding for household goods

appropriately pursued. The

relationship between mother and

child was noted in positive terms-

although the relationship with father

was not possible to assess as he

was absent for most of the visit.

In many ways, this was a

comprehensive visit, but the case

As above , and :

The HV had a high case load and there were a

number of organisational changes taking place.

The impact of organisational flux can have an

impact on front line delivery of services.

Whilst safeguarding supervision was available,

and could have been accessed, raising a case

59

Significant Event

Service Response Appraisal of Practice Contributory factors

recording was descriptive rather

than analytical. It was clear that the

parents were struggling with

numerous stressors & the support

from extended family was accepted

on the basis of self – report. This

case required oversight by the

agencies Safeguarding Lead &

consideration of a referral to Early

Help/ MASH.

within safeguarding supervision requires the HV to

self – select which cases will be discussed - this

was a case that had a history of CS involvement

that did not identify any safeguarding concerns.

AF2 ( 12 weeks) Mother reported to

ambulance service AF2 had fallen from a

bed

Ambulance service attended the

address and paramedic saw mother

and AF2. AF2 seen with 2 red marks

on head and mother reported AF2

had vomited once after the fall.

Mother was advised AF2 did not

need to go to hospital. Required

notifications were not sent.

The response time to the initial call

was very prompt. All required

observations and medical

assessments took place. However,

incidents such as this, involving a

pre- mobile baby, should have

resulted in transfer to hospital and

paediatric assessment. Lack of

transfer to hospital fell below best

safeguarding practice and the lack of

immediate safeguarding notifications

to HV & GP after the incident fell

below policy requirements.

The paramedic was an experienced practitioner,

the explanation from the parents was felt to be

plausible and observations were satisfactory. Non-

conveyance to hospital was not contrary to the

agencies training/non-mobile baby requirement,

the guidance available at the time did not

require transfer to hospital in these

circumstances.

Notifications were not made as the persuasive

parental narrative led to an assumption that there

were no safeguarding concerns.

The defences that can arise in response to the

challenging nature of human services are

relevant to this episode.

Next day

NHS 111 report received by GP

practice. Details of reported fall

provided in full. Notification stated

ambulance was requested to take

AF2 to hospital.

Adequate details were provided in

this report and the notification was

prompt. Contrary to expected

practice, the GP practice did not

respond to this notification. At this

time AF2 was just over 2 months but

in view of prematurity would be

It is unclear whether a GP saw this notification in

order for a clinical decision to be made.

At the time, notifications to this GP practice were

firstly seen by the administration team before

being placed in a patients file ( this has now

changed).There is a high volume of notifications

and an assumption could have been made that

AF2 was seen in hospital and received the

60

Significant Event

Service Response Appraisal of Practice Contributory factors

corrected to new-born – it was

unlikely she could roll.

Good practice would have been to

confirm outcome/make a

safeguarding enquiry and follow up.

This did not happen and was a

missed opportunity.

necessary medical intervention and safeguarding

review.

AF2 ( 17 weeks & 4 days ) AF2 seen at GP

practice for immunisations. Two-line bruises

on her arm observed.

No action taken The significance of an injury to a

pre-mobile child was not recognised,

professional curiosity was not

evidenced, and the medical

examinations policy was not

followed. AF2 required examination

by a paediatrician and a MASH

referral should have been made.

This was a missed opportunity to

take appropriate safeguarding

action.

Mother gave a plausible explanation for the injury

and appeared concerned. There were no current

safeguarding concerns and the previous missed

opportunity to adequately explore the alleged fall

from the bed, and raise safeguarding concerns,

contributed to why another opportunity was

missed.

The challenging nature of safeguarding work,

the anxieties and defences that can be

present, can skew decision making ( that in

hindsight may appear unreasonable).

AF2 (31 weeks) referred by NSPCC to MASH

& local police after anonymous referral

received from a member of the community

stating AF2 had unexplained bruising down

her arm, arm appeared dislocated. DA

reported as observed against mother,

perpetrated by male partner.

NSPCC phoned Norfolk police

control room and MASH requesting

a welfare check.

Police supervisor reviewed &

requested officers liaise with MASH

and visit the home.- no liaison with

MASH took place. Police visited the

home and completed a welfare

Appropriate prompt referral – Police

Control Operator clear of risks and

requested action asap by uniformed

officers.

A specialist police child abuse

response was needed by the police

child abuse investigation unit and

CS, but no liaison took place with

MASH and MASH provided no

response to the email. Whilst the

Two separate reports were made by the NSPCC,

this was contrary to expected practice- a single

report to MASH minimises the risk of agencies

working in isolation.

Officers were not experienced in child

protection and the task assigned of

completing a ‘welfare check’ is an ambiguous

instruction that can lead to confusion about

exactly what this means in practice, especially

when the subject is a pre- mobile, pre-verbal child.

61

Significant Event

Service Response Appraisal of Practice Contributory factors

check – no concerns were noted –

MASH were later informed via email.

No further action was taken by

police.

MASH undertook various checks

with GP & HV. They were informed

that there were concerns about AF2

relating to the previous incidents of

the fall from the bed and separately

when bruising was noted. After the

email was received from police, a

view was reached that the HV could

monitor AF2.

MASH sent information to the GP via

an established form in use at the

time, it was marked ‘for information

only’ (FIO) & no further action was

taken by MASH.

actions by police were prompt – they

fell below expected practice.

The use of emails in situations such

as this may comply with the

requirement to share information but

in the absence of a dialogue, multi-

agency collaboration is

compromised and opportunities for

debate and challenge are missed.

The recording of events in MASH

was confusing – various forms had

been completed recording different

pieces of information with various

expected outcomes. This

compromised decision making.

A joint Sc 47 ( child protection)

investigation was needed that

included a joint (CS & police) visit by

experienced safeguarding

professionals, a child protection

medical and a strategy meeting.

None of this happened & the

overreliance on a non- specialist

response compromised AF2’s

safety.

The information recorded in MASH

was confusing and in the absence of

a dialogue multi-agency

collaboration was not achieved and

it is unclear whether this form was

simply filed (FIO) or was seen by a

Using emails (or faxes) to ‘share ( or request)

information is common practice in Norfolk and

working relationships that feature dialogue

debate and challenge is not sufficiently

valued/facilitated.

At the time, MASH was dealing with a very

high volume of work and were struggling to

process recording of relevant forms – creating a

situation where information, and the sequencing of

information, was muddled.

The capacity for critical thinking can be

inhibited by the defences that can arise when

working in emotionally demanding/anxiety

provoking working environments. In a system that

is dealing with complex high demands, it may be

tempting to take short cuts.

The use of emails/faxes/forms, without dialogue, is

discussed above

62

Significant Event

Service Response Appraisal of Practice Contributory factors

clinician. In these circumstances

AF’s safety continued to be

compromised.

AF2 (32 weeks )

Mother attended GP surgery with AF2.

Report of projectile vomiting and bruising

appearing and disappearing. Bruises noted on

chin spine & lower back. Left arm floppy and

unable to use arm.

Transported to hospital by

ambulance & seen by paediatrician,

Strategy discussion

Swift and effective action to secure

medical attention by GP. Swift

examination by paediatrician &

immediate concern re: NAI correct.

Strategy discussion involved good

sharing of information, was prompt

and effectively secured AF2’s safety

through an emergency order.

The GP & hospital staff ( SHO) effectively

communicated and prioritised safeguarding AF2

as a matter of urgency.

There is a history in Norfolk of agencies working

well in a situation where the medical opinion is

clear (that NAI is suspected/diagnosed).

Later the same day: AF2 admitted to hospital

AF2 fitting - CT scan : cerebral

haemorrhage. Full skeletal survey

showed minimum of 15 fractures.

NAI confirmed. ICO granted, mother

and partner arrested, and foster

placement allocated.

Medical tests, results, treatment and

court action all prompt and

appropriate. AF2 secured in a place

of safety & foster placement found

immediately.

As above

63

Appendix 2 :

Recommendation 1 Terms of Reference for Task Force

The following is a list of the key learning to inform the terms of reference for the task

force:

• Data about NAI to young children to be gathered and mapped – any hotspots to

be identified and raised with senior management

• Cases to be audited against audit variables set out in this review

• Any concerns about service delivery in a case to result in immediate action

• NSCP50 to be kept informed of progress

• Operational and strategic recommendations to be made to NSCP

• Existing practice framework (Signs of Safety) to be discussed and reviewed

to explicitly include:

o Dynamic multi-agency assessment, decision making and planning that

features curiosity and avoids optimistic or polarized thinking

o Utilising opportunities for Multi-Agency (MA) reflective spaces to make better

sense of the case and improve decision making

o Scoping and mapping the full network (including GPs, voluntary sector,

faith/community links)

o Importance of information exchange in the form of active dialogue, debate and

challenge

o Importance of joint SW/HV visits, assessments and MA management

overview (in line with existing protocol)

o Use of SOS approach including application of this approach when assessing

extended family members that fully explores and evidences both the strengths

and vulnerabilities/ risks

o Consideration of ACE’s in parents/carers/associates, the vulnerabilities on

parenting capacity posed by ACEs and the dynamic interplay between the

vulnerabilities between the couple and with their caring responsibilities

(particularly when a child has specific vulnerabilities linked to prematurity,

feeding & or sleeping difficulties, stressful birth experience)

50 From September 2019 the Norfolk Safeguarding Children Board ceases to function under statute and the responsibility for local safeguarding arrangements sits with the Local Authority, police and health. The new arrangements are written into a published plan and the name of the responsible partnership board is the Norfolk Safeguarding Children Partnership (NSCP).

64

o Full consideration of levels of violence/ violent communication/ desensitisation

to violence by those in a parenting/caring role and the impact on MA decision

making and wellbeing

o Understanding the child’s lived world through observation of their behaviour

o Understanding the relationship between the child and primary care giver/

prime source of safety

o Factoring in prematurity & birth history and the interplay with parental

vulnerabilities in assessments of risk

o Recognition that couple reunification is a critical time of risk

o The importance of understanding the role of father’s/male partners in the lives

of children

o Recognition that MA practitioners have to make decisions/ take action when

there is often uncertainty. Establish mechanisms to support risk sensible

decision making

o Establish ways in which MA practitioners are supported to consider the

likelihood of harm and take action when there has not been an injury or when

there is no definitive diagnosis of NAI

o Acknowledge the psychodynamic components of the work that can hamper

practice and service delivery and provide a reflective space for these to be

explored and contained

o Recognition that the relationship between professionals has an important

impact on practice and service delivery, identify the importance of this and

establish/signpost ways in which these relationships can be nurtured