ISLE OF WIGHT SAFEGUARDING CHILDREN BOARD

RESPONSE TO THE Q FAMILY SERIOUS CASE REVIEW

Introduction
1.

The case was considered by the Isle of Wight Local Safeguarding Children Board
(IOWSCB) at its serious case review subgroup on 16 October 2013 under Regulation 5 of
the Local Safeguarding Children Board Regulations 2006. The subgroup found that this
case met the criteria for a serious case review and agreed the commissioning
arrangements in order to meet the requirements of such reviews as laid out in HM
Government Working Together to Safeguard Children, 2013

2.

Working Together 2013 allows LSCBs to use any learning model consistent with the
principles in the guidance, including systems based methodology. Alan Bedford an
independent safeguarding specialist, was commissioned as the lead reviewer to
complete the work using a systems-based methodology to ensure full participation by
the front line practitioners who had been involved with the family.

4.

As the case was so large, and covered nearly two decades, it was decided that it would
be an unnecessary use of agency resources to study the whole case in detail as in the
traditional model of SCRs. To think through a way forward, a scoping day was held,
chaired by the independent reviewer, with around 30 involved staff.

5.

The conclusion of the scoping day was to focus on themes of how the family impacted
on professional staff (and what could be done better with similar families in future) and
on some key turning points in the case, rather than the whole case history. The
independent reviewer worked with agency staff and documents to elaborate on these
areas of focus. The staff group was reconvened to consider the draft findings and
contributed to the learning and how things could be done better. In total 40 staff
contributed to the review process.

6.

To support the process there was a reference group of senior staff from involved
agencies which the reviewer used as a sounding board, and where necessary to
facilitate any stumbling blocks in the process. The SCR sub group quality assured the
final draft before presentation to the Board

7.

As part of the review the LSCB and each agency involved provided a report on what has
already been put in place as a result of their learning from this review, or has improved
since the events described. This can be found in Section 8 of the report whats better
now updates from agencies.

Lessons Learned
8.

Below are the recommendations from the report which the LSCB has considered. The
responses provided are the Boards collective view about how it has or will discharge its
responsibility for assuring the quality of child protection systems on the Isle of Wight.
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Recommendations have been clustered together to give a view of the IOWSCB where it
was felt appropriate to do so.
Recommendation 1: That in complex long term cases there is time to step back and reflect,
away from the heat of current crises
IOWSCB View
9.

Each agency will have a different definition of what constitutes a complex long term
case. IOWSCB recognises that it is important to share and acknowledge this differing
definition across all partners. This will enable and encourage an open dialogue and
practitioners will feel confident to raise their concerns and discuss these with their
colleagues. This is the foundation for creating the level of understanding required in
order to facilitate effective multi agency working.

10. The use of supervision, particularly reflective supervision, is accepted by IOWSCB as an

area requiring improvement in most agencies. Each agency recognises the need to
support staff and give time for supervision. Work is underway across he NHS trust to
enhance their existing supervision policy and childrens social care introduced a
revamped policy earlier in the year. IOWSCB will continue to promote a culture of
reflective practice as part of its on-going improvement journey.
IOWSCB Actions
11. An audit will be undertaken, led by the performance and quality assurance subgroup,
on the quality and regularity of supervision in all agencies, and the type of supervision
used. This will be completed by May 2015.
12. A resolution will be found to the on-going challenge of sharing information securely
across partners.
This will be led by the business management group and
recommendations presented to the February 2015 meeting of the IOWSCB.
13. The business unit will explore the feasibility of licensing all agencies to use the same
chronology software to facilitate a straightforward merging of information for complex
cases. This will be completed by January 2015.
14. The business management group will develop guidance for shared supervision of
practitioners in complex cases, similar to that used by the youth offending team. This
will be completed by March 2015.
15. The serious case review subgroup will review its processes and if necessary terms of
reference to ensure that it receives information about complex cases so that lessons
from good practice can be shared. This will be completed by January 2015.

Recommendation 2: That the impact of aggressive parents is understood, and staff are
supported with this so that they become resilient in face of the pressures
IOWSCB View
16. Intimidating and aggressive adults directly impact on the effectiveness of the
interventions and support being provided to our most vulnerable children and their
families. This can deflect practitioners away from their child centred approach as they
seek to find ways of coping with volatile situations. Staff need support to be resilient in
the face of aggression and to be actively encouraged to discuss the impact this is having
on both the children and themselves.
17. The re-introduction of multi-agency training on the Island, and specifically the
Sandstories workshops, is having a positive effect in equipping staff to deal with conflict
in a proactive way. A joint approach to working with hostile parents should be part of
the agreed multi-agency intervention plan. This will improve the sharing of knowledge
and understanding on individual cases and demonstrate a unified approach to the
family.
IOWSCB Actions
18. The performance and quality assurance subgroup will agree a mechanism for agencies
to alert each other about complaints received to improve information sharing and
responses to hostile families. This will be completed by February 2015.
19. The workforce development group will undertake an audit of single agency training
provided in relation to conflict management/dealing with hostile families. The group
will also ensure that this topic is included in the 2015/16 training plan. This will be
completed by April 2015.
Recommendation 3: That the value of history is high, that records are easily accessible,
and that assessments always take the full history into account.
Recommendation 7: That the resolution of a current problem does not prevent the
consideration of the long term wellbeing of the children.
Recommendation 8: That there are clear processes in place for multi-agency discussion of
chronic cases without necessarily a single trigger event
IOWSCB View
20. The context within which practitioners were working over the period of time covered is
accurately described in this report. However, much has changed on the Island,
particularly over the last 18 months since the Department for Education issued an
improvement direction following an inadequate Ofsted inspection. A key development
has been the introduction of Hants Direct and the multi-agency safeguarding hub
(MASH) in partnership with Hampshire Childrens Services. This has vastly improved the
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response for contacts made to and referrals received by childrens social care and
ensuring full history is taken into account to enable a long term view to be considered
when the assessment is undertaken.
21. The MASH makes sure there is a consistent approach to taking case history for all
referrals and enables the triangulation of information at a central point. Detailed
assessments are undertaken based on wider historical research and access to multiagency records. There is still some work to do to ensure there is consistent access to
adult services records and to address the challenges that the remote access to NHS
trust records can bring.
22. Improvements are continuing across all agencies around record keeping through the
sharing of best practice across schools, for example, and revising processes to allow
better sharing of information between midwives and GPs. All children open to
childrens social care have a plan of intervention which is regularly reviewed and
updated. Permanence planning is now included from the point of referral.
23. The meetings between health, social care and police to discuss chronic chases, or cases
where difficulties have arisen offer regular opportunities for multi-agency discussions
that are not triggered by any specific event.
IOWSCB Actions
24. The use of the same chronology software (see para 2.5) will facilitate and improve
information sharing in complex cases. This will be completed by the business unit by
January 2015.
25. The performance and quality assurance subgroup will review its audit tools to include
looking at the use of the resolving professional disagreements policy, the effectiveness
of information sharing and the use of historical intelligence in assessments. This will be
included in the 2015 audit plan.
Recommendation 4: That optimism in the face of changing evidence will sometimes
happen and needs to be addressed through good supervision and case review
IOWSCB View
26. A degree of optimism is always necessary when working with children and their
families. However, the risk is that staff become acclimatised to presenting risks and
optimism over-rides the need for a re-assessment. IOWSCB expects all partners to have
in place robust supervision policies which are regularly tested and reviewed. Childrens
social care undertake monthly audits to test how effectively their updated supervision
policy is being implemented.
27. There is evidence from recent multi-agency audits and learning lessons events that the
concept of professional challenge is becoming embedded. The joint meetings held with
health, social care and police senior managers allow the sharing of different views on
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cases and resolution to be achieved in complex, long terms cases. IOWSCB envisages
that the leadership demonstrated through these interactions will be replicated in every
tier of management across all agencies.
IOWSCB Actions
28. The performance and quality assurance subgroup will lead on the implementation of a
multi-agency peer assessment of supervision. This will test the use and quality of
supervision in all agencies and how practitioners are challenged where there is undue
optimism. This will be completed by September 2015.
Recommendation 5: That challenge is valued, and modelled by supervisors and managers
by both giving and receiving challenge well.
IOWSCB View
29. The culture of fear that was prevalent in agencies on the Island across most of the life of
this case is clearly evident throughout this serious case review. A change of culture and
attitude has been evolving over the last 12 months in the context of professional
respect and reflecting progressive practice. It is accepted that this will take time to fully
embed and the senior leaders who are members of IOWSCB will continue to contribute
to this important culture change by modelling this behaviour.
30. Quarterly partnership meetings take place involving the NHS trusts safeguarding team,
and senior managers from childrens social care and the police. This has and will
continue to support the use of challenge and the shift away from the belief of blame.
The implementation of IOWSCBs learning and improvement framework in December
2013 puts practitioners and their managers at the heart of identifying and
implementing system change.
IOWSCB Actions
31. IOWSCB will continue to support a culture of positive, professional challenge through
the content and learning outcomes of the multi-agency training that it commissions.
This will be reflected in its 2015 training plan.
32. Through its board development day IOWSCB will ensure strategic managers are
equipped to contribute to the continued creation of a culture of challenge and are able
to model appropriate behaviours. The development day will be held by March 2015.
33. The performance and quality assurance sub group will evidence and test individual
agency understanding, ownership and expectations around giving and receiving
challenge through its multi-agency audit plan and review of Section 11 compliance.

Recommendation 6: That the escalation procedures to resolve inter-professional and interagency disputes are understood and used.
IOWSCB View
34. There is evidence from recent multi-agency audits and learning lessons events that the
local escalation procedure (resolving professional disagreement policy) is well
embedded in practice. Single agency child protection processes reference this
procedure and are underpinned by revised internal processes. Staff attending the
learning lessons events are reminded about the policy and how to use it.
35. There is a clear recognition that multi agency approaches work best where there is
challenge as part of the dialogue. Partners understand the importance of hearing
different agency viewpoints and how this improves outcomes for children and young
people. Challenge and escalation are no longer perceived as a hostile action and staff
are pro-actively supported to stop being passive.
IOWSCB Actions
36. The performance and quality assurance subgroup will monitor the use and effectiveness
of the application of the local escalation procedure through its multi-agency audits and
the quarterly performance reports provided by each agency.

Recommendation 9: That, whilst valuing the contribution of parents to conferences, there

are clear processes in place to ensure staff can have some time to discuss their views
without the parents being present.
IOWSCB View
37. As part of the Ofsted improvement plan childrens social care have reverted to the
traditional style of case conferences. Parents and carers are and will continue to be an
essential part of creating and delivering the agreed intervention plan for the children.
This partnership approach is seen as being at the core of achieving effective and
sustainable outcomes from case conferences on the Isle of Wight.
38. The current case conference process allows for professionals to alert the chair in
advance if they wish to have a confidential discussion should they have concerns about
the impact that the information they will be sharing may have on the parents/carers
present. Agencies attending the conference can ask the conference chair to join this
discussion. Additionally, there are clear criteria in the 4LSCB safeguarding procedures
against which the conference chair would decide whether or not it is appropriate to
exclude either parent or carer from all or part of the conference.
IOWSCB Actions
39. The Hampshire and Isle of Wight workforce development group will, as part of the
refresh of the IOWSCB training plan, seek to include workshops or include in relevant
6

courses roles and responsibilities of practitioners before, during and after child
protection conferences and review conferences. This will be completed by April 2015.
40. Childrens social care will be asked to confirm and evidence that it has effective training
in place for its independent reviewing officers and conference chairs. This will be
monitored through the quarterly independent reviewing officer report that is to be
considered at the performance and quality assurance subgroup. This will be actioned
by March 2015.
41. Childrens social care will review the invitations sent out for conferences to ensure
agencies are reminded they can hold a confidential slot and that the conference chair
can be invited to join this. This will be actioned by January 2015.
Recommendation 10: That childrens social care would, other than in the most exceptional
circumstances, convene multi-agency meetings to discuss major concerns by other
agencies, and that the procedural requirement for the LSCB to rule on any dispute is
understood.
IOWSCB View
42.

All children open to childrens social care will have a multi-agency intervention plan
in place, and these are regularly reviewed. The current multi-agency safeguarding
procedures include the need to hold a strategy discussions and convene strategy
meetings where there are perceived or actual safeguarding concerns.

43.

Understanding of the term complex case does differ across agencies however the
introduction of locality hubs on the Island allows the opportunity for practitioners to
take cases there for discussion if they have any concerns. It will be important for the
locality hubs to be well attended and supported by all partners.

44.

Any organisation can convene a multi-agency meeting to discuss specific cases.

Childrens social care can attend where the case is not open to them to give advice
and share information but this should not be a route for referrals.

45.

Childrens social care will always convene a multi-agency meeting to discuss major
concerns raised by other agencies about open cases. The regular meetings between
childrens social care, health and police senior managers are used to discuss open
cases and agree appropriate courses of action. Additionally, the escalation policy is
well embedded and offers opportunities for appropriate professional challenge
where needed.

IOWSCB Actions
46.

IOWSCB to promote the new locality hub arrangements across all partners to ensure
there is a good understanding of what they are there to do, and that agencies
regularly attend and support the meetings. This will be actioned by February 2015
7

47.

The 4LSCB safeguarding procedures will be reviewed to make sure there is clarity
about who can convene meetings where there are concerns about complex cases.
This will be actioned by February 2015

Recommendation 11: That the contradictory evidence from children about an allegation or
disclosure does not lead to a failure to consider what is happening overall in the childrens
lives
Recommendation 12: That contradictory evidence is considered as a possible indicator of
abuse rather than something that disproves it
IOWSCB View
48.

Contradictory information should not be a reason to dismiss an investigation or case

but rather actually be expected. Hampshire Police ensure information and wider
evidence gathering is used to test, corroborate or dispel allegations so that an
informed, transparent and reliable picture is produced.

49.

Professionals are encouraged and expected to demonstrate appropriate professional

curiosity regarding the overall case/family circumstances. This will lead to holistic
analysis and assessment (including risks) and consider the reasons for contradictory
evidence where this occurs.

50.

The use of the child and family assessment in childrens social care and the
requirement for chronologies are a key component of the Islands improvement
journey. This will ensure there is a clear thinking, child centre approach for all cases.
Practitioners start with the premise of believing the child or young looking beyond
the current allegations and seeking to understand what lies beneath what is
currently happening.

51.

The multi-agency risk assessment conference (METRAC) is a good example of the

Police working in partnership with a range of agencies to assist in managing the risk
of highly vulnerable children and young people where there are no criminal
investigations or proceedings underway.

IOWSCB Actions
52.

The IOWSCB training offer for the childrens workforce on the Island is being
reviewed to include assessment and management of risk. Delivery of updated
training courses will commence in April 2015.

53.

The effectiveness of METRAC and its impact on improving outcomes for children and
young people will be tested through the performance and quality assurance multiagency audit programme in 2015.

Additional IOWSCB actions

54.

IOWSCB disseminated information from this case through a series of learning lessons
events held in October 2014. It will work with the Hampshire and Isle of Wight
workforce development group to ensure the lessons are incorporated into Level 2/3
IOWSCB endorsed safeguarding training and training for newly qualified social
workers.

55.

The above actions will form of an action plan which will be monitored by the
IOWSCB serious case review subgroup with exception reporting to each Board
meeting.

ACTIONS ARISING FROM RECOMMENDATIONS

Action

Lead

Target date

1.

An audit will be undertaken on the quality and Performance

and
regularity of supervision in all agencies, and the type quality
assurance
of supervision used.
subgroup

31 May 2015

2.

A resolution will be found to the on-going challenge Business

of sharing information securely across partners
management group

28 Feb 2015

3.

Explore the feasibility of licensing all agencies to use IOWSCB

the same chronology software to facilitate a unit
straightforward merging of information for complex
cases.

business

31 Jan 2015

4.

Develop guidance for shared supervision of IOWSCB

practitioners in complex cases, similar to that used unit
by the youth offending team

business

31 Mar 2015

5.

Review processes and if necessary terms of Serious case review

reference for the serious case review subgroup to subgroup
ensure that it receives information about complex
cases so that lessons from good practice can be
shared.

31 Jan 2015

6.

Agree a mechanism for agencies to alert each other Performance

and
about complaints received to improve information quality
assurance
sharing and responses to hostile families.
subgroup

28 Feb 2015

7.

Undertake an audit of single agency training Workforce

provided in relation to conflict management/dealing development group
with hostile families, and will also ensure this topic is
included in the 2015/16 training plan

30 Apr 2015

8.

Use same chronology software (see action number IOWSCB

3) to facilitate and improve information sharing in unit
complex cases.

business

31 Jan 2015

9.

Review audit tools to include looking at the use of Performance

and
the resolving professional disagreements policy, the quality
assurance
effectiveness of information sharing and the use of subgroup
historical intelligence in assessments

30 Apr 2015

10.

Implement a multi-agency peer assessment of

supervision. This will test the use and quality of
supervision in all agencies and how practitioners are
challenged where there is undue optimism.
Support a culture of positive, professional challenge
through the content and learning outcomes of the
multi-agency training that it commissions
Ensure strategic managers are equipped to
contribute to the continued creation of a culture of
challenge and are able to model appropriate
behaviours.

Performance
and
quality
assurance
subgroup

30 Sept 2015

Workforce
development group

30 Apr 2015

IOWSCB
members

28 Feb 2015

11.

12.

board

10

Action

Lead

Target date

13.

Performance
and
quality
assurance
subgroup

31 Dec 2015

Performance
and
quality
assurance
subgroup

31 Mar 2016

Workforce
development group

30 Apr 2015

Childrens social care

31 Mar 2015

Childrens social care

31 Jan 2015

IOWSCB board and

subgroups

28 Feb 2015

4LSCB
group

28 Feb 2015

14.

15.

16.

17.

18.

19.

20.

21.

Evidence and test individual agency understanding,

ownership and expectations around giving and
receiving challenge through its multi-agency audit
plan and review of Section 11 compliance
Monitor the use and effectiveness of the application
of the local escalation procedure through its multiagency audits and the quarterly performance
reports provided by each agency.
As part of the refresh of the IOWSCB training plan,
seek to include workshops or include in relevant
courses roles and responsibilities of practitioners
before, during and after child protection
conferences and review conferences.
Confirm and evidence that it has effective training in
place for its independent reviewing officers and
conference chairs. This will be monitored through
the quarterly independent reviewing officer report
that is to be considered at the performance and
quality assurance subgroup
Review the invitations sent out for conferences to
ensure agencies are reminded they can hold a
confidential slot and that the conference chair can
be invited to join this.
Promote the new locality hub arrangements across
all partners to ensure there is a good understanding
of what they are there to do, and that agencies
regularly attend and support the meetings
4LSCB safeguarding procedures to be reviewed to
make sure there is clarity about who can convene
meetings where there are concerns about complex
cases.
Review the IOWSCB training offer for the childrens
workforce on the Island to include assessment and
management of risk
Effectiveness of METRAC and its impact on
improving outcomes for children and young people
to be tested through the multi-agency audit
programme

procedures

Workforce
development group

30 Apr 2015

Performance
and
quality
assurance
subgroup

31 Mar 2016

11