Joint Learning Event - Wolverhampton Safeguarding · 2020. 6. 11. · April to September 2015 ......

Disseminating learning from

Domestic Homicide Reviews

Serious Case Reviews

and

Safeguarding Adults Reviews

Joint Learning Event

© Copyright Wolverhampton City Council 2016. All Rights reserved

Welcome

Simon Hill

Independent Consultant and

Chair of Domestic Homicide Reviews

Multi Agency Joint Learning Event 2016 © Copyright Wolverhampton City Council 2016. All Rights reserved

Key Messages

Linda Sanders Strategic Director - People


The Local Message

David Jamieson

West Midlands Police and Crime Commissioner


COLLECTIVE RESPONSIBILITIES

To Protect those who are most vulnerable in our society – children, young people and vulnerable adults

Which we discharge through

• Prevention – engaging communities through awareness raising, early intervention and culture change

• Protection – safeguarding those at risk and supporting those affected

• Justice – holding offenders to account and preventing reoffending

APPROACH

This will be achieved through Integrated Working to

transform our delivery of core public services

Governance of the programme is through the Chief

Officers Leadership Board as well as the PVVP Board

chaired by CEO Nick Page and ACC Carl Foulkes

Reporting through regional and partnership networks

as well as the West Midlands Public Services Reform

Board

WORKSTREAMS

There are 5 work-streams

• Child Sexual Exploitation

• Female Genital Mutilation

• Public Protection

• Sexual Violence

• Schools and Communities

CHILD SEXUAL EXPLOITATION - CSE

Implementation of Regional Framework published 2015

Consistent development of transparent data on risk and impact

Development of website and effective engagement with young people, parents and communities

FEMALE GENITAL MUTILATION - FGM

Following the West Midlands FGM report published last year this taskforce additionally reports to the West Midlands Police and Crime Panel

Regional Screening Tool

Establishing core elements of level 1 awareness training

Build understanding and data on prevalence of FGM

Develop Guidelines to protect girls born to mothers who have undergone FGM

Community engagement – map provision

PUBLIC PROTECTION

Development of consistent and coherent delivery of Multi-Agency Safeguarding Hubs

Implementation of Region-Wide Domestic Violence Standards

Development of Integrated regional DV practice

Identification of effective practice and development of evidence based perpetrator programmes

Tackling other specific forms of violence e.g. forced marriage and “honour” based crimes.

SEXUAL VIOLENCE

Multi-agency, holistic and seamless service to victims

and survivors

Development of concise regional standards for

tackling sexual violence

Development of regional provision for Independent

Sexual Violence Advisers

SCHOOLS AND COMMUNITIES

Develop appropriate regional mechanisms and tools to support

safeguarding work within schools and communities

Identify and develop best practice to promote a consistent approach to

the delivery of safeguarding and public protection work within schools

and communities

Streamlining communications to schools of PVVP and safeguarding

materials

Regional learning of Early Help Implementation

An Overview; Domestic Homicide Reviews

Serious Case Reviews Safeguarding Adults Reviews

Simon Hill

Independent Consultant and

Chair of Domestic Homicide Reviews

Multi Agency Joint Learning Event 2016


Case Study – Part One


The Bibi / Khan Family Family Tree Fozia Bibi

Salman Khan Samia Khan

Tamwar Khan Ayesha Khan



Case Study Family Household Genogram

Grandmother 72yrs Fozia

Bibi

Son - 50yrs Salman Khan

First Wife - Sajida Khan

(deceased)

Second Wife

26yrs – Samia Khan

Ayesha Khan –3 yrs

daughter

Tamwar Khan - 11yrs son

Previously married Current wife

Son from previous marriage Daughter from current marriage

Samia’s Sister

Son - 52yrs Naseer Khan

Son - 40yrs Javid Khan

Sister Parveen 32yrs – Khan


Case Study January to June 2014

Early evidence of domestic abuse

Issues around depression

Birth of Ayesha

Role of the Health Visitor


Case Study 28/03/14 to 09/04/14

Fozia’s community group

Salman’s problems at work

A&E attendance


Case Study April to May 2014

The Housing Office

Salman is arrested and threats to the family

Children’s Social Care Assessment

Referral to addiction services

Salman self medicates


Case Study July to November 2014

The district nurse’s concerns for Fozia

Fozia’s needs assessment

The Health visitor reviews Ayesha

Repairs to the home


Case Study December 2014

Domestic abuse or accident?

The GP visit

Samia at work


Case Study January to March 2015

Tamwar’s school have concerns

The Early Help Assessment

The home/ school liaison worker’s lead role


Case Study April to September 2015

Samia is pregnant and visits her GP

Early Help concerns for Ayesha

The maternity appointment

Police are called to the family home

Salman is taken to Naseer’s home

Tamwar moves school


Case Study October to November 2015

Samia gives birth to a baby boy born two months premature

The Nursery have

significant concerns Multi Agency Joint Learning Event 2016 © Copyright Wolverhampton City Council 2016. All Rights reserved

Case Study December 2015

An Ambulance is called as the baby

struggling to breathe having apparently rolled off the sofa onto the rug.

At hospital baby was examined and a significant bleed to the brain was identified and bleeds found to the back of both eyes. The baby is on life support.

Ambulance notes described household as very clean on the ground floor. Upstairs bedrooms raised significant concern.


The Toxic Trio

Kathy Cole-Evans, VAWG Lead,

Wolverhampton DV Forum

[email protected]

Any incident of threatening behaviour, violence or abuse

between adults who are or have been intimate partners or

family members, regardless of gender or sexuality. Includes

coercive control, controlling behaviour, female genital

mutilation, forced marriage, and honour based violence

(Home Office)

Domestic violence

Substance misuse

Intoxication by, or regular excessive consumption of

and/or dependence on – psychoactive substances,

leading to social, psychological, physical, or legal

problems. It includes problematic use of both legal and

illegal drugs including alcohol (NICE)

Includes a range of conditions including:

Depression and anxiety, psychotic illnesses such as bipolar

disorder and schizophrenia, and may also be associated

with alcohol or drug use, personality disorder, and

significant physical illness (Working Together)

Mental ill-health

Domestic violence

IMPERATIVE – Where one toxic trio ingredient is

identified, practitioners must proactively look for the

other two since: •Rarely exist alone (Working Together); studies show 3/5 children’s cases have 2

toxic trio ingredients; all 3 toxic trio ingredients are present in ¼ children’s cases

•Complex interaction between the 3 toxic trio ingredients – need to understand the

root cause

•Toxic trio are the most common issues in SCRs (OFSTED) and highly prevalent in

DHRs (Home Office)

Think Family and Carer Issues

Sandra Ashton-Jones and

Lorraine Millard

TJoinLearning Event 2016



Think Family

Don’t see people in isolation, think of the wider

family networks

Make the links with the people directly involved with

the individual e.g family members, carers,

professionals

Don’t make assumptions- check out each family

member’s circumstances


Carer Issues

Carers’ Assessments must be offered to all informal

carers who are involved in providing support to an

individual.

The insights and information available from families,

carers and informal networks must be central to care

planning processes and risk assessment.

Need for realism as to the level of care that can be

offered


36 © SafeLives 2015

DHR/SCR/SAR Learning Event

Wolverhampton

Information Sharing & Risk 3rd March 2016

Dawn Williams

& Judith Vickress


Risk identification is…..

… the process of looking at what the possible

outcomes might be from any identified hazard or threat, using a combination of known information

and informed judgment. (Regan et al 2007)

CAADA Risk Training


38


Risk Assessment


Methods to identify risk

Visible Risk

predicting from knowledge.

based on risk factors. uses a tool and evidence based approach. informs professional judgement.

Professional Judgement uses knowledge & professional experience. can be based on victims perception. utilises observation and assessment.

Escalation in severity and frequency


Professional judgement points:

• Is the person minimising?

• How frightened are they?

• Sadistic forms of abuse?

• Abuse not captured by RIC?

• Is diversity impacting on disclosure?

• Escalation?

• Lack of resources and wider needs?

• What is my gut feeling?


5 Steps to a Professional Judgment


CAADA MARAC Chairs Workshop

At the heart of a MARAC is the working assumption that no single agency or individual can see the complete picture of the life of a victim, but all may have insights that are crucial to their safety. A victim identified at high risk of serous harm or homicide needs a coordinated, multi-agency response with all agencies sharing relevant information to develop an action plan that is comprehensive, robust and addresses the risk to all parties.

The Primary focus of MARAC


Safety Planning

• Collaborative process

• Identifying and increasing harm reduction

• Empower individuals

• Increasing resilience

• Identifying sources of support (professional and

personal)

• Evidence your actions

• Prepares victim for ‘worse case’ scenarios - DA


Marac – positive outcomes for victims

65%

21%

14%

65% of victims experienced a

reduction in police call outs. 45%

had a total cessation of police call

outs, 20% reduced from an

average of 6 callouts before the

MARAC to 2 after 21% of victims experienced no

change in the number of police call

outs. 10% had none before or after

the MARAC, 11% had an average

of 2 before and 2 after

14% of victims experienced an

increase in the number of police

call outs. 4% went from none

before the MARAC to 1 afterwards,

10% had an average of 3 before

and 6 after


A place of greater safety Key findings: outcomes of the high risk approach

63% of adult high risk

victims report a cessation of

abuse following support from

an Idva

69% of victims report that

their quality of life has

improved

The more intensive the

support, the better the victim

outcomes


No 61%

Yes 33%

Missing 6%

Yes 59%

No 41%

Mental health problems Specialist service

involved at intake

No 89%

Yes 6%

Missing 5%

Yes 51%

No 49%

Drugs misuse Specialist service

involved at intake

No 85%

Yes 10%

Missing 5%

Yes 45%

No 55%

Alcohol misuse Specialist service

involved at intake

Pressure on the system

• 31% of Maracs have caseloads above

the recommended 40 per 10,000 adult

females

• 20 Maracs are currently operating at ‘high

volume’ levels

• ‘High volume’ = either 50+ cases per

10,000 adult females or more than 520

cases per year


- Social Care

- Police

- DV specialist (Idva)

- Substance Misuse specialist

- Mental Health specialist

Family &

friends

Statutory

Agencies

Voluntary

Agencies

Local Assessment Framework - a Common Understanding of Assessment such as BRAG Assessment*

MAPPA

Marac

Any safeguarding concern One Front Door

Blue

Low or

No Risk

Red

High

Risk

Amber

Medium

Risk

Green

Standard

Risk

Safeguarding

Self -

referrals

* Highest risk takes precedence

Identification

Assessment

Action

Fluid assessment linking children and adults simultaneously at the earliest opportunity

With consent

Advice and

Information

With or without consent

Multi Agency /

Strategy meeting

Social Care

Substance

misuse

Police

Probation

Housing

Mental health Health

DV

Specialist

(Idva)

Without consent

Statutory or

Voluntary

Agencies

Troubled

Families


How we can move forward

Improve links between

safeguarding forums

Induct and train participants so they

continue working together

Hard-to-reach groups

0.9% of cases heard

involve LGBT victims

1.8% involve 16-17 year

olds

3.6% involve a victim with

a disability

Understand why there is

high volume in order to

reduce it


45% alcohol misuse

41% drug abuse

32% mental health problems

Ensure visibility of perpetrators – which

services might they use?

Targeted enquiry in

universal services

% 0.05…

½ Pay attention to the data!

How we can move forward (2)

Closing Remarks


Alan Coe Chair of Adults and Children's

Safeguarding Board


Joint Learning Event - Wolverhampton Safeguarding · 2020. 6. 11. · April to September 2015 ......

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Transcript of Joint Learning Event - Wolverhampton Safeguarding · 2020. 6. 11. · April to September 2015 ......