1. Yvonne Onyeka Business Manager Bromley SCB LCPP in Bromley

2. Serious Case Reviews & Procedures 5 SCRs in 4 years 66 Recommendations 15 relating to procedures local / regional/ organisational. Chapter 5 of LCPP Children in specific circumstances (CISC)

3. SCRs & Procedures in Bromley Procedure AssessmentInformation Sharing Child C

4. Child D & Child B Long term neglect Several referrals to CSC Referral outcomes not always chased Parental mental health

5. Child D & Child B Note of one conversation with Child D. “Noted that Child D could not describe an evening meal this information does not appear to have been communicated to anyone” LCPP Information Sharing LCPP 3.3 & 3.4 Assessment 6.3.2- 6.3.4 - thorough assessment & viewpoint of the child. Confirm referrals in writing- all agencies. “instances of referral to Children’s Social Care, which are, effectively, lost by CSC but where this is not chased by the referring HV.” LCPP 6.5.5 All referrals from professionals should be confirmed in writing, by the referrer, within 48 hours. “HV3 clearly worked hard with this family but there is evidence from the service of an increasing lack of consistency and capacity to challenge the family.” LCPP 10.3 Unco-operative Parents & the impact of assessment of the child

6. Child D & Child B “referred them to the dieticians, but did not put this in the context of the safeguarding concerns. … This may have influenced her assessment that the children’s growth and diet was satisfactory. This illustrates the particular importance of consistency when sharing information in relation to complex families with multi-agency involvement. LCPP Chapter 3 Information Sharing. Chapter 6 Assessment “a referral was properly made from maternity services to CSC, in line with procedures for “surprise” births. We know that CSC have been unable to find their records of that referral … no action was taken by the Trust to determine its outcome. LCPP 6.5.4 and following All referrals from professionals should be confirmed in writing, by the referrer, within 48 hours. & ensure the referring agency understood what action was to be taken as a result of referral

7. Child C BSCB had concluded training with Barnardos on DV and the risk assessment matrix. A history of DV - several calls to the police. Notably a MERLIN Report was raised for unborn C. no further action taken by the CSC. LCPP advises consider assess in the case of DV & an unborn child or child under 1 Parents both with histories of depression & the mother self harm. - the parents Supplementary procedure risk assessment considers the increased risk. Further referrals to CSC after Child C was born, stating depression, self -harm, DV, head injury ( father) and the state of the family home. The parents were signposted to other services for parenting advice.

8. Child C Criteria for carry out Initial assessment were couple’s understanding of impact of DV on children. Domestic violence matrix in the pan London procedures not used. Thus many of the already known indicators of risk were absent LCPP Supplementary procedure on Domestic Violence & Risk Assessment Matrix. Section 47 should have been considered. The same for male and female perpetrators of DV. Parental mental health needs of both parents & other factors eg alcohol, dv & cognitive impairment The pan London procedures 5.32.1 state “Parental mental illness does not necessarily affect a child’s developmental needs, but it is essential to always assess its implications for every child in the family. Many children whose parents have mental ill health may be seen as children with additional needs

9. Child B(08) Baby 1 month old died – possible overlaying (sleeping on sofa with mum) Alcohol misuse (local procedure & LCPP cover parental substance misuse) and domestic violence (LCPP supplementary) Child protection plan on Child B, in a mother and baby placement. Other children in care. The importance of attendance and quality of reports to CP conference (Police CAIT & CP administrative process). Professional in all agencies – primary duty to safeguard & promote welfare of children.

10. Child B (08) Mother’s relationships characterised by domestic violence, chaotic lifestyle, drink, minor drugs, volatility. Several police MERLIN reports related to violence in family. Domestic Violence (supplementary procedure) (LCPP 5.12) Parental who misuse substances (LCPP 5.34). Affecting parents practical caring skills; perception attention to basic physical needs and supervision… Pre-birth conference took place. Several assessments requested none took place. No core assessment commenced / undertaken. Foster carer did not attend conference. Assessment LCPP Chapter 9.3. and 9.4 role of the lead social worker.

11. Child P 3 month old - harm due to parental mental illness (LCPP 5.32). Local procedure in place. Other children were in care, however, no pre-birth multi-agency planning (LCPP 6.4). Circumstances required a Section 47 assessment and concerns with the quality of the assessments (LCPP chapter 6.4 & 5.32.7) Effective collaborative working required. Joint visits for assessment. Adult mental health professionals must identify -service users who are pregnant, who are parents or who have regular access to children, whether they reside with children or not. Professionals should consider the needs of all children as part of their Care Programme Approach (CPA) assessments.Care Programme Approach

12. Questions What are the issues for Bromley? What should have happened? Would following the procedure prevent a child coming to harm? What happens when implementing the procedure is not clear cut?

13. www.bromleysafeguarding.org