The committee to receive the Gloucestershire Safeguarding Children Board Annual Report 2018/19.
34.1 Serious Case Review ‘James’
34.1.1 Serious Case Review (SCR) 0116 ‘James’ had been published the previous day and it was agreed that Kevin Crompton, Interim Chair of the Gloucestershire Safeguarding Children Board (GSCB), would present the findings of this SCR to the committee. Mr Crompton informed the committee that the convention with SCRs was to anonymise the individual to protect the remaining relatives; the BBC and other local media had chosen not to do so.
34.1.2 Mr Crompton informed members that ‘James’ died in awful circumstances. The SCR process was not about apportioning blame but to identify learning opportunities. The events that led to ‘James’ death took place three years ago; quite a lot of the practice at that time related to how partners were managing ‘James’ sibling. ‘James’ mother was in denial about the domestic abuse that she was experiencing, and lied about her drug use. All safeguarding partners needed to learn from this case.
34.1.3 The committee was informed that the report identified that there had been a lack of professional curiosity and challenge; questions had not been asked when the opportunity to do so had arisen. It was questioned whether this death could have been prevented. Mr Crompton stated that in his view the professionals involved could have called a strategy meeting to share information which would have meant they would have been better prepared/informed. He was, however, of the view that the mother would not have cooperated, and doubted whether the threshold would have been met for a care order. He reflected that the professionals involved should have been more aware of the risks. Whilst the professionals involved could have managed the case better and to some extent some aspects could have been predictable, he did not think that this death was preventable.
34.1.4 There was a shared view that yet again information sharing had proved a barrier, and members were frustrated that this continued to be a cause for concern. Some members were of the view that the concerns should have been spotted. The committee was clear that we must get this right. Mr Crompton accepted members’ points. He stated that information sharing had improved so it was disappointing that this had been such a significant factor in this case.
34.1.5 Chris Spencer, Director of Children’s Services, informed the meeting that he did not disagree with Mr Crompton’s statements. He also informed members that when he had joined the council this report had been in draft form. The report had been redrafted as a result of intervention from himself and Mr Crompton as they had been of the view that it was not sufficiently independent. This had contributed to the delay in publication. He also stated that we were already in the position where we had addressed the shortcomings identified in the report.
34.1.6 A committee member commented that everyone used different systems which made it hard to share data. They also questioned how often a strategy meeting was called by someone other than a social worker. In response Andy Dempsey, Director of Partnerships and Strategy, explained that this data was not available as irrespective of who asked for the strategy meeting as it would always be the social worker who would open the case online. He was clear that the views of partners would heavily influence the decision to call a strategy meeting. The committee was also informed that Gloucestershire has a higher proportion of strategy discussions compared to other areas; we needed to be more consistent in our approach and to not be too unnecessarily intrusive in people’s lives.
34.1.7 In response to a question it was explained that the MASH (Multi Agency Safeguarding Hub) was committed to giving feedback when concerns were reported, but Mr Dempsey acknowledged that this did not always happen. Members reiterated concerns regarding data sharing with one member stating that in their experience when discussing cases it was never possible to speak to the same person twice, and that it was necessary to put everything in writing. A member commented that it was important that there was a clear understanding of what data could be shared.
34.1.8 It was explained that the MASH received over 200 contacts per month, and there was complexity and challenge involved in the work to respond to these cases. Mr Crompton reminded the committee that we rarely celebrated the many good cases, and reinforced that the children’s safeguarding system in the UK was the best in the world.
34.1.9 Mr Spencer informed the committee that he could not guarantee that this would not happen again. Whilst accepting improvement was necessary it was important not to lose sight of the fact that the true culprits were the perpetrators. Mr Crompton explained that with regard to information sharing there were often difficulties around consent, particularly in the early stages. In this case the parents did everything they could to avoid giving consent. However, new guidance indicated that refusal of consent could be an indication that there were concerns that needed to be acted on. His philosophy was ‘dare to share’ and felt that professionals needed to take this approach. Members agreed.
34.1.10The committee agreed that social work was a difficult profession and that we should applaud those people that do this job. It was questioned whether the wider group of adults that came into contact with young people within school settings knew how to raise concerns. Mr Crompton explained that the volume of contacts received by the MASH seemed to indicate that people did know. He also explained that every teacher and employee at a school should know who their safeguarding lead was. He emphasised that safeguarding was everyone’s responsibility.
34.1.11In response to questions it was explained that given the level of concealment by the mother it was difficult to see how a third party could have guessed that domestic abuse was a factor in this case, particularly as the elder sibling was thriving at the time. This chimed with the national debate on domestic abuse.
34.1.12The committee agreed that it was important for all members of council as corporate parents to be fully informed on the issues that arose through the SCRs. It was agreed that the Chair and Vice Chair would take this forward with Mr Crompton.
ACTION: Chair/Vice Chair
34.2 Annual Report
34.2.1 Kevin Crompton, Interim Chair GSCB, discussed the process that had led to the changes in safeguarding governance. The work of the GSCB during the last 12 months had been dominated by the transition to the new governance arrangements.
34.2.2 As of 15 July 2019 the GSCB would no longer exist. However there remained a residual function relating to the outstanding SCRs; these must be completed and published by July 2020. In response to questions it was explained that the SCRs would be published as soon as we were able to, but for some criminal proceedings were involved; each case had its own complications. There was also a shortage of SCR authors nationally. It was also explained that there was a national panel that reviewed SCRs.
34.2.3 Mr Crompton informed the committee that he had no concerns with regard to the transition process. The Business Unit that had supported the GSCB would now support the new arrangements.
34.2.4 It was commented that the use of the category ‘other’ on the charts was not helpful, and questioned whether this data could be broken down further. It was explained that the allegations management system was being replaced and in future this this detail would be available. At present it would require a manual trawl through the data. The committee was assured that the Local Authority Designated Officer (LADO) system in Gloucestershire was very effective.
34.2.5 In response to questions relating to the funding arrangements for children’s safeguarding Mr Spencer explained that currently the majority of the funding came from the council. However under the new arrangements there was equal responsibility across safeguarding partners which in his view meant that there should be equal funding; the Police and Health were talking about equitable funding. This would be discussed at the Safeguarding Executive. He was of the view that the base budget was sufficient. A particular pressure related to SCRs as there was a high daily rate for report authors.
34.2.6 It was requested that a contextualised report on safeguarding matters be received at a future committee meeting.
ACTION: Andrea Clarke