A trio of serious case reviews has highlighted failures in children’s safeguarding at an under-pressure council.
The three reports, which uncovered both systemic flaws and individual poor practice, were published simultaneously last week by Norfolk safeguarding children’s board.
They deal with chronic sexual abuse by a father of his children; a baby who was killed at the hands of his father; and a young man with a history of harmful sexual behaviour who assaulted a teenager at a temporary accommodation scheme.
The reviews, which bring the total published in Norfolk since 2015 to 12, touch on areas flagged by Ofsted across the county council’s children’s services in successive ‘inadequate’ judgments, published in 2013 and 2015.
In January this year Norfolk council was found by Ofsted to have moved up to a ‘requires improvement’ grade overall – though inspectors voiced concern that the pace of change in services for children in need of help and protection was still too slow.
‘Wholly inadequate’ response
The first serious case review concerned a family – named as ‘Family U’ – known to children’s services since the mid-2000s. When one of the children – identified as ‘Sibling 2’ – was placed in foster care in 2015, she rapidly disclosed that she and three of her siblings had been sexually abused by their father.
As early as 2006 the father – whose mental health was poor and who had been abused by his own father – was accused by Sibling 2’s elder sister Sibling 1, then aged five, of making her perform sex acts as well as forcing her to drink washing up liquid.
The serious case review described the response by children’s services and the police at the time as appearing to be “wholly inadequate” and noted the father had later returned to the family home.
“Both the absence of any serious follow-up of the allegations of a sexual nature, and that the father simply returned to the home without any further assessment, would have been considered very poor practice at that time, as it would be today,” the review said.
Over the next few years a glut of agencies were involved with the family, with concerns including poor school attendance, chaotic conditions at home, including around sexual matters, and aggressive behaviour from some of the siblings. The children were subject to the common assessment framework (CAF) from 2011 but were not identified as meeting ‘child in need’ thresholds until 2013.
While foster care for Sibling 1 and Sibling 2 was discussed during 2014, decisions were delayed and placements for the two girls, then aged around 14 and 11 respectively, were not made until late 2015.
Problems ‘too slowly identified’
The serious case review found that “at the core” of the childrens’ experiences was the difficulty professionals and agencies had in getting a grip on what was happening within their family home.
Neglect, it added, was noted from an early stage, but its “chronic nature… and its implications for the children were too slowly identified and responded to”.
Professionals, the review found, were too ready to accept medical explanations advanced to explain the children’s challenging behaviour, rather than delving for other underlying causes.
“There is no doubt adults’ powerfully presented views of the children acted like a smokescreen, distracting professionals from other possible explanations,” it said.
The review uncovered a long chronology of sexual abuse indicators, but “no clear evidence” the possibility was being discussed in a multi-agency setting – despite concerns being raised about Sibling 1’s risks of child sexual exploitation (CSE).
“Where [professionals] did have concerns their attention became focused on other explanations [than what was going on within the family],” the review said. It went on to draw comparisons between the situation and recent research highlighting social workers’ lack of confidence in working around child sexual abuse.
Despite the complicating contextual factors, the serious case review said case drift was “absolutely central” to the outcomes faced by the children.
It found “considerable frustration” on the part of some professionals at perceived flip-flopping from social workers as to whether Sibling 1 and Sibling 2 should be moved into foster placements. “[Professionals] described their disbelief in one meeting when a decision to remove all four children was reversed, apparently in order to allow the mother to attend counselling,” it said.
At another juncture it found officers from a housing-based family support unit had terminated their work, feeling they were doing the jobs of social workers and that children’s services needed to be prodded into being more proactive.
But the review also found social workers’ ability to make progress was “overwhelmingly” affected by staffing and caseload pressures, needlessly siloed teams, poor information systems and a blinkered strategic focus on reducing the numbers of children in care.
The former three factors were picked up in Ofsted’s 2013 inspection of child protection services, while the latter ironically was driven by a directive from inspectors that numbers were too high.
“Evidence to this review was that when cases were taken by staff to the panels which made the decisions about placing children in care, this would frequently result in them being asked instead to try further interventions,” the report said. “The result was not to build in constructive opportunities to create change in families, but to build in delay.”
Serious sexual assault
The second review, relating to the death of six-month-old ‘Child V’ in March 2016 following a head injury inflicted by his father, homed in on several similar areas of concern.
In the wake of an April 2013 allegation that Child V’s father had sexually assaulted his mother while under the influence of alcohol, a referral was made to Norfolk’s multi-agency safeguarding hub (MASH).
The incident, which was witnessed by Child V’s then 18-month-old sister Sibling V, was not – for reasons unclear – followed up on by the experienced social worker who reviewed it. Nor were other agencies informed as per protocols.
In 2014, following an attempt by the father to kill himself, an assessment noted “concerning aspects in relation to the parental relationship, including intense jealousy, alcohol and substance abuse and an apparent acceptance of previous sexual violence by Sibling V’s mother”.
Despite other indicators of abuse and coercive control, the case was stepped down as the mother was felt to be protecting Sibling V, who had suffered “no apparent physical or emotional harm”.
Reflecting on the case transfer, which was delayed, the serious case review noted some of the same unhelpful tiered structures between child protection and child in need teams picked up by the ‘Family U’ review.
“[The] delivery model… created unnecessary difficulties and/or delays particularly at the point of transfer,” it said. “This ‘step up and step down’ approach also meant families were subjected to a series of new social workers with an inevitable lack of continuity.”
Later, a social worker argued that the mother would be unable to protect herself or Sibling V should an abusive situation, which could happen “at any time”, arise, and that section 47 thresholds had been reached.
But she was overruled by a team manager, who was experienced but new to the county, and instead a programme of restorative work to improve the parental relationship was pursued. Children’s services were no longer involved at the time of Child V’s death.
The review raised concerns that the apparent disconnect between the two social workers’ opinions was not further explored. The need for better systems to support team relationships was a key ‘new learning’ element identified in the report, which in other areas closely paralleled an earlier review, also involving serious injury to an infant in the context of alcohol and domestic abuse.
‘Out of her depth’
The final case review also centred on the relationship between a worker, PA1, and an “out of her depth” team manager, TM2, within a poorly functioning team structure.
PA1 was an inexperienced personal advisor to a care leaver, YPA, who in June 2016 sexually assaulted ‘Child Z’, a 14-year-old who was living in temporary accommodation after he and his family were evicted.
A year earlier, Norfolk council restructured its services for looked-after children in the wake of a second ‘inadequate’ Ofsted judgment, creating a new care leavers’ team headed up by TM2, whose background was in child protection. Neither PA1 nor TM2 had been rigorously prepared for their roles, the review found.
Shortly before the restructure, YPA, who had exhibited harmful sexual behaviour while in residential care, experienced a work placement breakdown that led to him losing his home and support networks, plunging his life into relative chaos.
Yet a report prepared in November 2015 by PA1 concluded that YPA posed no risk either to himself or others. The case review questioned the evidential grounds for that conclusion, noting that PA1 and TM2 had received “no training in HSB risk management and planning, nor had they accessed any specialist services to inform their views and decisions”.
Balance of risk
In December 2015, YPA was arrested following allegations of sexual abuse made by another child, ‘Child B’. No referral was made to the MASH, nor were other multi-agency safeguarding procedures followed, meaning his future risk went unassessed.
Six months later, at a time when PA1 had gone off work sick, TM2 then failed to disclose to a housing options officer YPA’s bail conditions or the ongoing police investigation – seemingly to avoid breaching his confidentiality without consent. As a result he was housed in the same block as Child Z.
“It was not evident TM2 had considered the balance of risk between YPA’s limited rights to confidentiality and the imperative around the protection of vulnerable children and young people,” the review said. It went on to criticise TM2 – who was unavailable for interview – for her lack of effective management, but noted that this should be seen in the context of conditions at Norfolk council post-Ofsted inspection.
“Service transformation had taken place within the context of several changes of senior management within Norfolk children’s services, which had created a sense of discontinuity for staff,” the review said. “The care leaving team operated within this wider organisational backdrop.”
Among a series of recommendations, the review said Norfolk must maintain its focus on improvement to ensure the care leavers’ team was fit for purpose in future.
‘A department that wasn’t working’
Sara Tough, Norfolk’s director of children’s services since 2017, said practice had been “completely transformed” over the past two years and that the reviews “reflect a department that wasn’t working properly at the time”.
Tough accepted staff had not acted quickly enough in the cases of Family U and Child Z. “It is clear many frontline staff were doing their very best for these children but, at the time, were hindered by systems that were not working effectively,” she said.
She added that issues raised in the case of Child V, and by similar case reviews, had been addressed by a domestic abuse awareness training programme.
David Ashcroft, chairman of the Norfolk Safeguarding Children Board, said: “It is clear the multi-agency response in all three cases was not good enough and I apologise on behalf of all of the services that worked with these children and young people.”
He added: “As a board, we are confident services to children in the county have improved in the last two years and continue to improve. The learning from these three reviews is already being shared and we have acted on the recommendations.”