Neglect toolkit - case studies

A community staff nurse within the School Nursing team worked with a family who had been the subject of three referrals to Children’s Social Care Services in relation to concerns about Kai’s* mother drinking excessively, domestic abuse, which Kai had observed, and Kai displaying behaviours which were resulting in disengagement from education.

Kai had a raised Body Mass Index (BMI) and it had been identified that there was little access to healthy foods in the home. A Children & Families Assessment had been undertaken by Children’s Social Care Services, but Kai disclosed to the nurse that their mother had “lied about everything” and the outcome was for the case to be allocated to Early Help. A family support worker was supporting the family, but Kai was concerned that their mother would continue to lie and thus the situation would not improve. The nurse continued to engage with Kai and support them alongside the family support worker and identified that the situation was not improving despite significant input and support.

In view of increasing concerns that Kai had been permanently excluded from school, was at risk of criminal exploitation and was observing increasing levels of alcohol use and domestic abuse, the nurse sought advice and support from the safeguarding team. A plan was made to utilise the Neglect Toolkit and threshold charts contained within, to understand the impact of the behaviours on Kai. This along with the use of the “Day in my Life” tool with the young person informed a MASH referral to Children’s Social Care Services detailing the different areas of neglect that Kai was enduring.

Following the comprehensive and informative MASH referral, which captured the lived experience and voice of the child well, the family were opened to Children’s Social Care Services and a Child in Need (CIN) plan commenced. Kai remains the subject of a CIN plan and work is ongoing with the family.

*Pseudonym

Referral: The GP referred Lucy* for a Child and Adolescent Mental Health Services (CAMHS) assessment at the request of the local paediatric team who saw her for an underlying health condition. There was a concern that Lucy's eating was having an impact on her and her family. Her weight to height ratio was below a normal range. Lucy’s bloods were fine but there was a concern regarding her dietary habits as she would make herself vomit and take hours to eat meals. Lucy also stored mouldy food.

Family context: Lucy lived with her dad and stepmother for a number of years. As a young child Lucy was reported to have experienced neglect from her biological mother.

CAMHS Triage completed: Lucy was booked for a routine initial assessment by CAMHS. The triage clinician felt Lucy's behaviour was likely to be the result of trauma than indicative of a true eating disorder or disordered eating condition.

CAMHS Initial Assessment: Lucy and her stepmother were seen for a face-to-face appointment. It was noted by the assessing clinician that there was no eye contact between Lucy and her stepmother. The stepmother only referred to Lucy as 'her' or 'she'. Initially, Lucy and her stepmother were seen together. The stepmother described a recent incident where Lucy took hours to eat. This caused the stepmother frustration and anger. Following an argument that ensued there was no communication from the stepmother to Lucy.

Lucy was then seen alone. The clinician who saw Lucy recorded that she cried constantly throughout the appointment with tears repeatedly falling from her eyes. Lucy confirmed her dad and stepmother had not spoken to her during the week, but that her siblings had. Lucy described having to eat everything she was given to eat, and she had no choice about what she liked to eat. Often, she would store food she did not like in her room where it became mouldy. When asked about what she liked to do, Lucy advised she was not allowed to read or watch television and she just sat in her room. Lucy was also not allowed out to socialise with her friends. Lucy's activity was monitored in her room by her stepmother. Access to her laptop was also denied due to her eating habits.

Supervision: The clinician sought supervision and was advised to refer the case to Children’s Social Care Services. Lucy's account of her experience was so powerful the recorded notes were copied and submitted via a MASH referral to Children’s Services.

Outcome: CAMHS were initially advised that a Family and Child Assessment would take place. Lucy was subsequently removed into police protection and placed in foster care, and an Interim Care Order was granted. Her eating and self-care habits have resolved whilst in foster care. Lucy expressed she did not wish to return to the family home.

*Pseudonym

Sandeep* became subject to a Child Protection (CP) plan and consideration was being given to the case going to court, with the matter also going into the public law outline (PLO) process for three months.

Concerns had been raised about Sandeep for some time, with a Young Carers support service becoming involved a year earlier, providing:

• Parenting support
• Help with household routines
• Help with decluttering the house, cleaning and decorating

Sandeep’s mother receives support from a charitable organisation for her anxiety and depression and the GP has arranged for her to have appropriate medication.

Sandeep and his mother also attend a family support group for hands on therapeutic sessions. The housing provider visits fortnightly and they undertook a ‘deep clean’ of the home.

The mother receives support from her parents, brother, and sister-in-law. A food bank has also provided the mother with food parcels.

Outcome

The PLO process ended after good progress was noted. A Review Child Protection Plan Conference (RCPC) was held, and the assessment evidenced significant improvements and progress against all of the aims and objectives of the CP Plan. The risks were clearly significantly reduced, and the mother had demonstrated a commitment to sustaining these changes and worked well to maintain the progress seen.

Sandeep is clearly presenting much more positively both at home and at school, and a Child in Need (CiN) plan was agreed at the most recent RCPC.

The planning process was truly multi-agency and the group worked very effectively together to support the family in achieving this very positive change.

*Pseudonym

Josh’s* early history was of his mother not managing to care for him and he was looked after from age two temporarily by the local authority before moving to his father’s care. Over time he and his siblings were the subject of low-level concerns to various agencies for bumps and bruises, non-school attendance, and poor home conditions. The children moved between the mother’s and father’s care but as short-term improvements in the children’s circumstances were not sustained, the family situation was discussed at the Early Help Hub meeting and attempts made to engage them. However, the family did not want to engage.

As more concerns were raised (health appointments not being kept, Josh soiling at school, and additional presentations at A&E where poor supervision had led to various accidents and incidents), a Child in Need (CiN) plan was put in place. This seemed to be effective at engaging the family and achieving positive change.

The family’s case was closed after nine months on a CiN plan but six months later a Child Protection (CP) investigation resulted in a CP plan being put in place.

The CP plan addressed the unmet heath needs of the children – immunisations and appointments, engagement with education setting, support with educational attainment, improved home conditions, and appropriate supervision.

Following the birth of Josh’s youngest sibling, the mother became seriously ill, necessitating hospital admission. The children were placed with suitable carers and were attending school well, while extended family supported the mother and maintained contact.

The children’s father gave up work and focussed on the CP plan. He ensured the children attended their health appointments and their immunisations were updated. He developed much better relationships with professionals and supported the family support worker to arrange a family meeting. This increased the support network for the family and enlightened grandparents who were previously unaware of the concerns held by agencies.

The school started to support the family more proactively, providing homework books and colouring pens. The father started to engage better with professionals, and this continued once the mother’s health improved. The improved communication enabled the social worker to challenge the mother about her previous disguised compliance. Due to progress on the CP plan, a CiN plan was put in place once again, and after three months, stepped down again to the Early Help Hub. Work took place to support the bond between the mother and the younger children and psychological support was also made available to the mother.

*Pseudonym

Background to case: Family of four comprising of mother and three children. The eldest child has a rare medical condition and has multiple complex additional care needs.

The three children each have different fathers and the mother’s relationships with each child has been physically and emotionally abusive.

The mother also has poor health and is not consistent in managing her health needs. Mother, Jane*, was in a relationship with the youngest child’s father, John*, which had all three elements of the toxic trio present.

John was both using and dealing substances which, although not specifically linked to his mental health, was believed to have been impacting and compounding his low mood, resulting in attempted suicide.

The children were exposed to the volatile relationship.

Police and Children’s Social Care Services became involved resulting in a Child Protection (CP) plan being implemented for all three children and charges brought against John for possession and intent to supply of illegal substances.

Jane, whilst still openly in a relationship with John at this time, was under intense strain and pressure and this resulted in her physically assaulting her youngest child.

Jane and John separated as a result, and the relationship became acrimonious. This resulted in the children being further exposed to risk due to the deterioration of John’s mental health.

Reason for referral/involvement: Although on a CP plan, a referral was made to support the parents accessing parenting programmes as per an action within the CP plan.

As the parents were separated, the risks were reduced and when CP was no longer required it was de-escalated to Child in Need Plan (CiN) for continued support.

Type of neglect: Physical and emotional neglect. The eldest child’s physical medical needs were sometimes neglected due to the lifestyles the children were exposed to and the impact on Jane’s ability to protect the children from the impact of her relationship choices and lifestyle.

What interventions/support were delivered?

• Incredible years
• Family nurture
• Signposted to support for domestic abuse

Both parents completed the courses separately.

How was support coordinated with other practitioners/agencies?

Support was initially coordinated via the statutory plan. Once this was de-escalated and CiN meetings were held to review targets against progress. This involved the school, domestic abuse

outreach, the substance misuse team, health etc. All agencies were involved in the review and planning of the continuing support needs.

What has been the outcomes for the child (ren) and wider family - what is different?

The parents recognise the impact of their behaviours on the children and remain separated. Parenting programmes were completed and Jane, as the main carer, was able to demonstrate and evidence her learning through practice. This in turn was of benefit to all the children as stability and routines replaced the previous chaotic and unpredictable lifestyle. Attendance at settings improved, as did engagement with supporting agencies. Jane was more able to address her own health needs. John did not have contact, as although he attended and completed the courses, his mental health continued to deteriorate.

How has change been sustained?

The parents are aware of how to access support through universal services e.g. school staff, drop in for support sessions. Transparent planning has supported raised confidence in communicating with agencies resulting in any issues being resolved quickly.

Critical success factors

• Effective planning alongside parents – ensuring that actions set were SMART and achievable promoting measurable progress
• Transparent working
• Building relationships and where possible a consistent contact – this had a big impact on achieving improved engagement with all professionals

*Pseudonym