By Sammie Jones-
A school attended by a teenager sectioned in 2015, was negligent in their decision to trust a social worker’s judgment, according to a serious case review (SCR). The decision not to intervene, following a referral it made two years earlier, was a grave mistake, the review found.
The review was one of three published by Sunderland Safeguarding Children’s Board (SSCB) last week. The review found that when the boy, code named as ‘Mark’ – was 12 years of age, school staff were concerned about his persistent drug use and deteriorating health and appearance. The raised alarm, but were carelessly dismissed. When Mark cane to the authorities attention that year, his escalating drug use, offending behavior, and periods of him going missing made professionals very concerned.
After being placed under a child protection plan, two years later, in 2015, professionals became more optimistic about the improvement of Mark’s well being, but in reality, his mental health continued to deteriorate. The main responsibility of the local safeguarding children’s board is to co-ordinate and quality assure the work of member agencies to safeguard children.
When severe errors are made that affect the well being of a child under such protection plan, a rigorous and objective assessment of what happened and why must be made.
REFERRAL
Despite a referral made to children’s services, a duty social worker apparently felt reassured Mark and his family were involved with drug services. They did confirm they were attending, and their failure made them very negligent, the report concludes.
The children were not attending any drugs services , and no further action was taken at the time, nor were follow-up referrals made. Mark came to the attention
The second of Sunderland’s SCRs concerned ‘Rachel’, another teenager, who was in 2015 accommodated by the local authority and made subject to a secure accommodation order , following concerns about her vulnerability, safety and wellbeing.
By 2015, Rachel was “associating with known sex offenders, misusing substances, and openly talking about risky sexual behaviours”. The SCR found that there was “no clear rationale” for not intervening sooner. Basically, the school and social services failed the child.
The SCR also flagged the national shortage of suitable secure placements for young people with complex needs, which a number of court cases have drawn attention to recently.
“This readiness of referring agencies to accept the decisions of social workers without being offered a clear rationale for their decision-making has emerged in other SCRs, both in Sunderland and elsewhere,” the review concluded. “If CSC [children’s social services] are noted ‘not to be concerned’, referring agencies can sometimes be reassured that ‘things can’t be that bad’.”
The review’s publication came after government statistics published at the start of November revealed that the proportion of initial social work assessments that fail to lead to further action is at its highest for six years.
The figures also shockingly showed that apart from the police, schools put forward the second highest number of referrals, in the year to 31 March 2017.
The period of review covering Mark’s case interestingly coincides with that of Sunderland children’s services being taken into special measures, after a 2015 ‘inadequate’ Ofsted inspection. Children’s services have now been transferred to an arms-length community interest company, Together for Children. This week, a report into an Ofsted monitoring visit to Together for Children found it was
“making sustained progress in improving services for its children and young people”.
Significant changes in the processes and systems of Sutherland have emerged from themes identified in the Report have already led to some. the report states that some have already been introduced, some are in the process of progress.
ADOLESCENT
The serious case review noted that no “significant contravention” by any professional could be identified as a critical factor in what happened to Mark in the lead-up to Mark’s sectioning. “There was evidence that many professionals with whom Mark came into contact were concerned about his welfare and safety, and sought to engage him or seek access to other services,” the report stated. Managers and practitioners in education , health and social care needed greater understanding of the interplay between adolescent choice and risk, especially in terms of substance misuse”. Shared assessment processes for vulnerable children not yet under a child protection plan was highlighted as an important lesson to learn and develop upon, with better management of concerns and referrals for adolescents suffering from mental health issues.
SYSTEMIC FAILINGS
The SCR also highlighted systemic local failings found by other reviews, and by Ofsted, around multi-agency working, professional curiosity. Harmful adolescent behavior was played down and considered as ‘just what teenagers do’.
From 2013, Mark’s use of drugs, including cannabis and MCAT (Mephedrone), escalated; some of his peers who normally used illegal substances with him, began expressing fears for his welfare to professionals. Concerns were additionally raised about his vulnerability to sexual exploitation . In an Ofsted 2015 report, it was identified as a weakness in the system.
Further revelations by the review that between May 2013 and January 2015, agencies had “at least” 14 contacts with children’s services relating to Mark.
“What is clear is that referrals and concerns, when they were raised with CSC, were viewed as individual episodes rather than emerging and escalating patterns of risk,” it said. “Consequently opportunities to view what was happening to Mark from a wider perspective were lost.”
Discussions with practitioners and managers revealed that “for some professionals, the interplay between adolescent choice and risk was not well understood nor carefully explored”, the review added. “ Information held by various agency records seemed to present Mark’s behaviour as ‘freely chosen, informed, and adult-equivalent’.”
Substance misuse
As well as tying in with the findings of previously published local SCRs, the review of Mark’s case noted several ‘new learning’ points of wider relevance for Sunderland.
One of these was around professionals’ apparent lack of knowledge about the different strengths of different substances, and the impacts it can have on troubled adolescence using these substances. This concern which has been exacerbated by the recent proliferation of so-called legal highs; also known as new psychoactive substances (NPS). Prior to the advent of synthetic cannabis, or ‘spice’, mephedrone was perhaps the most notorious of these.
“Mark’s continued use/progression from cannabis to the use of MCAT and other drugs did not appear to generate any additional concerns,” the review said. “Given the diversity of drug and alcohol use in young people, practitioners told the review team it is not always easy to decide what constitutes problematic use.”
The final serious case review concerned a family- ‘Family X’- known to multi-agency safeguarding services for more than 20 years.
“In late 2014 a large sibling group…were removed from their parental care because of a range of concerns for their welfare which indicated they had been exposed to, and were suffering from, chronic neglect.”
The SCR found that the case was illustrative of the “dissensus” around what constitutes neglect. “For Family X, the classification of neglect was generalised, and the records did not show how that neglect was manifested or experienced by the individual children,” it said. This means social workers did not even have a common understanding of what neglect really means, and what factors and circumstances come under it. Individual children were neglected, but social workers were not aware.
SSCB’s independent chair, Paul Ennals said that among other activities, the board was now
“leading a major piece of work to develop a framework to support practitioners working with highly vulnerable adolescents, especially where drug use is involved”.
“All the agencies in Sunderland involved with the three cases have reviewed their own practice and are acting on lessons learnt. Sunderland Safeguarding Children Board will monitor the delivery of those actions,”
The review said the publication of the three reviews meant Sunderland was “nearing the end” of a series of cases reviewing practice up to, and including 2015, the year of the council’s Ofsted report.