Establishing workable processes

The centrality of effective processes for safeguarding has been embedded in UK child protection practice since the 1970s. The various iterations of Working Together guidance have formed the basis for inter-agency working to safeguard children and are reflected in local protocols and procedures. Where local protocols are clear, they can support

effective inter-agency working, however, they also have the potential to be ambiguous or contradictory, or to present barriers to professional working. It is essential therefore that any guidelines or protocols are coordinated, kept up to date and based on the best available evidence, and are developed and made available in ways that support professionals in their role.

8.3.1 Being bound by structures or processes

Bureaucratic processes are implemented with the intention of forming a robust and replicable mechanism around professionals and families to ensure best practices are upheld, as in the following case:

“The assessment carried out by the probation service was necessarily determined by the focus of the service on reducing the risk of reoffending. Assessments took place shortly after Mr B was released on licence and identified the factors that the probation officer believed to be likely to influence possible reoffending. Mr B was assessed as a high risk of reoffending and referred to the local multi-agency risk assessment panel (MAPPA). The probation supervisor commissioned additional assessments in relation to risks associated with mental health and substance misuse. All of these assessments were within the framework of probation responsibilities and correctly carried out.”

However, the rigidity of these processes may at times be incompatible with the realities of how services operate and are accessed, as demonstrated by the following case where the constraints on a mother registering with a GP surgery led to her antenatal support being compromised:

“When Mother was interviewed as part of this review she said she thought that the [Area 1] Midwives would contact [Area 2] Midwives and they would contact her in due course. Mother told the Review that she had not known how to contact the [Area 2] Community Midwives because when she had tried to register with a number of Doctor’s surgeries she said she had been told she could not do so because she did not have a permanent address.”

To a degree, rigid procedures, combined with high workloads and limited resources can sometimes create a disincentive for acting outside of the usual processes. This was seen in the case of a six year old child who died as a result of neglect in which a lack of

response to appointments led to a mother and her children being removed from a GP’s list, contributing to even greater invisibility and vulnerability of the children:

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“The GP practice had removed [the mother] and the children from the register… due to her persistent lack of response to appointments to have the children seen and to have the opportunity for routine care such as immunisations. If [the child] had for example been seen by a GP prior to being removed from the register it would of course have been an opportunity for evidence about the extent of

malnourishment that contributed to the death... It is not a requirement for a GP to see a child before they are removed from the register.”

Over-reliance on these systems with the additional factor of human error can lead to the needs of families remaining unmet:

“Mother was only 17 years of age a referral should have been made to the Teenage Midwifery service as part of routine ante natal care. A referral form was completed but was not sent because the midwife forgot to obtain the mother’s signature and hence the mother did not receive the benefit of this service.” Use of Assessment tools

In the context of assessment various tools are used as a means of standardising information gathering, the interpretation of cases, and informing subsequent practice. However, variation in the effectiveness, value, and types of assessment tools available can be detrimental to their overall use. Rather than being led by the benefit and learning to be gained from using assessment tools, professionals can instead be led by the need to complete the task at hand. The following case illustrates how the execution of the assessment was considered to be the goal in itself:

“The majority of agencies involved in the review relied on some form of assessment tool in their day to day work with clients. It was clear from

conversations with the Case Group that issues regarding capacity mean people often complete these tools hastily and use them as a recording tool as opposed to an aid to understanding and analysing risk.”

Learning Points

 Guidelines and procedures can be useful tools for supporting professionals in working effectively. However, they need to be seen as tools to facilitate good working, and not as constraints or barriers to professional practice.

 This may require flexibility on the part of professionals responding

appropriately to the needs of children and families: professionals need to consider how they can best support the family and protect the child, not just how to follow the rules.

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8.3.2 Lack of clarity of processes

The efficacy of guidelines and procedures relies upon their integration into the target setting, the education and awareness of those involved, and the speedy identification of any unforeseen gaps.

Professionals’ familiarity and comfort using processes is integral to their effectiveness. In the following case, the issues arising from failing to use the correct reporting system were compounded by limited supervision and oversight:

“To compound this the junior member of staff appeared not to have fully understood the request for a social services referral and instead completed a concern and vulnerability form. Within the hospital this form has been amalgamated with the CAF [Common Assessment Framework] for ease of completion and to avoid duplication, in this instance it is unclear why this form was used and what happened to the form itself… This may have been a result of confusion in relation to the current hospital processes that had recently changed and a lack of knowledge of processes for flagging concerns to senior staff. Senior midwifery overview of practice appears to have been absent and if present is likely to have identified the confusion and flagged the need to escalate concerns.”

Additionally, constant evaluation of whether procedures are used effectively and remain fit for purpose is required. In the following case, the procedures failed to meet the required need, were used inconsistently, and betrayed large and systemic gaps in function, both in relation to recording information, and policies around missed appointments:

“The health agency chronologies and narratives highlighted the problems of health professionals not having common policies or systems of patient recording; this is a national problem. There was no sense of a shared view that could identify patterns of missed appointments, inconsistencies and risk.

The Child missed appointments with the GP, the Orthoptist, the Paediatric Consultant [Trust 1] and the Paediatric Respiratory Consultant [Trust 2]. Each of these component parts of the health service have their own policy and practice covering missed appointments. The missed appointment policies were not

consistently applied sometimes as a result of clinical judgement and sometimes as a result of error.”

The following case demonstrates the failure to abide by accepted clinical guidelines. In this case, a pregnant mother and her baby were at high risk of vitamin D deficiency. The infant subsequently died as a consequence of rickets in a context of extreme neglect. While guidance on vitamin D supplementation in pregnancy has been in place for a long time, in this case it appeared not to have been followed. This may have been due to lack

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of professional awareness or professional error. There was no deeper consideration in the SCR as to why the guidance wasn’t followed, but it raises issues around the

effectiveness, clarity and accessibility of national guidance:

“The GP practice failed to address [the mother’s] vegan diet and its impact on either her or her child's health… NICE guidance in 2008 noted the increasing prevalence of rickets and the need for vitamin D supplements in certain cases and recommends routine assessment within antenatal care for vitamin D supplements. The government issued guidance in relation to Vitamin D supplements in

pregnancy in 2012 and it can only be assumed that this practice were unaware of this guidance. However this is a common feature in this SCR as no other health practitioners appeared to proactively follow this guidance/recommendations.” One further issue in relation to clarity relates to the fragmentation caused by having multiple steps within any one pathway. This was highlighted in one SCR in which

potentially unhelpful stages were built into a referral pathway within an ambulance trust: “Given that [the Ambulance Service] is a regional service, the process for making referrals at the time involved any referral from an ambulance crew being faxed to a central Emergency Control Centre, who would then fax it on to the relevant

Children’s Services department … the service … recognised that there was a potential weakness in their systems for managing referrals.”

Learning Points

 Simplicity and clarity in published guidelines can help ensure that professionals are enabled to work effectively to safeguard children.

 Consideration needs to be given as to why, where national guidance is available, it is not regularly followed. This may require further research into professional behaviours.

8.3.3 Access to records

One of the major issues faced by professionals working within complex organisations or agencies is that of having access to appropriate information. This issue was flagged up within a number of different agencies in the SCRs. It is perhaps particularly marked within health, where many different organisations go to make up the local health economy. In such situations, different teams within an organisation may hold different records, let alone different organisations within the same agency.

In many areas, steps have been taken to overcome these barriers by unifying case records, moving to electronic recording systems, or establishing protocols for sharing information. In one SCR, the issue was particularly pertinent in relation to the armed forces, in which the SCR identified that there was no automatic system for medical

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records to be shared with civilian primary care services once a soldier leaves the army. In this case, in which an ex-soldier killed his two children in an extended filicide-suicide, the information about his mental health history could have had an impact on the GP’s

management of the case:

“It was confirmed that when a soldier leaves the service for whatever reason, he gets a final medical and at that medical he is provided with a full print off of his service medical records that he can take to a civilian GP in order to register. He is also provided with the address and details of who the civilian GP needs to write to (Army Personnel Centre) in order to obtain the actual medical records. The service person himself must give consent for the Medical records to be released to the GP for data protection reasons. The Civilian GP has no automatic right to that

information.”