Information Sharing - Messages from Serious Case Reviews


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From the Conwy and Denbighshire Local Safeguarding Children Board (LSCB) Conference, March 2012.

Shared with kind permission from David Spicer.

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Information Sharing - Messages from Serious Case Reviews

  1. 1. Conwy and Denbighshire Local Safeguarding Children Board Information SharingMessages from Serious Case Reviews David Spicer, LLB, Barrister © David Spicer
  2. 2. It’s not easy
  3. 3. Inter-agency Co-operation• Over 60 years from the first government circular encouraging inter- agency working (Dennis O’Neil)• 40 years since detailed guidance (Maria Colwell – Area Review Committees to ACPCs to LSCBs).• 8 years since major legislative reform (Victoria Climbié)
  4. 4. Inquiries Recommended• Should be better working together.• Should be better sharing of information.
  5. 5. CDLSCB Serious Case Reviews• Jane: baby 8 weeks. Serious physical injuries. Stress; prematurity; special needs.• Child A; baby 4 months. Serious physical injuries. Young parents. Stressful pregnancy, distressing, medical interventions.• Child 3C; baby. 2 days. Mother gave methadone. Long history of drug misuse.
  6. 6. CDLSCB Serious Case Reviews• Child CS 5 years; Child AS 4 years smothered by father. Mental illness.• Child B teenager. Committed suicide at home.
  7. 7. Serious Case Reviews• Child B 6 - 10; sexual abuse in foster care.• Children B; C; P; Z teenagers. Choked on vomit. Drug and alcohol misuse; sexual exploitation; domestic abuse.• Children N; R. Teenage suicides; domestic abuse.• Children M1;M2. Serious physical and sexual abuse. Longterm neglect, domestic abuse.
  8. 8. Serious Case Reviews• Children O; G. New babies. Serious physical abuse. Young carers; depression; domestic abuse.• Child F new baby. FII. Previous baby with fractured ribs; domestic abuse.• Children E (4) serious sexual abuse. Longterm neglect, domestic abuse.
  9. 9. Practice is within aframework of statutory, policy, practice and guidance imperatives
  10. 10. Policy Imperative.Practice imperative. Legal imperative.
  11. 11. Within a context of what we know …
  12. 12. Significant Factors• Mental Illness.• Domestic Abuse.• Alcohol misuse.• Drug misuse.• Poor childhood experience of adults.• Immature adults.• Male not the father.• Financial pressures / poor housing.
  13. 13. Ofsted’s evaluations of serious case reviews 2007 to 2008• 173 SCRs• Salutary to be reminded that the most common risk factor in the cases reviewed was neglect.• Distressing to read, for example, how often nobody thought to ask a child who was clearly unhappy what was wrong.
  14. 14. Child M2 Aged just 3 years was“his usual weary self”
  15. 15. Ages of Concern, learning lessonsfrom serious case reviews: A thematic report of Ofsted’s evaluation ofserious case reviews from 1 April 2007 to 31 March 2011(26 October 2011)
  16. 16. Babies• 608 children who had been the subject of SCRs during 2007 to 2011 in England,• 210 - 35% under 12 months old.• Majority under 3 months of age.• “practitioners underestimated the fragility of the baby.”• “ … means swift response is even more essential.”
  17. 17. Teenagers•14 – 18 years: 25% SCRs.•2007 – 2008: 40% 11 to 18 yearolds
  18. 18. With both: “Too often …”• Safeguarding procedures not used early enough.
  19. 19. Why not?• OFSTED – staff unaware of procedural requirements• Or• Knew about them but failed to act in accordance.
  20. 20. Child Welfare Policy to Practice Government Formulates Policy ▼ Legislation to Implement Policy ▼ Guidance to Assist Implementation of Legislation ▼ Procedures/Protocols ▼ Practice
  21. 21. What are the legal, policy and practice imperatives underpinning a procedural requirement? What are they expected to deliver?
  22. 22. publications-and-resources/child-law
  23. 23. SCR LAC sexually abused byadopted son of foster motherfor 4 years from 6 years to 10 years old
  24. 24. Why did she not tell someone?
  25. 25. Working Together 2006 Chapter 9 Safeguarding children whomay be particularly vulnerable
  26. 26. Working Together 9.11• “Social workers are required to see children in foster care on their own for a proportion of visits, and evidence of this should be recorded.”• Reflects statutory regulations.
  27. 27. Why?What are the Policy and Practice Imperatives behind the legal and guidance requirement?
  28. 28. Working Together 9.11• “Foster care is undertaken in the private domain of carers own homes. This may make it more difficult to identify abusive situations and for children to find a voice outside the family.”
  29. 29. Statutory Regulations and Guidance• To form a relationship and to encourage sharing concerns.• “a measure of child protection”.• “This performs the child protection element.”
  30. 30. Children Telling• 25% told at the time• 31% not told anyone by early adulthood• Of those who told• 55% told a friend• 29% told mother or step mother• 13% told a sibling• 11% told father• (Cawson et al 2000)
  31. 31. Reder and Duncan(Reder and Duncan (1999) Lost innocents: a follow-up study of fatal child abuse, London: Routledge.)• “… professional practice is based on a covert preparedness for a worst-case scenario.”
  32. 32. Child B• (she) considered her social worker to have shown ‘false friendliness’.• Her social worker was ‘rushed’ and she ‘never asked questions more than once’.
  33. 33. Child B• ‘for example, she would ask me how I was and I would say fine’.• ‘if she had asked me again for example - are you really sure? I don’t think I could have hidden it and may have let it all out’.
  34. 34. Seeing alone• Not just to give an opportunity to disclose.• Also to find out.
  35. 35. National Assembly for Wales Health, Wellbeing and Local Government CommitteeInquiry into Local Safeguarding Children Boards in Wales November 2010
  36. 36. Foreword• During the course of the Inquiry, we heard evidence of• a disconnect between the strategic work of LSCBs and the knowledge and awareness of front-line practitioners;
  37. 37. Child CS and Child AS• History of mental illness.• ned that• The authors were concerdespite the fact that a flawed protocol existed about communication between adult mental health and children’s professionals the local team were unaware of its existence.
  38. 38. Suicide Strategy• Great deal of work on strategy to address.• Agencies to develop services to deliver strategy.• To assist early identification of risk and referral to specialist group.• Training to equip staff across agencies to identify risk.
  39. 39. Serious Case Review following Suicide of 13 year old• Frontline staff unaware of arrangements.• No agency could identify any development of service.• One teacher had attended training.• LSCB had no information on which agency staff attended training and had not required evidence of development of services.
  40. 40. Check out that -• Staff and managers are aware of expectations.• They have understood why.• Policies and procedures are being applied in practice as intended.
  41. 41. Child Sexual Exploitation
  42. 42. Child Protection Procedures• Not followed for older children.• Despite serious harm and risk of death.• Apply until 18 years old.• Lack of interagency processes.
  43. 43. Child Sexual Exploitation Procedures• Not followed.• Perpetrators free to abuse others.• Suppliers of drugs and alcohol not investigated.• Contrast action against victims.• Action against perpetrators criminal and civil should be priority.
  44. 44. SCRs• Ascertaining wishes and feelings becomes -• Deferring responsibility for decisions and action (or inaction) to the child.• Need to record judgment about what child wants or does not want.• Consider whole range of options including secure accommodation.
  45. 45. Language used• 11 years 7 months: “sexual relationship with an older man.”• “was not prepared to give any details regarding her partner.”• 13 years: “had sexual intercourse” with 24 year substance user and registered sex offender.• “having sex with an older man.”• She “put herself in situations of harm.”• 13 year old with 28 year old “boyfriend”.• Identified in WG Guidance on Safeguarding Children and Young People from Sexual Exploitation January 2011.
  46. 46. Language Used – older children• Encourages desensitisation to circumstances.• Normalises experiences.• Allocates responsibility to the child.
  47. 47. Interagency Culture
  48. 48. Safeguarding Children isEveryones Responsibility
  49. 49. Safeguarding Children is Everyones Responsibility• Safeguarding and Promoting Welfare.• s28 Children Act 2004• s175 Education Act 2002
  50. 50. Policy Children Act 2004Government expects:• Radical and fundamental cultural change.• Whole system change.• Programme of fundamental reform.• Step change in how safeguard and protect children.• Strengthening child protection.• Involving transformation of children’s services.• Shift emphasis to prevention and early intervention.
  51. 51. s28 Duty• To ensure all functions are carried out having regard to the need to safeguard and promote the welfare of children• When arranging for others to deliver services to ensure that they do so.• All agencies have same duty.
  52. 52. Cultural shift required• Agencies not to be seen as different services.• But different parts of a single service for children.
  53. 53. Serious Case ReviewsNo reflection of the radical change expected in thepractice and inter agency arrangements.
  54. 54. Health, Wellbeing and Local Government Committee Inquiry 2010• Recommendation 3:• that the Welsh Government should ensure that LSCB guidance addresses the over-reliance on Social Services Departments and re-states the responsibility of all organisations at national, regional and local levels to working effectively together to safeguard and protect children.
  55. 55. Inter Agency Processes• Strategy meetings.• Assessments.• Child protection conferences.• Core Group meetings.• Individual and collective responsibility for effectiveness and ensuring all relevant information is considered.
  56. 56. Testing and ChallengingDangers of Consensus
  57. 57. Inter-agency Processes• Responsibility on all:• to ensure operating effectively.• assessments completed and effectively carried out.• that contribute to enquiries and assessments – proactively.• To test and challenge.
  58. 58. Working Together 2006 Multi/Inter-agency in approach8.14 Multi and inter-agency work tosafeguard and promote children’swelfare starts as soon as there areconcerns about a child’s welfare, not justwhen there are questions aboutpossible harm.
  59. 59. SCRs - Assessments• Inadequate assessments accepted by managers and interagency groups.• Judgments not properly reasoned.• Lack of forensic approach.• What do we need to know?• Evaluation and analysis - what does information mean and why?• Includes drawing appropriate inferences and opinion on what is likely to happen.
  60. 60. SCRs• Framework for Assessment not read.• Inadequate plans with vague generalised objectives.• Lack of clarity about who is to do what, when and how?• No contingency arrangements.• Changes occurred in crisis.• Plans persisted with – despite lack of impact.• Lack of interagency challenge.• Lack of effective challenge through supervision.
  61. 61. Inadequate shorthand• Problems will be addressed?• Situation will be monitored?• There will be engagement with the family?• The family will receive support?• Mental health problems.• Limited capabilities.• Challenging behaviour.
  62. 62. What will the protected child look like?
  63. 63. Failure to Review Failing Strategy• One of the most common, problematic tendencies in human cognition … is our failure to review judgements and plans – once we have formed a view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture.• (Fish, Munro and Bairstow 2009)
  64. 64. GroupthinkWhat drove thinking in direction it took?
  65. 65. “Groupthink”• Tendency of groups to avoid dissension is a hazard.• (Janis (1982) Groupthink: psychological studies of policy decisions and fiascos, Boston, MA: Houghton Mifflin, second edn)
  66. 66. Conformity• High level of conformity in case conferences.• Group leaders therefore have to challenge themselves to encourage dissent and be open to challenge, sometimes even appointing a ‘devil’s advocate’ to diminish this tendency.(Corby 1987; Birchall and Hallett 1995; Farmer and Owen1995) Working with child abuse, Milton Keynes: Open University Press.)
  67. 67. Assessments• Better not to carryout and acknowledge the impact.• Than to do it inadequately and rely on the conclusions.• Just because it is called an assessment doesn’t mean it is one.
  68. 68. Dr Henry Kempe• “If you do not understand someone’s behaviour, you do not have enough history.”
  69. 69. Analysing child deaths and serious injurythrough abuse and neglect: what can we learn? DCSF(2008).• “ If parents are experiencing difficulties in their parenting tasks, then knowing the parents’ own family history, assessing their understanding of the impact of what is happening to them on their parenting children, and their capacity to adapt and change becomes crucial.”
  70. 70. SCRs• History of parents insufficiently researched.• Childhood experiences.• If in care – files not accessed.• Previous relationships and children.• Particularly if information is elsewhere in Wales or United Kingdom.
  71. 71. It’s not easy
  72. 72. “Foster mother jailed for sadistic torture.” April 2007• Eunice Spry sentenced to 14 years imprisonment.• Over 20 years vicious abuse and neglect - beating with metal poles, forcing sticks down throat, forcing to eat dog faeces, told possessed by Devil.• Not attend school and not allowed to socialise.• Regular visits to the home.• Came to light because a child “escaped and told a friend.”
  73. 73. Dangers of ConsensusAgreed Court Outcomes
  74. 74. Danger• When experts are jointly instructed.• Recommendations accepted with insufficient challenge and testing.• Community professionals excluded from commenting or even knowing.
  75. 75. SCR• 4 children.• Father convicted of sexual offence against 6 year old visitor – 15 months.• National agency expert jointly commissioned to advise on• What is likelihood of offending against own children?• Ability of grandparents to protect if had care?
  76. 76. Court• Opinion in report accepted –• High risk to children outside family but• Low to medium risk to own children reducing to low if treated.• Grandparents could be relied on to protect.• Agreed residence order to g/ps who to supervise contact.
  77. 77. Real life• At time of assessment father was and had been seriously abusing children.• Continued to abuse.• Sufficient to justify life sentence.• Grandparents colluded with opportunities to abuse.
  78. 78. No challenge• Agency admitted little evidence base for their work on risk.• Received no information about outcomes of previous cases advised on.• No evidence base on assessing ability to protect.• Probation/MAPPA assessment that highly dangerous not known or considered.
  79. 79. Child E• “… no one had ever helped us … I was lied to and let down by everyone…. workers were told to go away … and they did. No one ever really tried to find out what was going on – why didn’t they try harder?”
  80. 80. Information Sharing
  81. 81. Jigsaw• “Often it is only when information from a number of sources has been shared and is then put together that it becomes clear that a child is at risk of or is suffering significant harm.”• Do not know what we do not know.• Not always know significance.• Do not know what others know or not know.
  82. 82. GlimpsesWhat is it like living in the household? 24 hours a day 7 days a week 52 weeks a year
  83. 83. Health, Wellbeing and Local Government Committee Inquiry 2010• During the course of the Inquiry, we heard evidence of:• problems with information sharing across agencies.
  84. 84. What is the Problem?
  85. 85. • Is it too much information being shared inappropriately?• Is it too much action being taken precipitously and without good cause?
  86. 86. Problem?• Is it a question of law?• Or good practice?• Or both?• More important – is the culture.
  87. 87. Culture• Despite the emphasis in guidance on the law.• Rare for individual practitioners to think about whether they should share information.• And then conclude that the law prohibits them from doing so.• More common is not to think about sharing and with whom.• Culture is as important as protocols and procedures.• Includes issues of trust.
  88. 88. Climbié Report 2003• Throughout this inquiry it was said that when there is professional concern about the welfare of a child, the free exchange of information is inhibited by the Data Protection Act 1998, the Human Rights Act 1998, and common law rules on confidentiality.(17.115)
  89. 89. • What happened before late 2000 when HRA and DPA implemented? Victoria died on 25/02/00
  90. 90. •Did Parliament intend tomake vulnerable childrenmore vulnerable?
  91. 91. IRT : Information Sharing to Improve Services for Children (August 2003)• … you need to develop co-operative ways of working with other agencies and service providers to ensure that you can all access all the relevant information to help secure the best outcome for the child.
  92. 92. Data Protection Act 1998. Human Rights Act 1998.Common law principles of confidentiality.
  93. 93. Sharing Information• Nothing in• Data Protection Act 1998• Human Rights Act 1998• Common law principles• To prevent appropriate sharing of information to safeguard and promote the welfare of vulnerable children and inform sound judgments.
  94. 94. Ministers 2004• Sharing information is a vital aspect of safeguarding children and ensuring they thrive, and• It is an intrinsic part of the duty to co- operate to safeguard and promote welfare• Under s28 Children Act.
  95. 95. Safeguarding and Promoting Welfare• Includes:• Acquiring necessary information to form judgments and shape services.• Ensuring others have information necessary to inform their judgements and shape services.
  96. 96. Communication and Terminology
  97. 97. Laming – Information Management• Competence in information management is no less critical … than competence in diagnosis or … in treatment.
  98. 98. Assume you will be misunderstood. Assume you will misunderstand. Make clearimplications/inferences to be drawn.
  99. 99. Karl Popper (1902 –1994)• It is impossible to speak in such a way that y
  100. 100. Sources - Test and Challenge• Be clear about sources of information.• Be clear about the basis of any opinions or assessments.• Receivers test and challenge.
  101. 101. SCR• Offender Manager’s office interviews informed assessment about dangerousness and life style and change.• Inconsistent with actual behaviour and serious risk.• Relied on by child care staff to allow contact.
  102. 102. Terminology• “chronic”• very serious?• or• long lasting?
  103. 103. Terminology• “Morbidity”• Concerned with death?• or• Concerned with sickness or disease?
  104. 104. Make no assumptions about knowledge?
  105. 105. SCR• Schedule 1 offender uncle.• Judge:• “… it is now quite clear that there is not a shred of evidence against him.• It verged on the incredible that he should have had the opportunity to groom and then to abuse his niece on “more than one occasion” without the parents or the other children becoming aware that something had happened. He is entitled to be wholly and publicly exonerated.”