COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Implications of the Baby P Case
15 January 2009
Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Samuel Gardiner
Mrs Carmel Hanna
Mr John McCallister
Ms Claire McGill
Ms Sue Ramsey
Witnesses:
Mr Sean Holland )
Mr Fergal Bradley ) Department of Health, Social Services and Public Safety
Mr Martin Quinn
The Deputy Chairperson (Mrs O’Neill):
The next item of business is an evidence session on the implications of the recent Baby P case in Haringey. The Department has provided a briefing paper on the matter. I welcome Sean Holland, Chief Social Services Officer, Fergal Bradley from the childcare unit and Martin Quinn from the Office of Social Services.
Mr Sean Holland (Department of Health, Social Services and Public Safety):
On 3 August 2007, at approximately 11.30 am, a woman telephoned the London Ambulance Service. Attending paramedics took the apparently lifeless body of a 17-month-old child, whom members now know as Baby P, to the North Middlesex University Hospital. Despite ambulance and hospital staff’s efforts to revive him, he was pronounced dead at 12.10 pm. A post-mortem completed on 6 August cited a fracture of the spine as a provisional cause of death and revealed that he had sustained several other injuries that could only have been the result of experiencing prolonged, extreme physical abuse and neglect.
Subsequently, it emerged that Baby P was subject to a multi-agency child protection plan, and, at the time of his death, his name was held on the Haringey child protection register. Following investigations by police and social services, Baby P’s mother, her partner and a male lodger have all been convicted of charges associated with his death. A serious case review was convened by the Haringey local safeguarding children board to examine the various agencies’ involvement and the services provided to Baby P and his family.
Although the serious case review highlighted learning in a number of areas associated with the case, Ed Balls, Secretary of State for Children, Schools and Families, commissioned a joint area review into the death of Baby P and the findings of the case review. That review found that the original review was seriously deficient in a number of areas, and it raised serious concerns about safeguarding arrangements in Haringey that required immediate attention. Those concerns included leadership weaknesses, failure to comply with the requirements of the inquiry into the death of Victoria Climbié, a lack of independence and challenge on the part of the local safeguarding children board, and several issues of poor professional practice.
On 12 November, Ed Balls informed Parliament that he has also asked Lord Laming to prepare an urgent report on progress being made across England to implement effective arrangements for safeguarding children. Lord Laming is expected to report his findings in March 2009. It should be noted that the legislative and organisational framework for delivering child protection services in Northern Ireland differs significantly from those in England. However, we have already taken steps to identify any early learning from the Baby P case, and we will give detailed consideration to Lord Laming’s findings when they are published.
In Northern Ireland, we have also experienced the tragic deaths of children, which have been the subject of major reviews. In 2007, the Department of Health, Social Services and Public Safety (DHSSPS) published the findings of a major inspection into child protection services in Northern Ireland. That report, along with reviews into the cases to which I have referred, identified a number of weaknesses in the child protection arrangements here. In response to those weaknesses, the DHSSPS has launched a comprehensive programme of child protection services reform. The work has been taken forward on a multidisciplinary, multi-agency and regional basis, and it has been underpinned by significant new investments in front-line child protection services, family support services and services for children in care and for children leaving care.
At this stage in the reform and modernisation process, we have made significant progress. We have established gateway teams in each trust area operating on a common basis. We have developed a new assessment tool for children in Northern Ireland, which is being supported by an ongoing training programme, and we have funded a number of senior and principal practitioner posts across Northern Ireland. We have also introduced policies and standards for supervision, and we have introduced guidance on caseload weighting and management. Furthermore, we have funded change co-ordinator posts in each trust to ensure that those new tools, policies, standards and guidance are more than just documents and that they are translated into improvements in professional practice in the area of child protection.
Although we have made significant progress in the task of improving services to protect our children, it must be a continuous process. That is why Minister McGimpsey has committed to continuing to fund the reform programme for the next three years.
Improving the lives of children and, specifically, safeguarding them, is an incredibly difficult and complex area of work. To undertake that work in a risk-averse manner is neither feasible nor is it in the best interests of the children and young people who come into contact with our services. Inevitably, we all focus on cases where things go wrong, especially those that have the most tragic consequences. However, what is not always widely recognised are the achievements of social services and our partners in other agencies, particularly in the voluntary sector, in supporting families, improving lives and, ultimately, saving children’s lives. That work often goes unrecognised and uncelebrated.
We should also recognise that the one positive legacy of cases such as that of Baby P is that we learn the lessons of failure and improve our services accordingly. Let me be very clear: we can never guarantee absolutely that human error and weaknesses in systems will not play a part in the death of a child, but I believe that services and professional practice in that area of work are better than they have ever been in Northern Ireland. However, I believe that that is not enough, and we must strive continually to improve services further. I hope that the briefing paper that we have provided has given you details of how we are trying to undertake that work.
We will now be happy to take your questions.
The Deputy Chairperson:
Thank you very much for your presentation. We welcome the improvements that have been made, and, as you said, it is a continuous process. Have a certain number of areas been identified, and how far have you got in changing the things that need to be changed? Is it as simple as that?
Mr Holland:
It is as simple and as complicated as that. We identified a list of areas where improvements needed to be made, and we have been making progress in those areas. We identified those areas by looking at the recommendations in reviews into serious failings in cases like the Toner report and the O’Neill inquiry and also from the overview inspection report. Those identified failings in a number of areas, and that has informed our targeting of areas for improvement.
One of the most obvious and significant changes that we have made a priority is to establish gateway teams. A common problem that reviews have identified here, and which has certainly been the case in England, is that, although child-protection work is among the most difficult and complex work that exists, the most inexperienced social workers may be the ones who were engaged in that work. We have established gateway teams in every trust, and, in those teams, we have concentrated experienced workers who focus purely on the business of initial assessment and investigation. That increases the quality and standard of that investigative work.
That has been supported by the introduction of a new assessment tool. Another common feature of cases where things have tragically gone wrong has been a failure to undertake an adequate and proper assessment of the needs of families and of children and of the risks that might be present. Uniquely for a region of the UK, we have a single assessment tool, which is called understanding the needs of children in Northern Ireland (UNOCINI). That tool is being operated across Northern Ireland, and it means that a common, standard approach to assessment is taken. That has been a significant movement.
We have also made much progress in examining the management of cases, particularly through caseload weighting. Analysis of where deaths have occurred in child protection services in the past 30 years shows that individual workers have sometimes been beleaguered by dealing with a large number of cases that had a great level of complexity. Sometimes, their supervisors did not appreciate that, or work was not allocated appropriately across a team. A caseload-weighting system offers the opportunity to ensure that the seriousness and complexity of a case can be quantified, and it offers the opportunity to manage the workload across a team. That is a significant improvement.
We could go through the detail of a number of other initiatives that we are taking forward, such as the safeguarding board for Northern Ireland (SBNI), but perhaps members wish to focus on particular areas on which we can answer questions.
The Deputy Chairperson:
I know that the safeguarding board is being established; when do you expect it to be fully operational?
Mr Holland:
We hope that the safeguarding board for Northern Ireland will operate in shadow form in the autumn of 2009. It has taken longer than we had hoped, but there are good reasons for that. We wanted to ensure that transferring from one system to a new system did not reduce the quality of safety in the service. Therefore, we are taking our time.
We are also trying to develop the proposals for the safeguarding board on an inclusive basis. Martin Quinn, who will speak in a moment, has been at the forefront of developing the papers on that. We have developed a number of papers about the safeguarding board, and, at each stage, we have sought a wide range of views. We have engaged with people, and we have had discussions and made amendments. We want to ensure that we get the proposals right, and we want to ensure that the people who will have to make the proposals work have a strong degree of ownership of those proposals. It is important that the process is developed on an inclusive basis.
To ensure that that there is no gap, we will continue to run the existing area child protection committees up until the point at which we can establish the new safeguarding board.
Mr Martin Quinn (Department of Health, Social Services and Public Safety):
The SBNI will differ from the English experience. In England, the local safeguarding boards are coterminous with local authorities. If that model were replicated here, there would be five safeguarding boards. Northern Ireland is unique, so we have tried to take the best of what is happening in England and translate that here, but we have also tailored that to reflect the needs of Northern Ireland. That is why we have decided on a single safeguarding board for Northern Ireland.
The safeguarding board must reflect and connect with the local communities and the local areas in order to pick up on the issues. Therefore, we have decided to set up five safeguarding panels, which will be coterminous with the local authorities in order to cover the full geographical area and to reflect the mix of urban and rural issues on safeguarding that must be taken on board.
From very early on, we have held the view that we must have an independent chair. Area child protection committees (ACPCs) were chaired by an assistant director who worked within the board. We felt, and still feel, that an independent chair would bring rigour and provide a challenge function to those committees. You will note that the local safeguarding board in Haringey was chaired by the director of social services. We feel that that is a confusion of roles and therefore creates real difficulties. For a long time we have held the view that those committees should have an independent chair.
Unlike the area child protection committees — which, on occasions were criticised both in the Laming report and in our own social services inspectorate report for lacking authority and an agency-wide focus — we will place the safeguarding board on a statutory basis. We want it to have a much higher profile, and a much broader understanding, of safeguarding, and that includes child protection. In all this, we must not lose that notion of child protection; if we cannot get the basics right, how can we address the sophisticated issue of safeguarding in the Province?
The Deputy Chairperson:
Is the Regulation and Quality Improvement Authority (RQIA) currently carrying out an independent inquiry into how child protection is rolled out across the trusts?
Mr Holland:
It is about to undertake an inspection of child protection services across Northern Ireland.
The Deputy Chairperson:
Do you know what the time frame for that inquiry is?
Mr Holland:
Meetings have already been scheduled, and, later this month, I think, people will meet with the RQIA to discuss exactly how that work will be undertaken. I anticipate that that work will take approximately nine months to 10 months. We can submit in writing details of the timetable for the RQIA inspection.
The Deputy Chairperson:
At some stage, we will probably invite the RQIA to the Committee.
Mr Fergal Bradley (Department of Health, Social Services and Public Safety):
As part of the early stages of that inspection the RQIA has already been out to some of the trusts to collect information.
Mr Gardiner:
How many unallocated cases are there?
Mr Holland:
We monitor the level of unallocated cases carefully; the latest figures that I have are for November, and, at that point, there were 880 unallocated cases. However, we have reason to believe that the December figures will be closer to 1,000.
Mr Gardiner:
That is 1,000 unallocated cases in Northern Ireland alone. That is scary.
Mr Holland:
It is very important to emphasise that unallocated cases are cases that have been screened. Any case received and screened by social services in which a child-protection concern is identified is immediately allocated. An unallocated case can be a request for children’s disability service, an information request or a family support case; however, if it is a child-protection case, it is immediately allocated. If, when screened, we identify child-protection concerns, those cases are immediately allocated. Although they are described as unallocated cases, they have undergone a process. Certainly, we would like to see that number reduced.
Mr Gardiner:
Are you satisfied with that situation?
Mr Holland:
No, not at all, and that is why we monitor it very closely.
Mr Gardiner:
Are you striving for a big improvement?
Mr Holland:
We are, and that is why we are allocating in-year resources to bring that number down, and why we continue to monitor it on a monthly basis.
Mr Gardiner:
Are there any financial restrictions that prevent social workers from proceeding through the courts with any of those cases?
Mr Holland:
I am very grateful to have the opportunity to make the point, with absolute clarity, that there should never be a consideration of the financial consequences when deciding whether or not to take steps to protect a child, including proceeding to court. We have duties, which are specified in legislation. Those duties are currently placed on the four boards, and they delegate those duties to the trusts. Those duties have to be fulfilled, and that means that trusts must take whatever steps are necessary to protect children. Steps taken must be based on a professional assessment of each individual case, of the needs of the child and of the circumstances that that child is in. Under no circumstances should any social worker involved in that process allow reference to the subsequent cost to influence the decision to initiate care proceedings.
Mr Gardiner:
I welcome that clarification and am grateful for your reply.
Mr Holland:
That situation is slightly different to the one in England where there is an element of hard charging on local authorities. There, when social workers take the decision to establish care proceedings, they face a hard charge associated with the court costs. That is not the case in Northern Ireland.
Mr Gardiner:
So that does not apply in Northern Ireland?
Mr Holland:
That does not apply in Northern Ireland
Mr McCallister:
I was truly shocked by the Baby P case. That shock resonated throughout the entire country. It was terrible. We must do all that we can to ensure that such a tragedy never happens again.
I am certainly encouraged by your reply to Sam’s question that there is no element of efficiency savings or costs coming in. I want to follow on from the Chairperson’s question on the safeguarding board’s membership. Martin, you answered the question; I assume that you mean the five trusts, rather than local authorities. From where do you envisage the membership of such an organisation would be drawn?
Mr Quinn:
Its membership would be drawn from the statutory, voluntary and community sectors. Unlike that of area child protection committees, the board’s membership would be pitched at a fairly senior level; for example, senior executives, directors, and Assistant Chief Constables — people who have direct influence over policy and resource allocations. When they come into the SBNI, they would act with the authority of the agency that they represent.
We would consider similar representation on the safeguarding panels, although, perhaps, at a less senior level, to examine more operational issues. We would consider a broad range of people from the community, voluntary and statutory sectors. Key players would be drawn from fields such as probation, youth justice, policing, health trusts, the new regional boards, as well as the voluntary sector.
The difficulty is how large the organisation should become. If it becomes too large, it will be cumbersome and will not produce any work. We have agreed to assess the membership during the first year of operation to ensure that it is as crisp as possible. We also want it to be as inclusive as possible.
In addition, we want there to be a forum to which others who, perhaps, do not sit directly on the SBNI, would be invited to express their views on safeguarding. That would include a safeguarding forum for young people, because my definition of safeguarding and, I am sure, your definition, would be different. Therefore, it is important that we understand what young people on the streets of Northern Ireland mean by safeguarding.
Mr McCallister:
Obviously, recent focus has been on the Baby P case, which occurred in south-east England. Northern Ireland is the one part of the UK that shares a land border with another EU country. My understanding of the child-protection system in the Republic of Ireland is that it is not as robust as the current system in Northern Ireland. Can the Department exert any influence on the Republic or work with it in order to try to match both systems and to shore up some of those issues? Children can be taken across the border. What work is being done on that issue?
Mr Holland:
First, I do not want to comment on the quality of child-protection arrangements in any other jurisdiction. However, we have always had a close working relationship with our counterparts in the Republic and have met officials from there.
Following North/South Ministerial Council meetings, a cross-border group of officials, which was co-chaired by the DHSSPS and the Office of the Minister for Health and Children in the Republic, has been established in order to intensify co-operation on child protection and to take forward child-protection issues that relate to an all-Ireland child-protection awareness campaign: identification of other medium- and long-term measures to improve child-protection, which includes examination of an all-Ireland approach to child protection with a particular focus on vetting and exchange of information; and areas for co-operation on children’s services emerging from the North/South feasibility study on health and social services.
The latest meeting of that cross-border group of officials, which was co-chaired by me and representatives of the Office of the Minister for Health and Children, took place in Dundalk in December 2008. The group continues to consider areas for greater co-operation on child protection and has agreed to continue to meet on a six-monthly basis. The next meeting is scheduled for 5 June 2009.
We have also established several subgroups to examine areas of co-operation, such as vetting and borrowing information. DHSSPS will lead that group and the group on research. Officials from the Republic will lead the group on internet safety and the group on all-island media-awareness. A group led by officials from the Republic will develop a protocol for the movement of children and vulnerable families across the border.
Mr McCallister:
It is vital to have some follow-up on someone who has been on a protection register in Northern Ireland and moves across the border.Mr Holland:
At this stage, we have established terms of reference for all of those groups, and we hope to progress the work this year.
Mr Buchanan:
I welcome the report and its measures to strengthen child protection measures in Northern Ireland. I am concerned, however, that it took the Baby P case to highlight several weaknesses in the system. I welcome all the measures that are being introduced, but the weaknesses could have left a child vulnerable and open to abuse. I welcome the common approach that has been taken, the measures that have been put in place and the work that is ongoing. However, I was somewhat concerned to hear that 1,000 cases remain unallocated. How vulnerable is a child in an unallocated case? You said that children were monitored monthly. Do you think that that is sufficient, or should they perhaps be monitored fortnightly?
Mr Holland:
Perhaps I should clarify a few points. All the reforms that I mentioned commenced well in advance of the Baby P case. The process of reform started two to three years ago. In January 2007, the overview report was published, by which stage some work had already commenced. Following the publication of the overview report, we undertook a full-blown reform and modernisation programme. We have made approaches to Lord Laming’s team and offered to let them examine the reforms that we have undertaken to determine whether there are lessons that they can learn from the work that has been done in Northern Ireland.
Although we would prefer there to be no unallocated cases, it is probably reasonable to say that, in any service, one will never achieve a situation in which there is not some time lag between the identification of a need for a service and the service being put in place. However, those cases have been screened, and any child protection case is allocated. Of the 1,000 cases, we identified none as having a child protection concern. Those cases are screened, and are put into the unallocated category because we do not have any immediate concerns.
The month-by-month monitoring to which I referred is not of an individual case; as we monitor the situation of unallocated cases across Northern Ireland, we consider the pressures that exist throughout the system. In doing so, we ensure that we can take remedial action, target additional resources, or performance manage any aspect of the system, as we deem necessary. We keep a close eye on unallocated cases. The Minister asked us to do that and to be kept regularly informed of that monitoring.
Mrs Hanna:
Good afternoon; you are all most welcome. Thank you for your presentation. It is reassuring to know that you are examining your systems in so much detail. In the past, one of the main weaknesses seems to have been that younger and less experienced social workers were working, particularly late at night when a crisis often occurs, and when, as we all know, it is far more difficult to contact people.
A lack of experience is probably one of the main factors that can cause problems, particularly out of hours. Are all the duty social workers who are now in place experienced in child protection?
Mr Holland:
It should be the case that there is always access to social workers with experience of child protection. I cannot give a 100% guarantee that every social worker who is called out every night has experience of child protection, but it should be an exceptional circumstance when that is not the case.
Mr F Bradley:
The Eastern Board, for example, has an out-of-hours team on which all the staff have experience of child protection. In the Western Trust, following the Toner inquiry, all of the staff involved in the out-of-hours service have been specifically trained in child protection.
Even in the Eastern Board — on a particular night when there is a lot of pressure on staff — there may be exceptional circumstances in which a staff member needs to visit a particular location, but they instead contact someone who is at that location. In typical cases, however, one would expect that that person is somebody who has been trained in child-protection issues.
One of the recommendations of the Toner Report was for the Department to study the out-of-hours issue. That is something that we are currently considering.
Mrs Hanna:
That is very important because that is the very time when a crisis is likely to occur — when it is not easy to get hold of somebody.
Mr Holland:
We asked some key members of staff from the Eastern Board area to undertake a review of the out-of-hours service. We expect their report very shortly. We will consider that report very carefully, and if there are clear proposals that we can make to further improve the out-of-hours service, we will develop those.
Mrs Hanna:
Are all line managers still qualified social workers? That was not the case in England, which seemed to be part of the problem.
Mr Holland:
We took a very different path to England in relation to that issue. From the point of contact — a social worker knocking on a front door — up the line, the only point at which it is not a professional social-work line is at accountable officer level, which is the chief executive. The line of accountability runs from the social worker through to the director of social services and children’s services in a trust. That director then reports to their accountable officer, who is the chief executive.
In the current health and social services boards, it is also the case that the people who are responsible for the commissioning of child protection services are the directors of social work and children’ s services. The proposals for the new regional board for Northern Ireland replicate that arrangement. Policy responsibility for children’s services at the Department of Health, Social Services and Public Safety rests with me, as chief social services officer, and I am a qualified social worker. That arrangement is unique to Northern Ireland.
Mrs Hanna:
That is also important. I have one other question — do social workers have the power to commission medicals, physicals or x-rays? In the Baby P case, the paediatrician did not examine the baby even though there were real concerns regarding the child.
Mr Holland:
As part of an assessment during a child-protection investigation, the social worker will refer the child for medical examinations. Obviously, they are not responsible for those examinations and the competence with which they are undertaken. We hope that the situation in Haringey was a very exceptional one as they were not competently undertaken. When we consider a child to be at risk of physical abuse, a medical assessment is an integral part of the process.
Mr Gallagher:
What was investigated by the Toner Report?
Mr Holland:
That was the report into the deaths in Omagh — the McElhill case.
Ms S Ramsey:
Thank you for your presentation. It made me want to ask more questions, but I know that the three of you are working daily to ensure that proper policies are in place.
Sean mentioned the 1,000 unallocated cases that were screened for child protection. What is your definition of child protection? I know that you might not have the answers with you today, but could you provide a brief outline of the 1,000 unallocated cases? You do not need to go into specific details, however, Baby P was the subject of a child-protection plan, but he still died. You said that there are 1,000 allocated cases that have been screened for child protection, but I want to know the Department’s definition of child protection.
The document highlighted that money was allocated for those 1,000 unallocated cases — whether that money was additional or money that was provided in the budget. The point that John McCallister made is too easy a point to make. My concern is that there are 1,000 unallocated cases, and the money is here. Will that money only target the 1,000 unallocated cases? It cannot be regarded as additional money if 1,000 cases are still unallocated.
Are you telling me — because I hear that there are potential cuts — that there are not going to be any cuts in the family and childcare budget?
Mr Holland:
There are quite a few points there: I will try to deal with them as we go through. To take the first point, I consider a child protection case to be any case where we have any reason to believe that a child is at risk of harm. I can provide a more detailed definition describing the different types of harm and levels of risk. We can supply that information subsequently. Any referral received where there is any information available that might indicate that a child is at risk of harm is a child protection case. If that is the situation, then it does not become an unallocated case; it has to be dealt with immediately.
Regarding the breakdown; we will supply the Committee with detail of the figures of where those cases are occurring, and what information we have. We can supply that in writing to the Committee as soon as possible. I will ask my colleague, Fergal, to talk about the money in detail.
Reference was made earlier to the comprehensive spending review (CSR). Understandably, when people talk about that, they focus on the efficiency savings. It is not a bad thing to make services more efficient, but a key feature of the CSR is that, where efficiencies have been made and money has been identified by virtue of efficiencies, it is then allocated for development. It has been a feature of this comprehensive spending review that there has been a significant investment of development moneys in the CSR in front-line child protection services, family support services, services for children in care and services for children leaving care. To put it simply, children’s services have been a winner in the current CSR proposals.
Ms S Ramsey:
I appreciate that. I am not a civil servant, but this is how I see it: there are 1,000 unallocated cases and there is money coming in. I assume that the money — which will not be seen as additional — is there to tackle those 1,000 unallocated cases.
Mr Holland:
We are putting in-year, non-recurrent money specifically to bring the —
Ms S Ramsey:
So, that money is coming in — are we going to revisit this issue next year and find that there are still 1,000 unallocated cases?
Mr Holland:
In addition to that, there is other recurrent investment which is strengthening the child protection services. Fergal, will you take us through the figures that we have?
Mr F Bradley:
If it offers any reassurance regarding child protection teams; as a result of the close working relationship that we have with the trusts, we know exactly how many posts are in each trust’s child protection front-line teams. That is something that we would be able to look at in the future regarding any future investments going into those teams.
The first point is that you will be able to see the additionality of extra bodies. Over the period of the CSR, we know that around £1·2 million has gone into securing additional posts in both child protection and family intervention teams. We know that the principle practitioner posts are additional; that is something that was never there. We can now see people in posts.
We are very conscious that people are concerned about resources, but as Sean was saying, a key element of the whole reform programme is the full continuum from family support right through to child protection, in care, leaving care, and adoption; all of those elements. If you do not fund the whole system and try to put resources into it, all you do is start to displace problems from one part of the system to another.
Ms S Ramsey:
I am an ally on this; I am trying to say that additional money is needed and it is not coming across.
I want to tie in a couple of other points, and I am conscious of the time. Again, you may not have the answers to my questions. Looking at the first review that was carried out — the case of the twins in Craigavon, the Briggs issue; then the McElhill case — inquiries took place and a number of recommendations were made. Would give me details of the number of recommendations that have been made in all of these inquiries and how many were implemented? Are we, because of our own issues, better off than some council areas in England? Although Access NI concerns a different department, it is run by the NIO. Is that creating more difficulties for you as regards child protection?
Mr Holland:
There have been many recommendations from reports over the years. We very carefully monitor the implementation of recommendations. As recently as last Friday, Fergal and I were in the Western Trust looking at their implementation of the recommendations from the Turner Inquiry. We do that at the direction of our Minister, who has asked us to make sure that those recommendations are implemented.
We are also cross-referencing recommendations. We have cross-referenced, for example, the recommendations of the Laming Report into the Climbie case in England with those of the child protection overview report to ensure that we are addressing all the issues identified. I think that those reports have improved services. However, we must find other ways to learn how to improve services for children. There is always a risk that people can become fatigued by hundreds of recommendations and can almost adopt a tick-box approach. Nevertheless, we do not believe that that has happened with the reports that I mentioned.
We face a challenge in moving services away from a culture of blame — in which people seek to find errors — to one that emphasises learning, governance arrangements and encourages organisations to continually improve service delivery. That is why we are interested in developing some self-audit tools to help people who are engaged in child protection work to improve their services.
Mr F Bradley:
As regards some of the figures mentioned; since ‘Co-operating to Safeguard Children’ — the guidance that sets out the conduct inquiries for cases in which children come to harm — was published in 2003, we have completed 18 case management reviews. The Briggs case and the Turner inquiry were conducted alongside those reviews. The O’Neill inquiry could probably be linked into that also.
The recommendations that we have to date from those inquiries concern events that happened prior to January 2007. We examined those recommendations to see in what way they correspond to what was said in the child protection overview report. We found that they were remarkably consistent with one another on the quality of assessments; the identification of risk; decision-making; supervision of staff; and information sharing. Those issues came up continuously. All those phrases also feature in the document on the Baby P case.
As regards the reform programme, all the things that we have developed correspond directly to the types of things that we have been trying to produce, such as a regional assessment tool. We have been producing supervision —
Mr Holland:
Returning to the Chair’s original question about what 10 things we would do, one can trace a very clear line from those reports’ recommendations and our review report’s findings to why we focused on those particular areas to improve services.
Ms S Ramsey:
I appreciate that, and I think that much good work has been done. However, I am not happy with the fact that there are 1,000 unallocated cases. Social services address cases based on whether child protection is involved.
Mr Holland:
That is not necessarily true.
Ms S Ramsey:
That is what you said.
Mr Holland:
I said that of those 1,000 unallocated cases, there will be cases that have been referred to children’s social services but that will not have anything do with child protection. It is important to realise that children’s social services intervene in many families’ lives, where there are no child protection concerns, to provide support and assistance with the intention of improving their circumstances. It is always difficult to separate those cases in which there is risk from those in which there are difficulties and people need assistance. Of those 1,000 cases, there are no child protection concerns.
Mr F Bradley:
Statistically, around 21,000 children a year are referred, 3,000 of whom will require child protection.
Ms S Ramsey:
Will you give us a breakdown of the 1,000 unallocated cases?
Mr Holland:
Yes.
Mr F Bradley:
I emphasise that many of the unallocated cases have actually been through an initial assessment. They are in the second stage, and are awaiting family support services. They are waiting to be allocated a social worker to provide family support.
Ms S Ramsey:
That is fair enough. However, how do you compare that to Baby P who died despite being on the child protection plan? I do not mean to be flippant, but we are trying to improve services based on what has happened and on recommendations and inquiries. Having 1,000 unallocated cases does not sit well with me.
Mr Holland:
The point is that Baby P was not an unallocated case. Baby P had been assessed, was on the child protection register and was subject to a multi-disciplinary child protection plan. Therefore, in the Baby P case, it was the services being provided that failed, it was not the feature of being an unallocated case.
Ms S Ramsey:
I know that, and that is my point: Baby P was on the plan and it failed. We have 1,000 unallocated cases; therefore, we do not know what we are up against. The sooner we get those figures, the better we will be able to understand the scale of what we face.
The Deputy Chairperson:
Perhaps the figures should be clearly set out, so that for instance, we can see whether people are being referred because they have a child with a hearing problem and will receive a visit from a social worker for the hearing-impaired. In the same way, it could be shown that people with a child suffering from a disability can expect a visit from a social worker for disabled children. A breakdown of such cases would enable us to be confident about the types of cases that are unallocated.
Dr Deeny:
I realise that time is moving on. I welcome the debate: there is nothing more important than the welfare of our children.
The Baby P case was tragic, but even more tragic was the fact that Victoria Climbie was in the care of the same council — Haringey. Lessons were not learnt. That was even more tragic, because if lessons had been learnt then the Baby P case might not have happened.
Often, good comes out of tragedy. In this instance it may be that all authorities are taking a step back and reviewing their child-protection procedures. Therefore, I welcome the report, which concludes that improvements have been made since January 2007. If that is the case, it must be welcomed.
As a healthcare worker, I have a practical question. My experience is that cases, such as Baby P and Victoria Climbie, often arise because of a breakdown or a difficulty in communication — sometimes a decision is taken to halt very important information being passed up the seniority ladder. Sometimes, perhaps, information should go higher.
My two questions have been partially answered. However, first, given that there is going to be a single regional safeguarding board, who will take overall responsibility for protecting children within each trust? Secondly, how does information get passed up the ladder? How does concern for a child received by a social worker from a GP, nurse, midwife, or even a teacher, get passed up the system? You have already said that that chain ends with the chief executive of the trust, and that the information is then passed to the regional safeguarding board.
I have another quick question regarding liaison and communication with the PSNI. I will not talk about the traumatic case in which an Omagh family lost their lives. That is subject to an ongoing investigation. However, what happens in the case of someone who has a record? There must be communication between police and the social workers involved.
Lastly, when a case arrives at the regional safeguarding board, I assume that the case will be treated as a very serious one, because it has been reported by the most senior person in the trust. I presume that action will be taken immediately: what will that entail?
Mr Holland:
Kieran said that his questions had been partly answered. I will go back over the ground. In relation to who takes decisions within trusts about child protection cases; in the first instance a social worker is involved. They work directly with the case under the supervision of a senior social worker. There is also a management chain, which stops at the director of social services. The director of social services in our trusts is also the director responsible for children’s services. That was a conscious decision that was made when drawing up the job descriptions for the directors in the new trusts.
Within that, a key mechanism for sharing concerns is the case conference process, which brings together all key professionals involved in the life of any child and family about whom there are concerns. That is also a key part of the decision-making mechanism. Therefore, there is a clear line of accountability for decision-taking and passing information, which stops with the director of social services. Ultimately, the accountable officer is the chief executive.
On behalf of several parties, the Turner Report focused on the issue of difficulties in relation to communication with the PSNI. There have been significant developments with the introduction of the public protection arrangements for Northern Ireland — those are new arrangements to ensure close, multi-disciplinary, working regarding people who may pose a risk to adults and children.
We have made specific investment commitments to ensure that social services and social workers are fully represented in those arrangements, both at local and regional levels. Those arrangements will deliver significant benefits in improved communications between professionals.
However, we have not been waiting for that. The Turner Report made other specific recommendations, which we have been asking trusts to take forward, and we have been monitoring progress. We are confident that significant progress is being made. An information-sharing protocol is one of the products that are being developed as part of the reform and modernisation programme. It is aimed specifically at ensuring that appropriate information is shared among all those who have a role to play in safeguarding children, and not just the police and social services.
Dr Deeny:
If information about a case is passed to the regional safeguarding board, what happens then? I presume that it would be deemed as a serious case. What is the purpose of that board if no one is available to act immediately, and, for example, remove a child?
Mr Holland:
I will ask Mark to explain the roles and responsibilities of the regional board and the local safeguarding panels.
Mr Quinn:
It is important to say that the trusts have the statutory responsibility to investigate such cases. The safeguarding panel will not take part in direct investigations. The point that you are making is about communication between the various agencies. I do not think that we have done that very well throughout the system. One of the key pillars of the safeguarding panel for Northern Ireland (SPNI) is to have a forum to allow communication to flow in a more concrete way.
Safeguarding is everyone’s business. In reality, that has translated into responsibility being carried by a few key people, such as nurses, medical professionals and social services personnel. In truth, a child’s needs are holistic, and we must look at the whole child. The way in which we intervene in a child’s life is vitally important. The SPNI will look at strategic issues, and how agencies translate those into reality. It is about how we communicate with the police, the medical profession and social services in order to meet the needs of the child. That is the form that the SPNI will take, rather than the operational issues.
The local safeguarding panels will pick up on cases that are not quite right. We have talked about case management reviews in the wake of a tragic death. The SPNI will also be interested in those cases that we would consider as near misses — when things have not gone that far, but we know that something is not right. We must take those cases into account. The SPNI will have a strategic rather than an operational role, but it will involve people at a senior level, which has been a weakness of the area child protection committees (ACPCs). People are involved who are too low down the food chain to make effective decisions about policy, resources, integration and co-ordination, and consistency. For me, those should be the by-words of the SPNI, and that will be one of its key tasks.
Mrs McGill:
Sean, you said that you and Fergal had visited the Western Trust last week, on the instruction of the Minister.
Mr Holland:
I apologise; it was this week.
Mrs McGill:
Was that on the instruction of Minister McGimpsey?
Mr Holland:
At the time of the publication of the Turner Report, Minister McGimpsey asked us to monitor closely the implementation of the recommendations of that report and keep him regularly briefed.
Mrs McGill:
I welcome that. I commend you and the Minister for doing that. Are improvements already in place in the Western Trust area? I ask that because, as Sue Ramsey mentioned, the McElhill case in Omagh falls under the aegis of the Western Trust. Fergal said that increased numbers of personnel were dealing with child protection issues. What size of an increase in resources has taken place in the Western Trust area?
Mr F Bradley:
I do not have the figures to hand for the Western Trust, but I can tell you that the number of additional posts that have been added to its child protection gateway teams corresponds to the amount of money that we have allocated. We can track an increase of around 30 child protection workers going into those gateway teams across the five trust areas in the past year or two, based on the additional money that we have put in.
Mr Holland:
Fergal is trying to make the point that sometimes it is hard for the Department to track money that it has issued. In this case, we have made sure that that has not happened and have asked for a detailed breakdown of the exact numbers of people who work in child protection teams. When we allocated and increased the investment, we wanted to see an increase in the number of people working in child protection teams, and we are monitoring that situation.
It is fair to say that over 90% of the recommendations that were made in the Western Trust have been implemented, and there is a clear plan to address the remaining recommendations. Some recommendations are outstanding because they have been progressed on a regional basis, and the timetable for certain pieces of work has not been completed. Of the recommendations that apply to the Western Trust, we estimate that 90% of them are green, which means that they have been implemented.
Mrs McGill:
Thank you for that answer. When you send the information requested, will you include the figures for the increase in personnel and resourcing in the Western Trust?
Mr Holland:
Yes.
Mr Buchanan:
There are 1,000 unallocated cases at the moment — is that an increase on the number three years go, and, if so, by how much? Were the Omagh and Portadown cases unallocated?
Mr Holland:
First, no; the McElhill case was not an unallocated case. There were different cases involved in the Omagh cases, but they were not unallocated cases.
Mr F Bradley:
It is difficult to compare figures, because a couple of years ago we only monitored unallocated cases at the front door. Now, we monitor unallocated cases at, for example, the family-support stage. We want to know the full picture: even if a case has been assessed and is waiting for services, we want to know about it. Three years ago, we were not monitoring all of that, so it is difficult to compare the figures.
Over the past several months, numbers have been increasing, which is due, in part, to the operation of the gateway teams. There are five gateway teams, each with a single point of contact; so it is much simpler and quicker for other organisations to know to whom they should refer. In some ways, the new structures are a victim of their own success.
As we have got common structures and processes, we can see where pressures are emerging across the board for the first time, which is very important. Some of those pressures probably existed 10 years ago, but they were not obvious unless there was a serious adverse incident, such as the death of a child, that prompted an inquiry. We are now trying to regularly monitor the pressures on the system so that we can try to respond to them.
The Deputy Chairperson:
Thank you for coming and for providing the Committee with information. Some information was requested, which you will send to the Committee, and we look forward to receiving that.