Death of an 8-year-old boy in April 2013, as the result of an asthma attack. Child H and his siblings were the subjects of a child protection plan under the category of emotional abuse at the time of the incident. Child H was diagnosed with moderate/severe asthma at 2-years-old and experienced problems with his eyesight, tooth decay, nosebleeds and enuresis. Issues identified include: paternal alcohol misuse; maternal depression; prolific domestic abuse; family debt and housing problems; missed medical appointments; and impact of mother's smoking, home environment and stress associated with witnessing domestic abuse on Child H's asthma. Uses some elements of the Social Care Institute for Excellence (SCIE) systems model to present key learning. Makes various recommendations, including: children subject to a child protection plan should have an individual Health Plan; the impact of stress on asthma should be considered during risk assessments, particularly for children living with domestic abuse and parental alcohol misuse; and early consideration of the use of legal processes to clarify and restrict contact should be employed where appropriate.
      
 Title:  Child H (Case C13): serious case review: overview report. LSCB: Bury Safeguarding Children Board Author: Clare Hyde Date of publication: 2014  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.                          1    Bury Safeguarding Children Board  Serious Case Review  Child H (Case C13)   SERIOUS CASE REVIEW  OVERVIEW REPORT  Report Author:   Clare Hyde Date:     6 January 2014   Signed:  Clare Hyde   Date: 06/01/14    Commissioned by: Bury Safeguarding Children Board 2  I can confirm that the Serious Case Review on Child H (Case C13) was submitted to the Extraordinary Bury Safeguarding Children Board (BSCB) meeting on Monday 6 January 2014.  BSCB members agreed to accept the Serious Case Review Report and multi-agency action plan for submission.  I can confirm that BSCB endorse the recommendations made in the overview report and that the BSCB Executive Group will monitor their implementation.                       Gill Rigg       Independent Chair of BSCB   Signed: Date: 6 January 2014 3  CONTENTS CONTENTS .......................................................................................... 3  1. INTRODUCTION AND CONTEXT ........................................................ 4  2.  METHODOLOGY .............................................................................. 5  3.  THE SCR LEARNING REVIEW PARTICIPANTS ...................................... 7  4.  CHILD H’S FAMILY .......................................................................... 9  5.  THE INTEGRATED CHRONOLOGY ...................................................... 9  6.  ANALYSIS AND RECOMMENDATIONS ............................................. 22  7. SUMMARY OF KEY LESSONS AND ASSOCIATED RECOMMENDATIONS . 40  8. SUMMARY OF REVIEW RECOMMENDATIONS .................................... 42  9. REFERENCES ................................................................................ 43  10. GLOSSARY ................................................................................... 45         4  1. INTRODUCTION AND CONTEXT 1.1 On 28 April 28 2013 Child H, aged 8 years, suffered a fatal asthma attack. 1.2 Child H was the middle of 3 children. He had an older brother (BCH) aged 10 and a younger sister (SCH) aged 5. 1.3 The 3 children lived with their mother (MCH). Their father (FCH) was not living with the family at the time of Child H’s death but was having contact with the 3 children.  1.4 All three children were subject of a child protection plan (CPP) at the time of Child H’s death.  1.5 The Serious Case Review (SCR) was commissioned by the Bury Safeguarding Children Board (BSCB) in line with its statutory reviewing functions as defined in ‘Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children’ (2013). 1.6 Case C13 was referred to the BSCB Screening Panel in July 2013. There was significant debate about whether or not the case met the criteria for an SCR. It was finally agreed that the case did meet the criteria as the possibility of parental neglect was considered due to missed medical appointments. 1.7 It was also felt that valuable learning from the case could be gained by reviewing how agencies had worked together.  1.8 The number of children affected by the overlapping and often compounding issues of parental alcohol problems and domestic abuse is not known. Estimates of the number of children affected by the single issue of parental alcohol problems vary between 300,000 and 2.5 million (Cleaver et al. 1999, Tunnard 2002, Templeton et al. 2006). Prevalence estimates of children living with domestic abuse are similarly wide ranging. What is known is that more than one in four women suffer domestic abuse at some point in their lives and that women with children face double the risk of domestic abuse than women without children (Walby and Allen 2004).   1.9 In spite of the limited prevalence data on the number of children living with both problems, it is clear from research, professionals' experiences and service users' reports, that these two issues frequently overlap.  1.10 These sources suggest these are not small numbers of children. The result of this overlap is that children are exposed to, or caught up in, the effects 5  of parental alcohol problems and domestic abuse which places them at higher risk of harm and presents child protection concerns (Cleaver et al. 1999, Templeton et al. 2006).  1.11 The government has indicated that it supports changes recommended by Professor Eileen Munro that serious case reviews should be conducted using systems based learning methodology and it was agreed that important learning could be gained by conducting a whole system review of Case C13 in order to conceptualise how services routinely operate and to identify what is working well or where there are problematic areas.  1.12 The BSCB Serious Case Review Sub Group recognised that the review would need to be as robust and transparent as the former SCR process and should be measured by the extent to which it would make a difference and improve Bury’s multi agency safeguarding response.  1.13 Consequently, the BSCB Serious Case Review Sub Group made a recommendation to the Chair of BSCB, that the BSCB should conduct a ‘Learning Review’ to address how agencies had worked together; identify any additional learning and aggregate lessons from individual organisations and ensure that an improvement action plan was put in place.  1.14 The analysis in this report uses some elements of the framework developed by SCIE to present key learning within the context of local systems. This also takes account of recent work that suggests that an approach of developing over prescriptive and SMART recommendations have limited impact and value in complex work such as safeguarding children. For example, a 2011 study of recommendations arising from serious case reviews 2009-2010, (Brandon, M et al), calls for a limiting of ‘self perpetuating and proliferation’ of recommendations. Current thinking about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans. 2.  METHODOLOGY 2.1 The Learning Review was designed and led by Clare Hyde, independent facilitator, from The Foundation for Families (a not for profit Community Interest Company). Ms Hyde worked with the Chair of the Serious Case Review Sub Group and the BSCB Business Manager to develop a model that would enable participants to consider the events and circumstances, which led up to the tragic death of Child H.  2.2 A serious case review panel was convened of senior and specialist agency representatives to oversee the conduct and outcomes of the review. 6   2.3 The panel agreed specific terms of reference that provided the key lines of enquiry for the SCR in addition to the terms of reference described in national guidance. The panel established the identity of services in contact with the family during the time frame agreed for the review.   2.4 The SCR aimed to provide an innovative ‘whole system’ approach involving key front line practitioners (and their line managers) who worked with the children and adults of Child H’s family.  In this way, Child H’s ‘story’ was to be central to the Learning Review. In preparation for the Learning Review practitioners were asked to complete a chronology identifying key practice episodes and describing:  • What could / should have been done differently? • What worked well and how was this evidenced? 2.5 In addition practitioners were asked to complete a case review template which encouraged them to consider the whole family, including parental histories and reflect on their practice. 2.6 Participants were also asked to consider the following key questions at the Learning Review which had been posed by the BSCB SCR Screening Panel and Child H’s family members: i. Is there evidence that Child H’s parents were given advice on how to manage the asthma?  ii. Were Child H’s parents informed of the possible impact on him caused by their failure to attend medical appointments?  iii. What procedures were followed when Child H did not attend appointments?  iv. What is your clinical opinion of the management of Child H’s asthma?  v. Was there adequate communication between the consultants and others involved in the care of Child H? vi. Is there any research that suggests that stress can bring on an acute asthma attack?  vii. What would the cumulative effect be of acute attacks on a child with asthma?  viii. Is there any evidence to demonstrate that acute attacks can be caused by passive smoking?  7  2.7 In addition members of Child H’s family asked the following questions:  • What was the classification of Child H’s asthma?  • Why was the family’s request for a home nebuliser refused?  2.8 It was anticipated that further questions would emerge during the course of the Learning Review.  2.9 The Learning Review event took place over a full day. During the first part of the day practitioners and their line managers had the opportunity to review the combined chronologies of each agency; which was represented as a ‘whole system’ timeline. Each agency then talked through their involvement with Child H and his family. Questions were asked and comments and reflections made by other participants. The results of this chronology based exercise informed the second part of the Learning Review which focused on identifying areas for improvement and best practice for agencies working together to safeguard children.  3.  THE SCR LEARNING REVIEW PARTICIPANTS 3.1 The following agencies have provided chronologies, completed a case review template and participated in the Learning Review event:- Six Town Housing (STH) Greater Manchester Police (GMP) Children’s Social Care (CSC) Greater Manchester Probation Trust (GMPT) Bury Drug and Alcohol Service (Bury DAS) Bury Clinical Commissioning Group (Bury CCG) GP Central Manchester University Hospital Foundation NHS Trust (CMUHFT) Children’s Services Early Help Team Pennine Acute Hospitals NHS Trust (PAHT) Primary School Community Services Bury, Pennine Care Foundation NHS Trust (CSB/PCFT) 8  Women’s Housing Action Group (WHAG) Children’s Community Nursing Team, Pennine Care Foundation NHS Trust (CCNT) Mental Health Services, Pennine Care Foundation NHS Trust 3.2 Also in attendance at the Learning Event were:- Independent Chair Admin Support Worker, BSCB Business Manager, BSCB PhD Research Student 3.3 Due to an oversight an Outreach Support Worker (OSW) from the Children’s Centre, who worked with the family from March 2013 and her line manager were not asked to participate in the Learning Review.  As the OSW had worked closely with the family her input was sought as soon as the oversight came to light. The OSW completed a chronology and a case review template and had a lengthy discussion with Ms. Hyde about her involvement with the family.  3.4 Ms Hyde and the Interim Chair of the BSCB SCR Screening Panel met with two members of Child H’s family, FCH and Child H’s paternal aunt and sought their views before the Learning Review took place. 9  4.  CHILD H’S FAMILY   How did agencies respond to Child H and his Family? 4.1 Child H and his family raise a number of practice issues, both for individual agencies and for the BSCB; particularly in relation to families with complex and/or multiple needs and risk factors.  • FCH is a recovering alcoholic. Throughout the timescale covered by the SCR, FCH was struggling to control his drinking and made attempts to stop several times.  • Although the time frame of the review covers the period 1 January 2009 to 28 April 2013, Greater Manchester Police (GMP) had recorded domestic abuse incidents at the family home from as early as 2005. There were prolific domestic abuse incidents throughout the timescales of the SCR.  • The 3 children were subject of a Child Protection Plan under the category of emotional abuse following an assault by FCH against Child H during a domestic abuse incident.  • MCH was being treated for depression and this appears to have been directly related to FCH’s alcohol dependency, domestic abuse, harassment and financial hardship.  • As a result of long standing financial difficulties leading to rent arrears MCH’s housing status was insecure.  • Child H experienced several health issues including moderate/ severe asthma, problems with his eyesight, tooth decay, nosebleeds, enuresis, and his height and weight were on the 2nd centile.   5.  THE INTEGRATED CHRONOLOGY 5.1 The review attempted to identify how agencies and organisations responded to the needs of Child H and his family between 1 January 2009 and 28 April 2013.  5.2 Participating agencies carried out reviews of their records and materials including:  10  • Electronic records  • Paper records and files  • Patient or family held records   5.3 There are more contacts with health care workers, police and probation officers than are referred to in the following summary of professional contact with Child H and his family. This summary provides an account of the most significant events and decisions from the different services involved during the timeframe of the SCR.  Note 5.4 The Health Visiting (HV) service was in contact with the family between 2007 and 2011 in respect of SCH.  However, they did provide MCH with support and advice in respect of all the children and, therefore, a chronology of their involvement was requested and key practice events are included in the integrated chronology below.  Key Events 2009 to 2013 Child H 5.5 Although before the time frame of the SCR; it was noted that Child H was diagnosed with asthma in October 2007; aged 2 years and 6 months. (Child H had breathing related difficulties at the age of 13 months and again at 2 years of age although these were due to viral infections.)  5.6 The 3 children became subject of a ‘Child in Need’ Plan (CIN) on 3 August 2009 after Children’s Social Care (CSC) were notified of a serious domestic abuse incident which had also involved FCH looking after the children whilst very intoxicated. (This was the third incident of domestic abuse that CSC were aware of however the earlier incidents fall outside the timescales for this SCR; this is discussed in more detail in section 6.)  5.7 Child H’s GP received a letter from the Orthoptist on 12 December 2009, stating that Child H had been discharged from their service as he had not attended two consecutive appointments. (There were subsequent re-referrals of Child H to the Orthoptist and 2 further discharges for non attendance.)  5.8 The Health Visitor (HV) carried out a home visit to MCH on 12 December 2009. MCH was open about recent domestic abuse incidents and FCH’s behaviour. MCH told the HV that the domestic abuse had been going on over the last 5 years and had left the family financially compromised.  MCH also said that she was in contact with solicitors to stop FCH contacting her (although there was no evidence provided to confirm this.) The HV recorded that the family were in considerable debt to Six Town 11  Housing and Utility Companies and this was causing anxiety. The HV contacted The Salvation Army to request a food hamper for the family.  5.9 On 2 February 2010 the HV carried out a further home visit and discussed the domestic abuse with MCH, who reported that she had met with the Women’s Housing Action Group (WHAG) worker. MCH also reported that she feels down at times and the HV advised her to see her GP.  5.10 The HV discussed issues around passive smoking with MCH who reported that she was due to see the GP the following day with Child H as he was chesty.  5.11 At a further home visit on 25 February 2010 the HV discussed and attempted to complete a United Utilities Trust Fund Application for support with debt problems.  5.12 MCH reported that she was attempting to gain information from the Council tax Dept and Housing to support her application. She also reported to have seen the GP with Child H but still needed to see the GP in respect of her own health needs.  5.13 MCH stated that she was not feeling low at present but was under stress.  5.14 On 18 March 2010 the HV carried out a home visit where the current situation with FCH and the domestic abuse was discussed. MCH reported that she was having contact with FCH but said that he hadn’t been violent towards her or the children.  5.15 MCH had still not accessed the GP for her own health issues and the HV advised her again to do so. The HV reported that MCH was underweight and gave her advice about healthy eating.  5.16 On 12 May 12 2010 the HV received a telephone call from the support worker (WHAG) to say that MCH had disengaged with their service and the suspicion was that MCH and FCH had resumed their relationship. As a result of this information the HV carried out a home visit during which MCH disclosed recent domestic abuse incidents; FCH had stayed overnight; MCH was sleeping with SCH; FCH spat in MCH’s face and dragged her downstairs by her hair, all 3 children were present. This had followed a previous incident when FCH had assaulted MCH whilst she and the children were asleep. The Police had been called as FCH would not leave the house; MCH reported this as a verbal argument to the police at the time.  5.17 MCH told the HV that she was committed to ending the relationship.  12  5.18 Child H’s GP made a referral to the Consultant Paediatrician at Pennine Acute Hospitals NHS Trust (PAHT) on 10 June 2010 as the GP was struggling to control Child H’s asthma.  5.19 On 26 June 2010 the HV completed a Common Assessment Framework (CAF) and planned a child in need (CIN) meeting to be held at the Primary School. The HV also discussed arranging an appointment at the Children’s Centre with the Citizen’s Advice Bureau (CAB) to discuss debt issues and MCH agreed.  5.20 Child H was seen and assessed by the Consultant Paediatrician in July 2010 and was referred by him to an Ear, Nose and Throat specialist within PAHT for recurring nose bleeds. Child H was also vomiting when he had an asthma attack. The Consultant Paediatrician also referred Child H to the Children’s Community Nursing Team (CCNT) and asked that they also supported Child H.  5.21 Two members of the CCNT visited Child H at home on 23 July 2010 and discussed Child H’s Asthma management and triggers with MCH and checked Child H’s inhaler technique.  A copy of Child H’s management plan was sent to MCH by post on 25 July 2010.  5.22 On 1 September 2010, a joint visit by the HV and a student HV was carried out. The HV discussed concerns about the children having contact with their father and advised MCH on safety issues in respect of FCH’s alcohol misuse. The HV informed MCH that Children’s Social Care would become involved if concerns were raised around the safety of the children.  5.23 The HV also outlined the importance of working with the Outreach Support Worker (OSW) at the Children’s Centre.  5.24 MCH agreed to attend Freedom Programme and parenting Course.  5.25 Between 3 September and 29 September 2010 the HV maintained contact with MCH and liaised with WHAG to ensure that MCH was reassessed for their service. The HV also strongly encouraged MCH to attend the CIN meetings.  5.26 On 14 October 2010, the Consultant Paediatrician at PAHT referred Child H to Central Manchester University Hospitals NHS Foundation Trust (CMUHFT) for a second opinion. He also referred Child H to the Enuresis Team for help with night time bed wetting.  5.27 An initial assessment process was started by Children’s Social Care (CSC) on 29 October 2010 following a further notification of domestic abuse. 13  Child H’s elder sibling also stated that his mother MCH sometimes slapped him.  5.28 Following the initial assessment process MCH withdrew from the HV service and requested that she was allocated a new HV. (Between October 2010 and 13 May 2011, the HV remained in contact with MCH although only one further home visit was carried out and SCH transferred from the HV service to the School Nurse (SN) at the Primary School in September 2011.)  5.29 In November 2010, the SN at the Primary School delivered two training sessions for staff on awareness and management of asthma.  5.30 Child H missed an appointment with the Consultant Paediatrician at PAHT on 13 January 2011.  5.31 On 21 January 2011 MCH brought Child H to the Accident and Emergency Department (A&E) suffering from an asthma attack. However MCH left with Child H before the Paediatric doctor had seen him. A ‘cause of concern’ form was completed by staff at the A&E Department, which was faxed to the Safeguarding Team, Community Services Bury (PCFT) who, in turn forwarded the ‘cause of concern’ to the School Nursing Team (SNT). This is a standard procedure. A referral was also made to the CCNT. The GP was not sent a copy and again, this is standard practice.    5.32 On 18 May 2011, the actions contained in the plan put in place as a result of the Core Assessment process are deemed to have been met.  5.33 Child H had a further hospital admission via the A&E department on 8 September 2011. He was discharged on 10 September 2011.  5.34 On 15 September 2011, the Consultant Paediatrician at PAHT saw Child H in clinic and wrote to the Paediatric Respiratory Consultant at Royal Manchester Children’s Hospital (RMCH) (part of CMUHFT) as he was concerned about Child H’s growth and the amount of asthma related medication Child H was taking.  5.35 Between September 2011 and April 2013 Child H’s school maintained Child H’s Health Care Plan and Medication Record.  5.36 Child H was seen by the Paediatric Respiratory Registrar (CMUHFT) on 29 September 2011, who arranged for Child H to have a chest x-ray. He advised MCH to continue with Child H’s current medication as it seemed to be controlling his asthma.  14  5.37 The Paediatric Respiratory Registrar at (CMFT) saw Child H again on 16 February 2012 and he discussed Child H with the Respiratory Consultant and increased Child H’s medication and referred him for further tests. A letter advising Child H’s Paediatrician at PAHT of this change to Child H’s medication was however not written until 4 April 2012.  5.38 On 21 February 2012 two further training sessions on asthma were delivered at Child H’s school by the School Nurse.  5.39 On 26 July 2012 the Paediatric Respiratory Consultant (CMUHFT) wrote to Child H’s GP following a missed appointment by Child H. In this letter the Paediatric Respiratory Consultant suggested a trial of two drugs for Child H’s asthma related symptoms. Although this letter was dictated on 26 July 2012 it was not typed and sent until 9 September 2012; a six week delay. The Paediatric Consultant at PAHT (the referrer) was not copied into this letter.  5.40 On 28 August 2012 Child H was admitted via ambulance and the A & E Department to North Manchester General Hospital and was discharged after treatment on 29 August 2012.  5.41 On 6 September 2012 Child H was seen by a Specialist Doctor at RMCH, who referred Child H for tests on his adrenal gland. Although this letter was dictated on 6 September it was not typed and sent until 9 October 2012. The Paediatric Consultant at PAHT (the referrer) was not copied into this letter.  5.42 On 2 October 2012 Greater Manchester Police (GMP) made a referral to CSC following a domestic abuse incident during which Child H had been physically harmed by FCH who slammed a laptop lid down on Child H’s fingers. CSC initiated a Core Assessment and a Strategy Meeting (Section 47 Children’s Act 1989) the outcome of which was a decision to initiate a child protection case conference with a view to children being made subject to a Child Protection plan.  5.43 On 24 October 2012 the family was allocated to the OSW (as an action from the case conference). The OSW’s role was to offer support to MCH and the children.  5.44 On 31 October 31 2012 the initial child protection conference was held and all three children became subject to a child protection plan under the category of emotional abuse. The child protection plan outlined work with MCH and particularly with Child H and his elder sibling about their experiences of domestic abuse and its impact on their emotional wellbeing. FCH was to engage with his community order and address his alcohol misuse by engaging with probation and Bury Community Drug and 15  Alcohol Service. The OSW attended the conference and introduced herself to MCH. Family members were to support the children’s contact with their father by supervising his contact.  5.45 On 11 January 2013 the first review child protection conference was held. The Social worker reported that three core group meetings had been held since the first Child Protection conference.  He reported that MCH was cooperative with the plan and had allowed access to the family home and the children.  He reported no concerns about MCH’s care of the children.  However issues that remained included a lack of clarity about MCH and FCH’s relationship. MCH was reluctant to take out an injunction against FCH and although MCH had attended the Domestic Abuse Freedom Project, her understanding of the impact of domestic abuse on the children’s overall development and emotional wellbeing was felt to be still questionable as she had continued to allow FCH to have contact with the children.  5.46 It was observed that the children appeared to be very guarded in their responses to professional’s questions. Child H’s health was also discussed; this is the first mention of his asthma that is noted.  5.47 Probation reported father’s compliance with his Community Order which he received on 29 October 2012 for 9 months with an alcohol treatment requirement.  FCH attended his treatment and probation appointments and undertook domestic abuse work on a regular basis.  He had also found full time employment.  Concerns were raised by his Offender Manager, OM2, about the slow progress made regarding arrangement of supervised contact between FCH and all three children.  5.48 On 2 February 2013 the Paediatric Respiratory Consultant (CMUHFT) dictated a letter (which was typed and sent on 19 February 2013) to Child H’s GP discharging Child H from the Respiratory Clinic due to a missed appointment on 2 February 2013 and one the previous year on 26 July 2012.  5.49 On 8 February 2013 Child H missed an appointment with the Consultant Paediatrician at PAHT and a letter was sent to Child H’s GP asking that the GP Practice Asthma Nurse reviewed Child H and checked that he was compliant with his treatment.  5.50 On 15 February 2013 the GP wrote to MCH to ask her to arrange a telephone consultation to discuss Child H’s missed hospital appointments.  5.51 The offer of support to MCH from the OSW was not taken up by MCH until 5 March 2013. The OSW carried out a home visit and MCH told her about 16  her rent arrears and also sought advice about adult education opportunities. (MCH had just completed a Return to Work course.)  5.52 The OSW visited MCH and the children again on 26 March 2013 when she provided immediate practical support, gave advice and made arrangements for MCH to see a solicitor about FCH contact with the children and his payments of maintenance. The OSW arranged to pick MCH up and take her to the appointment with the solicitor.   5.53 On 9 April 2013 the OSW supported MCH at the appointment with the solicitor, who gave advice about a restraining order in respect of FCH. On returning to MCH’s home the OSW contacted STH, to report mould and what appeared to be subsidence in the home.  The OSW recorded that she was informed by STH that they would make an appointment with MCH to assess the house. The OSW also spoke to Housing Choices, and asked if a letter from Child H’s G.P in respect of his chronic asthma would assist the family to move into a higher band (priority for re-housing).   5.54 On 10 April 2013, the fifth core group meeting was held.  MCH attended and was reported to be complying with the child protection plan.  FCH was still engaging with probation and his community order although he had had two lapses i.e. he had consumed large amounts of alcohol, which he and OM2 felt may have been due to stress caused by the slow progress being made by CSC to put supervised contact arrangements in place.  5.55 The Core Group also discussed Child H’s asthma and how much this was affecting his education. At this time he was using inhalers 5 to 6 times per day whilst in school.  As a result he was missing his lessons.  He had also missed school due to attending his medical appointments.  MCH said she would arrange to take Child H to see his GP again as he was using his inhaler more frequently.  MCH reported no health concerns with the other children. The Core Group recorded that Child H was under the care of a consultant at Royal Manchester Children’s Hospital and Fairfield General Hospital, he also sees the GP and asthma nurse.  There was no indication that Child H had missed medical appointments or that his asthma was in any way unmanaged.  5.56 It was noted that FCH continued to contact MCH, the last incident was two weeks previously.  MCH had asked her solicitor to write to FCH to ask him not to contact her.  5.57 Child H’s school wrote to the GP on 10 April 2013 to express concern at the number of days that Child H was missing from school due to asthma; the GP wrote to MCH to discuss schools concerns on 24April 24 2013.  17  5.58 On 16 April 2013 the CSC Social Worker carried out a Child Protection visit at the family home. MCH had taken Child H to see his GP to review his medication. Child H had been provided with a three day course of steroids and antibiotics.  MCH stated that she was happy with current contact arrangements between FCH and the children. MCH was advised not to smoke in the kitchen but to smoke outside the house.  All the children were seen by the Social Worker at this visit.  5.59 On 18 April 2013 the OSW visited MCH and the children at their home. She provided advice and support to MCH about the behaviour of BCH. The OSW talked to MCH about the impact of the domestic abuse and FCH’s alcohol dependency on BCH and gave suggestions to help BCH work through his feelings of anger and distress.  5.60 The OSW carried out another home visit to MCH and the children on 25 April 2013. MCH reported that BCH’s behaviour had improved. MCH also stated it was the first week in a long time that all the children had been at school together.  MCH told the OSW that Child H’s medication had been updated and he appeared to be responding well.    5.61 MCH stated that the children had visited FCH at the weekend, at his sister’s house. FCH was initially fine however, after some time all children noticed he smelt of alcohol.  When MCH returned to pick the children up FCH was sat on a wall in front of the house and she stated that she knew instantly he had been drinking.  MCH stated that she would only give him one last chance.   5.62 MCH also stated that she had responded to a text he had sent because she was angry with him for drinking when the children were with him.  The OSW contacted SW2 and updated her.  MCH showed the OSW a letter from her solicitor advising FCH not to contact her. The OSW scanned the letter to SW2 and put a copy in the Children Centre records.  5.63 Child H achieved 100% attendance at school between 22 April and 26 April 2013 and was also awarded a school prize.  5.64 Child H collapsed at the family home on 28 April 2013 following an asthma attack and died.  5.65 At the time of Child H’s death the rapid response protocol (SUDC) was initiated as this was a sudden and unexpected death of a child. Child H’s Parents; FCH and MCH FCH 18  5.66 Greater Manchester Probation Trust (GMPT) began managing FCH on 2 February 2009 for domestic abuse related offences against MCH. (FCH was made subject to 24 months suspended sentence order (52 weeks custody); 24 months supervision).  5.67 The domestic abuse was prolific and did involve physical assaults by FCH against MCH. The majority of the domestic abuse occurred when FCH was intoxicated or when he wanted money to purchase alcohol.  5.68 The children were present during many of the domestic abuse incidents.  5.69 Throughout the period February 2009 to 16 November 2010 FCH reported to his Offender Manager (OM1) that he was having regular contact with MCH and the children including spending days and nights at the family home. FCH also reported that he continued to drink alcohol. He describes MCH’s attempts to manage his alcohol consumption during this time (e.g. not allowing him to drink in the family home or restricting his alcohol consumption to an agreed number of ‘cans’ per night once the children were asleep, or preventing him from seeing the children if he exceeded the agreed number of drinks).  5.70 On 11 May 2009, FCH reported to OM1 that he was facing a disciplinary action at work as he was involved in a physical fight with another member of staff. This and other incidents finally led to him losing his job in June 2009.  5.71 On 3 November 2009 FCH told OM1 that he wished to address his alcoholism and OM1 made a referral to the Community Drug and Alcohol Team (CDAT) on 12 November 2009. It was, however, March 2010 before FCH underwent a home detoxification programme.   5.72 FCH continued to drink alcohol and have contact with MCH and the children although MCH attempted to control this dependent on how little / much he was drinking.  5.73 On 29 October 2010, FCH’s OM1, following discussion with the Probation Operations Manager, was granted permission to apply for early revocation of FCH’s order for good progress.  5.74 Throughout the period that FCH was managed by OM1, the police were called to 11 incidents involving FCH, the majority of which were domestic abuse incidents at the family home.   5.75 FCH’s order was revoked on 16 November 2010.  19  5.76 On 1 October 2012, FCH visited MCH at the family home in a drunken state. He went upstairs and began to shout at the children who were playing on a laptop computer. He slammed the laptop lid down on Child H’s fingers. The police arrested FCH and charged him with common assault against Child H.  5.77 GMPT’s pre sentencing processes included:  • Completion of risk assessments and management plan.   • Full consideration of previous domestic abuse and impact on child, given offence committed following conflict with partner precipitated by alcohol misuse.    • Discussions held with other partners to ascertain full details and all recorded appropriately.  • Consideration for registration as high risk of serious harm given previous offending and violent behaviour within the context of domestic abuse (convicted and non-convicted).    • Consultation (with line management) and agreement that FCH was medium risk based on current non-contact conditions protecting family, plus his compliance with these.  5.78 FCH appeared before Bury Magistrates on 15 October 2012 and pleaded guilty to an offence of common assault and battery. FCH was sentenced to a community order for nine months with six months alcohol treatment requirement and nine months supervision.  His case was allocated to an Offender Manager (OM2) given the domestic abuse and child protection concerns.  5.79 OM2 made early contact with CSC, the Domestic Violence Unit (DVU) of GMP and the CDAT.  5.80 On 1 November 2012 FCH attended an initial appointment with the CDAT and then attended for an Alcohol Treatment Requirement (ATR) Assessment as ordered by the court.  FCH attended appointments as scheduled; gained employment and self reported that he was maintaining abstinence which random breath tests confirmed.  5.81 On 12 November 2012 OM2 attended a Core Group meeting and was informed that FCH had been contacting MCH by phone and it was agreed that OM2 would tell FCH not to contact MCH. On 14 November 2012, at a planned appointment, OM2 advised FCH not to contact MCH again. 20   5.82 Throughout November and December 2012, OM2 attempted to speed up the process being led by CSC of risk assessing family members to supervise contact for FCH with his children. This delay in establishing supervised contact was causing frustration for FCH and OM2 was aware that FCH was still in contact with MCH and could potentially use this contact to manipulate access to the children.  5.83 However, by December 2012 there were concerns, expressed by CSC that FCH and MCH had reconciled. FCH was open with OM2 about his contact with MCH (he denied contact with the children) and about his wish to reconcile. OM2 challenged FCH about his perceptions of the relationship with MCH, his use of alcohol and domestic abuse.  5.84 During February 2013, FCH began drinking again and continued to do so, intermittently up to the end of the period covered by this review.  5.85 Throughout the period of FCH’s engagement with the CDAT, his supervision by GMPT and during the time that his children were subject to a child protection plan; FCH continued to have contact with MCH and with his children (some of this contact was via text messages).  MCH 5.86 MCH remained with the 3 children in the family home throughout the period of this review. She was a tenant of Six Town Housing (STH) the principle social landlord in the area.  5.87 In September 2009, MCH informed STH that her partner had moved out of the property.  5.88 On 20 January 2010 the Women’s Housing Action Group (WHAG) began to support MCH; making a referral to the Bury Multi Agency Risk Assessment Conference (MARAC) in respect of the domestic abuse on 25 January 2010.  5.89 On 5 February 2010, STH put in place target hardening at the family home due to domestic abuse following a request from GMP.  5.90 On 1 March 2010 MCH reported to her Support Worker (SW) from WHAG that her parents had fallen out with her as she was not allowing FCH to see the children as he was intoxicated most of the time and could not be trusted to look after the children. The SW (WHAG) reassured MCH that she was protecting her children by not allowing them to see FCH whilst he was drunk.  21  5.91 On 17 May 2010 the SW (WHAG) and a Health Visitor carried out a joint visit to MCH at her home. During the visit MCH described several recent domestic abuse incidents including physical assaults against her. The SW (WHAG) and Health Visitor expressed their concerns to MCH that the children were present during the incidents and that they were witnessing their father being heavily intoxicated.  5.92 WHAG continue to support MCH until 8 May 2011; offering practical and emotional support and liaising with other agencies on MCH’s behalf. MCH expressed her unhappiness to the SW (WHAG) that information about her family was being shared with children’s social care by the Health Visitor.  5.93 Between August 2010 and January 2013 STH arranged six pre-eviction interviews with MCH; two of which she did not attend.  5.94 On 2 July 2011 MCH was first treated by her GP for depression.  5.95 On 8 February 2013 MCH was seen by her GP, who documented depression, stress with her ex partner and court proceeding for an injunction. MCH also reported symptoms of Irritable Bowel Syndrome (IBS) which settled with treatment but the GP documented that MCH couldn’t afford to buy the non prescription medication for her IBS.  5.96 On 9 February 2013 STH received a letter supporting MCH’s application for re-housing from the family’s Social Worker; citing overcrowding; domestic abuse by former partner; and MCH’s attempts to pay off her arrears. Bury Council deemed that the family did not meet the threshold for statutory overcrowding.  5.97 On 16 April 2013 STH received an email from MCH regarding her application for re-housing. In this email she refers to Child H’s asthma and damp at the property as well as overcrowding.  5.98 STH made an internal referral to their Repairs & Maintenance department and an inspection of the property was arranged for 25 April 2013.  5.99 MCH made several phone calls to STH between 16 April 16 and 25 April 2013 and wrote to a Bury Council stating that her property was not suitable for her and was having a detrimental effect on Child H’s health; he suffers from chronic asthma and damp and mould are affecting his condition. Housing Options sent a ‘SAM’ (medical assessment form) to MCH requesting supporting evidence from Child H’s paediatric consultant. MCH was also advised about other housing options with other housing providers.    22  5.100 An independent assessment of the damp /mould at the property was carried out on 3 May 2013 and although this is outside the timeframe for the SCR the findings of the independent assessment are highly relevant. The findings of the assessment were that mould growth infection was evident due to condensation through inadequate ventilation requiring:  • The removal of infected sealant in the lounge, bedroom 1, bedroom 2 and hallway.  • Mould treatment in the hallway due to damp proof course failure.  6.  ANALYSIS AND RECOMMENDATIONS 6.1 This section sets out an analysis of key findings and associated recommendations that are designed to offer challenge and reflection for the BSCB and partners. 6.2 Is there evidence that Child H’s parents were given advice on how to manage the asthma?  • There is significant evidence particularly from the CCNT records that MCH was given information, advice and support around the management of Child H’s asthma and she was able to comply with Child H’s Asthma Management Plan and had put plans in place with school and other family members to ensure that they knew what to do if Child H had an asthma attack or became wheezy. Child H himself was noted by several practitioners to have excellent technique when using his inhalers.  6.3 Were Child H’s parents informed of the possible impact on him caused by their failure to attend medical appointments?  • There is evidence that the GP contacted MCH by letter following notification of missed medical appointments in June 2010, January 2013 and February 2013.  However, there is only one conversation recorded between MCH and the GP on 15 January 2013, in which the GP advised MCH to take Child H to the Orthoptist. It does not appear that any other health practitioner discussed the possible impact of missed medical appointments with MCH or FCH.  6.4 What procedures were followed when Child H did not attend appointments?  23  • Child H missed appointments with the GP, the Orthoptist, the Paediatric Consultant (PAHT) and the Paediatric Respiratory Consultant (CMUHFT). Each of these component parts of the health service have their own policy and practice covering missed appointments. The missed appointment policies were not consistently applied sometimes as a result of clinical judgement and sometimes as a result of error.  • In line with the current CMUHFT Missed Appointments Policy, when a first new appointment is missed a further appointment is not routinely offered unless clinically indicated.  On this occasion the clinician took a professional judgement that a second appointment was indicated, which is good practice.    • CMUHFT policy was not followed in respect of discharging Child H following a missed appointment in February 2013 (their policy states that discharge should take place after 2 consecutive missed appointments). There is no written documentation to indicate who made the decision to discharge and how the case was reviewed.  (Child H had not missed 2 consecutive appointments).  • There is no evidence that a letter was sent to the parents informing them that Child H had been discharged from their service and this was not compliant with CMUHFT Missed Appointments Policy. There is no documentation to indicate whether there was any contact with the Named Nurse for Safeguarding at CMUHFT for advice. In line with the Missed Appointments Policy following 2 consecutive missed appointments consideration should be given to any safeguarding issues. The discharge of Child H from CMUHFT was not compliant with CMUHFT policy.  • CMUHFT did not inform P1 (PAHT) who had referred Child H to their service about the missed appointments again; this is not compliant with CMUHFT Missed Appointments Policy. (See 6.6 below for further comment and recommendations).  6.5 What is your clinical opinion of the management of Child H’s asthma? • The management of Child H’s asthma was compliant with current British guidelines. • Management goals for childhood asthma are for a "normal life" free of any symptoms (eg cough, wheeze and breathlessness), the ability to have a restful sleep, to grow and develop normally, to attend school or preschool regularly and participate in all school 24  activities including sports, to minimise the number of attacks of acute asthma, to avoid hospitalisation and to avoid medication related side effects. • The impact of the disease needs to be weighed against the possible impact of the therapy. In the case of asthma treatment for children there are issues which are also extremely important to the parents, such as normal appetite, good academic performance at school, social development and lack of irritability or disruption of family life.  • The choice of treatment for Child H was influenced by his history which considered the frequency of previous attacks, the severity of previous attacks, previous hospitalisation, repeated use of oral steroids, the level of treatment previously necessary to obtain "control", and rate of response to treatment.  • Child H had few emergency admissions to hospital as a result of asthma attacks and P1 observed that Child H was not a child who he would have expected to ‘crash’ or end up in Paediatric Intensive Care.  6.6 Was there adequate communication between the consultants and others involved in the care of Child H? There was inconsistent and at times inadequate communication between the consultants and others involved in the care of Child H. Some examples include:  • Child H missed appointments with P2 (CMUHFT) on 6 January 2011 and 21 April 2011 and a letter was sent to Child H’s GP to inform them of this.  However, a letter was not sent to P1, which was not in line with CMUHFT’s missed appointments policy (ie A letter should have been sent to the original referrer to enable them to make a decision on what action to be taken.)  • In line with CMUHFT policy, a letter should have been sent by CMUHFT to Child H’s parents, his GP and P1 following each clinic appointment but this was inconsistent and did not always happen.  • Changes to Child H’S medication were recommended by a Paediatric Registrar CMUHFT on 2 February 2012.  However, the letter to Child H’s GP to effect the change in medication was not typed and sent until 4 April 2012.  • New medication for Child H was suggested by P2 CMUHFT on 26 July 2012.  However, the letter to Child H’s GP was not typed and 25  sent until 10 September 2012. A copy of this letter was not sent to P1 (PAHT).  • The CCNT did not liaise with the School Nursing Team (SNT) to ensure that they were made aware of deteriorations in Child H’s asthma or that they had failed to make contact with MCH on several occasions.  • The lack of communication between the CCNT and the SNT meant that the CCNT were not aware of the domestic abuse and child protection concerns until 22 November 2012. At this point, the information that the CCNT held in respect of Child H’s missed appointments, failed contacts and the failure of MCH to always follow the CCNT advice would have been highly relevant to the child protection processes.  • The Cause for Concern form faxed by the A & E department generated when MCH did not wait to be seen with Child H was not shared with the GP. This was routine practice at the time,  however, a new information sharing system is due to be introduced in Bury in Spring 2014 which will flag children who are subject to a Child Protection Plan (CPP). CSC will be notified that the child has been to A and E and this will trigger enquiries and information sharing with other agencies (including GPs) as appropriate.  Recommendations:   • BSCB need to assure themselves that health partners apply their policies correctly in particular in relation to the non attendance by children. • BSCB Health partners should urgently consider if their internal and external communication processes are functioning well and/or could be improved using this Case C13 as a ‘test case’.  6.7 Is there any research that suggests that stress can bring on an acute asthma attack?  • Physicians, scientists, and asthma sufferers have long believed that stress contributes to exacerbations of asthma. However, it has only been in the past two decades that convincing scientific evidence has accumulated to substantiate this hypothesis. For example, in an 18-month prospective study of children with asthma, the experience of an acute negative life event (eg death of a close family member) increased the risk of a subsequent asthma attack by nearly 2-fold (Sandberg et al., 2000). The impact of an acute negative event was 26  accentuated when it occurred in the context of chronic stress. Children exposed to high levels of acute and chronic stress showed a 3-fold increase in risk for an attack in the two weeks that followed the acute event.  • There is no doubt that Child H and his siblings were suffering significant emotional distress and, on one known occasion, physical harm because of their exposure to domestic abuse. They were also left in the care of FCH whilst he was intoxicated despite the efforts of MCH to ensure that he remained sober, whilst the children were with him. It is highly probable that they found it stressful to be with their father when he was intoxicated.  • Four further studies have reported that children exposed to domestic abuse were more likely than their peers to develop asthma (Breiding & Ziembroski, 2010; Subramanian, Ackerson, Subramanyam, & Wright, 2007; Suglia, Duarte, Sandel, & Wright, 2010; Suglia, Enlow, Kullowatz, & Wright, 2009.)  Recommendations:   • BSCB should consider raising Multi agency practitioner awareness of the impact of stress on children with asthma; particularly children living with domestic abuse and/or whose parents have mental health or substance misuse issues.   • Where a child is subject to CPP or CIN arrangements the impact of stress on asthma should be assessed as a risk / need and reflected in the child’s individual Health Plan as a discreet, integrated part of the overall CPP.  6.8 What would the cumulative effect be of acute attacks on a child with asthma?  • A higher asthma symptom score in childhood, which represents more severe asthma, is a well known risk factor for the persistence of asthma in adulthood. The clinical severity of asthma in childhood is, therefore, an important predictor of asthma persistence in adulthood.  • FCH reported that many of his family members, himself included, were asthma sufferers.  However, family history does not determine individual asthma prognosis.  The implication being that the severity of asthma is not genetically determined, even if the individual has a genetic predisposition to the disease. Therefore, 27  environmental factors are probably the most important factors in the clinical expression and prognosis of asthma.  6.9 Is there any evidence to demonstrate that acute attacks can be caused by passive smoking?   • There is significant evidence that exposure to passive smoking exacerbates asthma (Cooke et al 1997, Strachan et al 1998). MCH was given information about the effects of passive smoking on Child H’s asthma by the family GP, the Children’s Community Nurses; the P1 (PAHT) and the P2 (CMUHFT). MCH was also advised to stop smoking by the same health professionals but there was no evidence that MCH accessed local ‘stop smoking’ support service.  6.10 What was the classification of Child H’s asthma?  • Child H’s asthma was moderate in terms of his presentation (i.e. when seen by his GP, the Children’s Community Nurses). The P1 (PAHT) and the P2 (CMUHFT) felt that Child H’s asthma appeared stable.  However, it was severe in term of the dosage and type of medication he was taking. It was also severe in terms of the impact on his education and other quality of life indicators.  6.11 Home Nebuliser  • Nebulisers are not available on prescription from the NHS. Nebulisers are no longer recommended as first-line treatment for acute asthma. The British BTS/SIGN Guidelines states that there is insufficient evidence to make recommendations about the use of nebulisers in an emergency situation but do recommend their use in severe asthma attacks.   • Asthma UK Nebuliser Fact-file states “Even if you’ve used a nebuliser before, it’s not recommended that you rely on a nebuliser to self-treat asthma attacks at home as it can be dangerous. This is because when you have an asthma attack you need to be properly assessed by a doctor or nurse. This includes having your pulse, breathing rate and oxygen levels checked. You might also need additional treatment such as oxygen and steroid tablets”. Additional analysis A. The Safeguarding Process  6.12 The assault on Child H by FCH in October 2012 was “a trigger” for action resulting in Child H and his siblings being made subjects of a child 28  protection plan.  However, there were five referrals to CSC due to domestic abuse and parental alcohol misuse between 2007 and 2012. The referrals do not appear to have been recognised or responded to as a significant pattern of risk and harm. MCH and the children continued to live with the impacts of domestic abuse and FCH’s alcohol dependency for a further 5 years before the children were made subjects of a child protection plan (CPP).   6.13 As described by Professor Eileen Munroe’s review it is apparent that the ‘safeguarding system’ and to some extent professional practice has been geared to recognising emergency incidents rather than more enduring patterns of harm or risk.  This contributed to the children being left in a harmful situation for too long with agencies responding to a ‘trigger’ incident before intervening.  6.14 There needs to be a continued shift in culture and practice so that there is earlier recognition of patterns of risk and harm and earlier intervention to protect and safeguard the long-term needs of the child.  6.15 The formal early use (within CAF and CP processes) of single and multi-agency chronologies, particularly for families with complex needs/ risks, enables professionals to ‘see’ the whole family context and reduces the risk of missing vital information. In the case of Child H and his family, some professionals did not have access to important information which would have had a bearing on their decision making and upon their assessment and management of risk.  6.16 There was considerable delay in establishing supervised contact arrangements for FCH and the children. This delay increased the risk of FCH attempting to manipulate MCH to allow him to see the children outside of the CPP arrangements.  6.17 The CP process did not consider supporting MCH to apply for a Non Molestation order and/or a Residence Order. This meant that MCH and FCH’s offender manager OM2 had to attempt to control and manage FCH’s access to and contact with MCH and the children without any formal recourse, when he made contact against OM2’s advice or against MCH’s wishes.  Recommendations:  • BSCB partners should ensure that their workforce has the skills and capacity for completing appropriate individual and family histories and that the early use of chronologies for families with complex needs is embedded in service expectations and practice. (Note: BSCB are planning 29  to pilot the development and use of a multi-agency chronology template which can detail a family’s context enabling professionals to gain an overview of co-existing factors, complexities etc.)   • Early consideration of the use of legal process to clarify and formally manage, restrict or prevent contact in future cases would be good practice.   B. Understanding the Complexity of MCH’s Life; how this influenced the CP process  6.18 MCH was the victim of prolific domestic abuse over many years. MCH tried to manage and mitigate the impact of FCH’s abuse and alcoholism on herself and her children. It was apparent that MCH was manipulated by FCH. She felt responsible for and sorry for him.  6.19 MCH was facing long term extreme financial hardship and the ever present threat of eviction. Some of the financial hardship was as a direct consequence of the domestic abuse compounded by FCH’s alcoholism. Research from 2008 by Family Action and Gingerbread reveals the extent to which domestic abuse can push women into severe debt and hardship (Bell and Kober 2008).  6.20 MCH was sole parent to the 3 children for significant periods of time either because FCH was not present or when he was present he was intoxicated. MCH attempted to manage FCH’s intake of alcohol in order to minimise the impact of his drinking on the children.  6.21 MCH came under pressure from different family members at various points in time either to end or resume her relationship with FCH.  6.22 MCH did not appear to tell any single agency the true extent of the domestic abuse and it is only in integrating the various agency chronologies and bringing practitioners together that a truer picture of the nature of the abuse becomes clearer.   6.23 Child H had significant health needs and his asthma in particular was an ever present concern to MCH. From agency chronologies it appears that for the vast majority of the time MCH took sole responsibility for communication with health practitioners and for taking Child H to his various medical appointments. MCH did not take Child H to some of his medical appointments (although she did take him to the majority) and she understood his asthma treatment plan. FCH and Child H’s maternal aunt described the journey to take Child H to hospital appointments as difficult; 30  requiring MCH to juggle child care arrangements for Child H’s siblings. The financial costs of the journey may also have been an issue for MCH.  6.24 MCH was also strongly advised by every health professional she came into contact with in relation to Child H’s asthma to stop smoking. Although MCH reported that she did not smoke in the house (and was not observed to do so by any of the professionals who visited the family home) she was advised that cigarette smoke would still be an irritant for Child H’s asthma.  6.25 When the 3 children became subject of a CPP there were expectations of MCH and, at the same time, suspicion that she was not totally open and honest with professionals about the status of her relationship with FCH. The CP Core Group meetings were attended by MCH and she was noted to be ‘complying with the plan’.  As late as 10 April 2013, the fifth Core Group meeting recorded that FCH had continued to contact MCH and that she had asked her solicitor to write to him to stop him doing so.  6.26 The ways in which domestic abuse was recognised and understood shaped the orientation of work undertaken with the family. Importantly a failure to understand the coercive and gendered aspects of domestic abuse can contribute to both the exclusion of men from ‘planning and practice’ and the focusing of professional attention upon women who are often misunderstood and held accountable for their situation and how it impacts upon children.   6.27 MCH was being treated for depression and had described to the HV and her GP the significant stress and strain she was experiencing on a daily basis.  6.28 There was significant evidence, despite MCH’s assertions that the relationship had ended, that FCH remained in contact with her and the children. The daily difficulties that MCH faced as an abused and coerced woman and the impact that this would have on her decision making, her self-identity and her ability to protect herself and the children was not understood within a framework of research informed knowledge.  6.29 Evan Stark (Coercive Control: How men entrap women in personal life) for example, describes how domestic violence has to be understood more clearly as coercion in order to understand the impact on the women and to understand why these relationships endure and why abused women develop a profile of problems seen among no other group of assault victims.   Recommendations:  31  • BSCB should consider how partners currently approach case management, supervision and ongoing professional development for practitioners working with families living with domestic abuse and other risk factors such as substance misuse.  • Adopting a reflective approach to case management, supervision and ongoing professional development, which incorporates an understanding of domestic abuse and other risks offers opportunities for agencies and practitioners to improve their responses to families affected by domestic abuse, and crucially, to enhance the safety and protection of women and children. Such approaches should offer opportunities for individual professionals and multi agency groups of professionals to reconsider their work in this area; this should take into account how they understand domestic abuse and women and children’s situations, and how they respond to everyone involved including the perpetrator and the risks they pose. (Note: There is currently an audit being undertaken within CSC of supervision practice)  • BSCB should promote consistent multi agency use of the DASH (Domestic Abuse, Stalking and Harassment) Risk Assessment tool and the development of a multi agency risk assessment tool specifically in relation to children living with domestic abuse which will ensure that a consistent and collaborative approach to assessing risk is taken. C. FCH 6.30 FCH was a source of risk to Child H and his siblings both in respect of the domestic abuse he perpetrated and his alcohol dependency. FCH appeared to be open and honest in reporting his frequent contacts with MCH and the children and the levels of his alcohol consumption to his offender managers (GMPT).  6.31 Children living in households where there is an alcohol dependent parent will be susceptible to several risks including: poverty exacerbated by an inability to maintain a routine of work as well as diverting household income to fund the purchase of alcohol, care ‘whilst intoxicated’ that exposes children to the risk of immediate physical harm and longer term emotional damage.  6.32 Additional risk could have been associated with MCH’s increasingly serious attempts to separate from FCH and from the plans to limit his contact with the children. Saunders (2004) highlights the period following separation and contact disputes as particularly high risk. Triggers include new or pending legal decisions on issues such as contact, residency or child protection proceedings, or the fear of losing a job or a home.  32  6.33 No investigation by OM1 into ongoing domestic abuse and alcohol use led to the decision to apply for early revocation of FCH’s order by OM1 in November 2010 being supported by management despite the fact that:  • During the period of time FCH was being managed by OM1, there were 11 incidents reported to GMP involving FCH, the majority of which were domestic abuse incidents at the family home and witnessed by the children.  • FCH self reported that he was still drinking alcohol and was not engaged with substance misuse services.  6.34 This application for early revocation appears to demonstrate a lack of understanding of the risk of continuing harm to MCH and the children both from FCH’s alcohol dependency and the domestic abuse.  6.35 On 1 October 2012, FCH visited MCH at the family home in a drunken state. He went upstairs and began to shout at the children who were playing on a laptop computer. He slammed the laptop lid down on Child H’s fingers. The police arrested FCH and charged him with common assault against Child H.  6.36 GMPT’s pre-sentencing processes included:   • Completion of risk assessments and management plan.   • Full consideration of previous domestic abuse and impact on child, given offence committed following conflict with partner precipitated by alcohol misuse.    • Discussions held with other partners to ascertain full details.  • Consideration for registration as high risk of serious harm given previous offending and violent behaviour within the context of domestic abuse (convicted and non-convicted).    • Consultation (with line management) and agreement that FCH was medium risk based on current non-contact conditions protecting family, plus his compliance with these.  6.37 When FCH was convicted of the common assault and battery of Child H his case was allocated to OM2.  6.38 Throughout the period October 2012 to April 2013, FCH continued to contact MCH despite having been told to have no further contact with her 33  by OM2. FCH also continued to use alcohol (with the exception of several weeks during a detoxification programme).  6.39 OM2 challenged FCH about his behaviour and beliefs on many occasions and discussed with him the impact of his actions on MCH and the children.  For example, she challenged the fact that he was drinking alcohol at weekends when he was planning to see the children.   6.40 Throughout the period October 2012 to April 2013 OM2 attended Core Group meetings and a tension appears to have developed between SW1 CSC and OM2 whereby OM2 was advocating on FCH’s behalf to progress the delayed supervised contact arrangements. This delay was presented by FCH and OM2 as a stress factor which led to FCH’s alcohol relapses rather than the relapses themselves being understood as a pattern of alcohol dependency and assessed as a significant risk to both MCH and the children. OM2 also recognised that the delay in establishing supervised contact arrangements could have increased the likelihood of FCH contacting MCH and the children outside of the CPP arrangements, which was indeed the case. OM2 attempted to expedite the recommendations of the CPP to put these arrangements in place.  6.41 GMPT pre sentencing process had determined that FCH was ‘medium risk based on current non-contact conditions protecting family, plus his compliance with these’ with an explicit understanding that he would be high risk otherwise.  6.42 Formal and robustly supervised contact arrangements, including plans for what would happen if FCH had been or was drinking alcohol, would have lessened the risk to the children. The delay in putting these arrangements in place undoubtedly caused FCH frustration and distress however, what is clear in law and policy is the need to protect children and vulnerable adults and prioritise their safety regardless of the area of specialist practice.  For services that work mainly on an individual basis with adults on issues other than their parenting (for example their offending and/ or alcohol use), this may be a particular challenge and can be the source of service generated risk.   Recommendations:  • It may need specific focus at CP meetings and guidance from the Chair to ensure there is agreement and clarity over why children's needs come before adults' needs if it comes down to a choice between the potential breakdown of a supervisory, therapeutic or other ‘adult focused’ relationship or the protection of a child. 34  (Note:  In January and February 2012 mandatory enhanced safeguarding training took place for all GMPT practitioners and line mangers which focused on the child being central to all risk assessments and management plans.  Sessions focused on child protection issues emanating from domestic abuse, sexual offending, parental substance misuse and mental health.  The complexity of need and risk and the necessity of a formal assessment and plan to mitigate any impact upon any children in the care of an adult with such issues, was studied in depth within this training.  Subsequent to this there was a formal audit of safeguarding cases to ensure that plans demonstrated how children were being protected, with one-to-one work being undertaken with colleagues who did not appear to have incorporated such actions.  Three monthly case audits now take place on a random selection with safeguarding issues, including external referrals, CAF co-ordination, home visiting and contact with child-centred agencies being fully reviewed. In addition from January 2012 all police Force Wide Incident Numbers (FWINs) for domestic abuse cases are sent direct to the risk support officer who forwards these to the relevant offender manager.  This ensures that probation are fully updated at all times with ongoing risks pertaining to domestic abuse related behaviour, whether this results in a formal charge/conviction or not.  Risk assessments are dynamic and therefore fully reviewed when new information is received - whether the individual is on an order/licence for domestic abuse or not.  In November 2012 Risk of Serious Harm briefings were held which led to a differential application of the definition of serious harm to include cumulative and potential harm.  With regard to domestic abuse perpetrators, risk of serious harm had previously been based upon convictions and the seriousness of a specific offence.  The potential cumulative risk of significant emotional harm resulting from persistent ‘low level of harm’ offences is now fully considered.  An audit in summer 2013 demonstrated the consistent application of this, refresher briefings and individual action plans being developed for those who did not apply it correctly.). D. The Voice of Child H 6.43 The CP process focused on the domestic abuse and to an extent on FCH’s alcohol dependency (ie it was ‘parent focused’).  Although there was an apparent awareness of the impact of domestic abuse and parental substance misuse on the children and there was some focused action detailed in the CPP to carry out direct work with them, which would address this, there was no evidence that this had been carried out with Child H or his siblings.  35  6.44 The feelings and wishes of Child H and his siblings are not clearly captured and recorded in any agency chronology and it appears very little focused and specific direct work took place with the children to address the impact of domestic abuse and parental alcohol misuse. The feelings and wishes of Child H and his siblings in respect of contact with their father are also not clearly captured.  6.45 Child H’s asthma is likely to have been exacerbated by stress, however, there was no indication that he was asked about what he was experiencing or that stress was considered as a possible trigger for his asthma.  Recommendations: • BSCB should review current practice in order to ensure that the wishes and feelings of children are addressed. • Where appropriate children and young people should be given opportunities to contribute directly to decision making and to assessments of need and risk and this should be documented. E. Child H Health Needs; a Secondary Issue in the CPP 6.46 The domestic abuse experienced by MCH and the children was the primary focus of the CPP and other CP processes. However, the impact of the domestic abuse meant that MCH’s ability to manage so many competing physical, financial and emotional demands (including attending medical appointments) was likely to have been compromised. This does not appear to have been considered by the CP Core Group Meetings or in ongoing assessments. Child H had several health needs and assumptions were made that MCH was able to meet his needs and that he was being taken to all of his health related appointments. The Chair of the CP Case Conference was unaware that Child H had been discharged from secondary and tertiary care because of missed appointments.  Recommendation:  • Each child who is subject to a CPP should have an individual Health Plan which is integrated into social work assessments and the CPP. The plan should record every service/ practitioner involved in their care. This Health Plan should be a standing agenda item for case conferences and reviews and revisited at each meeting or review.    F. Information Sharing 36  6.47 Ofsted’s evaluation of serious case reviews from 1 April 2009 to 31 March 2012 identifies that nationally there are problems in how information is sought and shared.  6.48 Many serious case reviews identify issues in regard to the importance of securing relevant historical information in order to inform current assessments.  6.49 In this case gaps in the sharing of information left some professionals without a complete picture and when episodic incidents occurred they were not seen as symptomatic of longer term historic patterns. One of the consequences of this was that Child H’s health was not considered within the context of the whole family dynamic.  6.50 The use of a combined chronology at the Learning Review was the first opportunity that practitioners had to ‘see the whole picture’ for Child H and his family. Many of the participating practitioners were unaware of key pieces of information about Child H and his family.  6.51 Good information sharing can be characterised by a clear understanding and shared knowledge about a child within the context of his/ her family, as they progress through various systems of help and support that they and their families encounter.  6.52 The following paragraphs give examples of where and how information was shared.  Secondary and Tertiary Care  6.53 The health agency chronologies and narratives; highlighted the problems of health professionals not having common policies or systems of patient recording; this is a national problem. There was no sense of a shared view that could identify patterns of missed appointments, inconsistencies and risk.  6.54 As previously described; neither secondary care paediatrician was aware that Child H was the subject of a CPP; P1 (PAHT) felt that, had he known, it would have affected his decision to discharge Child H. The core assessment of Child H and his siblings identified that Child H had asthma and other health issues however no contact was made with the paediatric consultants at either PAHT or CMTH. This also meant that the two paediatricians were unable to inform the CP Core Group Meetings that Child H was missing some of his appointments or to contribute their knowledge about the impact of stress on asthma.  CCNT 37   6.55 The CCNT did not consistently share information with the SNT or the GP resulting in information regarding missed appointments and deteriorations in Child H’s asthma not being shared.  WHAG  6.56 WHAG did not share the fact that MCH was withdrawing from their services with other agencies involved with the family. WHAG had a good understanding of the nature and extent of the domestic abuse and exposure of the children to the abuse and FCH’s alcohol use, which no other agency had at that time. MCH had expressed to her SW (WHAG) that she was not happy that the HV was sharing information with a social worker which was potentially risk increasing as MCH had already expressed her negative feelings about the involvement of other agencies and could have actively withdrawn from services.  Recommendations:  • The person who takes responsibility for identifying and contacting health agencies involved in the care of a child, who is subject to a CPP or who is a child in need, should be agreed and documented at the earliest point of the CP process. This person should then be responsible for bringing information to the CP process and sharing information with health agencies as appropriate. (Note: A Safeguarding Team is established in each secondary and tertiary care hospital trust and this team was identified as a good single point of access to information and communication for other professionals working with children in need or at risk.)  • The CCNT should test their information sharing processes using this SCR as a case study.  • WHAG should review their information sharing process and practice when women withdraw from their services.   G. Capacity 6.57 A serious case review offers opportunities to reflect on the options that were available to act differently and to understand the barriers that prevented opportunities either being seen or else followed through. Organisational capacity is an important aspect to understanding how 38  aspects of a case were handled at the time and the contributory factors that determined how judgments, decisions and actions developed. 6.58 In this case there are issues; identified by participants at the Learning Review, about the capacity of some services. For example: a) there are fewer administrative staff at CMUHFT meaning that they have a much heavier workload, which can cause delays in administrative functions; b) there are 12 WTE school nurses covering the Bury area, which was reported to have an impact on practice.    Recommendations: • BSCB should consider which factors ensure that challenge / risk brought about by organisational and individual capacity is identified and that strategies for managing that challenge are appropriate and are understood by relevant stakeholders.  H. Areas of good practice 6.59 The following paragraphs provide examples of good practice during contact with Child H and his family.  GP   6.60 Child H’s GPs were persistent and consistent in their contacts with MCH and Child H particularly in respect of inviting Child H for flu jabs and inviting Child H’s parents to attend the practice for asthma reviews.  CMUHFT  6.61 CMFT used discretion in respect of their Missed Appointments Policy which states that when a first new appointment is missed a further appointment is not routinely offered unless clinically indicated.  On this occasion the clinician took a professional judgement that a second appointment was indicated, which is good practice.  CCNT  6.62 The CCNT responded effectively and persistently following missed appointments.   SNT and Primary School  39  6.63 The SNT and Primary School worked closely and consistently to ensure that staff were trained and that Child H’s asthma plan was reviewed and regularly updated. In April 2013, the Primary School contacted Child H’s GP to express their concern; their perception of the management of Child H’s asthma and the impact that this was having on his education. This was proactive and demonstrated that the Primary School were aware of a deterioration in Child H’s asthma symptoms.   CSC   6.64 SW1 established a positive relationship with MCH and demonstrated a good understanding of some of the difficulties experienced by MCH including financial hardship and domestic abuse. The handover of the case from SW1 to SW2 was well planned and took place over a defined period of time ensuring that SW2 was familiar with the case and understood the dynamics of the whole family.   PAHT  6.65 P1 knew Child H well and used his discretion to waive PAHT discharge policy when he believed this to be in the best interests of Child H.  Children’s Centre and WHAG  6.66 The OSW and WHAG workers were able to establish a trusted relationship with MCH at the most challenging times in her family’s life. MCH felt able to confide in them the truer extent and nature of the domestic abuse she and the children were experiencing.   HV  6.67 The two HVs who visited MCH at home recognised the stresses and risks posed to MCH and the children by the domestic abuse, alcohol dependency and associated poverty. They were empathetic to MCH but did not allow their empathy to influence their judgement, making appropriate referrals and at the same time offering consistent support and challenge.  40  GMPT  6.68 OM2 consistently challenged FCH about the impact of his behaviour and alcohol use on MCH and the children and demonstrated a good understanding of manipulative and coercive control.  7. SUMMARY OF KEY LESSONS AND ASSOCIATED RECOMMENDATIONS 7.1 This serious case review has highlighted important learning specifically about the physical and psychological impact of stress on children who are living with domestic abuse and parental alcohol dependency.  7.2 A full understanding, recognition and management of the risk caused by domestic abuse and FCH’s alcohol dependency to Child H, his mother and siblings was not shared by all of the practitioners involved with the family.  7.3 Child H had several health related needs and was reliant on MCH to ensure he attended appointments with a range of health practitioners and for a range of medical tests and procedures. This required time, effort, focus and reliable child care for the other children. MCH had depleted resources with which to juggle and manage the demands of attending all of Child H’s medical appointments.  7.4 The impact of the stress factors in MCH’s life was underestimated by some agencies and therefore her ability to cope and manage was overestimated.  7.5 Information was not consistently shared between agencies and this led to parts of the health system not knowing that Child H was the subject of a child protection plan. This affected decision making and may also have led to a discussion about the impact of stress on Child H’s asthma. Clinical Indicators 7.6 Child H’s paediatrician (P1) was shocked by the death of Child H and had no clinical reason to anticipate that Child H would suffer such a life threatening attack. Even if Child H had not been discharged from PAHT, P1 would not have seen Child H at his clinic for a further 4 months.  He confirmed that Child H was not a child he anticipated would require intensive care as a result of asthma.   7.7 The medical appointments which Child H did not attend were important both in terms of his health needs but also as an indicator that MCH was struggling to manage the demands of an extremely stressful life. The missed appointments were however outnumbered by attendances and it is impossible to determine that they contributed to a worsening of Child H’s asthma. 41   7.8 The health agencies involved in the care of Child H focused primarily on his physical health needs and advice was given to MCH and FCH about the impact of secondary smoking on Child H’s asthma.   7.9 No practitioner seemed to consider the impact of stress upon his asthma, although the GP, SN and CCNT were each aware of the domestic abuse and FCH’s alcohol dependency as significant stress factors in the family.   7.10 The HV although not ‘working’ directly with Child H did discuss the psychological and other impacts of domestic abuse on all the children with MCH.  7.11 In the case of Child H’s secondary and tertiary care providers they did not know that Child H was the subject of a child protection plan and this influenced their decision to discharge Child H after he missed attending appointments. Multiple Stress Factors 7.12 There is no doubt that Child H suffered physical and emotional harm as a result of living with chronic domestic abuse and FCH’s alcohol dependency. The stress of the family’s environment is likely to have contributed to the frequency and severity of Child H’s asthma attacks. However, it is not possible to say what triggered the asthma attack, which led to the tragic death of Child H in April 2013.   7.13 In the week leading up to his death; Child H had been awarded a special prize at school and had achieved full attendance for that week.  He had been described by his paternal aunt and FCH as being ‘full of beans’ and had enjoyed an active weekend. MCH confirmed that Child H had seemed particularly well when she spoke to P1 immediately following Child H’s death.  In other words, there does not appear to have been a specific trigger for the asthma attack or any indication that he would suffer such a severe attack.   42  8. SUMMARY OF REVIEW RECOMMENDATIONS 8.1 BSCB need to assure themselves that health partners apply their policies correctly in particular in relation to the non attendance by children. 8.2 BSCB Health Partners should urgently consider if their internal and external communication processes are functioning well and/or could be improved using this Case C13 as a ‘test case’.  8.3 BSCB should consider raising multi agency practitioner awareness of the impact of stress on children with asthma; particularly children living with domestic abuse and/or whose parents have mental health or substance misuse issues. 8.4 Where a child is subject to CPP or CIN arrangements the impact of stress on asthma should be assessed as a risk/need and reflected in the child’s individual health plan as a discreet, integrated part of the overall CPP. 8.5 BSCB partners should ensure that their workforce has the skills and capacity for completing appropriate individual and family histories and that the early use of chronologies for families with complex needs is embedded in service expectations and practice. 8.6 BSCB should consider how partners currently approach case management, supervision and ongoing professional development for practitioners working with families living with domestic abuse and other risk factors such as substance misuse.   8.6.1 Adopting a reflective approach to case management, supervision and ongoing professional development which incorporates an understanding of domestic abuse and other risks offers opportunities for agencies and practitioners to improve their responses to families affected by domestic abuse, and crucially, to enhance the safety and protection of women and children. Such approaches should offer opportunities for professionals to reconsider their work in this area.  This should take into account how they understand domestic abuse and women and children’s situations, and how they respond to everyone involved including the perpetrator and the risks they pose. 8.6.2 Consistent multi agency use of the DASH (Domestic Abuse, Stalking and Harassment) Risk Assessment tool and the development of a multi agency risk assessment tool specifically in relation to children living with domestic abuse will ensure that a consistent and collaborative approach to assessing risk is taken. 8.6.3 Early consideration of the use of legal process to clarify and formally manage, restrict or prevent contact in future cases would be good practice. 8.7 It may need specific focus at CP meetings and guidance from the Chair to ensure there is agreement and clarity over why children's needs come 43  before adults' needs if it comes down to a choice between the potential breakdown of a supervisory, therapeutic or other ‘adult focused’ relationship or the protection of a child. 8.8 BSCB should review current practice in order to ensure that the wishes and feelings of children are addressed. 8.8.1 Where appropriate children and young people should be given opportunities to contribute directly to decision making and to assessments of need and risk and this should be documented. 8.9 Each child who is subject to a CPP should have an individual Health Plan which is integrated into social work assessments and the CPP. The plan should record every service/ practitioner involved in their care. This Health Plan should be a standing agenda item for case conferences and reviews and revisited at each meeting or review. 8.10 The person who takes responsibility for identifying and contacting health agencies involved in the care of a child who is subject to a CPP or who is a child in need should be agreed and documented at the earliest point of the CP process. This person should then be responsible for bringing information to the CP process and sharing information with health agencies as appropriate. (Note: A Safeguarding Team is established in each secondary and tertiary care hospital trust and this team was identified as a good single point of access to information and communication for other professionals working with children in need or at risk.) 8.11 The CCNT should test their information sharing processes using this SCR as a case study. 8.12 WHAG should review their information sharing process and practice when women withdraw from their services. 8.13 BSCB should consider which factors ensure that challenge / risk brought about by organisational and individual capacity is identified and that strategies for managing that challenge are appropriate and are understood by relevant stakeholders.  9. REFERENCES Brandon et al. A study of recommendations arising from serious case reviews 2009-2010, Department of Education, September 2011 Bell K, Kober C. The Financial Impact of Domestic Violence. Family Welfare Association and Gingerbread 2008. Breiding MJ, Ziembroski JS Pediatr Allergy Immunol. The relationship between intimate partner violence and children's asthma in 10 US states/territories 2011 Feb; 22(1 Pt 2): 44  Cleaver, H., Unell, I. & Aldgate, J. (1999) Children’s Needs – Parenting Capacity. TSO (The Stationery Office). Cook DG, Strachan DP. Parental smoking and prevalence of respiratory symptoms and asthma in school age children. Thorax 1997 Copello, A., Templeton, L. & Velleman, R. (2006) Family intervention for drug and alcohol misuse: is there a best practice? Current Opinion in Psychiatry, 19, 271–276. Sandberg S, Paton JY, Ahola S, McCann DC, et al. (2000). The role of acute and chronic stress in asthma attacks in children. Lancet. Saunders, H. (2004) Twenty-nine child homicides: lessons still to be learnt on domestic violence and child protection. [Bristol]: Women's Aid Federation of England (WAFE). Stark Evan; Coercive Control: How men entrap women in personal life: Oxford University Press 2007  Strachan DP, Cook DG. Parental smoking and childhood asthma: longitudinal and case-control studies. Thorax 1998 Subramanian S, Ackerson L, Subramanyam M, Wright R. Domestic violence is associated with adult and childhood asthma prevalence in India. International Journal of Epidemiology. 2007 Suglia S, Enlow M, Kullowatz A, Wright R. Maternal intimate partner violence and increased asthma incidence in children: Buffering effects of supportive caregiving. Archives of Pediatric and Adolescent Medicine. 2009 Suglia SF, Duarte CS, Sandel MT, Wright RJ. Social and environmental stressors in the home and childhood asthma. Journal of Epidemiology and Community Health. 2010 Tunnard, J. (2002b) Parental Drug Misuse: A Review of Impact and Intervention Studies. Research In Practice. Walby, S., Allen, J., (Home Office Research, Development and Statistics Directorate) (2004) 45  10. GLOSSARY  Acronym Definition MCH FCH BCH SCH Mother of Child H Father of Child H Brother of Child H Sister of Child H GP General Practitioner PAHT Pennine Acute Hospitals NHS Trust CMUHFT Central Manchester University Hospitals Foundation Trust CCNT Children’s Community Nursing Team SNT School Nursing Team SN School Nurse HV Health Visitor GMP Greater Manchester Police GMPT Greater Manchester Probation Trust OM Offender Manager WHAG Women’s Housing Action Group SW (WHAG) Support Worker (Women’s Housing Action Group) OSW Outreach Support Worker Children’s Centre CSC Children’s Social Care SW Social Worker P P1 P2 Paediatrician Paediatrician Pennine Acute Hospitals NHS Trust Paediatrician Central Manchester University Hospital Trust SCR Serious Case Review 46  MARAC Multi Agency Risk Assessment Conference CPP Child Protection Plan BSCB Bury Safeguarding Children Board CP Child Protection CADT Community Alcohol and Drug Team STH Six Town Housing DVU Domestic Violence Unit CAF Common Assessment Framework CIN Child in Need FWIN Force Wide Incident Number  