Thematic review of five cases involving non-accidental injury to infants under 1-year-old. Themes include: local effectiveness of system wide, universal and early intervention programmes; the scope of midwifery involvement and relationships with parents; commissioning and contracting midwifery services with clinical commissioning groups; quality assurance mechanisms, practice audits and service quality with parents and babies under one-year-old; the effectiveness of intra-agency working, transitions, handovers and information sharing; professional recognition of the inherent vulnerability of babies under one-year-old; professional recognition, triggers and intervention thresholds and the nature of response to vulnerable families; pre-birth assessments and thresholds for Continuum of Need; the importance of adopting a Whole Family approach; and how well the role of fathers and the importance of engagement is recognised by professionals. Learning includes: the early months of infant life can be a period of potential maximum risk to the infant; ensure there is a secure, universal first line of defence, for example an ante- and post-natal safety planning programme such as ICON (an early intervention programme designed to prevent abusive head trauma, which addresses caregiver frustration with crying infants); additional first lines of defence involving universal services such as midwifery, general practitioners, and health visiting could complement and reinforce early intervention programmes; fathers and male care givers can be marginalised by some agencies, they should be routinely included in service interventions, notwithstanding considerations of any safety issues around domestic abuse, coercion and control.
      
 Title:  Thematic review: the non-accidental injuries to babies under one year old. LSCB: Cheshire West and Chester Safeguarding Children Partnership Author: Paul Sharkey Date of publication: 2022  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                             Cheshire West and Chester Safeguarding Children Partnership                       Final Report        Thematic Review: The Non-Accidental Injuries to Babies Under One Year Old               Independent Author and Reviewer: Paul Sharkey (MPA)                            October 2021        1   Contents Page  Introduction and Purpose of Review      2  The Five Infants         2  Overarching Review Questions, Key Themes and Scope   3  Panel Composition        4  Context and Literature Review: Non-Accidental Injuries to Infants  5  Abuse Head Trauma        5  Themes; Analysis, Findings and Recommendations    8  Early Intervention Programmes: ICON     8  Non-ICON Services        12  Midwifery Services        15  Midwifery Services: Commissioning and Contracting   19  Vulnerable Families and Safeguarding Pathways    20  Pre-Birth Assessments       21  Engagement of Fathers and Male Care Givers    22  Professional Disagreement: Challenge and Escalation   23  Summary and Conclusions       23  Key Lessons for Policy and Practice: Locally and Nationally  24  Glossary of Terms        25  References         25  Appendix 1 (Methodology)       26                     2    Cheshire West and Chester Safeguarding Children Partnership        Thematic Review of Non-Accidental Injury to Babies Under One Year Old1   1. Introduction and Purpose of the Review  1.1 This thematic review was commissioned by the Cheshire West and Chester Safeguarding Chil-dren Partnership (herein referred to as the Partnership) on the 27 September 2019. It followed inci-dents earlier in the year of non-accidental injury (NAI), whilst in parental care, to five babies under one year old; two of whom were subject to rapid reviews.  1.2 Given the cluster of NAI episodes, the Partnership came to the view that greater learning could be gained by undertaking a thematic review, rather than separate child safeguarding practice re-views. Its purpose was to,  ‘Identify any improvements required to policy and practice, so as to maximise the safeguarding of babies under one year old; by undertaking a systemic analysis of emerging themes coming from several instances of recent non-accidental injury and serious harm to infants in Cheshire West and Chester’.   1.3 An independent reviewer was commissioned in January 2020 to undertake the review and a panel was duly convened by the Partnership Business Manager. There was an intention to have completed the review by July 2020; within the six months set down by Government Guidance in ‘Working Together 2018’. Unfortunately, this was not possible due to the advent of coronavirus 19 in early 2020 and the resultant Governmental public health measures in March, restricting contact, in addition to the increased pressures on professionals’ time.   1.4 The Panel met in late February 2020 with the lead reviewer to scope the review and develop some terms of reference, key lines of enquiry and significant themes. These were agreed at its May 2020 meeting.   2. The Five Infants  2.1 It was not the intention of this review to conduct detailed analysis of individual infants, but the panel felt it was necessary to understand sufficient about each of their lived experiences to be able to identify key themes that warranted further exploration within the review. Two of the infants were the subjects of Rapid Reviews and therefore Panel considered both reports which were based on a range of multi-agency information and identified local learning. For the other three infants, Panel utilised information contained in Children’s Social Care Records and the Children and Families As-sessments which were completed in response to the injuries they sustained. This has enabled the panel to draw on multi-agency information shared with Children’s Social Care. 2  2.2 The infants in this review were all born healthy, and none were considered premature. One infant is known to have suffered with reflux, there were no other health conditions noted prior to injuries.  The infants ranged in age from 3 weeks to 12 weeks old at the time they sustained their injuries. All five infants were male and White British. Only one of the infants lived with a sibling, the others were first born to their parents. Two of the five infants were planned pregnancies, although it is noted that  1 Herein, referred to as ‘Infants’.  2 NB. The families of the infants have not been involved in this review, most notably because the Police investigations in respect of the two infants subject to the rapid reviews are ongoing.  3 the parents of the other three infants all described feeling happy and excited at the prospect of becoming parents.   2.3 The injuries sustained by the infants varied in nature and severity and as a result, so too did the long-term impact of their injuries. Two infants suffered injuries consistent with Abusive Head Trauma (AHT), with resultant brain injury and significant ongoing health needs. One infant suffered a frac-tured skull as a result of falling from a table the parent had placed the baby on. This infant had been included in the review as the initial accounts from parents were not consistent with the nature of the injuries. It was subsequently accepted that the injuries were unintentional but reflective of a serious lapse in judgement. One infant had evidence of bruising to the face and two fractured ribs.   2.4 Four of the infants lived with both biological parents at the time their injuries were sustained; one infant lived with mother in supported accommodation. Two sets of parents were also noted to live with the infant’s grandparents (although it is recorded that neither grandparents were at home when the incidents occurred).  The review heard that three of the infants were believed to have been injured by their fathers. This is based on self-report or police charges which at the time of writing (September 2021) are awaiting trial. One of the infants could have been injured by either parent and one of the mother’s was charged with neglect; again the matter is yet to be tested in court.   2.5 One or both parents for three of the infants had a history of offending and it was deemed relevant to note that these included acts of violence or public disorder perhaps indicative of poor anger man-agement. It is also notable that only one of the infants was open to Children’s Social Care at the time the injuries were sustained; the other four had not been known or previously referred in respect of safeguarding concerns. However, this was contested in one of the rapid reviews as the hospital stated that they had contacted Children’s Social Care and were told the concerns did not meet the threshold. However, Children’s Social Care has no record of this contact. As such, four of the infants had no pre-birth assessment completed prior to their arrival.   2.6 What is apparent is that for three of the infants, at least one parent, and in one instance both parents, had been known to Children’s Social Care when they were children. Two parents of different infants had themselves been children in care. Even for those parents with no prior involvement with services, information available to the panel indicated that for four infants, one or both parents had experiences of Adverse Childhood Experiences (ACEs) as they grew up. This included death of their parents, witnessing domestic abuse between their parents and being victim of sexual abuse and neglect.   2.7 The review explored the presence of the complex trio (parental substance misuse, domestic abuse, mental health) and noted that there was evidence of domestic abuse in only one couple’s relationship. Parental substance misuse was a factor for two infants and parental mental health fea-tured for three of the infants; for one baby this was a factor for both parents. The review also explored the prevalence of parental learning difficulties and noted two infants had a parent that had learning difficulties, one of whom had attended a special school as a child.    2.8 The review heard that since commissioning this thematic review two more infants had suffered non-accidental injury. The review had progressed too far for the children to be included but learning from the respective rapid reviews was used to shape the questions asked of practitioners for this review and forms part of the wider learning identified through this review.    3. Overarching Review Questions  3.1 Having considered the five infants’ individual circumstances the panel set out to explore the following overarching questions and identified a number of key themes (as set out in 3.5 below).  3.2 What arrangements are there to safeguard the babies from harm and promote their welfare?   4 3.3 What support is available to babies under one and their parents/carers and what does it look like?   3.4 How effective is the current service offer to babies under one and their families, including those deemed vulnerable?          Key Themes  3.5   (i) Local effectiveness of system wide/universal/early intervention programmes. (ii) The scope of midwifery involvement and relationships with parents. (iii) Commissioning and contracting midwifery services with Clinical Commissioning Groups. (iv) Quality assurance mechanisms; practice audits and service quality with parents and babies un-der one year old.  (v) The effectiveness of inter-agency working; transitions, handovers and information sharing. (vi) The professional recognition of the inherent vulnerability of babies under one year old.  (vii) The professional recognition, triggers and intervention thresholds and the nature of response to Vulnerable families.  (viii) Vulnerable Families and Safeguarding Pathways; HCP, NICE and Working Together 2018 Guidance. Are they present locally and how is ‘vulnerable’ defined and understood?  (ix) Pre-birth assessments and thresholds and Continuum of Need.  (x) The importance of adopting a, ‘Whole Family’, approach.  (xi) How well is the role of fathers and the importance of engagement recognised by professionals?  (xii) The role of Public Health messages (I-CON, Don’t Shake the Baby, Safe Sleeping) (xiii)  Challenging assessments and decisions of I-ART3 as expert.   Scope  3.6 The review focused on infant NAI and excluded sudden unexpected death in infancy (SUDI) 4, albeit there are overlapping themes. In this respect, the Child Safeguarding Practice Review Panel (henceforth referred to as the, SUDI report; July 2020) report contains a wealth of insights and learn-ing relevant to this review.  4. Panel Composition  Senior Manager, Safeguarding and Quality Assurance Unit-Cheshire West and Chester  Police Reviewing Officer, Cheshire Police Designated Nurse for Safeguarding Children, Cheshire Clinical Commissioning Groups Senior Manager, Cheshire West and Chester Children’s Social Care Senior Manager, Early Help and Prevention Cheshire West and Chester Designated Doctor for Safeguarding and Child Deaths Service Manager, Safeguarding Children in Education Business Manager, Cheshire West and Chester Safeguarding Children Partnership Business Co-Ordinator, Cheshire West and Chester Safeguarding Children Partnership Independent Lead Reviewer/Chair: Paul Sharkey5     3 Integrated Access and Referral Team 4 See the Child Safeguarding Practice Review Panel; July 2020; Final Report; ‘Out of Routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk off significant harm’ 5 Mr. Sharkey had no prior involvement with the CWAC SCP or any of the constituent partner agencies.   5 5. Context and Literature Review: Non-Accidental Injuries to Infants  5.1 Non-accidental injury (NAI) is defined as ‘any abuse inflicted on a person or knowingly not pre-vented by a care giver (where) the injury is not consistent with the account of its occurrence’ (Rizwan.M et al, 2017). NAI is a significant cause of injury to children under 2 years old (Davies, C. et al: 2018); with 76.3% of severely injured children suffering trauma because of suspected child abuse occurring in infants under the age of one. Brandon et al (2016) found that ‘infancy remains the period of highest risk for serious and fatal child maltreatment; there is a particular risk of fatality for both boys and girls during infancy ’(p.40).   5.2 Common forms of infant NAI typically include head injuries (abusive head trauma/AHT) through shaking, skeletal fractures (especially to ribs, vertebrate and limbs), thermal injuries (burns, scalds and acid), ingestions and poisoning (bleach, methadone, drugs and salt), soft tissue injuries (bruises, bites and lacerations) especially to non-independently mobile infants, asphyxiations and cardiac ar-rest.  5.3 Two of the five infants (both of whom were subject to rapid reviews) suffered abusive head trauma (AHT) at four and five weeks respectively. 6       AHT: Definition and Incidence  5.4 Turning firstly to abusive head trauma (AHT) or shaken baby syndrome (SBS). This is a severe form of child maltreatment that can often have serious or even fatal consequences for infants and is the number one cause of death (Taylor et al/Birmingham Children’s Hospital). It is defined as, ‘an injury to the skull or intracranial contents of a baby or child younger than five years due to intentional abrupt impact and/or violent shaking incidence of infant’ (Lopes et al: 2013). AHT incidence in the UK is up to 25/100,000 live births per year (Jones, 2020) rising to 36/100,000 in babies under six months (Smith: 2016). Smith (2016), states that AHT affects one in 4000-5000 infants per annum and that, in practice, an average size district general hospital in the UK can expect to see a case every one or two years.  5.5 Given the above incidence and frequency it was of some concern that the two infants mentioned above suffered AHT in close proximity and presentation; thankfully (so far as is known) with no iden-tified long-term effects.        Consequences of AHT  5.6 Typically, AHT can result in bleeds in the brain and behind the eyes (subdural hematoma, retinal hemorrhage), fluid build-up around the brain causing intra-cranial pressure (brain edema), and sometimes fractures of the long bones or ribs, with little or no evidence of trauma (Barr:2018). Lopes et al (2018) cite a (US) figure of 25% -30% of children who die from AHT and only 15% who survive without any significant consequences. Immediate effects include respiratory arrest or impairment, irritability, seizures, stiff posture, decreased levels of consciousness, vomiting, decreased appetite, an inability to suck or swallow, cardiac arrest, or death. Long term outcomes can include, learning difficulties, vision problems (including blindness), hearing and physical disabilities, cerebral palsy, speech problems, seizures, cognitive impairment, and death.   5.7 Although AHT can occur in older children and even in adults, around 80% of cases occur before the age of one year (Barr: 2018) with a peak incidence at around three months. Victims are predom-inately male (Child Abuse Review; May-June 2020) 7. One in fourteen cases is fatal before hospital discharge and half of severely injured survivors will die before the age of 21 (Smith: 2016). Lopes et al (2018) suggest that infants have an increased susceptibility to serious injury at between two to four months because compared to older children, babies are more often alone with their care givers, need constant care and cannot provide reports on their history. The increased susceptibility to AHT  6 See section 2 above  7 All of the five infants in the current cohort were male.   6 is due to the infant head being relatively bigger and the brain relatively heavier for their body. Also, neck muscles are not yet fully developed and strengthened, since the ability to sustain the head upright develops around 2-4 months of life.    Risk Factors   5.8 Smith (2016) references two studies suggesting that males represent 70% of perpetrators and that fathers and male surrogates are nearly five times as likely as mothers to shake an infant.8 Other risk factors include, lone parent families, families from low socio-economic backgrounds, societal and family stress ( domestic abuse, parental mental health and substance misuse), multiple births, developmental delay and a childhood history of abuse/adverse childhood experiences (ACE) with the perpetrator ( Barr:2012, Lopes: 2013). Additionally, characteristics with the infant, such as being male, under one year old, prematurity and low birth weight appear to increase the probability of AHT. Race and ethnicity are not thought to be risk factors (Barr:2012).   5.9 Lopes et al (2018) cites a three-component model by Stephens et al (2012) as a means of un-derstanding the causes of AHT, namely, factors related to the infant, situational-pre-disposing- fac-tors and those appertaining to the caregiver; all of which interact and result in injury to the baby. Child development characteristics relating to the infant can include crying patterns and separation anxiety. Situational factors would include stressful situations related to social and familial isolation and lack of support, drug and alcohol misuse, domestic abuse, parental mental health, poverty and housing issues and difficulties in pregnancy. Care-giver factors may include lack of knowledge and inexperience concerning the baby’s normal pattern of crying, the inherent risks to the infant of shak-ing, frustration tolerance, lack of experience as a care giver to other children, psychopathological factors, and jealousy of the relationship between the baby and other care givers.   5.10   Within the interplay of the three-component model, the professional consensus (Child Abuse Review: 2020) suggests that the baby’s crying pattern appears to be the main trigger factor for the occurrence of AHT. Shaking by the care giver is used as a means of either calming the infant or disciplining. Several of the above risk factors were present in the circumstances around the AHT injuries to the two infants subject to the rapid reviews.  5.11 Of significant concern regarding shaking (in addition to the aforementioned serious damage to the infant) is the effect on both the perpetrator and the baby, compared to other forms of infant abuse. Barr points out that slapping a baby will usually result in the perpetrator experiencing a stinging sensation with a likely increase in the infant’s crying, thus signaling to the care giver that they have acted in an inappropriate manner, having lost control. Shaking is less likely to result in any pain sensation to the perpetrator, whilst often leading to the baby stopping crying due to the concussion like brain injury. The shaking dynamic reinforces a positive feedback cycle which rewards the care giver by improved infant behaviour (stopping crying) and no negative consequences to the care giver.   5.12 Barr suggests that this dynamic may promote repeated shaking over time thus seriously com-pounding the harm done to the infant. He cites evidence of 55% repeated shaking and a range from 2 to 30 times (with a mean of 10 times). Daily shaking occurred for several weeks in 20% of cases and was repeated because it stopped crying in all cases. A further consequence of AHT relates to the discrepancy between the incidence of clinically recognised and unrecognised cases, given that shaking may not always result in obvious signs of injury and damage to the baby. Less severe cases may not come to medical professionals’ attention and thus not diagnosed, leading to under recogni-tion of the maltreatment and an unknown number of infants developing milder forms of motor dys-function, sensory compromise, or cognitive loss (Barr: 2012).   8 See the very important and recently published ‘Safeguarding children under 1 year old from non-accidental injury; National review into babies seriously harmed or killed by their father male carer’, Child Safeguarding Practice Review Panel, 16.09.21. Also note 30 below.  7  5.13 Barr cites prior shaking in 30%-70% of cases at the time of AHT diagnosis, thus suggesting that significant abuse had happened without coming to medical attention. Even on first presentation 31% of cases were missed with 28% of the missed cases being repeat injuries following the original missed diagnosis. Barr concludes that, ‘Coupled with the high incidence of repeated shaking as a common care giver strategy, such observations reinforce the importance of primary and universal prevention strategies.     Infants’ Crying Pattern  5.14 It is well established that crying acts as a key communicating function in securing an infant’s survival, health and development with its caregiver. Studies (Lopes, 2018) suggest an infant crying pattern marked by an increase in the daily duration of crying in the first weeks of an infant’s life, reaching a peak at around the sixth week. Thereafter, there is a marked decrease in daily crying, with a corresponding decrease of inconsolable crying after the fourth month; the crying becoming more intentional and related to environmental events.   5.15 AHT is often likely to happen during the peak period of an infant’s crying at between 1-4 months. The crying appears to be inconsolable to the caregiver who feels that there is something ‘wrong’ with the infant (colic, being ‘naughty’), leading to overwhelming feelings of powerlessness, lack of control and frustration which then trips over into shaking and the quieting of the baby. The reinforcing effect for the care giver then results in repeated and multiple shaking episodes with devastating conse-quences for the baby. Additional studies established a direct relationship between peak infant crying and the incidence of AHT (Barr; 2012), thus demonstrating empirical evidence for infant crying as a precipitation factor in this form of infant maltreatment.   5.16 Most importantly, current professional thinking has re-interpreted inconsolable infant crying as a typical behavioural development in normal infants and not usually a sign of anything wrong or abnormal with the baby. AHT, within this perspective can be seen as the, ‘consequence of failure in an otherwise common, iterative and developmentally normal infant-care giver interaction’.  (Barr:2012:) Given this fundamental reframe of infant crying it can be seen that AHT is preventable.    Prevention of AHT  5.17 Following on from Barr’s conclusion in paragraph 6.13 regarding the importance of primary and secondary prevention strategies to counter the incidence of AHT, the professional literature (Rebbe et al: 2020; Smith:2016) suggests that Public Health can provide a useful framework for child mal-treatment prevention. The framework entails a four-stage approach starting with (1) surveillance to define the problem in the population, followed by (2) the identification of risk and protective factors in order to (3) develop and test protective strategies, which can be (4) adopted widely. Barr contends that, ‘prevention strategies need to be primary (delivered before occurrence) and universal (delivered to all parents of newborns and not targeted at just some parents)’ (Barr: 2012: 17298).  5.18 Essentially, there is a key window of opportunity for the prevention of AHT via a Public Health preventative strategy, broadly in line with the Prevent and Protect model (SUDI report; July 2020). This would aim to change the knowledge and behaviour of care givers, and society in general, re-garding the normal development of infants and the significance of early increased infant crying. Such a strategy needs to focus on two key issues, namely (1) teaching parents how to respond to infant crying and the attendant dangers of shaking babies - on a universal preventative basis; and (2) addressing social and professional factors related to AHT awareness and risk factor mitigation- when additional needs are identified and safeguarding is required (corresponding to CWAC Universal Plus, Partnership Plus and Statutory Social Work on the CoN)  5.19 Until recently, there was no instance of a fully co-ordinated multi-agency programme aimed at preventing AHT, albeit the NSPCC had launched a resource pack for professionals in 2016 (Protect-ing Babies and Toddlers). Smith (2016), following a study tour of the US and Canada in 2016 where  8 she studied several public health AHT preventative initiatives; subsequently developed the ICON9 programme. This has since been adopted in Hampshire, Gloucestershire, Lancashire and im-portantly to this review, Pan-Cheshire, including Cheshire West and Chester.    6. Themes: Analysis and Findings   6.1 The Effectiveness of Local System Wide, Universal, Early Intervention Programmes  The ICON Programme  6.1.1 This section will focus on the CWAC ICON programme as a public health approach to the prevention of AHT as a type of infant NAI, notwithstanding the other forms of injury mentioned above in paragraph 6.2; the prevention of which will be looked at in a later section.   6.1.2 The ICON programme is based upon four core principles, namely that infant crying is normal and peaks in intensity at between 4 to 8 weeks, the recognition of care giver feelings of frustration and powerlessness, simple coping and control strategies and most importantly, to never shake the baby. The programme (Smith; August 2020) works by delivering the four key messages of the ICON acronym to all parents/caregivers, at a, ‘reachable moment’, (see SUDI report; July 2020) for mid-wives, health visitors, GPs and other professionals within mainstream services, to engage par-ents/caregivers through a set of five, ‘Touch Points’.   6.1 3 The first is prior to hospital discharge when both parents/caregivers are taken through the four key messages through a variety of mediums including, verbal script/information, leaflets/printed ma-terial, social media and video.10 A key consideration is the need to include fathers and male care givers in the programme given the raised likelihood of AHT perpetrators being male. A second touch point ‘reminder’ of the four messages is delivered by the community midwife within the first 10 day visiting period. A third message comes through the health visitor at an early stage (fourteen days) in their involvement when enquiries can be made about parental coping strategies with the infant’s crying, especially reinforcing the no shaking imperative. A fourth touch point reminder comes a few weeks later followed by the fifth at the 6–8-week GP development check. Smith (August; 2020) is currently developing two additional touch points incorporating interventions at High Schools and by ante-natal maternity services.   Effectiveness: Does Prevention Work?  6.1.4 There is evidence from North American programmes that, ‘A co-ordinated, hospital-based par-ent education programme targeting parents of all newborn infants can significantly reduce the inci-dence of AHT in children less than 36 months’ (Smith: Training for Trainers)11. Bechtel et al (2020) 12 evaluated the Take 5 Safety Plan for Crying given to care givers of newborns at Yale New Haven Hospital (Connecticut; USA). They found that the infants whose care givers had received the pro-gramme were 79% less likely to have suffered AHT. Bechtel et al concluded that Take 5 had the potential to prevent AHT in infants 13, albeit that further study, using a randomised controlled meth-odology was needed to confirm whether exposure to the Take 5 programme reduced the occurrence of AHT in the first year of life.    9 ICON stands for I-infant crying is normal; C-comforting methods can help; O-its ok to walk away; N-never, ever shake a baby.  10 Additional infant safety messages such as those around safe sleeping can also be included.  11 Cited from Dias et al (2005) Preventing Abusive Head Trauma Infants and Children; a hospital-based prevention program; Paediatrics; 115: 470-477; Altman et al (2010); Parent Education by Maternity Nurses and Prevention of AHT.  12 See Child Abuse Review, Vol 29: 282-290 (2020).  13 But see ‘ Limitations’Child Abuse Review Vol 29: p 288.   9 6.1.5 In the UK the Hampshire ICON programme was evaluated after one year of operation (Jones; 2020). The programme was initiated in September 2018 with a public launch in January 2019 that included a social media campaign and public information sharing events that reached a range of multi-agency professionals, parents, carers and grandparents. It was too early to have determined whether the programme had resulted in decreased incidence of AHT given that it had only been in operation for a year. Other key performance indicators were measured. These included 100% of 25 care givers remembering the key message, not to shake the baby, 19 out of 25 (76%) who reported changing their behaviour in relation to their baby crying after receiving the ICON information. Re-garding embedding the ICON messages, 95% of GP practices (on an 86% survey return) in Hamp-shire reported having discussed crying at the six-week review compared to only 10% in 2018 at the time of the pilot, with 84% of GPs reporting full awareness of the ICON programme one year on.   6.1.6 Arguably, these are positive, albeit early and partial indications for the potential of good out-comes, namely a decrease in infant AHT. It will be interesting to see what progress has been made in say 3-5 years-time. In any event, the progress made by the Hampshire project would seem to offer a wealth of useful learning for other areas in the early stages of ICON implementation, including CWAC safeguarding partnership.   Cheshire West and Chester (CWAC) Safeguarding Children Partnership (SCP) Development of ICON  6.1.7 The CWAC SCP, following initial development of the ICON scheme by a Pan Cheshire group14 in the second half of 2019, produced and circulated an ICON leaflet (based upon the Hampshire leaflet) in September 2019, which was further promoted in 2020, during the covid19 pandemic. Am-bassador training ( agency representatives trained in the ICON programme-using the ICON slides and material from Hampshire- and expected to cascade their knowledge within their organisation) took place in November/December 2019 and led to 63 professionals ( acute and community staff, 0-19 NHS staff ( midwives, Family Nurse Partnership, health visiting teams, neonatal intensive care ( NICU) staff, paediatric nurses, emergency department staff, children’s services ( social workers, family support workers and early years), the HMP mother and baby staff, police and probation,  re-ceiving training.   6.1.8 In July 2020, the steering group was informed that training had been implemented within all agencies, including early help in Cheshire West, all of the health visiting and Family Nurse Partner-ship teams, the Acute Hospital Trusts midwifery services, paediatric, neonatal and accident and emergency staff groups. Training was also delivered between July and September 2020 to the per-inatal mental health team and CAMHs, GPs and practice nurses. Several briefing sessions were delivered to 28 local authority family intervention workers from Early Help and Prevention. The local authority designated district manager attended the steering group in addition to the district practice lead for casework also having responsibility regarding Early Help and intervention involvement in the ICON programme.   6.1.9 Regarding Starting Well, the agency consultant nurse took the strategic lead on implementing ICON across the service. Train the trainer sessions for staff took place in the autumn of 2019 when the ICON message was cascaded across the service. Each district has trainers in the ICON message and new starters to the service receive ICON training. Health visiting staff are trained in NBO (New-born Behavioural Observations) assessment which supports the development of positive parent/in-fant relationships and also provide further opportunities to discuss infant communication so that par-ent can intervene early in the event of their baby showing early signs of distress. Starting Well is currently undertaking an audit of parents to assess whether the ICON messages have been,’ heard’.    6.1.10 None of the parents/care givers of the two infants identified as having suffered from AHT/mal-treatment in the summer of 2019 had the benefit of exposure to the ICON programme which started later in the year.    14 Composed of representation from health, midwifery, 0-19, Children’s Social Care, early help, named GP and the training manager   10  6.1.11 During the lockdown period of 2020, the SCP promoted ICON information via its website, social media and the newsletters, that included a website parent’s page. The CWAC SCP ICON project was officially launched on the 22 October 2020 with the participation of Dr. Suzanne Smith. This included the importance of including fathers and male care givers. Warrington Hospitals (War-rington and Halton) presently host the Pan Cheshire ICON which appears to be a very comprehen-sive and useful resource.     Recent Developments  6.1.12 An initial evaluation of the Cheshire West and Chester ICON programme15 is well underway and due for completion later this year. A report with findings is scheduled to be presented to the SCP executive for its scrutiny in due course. Mention was made by the panel that the local ICON pro-gramme had been in operation for a relatively short period of time and that numbers were small. It was suggested that there should be further evaluations over the medium to long term to provide evidence of what differences if any, the programme was making to reducing the incidence of infant AHT.    6.1.13 Further issues for the steering group include use of the, ‘Dad Pad’, (An app guide for young fathers developed with the NHS) to reinforce previous video messages, the identification and target-ing of those agencies (including the voluntary sector) where staff have not attended training sessions and considering including Safe Sleep and Safe Handling messages along with the ICON pro-gramme.   6.1.14 The electronic medicine information system (EMIS) in Cheshire West has been updated to enable the ICON message to be coded and reported on in regard to delivery, thus keeping a track on when (and by whom) messages have been given. The recently revised personal child health record (PCHR) has a comprehensive section on ICON. These are now in circulation and support clinicians in highlighting the key messages in addition to providing a quick and easy reference point for parents during the current Covid-19 pandemic.   6.1.15 Evidence from the practitioners’ learning event suggested that ICON is well embedded and understood by health and early help practitioners (health visitors, midwifery, family nurse partnership and family intervention workers) albeit there would seem to be a, ‘mixed picture’, with GP practices. This finding would suggest the need for systemic dissemination of the ICON concept across the local GP practice network, given the key role that GPs play within the universal offer. There was some evidence that parents may not have necessarily recognised the term,’ ICON’, but that many under-stood the key principles when GPs discussed these with them.   6.1.16 There were reported gaps in Police knowledge requiring more awareness raising.   6.1.17 There was a suggestion that it was important to identify the optimum time to share the ICON messages with both parents (and male carers), usually at around 25 weeks into the pregnancy. Post-natal messages could be repeated and reinforced by the health visitor. The use of user-friendly online information written in plain English (but also other appropriate languages) was highlighted. It was noted that there would be value in re-instating post-natal support groups and the involvement of peers, covid 19 permitting and when safe to do so.   6.1.18 Key ICON messages could be promoted in libraries, mother and tots groups and across other appropriate community networks, especially the normalisation of the ‘crying curve’.    15 It is understood that two acute trusts located in neighbouring Cheshire localities were also in-volved in the ICON programme.   11 6.1.19 Notwithstanding the above evidence of progress with the CWAC ICON programme, this re-view would suggest that consideration be given to some of the findings (see paragraphs 5.8 to 5.12) from the SUDI report; July 2020. Albeit in relation to promoting preventative messages to parents about safe sleeping this review would argue that there are parallels with dissemination of the key ICON messages. So, for example,  ’better use could be made of social media to provide information….in relation to safer sleep-ing………(and) that information for parents needed to be more direct and hard-hitting in explaining the consequences of an unsafe sleep environment. Research evidence suggests that parents are more likely to respond to safer sleep advice where they understand that there is a clear link between advice and risk’ (SUDI report; July 2020, paragraphs 5.8/5.9)   6.1.20 A further very interesting finding suggested that,  ‘Some of the most promising interventions involve the use of peer educators, such as parents from within vulnerable communities or young people’. (SUDI report; July 2020, paragraph 5.30)   Findings     6.1.21 Universal and early intervention safety planning programmes for caregiver frustration with infant crying, such as the ICON initiative, are, potentially, a key element in the prevention of non-accidental injury to infants; and may help reduce the likelihood of AHT.  6.1.22 The evidence provided to this review would suggest that the Cheshire West and Chester ICON programme is well advanced, (notwithstanding the constraints of the current covid 19 regula-tions), underpinned by extensive training and dissemination of the key messages to a wide range of professionals and agencies. It would seem that the infrastructure is in place to deliver a coordinated, preventive, universal, multi-agency, whole systems programme to disseminate and track-via EMIS- the key ICON messages to parents and caregivers at the five touch points.  6.1.23 Systemic dissemination of the ICON concept needs to happen across the local GP practice network given the key role that GPs play within the Universal offer.   6.1.24 There were reported gaps in Police knowledge, particularly in relation to knowledge about ICON, indicating more awareness raising is required.   6.1. 25 Consideration should be given to the appropriate use of social media and a more hard-hitting style in delivery to parents that makes the link between the ICON messages and consequential risk to infants. The potential and sensitive use of peer educators could be explored  6.1.26 Self-evidently, in order for there to be an effective dissemination of the ICON messages there needs to be an integrated, joined up approach with the relevant agencies and professionals involved in the Universal/Preventative offer; but importantly, also within the Universal Plus and Partnership Plus elements of the CWAC SCP Continuum of Need and between them. A strategic whole system joined up approach would not only facilitate an effective implementation of the ICON programme but could also meet the needs of vulnerable infants and their families at Universal Plus and Partnership Plus, thus resulting in better outcomes for children and the reduction of demand on Statutory Social Work (children in need-S.17 and child protection/looked after children-S.47) services.   6.1.27 The ICON evaluation mentioned previously at 6.1.12, should provide a useful progress review of the Programme, particularly in relation to the consistency and extent to which parents/caregivers are given the key messages at the five touch points, taking them on board and enacting them.      12 Recommendations  6.1.28 The forthcoming CWAC ICON evaluation should be scrutinised by the CWAC SCP in regard (amongst other things) to establishing,   (1) Programme outcome effectiveness-the ‘So what’ question- regarding AHT injuries to infants.   (2) That the Programme is effectively integrated across the CWAC SCP Continuum of Need.  (3) The sensitive use of social media, a more, ‘hard hitting’ style of message giving and deployment of peer educators should be explored to enhance the effectiveness of the programme.  (4) That any actions from the evaluation are incorporated into the action plan of this the-matic review.    (5)  Considering the possibility of future follow up evaluations to determine Programme effectiveness, or otherwise, over the longer term (5-10 years).   6.1.29 The CCG should assure the SCP that a systemic dissemination of the ICON programme has included the local GP network and Midwifery Services.   6.1.30 The Local Authority should assure the SCP that there is systemic dissemination of the ICON programme across Health Visiting Services.  6.1.31 The Cheshire Police should assure the SCP that any gaps in Police knowledge regarding the ICON programme should be addressed as soon as possible.   6.2 Local System Wide, Non-ICON Programmes That Are Involved with Parents/Care Givers at the Ante and Post Natal Stage of Birth: Extent of Integration  6.2.1 The three non-independently mobile infants16not subject to rapid reviews variously sustained bruising and bone fractures. This section of the review will thus focus on system wide, preventative and early help approaches (non-ICON) to mitigating the incidence of infant NAI in relation to non-AHT injuries as mentioned in paragraph 5.2 above.17  6.2.2 In some instances, the provision of universal (as per the CWAC SCP Continuum of Need ‘CON’ threshold) services to parents, such as midwifery, health visiting and GP services, may not be suffi-cient to either meet their needs or address predisposing vulnerabilities, stressors and attendant risks. These would include a range of pre-disposing vulnerabilities and risks,18 young first-time parents, lack of family and social network support, poverty, social isolation, lack of suitable housing, parental conflict, domestic abuse, mental health and substance abuse, effects of living with the covid19 pan-demic and low infant birthweight.   6.2.3 It is at this stage in the prevent and protect model that Universal Plus (Single agency interven-tion) and Partnership Plus (Multi-Agency) Team around the Family (TAF), as per the Continuum of Need) services are required to mitigate emerging problems and risks. In these situations, it is imper-ative that there are well integrated, early help and prevention systems and processes in place (and if necessary, safeguarding measures) to recognise and respond to unmet/additional need and emerging risks.   16 See, ‘Bruising in Children who are NOT Independently Mobile’, April 2018, West Cheshire SCB 17 See Cheshire West and Chester Council/West Chester Children’s Trust (2017-2020), refreshed January 2019, Early Help Strategy.  18 Common but not exclusive risks and stressors.   13  6.2.4 What then are the local (CWAC) services at Universal Plus and Partnership Plus available to mitigate risk, meet the needs of vulnerable parents/caregivers and support them at the ante and post-natal period, especially over the early period of infancy; and how well integrated are they?   6.2.5 In essence, Universal Plus and Partnership Plus services are met by the 0-19 Starting Well 19 and the local authority (CWAC) Early Help and Preventative Services respectively, with support of other agencies as necessary. In regard to infants and their parents/carers, Starting Well provides support through, family nurse partnerships, health visiting and children’s centres (core offer). Early Help and Prevention has three service delivery arms, namely: • Family casework and domestic violence and abuse (DVA) • Schools and Partnerships  • Community safety and youth services Service delivery is configured geographically via three separate districts, these being, Ellesmere Port, Northwich/Winsford and Chester. Children and families requiring Universal Plus and Partner-ship Plus support and DVA services, including those with infants under one, can access family in-tervention workers (managed by district practice leads) as part of a Team around the Family (TaF) plan. Both the CWAC and Starting Well services work within the local authority Partnership agree-ment of early help and prevention and Continuum of Need (CoN) framework. 20    Intra and Inter-Agency Integration  6.2.6 A joined up intra and inter approach between agencies and professionals across the CoN needs to be underpinned by appropriate and effective integrative processes. Such processes would include common understandings across the system regarding needs/risk assessments (Early Help/ Pre-Birth/ TAF/ Universal Plus/Partnership Plus assessments), a working definition of ‘vulnerability/ vulnerable families, knowledge of the ‘Think Family’ concept, the CWAC Continuum of Need, inter-operable communications/information sharing systems and a sound knowledge of the range and offer of services available to vulnerable families with infants.   6.2.7 In principle,21 it would seem that there is an effective degree of intra and inter agency integra-tion. This is evidenced within Starting Well, by what is described as a, ‘seamless’ offer across the 0-19 age range, involving the allocation of a single health practitioner for the family who will follow them through their ‘journey’. This negates, for example, the need for any ‘referrals’ from health visi-tors to early years workers. Care is co-ordinated through an allocation process within Starting Well. Families identified as needing early help following an assessment at the universal, Healthy Child Programme core contacts, are offered targeted group work or home learning on an individual basis through the Children’s Centre core offer.   6.2.8 There is a single health record (EMIS-electronic management information system) ensuring continuity of information sharing within the agency. EMIS is also the recording system in use by local GP practices, most of whom are part of an information sharing agreement that allows access to a shared view of the EMIS record. This supports integration, co-ordination and continuity across the Starting Well service and with GP provision.   6.2.9 Where in place, GP practices have a link health visitor to support effective communication between it and Starting Well; in addition to attendance at multi-disciplinary team (MDT) meetings, which can focus on families needing Partnership Plus support. However, these arrangements are not consistent.    19 Commissioned by the local authority and provided by Cheshire and Wirral Partnership NHS Foundation Trust. 20 As per the Early Help Strategy, see note 13.  21 This followed a discussion with senior managers from the two agencies regarding integration.   14 6.2.10 Moreover, as previously mentioned, these professionals can play a key role in reinforcing at appropriate touch points, the key ICON messages and ensure that parents/care givers (especially fathers and male care givers) have safety strategies for coping with intense infant crying and are implementing them.   6.2.11 Evidence of interagency integration can be demonstrated by the following examples. Regard-ing Starting Well and midwifery, an essential link in the context of this review, Starting Well receive notification from midwifery, provided by the two CWAC acute hospital trusts22, of pregnant women at the ante-natal stage. Information can include identification of additional needs and any vulnerabil-ities. Starting Well can offer an ante-natal face to face contact with families who have been identified by midwifery as vulnerable or who are primigravida (a woman who is pregnant for the first time). A needs/ vulnerability assessment under the TaF framework can be undertaken if required and with the family’s consent. This would enable a TaF plan of parental/carer support to be given by Starting Well and the midwife, aimed at mitigating at an early stage any risks or adverse impacts to the unborn child/baby.   6.2.12 Additionally, the midwifery service is integral to the Children’s Centre core offer and are able to deliver ante-natal clinics from all of the centres. As mentioned below at paragraph 7.3.8, the En-hanced Midwifery Team at Hospital Trust 1 can take referrals regarding any significant child protec-tion concerns. In this event, they can liaise, as appropriate, with the family GP, Starting Well, the health visitor, family nurse partnership and Children’s Social Care.  6.2.13 Regarding TaF assessments and plans, these can be initiated and co-ordinated by any prac-titioner from either agency (Starting Well/Early Help) where a family is identified as having two or more unmet needs as per the CoN framework. Senior managers from both agencies meet monthly to discuss and facilitate TaF cases and any relevant practice issues. There are also weekly multi- agency case management meetings held under the auspices of the local authority Integrated Access and Referral Team (i-ART) which include representatives from both agencies, the purpose of which is to take forward actions and ensure that a TaF has been started.   6.2.13 Regarding electronic information systems, Starting Well, as previously mentioned use the EMIS which is linked to the same system used by GP practices. The local authority Early Help ser-vice uses e-TAF which is a module within ‘Liquid Logic’ (used by Children’s Services) and can be accessed by Starting Well via a token/authenticator process; albeit the two systems are not inter-operable. That said, TAF assessments can be completed in e-TAF and copies then attached to the EMIS record system.   6.2.14 There are pathway processes for both ‘stepping up’ to Children’s Social Care and back down to Starting Well. Following a manager-to-manager meeting and agreement between them a family can be stepped down into the Starting Well e-TAF tray which is then picked up through the e-TAF system and allocated.23  6.2.15 Evidence from the practitioners’ learning event regarding inter-agency integration, suggested that agencies and their practitioners had taken on board, understood and engaged with the, ‘Think Family’ concept. Albeit this was not always the case with adult facing services and comments were made about the need to,’ reconsider and refresh relationships with adult services’, regarding ‘Think Family’. It was encouraging to hear that there were very positive relationships between Early Help and Starting Well, albeit there were some issues with meeting intervention thresholds. Co-location was suggested as a means of improving information sharing and strengthening working relation-ships. In the event of professional disagreements, the SCP escalation process was available for use by practitioners, including discussions with agency safeguarding leads as part of the process.    6.2.16 Relevant lessons from these key practice episodes would be firstly for the CWAC SCP to be assured that the ‘Think Family’ message is well embedded in adult social care and mental health   23 See CWAC TaF Guidance.   15 services. Secondly, for Early Help and Starting Well to review the threshold criteria so that families can access, ‘the right care at the right time in the right place’ (Principle 3, NHS Commissioning for Carers Principles) at Universal Plus and Partnership Plus of the CoN. Thirdly, to consider the efficacy or otherwise of Early Help/Starting Well service co-location as a means of service enhancement.    6.2.17 In addition, practitioner knowledge regarding the inherent vulnerability of infants24 and dy-namic risk are essential tools in the prevention and protection of infants. The evidence from the practitioners’ learning event was that, in general, these issues were well understood and articulated in practice. However, attention was drawn to the importance of incorporating the inherent vulnera-bility of infants concept into the training of peripheral workers such as new police starters and hous-ing officers, whilst recognising the challenges of this in regard to large workforce turnovers. It was noted that practitioners were increasingly referring families for vulnerability rather than determining whether the case met the threshold, which was seen as a positive development. Interestingly, pa-rental participation in virtual meetings was better than in pre-covid 19 face to face meetings, albeit, there was a greater recognition of parents’ ability to disguise their vulnerability.   Findings   6.2.18 Well integrated Universal Plus and Partnership Plus services at both intra and inter-agency level are (along with universal/ICON services) key to effective mitigation and the minimisation of non-accidental injury to infants. Within the CWAC SCP, Partnership Plus support is mainly provided jointly by Starting Well and the local authority’s Early Help and Prevention services. Schools also have a key role in support where infants have older school age siblings.   6.2.19 Evidence provided at both strategic and operational levels suggest that current systems, pro-cesses and practice underpin an effective degree of intra and inter-agency integration within the Partnership Plus offer. GP and midwifery services (provided by the two acute hospital trusts operat-ing in the CWAC area) are linked to Partnership Plus services via EMIS, the electronic information sharing platform and health visitor attachments to GP practices.  6.2.20 The, ‘Think Family’, approach appeared well embedded within the broad range of children’s services. However, this was less the case with adult facing services, including adult social care and mental health; where it was identified at the practitioners’ learning event (PLE) that there was a need to ‘reconsider and refresh relationships with adult services’. In this regard these two agencies should review the CoN to provide assurance to the SCP that they understand and can effectively apply it.   6.2.21 There was a suggestion from the PLE that Starting Well and Early Help and Prevention could usefully review the threshold criteria for families to access the right care at the right time in the right place. Co-location, where possible, could be considered.   6.2.22 Where in place, GP practices have a link health visitor to support effective communication between it and Starting Well; in addition to attendance at multi-disciplinary team (MDT) meetings, which can focus on families at Partnership Plus. However, these arrangements are not consistent.   6.2.23 The ’inherent vulnerability’, of infants was well understood by children’s services practitioners, albeit the concept needed to be included in the training of peripheral workers such as new police starters and housing officers.   Recommendations   24‘Babies are disproportionally vulnerable to abuse and neglect. In England they are seven times more likely to be killed than older children. 36% of serious case reviews involve a baby under one’. See,  'The 1001 Critical Days-The Importance of the Conception to Age Two Period; A Cross Party Manifesto; page 5.   16 6.2.23 The ‘Think Family’ concept needs to be disseminated and better embedded within adult social care and mental health services. These services should provide assurance to the SCP that they understand the CoN and can effectively apply it.   6.2.24 The SCP should seek assurance from Starting Well Services and Early Help and Prevention that they are applying the criteria and CoN thresholds appropriately to ensure that vulnerable families can effectively access the right service at the right time in the right place. They should consider whether some co-location, where possible, could improve access and service outcomes.   6.2.25 The Local Authority and CCG should take steps to assure the SCP that the current arrange-ments for GP practices to have a link health visitor are appropriately joined up throughout the local GP network.   6.2.26 The concept of the, ‘inherent vulnerability’, of infants needs to be included in the training of peripheral workers, such as new start police and housing officers.   6.3 The Role of the Midwifery Service, Early Intervention, Prevention of NAI and Relation-ships with Parents  6.3.1 Midwives (both hospital and community based) are the lead professionals for the care and support of women and new-born infants, partners and families and make a key contribution to the quality and safety of maternity care (Nursing and Midwifery Council: 2019). Their intervention at an early stage of a women’s pregnancy-at the 8-10 week booking appointment- places them in a key position not only to promote the mother and unborn child’s health and safe birth, but also to anticipate and recognise any emerging issues and additional care needs, including support to the mother and father; and safeguarding matters relating to the infant, both pre and post birth. In the event of such issues arising the midwife has a responsibility -in collaboration with the parents - to manage, escalate and refer onto other inter-disciplinary and multi-agency colleagues.   6.3.2 The five infants in this review received services from four different midwifery providers, two of which were in the Cheshire footprint and the other a neighbouring authority. Three providers were mainstream hospitals, the other was an independent provider. The independent midwifery company provided contracted community midwifery services for several NHS commissioning Trusts in the North West (and Essex), including Cheshire. It provided a single midwife to see women through ante-natal, birth and post-natal care and focused on home births where possible. Unfortunately, the company collapsed in late July 2019.    Independent Midwifery Service  6.3.3 One of the five infants was involved with the independent midwifery service.  It was not the role of this review to look in detail at individual child health records. However, assurance was sought that, generally speaking and when necessary, safeguarding concerns and information were shared ap-propriately. The review saw evidence through the submission of a quarterly dashboard that safe-guarding referrals were made and monitored and that there was evidence of communication be-tween the independent midwifery service, acute providers and the designated nurse for safeguarding children regarding safeguarding cases.   Findings  6.3.4 A copy of the commissioning schedule demonstrated that the clinical commissioning group required compliance with Cheshire West and Chester Safeguarding Children Partnership guidance, a quarterly dashboard was submitted evidencing safeguarding activity and compliance with intercol-legiate safeguarding training. The expected level of compliance with safeguarding training was 90%. This episode highlights the need for commissioning agencies, in this case the Strong Start Partner-ship, Cheshire CCG to ensure services operating across multiple local authorities are aware of local  17 initiatives e.g., the CoN threshold, ICON and early help; given its very significant role at the early stages of ante natal, birth and post-natal infant development. This is a key learning point.     Recommendation  6.3.5 That the Safeguarding Children Partnership seek assurance from Commissioners, including Cheshire CCG, that services; particularly those which are commissioned across multiple local au-thority areas, are aware of local key pathways and interventions i.e., the CoN threshold, early help offers (including ICON).  The Two Hospital Trusts   6.3.6 Regarding the two Hospital Trust midwifery services, the review was informed that the eight weeks’ booking appointment is the crucial entry point into the maternity system by the mother. The midwife undertakes a holistic assessment of the mother’s clinical and wider social and psychological needs. A care plan is developed with the mother (also to include the father/male care giver) and any significant medical information shared with the GP. The assessment and care plan would include consideration of any additional or unmet needs and potential risks to the infant beyond the universal services.   Hospital Trust 1  6.3.7 With regard to Hospital Trust 1, a referral can be made, in the event of significant concerns, to its Enhanced Midwifery Team (EMT) which is a targeted service for ‘vulnerable’ families that seeks to safeguard the unborn/newborn infant, the mother and the family. Referral criteria would include, previous or current CSC involvement, unwanted pregnancy/adoption, disclosure of domestic abuse, stalking and harassment (DASH), parental substance abuse and mental health issues. The EMT would liaise in a timely way with the maternity department to facilitate a seamless service and include other partner agencies such as the 0-19 Starting Well Service and the GP when needed. In the event of safeguarding concerns and other vulnerabilities emerging, the EMT would share a Safeguarding Adult and Children Midwifery Notification form with the health visitor/Family Nurse Partnership and the GP at 25-28 weeks gestation. There are referral procedures for pre-birth assessments in the event of concerns around significant harm.    6.3.8 Clearly, these processes are key elements in any strategy seeking to prevent NAI/infant mal-treatment. One of the infants in this review received services from Hospital Trust 1. The Rapid Re-view highlighted that no multi-agency referral form (MARF) for a pre-birth assessment had been submitted to CSC iART (Information, assessment and referral team), as per CWAC SCP guidance, when mother presented for her ante natal care, despite the presence of known risk markers and other concerns that warranted a written referral. The hospital dispute this stating that they had con-tacted CSC but were advised that the threshold for a pre-birth assessment was not met. Neither agency record was sufficiently detailed to confirm the accuracy of information provided and this was learning from the Rapid Review.  6.3.9 The mother was referred at an early stage by the midwifery service to the Family Nurse Part-nership for support. Unfortunately, due to non-engagement from the Mother and Family Nurse Part-nership staff sickness, the 28-week criteria for service had passed and she was inappropriately re-ferred onto the health visitor (0-19 Starting Well Service) within the universal offer.    Findings    18 6.3.10 Hospital Trust 1 documented arrangements and processes25 would seem fit for purpose in relation to the initial assessment of the mother’s clinical and wider holistic needs, early identification of any potential unmet needs and, if necessary, a referral onto the Enhanced Midwifery Team in the event of any safeguarding/vulnerability issues.   6.3.11 Self-evidently, the assessment appears to be beyond a narrow focus on measuring and mon-itoring of clinical factors. Liaison and information sharing with tier 2/3 agencies including GPs are provided for.  6.3.12 There was no mention of whether parents are routinely referred to the ICON programme.  However, over recent times the ICON programme has been implemented in Cheshire. The recent evaluation (see paragraph 6.1.28 above) will demonstrate compliance with all touch points within the programme.   6.3.13 The problems in making a pre-birth referral, referred to above, would suggest the need to review and if necessary, address any interface difficulties with the CSC i-ART, including use of the CWAC dispute resolution/ challenge and escalation process. (see section 6.8 below)  6.3.14 In relation to the MARF issue cited above (paragraph 6.3.9) the lessons are two-fold; agency records must specify which professionals communicated with one another and regardless of whether iART had indicated threshold for a pre-birth assessment was not reached, this should have been escalated by Midwifery Services.  Hospital Trust 2  6.3.15 Evidence from Hospital Trust 2 suggests that, firstly, it has an ICON programme which is, ‘actively and robustly promoted within midwifery and will continue to be further embedded’ (Hospital Trust Report: 7). Reportedly, the ICON messages are routinely given out through the leaflet at book-ing, discharge from hospital 2 and at the neo-natal unit post-delivery. There is evidence to suggest that parental absorption of the key messages may be more effective through direct, face to face contact, using a video presentation and the use of appropriate social media, rather than the giving of a leaflet (SUDI report; July 2020) Hospital Trust 2 is seeking ways on how to improve the way in which the completion of this work is recorded in maternity records. The ICON programme is also included in safeguarding training.  6.3.16 An initial booking meeting at around 8 weeks of the pregnancy is used to undertake the clinical and holistic assessment when the ICON message is discussed. Screening questions identify any needs for early support for mental health, social and safeguarding issues. If necessary, the midwife, with the mother’s consent, can refer onto Family Nurse Practitioner; and if appropriate and following a discussion with the Safeguarding Children Team, CSC safeguarding services and a pre-birth as-sessment in line with local guidance. Arrangements exist to undertake a single agency team around the family (TAF) led by the community midwife or a referral for Early Intervention and Prevention involvement from other partner agencies.   6.3.17 Midwives regularly work in multi-agency settings including TAF/Child in Need/Strategy meet-ings and Child Protection Care Conferences. In the event of a TAF or safeguarding/domestic abuse issues, a maternity safeguarding pro-forma is entered onto the electronic maternity records; in addi-tion to placing an alert, thus allowing all professionals involved in delivering care to the mother know-ing what is happening. This is said to be well established and fully embedded at Hospital Trust 2; new midwives quickly familiarise themselves with the alert system.  Clinical supervision by the safe-guarding children team is provided to midwives where there are ongoing safeguarding matters.  Safeguarding training is mandatory.   6.3.18 Post-natal care is provided by the community midwife who should be aware of any issues from the safeguarding children pro forma alert. Visits take place on days one and five after discharge  25 See Hospital 1 report prepared for this review.   19 (with a telephone call from a maternity support worker at 2 days to ensure that baby feeding is proceeding well). Where there is a safeguarding children pro-forma in place a multi-agency dis-charge planning meeting is held prior to the discharge of mother and infant. This would include a transfer of care from the hospital to the community midwife, with a handover to the health visitor at between 10-14 days.   6.3.19 The Hospital Trust 2 report mentions that, throughout the maternity care episode, the midwife will make every attempt to include the partner, any existing children and other family members ( as per the mother’s wishes) in the care planning, within a ‘ Think Family’ perspective. Reportedly, from the first contact at the booking appointment, every effort is made to identify the identity of the baby’s father and establish any potential risk; in addition to any parental vulnerabilities and subsequent additional services. It was not clear whether the Hospital Trust 2 midwifery ICON programme in-cluded touch points with the community midwife.  Findings   6.3.20 Evidence indicates that, firstly, the ICON is seemingly well developed with touch points at the booking appointment, pre and post discharge. Useful learning could be gained by the Hospital Trust 2 midwifery service considering the findings of the recent ICON evaluation as to effectiveness, de-gree of integration into the wider safeguarding/CoN system including feedback from parents and whether there has been a reduction in infant AHT/maltreatment. The same would apply to Hospital Trust 1. (See Recommendation at paragraph 6.1.28 above)  6.3.21 Secondly, in principle, there would seem to be robust systems and processes in place to enable effective safeguarding of mothers and infants, recognise parental vulnerabilities and offer additional support and prevention interventions at Universal Plus and Partnership Plus and statutory services where necessary.   The adoption of a ‘Think Family’ is said to be well rooted.   6.3.22 Thirdly, the midwifery involvement with mothers appears to be comprehensive, holistic and not solely confined to the measurement and monitoring of clinical/medical factors.    Recommendations  6.3.24 The SCP should undertake a case audit to assure itself of the effectiveness and extent of integration of the current midwifery services into the wider CON/safeguarding system. This could be more effective if it was done as part of a multi-agency tri-angulation audit in order to compare the information held by all agencies.   6.4 Commissioning and Contracting of Midwifery Services by Clinical           Commissioning Group  6.4.1 The Clinical Commissioning Group report for this review states that NHS Standard contracts are in place for all maternity providers that detail:  • Service specification • Safeguarding standards • Key performance indicators • Quality requirements   Monitoring Process  6.4.2 The contracts are monitored monthly with the providers, thus enabling any matters to be raised formally, recorded and responded to in a structured manner. Specific issues are tabled through a formal agenda in advance which ensures that the relevant representation is present when needed.  20 In the event of any quality, safeguarding or performance concerns, the provider is notified and re-quested to respond by a set time. Contract managers can raise issues outside of the formal system of contract meetings by issuing a contract letter asking concerns to be addressed and convening a separate meeting if needed.  6.4.3 Underpinning the safeguarding monitoring process, the clinical commissioning group has an assurance process whereby providers must complete an annual self-assessment audit (see Com-missioned Service Standards for Safeguarding Children/ Looked After Children and Adults at Risk, Version 6, 04.03.2020). The completed audit is reviewed by the CCG who provide feedback on any non-compliance along with an improvement action plan. Any assurance breaches are discussed at the Quality and Safeguarding/ Contract meeting and in the event of significant failure are escalated to the CWAC safeguarding children partnership, and if necessary, NHS England Cheshire and Mer-seyside sub-regional team quality surveillance group.    Strong Start Partnership Programme  6.4.4 Under newly established governance arrangements the Cheshire CCG has developed the Strong Start Partnership Programme which manages the contracting and commissioning of services for women and children, including maternity services. Members of the Partnership Programme in-clude commissioning and lead providers and other key partners including the CWAC SCP26. It aims to be accountable for overseeing the delivery of the Strong Start Programme that seeks to achieve improved outcomes for babies, children and young people (see Strong Start Partnership - Terms of Reference; (6.7.20) for a list of objectives).   6.4.5 Of some significance, this review notes that there will be a requirement for midwifery service providers to demonstrate compliance with midwifery service standards27, thus strengthening current quality assurance of midwifery services.   6.4.6 The Review was told that there is a learning cycle of continuous improvement provided by the Cheshire CCG sharing learning from serious incidents and producing quality reports for the CCG Quality and Safety Committee. Strong Start has a dashboard that includes all midwifery key perfor-mance indicators (KPIs), including the two acute hospital trusts (HT1, HT2) and other commissioned services. Commissioning arrangements currently address the need for service compliance and inte-gration with CWAC SCP safeguarding policies and procedures and the wider local safeguarding system.    Findings   6.4.7 Cheshire CCG’s monitoring and assurance processes (the Strong Start Partnership) regarding service providers’ safeguarding performance would seem to contain the appropriate arrangements to achieve safe practice. 28    Recommendations  6.4.8 None     6.5 Vulnerable Families and Safeguarding Pathways: The Continuum of Need (CoN) and the      Application of Thresholds   26 Through the link with the designated nurse for safeguarding who sits on the SSP partnership and the CWAC SCP. See, Strong Start Partnership-Terms of Reference, page 3, 6.7.20 27 These are delivery of the standards as set out in, ‘Better Births-Saving Babies Lives Care Bun-dle version 2’ delivery of CNST-10 Safety Actions and will also include the requirements the Ock-enden Report.  28 Updated in 2020 but in place for many years.   21 6.5.1 Working Together 2018 does not define the term, ‘vulnerable’, albeit it is in use (see page 8, paragraph 12). The Oxford English Dictionary definition is, ‘weak and easily hurt physically and emo-tionally’. The College of Policing defines the term as, “A person is vulnerable if, as a result of their situation or circumstances, they are unable to take care of or protect themselves or others from harm or exploitation.”   6.5.2 The Starting Well Service views vulnerability as those families where additional need(s) are evident or where there are complex needs and\or identified risks. Recourse to the CWAC SCP Con-tinuum of Need is made to determine the extent of a vulnerable family’s need (one additional need equates to a Universal Plus - Single Agency); two or more can result in support coordinated through a multi-agency TAF at Partnership Plus), complex needs and risk of significant harm/child abuse will lead to statutory CSC intervention through a Child in Need/CiN or Child Protection Plan/Care Pro-ceedings under the Children Act 1989.     6.5.3 Cheshire Police use the Vulnerable Person Assessment (VPA) tool for assessing vulnerability at the time of a critical incident. This would include attending an incident involving a pregnant woman (e.g. in a domestic abuse and violence situation) or where there was a young child/infant, and where vulnerability or risk of harm was evident.   6.5.4 The review was informed that Cheshire Police was developing a new VPA that seeks to high-light the vulnerability of infants/under ones and pregnant women. This will target the information that childcare agencies (CSC, midwifery, home visiting, GPs) need for further interventions, including the voice of the child.  Officers will be encouraged to take a more holistic approach to VPAs regarding pregnant women and unborn/post-natal children and not assess individual incidents in isolation but rather, within a more holistic/ bigger picture context.29 Additional training regarding awareness spe-cifically around the issues of abuse/NAI/AHT of infants and the unborn, to include the idea of the officer being, ‘the voice of the child’, was welcomed by the review.   6.5.5 The review was told that the VPA tool has been progressed continuously and is updated every 2-3 months.        Discussion   6.5.6 Given the complexities of current policing and the myriad demands on police officers, espe-cially in regard to public protection issues, the review was encouraged to learn that Cheshire Police was making improvements to its VPAs, in addition to having cited the ICON initiative and its key messages. There would appear to be well established procedures, via the VPA to notify CSC/i-ART when officers come across domestic abuse and concerns about children, including infants. It is sug-gested (in line with the Chief Constable’s weekly orders, see note 27 below) that further work is done on submitting VPAs for childcare concerns at Early Help and Prevention, additional to the mandatory criteria, statutory child protection. Getting support for families may prevent child maltreatment in children under one year. Specific training around infant maltreatment was seen as helpful.   Midwifery  6.5.7 As discussed previously, the midwifery service understands vulnerability within the context of the Continuum of Need (CoN) and interventions that correspond to universal, universal plus, part-nership plus and statutory social work. The CoN and pre-birth assessment tools are the key child welfare and safeguarding pathways.   Findings     29 A message to Cheshire police officers was included in the Chief Constable’s weekly orders of the week ending, Friday 7 2020, to this effect. This included dissemination of the ICON message.   22 6.5.8 There is no accepted uniform working definition of ‘vulnerability’ in regard to infants and their families, used by the CWAC SCP and partner agencies.   6.5.9 The term seems to be implicitly understood and differentially operationalised by professionals and agencies as a function of their interpretation of the Continuum of Need. This results in a degree of variation in how the CoN is used by professionals to assess need/risk and decide on the appro-priate level of service intervention, including no intervention.  Recommendation   6.5.10 The SCP should seek to develop a common definition and understanding of vulnerability across the partnership and achieve a reasonably consistent level of service intervention within the CoN, that correspond to assessed needs and risks.    6.6 Pre-Birth Assessments   6.6.1 There is a well-established pre-birth assessment procedure and set of guidance contained on the CWAC SCP website. This sets out a clear pathway for progressing the assessment, including points at which key decisions can be made regarding next steps and service/intervention outcomes for the child and family. It emphasises the need for relevant professionals (midwives, GPs, hospital ante-natal services, health visitors) to be familiar with potential indicators of harm to the unborn child/infant; and/or the family’s need for additional support to safely progress the pregnancy and care for the new baby. The assessment should start in the early ante-natal period. It should include de-tails, where possible, of the mother’s partner and his/her wider family and environment. A clear set of referral criteria to CSC is set out at page 7 of the guidance. 30A pre-discharge meeting should take place, along with a clear plan before the infant leaves hospital.   6.6.2 Regarding the effectiveness of early intervention and referrals to CSC, the review was pre-sented with an audit of five pre-birth assessments completed during the early part of the covid 19 regulations, between 01.03.20-22.07.20. Most assessments (3/5) were judged as adhering to prac-tice standards with appropriate outcomes. All but one (4/5) involved the father/partner in the process. Regarding midwifery, all of the cases had accessed safeguarding supervision with evidence of a clear relationship between midwifery and the i-ART (Integrated access and referral team) at the point of the mother’s booking with the midwifery service. The audit concluded that, overall, there was a positive picture of multi-agency practice.    Findings   6.6.3 The local guidance on pre-birth assessments is comprehensive, detailed and has a clear path-way regarding progress and decision making.   6.6.4 The audit evidence presented to the review (albeit a relatively small sample of 5 cases) sug-gests that the pre-birth guidance is being effectively used by professionals. Agreed practice stand-ards are being achieved in majority of cases, with positive outcomes for children and good multi-agency practice. It was encouraging to see that in 4/5 cases (80%) fathers/male care givers were included in the assessment process.   Recommendation   6.6.5 Given the small sample the SCP should undertake a larger audit of pre-birth assessment prac-tice in order to confirm (or otherwise) the positive picture from the first audit.    30 In the case of one of the infants subject to a rapid review there were several relevant risk factors that warranted a referral to CSC. The guidance explicitly states that, ‘referrals to CSC must always be made in the following circumstances (see section 4.3 for these).   23 6.7 Engagement of Fathers and Male Care Givers31  6.7.1 There is a wealth of evidence and learning from previous serious case reviews and professional studies (NSPCC; Caring Dads) highlighting the importance of including fathers and male care givers (so called ‘Invisible men’) in working with professionals regarding their children’s well-being and safety. An important caveat being as long as this does not compromise the safety and wellbeing of women and children from domestic abuse and violence, male coercion and control.   6.7.2 Previous mention has been made of the imperative of involving fathers and male care givers in the ICON programme, given that 70% of perpetrators are male. Inclusion only of the mother of the unborn child will be unlikely to mitigate the key risk from the male and thus be ineffective in prevent-ing infant AHT/maltreatment.   6.7.3 As previously noted, most pre-birth assessments include males. Child and Family assessments (see CSC review report) involve fathers, albeit not always consistently. Self-evidently, practice needs to routinely include males in Child and Family work, where it is safe to do so and consistent with the child’s paramount interests.   6.7.4 The practitioners’ learning event noted that fathers and male carers tended to be marginalised by professionals and were not involved with ante and post-natal services, including ICON as much as they could be. The impact of Covid 19 attendance regulations had not improved the situation. It was questioned whether professionals made enough effort to identify the father if he was not present at ante and post-natal appointments. There was a need to pro-actively include fathers and male carers more at both ante and post-natal stages and seek to give them a voice, including those males who were not the biological parent. Generally, there was a need to adopt a more holistic, ‘Think Family’, approach.   6.7.5 This position is reinforced by learning from the Rapid reviews, one of which note “very limited information was known by Midwfiery Services about Dad, and not uncommonly, he was not present at the majority of antenatal visits”; also, that “there was a lack of engagement by agencies with father both in respect of assessment and intervention”. Conversely, in the second review, agencies had a good knowledge of father’s history which had been openly shared with them, including a diagnosis of Post-Traumatic Stress Disorder and a request from Father for support in managing his anger. Whilst this information was known, it was not analysed in the context of the additional stressor that a new baby can bring and the impact on fathers’ capacity to care. No intervention or additional sup-port was offered to father.   6.7.6. The recently published report by the Child Safeguarding Practice Review Panel (see note 29 above) contains a wealth of findings and recommendations salient to this review.   Findings   6.7.6 Evidence from the PLE strongly suggested that fathers/male carers tend to be marginalised from ante and post-natal services, including the local ICON programme.   6.7.7 In most cases, fathers/males are included in pre-birth assessments. There is some incon-sistency regarding Child and Family assessments.   Recommendations  6.7.8 Maternity services and Local Authority health visiting should seek to proactively involve fa-thers/male carers in all interventions, consistent with the mother and child’s safety.    31 See’ Safeguarding children under 1 year old from non-accidental injury; National review into ba-bies seriously harmed or killed by their father male carer’, Child Safeguarding Practice Review Panel, 16.09.21.   24 6.7 9 Consistent with the mother and child’s safety, the current CWAC ICON initiative should ensure, as is the stated intention of the initiative, that fathers/male care givers are routinely included in the programme, from start to finish.   6.7.10 Practice guidance, learning and development should emphasise the imperative of routinely involving fathers and male care givers in the assessment and planning processes for their children, notwithstanding consideration of any safety issues. This would apply to all health and children’s services.    6.8 Challenge and Escalation Regarding Professional Disagreements in Decision Making  6.8.1 This issue arose in one of the rapid review cases when there was a strong case for the mid-wifery service, through use of the escalation process, to have challenged the i-ART response that there were insufficient grounds to make a pre-birth assessment.   6.8.2 The Pan Cheshire SCP escalation procedures regarding professional disagreement of decision making is well established. It includes clear guidance about the four stages for escalation and reso-lution which is replicated in the i-ART manual’s four step process for dispute resolution.   6.8.3 External agencies such as midwifery, as a first step, can discuss a decision outcome with a team manager or senior social worker. If not satisfied, the issue can be escalated up the manage-ment chain to the SCP Chair who will make a recommendation for the most appropriate way forward.  Findings   6.8.4 Clear guidance is in place regarding professional disagreement and escalation. It may be that the SCP needs to remind agencies of its existence and use when necessary.   Recommendations  6.8.5 That the CWAC SCP continues to promote the existence and use of the Challenge and Esca-lation procedures.    7.0 Summary and Conclusions  7.1 This thematic review arose following a cluster of NAI incidents in Cheshire West and Chester to five infants in the summer of 2019. After due consideration involving two rapid reviews, the CWAC Safeguarding Children Partnership decided on the 27 September 2019 to commission a thematic review into the non-accidental injury to babies under one year of age.   7.2 A panel and independent reviewer/chair were duly convened and met initially in late February 2020; progressing the review during 2020/21, notwithstanding the challenges to process from covid 19 and associated regulations.   7.3 Regarding the three overarching questions from section 3 the evidence of this review suggests;   7.3.1 Current Arrangements to Safeguard Infants from Harm; Promote their Welfare and Support their Parents/Carers (questions 1 and 2)  7.3.1.1 There are currently (August 2021) a range of services in place within the CWAC SCP Con-tinuum of Need spectrum aimed at preventing and protecting infants from suffering harm. These include, the relatively new ICON service, operated by the two hospital trusts (HT1 and HT2), which seeks to prevent infant abusive head trauma (AHT) through parental/professional ante and post-natal contact via the five touch points. Universal Programmes like ICON are a key element in the layers of defence (as per appendix 1, paragraph 5.5 below) that makes up the integrated service system aimed at mitigating risk of infant AHT and non-accidental injury.   25  7.3.1.2 An evaluation of the local ICON programme has been recently completed and is due to be presented to the CWAC SCP in early October 2021.   7.3.1.3 Midwifery services from the two hospital trusts and local GP practices also provide important universal provision -first line of defence- against infant non-accidental injury.    7.3.1.4 Underpinning the ICON initiative are early help and prevention services. These include the 0-19 Starting Well programme aimed at responding to families with additional needs and the local authority family intervention service. Statutory social work services (Child in Need and Child Protec-tion) are provided by CWAC Children’s Social Care and supported, when necessary, Cheshire Po-lice.   7.3.2 The Effectiveness of the Current Service Offer to Infants and their Families, including those Deemed Vulnerable (question 3)    7.3.2.1 There is evidence from the HT2 data that there were no non-accidental head injuries to chil-dren under one year old from September 2019 to March 2021 and that infant NAI numbers were down from the previous year. Data from HT1 suggested that there was one confirmed NAI to an infant caused whilst in parental care.32 However, it is suggested that the ‘raw’ data would need to be contextualised through a robust public health analysis to give an accurate and meaningful account of the state of NAIs to infants in the CWAC area33, and thus the effectiveness or otherwise of the current service offer to babies under one and their families.   7.3.2.2 Evidence provided at both strategic and operational levels suggest that current systems, processes and practice underpin an effective degree of intra and inter-agency integration within Partnership Plus responses. GP and midwifery services (across both HT1 and HT2) are linked to Partnership Plus via EMIS, the electronic information sharing platform and health visitor attachments to GP practices.   8.0 Key Lessons for Policy and Practice: Locally and Nationally  8.1 Infant crying is normal and peaks at between 4 to 8 weeks. However, the early months of infant, inherent vulnerability’, can be a potential maximum period of risk to the infant.   8.2 A ‘prevent and protect’ model of an integrated service offers across the CWAC SCP Continuum of Need - similar in outline to that set out in the SUDI report; July 2020- is a key element in minimising and mitigating non-accidental injury to infants under one.    8.3 Ensure there is a secure, universal, first line of defence. A universal ante and post-natal safety planning programme such as ICON, which addresses caregiver frustration with crying infants, is a key element in preventing infant NAI and can help reduce the likelihood of AHT.  8.4 Additional first lines of defence involving universal services such as midwifery, GPs and health visiting should complement and reinforce the ICON programme. They should be attuned to the in-herent vulnerability of infants, be familiar with how to recognise and respond to unmet/additional need in families requiring Universal Plus or Partnership Plus support and dynamic risk, requiring a referral to CSC for a pre-birth assessment.   8.5 Services within Universal Plus or Partnership Plus on the CoN spectrum (namely, those provided by Starting Well and Early Help and Prevention) should be optimally integrated both intra and inter agency. They should be underpinned by a range of integrative and effective processes such as those cited in paragraph 6.2.6 above, including familiarity with how to make (and receive) pre-birth assess-ment referrals.  32 Time scale was from 31.10.19 to 11.3.21 33 A longitudinal study over a reasonably long period of time, say 5-10 years.   26  8.6 The Think Family concept should be thoroughly disseminated to and embedded by adult facing services, including mental health.   8.7 Fathers and male care givers have a tendency to be marginalised by some services. They should be routinely included in service interventions, including ICON, notwithstanding consideration of any safety issues around domestic abuse, coercion and control.    9.0 Glossary of Terms  AHT; Abusive head trauma CAMHs; Children and adolescent mental health service CCG; Clinical Commissioning Group CoN; Continuum of Need CNST; Clinical Negligence Scheme for Trusts CSC; Children’s Social Care CWAC; Cheshire West and Chester DASH; Domestic abuse, stalking, harassment and honour violence DVA; Domestic violence and abuse EMIS; Electronic medicine information system EMT; Enhanced Midwifery Team GP; General Practitioner HMP; Her Majesty’s Prison (Service) KPI; Key performance indicators NAI; Non accidental injury NICU; Neo-natal intensive care unit NHS; National Health Service PLE; Practitioners’ Learning event HCP; Healthy Child Program MARF; Multi-agency risk form MCHFT; Mid Cheshire Hospitals NHS Foundation Trust MDT; Multi-disciplinary team NICE; National Institute for Health and Care Excellence I-CON; Infant crying is normal, Comforting methods can help, Its ok to walk away, Never ever shake a baby i-ART; Integrated, access and referral team NWAS; North west ambulance service PCHR; Personal child health record SCP; Safeguarding Children Partnership SUDI; Sudden unexpected death in infancy SBS; Shaken baby syndrome TaF; Team around the Family UPP; Universal Partnership Plus UP; Universal Plus NSPCC; National Society for the Prevention of Cruelty to Children VPA; Vulnerable Person’s Assessment  10.0 References   Altman RL et al: 2010; ‘Parent Education by Maternity Nurses and Prevention of Abusive Head Trauma’; Pediatrics: 128;e 1164 Barr RG: 2012: ‘Preventing Abusive Head Trauma Resulting From a Failure of Normal Interaction Between Infants and their Caregivers’; Proceedings of the National Academy of Sciences of the USA; 109 (supply) 17294-17301 Barr RG: 2018: ‘Eight year outcome of implementation of Abusive Head Trauma prevention’; Child Abuse and Neglect; 84 (106-114)  27 Bechtel K et al:2011: ‘Impact of an educational intervention on caregivers’ beliefs about infant cry-ing and knowledge of shaken baby syndrome’. Academic Pediatrics 11(6) 481-486   Brandon M et al: May 2016; ‘Pathways to harm, pathways to protection : a triennial analysis of se-rious case reviews 2011 to 2014’ ; Final report; University of Warwick; University of East Anglia: Department for Education Brandon M et al: March 2020: ‘Complexity and challenge: a triennial analysis of SCRs 2014-2017’: Final report; Department for Education Child Abuse Review; May-June 2020: Special Issue: Abusive Head Trauma: Recognition, Re-sponse and Prevention.  Child Safeguarding Practice Review Panel; July 2020, Out of routine: a review of sudden death in infancy (SUDI) in families where the children are considered at risk of significant harm’ Crown cop-yright Child Safeguarding Practice Review Panel; September 2021: ‘The Myth of Invisible Men’; Safe-guarding children under 1 from non-accidental injury caused by male carers’.  Department for Education: 2018: ‘Working Together to Safeguard Children; A guide to inter-agency working to safeguard and promote the welfare of children’ Dias et al: 2005: ‘Preventing Abusive Head Trauma Infants and Young Children; a Hospital Based Prevention Programme’; Pediatrics 115: 470-477 Lopes NRL et al; 2013: ‘Abusive Head Trauma in Children; a Literature Review’; Journal de Pedi-atria; 89(5) 426-33 Lopes NRL et al: 2018: ‘Pediatric Abusive Head Trauma Prevention Initiatives, A Literature Re-view’, Trauma, Violence and Abuse, 19(5), 555-566 NSPCC: 2016: ‘Protecting Babies and Toddlers’ NSPCC: 2016:‘Caring Dads, Safer Children’ Ofsted 2019: Cheshire West and Chester, Inspection of Children’s Social Care Services Rebbe R et al: 2020: ‘Incidence and Risk Factors for Abusive Head Trauma: A Population Based Study’; Child Abuse Review 29; 171-181  Rizwan M et al: ‘Non accidental injury in disguise; a paediatric enigma. International Journal of In-tegrated Care; 2017, 17(5) Smith S: 2016: ‘Abusive Head Trauma, The Case for Prevention: The Dulverton Trust Smith S: 2020; ICON, Babies cry, you can cope; The research evidence base for the prevention of Abusive Head Trauma and opportunities for development’  Taylor et al; Non-Accidental and Neglectful Injury in Children: Patterns and Typology, Birmingham Women and Children’s NHS Foundation Trust A Cross Party Manifesto: Leadsom A et al: ‘The 1001 Critical Days-The Importance of the Concep-tion to Age Two Period’: www.1001criticaldays.co.uk  Welsh Government: 2012: ‘Protection Children Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews’, www. cymru.gov.uk  West Cheshire Children’s Trust (2019): ‘Early Help Strategy’: Cheshire West and Chester Council  Appendix 1: Methodology  11.1 This review uses a whole systems approach that involves an understanding of how things (el-ements and system) are related and how they influence one another within a whole. In this case how the various agencies in the multi-service offer to infants, pre and post-birth, and their parents; namely midwifery, GP, health visitors, maternity services, children’s social care, early help and prevention, clinical commissioning group (CCG), etc, co-ordinate (or not) with each other to minimise non-acci-dental injuries to infants.   11.2 The approach seeks to focus on a critical analysis of the strengths and weaknesses of the multi-agency service offer using the information from the five infants’ cases set out above but will not provide a detailed review of each individual case.   11.3 The review is informed by elements of the, ‘Welsh model’ (Protecting Children in Wales, 2012) and the ‘Pathways to harm, pathways to protection’ framework; (Brandon et al, March 2020, pp 23- 28 24, NB See ‘Serious Case Reviews: Research into Practice, by Peter Sidebotham: seriouscasere-views.rip.org.uk, for an excellent video presentation of systems methodology and the pathways to harm model).   11.4 The approach uses the notion of organisational barriers and enablers that either hinder or em-power practitioners to make safe decisions and take actions that may lead to adverse or optimum safeguarding and welfare outcomes for children. The model seeks to analyse the intra and inter agency systems and processes that can provide opportunities to support prevention and protection, in addition to the pre-disposing vulnerabilities and risks for families that set the context for a ‘situa-tional’ trigger event such as infant crying, leading to infant NAI/maltreatment.  11.5 This review also uses the concept of, ‘layers of defence’ in minimising and mitigating harm to babies under one. Thus, the four stages of intervention contained in the CWAC SCP Continuum of Need (CoN) framework, namely, Universal, Universal Plus, Partnership Plus and Statutory Social Work intervention would correspond to four layers of defence.   The ‘Prevent and Protect’ model of Infant NAI  11.6 The review has been informed by the, ‘Prevent and Protect’ model of systems and processes to support prevention and protection from SUDI (see parts 3 and 4; pages17-24 of the SUDI report July 2020); and is a refinement of the original ‘pathways to harm, pathways to protection framework’. This review argues that the Prevent and Protect model can be usefully applied to an understanding of infant NAI; using the ‘continuum of risk’ concept and the notions of ‘opportunities for prevention’ at the population level (corresponding to the Universal within the CWAC Continuum of Need frame-work) and ‘opportunities for protection’ responding to predisposing needs and risks of families with additional needs (Universal Plus and Partnership Plus CWAC continuum of need) and Statutory Social Work (Child in Need/Child Protection) safeguarding/child in need) intervention for families with children at risk of harm.   11.7 This report has also been underpinned by the review panel members considering the themes and questions contained in section 3 above and providing their analyses following remote panel meetings of July and October 2020. A rough first draft was provided by the lead reviewer in January 2021 to the panel for initial critique and a second draft was completed in April 2021. An on-line practitioners’ learning event (PLE) was held on the 15 July 2021. The learning has been incorporated into the analyses of the key themes. The panel considered a third draft in September 2021 and amendments were made resulting in draft 4, the current version.   11.8 The findings and lessons of this review were informed by the evidence presented in the short reports from members of the panel or practice leads, conversations between the Independent Author and Practice Leads and the Practice Learning Event. Because of the constraints imposed by covid 19 regulations and staff time demands, only a limited amount of hard data was able to be collected from audits 34so as to triangulate with the evidence from the panel and the PLE. The review is aware of the positive Ofsted Children’s Services Inspection report or May 2019 which, in relation to co-ordinated, inter-agency working noted at page 1 that, ‘There are strong partnerships in place, at both strategic and operational levels, and this leads to proactive and coordinated intervention for children.                 34 This refers to a small-scale audit of five pre-birth assessments cited at paragraph 6.6.2 above.   29   