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"It's everyone's job to make sure I'm alright"
Report of the Child Protection Audit and Review

Chapter 3: The case audit: Protecting children

Raising concerns about a child
Initial enquiry and investigation
Recording of investigations
Initial assessments
Full assessments
Case conferences and reviews
Referral to the Reporter
Key Messages

3.1 The previous chapter clearly sets out the extent of the challenge for practitioners working to protect children and to improve their lives. Few of the children were known to only one agency and we were, therefore, able to consider individual and multi-agency responses to these complex situations.

Raising concerns about a child

3.2 In very few of the 188 cases were concerns about a child's welfare minimal, or the result of a 'one-off' or trivial incident. Even those cases (34) on the health visitor's cause for concern list were generally considered to be 'in need' and some were on the Child Protection Register.

3.3 Most of the children had been known to agencies as in need of assistance for a considerable time or had been previously referred for help on one or more occasion. The needs of the children were generally wider than just the need for protection due to a single incident. A 'referral' from one agency to another was sometimes an 'exchange of information', particularly when children were well known to both agencies. In these circumstances it was not always possible to clearly identify when the first significant concern about a child emerged.

3.4 As we will see in Chapter 6, very few children contact statutory agencies when they need help. Only seven of the 188 children in this sample self-referred to any agency:

• one girl reported sexual abuse to school;
• one girl reported physical abuse to school;
• four boys reported physical abuse to school but it was not clear whether the reporting was deliberate, or by way of explanation of other difficulties; and
• one girl phoned social work to say she did not want to go home as her parents had been drinking alcohol for a few days.

3.5 Most abuse was identified by third parties, normally health, education or the police, but others such as housing departments, Women's Aid or ChildLine also made referrals. Referrals rarely came from other agencies or organisations which are in regular contact with children or adults who might harm them. There were no referrals, for example, from youth clubs/ associations, sports or leisure clubs, churches, drug misuse agencies or organisations working with parents. In many cases relatives or neighbours contacted social work. A neighbour e-mailed a social work department about her concern over a child's failure to thrive and hostel residents raised concerns about the way other residents cared for their children. In one case a member of the public informed the police he had seen children playing in the bedroom of a single man. The man subsequently turned out to be a sex offender.

3.6 Where a member of the public or another agency raises a concern or where there are a number of smaller events or incidents that add up to a significant concern about a child's welfare, professionals consider whether they need to follow their local agency child protection guidance and formally refer the matter to social work services or the police. Child Protection guidance encourages internal agency discussion prior to referral. We found, however, that many health professionals did not know who their lead officer for reference was, and in schools, there were instances where the headteacher's absence from the premises resulted in delay in referring a child until his or her return.

3.7 Medical staff did not always make the necessary checks with other medical records to establish if an injury was part of a pattern which might indicate it was non-accidental.

3.8 Some health visitors and headteachers were reluctant to jeopardise relationships with a family by passing on their concerns to another agency. In a few cases this resulted in information not being shared promptly.

3.9 Some referrals were presented clearly and with good information but many referrals to social work were made by telephone and were not always followed up in writing as agency guidance generally stipulates.

3.10 Incidents coming to the attention of the police were referred promptly to both social work and the Reporter.

3.11 Some health visitors and education staff thought that their referrals to social work were not taken seriously enough. There were a number of reasons for this:

• a false expectation that an informal phone discussion would result in formal action being taken;
• single incidents were referred, when the real issue for the referrer was the cumulative effect over time;
• a lack of physical evidence of abuse; or
• a lack of detailed recording of concerns by the referrer.

3.12 There was a general perception by all agencies that it was social work's responsibility to take the lead in protecting children. There were few exceptions to this and even where there were it was rarely on the first occasion that another agency took independent action.

3.13 Most education authorities had procedures whereby all formal referrals to social work were automatically copied to the Reporter. In most areas the police had a policy of routinely referring to both social work and the Reporter every child present in the house during a domestic abuse incident. We were told by other agencies, particularly Reporters, that this resulted in a huge increase in referrals, mostly unaccompanied by evidence of need or risk.

3.14 Good practice in the recognition and referral of abuse was found when:

• all professionals working with children could identify signs of abuse and neglect and knew how to respond;
• referring agencies produced a written referal detailing the circumstances, behavours or incidents of concern; and
• social work and the police responded promptly to concerns.

Initial enquiry and investigation

3.15 When social work or the police receive a referral they must consider:

• the needs of the child;
• whether a referral should be made to the Reporter;
• if particular child protection measures should be taken; and
• if there should be a criminal investigation or prosecution.

3.16 In order to make decisions about how to proceed, further initial enquiries may be necessary. In some cases enquiries were not sufficiently extensive. In many interviews we were told that agency records and the Child Protection Register were consulted at the start of each investigation or enquiry, yet this was often not recorded on the files. We also found one case where a man's criminal convictions were not checked by police until after a case conference. Medical practitioners did not always seek the full medical history of or background information about children who presented with an injury. A number of police investigations did not involve extensive interviewing of family members and rarely involved the interviewing of neighbours, even in those cases where neighbours had first raised the concern. The police did not always take DNA samples in serious cases from alleged abusers as guidance indicates.

3.17 We were also concerned about the narrow focus of enquiries. In most cases where there was a clearly identified incident of abuse, such as an assault or allegations of sexual abuse, the focus of the early work by police and social work was on establishing if the case was one of 'child protection' and if an offence had been committed. This required obtaining factual information or evidence about injuries and circumstances of the incident. This emphasis on evidence gathering sometimes led to the needs, particularly health needs, of the child, being a secondary consideration. Medicals were usually requested for 'evidential' rather than health or welfare purposes. Though there would have been good health reasons for doing so, police or social work did not initiate medical assessments or examinations as part of their enquiries where:

• a child had been hit so hard in the eye that his head 'ricocheted back';
• a child, who was exhibiting sexualised behaviour complained of a 'sore bum' for nine months;
• there were regular reports of hungry children; and
• children were not receiving health care, including attention to hearing, sight and dental problems.

3.18 In only one area was there a procedure for routine discussions with education during enquiries. In some areas routine 'initial referral discussions' held jointly with health, the police and social work took place at an early stage of investigations or enquiries but this was not the norm across the country. Where we saw examples of good multi-agency approaches they had a positive impact on planning future work.

3.19 Where medical opinion had been sought, social work and the police were highly dependent upon that opinion as to the cause of injuries or symptoms. In some of these cases, an ambivalent medical opinion was cited by police and social work as preventing them from taking action to protect the child.

3.20 In three cases, where there were serious concerns about the current welfare of children in the family, previous children of one of the parents had died. In each case the medical opinion had been that there was no evidence to indicate that the deaths were suspicious. In one case (which we could not consider in detail because proceedings were ongoing) a previous child of the father had died. In another case the father of a child who died had had two previous children, by different women, who had also died. The cause of both deaths had been recorded as Sudden Iinfant Death Syndrome. In the third case a child's sibling had died and the death was recorded as SIDS. Previous deaths of children in a family in combination with current concerns about children's welfare heightened concern. But professionals, particularly social work, felt unable to take protective action as a diagnosis of SIDs implied that no concerns were evident in previous care. Many professionals thought that more in-depth enquiries into the circumstances of some children's deaths may reveal parenting practices that should inform future child care decisions.

3.21 Whilst joint planning of investigations or enquiries was a feature of good practice, we did not find that Joint Police/Social Work Units for child protection necessarily resulted in significantly better handling of cases.

3.22 Occasionally, the effectiveness of an investigation was hampered by lack of equipment, or lack of practitioners experienced in the use of specialist equipment. In some cases, children had to be driven considerable distances for a medical examination. In another case a child's interview was not properly recorded due to broken equipment.

3.23 In a few cases, there were significant delays in conducting investigations when children moved across police division boundaries or across local authority boundaries. In such cases the child's needs were lost sight of in discussions over responsibilities.

3.24 In almost all the cases reviewed, the impact of the investigation on the child was at the forefront of professionals' thinking. Investigations were conducted sensitively and at the pace of the child. If necessary, interviews were suspended if a child became upset. Only rarely were children required to return for further interviews. Agencies ensured that, where possible, duplication was minimised. We concluded that the experience for most of the children interviewed had been as sensitively handled as possible given the nature of the complaints.

3.25 There were particular problems if the children had significant learning and/or communication difficulties. One girl's complaint to the police was not proceeded with on the basis of her potential 'unreliability' as a witness. In these cases, specialist resources could have been employed to enable children to express themselves better, to gather additional evidence or to provide an expert assessment of evidence reliability, but we did not see any examples of this.

3.26 Effective investigations and enquiries were characterised by:

• full gathering of information from all relevant sources;
• police investigating thoroughly, for example, taking DNA samples and searching for evidence to corroborate the accounts of children, parents and suspects;
• doctors seeking full medical information when examining the presenting injury, particularly previous accident and emergency visits, and taking account of social history from all sources in drawing conclusions;
• social workers seeking and taking account of the information held by other agencies;
• sensitive interviewing of children and attention to their needs; and
• using medical examinations to identify health care needs - not just evidence gathering.

Recording of investigations

3.27 Many investigations were poorly recorded across professions. Hospital accident and emergency records described injuries, but not the circumstances of their occurrence, and incidents tended to be considered in isolation. Social work files contained details of the processes undertaken, but often did not contain investigation details or copies of witness statements. Most agency records summarised concerns about children rather than providing the detail needed for any future reopening of the case or future investigations. Some Reporters' files, in accordance with agency policy, were 'weeded' to the point that essential information was missing when a new concern arose. Such weaknesses made it difficult for practitioners to recognise patterns of incidents.

3.28 From the initial identification of a child protection concern, professionals working with children had to make assessments about risks and needs. There were some positive examples of good initial assessments. Generally police and social work had access to information to help them make an initial assessment. Medical practitioners, however, particularly those in adult accident and emergency units, frequently had insufficient information on which to make a sound initial assessment, and were unaware of other relevant records. They sometimes only had access to their unit's records when key medical information concerning the child was contained in separate case notes covering child protection, child development, and mental health. In one area, up to 11 separate medical records were kept on children.

3.29 There were also problems when children, for one reason or another, had moved between authorities, with a consequent dispersal of records. In one instance an emotionally damaged boy had attended 12 schools in three authorities and two countries over six years. It was difficult to piece together an appropriately detailed picture of him and his history.

Full assessments

3.30 In many cases concerns about children were ongoing and each incident or event of concern in a child's life was one of many factors to be considered as part of an assessment.

3.31 Assessments of what immediate action needed to be taken were generally sound but longer-term assessment of the risks to children was poor. Some children were subject to a number of assessments since different disciplines, Hearings and meetings require different assessments of different aspects of children's lives. Most of the children in the sample were assessed prior to case conferences and Hearings and a number had other assessments for specialist services.

3.32 In complex cases, more comprehensive assessments were needed. In these cases, assessments usually required the collaboration of a number of professionals. This was not always forthcoming - an accident and emergency consultant refused to discuss with a child's social worker an incident of abuse requiring hospital treatment. Some schools did not keep social work informed of serious incidents involving children at risk - one boy's social worker only heard of an assault when he was asked to prepare a report for the Children's Hearing.

3.33 In the majority of cases, social work was the primary agency for assessing the needs of children at risk. In conducting assessments, social workers often had a wealth of relevant information but it was not always readily accessible. The case audit team found key information, sometimes going back 10 or 20 years, that was 'buried' in the files and had not been included in the assessment: in one case a man convicted of sexual offences against children in the 1960s was now caring for his grandchildren; in another a father of five children, about whom there were concerns about possible sexual abuse, had convictions for sex offences dating back to his youth. In many other cases we saw patterns of behaviour, usually related to poor parenting, being repeated with later children, sometimes a decade apart. Again the information was there but not readily accessible.

3.34 There were few examples of good, comprehensive written assessments. Weaknesses included:

• failure to consider the chronology and pattern of previous events;
• insufficient use of inter-agency information, especially health and education;
• insufficient attention to the role of at least one key person in the child's life - most commonly the mother's partner or ex-partner;
• lack of focus on the child - for example, the assessment of a child of drug-using parents focused on the parents' problems rather than the child's needs; and
• social workers not applying for an Assessment Order in the face of parents' non-co-operation.

3.35 Much information provided had to be treated with caution. Grandparents, understandably, often offered over-optimistic views regarding family progress. Professionals, such as drug misuse workers reported on clients' progress and stability. Whilst that progress might be viewed as adequate for adults, in some cases it was not sufficient for adults who were also parents.

3.36 In a number of cases, staffing changes resulted in long, drawn-out and inconclusive assessments.

3.37 Frequently there were inadequate assessments of the parents' ability to make use of the support on offer and to change quickly and sufficiently enough to offer their children an acceptable level of care. This was particularly an issue in relation to young children whose parents had already had older children taken into care. In these cases there was rarely a full assessment of:

• the parents' capacity to care and protect;
• the extent to which their circumstances or skills had improved for the better since the birth of previous children; and
• the steps the parents had taken to ensure a repetition might be avoided in the future.

3.38 In a number of cases the risks were clear, but social workers could not remove

children without clear evidence of current abuse.

3.39 In some cases, services such as home support, nursery or day care were provided without a full assessment of need - perhaps on the recommendation of a health visitor or school. In other cases, support was provided as a response to evident immediate need. In these cases support staff were able to monitor the child or family's progress but were not in a position to take the longer-term overview that was so badly needed.

3.40 It was often difficult to establish exactly what assessment had been undertaken, due to the absence of clear, well-focused records. Assessments, but not necessarily full assessments, appeared in a variety of reports and, occasionally, assessments formed a part of the case record.

3.41 In those cases where we identified practice as being very good, clear planning to meet the child's short- and long-term needs was reflected in good written assessment records characterised by:

• well-structured assessment frameworks;
• clear details of the behaviour(s) or incident(s) of concern;
• a focus on the child's needs;
• a focus on the parent's ability to meet them; and
• action needed to reduce risk both in the short and long-term and to meet the wider needs of the child.

3.42 Additionally good assessment records clearly separated fact from opinion and were based on the most up-to-date knowledge about child abuse and neglect and best practice.

Case conferences and reviews

3.43 Once investigations or enquiries had been conducted and initial or full assessments completed, social work, sometimes in conjunction with other agencies, decided whether or not to hold a case conference. Social work based this decision on the level of risk faced by the child and whether the best way of protecting the child and addressing his/her needs was through multi-agency action. If this was the case they sought to place the child's name on the Child Protection Register, and to involve other agencies. A referral to the Reporter would also be considered if this had not happened already. Other agencies, however, saw placement on the register less in terms of the need for multi-agency work and more as a means of guaranteeing resources for the child, so there were often clear differences of opinion about the appropriateness of registration. Child protection registers were originally created to keep track of families moving from one area to another and this function seems to have been lost sight of.

3.44 The quality of case conferences, as evidenced by the minutes and plans deriving from them, was variable, as was attendance by agencies other than social work. Good structures for inter-agency case conferences and reviews proved very effective mechanisms for ensuring issues were identified, needs assessed and progress maintained. Where structures were less clear, the case audit found a number of recurring problems:

• lack of involvement of key personnel, including, on occasions, key members of the child's family;
• failure over a significant period of time to clearly assess needs;
• a lack of clarity as to whether the child's or the parents' needs took priority;
• lack of a clear plan of action;
• confusion between activity and progress; and
• uncertainty over the means of decision making which could give rise to serious resentment.

3.45 Good inter-agency attendance and co-operation at conferences helped ensure a full consideration of the needs of both children and parents and of the range of support options available. Relevant agencies did not always attend. Schools did not generally attend case conferences in school holidays and GPs rarely attended and were reluctant to share information. The amount of information drugs or mental health workers felt able to share varied and was sometimes dependent on agreements with patients. In one case a health visitor was not invited although a previous sibling had died from Sudden Infant Death Syndrome. In some areas, social work 'reviewing officers' chaired all case conferences and were able to retain an overview of the risks and needs of children.

3.46 Joint planning could be particularly useful in maintaining current support mechanisms, for example, within the extended family, or through the school, even where a decision was made to move a child from the immediate family.

3.47 There were difficulties when agencies with crucial information about children were in another area or, in some instances, different countries. We found that, generally, case conferences did not fully involve out of area agencies, and often were content to receive their views as reported by another contributor. In two cases foster carers provided comments on how children were doing in new schools in a new local authority area.

3.48 In some areas, voluntary and private organisations were not included in case conferences. In one instance this resulted in important information held by a private nursery being overlooked.

3.49 At case conferences, the views of the children themselves were often not fully considered, or heard only as presented through third parties because:

• children refused to become involved;
• they were reluctant to express views critical of their parents in their presence;
• they felt overwhelmed by the setting;
• children under secondary age were regularly excluded from case conferences, even where it was clear that they could give an informed view; or
• where several children of the same family were involved, the needs of different children were not considered separately, for example, in one family of three children, the oldest boy regarded any placement other than with his mother as an improvement, while his youngest sister pined to return home.

3.50 In one or two areas children were encouraged to write their views prior to the case conference or Children's Hearing, and in almost all instances this opportunity was well used by the young people concerned. This can be a very effective way of helping children express their views, especially if they have difficulty in doing so in a meeting. Parents attending a Children's Hearing have a right to all the information that is being presented to the Hearing and this may include written statements about a child's wishes and views. Children, in preparing statements for the Hearing may not be aware of this. Evidence, from discussions with young people, indicates that the provision of such information may increase the risks to the child if parents are angry with the views expressed or wish to silence them. In the 'messages to young people' study there was one example of a girl, whose father had been convicted of assaulting her, who was advised that her statement would not be made available to either her mother or father. The statement was given to her father prior to the Hearing (but not to her mother). She was very distressed and stated she would not confide her views to anyone again in the future.

3.51 Some families felt overwhelmed by case conferences. Arrangements to provide families with support for conferences were variable, as was practice in ensuring that they fully understood the outcomes of the meeting. Sometimes key players, such as grandparents, were omitted from the discussion.

3.52 Since case conferences are not statutory, any decisions they reach about agencies' intervention in families' lives, can only be implemented through one of three routes: voluntary co-operation, emergency powers or referral to the children's Reporter. Where parents refused to co-operate with the decisions of the case conference, agencies sometimes treated this as a cause for referral to the Reporter. Conversely, in some cases, parents were persuaded to agree to case conference decisions, or even to have their child looked after away from home on a voluntary basis, as a means of avoiding a referral to the Reporter.

3.53 Good practice in case conferencing was found when:

• case conferences were held timeously and the minutes of the conference were circulated promptly;
• all participants were clear about the purpose of the meeting, the process being followed, how decisions would be made and the conference recorded;
• all individuals and organisations with information to contribute attended and shared accurate information openly;
• both the discussion and the minutes distinguished between facts, inferences and assessments; and
• as far as possible children and parents were fully involved.

Referral to the Reporter

3.54 The purpose of the children's Hearing system is to consider the need for compulsory orders in relation to children, taking account of the child's welfare throughout his or her childhood. In many cases of child abuse and neglect the nature of the abuse or the level of parental co-operation may suggest the need to consider having a legal order to underpin work with the child and family. In two-thirds of the cases in the audit sample, where a referral was made to social work or the police about abuse or neglect, a referral was made also to the Reporter, although not always for child protection reasons and not always in relation to the same incident. The referral may have been made at the same time as a referral was made about an incident to social work or the police. Alternatively it may have been made following another incident at another time or following initial enquiries or a case conference. In some cases referrals were made later if concerns remained or if families did not co-operate with agencies.

3.55 Children's Hearings also deal with referrals unrelated to abuse and neglect, for example, offending and truancy. The audit sample included two cases of young men (aged 13 and 15 years) about whom there had been previous concerns about abuse and neglect, who were now attending a Hearing on offence grounds.

3.56 The reasons for referral to the Reporter and the Reporter's grounds for registration could and often did, differ from those used for registering children as being in need of protection (see figure 4). Different sets of procedures, reports and information were required for different purposes and meetings (Hearings, case conferences, looked after children and other review.

Figure 4: Different reasons for intervention

3.57 Because the Children's Hearings have to decide on the need for compulsory measures of care, the bases for their decisions are necessarily defined in law. Some of the problems the different demands create might be eased by a more standard approach to assessments, and by making more straightforward use of case conference information in preparing Children's Hearing reports.

3.58 Reporters can request any information they think is relevant on a child from social work, education or any other agency. Local authority social workers are generally expected to provide all the necessary information on which the Reporter or a Hearing can base decisions. They did not always do so, for example, they did not always provide information about the health and achievement of, or developmental milestones of very young children. On only one occasion did a Reporter seek additional information from a health visitor. Both health and education practitioners made referrals to the Reporter about abuse and neglect, but most did not feel able to make an independent referral without the explicit support of social work.

3.59 Where the Reporter decided action was necessary and the child was young, or where the child or parents disputed or did not understand the grounds for referral, the case was referred to the sheriff court for a proof Hearing. This occurs in 80% of care and protection cases. In these circumstances, the less formal approach of the Hearing was replaced by a more adversarial one. We were told by both social services and Reporters that this sometimes made parental co-operation more difficult to achieve.

3.60 Reporters generally operated within the timescales given for processing paper work or arranging Hearings, but there were often significant delays in decision making, some of which were beyond their control. In some cases delays were caused by late presentation of reports by social workers (schools invariably produced reports on time). In one area, the Reporter had a list of outstanding reports, some of which were more than a year overdue. Reporters particularly commented on the burden of referrals in respect of domestic abuse cases, the majority of which they thought required 'No Further Action'.

Key messages

• Most cases of child abuse are referred to agencies by third parties, very few children or adults self-refer.
• Enquiries and investigations are not always sufficiently extensive and investigations are often poorly recorded.
• Assessment of what immediate action needs to be taken is generally sound but longer-term assessment of the risks to children is poor.
• Good inter-agency attendance and co-operation at case conferences helps ensure a full consideration of the needs of children and their parents.
• Children and their families experience a number of hearings, assessments and enquiries.
• There can be many delays in the Hearings system.

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