Stockport review

The case highlights a number of missed opportunities in relation to safeguarding the children in this case. The Panel recommends that the Local Safeguarding Children Board should initiate a multi-agency practice review of safeguarding children living in families where there are multiple complex needs and where one or both of the parents have mental health problems.

The needs of MVD1 were not fully assessed or responded to. Despite her significant responsibilities as a young carer, and the fact that she lived with two vulnerable adults and three siblings with chronic medical conditions, she was not an open case to CSC, having never received a CAF assessment. As recommended in 1a above, the LSCB should ensure that the learning review considers the fitness for purpose of multi-agency policies and procedures in relation to the needs of Young Carers. Following the learning review all agencies should update their policy in relation to supporting young carers, recognising and meeting their specific needs.

As part of the LSCB learning review the processes and systems for information sharing with voluntary sector agencies should receive focus. This should ensure that voluntary and third sector agencies have equal access to relevant information to safeguard vulnerable adults and children.

The CCG should be assured, by audit evidence, that the training delivered to and the supervision received by Pennine Care NHS FT (Mental Health) staff thoroughly explores the impact of adult mental health on parenting capacity including staff’s responsibilities if concerns are identified.

The victim was advised to refer to alcohol services and consented to this however, current practice does not require self-referral advice to be followed up by services. The DHR panel recommend that it would be good practice to initiate referrals in cases where the adult is particularly vulnerable or high risk (i.e. where there has been a serious attempt at self-harm). The Drug and Alcohol Joint Commissioning Group should develop the assessment and referral pathways for alcohol misuse where there are co-factors of mental health and domestic abuse. The aim should be to ensure that high risk adults with complex needs are referred to services and that the referral is followed up

Developing the skills and capacity of the local workforce in relation to identifying, referring and responding to domestic abuse is key to the success of the local domestic abuse strategy. The Safer Stockport Partnership should give specific focus to workforce development in its revised domestic abuse strategy, the focus should be on ensuring that all agencies build confidence amongst their workforce in dealing with domestic abuse.