CYSCP

Background

Sarah was a 13 year old female, and her brother Tom a 15 year old male at the time of a significant safeguarding incident. Both children were subject to Child Protection plans under the category of emotional abuse and had been so for a period of 22 months. Concerns remained regarding mother's mental and physical health following a diagnosis of a chronic health condition which significantly impacted upon her ability to provide appropriate routines and boundaries for the children. The Police had also attended the family home on numerous occasions due to conflict between the siblings that had resulted in them physically attacking each other and their mother. It had been reported on one occasion that weapons were used, this included a baseball bat and a knife. The children’s school attendance remained very poor however, it is felt that this in the main was due to there being no routines in place at home.

Prior to the children becoming subject to Child Protection plans there had been a significant amount of historical children's social care involvement dating back many years when the GP had raised concerns regarding the mother's mental health. Additionally, concerns were later raised regarding domestic abuse in the family home.

In November 2021 Sarah went into school late (at lunchtime) and reported to her class teacher that her father had hit her and her brother with a belt and punched her in the middle of her chest.

The class teacher informed the Designated Safeguarding Lead (DSL) within the school of the incident at the end of the day, which meant that the DSL could not report the incident to MASH in a timely manner thus meaning that the contact was dealt by the Emergency Duty Team (EDT) as it was out of hours.

What areas of good practice was highlighted?

EDT recognised that this case required urgent follow up to establish further details from the School, children and both parents.

MASH held a timely strategy meeting. There was good multi-agency attendance and actions were identified at the meeting with clear timescales identified.

Key Learning Points

Learning Point 1

Had the class teacher reported the incident in November immediately to the Designated Safeguarding Lead (DSL), this would have afforded the DSL to make a timely referral and thereby following City of York Safeguarding Children Partnership (CYSCP) Procedures.

The DSL did attempt to contact the allocated social worker but was unable to get through which led to further delay. Since this review the MASH has updated their telephone system which now enables them to triage calls to the most appropriate team. Information on the CYSCP Website has been updated to reflect this.

Learning Point 2

Whilst EDT contacted the mother of the children to have a discussion with her in regard to the information received from the school and confirmed that the children's father did not live in the family home, they did not instigate safeguarding procedures and a strategy meeting should have been convened. EDT did not undertake a home visit or make contact with the Police. A Police visit could have afforded the opportunity to have visited the children, made a record of any physical injuries, home conditions, physical demeanours, considered any sufficient grounds to arrest and make a referral.

Learning Point 3

Although EDT did some safety planning with the mother over the telephone, this was not felt to be robust. Additionally they did not provide any challenge when the mother refused to speak to them further and stated she would only speak to the allocated Social Worker despite the significant safeguarding incident. EDT appeared to see the children's mother as a protective factor, despite her having been in the house at the time of the alleged incident.

Learning Point 4

There had been numerous referrals to Children’s Social Care (CSC); the outcome of the majority of these referrals led to an Early Help response despite previous non-engagement by mother and historical Social Care intervention. Each referral was looked at individually and there appeared to be no consideration to look at the cumulative harm/historical risks. If the historical information had been tri-angulated and consideration given to the lack of family engagement with Early Help this may have led to the case being escalated at an earlier stage.

The audit highlighted that if an Early Help Plan is in place that this should always be shared with partner agencies. Where a case needs either Targeted Intervention support or escalation then the Early Help Plan should be shared with the MASH as part of the referral.

Learning Point 5

A multi-agency decision was taken in two strategy meetings to commence a single assessment, however it was agreed that if the mother did not consent to this then Section 47 enquiries would commence. On both occasions, the mother did not engage but Section 47 enquiries were not instigated. It is not clear whether the decision not to proceed with the Section 47 enquires was communicated with partner agencies or whether this was challenged at all.

Children’s Social Care need to communicate to partner agencies any changes to agreed multi-agency decisions providing a clear rationale. Partners are also responsible to follow up cases where a multi-agency decision has been made and challenge any decision they do not agree with.

It is the responsibility of all partner agencies to ensure that professionals and their teams are aware of the local escalation policy.

Learning Point 6

The Child Protection plan was not SMART (Specific, Measurable, Achievable, Relevant, Time-bound). The children’s educational attendance remained low despite this being an action within the plan. Additionally, there were no specific targets agreed within the plan for improvements in school attendance. The plan was not clear as to tasks that individual professionals should have undertaken. Both children were not taken to a number of health appointments but ‘health appointments’ were not included within the plan.

Learning Point 7

The children were subject to a Child Protection plan for 22 months at the time of the incident but despite this the risks to the children do not appear to have reduced significantly. It was not clear whether the plan had been reviewed at each core group meeting and updated accordingly. It was not clear from the information that was recorded that all actions within the plan had been addressed as there was no clear rationale as to why an action had been closed.

Child Protection Plans must be reviewed at each core group meeting and updated. If actions have been completed, then a rationale should be recorded on the Children’s file.

All multi-agency partners need to fully understand their roles and responsibility within a Child Protection Arena/Plan and the Independent Reviewing Officer is responsible for ensuring that partners are held to account.