A Learning Lessons Review in Kirklees: Child Q - Paul
This briefing has been produced to provide practitioners and managers with the key learning. A Learning Lessons Review (LLR) takes place after a child is seriously injured and abuse or neglect is thought to be involved and it is believed lessons can be learned from the way in which the local authority, their board partners or other relevant persons have worked together to protect the child.
What was the story?
On August 13th, 2021, the emergency service team responded to a 999 call at 10:55am regarding Paul who was not breathing in the bathroom. The call was made by Mark who was the biological mother’s partner. It is unclear if mother (Marie) was present in the family home at the time of the incident. The ambulance arrived at 11:01am. The Patient Care Record reports Paul was in cardiac arrest. It was also documented that the family told the ambulance crew Paul had previously experienced physical and emotional abuse by his biological father, Steve. Paul was transported to Huddersfield Royal Infirmary. Life was pronounced extinct at 11:34 am hours and the scene secured. Two people linked to the address were arrested and charged on suspicion of murder.
Background:
Marie and Mark resided in the UK for a number of years prior to Paul`s arrival on October 4th, 2020. Criminal activities have been logged for both subjects between May 2012 and November 2020. Mark and Marie were unknown to support services at this time. Paul arrived in the UK on October 4th, 2020. It is understood that Paul entered the UK accompanied by Marie and Mark. Paul was registered at a Kirklees school on October 19th, 2020. Marie was given access to the My Ed system for school to home communication. Paul had what would be considered an appropriate attendance level (94%), and any absences did not follow a pattern or cause concern.
Communication from Paul at this time was largely around seeking clarification on activities and points of learning; several of them are in response to questions/tasks. School report Google translate was used in some communication and some of the emails from Paul supported a limited understanding and use of English.
School reported that Paul was not flagged as vulnerable and had a good attendance record. School maintains there was evidence of engaging in learning with a consistent flow of communication between Paul and members of staff. School state as a student with limited English, Paul was being supported by the “English as an Additional Language” department in school.
On April 7th, 2021, Paul registered at a local GP Practice.
In April 2021 Locala sent out a letter to the family introducing the Thriving Kirklees 0-19 Team. A leaflet regarding the School Nursing service was also enclosed, which included advice to register Paul with a GP, dentist, and contact the GP for information regarding childhood immunisations. A Meningitis immunisation was scheduled on July 15th, 2021, following correspondence via mobile phone with the family. This appointment was cancelled by the GP practice.
August 13th, 2021, emergency services were called to the family home in response to a child being unconscious in the bathroom not breathing. Paul was transported to Huddersfield Royal infirmary; Paul was pronounced dead in the Emergency Care Facility. On September 9th, 2021, school records indicate an entry where there had been a discussion with friends of Paul in school and one of the friends had disclosed that Paul was ‘frightened’ of his mother. The child stated they had witnessed this outside the school gates on October 19th, 2020.
Overview and Analysis
Strengths and Protective Factors
School contact during the pandemic
Risk/Harm/Danger
Limited understanding of English
Possible abuse from the father in Poland
Grey Areas
Not clear on the level of support provided from school during the period of home schooling.
Complicating Factors
Covid – 19 pandemic
Mothers medical issues/ child carer
Voice of the Child
School contact during the pandemic
Analysis
There needs to be a consistant approach to the understanding of “vulnerable children”
A better awareness of the International New Arrivals Team, and what services they provide.
A better understanding of what “normal” means for people of other cultures.
Learning for Professionals and Multi-Agency Working
• All professionals need to understand the challenges of being a new arrival to the UK and the requirements and opportunities to access health, education, and support services including INAT.
• It is important for professionals to understand relationships in families and understand a full background history of where new arrivals are concerned.
• Professional curiosity cannot be overlooked or discounted and should be promoted through training and challenge.
• Significant time needs to be spent understanding the impact of the global pandemic nationally and locally and how locally the systems and processes applied by services and settings work. The impact of Covid-19 on professionals needs to be recognised and that the workforce are feeling the pressure of this. Work needs to be done to support resilience in the workforce.
• Consideration around the recovery phase especially for children coming out of a pandemic and the support that can be sought to aid that recovery.
• The statistics note that domestic abuse in families has not been increasing over lockdown, but from anecdotal evidence, a lot of families were really struggling in lockdown – maybe the statistics do not show the whole picture. They may be under pressure not to report, so cases may just be staying under the radar.
• Consideration should be given to how and when we share information to support families and young people, to be aware of services and how to access them, be that health or wider services. Also, to ensure that they are tailored to meet the individual needs of that family.
• Work is ongoing on the Corporate Safeguarding Strategy that sets out the role of all individuals who might come across children, families, adults and how they might recognise concerns and what to do about
For more information about National Reviews and learning visit:
https://www.gov.uk/government /groups/serious-case-reviewpanel
https://www.nspcc.org.uk/preve nting-abuse/child-protectionsystem/case-reviews/nationalcase-review-repository/
For more information about Local Reviews and this case visit:
Relevant Tools & Multi-Agency Responses for this case include:
International New Arrivals Team
Domestic Abuse
Impact of Covid
Language interpreting and translation for healthcare professionals
People whose first language is not English: learning from case reviews