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Paragraphs: 8.1 - 8.9
| 8.10 - 8.19 | 8.20 - 8.31
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8.1
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Enfield Social Services had case responsibility for Victoria for
just over 24 hours - from 3.15pm on Monday 26 July 1999, when she
was referred to the North Middlesex Hospital social work team, until
4.30pm on Tuesday 27 July 1999, when they transferred responsibility
for the case to Haringey Social Services.
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8.2
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That the local authority of Enfield had any involvement with Victoria
at all was largely a matter of history and geography. The North
Middlesex Hospital is in the borough of Enfield, just north of the
Haringey border and about 12 minutes' walk from Haringey's North
Tottenham District Office. Karen Johns, the Enfield hospital social
worker allocated to Victoria's case, thought that about 75 per cent
of the children admitted to the North Middlesex Hospital came from
the borough of Haringey. Yet in 1999, Haringey employed no social
workers at the hospital. That has since changed.
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8.3
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At that time, Haringey had an arrangement with Enfield Social Services
whereby Enfield children and families' social workers would provide
basic initial services for Haringey children admitted to the hospital
before the cases were passed to Haringey. The arrangement was set
out inadequately in a two-page minute of a meeting held between
the two agencies in July 1996. It was modified following a further
meeting in September 1996.
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8.4
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The location of such a key operational protocol in a set of minutes
was not ideal, and I shall return to the content later. The arrangement
should have been set out in greater detail as part of Enfield's
or the hospital's updated guidelines. At the time, the hospital
social work team was expected to follow procedures set out in a
variety of written documents, some of which were out of date. These
included:
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•
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the Enfield Child Protection Guide, published
in August 1996, which required that in child protection cases an
inter-agency case conference should be held before a case is transferred
to the responsible area team;
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•
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the protocol setting out the arrangement between Haringey and Enfield,
which although produced at around the same time, envisaged a lesser
scale of Enfield involvement;
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•
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the North Middlesex Hospital child protection guidelines of 1998.
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8.5
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Also available were the Haringey child protection guidelines, which
might be thought to have more than a passing relevance to Haringey
children admitted to the hospital and referred on to Haringey Social
Services. However, according to Ms Johns, these were not followed.
Instead the hospital social workers relied on the protocol between
the two agencies and the brief and less than adequate North Middlesex
Hospital procedures.
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8.6
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Lesley Moore, the seconded assistant director for children and
families from July 2000, did not seek to defend the "poor state
of procedures and arrangements". She admitted, "Although staff had
access to the right people to give them advice about what should
happen and what was in current guidance, it was not readily available
to them in the form of accessible written practice, guidance and
procedure."
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8.7
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I would go further and say that the profusion of guidance in various
documents relating to the different agencies made it very unclear
what was expected of front- line staff. Even worse for Haringey
children was the confusion over where Enfield's responsibility ended
and Haringey's began. The inadequacy of this arrangement potentially
put the safety of children at risk. Therefore, I make the following
recommendation:
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Recommendation
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Directors of social services must ensure that staff working with
vulnerable children and families are provided with up-to-date procedures,
protocols and guidance. Such practice guidance must be located in
a single-source document. The work should be monitored so as to
ensure procedures are followed.
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8.8
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Although Ms Johns thought that 60 to 70 per cent of the referrals
she dealt with were Haringey children, she admitted Enfield responded
to them differently from Enfield children. Moreover, when faced
with competing pressures in 1999 owing to staff shortages, she sometimes
felt obliged to give priority to an Enfield child over a Haringey
child. Indeed, Enfield's own management review of Victoria's case
found that the issue may not have been about the quality of Ms Johns's
practice but about how Enfield social workers at the North Middlesex
Hospital regarded Haringey cases at the time. Perhaps not surprisingly,
Ms Johns said in evidence that she thought the arrangement with
Haringey was "not the best arrangement" and that Haringey should
have employed their own social workers at the hospital.
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8.9
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These were not the only issues of concern for the North Middlesex
Hospital social work team in the summer of 1999. There were long-standing
staff tensions within the team and there were tensions between the
team and the North Middlesex Hospital medical staff, all of which
drifted without resolution, in some instances for years. Indeed,
the evidence pointed to a complete lack of management grip on any
of these issues. As a result, there was a vacuum created by the
absence of responsible, managerial decision-making.
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Paragraphs: 8.1 - 8.9
| 8.10 - 8.19 | 8.20 - 8.31
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8.10
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None of this was helped by the line management and accountability
arrangements that existed at the time. Since 1997, there had been
two specialist social work divisions within Enfield, one for adults
and one for children and families. The hospital social work team
had stayed in the adult division as it consisted predominantly of
social workers dealing with adults. Therefore, the assistant director
for adult services managed all hospital social work.
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8.11
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The next in command was Lesley Howard, service manager for hospitals
and health liaison from April to August 1999. Ms Howard was responsible
for the line management of both hospital social work team managers
at Chase Farm Hospital and the North Middlesex Hospital. While she
was experienced in both adult and children's social work, she had
limited experience and training in child protection work. As a result,
temporary arrangements were put in place to ensure team leaders
and social workers at the hospital could access support and guidance
from colleagues in the community children and families' division.
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8.12
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In July 1999, Lesley Carr was appointed as the new intake and assessment
manager for children and families, reporting directly to the assistant
director of the children and families' division. Ms Carr was given
the specific task of bringing the children and families' hospital
social workers at both Chase Farm Hospital and the North Middlesex
Hospital within the fold of the children and families' division.
Ms Johns was one of only four and a half full-time equivalent hospital
social workers specialising in children's work at the time. By the
time Ms Carr left her post in October 2000, she had still to complete
this task. Indeed, it was not until April 2001 that the hospital
social workers specialising in children and families were finally
brought under the wing of the children and families' division.
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8.13
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As a result, during her time in office Ms Carr assumed no management
responsibility for children's social work within the two borough
hospitals. Her role was "mainly consultancy in terms of service
delivery". She would advise on particularly complex childcare cases
but only when asked to do so. It was not her job to routinely check
case files or to do random samples of the quality of a social worker's
work. That was the province of the line managers within the adult
division.
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8.14
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However, this was not a perception shared by Ms Howard. In terms
of her own children and families' work, Ms Howard saw her role as
being responsible for management and staffing issues. While ultimately
responsible for practice issues, she was happy for the team leaders
to seek support through "the informal channels that had been put
in place". Thus it seemed that there was nobody above team manager
who routinely and actively monitored the childcare practice of the
hospital social workers.
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8.15
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I was presented with a number of reasons as to why it took almost
two years to move the children and families' social workers. Decisions
had yet to be made as to whether the move would be accompanied by
a physical move of the social workers away from the hospital site
to Edmonton Social Services office. The hospitals did not favour
such a move because they saw value in retaining easy face- to- face
communication with hospital-based social workers. On the other hand,
the alternative solution was the integration of the referral and
assessment team. This would have given Enfield greater flexibility
in allocating its resources, particularly during periods of staff
shortage. Ms Carr told the Inquiry:
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"Part of it was to do with disentangling the bureaucracy around
the paying of staff and around the budgets. Part of it was around
the fact that we would be taking these staff on with no managers
at all. Part of it was linked to the retirement of managers and
part of it was linked to not having sufficient managers based in
Edmonton and no structure to actually take on the work, and part
of it was very much based on concerns the hospitals were raising
about moving the hospital children's social workers out of the hospital,
the biggest difficulty being if they were based, as they were, in
the two hospitals, providing cover between them would have been
a very difficult business. There were insufficient numbers to actually
do the job properly and that was really what held up a lot of things,
was trying to ensure we had enough finances to be able to staff
it adequately and run a good service, and it was not something we
could actually change overnight, much as I would liked to have."
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8.16
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Two years could hardly be said to be "overnight". Far more damaging
was the admission that the team was insufficiently staffed and had
inadequate children and families' team management capacity to do
the job properly.
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8.17
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Ms Carr also suggested the changeover was held up until after budgets
could be restructured in April 2000. She acknowledged that budget
restructuring was purely an accountancy exercise within the same
organisation and did not involve a big transfer of money or a change
in conditions of service. However, she had no answer as to why someone
with line management responsibility simply did not force the transfer
quickly.
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8.18
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By the time Ms Moore arrived in post, the proposal on the table
was to pull the social workers from the hospital and relocate them
in the community. She considered this unacceptable and was therefore
partly responsible for putting the emerging plans on hold. She felt
that the management transfer was slowed because of complex plans
to reorganise the whole social services department. She said, "It
was not just a question of throwing the hospital teams up in the
air and deciding where they may land in a better place, but also
all the teams right across the community in adults' and children's
services." There were difficulties with senior management agreeing
what that structure should look like, although Ms Moore thought
these were beginning to resolve themselves by October 2000. At that
time, management were "pulled up in [their] tracks by two things".
First, the director was taken ill very suddenly and was off sick
for a substantial period of time. Second, there was a major financial
crisis that occupied senior management's attention. Extreme measures
were put in place and eligibility criteria were tightened, with
all the associated political issues. According to Ms Moore, "The
whole of senior management's group time was taken up in dealing
with the practicalities of that and putting straight so that we
did not end up without the money to run a service."
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8.19
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With the appointment of an interim director in January 2001, and
the worst of the financial crisis behind them, Enfield's senior
management team revisited the structural reorganisation. When it
finally came, the decision to relocate the hospital children's social
work teams took three months to implement. This, according to Ms
Moore, was "as fast as we could humanly function from that point
on". Therefore, I make the following recommendation:
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Recommendation
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Directors of social services must ensure that hospital social
workers working with children and families are line managed by the
children and families' section of their social services department.
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Paragraphs: 8.1 - 8.9
| 8.10 - 8.19 | 8.20 - 8.31
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8.20
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The fact that hospital social workers were managed by the 'adults'
team within social services led to a lack of clarity as to who was
responsible for ensuring hospital social workers attended hospital
meetings. Had there been effective line management, this unsatisfactory
state of affairs would have been resolved.
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8.21
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These tensions came to a head over social worker non-attendance
at hospital meetings, particularly the Monday afternoon psychosocial
meetings. The weekly psychosocial meetings were arranged to be held
at the North Middlesex Hospital on Mondays at 2pm. The meetings
took, on average, one and a half to two hours and, according to
Ms Carr, looked at every child in the ward. Enfield social workers
were supposed to attend. Indeed, attendance at multi-agency meetings
was an intrinsic and important part of a social worker's role and
this expectation was clearly set out in the hospital social workers'
job descriptions. The meetings were supposed to be a valuable forum
for the exchange of information between medical staff and hospital
social workers. Ms Carr said that information exchange "helps to
give a more complete picture for the social worker who is doing
an assessment". Ms Carr added:
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"It allows a much wider understanding of a range of issues
that are going on and certainly helps the social workers to understand
the medical perspectives, and it also helps the social worker in
interpreting the medical understanding for parents and for supporting
other parents and children while in hospital."
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8.22
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However, by the time Victoria was admitted to the North Middlesex
Hospital, Enfield's hospital social workers had long since ceased
to attend both the psychosocial meetings and the weekly non-accidental
injury forum on Tuesdays. On instruction from the team managers,
Cynthia Lipworth and Pat Dale, the hospital social workers ceased
attending these hospital meetings as long ago as February 1998.
They were not to resume attendance until May 2001, a period of over
three years altogether. Hospital medical staff were less than happy
with this. The evidence of Nurse Beatrice Norman and Dr Mary Rossiter
suggested that the hospital staff placed greater value on these
meetings than the social workers did.
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8.23
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Although the instruction to cease attendance had come from the
team managers, it appears to have been driven by the social workers
themselves. Evidence from Ms Carr, Ms Lipworth and Ms Johns all
suggested that when social workers did attend, they felt deskilled
and devalued. They felt their professional expertise was not appreciated,
their opinions were not always heard, time was not always provided
for their feedback, and meetings were not clearly structured. There
was also a concern that the meetings were used to shortcut the formal
routes for referrals of work from medical staff to Enfield Social
Services.
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8.24
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Ms Carr felt the problem "should have been resolved and should
have been resolved at the beginning", but she also said, "There
were a number of what is probably best to describe as difficulties
within personalities of the staff involved ... [By July 1999] the
position had become pretty intractable and it was not going to be
solved overnight." She did not think forced attendance would necessarily
have aided communication. Instead she said she tried to work with
the consultant paediatricians to formalise the meeting process.
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8.25
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Ms Carr felt the social and medical staff misunderstood each other's
roles, which hindered communication. There were problems getting
busy people, particularly Dr Rossiter, to look at the issues closely.
Ms Carr scheduled a number of meetings with Dr Rossiter and Dr Naidoo,
a consultant child psychiatrist, but they were "occasionally cancelled
at short notice" because there were other issues on the agenda and
these matters tended to slip down. Ms Carr did have a number of
meetings with Dr Rossiter to look at changing working practice as
a whole. While the psychosocial meetings were part of those discussions,
Dr Rossiter was more concerned about other issues and, according
to Ms Carr, those "took up a lot of the discussion time in the early
days".
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8.26
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When pressed, Ms Lipworth agreed that the non-resolution of social
work attendance at these hospital meetings had become a big issue.
She accepted that it was her responsibility to take the problem
up the management chain until it was resolved. Ms Lipworth had attended
one of the meetings herself to confirm the social workers' perceptions
and she was sure she would have taken the matter up with her line
managers, but she could not recall those discussions.
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8.27
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Ms Moore also partly blamed the organisational structure. Staff
from the children and families' division were aware of the issues
and had been involved in meetings to resolve the conflict, but because
they had no line management responsibility they "pushed the issue
across to adults [division] who should have been the ones that made
the decision". Ms Moore emphasised the problems that existed within
the organisation about decision making:
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"There were certainly more discussions about issues than there
were decisions about issues ... and some of the issues did not get
resolved. What was needed was a decision. Once I was aware that
there was a problem, a decision was made and the meetings have resumed."
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Therefore, I make the following recommendation:
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Recommendation
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Directors of social services must ensure that hospital social
workers participate in all hospital meetings concerned with the
safeguarding of children.
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8.28
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According to Ms Johns, by the time Victoria was admitted to the
North Middlesex Hospital, workloads were "high but not overwhelming".
Others disagreed. With hindsight Ms Moore thought the workload was
very high at the time, with caseloads exceeding 12 per worker. As
a result, she thought there were some cases "which did not receive
speedy enough and adequate enough attention".
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8.29
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When the specialist children and families' staff were overstretched,
adult care workers at the North Middlesex Hospital would provide
services to children and families as back-up, as would the hospital
social workers at Chase Farm Hospital and the community social workers
in the Edmonton Centre. However, as Ms Carr pointed out, back-up
staff would then have to adapt to a new environment and new procedures,
which was invariably problematic.
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8.30
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Ms Johns was an experienced social worker who had been with the
Enfield hospital social work team for nearly five years. She was
one of only two and a half full-time equivalent children and families'
social workers in Ms Lipworth's 10-strong team (nine full-time equivalents)
at the North Middlesex Hospital. By July 1999, she worked primarily
in antenatal, postnatal and general paediatric social work. She
had recently returned to work after a month's sick leave from work-related
stress caused, she believed, by strife within the team. Ms Johns
described difficulties caused by absences and sickness of other
full-time staff. Ms Johns also stated that there was "chronic conflict
and tension" between staff, including her own line manager Ms Lipworth.
As with much else that required managerial resolution in the North
Middlesex Hospital social work team, this staffing issue was left
unaddressed until June 2000.
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8.31
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However, Ms Johns was quite clear that these matters in no way
influenced her handling of Victoria's case, nor did she rely on
work pressures at the time or the availability (or otherwise) of
professional advice to explain her actions.
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