1. Family M Published April 2018
Serious Case Review
Family M
Published April 2018
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2. Outline of case
5 siblings – aged 4, 6, 8, 10, 12 (at time of review period)
Historic concerns regarding neglect, emotional abuse, physical abuse and domestic abuse
Mr W found to have downloaded video images of children being sexually abused and sharing with others in chat rooms
MR W arrested, admitted offences and released on bail; with conditions not to have any unsupervised contact with children
Joint investigation started
Delay in reviewing images due to volume of serious police investigations at the time
Outlines details of case
Mr W was partner of mum and father to the two youngest siblings

3. Outline of case
Further assessment by children’s social care and Initial Child Protection Conference (ICPC) planned but then cancelled; case held at child in need (CiN)
Mother separated from Mr W
CiN plan ceased after 12 months, despite ongoing concerns about neglect and physical abuse
Various anonymous allegations that Mr W had been seen at the family home – not substantiated
Forensic examinations established that sexual images provided evidence that one of the children had been subject to sexual abuse (17 months after images first found)
Mr W convicted and substantial prison sentence imposed
Further information:
Acknowledged in the review that the ICPC should have gone ahead and the decision to cancel was not the right one – two agencies stated their disagreement with the cancellation of the conference but neither followed this up
Children are now living away from mum, either with their respective fathers or in care

4. Practice features of the case
Practitioners found it hard to challenge mum, in relation to a number of issues - for example mum said that she was treating persistent headlice in one of the children despite the evidence suggesting otherwise
Concerns about neglectful behaviour by mum were consistently raised however information often focused on the presenting issue rather than an analysis of the gaps in parental care and impact of this on the child
The interviews of the children were not well planned and did not involve relevant school staff who may have helped the children to feel able to “tell their story”; there was an overreliance on them disclosing
Further information:
Asking questions and seeking clarification of a parent is good practice and supports practitioners ability to retain a position of “respectful uncertainty”
When presenting information to social care there should be a clear analysis of risk and impact on the child; if not the information may not be picked up in the way it would be expected to and this can leave professionals feeling helpless and frustrated
This was a finding specific to this case. The structure of the interviews was not planned with relevant school staff who knew the children well and if they had also been present may have helped them to ‘tell their story’ by providing a more sensitive environment. The recording of the interviews was also not sufficient. WSCB are seeking assurance from Wiltshire Police and Children’s Social Care that current guidance for interviewing children includes good practice for interviews that take place outside of the ABE framework and that there are sufficient number of practitioners, across agencies, trained in appropriate interviewing techniques.

5. Multi-agency findings: Finding 1
The exponential increase in the number of men who view online child sexual abuse images is not matched by the development of knowledge of best professional practice leaving professionals uncertain how to respond and children at continued risk of harm.
For consideration…
How confident are you as a professional in understanding, assessing and responding to the risk from men who view online child sexual abuse images?
What would increase your confidence?
Key messages:
The act of downloading and possessing images of children being abused is not a passive activity. Watching children being abused by others is child abuse and should be appropriately challenged
The research is not clear about on whether downloading abusive images will lead to offenders sexually abusing children, but work by CEOP suggests that there is a clear correlation between downloading sexual abuse images and sexual offending against children; although a clear causal pathway cannot be established. The research suggests that it is important to assess the risk that each individual poses, with the presumption that each is a potential sexual abuser.
WSCB are sourcing best practice evidence and guidance for practitioners on online abuse, exploring opportunities for relevant training and encouraging wider discussion of risk of contact abuse by online offenders, informed by current research

6. Finding 2
2. Children need professionals to provide the best opportunity for them to be able to talk to professionals about any abuse they have experienced. The absence of a clear framework when these interviews take place outside of the established ABE process alongside the pressures to balance the requirements of evidence gathering with the need for child sensitive approaches can lead to inconsistency and unclear interview approaches.
For consideration…
What does your agency put in place to support children to talk about abuse? Do staff have necessary skills to help children communicate and be able to say if harm is occurring?
Are staff equipped to notice the behavioral signs that can indicate abuse? How do you know?
This was a finding specific to this case. The structure of the interviews was not planned with relevant school staff who knew the children well, and recording of them was not sufficient. WSCB are seeking assurance from Wiltshire Police and Children’s Social Care that current guidance for interviewing children includes good practice for interviews that take place outside of the ABE framework and that there are sufficient number of practitioners, across agencies, trained in appropriate interviewing techniques.
Not all staff will be involved in interviewing children however all practitioners should have the necessary skills and knowledge to identify behavioural signs and provide opportunities in which children may feel more able to ‘tell their story’.

7. Finding 3
3. Appropriate routine professional challenge and the use of escalation processes is insufficiently embedded in the multi-agency network in Wiltshire leaving differences in professional opinion unaddressed and causing feelings of “learned helplessness” which in turn makes resolution less likely. This undermines the safety and wellbeing of children and does not support action to address concerns.
For consideration…
How confident are you as a professional to challenge decisions made by other agencies which you feel are unsafe for a child or young person?
How do you know that staff within your agency are confident about professional challenge and having ‘difficult conversation’?
In this case concerns were held by professionals but not escalated or decisions were not sufficiently challenged ( e.g. the decision to cancel the ICPC was challenged by 2 agencies but not followed through to resolution).

8. Finding 4
4. There is a tendency for professionals to uncritically accept what parents tell them about their children in the mistaken belief that this is “working in partnership”, resulting in an inaccurate description of children’s needs and circumstances which are left unaddressed as a result.
For consideration…
Do you retain ‘respectful uncertainty’ or ‘healthy scepticism’ in your practice? How do you know? What does it look like in practice?
Key messages:
Asking questions and seeking explanation from parents is something to be valued; healthy challenge can provide assurance that the assessment of the situation is accurate. A high reliance by professionals on self-report by parents brings with it significant risks of proceeding on false information. Good information sharing, supervision and open discussion at key decision making meetings to ‘check and test’ information can be crucial in ensuring this does not happen.

9. Finding 5 For consideration…
5. The lack of an effective practice framework for working with neglect in Wiltshire has left professionals deskilled in their response and inconsistent in how they explicitly name child and adolescent “neglect”.
For consideration…
The assessment of neglect needs to be transparent and systematic and should consider both historical and current evidence. Do practitioners in your agency have the necessary skills and knowledge to support this?
Are the links between neglect and other forms of abuse well understood within your agency? How do you know?
WSCB will be introducing a neglect tool for practitioners shortly to assist with effective assessment and identification of neglect.
Chronologies are an essential tool in helping to identify patterns of neglect over time

10. Finding 6
6. Although there have been changes to the way in which Child in Need processes are delivered in Wiltshire there appears to be continued evidence that they lack the rigour and focus seen in child protection processes with the result that there is insufficient analysis of children’s needs. This can result in plans which are incident-led and not focused on addressing the concerns they were tasked with. In addition, there is insufficient care or thought given to the role and place of parents within the CIN meetings which has the capacity to undermine their effectiveness.
For consideration…
How does your agency monitor their contribution to the child in need process?
Is this contribution appropriate and sufficient?
WSCB have been undertaking a thematic review of CiN and will be setting out recommendations shortly.

11. Learning from SCR Family M
What is the learning for you as a practitioner?
What is the learning for your agency?
What is the learning for how you work with other agencies?
Questions to discuss and identify learning and any actions to be taken forward within your agency