Death of a 6-week-six-day-old girl found unresponsive on the couch next to her mother in November 2016. Baby A was born prematurely at 36-weeks' gestation. Mother sought help for her infant's feeding difficulties, vomiting and general unsettledness. At the time of her death, both parents had been drinking alcohol and were significantly intoxicated. Baby A's mother had a complex health and social history; substance misuse began when she was 12-years-old; her emotional and mental health challenges dated back to 2005 and in 2011 she was diagnosed with borderline personality disorder. Between 2009 and 2016 children's social care logged at least 13 contacts; a child protection referral was made by a consultant psychiatrist just before the birth of Baby A but the referral box was not ticked so was de-escalated to early help under midwifery and health visiting services. Ethnicity or nationality of Child A is not stated. Learning: practitioners should be aware that pregnancy and post-delivery is a critical time for women to experience deterioration in their mental health; monitoring and assessing growth of new born, premature infants should be in line with expected practice standards; all relevant multi-agency professionals should be contacted for a core assessment; all agencies should contribute to effective information sharing. Recommendations: to ensure all early help guidance addresses the issues identified in this review; to seek assurance that 'Did Not Attend' policies contain clear guidance on the actions to be taken when adults with caring responsibilities fail to engage with services dealing with health issues that can adversely impact on parenting capacity.
      
 Title:  Serious case review: Baby A. LSCB: St. Helens Safeguarding Children Board Author: Jane Carwardine and Melanie Hartley Date of publication: 2018  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.                                    SERIOUS CASE REVIEW  BABY A       20th November 2017     Page 2 of 52      CONTENT PAGE        SECTION CONTENT PAGE  Content page 2  Abbreviations used 3 Section 1 Executive summary 4 Section 2  Introduction to the review 7 Section 3  The review: a narrative 12 3.1 A portrait of Baby A 12 3.2 Family functioning 13 3.3 Significant historic safeguarding events and emerging themes between 2005 – 2014 17 3.4 Significant safeguarding events and emerging themes between February 2014 and November 2016 21 Section 4 Baby A: an analysis 29 4.1 Was relevant historic information about family/parental functioning known and considered in multi-agency risk assessment, planning and decision-making in the pre-birth and neonatal period?  29 4.2 Was the multi-agency planning robust, appropriate, effectively implemented, monitored and adequately reviewed in the pre-birth and neonatal period to reduce the risk of harm to the infant? 30 4.3 To what degree did agencies challenge each other regarding the effectiveness of the risk management, planning and decision making? 32 4.4 Were the respective statutory duties of agencies working with the infant, parents and family fulfilled? 34 4.5 Were there organisational, contextual obstacles or difficulties in this case that prevented agencies from fulfilling their duties? 41 Section 5 Conclusion 45 Section 6 Recommendations 48 Appendix 1 Collated learning points and good practice 49 Appendix 2 Bibliography 52 Page 3 of 52       ABBREVIATIONS  ABBREVIATION/TERM DESCRIPTION ANCC  Antenatal Cause for Concern  BEP Bleeding in Early Pregnancy  BPD Borderline Personality Disorder CAF Common Assessment Framework CAFCASS Family Court Advisory and Support Services  CDOP Child Death Overview Panel CIP Critical Incident Panel  CPA Care Programme Approach CRP Case Review Panel  CSC Children’s Social Care  DBT Dialectic Behaviour Therapy DNA Did Not Attend  EHAT Early Help Assessment Tool  EPDS Edinburgh Post Natal Depression Scoring Tool  GP General Practitioner HV Health Visitor/Visiting Home Treatment Team Home Treatment Team LSCB  Local Safeguarding Children Board MARAC Multi-Agency Risk Assessment Conference PMH Midwife Perinatal Mental Health Midwife SCR Serious Case Review SIDS  Sudden Infant Death Syndrome STR Worker Support, Time and Recovery Worker  SUDIC Sudden and Unexpected Death in Infancy and Childhood                         Page 4 of 52  SECTION 1: EXECUTIVE SUMMARY  Keywords: Pre-Birth Assessment Of Risk, Pre-Birth Early Help, Pre-Birth Social Work Assessment (Section 47), Maternity Cause For Concern Processes, Borderline Personality Disorder, Assessment And Intervention With Parental Substance Misuse (Alcohol, Cannabis And Cocaine), Domestic Abuse,  Managing Parental Non-Compliance With Mental Health Intervention, Assessing Parental Capacity, Silo Working, Multi-Agency Assessment, Thresholds Of Concern,  Effective Communication, Impacts Of Organisational Transformation, Alignment And Adoption Of Multi-Agency Practice Guidance, Assessment Of Parental Capacity, Understanding History And Assessing Capacity For Change.  1.  In November 2016, early one morning, Baby A was found un-responsive on the couch by her mother. Her mother called the Ambulance Service and commenced resuscitation. Resuscitation continued when the paramedics arrived and Baby A was transferred to a local NHS Emergency Department, where it was confirmed she had sadly died. The history given at the time of the event by her parents was that both parents had been drinking alcohol during the night of Baby A’s death. Her father went to bed at 00.45hrs and her mother continued to drink vodka until 02.00hrs. Baby A’s mother fed her baby, who fell asleep in her arms. Mother and baby then fell asleep on the couch. Mother advised she had drunk around 22 units of vodka. Toxicology blood tests confirmed both parents were significantly intoxicated (alcohol) at the time of her death and her father had the higher alcohol reading.   2.  Baby A was the youngest of the sibling group, all of whom were of primary school age. She lived with her sister, their mother and father. Her paternal half-brother and maternal half-sister stayed regularly at the family home, subject to agreements made through shared care arrangements. It was difficult during the review period to gain a picture of how the siblings experienced their daily life, especially during periods of instability. Extended family members provided some support. However, there was evidence of conflict within the maternal family and substance misuse by some extended family members. The ex-partners of both the mother and father were fully involved in their children’s lives and there is evidence the adults with parental responsibility worked together in times of crisis to keep the children safe. Occasional conflict was evidenced when Children and Family Court Advisory and Support Services (hereinafter known as CAFCASS) or Children’s Social Care within Peoples Services (hereinafter known as CSC) mediated a resolution.   3.  There was limited historic or recent information related to father except, he worked full time on a self-employed basis as a contracted painter and decorator. Practitioners advised, he could be supportive of Baby A’s mother and provided care and activities for the children. There was evidence Baby A’s mother had a complex health and social history. It was unclear the level of parenting she provided her children on a consistent basis. Practitioners advised she interacted positively with her children when well and able to do so. Baby A’s mother life was settled at times but could quickly become chaotic. At 12 years of age, she began to use cannabis and her substance misuse behaviours (cannabis, alcohol, cocaine) escalated after that point. There was no evidence of meaningful intervention by Substance Misuse Services. Whilst there was evidence General Practitioner Services asked about alcohol intake, other professional groups tended to “normalise” her alcohol behaviours and there was no significant evidence of professional inquisitiveness. Her alcohol usage was not accurately understood by front-line practitioners involved in providing ante-natal and postnatal care, despite an expert risk assessment by a Consultant Psychiatrist in 2016.   4.  In 2011, mother was diagnosed with a borderline personality disorder 1 (hereinafter known as BPD) following a long history of emotional/mental health challenges, dating back to 2005. She presented with                                                            1 An emotionally unstable personality disorder is also referred to as a borderline personality disorder. It is a disorder of mood and how a person interacts with others. A person with this disorder will differ from an average person in terms of how she thinks, perceives, feels or relates to others. The symptoms fall into 4 main categories; emotional instability, disturbed patterns of thinking, impulsive behaviour, intense but unstable relationships. Downloaded www.nhs.uk 23.8.2017. Page 5 of 52  mental health behaviours on a continuum of low to medium severity, as was her presentation of BPD. A range of behaviours were described including; social anxiety, self-harm (cutting and overdose), suicide attempts (overdose), obsessive compulsive disorder, anxiety and depression. She developed positive relationships with practitioners, but overall did not engage with intervention, therapy or medication to sustain stability and improvement in her condition. She was regularly referred to Mental Health Services for assessment and frequently her case would be closed due to non-compliance. Between 2010-2014 she was a victim of domestic abuse on at least eight occasions, perpetrated by differing partners. These incidents were assessed at different levels of severity and her children were present on many occasions. Her case was subject to the local multi-agency risk assessment conference process (hereinafter known as the MARAC) 2 and she worked effectively with multi-agency practitioners to help her manage the risk. There was no significant evidence of violence within her current relationship, although some practitioners documented she had historically described that she had felt emotionally abused by him.   5.  Between 2009 and 2016, at least thirteen contacts were logged by CSC. Four of these proceeded to an initial assessment and two core assessments were completed. Ten contacts proceeded to no further action. In September 2016, 11 days before the birth of Baby A, a child protection referral/contact was made to CSC by a Consultant Psychiatrist. The referral technically was not logged as a child protection referral as the drop box indicating it was a referral, hadn’t been ticked. The referral/contact indicated the need for a statutory pre-birth social work assessment, due to the high risk of mother relapsing in the post-natal period. The concern was this would lead to increased anxiety, self-harm and substance misuse therefore impacting negatively on the care she could provide to Baby A. The referral/contact was screened but not assessed as requiring an immediate response. The referral was de-escalated the day after Baby A’s birth to be managed by Mental Health, Midwifery and Health Visiting Services under the framework of early help. This was a missed opportunity to complete a formal social work assessment or to support understanding of the complex interrelating issues to manage the risk for the infant. The communication systems between Health Services were not effective in ensuring front-line practitioners with the responsibility of co-ordinating early help provision were aware of the plans.   6.  At the time, front-line Social Workers assessing contacts/referrals were struggling to process the high numbers of contacts. This could have resulted in the pre-birth assessment taking only a narrow risk management approach. The de-escalation process was not managed effectively by multi-agency partners, communication was ineffective, a “Think Family” 3 approach was not developed and a lead professional role was not established. Practitioners did not understand the risks nor have access to historic information that may have supported their risk assessment and subsequent interventions. Practitioners with ongoing responsibility for the provision of services were not made aware of the recent child protection referral/contact or the plan to work the case through early help. Practitioners’ motivation to provide high quality care was evident but they were working very much in their own agency silos, with only their own agency information. A more co-ordinated multi-agency statutory response was indicated when considering the known history, parental risk factors and the expert opinion which hypothesised the risks to the new-born infant in the post-natal period.  7.  At the time there was no LSCB multi-agency pre-birth guidance to guide the multi-agency arrangements. This is now in place, but its focus is the pre-birth statutory intervention process. It does not include guidance for early help in the pre-birth period and should be strengthened to support multi-agency practice. There are confusing ethical dilemmas regarding the rights of an unborn infant and the reluctance of statutory agencies to become involved before the 24th week of pregnancy due to abortion                                                            2 Multi-agency Risk Assessment Conference (MARAC) is a meeting where information is shared on the highest risk domestic abuse cases between Police, Health, Child Protection, Housing, Independent Domestic Violence Advisors and other specialists from statutory and voluntary sectors to coordinate a plan to safeguard the victim. 3 Think Family is an approach to support agencies to work together to meet the assessed needs of children and families. The local arrangements are supported by guidance and policy. Page 6 of 52  legislation. However national guidance 4 5 provides a clear expectation of universal agencies (Primary Care, Mental Health, Maternity Services). Their function is not only identifying pregnant mothers with complex health and social needs who may require additional support, it is also about their role in working with pregnant mothers to achieve the optimum outcomes for the infant through early help processes. Baby A’s mother was vulnerable, identified as having complex needs but universal agencies did not have their own early pre-birth practice guidance or services in place to support practice. There was no evidence universal agencies assessed the risk on an ongoing basis, assessed parental behaviours to sustain change or planned early intervention to maximise the parental capacity for positive parenting. Crucially there was no significant evidence of safety planning in respect of parental alcohol or mental health behaviours to manage the risk of a relapse. Following Baby A’s death, it is positive that mother received a comprehensive package of support, including a Mental Health Care Co-ordinator, through the care programme approach (hereinafter known as CPA) 6  to monitor her mental health progress and care delivery. This would have been a positive approach in the ante-natal period.                                                               4 HM Government (2013) Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children.  5 HM Government (2015) Working Together to Safeguard Children- a guide to inter-agency working to safeguard and promote the welfare of Children. Crown Copyright. 6 Care Programme Approach (CPA) is a system used to plan many people’s mental health care. The approach appoints a Care Coordinator to work with the adult with complex mental health issues and complete a care plan that details how the NHS will support the adult. Page 7 of 52  SECTION 2: INTRODUCTION TO THE REVIEW  8.  Copyright This serious case review (hereinafter known as SCR) has been jointly chaired and authored by Jane Carwardine and Melanie Hartley as Independent Reviewers. Its content has been quality assured by the Safeguarding Children Board (hereinafter known as the LSCB) and the Case Review Panel (hereinafter known as the CRP). It is owned by and copyright remains with the LSCB. Permission should be gained from the LSCB prior to sharing the content of this review either in paper form or electronically with any organisation or individual.  9.  Thanks The Independent Reviewers would like to thank practitioners, managers, multi-agency and provider organisations who openly and honestly reflected on and shared their experiences whilst working on the case. Their contributions were extremely advantageous, enabling enhanced learning and the identification of good practice. The motivation and passion of front-line practitioners, to make a difference to the life of Baby A and the family was evident throughout the process.  10. Anonymity The review has been written to protect the identity of Baby A, the family and practitioners. The emerging themes, key lines of enquiry and significant events have been discussed in a style which minimises the risk that either child or family’s identity will be unintentionally revealed. Multi-agency employees will be described in respect to their job role to protect their anonymity. This approach is taken to encourage open and honest reflection of safeguarding practice.   11. The Decision In November 2016, the case was notified to the LSCB Critical Incident Panel (hereinafter known as CIP) by a CSC Safeguarding Manager. In November 2016, early one morning, Baby A was found un-responsive by her mother. Baby A was transferred urgently to hospital where it was confirmed she had died. Both parents admitted to drinking alcohol the preceding evening. Father went to bed at 00.45hrs and mother continued to drink vodka until 02.00hrs. Mother reported she fed her baby, who fell asleep in her arms and they went to sleep on the couch. Mother advised she had drunk what equated to around 562mls of vodka prior to going to sleep. Toxicology blood tests confirmed both parents were significantly intoxicated (alcohol) around the time of her death. On the 6.12.16 the CIP reviewed the case and concluded the criteria for a SCR as defined in Working Together 2015 7 was met and this decision was agreed by the LSCB’s Independent Chair. The initial review of multi-agency information highlighted there was concern on how board partners worked together to safeguard Baby A in the pre-birth and post-natal period. The CIP developed the SCR research question and terms of reference. A case review panel was convened, and two Independent Reviewers were commissioned to undertake the review process with the panel.   12. The Case Review Panel  Independent Safeguarding Reviewers (chair and author).  LSCB: Business Manager, Business Administrator, Quality Assurance Coordinator, Lay Member.  Police: Detective Inspector.  Local Authority: Assistant Director of Safeguarding, Senior Assistant Director-Schools Services, Assistant Director of Social Work.  Legal Services: Principal Solicitor.  CCG: Designated Nurse, Safeguarding Children.                                                            7   HM Government (2015) Working Together to Safeguard Children- a guide to inter-agency working to safeguard and promote the welfare of children.  Crown Copyright. Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews. Page 8 of 52   CCG: Named General Practitioner.  13. The Serious Case Review A comprehensive SCR was commissioned; a hybrid methodology was used to complete the review, combining several theoretical models and techniques.8 9 10 These methodologies are regularly used to undertake safeguarding reviews. The format ensures key events, lines of enquiry and themes relating to safeguarding practice are critically analysed, with practitioner and service user involvement. It was felt this approach would provide a greater understanding of Baby A’s experience. A combined inter-agency chronology was developed, and further information was sought as gaps in data appeared. A timeline of significant events was developed in preparation for two practitioner events. Single agencies produced learning summaries including analysis of specific incidents and themes. All agencies/services were requested to share information relating to single agency incident reviews undertaken in respect to the case.   14. Participation The CRP considered the participation of the family in the process. Baby A’s parents were informed of the review process in writing through their Solicitor. At the time of the review’s completion their participation had not been secured due to parallel criminal investigations. Their participation will be an ongoing consideration for the LSCB.  Multi-agency services were mostly provided by agencies working within the responsible Local Authority area. Some of the services also worked across geographical boundaries and in other Local Authority areas. Multi-agency organisational and practitioner participation was encouraged to enrich the information within the chronology. An initial short introductory practitioner event was attended by twenty-five multi-agency practitioners and their managers, to ensure they were fully briefed on the process. This was followed by a practitioner only event with eleven practitioners in attendance. Positive feedback was received in respect of both these events. The practitioner events improved understanding of the significant events, key lines of enquiry and emerging themes. Additional verbal and email conversations were convened when necessary. The content of the review has been shared with practitioners involved. Practitioners from the following agencies participated in the process;    People’s Services: Independent Reviewing Officer, Team Manager, Social Worker.  Maternity Services: Community and Hospital Midwives, Community Midwife Manager, Specialist Midwife.  Community Nursing Services: Health Visitor, Matron for Quality, Named Nurse.  NHS Mental Health Services: Consultant Psychiatrist, Nurse Practitioner, Recovery Team.  Primary Education: Headteacher, Pastoral Care Lead.  Police.  Primary Care Services: Named General Practitioner (hereinafter Known as GP), Practice Manager.  Sudden and Unexpected Death in Infancy and Childhood (hereinafter known as SUDIC)11 Service.  Safeguarding Specialist Nurse.  15. Timeline, Research Question and Terms of Reference All records to be reviewed in depth for 2 years prior to the death of Baby A in November 2016. Relevant historical information relating to domestic abuse, child concern, parental/carers substance misuse and mental health to be provided by all agencies.                                                             8 Welsh Government (2012) Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Model. 9   SCIE Learning Together to Safeguard Children: A Systems Model for Serious Case Reviews. 10 HM Government (2015) Working Together to Safeguard Children- A Guide to Inter-Agency Working to Safeguard and Promote the Welfare of Children. Crown Copyright. 11 SUDIC service responds to sudden and unexpected deaths in childhood and infancy to support the investigation at the time of the death. The NHS service works with multi-agency practitioners and families. Page 9 of 52   16. Research Question “Is the LSCB assured that multi-agency partnerships work cohesively and effectively with infants, children and their families to provide early help and protection where there is a history of a parental personality disorder/mental health issues and parental substance misuse?”  17. Terms of Reference  No.  Issue  1 Was relevant historic information about family/parental functioning known and considered in multi-agency risk assessment, planning and decision-making in the pre-birth and neonatal period?  2 Was the multi-agency planning robust, appropriate, effectively implemented, monitored and adequately reviewed in the pre-birth and neonatal period to reduce the risk of harm to the infant? 3 To what degree did agencies challenge each other regarding the effectiveness of the risk management, planning and decision making? 4 Were the respective statutory duties of agencies working with the infant, parents and family fulfilled? 5 Were there organisational, contextual obstacles or difficulties in this case that prevented agencies from fulfilling their duties?  18. Considerations of Parallel Investigations The Coronial Inquest was not concluded at the completion of this review; therefore, the verdict is not available. The case had been presented to the Child Death Overview Panel however the findings of its investigation will not be completed until the SCR is finalised.  The criminal investigation is complete, and the evidential bundle has been presented by the Police to the Crown Prosecution Service. A decision regarding possible charges or prosecution in respect of the death of Baby A is awaited.  Agencies were asked to identify their agency critical incident reviews in respect of the case. There have been no disclosures of incident reviews undertaken in respect of this case.  19. Equality and Diversity Considerations There is a growing body of evidence to demonstrate that very young babies are extremely vulnerable to abuse either intentionally or unintentionally.12 Working with parents and families to assess the risk and plan intervention in the antenatal period can reduce the risk of harm to an infant. This intervention can be offered under the framework of early help (also known as the EHAT) or through the statutory social work pre-birth assessment process. Nationally there are many Local Authority/LSCBs that have multi-agency pre-birth guidance to manage the continuum of safeguarding need from early help through to statutory intervention; however these systems are frequently not as well embedded as safeguarding children processes.   There are complex ethical dilemmas when considering interventions in pregnancy with parents who have complex social or health support needs and are engaged in behaviours that might cause harm to the unborn infant. A significant dilemma is that the statutory pre-birth assessment is complex partly because the foetus has no legal status. In addition, early intervention in the United Kingdom can be problematic as a pregnant mother can seek a termination of pregnancy up to the 24th week of pregnancy under the Abortion Act (1967). As a result, in practice there may be conflicts between the pre-birth procedure for intervention and the legal power to intervene which is not a legal requirement                                                            12 Ofsted (2011) Messages from Serious Case Reviews.  Page 10 of 52  until birth. There is also limited focus on the pre-birth assessment in research which only forms a small part of the literature assessment base in safeguarding and protection work.13 14  20. Protected Characteristics There is gradual but increasing recognition in society, that parents with mental health issues have the right to family life and the right to become parents, with the outcome that the infant/child remains a part of family life. However, to be successful in this outcome and ensure the risk is managed for the infant, these parents may need reasonable adjustments in the provision of services. They are entitled to these adjustments under legislation (Equality Act 2010).  There are examples when practitioners made reasonable adjustments in their intervention with Baby A’s mother. The Midwifery Service allocated a Specialist Midwife, who maintained an overview of the case and in the post-natal period there were increased contacts documented in recognition of the need to monitor Baby A and her mother’s wellbeing. Mother’s mental health was unstable resulting in her presenting with social anxiety, so her in-patient experience in a ward with other mothers following the birth would have added to her stressors. She identified her dilemma and the Midwifery Service tried but could not meet her request for a single room. There is no evidence the Midwifery Service understood the complexity of her mental health condition or how her behaviours would respond in certain situations. Maternity Services should ensure that they strengthen their approach to women with protected characteristics under equality legislation. The use of a healthcare passport could have supported professional understanding and communication and is at the heart of equality and diversity work with women who have protected characteristics.   Learning Point 1: Pregnancy and post-delivery is a critical time when at least 1:5 women will experience a deterioration in their mental health. Women with a history of mental ill-health are at significant risk of a deterioration therefore practitioners delivering care should be aware of how individual women may present and the triggers to activate a deterioration. The use of healthcare passports 15 is a way of enhancing understanding and communication between the woman, her family and practitioners/services.  21. The Independent Safeguarding Reviewers Jane Carwardine has worked as an Independent Safeguarding Consultant since April 2015 and has completed several case reviews. She holds an MA in Child Care Law and Practice (Keele) and a BA Honours in Health Studies (Bolton).  Her professional background is in nursing (Nurse, Health Visitor and Midwife). Jane has undertaken a range of strategic, provider and commissioning management roles. She has had 15 years dedicated safeguarding experience in a variety of leadership roles including; senior and line management, Named Nurse, Designated Nurse for Safeguarding (adults and children) and Head of Safeguarding. Examples of her safeguarding activities includes; supporting the completion and quality assurance of SCRs, leading on multi-agency safeguarding learning and development, assuring the quality effectiveness of safeguarding activity, complex case management, development of multi-agency teams, developing and facilitating supervision systems, developing and leading safeguarding advisory services, membership on safeguarding boards and providing advice to a range of strategic boards. Jane has been directly involved in the completion of more than twenty serious case and multi-agency learning reviews. She has worked intensively to improve the quality effectiveness of the case review process and has recently represented the Royal College of Nursing on the Royal College of Paediatrics and Child Health Child Protection Committee. She has not been employed by any organisation aligned to this review.                                                            13 Hodson A., (2012) How Research on Pre-Birth Assessments Should Affect Practice. Community Care 30.8.2012. Downloaded comunitycare.co.uk 27.8.17. 14 Calder M., Hackett., Et Al (2013) Assessment in Child Care –- Using and Developing Frameworks for Practice. 2nd Ed, Russell House Publishing. 15 A healthcare passport is a communication/information leaflet designed originally to facilitate and improve work with adults with learning difficulties in a NHS setting. Its scope can be extended for service users in other situations.  Page 11 of 52   Melanie Hartley has recently retired from the NHS after 41 years of service, to undertake the role of Independent Safeguarding Reviewer. She holds an MA in Child Welfare and Protection (Huddersfield) and firmly believes that effective multi-agency working is vital if vulnerable children are to be adequately safeguarded. The case review process is a key component in this work. It ensures that multi-agency lessons are learnt and that actions are implemented leading to improvements in multi-agency safeguarding practice. Melanie’s professional background is also in nursing (Nurse, Health Visitor), including 20 years’ frontline experience as a Health Visitor, working with complex and vulnerable families and 10 years’ specialist safeguarding experience (Named Nurse Safeguarding Children, Designated Nurse for Safeguarding Children/Children Looked After and the Head of Safeguarding). These roles required the development of expert skills and knowledge in all areas of multi-agency operational and strategic safeguarding work. Melanie has been involved in the production and quality assurance process for numerous single and multi-agency case reviews. She has significant experience of leading and chairing a LSCB’s case review panel which enhanced her experience in case review methodologies and practitioner involvement. This is her third review as an Independent Reviewer. In preparation, Melanie has undertaken relevant training and fully participated in and shadowed a SCR process. She has not been employed by any organisation aligned to this review.     Page 12 of 52   SECTION 3:  THE REVIEW: A NARRATIVE  3.1 A PORTRAIT OF BABY A  22. The first six weeks of a baby’s life is developmentally exciting. The infant is beginning to settle into family life, may begin to smile, start to follow sound, fix onto her mother’s gaze, communicate through gurgling and settled through cuddling by mother and/or father. It has not been possible to develop a comprehensive pen-portrait of Baby A from her parents’ perspective due to ongoing criminal investigations. The portrait of Baby A has been built from the information reviewed and practitioner conversations undertaken.  23. In October 2016, Baby A was born prematurely at 36 weeks gestation. Her delivery was normal, and she weighed 2.64kg (just above the 50th centile which is the average for an infant). It is positive she remained with her mother on the hospital ward for 6 days due to her prematurity and did not require admission to the Special Care Baby Unit. Her extended stay in hospital was due to her prematurity, for the assessment and treatment of sepsis and to manage her jaundice. She was discharged to the family home under the care of her mother and father.   24. At the age of 11 days, Baby A was weighed and was maintaining her growth. The Community Midwife discussed safe sleep and observed the infant’s sleeping arrangements which were in line with expected guidance. Midwifery Services undertook six visits and documented that Baby A had continued to gain weight until her discharge at 27 days post-delivery. Midwifery Services did not record her growth on the centile chart although assessed her growth not to be of concern. Further conversations with Midwifery Services have highlighted it is not a current expectation of practice to plot centile charts. This practice should be strengthened to meet the requirements of national guidance.16 The expectation is that when an infant is weighed the growth should be plotted to ensure accurate interpretation of the data. Baby A was due to be weighed and assessed on the day prior to her death but did not attend the GP appointment. Baby A’s mother told the Health Visitor (hereinafter known as HV) “mother was asleep and had missed the appointment.”  Learning Point 2: Monitoring and assessing growth of new-born, pre-term infants is a core activity to ensure optimal growth. There is an expectation that all new-born infants are weighed, and the weight is then plotted on a growth chart which enables accurate interpretation of the data. All infants have growth charts in their parent held Child Health records, to support growth monitoring processes. Maternity and HV Services should ensure that growth assessment and monitoring are in line with the expected practice standards.   25. When Health Practitioners visited the home, they observed Baby A being cuddled by her mother and advised mother to infant attachment was good. On some occasions, the infant  was sleeping in her moses basket. Her mother described her as a fractious, unsettled baby, however practitioner observations were Baby A was settled and normally asleep when they visited. At the age of 4 weeks, Baby A attended the GP for the treatment of “sticky eyes” and “infantile colic”. The outcome of the treatment is unclear. The information in respect of her feeding patterns indicates she was initially breast fed, although this was through expressed milk via the bottle. Her feeds were supplemented with infant formula. Prior to her death she was completely bottle fed. Maternity and HV Services had no concerns about her feeding patterns. At the age of 5 weeks, Baby A attended the GP and was reported to have been vomiting all her feeds back since her birth. The GP had no concerns at that point and documented baby A was “thriving” although noted that there was no Child Health parent held records. The information demonstrated inconsistencies with practitioners in regular contact assessing Baby A as a settled, content and thriving baby. However, her mother’s perspective differed, and she sought help due to her infant’s feeding difficulties, vomiting and general unsettledness.                                                             16 RCPCH (2009) Using the new UK-World Health Organization 0-4 years growth charts. DoH. Page 13 of 52  26. At the age of 6 weeks and 6 days, Baby A was found by her mother at 06.00hrs, underneath her arm, on the couch not breathing.  Her mother called the Emergency Services and commenced resuscitation. The paramedics arrived within 6 minutes of the initial call and as they got to the address her mother carried Baby A to the Ambulance. The baby was noted to be pale, cyanosed but was warm to touch. There were no signs of life or no recordable observations. Resuscitation continued enroute to the Emergency Department. Sadly, Baby A did not respond to resuscitation attempts either in the Emergency Department or in the Ambulance and was pronounced dead at 07.15hrs. The father to Baby A was present throughout the process. The SUDIC response to the death was robust and in line with expected practice.  3.2 FAMILY FUNCTIONING    27. Family Dynamics   Mother  Gender  Relationship Residence Female  Mother to Baby A, Child M and N Co-habiting with father. Father  Male  Father to Baby A, Child M and O Co-habiting with mother. Birth-Mother (EFR) Female  Mother to Child O Shared care arrangements with father in respect of Child O Birth-Father (EL) Male Father to Child N Shared care arrangements with mother in respect of Child N Boyfriend 1 (NE)   Mothers ex-boyfriend  Boyfriend 2 (TL)  Mothers ex-boyfriend  Boyfriend 3 (KT)  Mothers ex-boyfriend  Baby A** Female aged 6 weeks. Daughter of mother and father. Lived with mother and father. Child O Male  Son of father. Shared care between father and birth-mother (EFR).  Child M Female. Daughter of mother and father. Lived with mother and father.  Child N Female  Daughter of mother. Shared care between mother and birth-father (EL).  ** denotes subject of the SCR.  28.  The Nuclear Family At the time of her death Baby A lived at the family home, with her mother, father and full-sister Child M. Her mother and father’s relationship was long-standing but at some point, in 2008 following Child M’s birth they separated. Father remained in contact with Child M and in 2012 became a father again, when Child O was born into a new relationship. Around December 2013, mother and father’s relationship re-kindled although they appear not to have co-habited as during 2014 she was homeless. In October 2016, Baby A was born and at that point mother and father were co-habiting. Baby A had regular contact with her maternal half-sister Child N and her paternal half-brother Child O who regularly stayed at the family home. The family appeared to have positive support by extended family members including grandparents, step-grandparents and aunts on both the maternal and paternal sides, this contact was viewed as a strength by practitioners. There is historic evidence that mother’s relationships with her own mother and other family members was variable, it could be difficult and unsupportive with some evidence of family violence and substance misuse. During practitioner conversations some Page 14 of 52  practitioners assessed her relationship with Baby A’s father to be supportive and positive, whereas other practitioners had not met Baby A’s father. This will be discussed later in the review.  29. Baby A’s Mother Historic information identified Baby A’s mother had significant social and health challenges as a young person which continued into her adult life. In 2000, at the age of 12 years, it was documented she used cannabis. Her substance misuse behaviours escalated with further evidence of alcohol, cocaine and cannabis use in her adult years. She was regularly assessed to be a “heavy drinker” by GP Services. In 2013, she was arrested for shoplifting alcohol from a supermarket for which she received a restorative justice disposal order (a civil remedy for shoplifting). There was additional evidence of attendances at urgent care due to excessive alcohol intake. This issue will be analysed later in this review.  30. In 2003, at the age of 15 years, mother began to present with unstable mental/emotional health. Many presentations were documented between 2003 and 2016 e.g. obsessive-compulsive disorder, anxiety state, low mood and depression. Mother also had long history of self-harming behaviours (overdose and cutting). In 2009, when Child M was two months of age, an initial suicide attempt (tablets) was documented, which became a repeating pattern of behaviour. General Practice and Mental Health Services offered support and medication. Mental Health Services were regularly involved in assessing and managing her care, following which she would be discharged, as was the expectation in practice. Her engagement and adherence to treatment was inconsistent which was one of the reasons for her case being closed. It is clear from practitioner conversations she formed positive relationships with workers who were supporting her. There is evidence that she would seek support when in crisis and frequently accessed Urgent Care, Mental Health or GP Services.   31. In 2005, at the age of 17 years, she became a teenage mother after giving birth to Child N. Over the following years there were regular concerns documented for her well-being and her ability to provide a suitable environment for her children. Homelessness and poor household hygiene were documented to be an early feature of family life.  32. From 2010, on at least 8 occasions mother was a victim of domestic abuse, perpetrated by differing partners. There was no evidence presented in respect of domestic violence between Baby A’s parents. Mother worked with a range of multi-agency services to manage the risks, resulting in a de-escalation of recorded incidents after 2014. This will be analysed later in the review. Despite these challenges practitioners advised when her presentation was stable she made significant attempts to provide good enough care for her children and there was no significant evidence of neglectful outcomes on her children. Her children were reported to be attached to her. Education advised they did not have any concerns about either Child N and Child M in the school environment at the time of Baby A’s death. Assessment of her parenting capacity and outcomes on the children will be discussed later in the review.  33. In 2011, she was diagnosed with BPD and in 2016 was offered dialectical behaviour therapy (hereinafter known as DBT)17 to be provided by a Psychological Therapist. It was hard for mother to engage in this work and she only attended on an ad-hoc basis, so the therapy was discontinued. She developed a social anxiety problem which can be one of the manifestations of this condition, resulting in her finding it difficult to leave the home. This impacted on her ability to attend events at her children’s school and may have contributed to her non-compliance behaviours. The Independent Reviewers were advised that her mental health presentation did not meet the threshold for care co-ordination through the CPA pathway. Her mental health presentation was low to medium in severity as was her presentation in respect of BPD.                                                             17 Dialectical behaviour therapy is a type of talking treatment based on cognitive behavioural therapy. It is used to treat problems associated with a border line personality disorder and more recently has been used to treat other mental health problems. Downloaded mind.org.uk 23.8.2017. Page 15 of 52  34. Baby A’s Father: The review has not been able to gain an in-depth profile of Baby A’s father. The only information known is some practitioners perceived him to be very supportive of Baby A’s mother, who rang him regularly for support during his working day. He was noted during the practitioner conversations to interact positively with the children, doing the school runs, taking them to activities and was documented to be keen to engage in the care of Baby A.  He worked full-time on a self-employed basis. His family were documented to be a positive support network, although practitioners also expressed concerns that his sister, who was a regular supporter, had known challenges regarding alcohol use. Education Practitioners highlighted that Baby A’s paternal grandmother did the school run every day with Child M. It was documented father consumed alcohol, but this was at a manageable level. The toxicology results from the blood samples taken after Baby A’s death highlighted he had higher levels of alcohol than Baby A’s mother at the time of the death. The professionals’ perspective was that the re-established relationship between Baby A’s parents was positive and generally supportive. Practitioners did not appear to have had much if any direct contact with Baby A’s father. The issue of the professional assessment of the father will be analysed later in this review.  35. Child N – Baby A’s Maternal Half-Sister. Child N lived with mother and her birth-father (EL) until their relationship broke down when she was a toddler. EL continued to have regular contact. In 2012, there were concerns about Child N’s school attendance and arrangements were made for her to be transported to school by an Education Welfare Officer, who collected Child N from her mother’s house. In 2013, a Residency Order was pursued by her EL through the Family Courts. In February 2013, an agreement was reached that Child N would live with her mother during the week. In April 2013, mother was evicted from her home and Child N went to live with EL. There is evidence that Child N continued to have shared care arrangements. CAFCASS and CSC mediated these arrangements at times. In September 2016, Child N’s mother approached CSC’s First Response Team for support. She was concerned that Child N was seeing inappropriate peers and being left in “risky situations”. She was provided with legal advice re her contact arrangements. EL had been assessed to be a protective factor and was advised to only allow maternal contact if he was assured Child N would be appropriately cared for. It is documented he was supportive of the contact arrangements with Child N’s mother and Baby A’s father and there appeared to be minimal conflict.   36. At the commencement of this review, Education Services advised Child N had no contact with her mother, although there was contrary evidence that Child N remained in contact with her mother. The school in response to the information request stated they had no concerns; “attendance is excellent 98% and she is a lovely, polite, clever, sensible girl and we have no worries or concerns regarding her." The information states she was obviously upset after the death but came into school as normal and support was in place if she needed it "but she was fine".    37. Child M – Baby A’s Sister. Following Child M’s birth there is evidence she lived with her mother and had regular contact and overnight stays with her father. She would live for periods of time with her father when her mother was in crisis. Her parents had a positive relationship and appeared to manage the shared care arrangements positively during their period of separation. There is evidence that Child M was present when her mother was subject to domestic abuse by three different partners.   38. In September 2014, Child M had seen her mother cutting her legs with razor blades which required suturing. Her mother disclosed to Accident and Emergency Practitioners that Child M’s father had woken her up to see the incident. There is no evidence this was referred as a child protection referral due to the risks of emotional harm and there was no paediatric liaison to inform other agencies. Two days later, co-incidentally, Child O became subject to a child protection referral. He had returned to his birth-mothers home with bruising, following a visit to his father’s. This investigation progressed to a core assessment but there is no evidence that the self-harming incident was taken into consideration as there had been no paediatric liaison or child protection referral undertaken. The mother refused treatment by the Accident and Emergency Doctor and approached her GP to treat the injuries. The GP was not involved in the core assessment, therefore could not contribute the information. The outcome of the safeguarding assessment was no further action as the family could support the situation when Page 16 of 52  mother’s mental health deteriorated, and mother was assessed to be able to “manage her mental health most of the time”. The information gathered for this review does not corroborate this perspective as her mother was having significant challenges in stabilising her mental health during this period. In October 2014, Child M began to exhibit difficult behaviour at home and school which the school offered to support her mother to manage. However, mother felt it difficult to work with school on this issue due to the challenges she faced with her social anxiety behaviours.  39. In November 2014, the Primary School made a safeguarding contact/referral to CSC. Child M was “sitting on carpet trying to stick a drawing pin in her inner left thigh”. The school made a child concern contact/referral to the Local Authority and over the next 10 days had at least 3 contacts with the First Response Service in respect of the referral. School were advised to follow this up with the Contact Centre, but there is no evidence as to whether this action was completed. The case was closed with no further action. The school could not secure engagement with Child M’s parents and there is no evidence of a plan to support the child or consideration of a referral for an assessment by Child and Adolescent Mental Health Services.  40. In September 2015, the Primary School had concerns as Child M seemed “very distant, not listening to instructions and her mind elsewhere”. The school worked with paternal grandma and spoke to Child M who reported her mother and father had been arguing as mother had been sick. Father had taken Child M for a walk and mother wasn’t there when they returned. Child M didn’t know where mother was or when she was coming back. Following the death of Baby, A, it is positive that nurture intervention and timetable was put into place to provide support. A special memory book was set up for Child M.  41. Child O – Baby A’s Paternal Half-Brother. From birth Child O lived with his birth-mother (EFR) and Baby A’s father. The HV Service advised his first year of life was difficult as he struggled with feeding. He was under the care of his GP and Paediatric Services. Parental engagement with all services was good and in February 2013 he was discharged from Paediatric Services. His mother regularly requested and accessed advice from the HV Service in respect of Child O for tonsillitis, biomechanics18, feeding and behavioural issues.  42.  In December 2013, his parents separated, and Child O continued to have contact with his father through joint care arrangements. There is documentation that he stayed at least one night a week and that he lived with his father for at least one period. These arrangements were mediated at times by CAFCASS due to parental conflict.   43. In September 2014, a Section 47 19enquiry was initiated by his birth-mother. She had found bruising on her child on his return home from visiting his father. Following a child protection medical and a core assessment the case was closed with no further action, the bruising was advised to be non-specific, felt to be accidental and no further safeguarding action was taken.  44. In December 2015, Child O was assessed by Speech and Language Therapy Services due to a stutter. His birth-mother (EFR) was provided with verbal and written strategies to manage the stutter. The first follow-up appointment was cancelled by the service as Child O had chickenpox and he did not attend the second appointment. In April 2016, his case was closed to the service as per policy.   45. In December 2016, following the death of his baby sister, Child O exhibited signs of distress and began bedwetting. His birth-mother sought support and advice from the School Nursing Service who                                                            18   Biomechanics are services that assess the way lower limbs function, checking for abnormalities and possible causes of pain in the foot, ankle, knee and back and advise on orthotics, made to measure insoles and exercise to improve strength and flexibility. 19   A Section 47 (Children Act 1989) enquiry means that Children’s Social Care must investigate if they have “reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm. The enquiry will include information from multi-agency partners and communication with the child and family. The aim is to determine what action should be taken to safeguard the child. Downloaded scie.org.uk Downloaded 21.09.17. Page 17 of 52  approached Winston’s Wish 20 for expert advice and undertook home visits to support Child O. At the time of Baby A’s death Child O had only been in school for 2 months. The school were not aware of any safeguarding issues and reported he was always “punctual and well presented.”  Good Practice 3: Education and the School Nursing Service were very responsive following the death of Baby A in providing Child M and Child O with bereavement support, in seeking expert help and ensuring follow up.  3.3 SIGNIFICANT HISTORIC SAFEGUARDING EVENTS AND THEMES BETWEEN 2005 – 2014  46. This section will not replicate the multi-agency chronology but will provide a narrative in respect of the most relevant historical family history that may have informed the pre-birth assessment process and supported the assessment of the capacity to sustain positive change in parenting capacity.  47. Early Patterns Identifying Challenges for Practitioners in Securing Maternal Engagement In November 2005, Baby A’s mother was in her mid to late teens when her first daughter Child N was born prematurely at 31 weeks gestation. Her condition at birth was good and she was discharged home to her mother’s care after 5-days care in the Special Care Baby Unit. The initial weeks were challenging as the HV Service could not secure mother’s engagement. Child N was not taken to the GP for her routine 6-week assessment. However, her mother would attend Urgent Care Services for advice and support and there were no professional concerns for Child N’s wellbeing. The HV Service consulted with the Named Nurse for Child Protection and the concerns regarding non-engagement were documented as a significant event. In November 2005, the day following the consultation between the Named Nurse and the HV, Child N (aged 11 weeks) was admitted to hospital for nine days for intensive care, due to bronchiolitis. Following this event Child N did not attend for paediatric follow-up. This was followed up by the HV Service and a third appointment was sent, when she was taken by her birth-father. This was documented as a further significant event in the child’s records. The early indicators of parental engagement patterns were beginning to emerge.  48. Early Intervention In June 2006, during an opportunistic contact with the HV Service mother disclosed she was “struggling” and finding parenting Child N difficult. The HV had no concerns about her care of Child N and mother said she had some support from her family at the weekends.  Early indicators of maternal instability in her mental health were evidenced. She was “anxious”, “felt down” and disclosed self-harming behaviours related to overdose of tablets. She was assessed using the Edinburgh Post Natal Depression Scoring tool (hereinafter known as EPDS) 21 and scored high indicating the need for further assessment of her emotional/mental health. Single agency early intervention planning for mother and Child N was evident, but there was no evidence of referral for specialist mental health support until 2007. The Teenage Pregnancy Worker began outreach work and in July 2006 expressed further concerns to the HV Service that mother’s mental health was deteriorating, the hygiene conditions in the home were poor, she was isolated and unsupported. It is positive now that in practice young teenage mothers under the age of 19 years are supported antenatally and up to the child’s second birthday through the Family Nurse Partnership Service. The service provides an intensive and voluntary home visiting programme.                                                             20 Winston’s Wish is the United Kingdom’s childhood bereavement charity. It provides professional therapeutic help in individual, group and residential settings. It is one of the only specialist provider of support for children bereaved through homicide, suicide and because of a loss in a military family. Downloaded winstonswish.org.uk Downloaded 21.09.17. 21 The Edinburgh Post Natal Depression scale (EPDS) is a 10-item questionnaire that was developed in 1987 to identify women who have post -delivery depression. Items on the scale correspond to various clinical depression symptoms. It can be used in the ante-natal period but generally is used within 8 weeks of delivery. It is a widely used tool which has been adapted and validated in many languages. Downloaded en.wikpedia.org 23.8.17 Page 18 of 52  49. In May 2007, the HV Service made a child protection referral. Following a disclosure earlier in the month, mother had overdosed following an argument with her boyfriend (Child N’s father). The HV Service had attempted to engage mother with Mental Health Services. She was about to move to a new house which was causing her stress and her relationship had broken down with both her boyfriend and her own mother. Mother refused to be referred for a psychiatric assessment but agreed to be seen by the Primary Care Mental Health Team. The HV Service was concerned about her use of alcohol and it is positive they advised her about the risk of alcohol exacerbating her depressive illness. Mother sought further help from the HV Service 16 days later when she was in crisis and her mental health had significantly deteriorated. Further referrals were made for crisis intervention to Mental Health Services and for child protection concerns to CSC. The child protection referral was not accepted as Child N was not deemed to be at risk because she was with her father. The HV Service made further requests for support and services from CSC under child in need arrangements (Section 17 Children Act) 22 and then positively instigated the Common Assessment Framework to enhance multi-agency planning through early intervention. It is not clear what action was taken by the HV Service to escalate their concerns to CSC or whether further expert supervision was secured to support the case management. This incident was outside of the timeline for information gathering in respect of this review. However, in this period, the evidence reviewed demonstrated that there was evidence of early intervention, planning and communication between agencies which was in line with expected practice at the time. This period also reflects the challenges in understanding the thresholds of concerns as the HV Service attempted to secure intervention with CSC. There was a recognition of the risks for Child N and significant attempts made to support her teenage mother who was isolated, at times struggling to manage to everyday tasks of motherhood, beginning to present with self-harming behaviours, emotional distress and early indicators of alcohol misuse.   Good Practice 4: In 2006/07, whilst there was evidence of the challenges in managing the thresholds of child concern between multi-agency partners, there was positive evidence that the common assessment framework was being implemented in practice. It is positive that at that time the HV Service used this process to plan and provide a range of services to support mother and Child N.  50. The review has not received any information regarding the birth of Child M or the status of mother’s relationship with Child M’s father at that time. It is known that they separated although Child M’s father continued to have contact with his child including overnight stays. In December 2009, CSC received a contact regarding concerns that mother was abusing drugs and that this was impacting negatively upon her care of her children, the outcome documented was “no further action.”23   51. Domestic Abuse In September 2010, an initial domestic violence incident was recorded. Baby A’s mother had rung the Police for help, when her boyfriend (NE), threatened to assault her. She took Child N and Child M to a next-door neighbour to protect them, but he continued to intimidate them at the neighbour’s home. During the investigation mother, disclosed her boyfriend (NE) had been violent on many occasions during their short relationship and Helena Partnership 24, expressed concerns having observed mother with bruising and knew of several violent incidents observed by the children. Following the event mother minimised the incident and the risks to the children. A referral was forwarded to CSC, an initial assessment was undertaken, and the case closed as mother had responded appropriately. Mother was                                                            22 Section 17 of the Children Act 1989 provides a definition of  a child in need. The Local Authority is obliged to offer the following specific services/support for children in need in their area: advice, guidance and counselling, occupational, social, cultural and recreational activities, home help (including laundry facility), facilities or assistance with travel to and from any services provided under the Act or similar service, assistance to enable the child and the family to have a holiday. Downloaded from protectingchildren.org.uk 24.11.15. 23 This was documented in the original SCR referral made to the LSCB. This incident was not subject to further scrutiny as the date pre-dated the timeline of the review. 24 Helena Partnership is one of the largest housing associations in the North West and is based in the local area. Their role is to build and manage homes, regenerate communities, create opportunities and improve people’s lives. Page 19 of 52  subject to the MARAC process and worked with practitioners. She is reported to have ended the relationship after this event.   52. In March 2011, Education referred their concerns to CSC regarding the emotional impact on Child N and Child M of mother’s allegations against the children’s father. They had separated and were involved in legal proceedings regarding contact. There was no information available as to provide clarity into the allegations.  53. Between May 2011 and September 2011 there were four domestic violence incidents logged. In May 2011, the Police attended an incident when mother had called due to an argument with her new boyfriend (KT). Child M was in bed, KT was advised to leave but refused so mother locked herself in the bathroom whilst her child was in bed. KT was removed from the house. Another similar event was logged twelve days later, and Child M was in bed again. Both parties were “drunk;” KT had attended her home drunk and was banging and kicking the door. He had left when the Police arrived. This incident was documented in Community Health records. In July 2011, the Police attended a similar incident between mother and KT, again both adults were “drunk” and arguing. They had separated, and KT was outside the home. Child M was in bed. Mother was concerned that KT would be violent towards her. He was arrested, and it is documented she decided to pursue a complaint against him. The impacts of domestic abuse on her children were discussed with mother by the Police but she declined further support. This was documented as a significant event in Community Health records. In September 2011, Police attended mother’s home. She was at home with her sister (age 13) and Child M and Child N. KT had been banging and kicking her door having had thirteen cans of alcohol. He left the home and the Domestic Violence Project offered support. In November 2011, the Police attended mother’s home as mother and KT had recently separated and he wanted to resume the relationship. He was banging on the window and mother reported he had been violent previously.  54. In July 2012, a domestic abuse incident was recorded as a contact by CSC, involving Mother and an ex-boyfriend (KT). This event occurred at her parents’ home and the maternal grandmother, maternal step-grandfather sustained minor injuries. The adults didn’t want to make a complaint. The event was witnessed by children present and one of the children was pushed to the ground. The children were reported to be distressed. An initial assessment was completed. No further action was taken as mother had ended her relationship and was pursuing a complaint against him. However, in November 2012 Child N disclosed to her birth-father EL that she had witnessed domestic abuse between her mother and KT. An initial assessment was completed, and no further action taken as mother reported she had ended her relationship with KT and school will monitor the situation and refer additional concerns. The child was distressed but there is no evidence of work undertaken to support the children or build their resilience.  55. On the 1st February 2013, CSC received information Child M and Child N were at home with their mother and her ex-partner (KT) when 3 men entered and assaulted both adults. The incident was not reported for 2 days. Criminal proceedings did not progress, and the incident was thought to be linked to her ex-boyfriend’s (KT) criminal behaviour. A child protection referral was made by the Police and an initial assessment was initiated by CSC with no further action to be taken.  56. Around the 18th February 2013, mother was in a new relationship with a boyfriend (TL), who had a history of psychosis, but did not take the prescribed medication. The HV Service documented a domestic violence incident when Child M had witnessed her mother being assaulted by her boyfriend (TL), who had held a screwdriver to mother’s neck. This information was referred to CSC. An initial assessment was initiated, and the plan was to close the case. On further review of the information the case progressed to a core assessment.  In April 2013, the core assessment was completed including all adults with child care responsibilities. Child N and Child M at this point were living with their respective fathers, an arrangement which would continue until mother had more secure accommodation arrangements. During the core assessment process family members expressed concern that the children remained in contact with their mother’s boyfriend (TL) who was abusive. Page 20 of 52  However, CSC perspective was that he did not pose a risk to the children, following checks with the Probation Service. The case was closed with advice given in relation to family law and residency arrangements. On the 20th April 2013, 2 days after the case was closed to CSC, mother was detained by the Constabulary due to shoplifting alcohol from a local supermarket. She was handed down a restorative justice order, a civil remedy used for shoplifting.  57. Escalating Mental Health Issues In August 2013, a referral was made to Secondary Mental Health Services (Assessment Team) by GP Services due to concerns about mother’s mental health. She was thought to be a risk to herself and was struggling to manage her emotions. Her risks were assessed to be mild-moderate, complicated by social and continued drug use. She was advised regarding prescribed medication and continued support was offered by the Home Treatment Team (hereinafter known as Home Treatment Team) 25. She disengaged with the team, was non-compliant with medication and therefore discharged back to her GP in September 2013. During this period of intervention, she attended a local NHS Emergency Department following an episode of self-harm (razor lacerations to left wrist and hip), she absconded from the department and was returned by Security Services and the Police. It is positive that details of her children’s whereabouts were documented and that there was liaison with the Mental Health Services involved providing care.  58. In September 2013, CSC initiated an initial assessment following a contact from school expressing concerns that Child N had disclosed “her father (EL) and his partner are not nice to her”. There is no information available regarding the outcome of this assessment.  59. In October 2013, 5 weeks after the previous episode of self-harm Baby A’s mother attended the same NHS Emergency Department, having taken an intentional overdose and “wanted to die”. She had also sustained a laceration to her head after a fall whilst intoxicated with alcohol. She was re-referred to Mental Health Services for a re-assessment and treatment. Mental Health Services made a referral to CSC as mother disclosed her relationship with her partner was verbally abusive and she had moved out of the family home to live with her own mother. It was documented that mother was requesting an injunction against her partner, due to reports of domestic abuse by her partner (TL), who had bitten her. Mother alleged her own mother had been aggressive toward her and recently assaulted her, so it was her intention to move into a refuge. No further action was taken by CSC as the children were being cared for by their respective fathers, however it was documented a core assessment was required. There was positive evidence of information sharing between NHS agencies and CSC. Her case was closed the same month.  60. Domestic Abuse In November 2013, the mother’s case was referred by the Refuge and discussed within the MARAC process. Mother openly discussed the regular and sustained violence she had experienced whilst in a relationship with her ex-boyfriend (TL). She couldn’t remember all the incidents as there had been so many but described being; “spat at…stabbed in the neck with a screwdriver…kicked in the head…punched in the ribs”. The incident that precipitated her leaving was he had bitten her. The conference was well attended by multi-agency practitioners. A safety plan and a plan of care for mother was initiated. This included referrals  to Addaction,26 the Freedom Project and the Chrysalis Centre.27 CSC agreed to undertake a core assessment. The core assessment progressed to provision and coordination of services under Section 17 Children Act and a child in need plan was enacted. The                                                            25 The Home Treatment Team provides intensive home treatment for people who have mental health needs, that are best supported by Secondary Mental Health Services and provides services 365 days a year from 8am to 8pm. 26 Addaction is a service that helps people change their behaviour to become the very best they can be. It supports people with drug, alcohol and mental health challenges to make lasting changes in their lives. 27 The Freedom and Chrysalis Centre is an established women’s mental health charity and offers a range of services to women including; counselling, drop-in, CBT for depression, stress and anxiety management courses, domestic abuse support, confidence and assertion classes, creative therapy. Page 21 of 52  practitioners involved were from the Refuge, the Domestic Violence Project and the Primary School. During this period, it was documented Child M had returned to her mother’s care and further concerns were expressed by an ex-partner. In January 2014, the case was  closed to CSC.  There was no evidence of Community Health, Mental Health or Primary Care practitioners’ involvement which would have strengthened the planning and intervention. There was evidence that mother continued to have contact with Child N during this period as she attended a Minor Injuries Unit with the child.  Good Practice 5: In 2013, there was a cohesive response by the Police and multi-agency partners to the incidents of domestic abuse which included safety planning and the use of specialist domestic abuse services for mother.   Learning Point 6: There is a practice expectation that all relevant multi-agency professionals are contacted for information during a core assessment however in this instance key professionals were not involved. This should be embedded in practice and is not a recent expectation. The Local Authority should lead work on ensuring this area of practice is strengthened.  61. In December 2013, Child O’s mother reported to the HV Service that Baby A’s mother and father re-kindled their relationship. It is not known at what point they began to co-habit.  3.4 SIGNIFICANT SAFEGUARDING EVENTS AND EMERGING THEMES  FEBRUARY 2014 - NOVEMBER 2016   62. The Timeline Preceding the Pregnancy  In February 2014, another referral was made to Mental Health Services by the GP following a consultation with mother who had expressed a wish to return to work. The reason for the referral was unclear except for a review of mother’s mental health and that she had re-commenced her medication.  She did not attend on two occasions, so her case was closed in March 2014. This was despite a further deterioration in her mental health as she began to suffer with anxiety and depression.  At the beginning of June 2014, the GP documented that mother was “really struggling” with anxiety and depression, not taking medication and “had a Social Worker supporting her”. It has not been possible to clarify that she was being supported at this point by a Social Worker as the case was closed to CSC.  63. At the end of June 2014, mother attended the NHS Emergency Department with a history of vomiting and had a headache following a 3-day history of drinking excessive alcohol. She was appropriately treated clinically and discharged. There was no further enquiry or referral for specialist support regarding alcohol misuse which was a missed opportunity. Despite enquiry about her children there was no paediatric liaison completed to Community Nursing Services. Her GP was informed about this attendance. In July 2014, an appointment was made for mother to attend Addaction, but she failed to attend 2 appointments. Following a referral, Mental Health Services invited Baby A’s mother to attend a consultation with a Psychiatrist on the 15th July 2014, which she did not attend as she was feeling well on the day.  64. On the 23rd September 2014, mother attended the NHS Emergency Department following an episode of self-harm and suicidal thoughts. She had lacerations to her legs sustained with a razor blade and reported that father had woken up the children to show them what mother had done to herself. Mental Health Services documented that the Ambulance Service had advised CSC of the issue. Their argument could be heard on the emergency telephone call. There is no evidence of this contact.  Baby A’s mother was homeless, living between her own mother and Baby A’s father’s homes. She took her own discharge, refused treatment and referral to Psychiatric Services.  Again, there was no paediatric liaison. It is positive she attended the GP for treatment and for follow up.  Two days after this incident Child O became subject to a child protection referral. He had returned from his father’s to his birth-mother’s care with bruising. An assessment was completed, a Section 47 investigation agreed, and a strategy meeting completed. The concerns were not substantiated, and the case was closed. There is no evidence that these two incidents were linked as children belonging to the same sibling group. Page 22 of 52   Learning Point 7: In complex family units, it is crucial the safeguarding investigation undertaken by CSC gathers information in respect of all the children in the nuclear and extended sibling group to build a jigsaw in respect of the impact of an event on all the children involved. All agencies should contribute to effective information sharing to enable CSC to effectively lead the investigation. All agencies should be assured their role in this process is robust.  65. In October 2014, the Primary School reported concerns to CSC that Child M had attempted to deliberately hurt herself with a drawing pin. The school was advised to discuss the issues with the parents. The outcome of the assessment was no further action as all adults with parental or child care responsibilities worked together to support and provide stable care for the children when mothers mental health declines. Whilst this assessment was positive and evidenced information gathering from multi-agency partners, there were some inconsistencies. It detailed that mother managed her mental health well which isn’t demonstrated in the evidence reviewed, it didn’t acknowledge the maternal substance misuse issues or provide understanding into the allegation that the children were awoken to observe mother’s injuries. There is no evidence of professional consideration that the child’s behaviour could have been a possible outcome of observing her mother’s self-harming behaviour/deterioration in mental health and could have been an indicator of emotional harm.  66. On the 20th October 2014, Mother attended a consultation with an Assessment Team Consultant Psychiatrist and disclosed she had not taken her medication for 2 months. A meeting was held with the Recovery Team 28 for psychological therapy. She was discharged as she did not attend a subsequent appointment. In November 2014, Mother was referred to the Mental Health Assessment Team after she had attended an appointment with Open Minds 29 when she expressed difficulty in managing her emotions, impaired motivation, erratic sleep, and ruminating thoughts over a 3-month period.   67. In December 2014, CSC received a contact from the Hospital as mother had self-harmed and was under the influence of alcohol. A decision was taken to complete an assessment although there is no evidence to the outcome of this work. Between December 2014 and May 2015, she presented at both her GP and Accident and Emergency Department with a range of health problems including backpain, depression, asthma, eczema and feeling generally unwell. In July 2015, she asked her GP to support her via a letter to the housing association and later that month she had a miscarriage.  68. In August 2015, the Hospital Accident and Emergency Department referred concerns to CSC as the maternal grandmother, who was considered a positive support to Baby A’s mother had taken an overdose and disclosed she misused alcohol and cannabis daily. It was considered there was no role for CSC and the contact closed. This information was crucial in understanding the family strengths and weaknesses. During practitioner conversations, it was clarified that this information would not routinely become part of the information held in respect of the children in the family. The information system does not link information of extended family members.   69.  A Summary of GP Involvement During 2014/15 mother attended the same GP on at least 14 occasions. The records identify the GP Practice was aware of mother’s social and health challenges. There were recordings made in respect of her experience of domestic abuse, child care responsibilities, Social Worker, mental health challenges and substance misuse issues. The consultations were primarily recorded under the heading of anxiety and depression and it was known there were periods of non-compliance with medication as well as non-attendance at mental health appointments. It is positive there was evidence of direct communication with mother to encourage her uptake of Mental Health Services. It was noted she                                                            28 Recovery Team is a NHS multi-agency mental health that provides a recovery focussed approach for people who have secondary mental health needs. It offers treatment based on hope, control and opportunity. 29 Open Minds provides information, advice and access to local mental health services in the area for any one over the age of 16years. Page 23 of 52  tended to consume large amounts of alcohol in a binge type pattern and letters received from the Mental Health Services confirmed that she reported drinking up to a bottle of vodka and 6 to 10 pints of lager during any 1 session.    70. The GP Practice made a referral to Mental Health Services on the 4th November 2015 due to maternal increasing low mood, risk of self-harming and increased alcohol consumption. She was assessed 13 days later, and a short crisis hospital admission was arranged for 5 days on a voluntary basis as she expressed concerns regarding her safety and the effect of her current mental state on her children. In November 2015, during this period of admission Mental Health Services made telephone contact with CSC to discuss the concerns and this is logged as a safeguarding referral in the GP records. There is no evidence of this contact/referral in the CSC information system.   71. During this period, there was positive communication between the GP Practice and Mental Health Services. However, whilst GP Practice understood the safeguarding issues there did not appear to be any communication between the GP Practice and CSC, Community Nursing (School Nursing), Midwifery or Education or vice-versa. The role of GP Practices in multi-agency safeguarding work is clearly documented in guidance.30  Learning Point 8: GP Practices have ongoing responsibility for the health and wellbeing of their practice population; they have the potential to be a hub of information. Currently the review was informed that practices do not receive information directly from CSC, Midwifery or Education. Therefore, the information they hold on families is incomplete. There has been local work to strengthen their role in multi-agency safeguarding arrangements but improved information sharing needs to be a continual focus to ensure the full participation of GP practices in safeguarding arrangements.   Recommendation 6: The LSCB to consider how General Practitioner Practices can be supported in increasing their involvement within multi-agency safeguarding work.  72. The Antenatal Period Non-attendance for maternity care was a feature in this case. Mother did not attend 5 appointments within the ante natal period. In addition, there was limited opportunity for the Perinatal Mental Health Midwife (hereinafter known as PMH Midwife)31 to adequately assess any ongoing issues and inform the maternity plan of care as mother did not attend the appointments offered. The records do not reflect any consideration relating to the impact of missed appointments, particularly in relation to mental health which should have been considered in the context of impact on the unborn and maternal parenting capacity. There is no evidence of safeguarding supervision or of management oversight of the case which would be an expectation given the combination for health and social concerns. The Maternity Learning Summary has reviewed this issue and has made suggestions to strengthen practice.  73. The First Trimester Weeks up to 12 Weeks Gestation Between February to April 2016, mother attended 4 sessions of 1:1 DBT. This is the therapy of choice for adults who have a diagnosis of BPD, who have a history of suicide or serious self-harm as a poor coping strategy, a desire to develop and maintain healthy relationships and are trying to find new ways of understanding and coping with emotions. She was also reviewed by the Team Psychiatrist in March 2016 when she was 6 weeks pregnant. Mother’s engagement with therapy was poor and following several unattended sessions, a decision was made to discharge her back to the care of her GP. The Team Psychologist notified the Perinatal Midwifery Team and the GP by letter informing of the discharge plan and provided advice regarding further support by Secondary Services should her condition deteriorate.                                                            30 RCGP (2011) Safeguarding Children & Young People a Toolkit for General Practice. 31 Perinatal Mental Health Midwife (PMH Midwife) is a specialist Midwife who specialises in maternal mental health at a senior level, the role described in RCM (2015) Specialist Mental Health Midwives downloaded 19.9.17 rcm.org.uk Page 24 of 52   74. On the 26th February 2016, mother attended the GP, she was 3 weeks pregnant with Baby A. At that time, she had stopped taking medication, but was in regular contact with the Mental Health Clinic held at the GP Practice. There was evidence she was trying to stop smoking, as her GP prescribed a nicotine patch.  The ante-natal care pathway was quickly instigated. However, it was an anxious time as she had had a recent miscarriage and begun to bleed early in this pregnancy. She attended the BEP clinic32 for assessment. During this time, she attended the GP regularly for treatment of her eczema. After non-attendance at the initial antenatal appointment she booked in the 12th week of pregnancy at the local NHS hospital for maternity care. She was referred to stop smoking services.   75. Mother disclosed an alcohol intake of 30 units weekly, a history of substance misuse and her mental health challenges which triggered a referral to the PMH Midwife and an antenatal cause for concern form (hereinafter known as ANCC form) was generated due to the “requirement for her unborn to be safeguarded”. This form is used to inform key practitioners involved in the provision care to mother and baby. It included details of mother’s mental health history but not her alcohol disclosure. Therefore, key practitioners (Community Midwifery and HV) were not alerted to mother’s alcohol history. Midwifery Services do not have a single record, this meant that the Community Midwifery Service did not have access to the information regarding mother’s alcohol history. Maternity Services should strengthen this issue to enable all Midwives involved in the provision of care to have access to the full information. The HV Service received the ANCC form but the family HV did not so did not have insight into the maternal mental health issue. The system has been improved to prevent a re-occurrence of this issue in HV Services.   Learning Point 9: The maternity ANCC form is used to share information between Health Practitioners when there are safeguarding concerns. It is a system that has been in place for many years and has recently (July 2017) been reviewed as a part of the standard operating process. It could be used to trigger the early help assessment tool (hereinafter known as the EHAT) in the pre-birth period. Early assessment, planning and intervention could then be used to inform the statutory social work assessment in either pre-birth or neo-natal period.  76. The Antenatal Period: 2nd Trimester up to 27 Weeks Gestation This was a difficult time as mother experienced several pregnancy related ailments including  repeated headaches, abdominal pain, pelvic instability, as well as asthma and eczema. There was some evidence of Maternity Services having challenges in securing mother’s engagement to planned appointments. However, she regularly sought support by Maternity and GP services for advice and treatment, when she felt it necessary.   77. In her 15th week of pregnancy, mother was re-referred into Mental Health Services for an assessment by Maternity and GP Services. A request was made for a review of her mental health due to low mood and anxiety. In her 16th week of pregnancy she was seen by the Assessment Team Psychiatrist who commenced her on medication to assist with her depression. She did not want to engage in psychological therapy work and was discharged back into the care of the PMH Midwife and GP Services. She did not attend for follow-up by the Midwife in the 18th week of pregnancy, there is no evidence that this non-attendance was followed up by Maternity Services.  78. In her 22nd week of pregnancy she attended for antenatal care and was urgently referred to the PMH Midwife. She presented with relapsing mental health symptoms, was tearful, having racing thoughts and feeling low. Mother reported feeling worried about how her mood would impact on her partner. She had thoughts of self-harm but denied any level of intent to do so. She was offered a joint appointment with the Perinatal Team Consultant Psychiatrist and a Senior Nurse Practitioner to review her level of                                                            32 The Bleeding in Early Pregnancy (BEP) Clinic is a Maternity Service offered to support and assess women in early pregnancy when there are concerns about the viability of the pregnancy. Page 25 of 52  need and offer appropriate intervention. The following day, mother made telephone contact with the Antenatal Ward. She had recognised further deterioration in her mental health and could not wait the 3 days for the appointment with the Home Treatment Team. It is good practice that the Midwifery Service expedited the appointment. She was seen the same day for an assessment and medication review. The Home Treatment Team remained involved for a period of 5 weeks before her case was transferred to the Recovery Team. Mother reported she felt “well supported” during the period of more regular intervention by the Home Treatment Team. There was a 6-week gap in intervention before the Recovery Team commenced their assessment in her 33rd week of pregnancy.  Good Practice 10: The Midwifery Service was proactive and person-centred in recognising mother’s deterioration and expediting her appointment to the same day, for review and assessment by Home Treatment Team Mental Health Services.  79. The Antenatal Period: 3rd Trimester from 28 Weeks Gestation to Delivery Mother’s pregnancy related symptoms continued to cause her anxiety and Maternity Services continued to provide care alongside GP services, although there remained challenges in securing mother’s engagement.   80. At 33 weeks gestation, mother was offered an appointment to meet with the Recovery Team to assess her needs and plan appropriate intervention. Unfortunately, she did not attend this appointment due to pregnancy related difficulties, requiring attendance at hospital. The Support, Time and Recovery Worker (hereinafter known as the STR worker) 33 assertively followed up this non-attendance and a detailed contingency plan was developed to ensure robust communication was available within Mental Health and Midwifery Services. The STR Worker undertook a home visit 3 days later, when mother reported her pregnancy symptoms were making her mental health much worse. She was not taking her medication, had no thoughts of self-harm and felt supported by her family. She agreed for the STR Worker to visit weekly and agreed to attend the next appointment with the Recovery Team Consultant Psychiatrist. There was evidence of good communication between the STR Worker and Midwifery Services.   81. Around this time, mother attended CSC as she was concerned about Child N, her eldest child. She was concerned that; her birth-father was allowing her to have contact with inappropriate persons and her contact arrangements with Child N. She was offered advice and no further action was taken. The CSC learning summary makes reflections on this issue documenting the decision was in line with expected practice. A more proactive approach could be possible but the pressures in the First Response Team at the time made a more proactive response a challenge due to the volume of contacts. The learning summary advised; “The only thing that may have benefited the situation would be for First Response to contact Dad, advise them of mother’s attendance and discuss with him what the concerns were to see if he give any context. Where possible, both parents should be contacted.”  82. In the 34th week of pregnancy, mother attended a consultation with the Recovery Team Psychiatrist, who undertook a reflective discussion in respect of her history, previous service involvement and her difficulties in engaging with treatment and services. Her professional concerns were shared with mother. She was advised that a referral to CSC would be made to request an assessment of her support needs. Mother was unhappy and left the appointment abruptly. The Consultant Psychiatrist ensured the mother was followed up and thought she had made a child protection referral to the Contact Centre. There was confusion whether the referral was for a statutory assessment under child protection arrangements or whether it was a referral asking for support. During the practitioner conversations, it was highlighted the referrer had not ticked the box indicating this was a child                                                            33 A support, time and recovery (STR) Worker provides practical support to adults and young people who have mental health issues or learning disabilities with a range of social issues, including their health. There are no set entry requirements however employers may ask for a health care qualification. Page 26 of 52  protection referral. The referral was screened the same day, but not prioritised for immediate assessment. The referral clearly highlighted the risks to the unborn infant and that there was a high possibility this mother’s condition would relapse in the post-natal period. The hypothesis made was this could exacerbate her risk-taking behaviours including substance misuse. The Consultant Psychiatrist advised that a pre-birth statutory assessment was indicated. Three days later it was recorded the case would be closed. The decision to close the case was documented as “Mother has a history of mental health issues, however reports to be currently well and settled.  Mother gave birth yesterday and Midwifery report no concerns”. The rationale for closing the case was that it would be de-escalated to be managed by Maternity, HV and Mental Health Services at Level 2 of the Continuum of Need.  83. The Birth: At 36 weeks gestation, eight days after the referral to CSC, Baby A was born by normal delivery prematurely and weighed 2.640kg. She had septic screen on Special Care Baby Unit, commenced on intravenous antibiotics and commenced 4 hourly observations due to the risk of sepsis. Baby A then returned to mother and was admitted to post-natal ward following delivery with her mother. Baby A made very satisfactory progress, initially having breast milk expressed into a bottle and then feeding on formula fully. She was treated for jaundice, a little sleepy at times and was given antibiotics as a precautionary measure. Baby A was well enough to be discharged home after six days. Baby A’s health, feeding and well-being patterns during her short life is described previously in this report (Section 3.1: a portrait of Baby A).  84. The Post Natal Period and Discharge Planning: Mother was seen on the ward by the PMH Midwife, who reported her to be emotionally stable and confirmed the Community Mental Health Care Coordinator was aware of the admission and planning to visit the following day.  Mother had requested a single room as she found it difficult to socialise, but no single rooms were available. This issue has been discussed within the review (pp 20). There were no significant concerns expressed about mother’s presentation except on occasions she was thought to be anxious and stressed about her baby.   85. Mental Health Services documented professional communication between the STR Worker, the PMH Midwife and the Social Worker. The Social Worker advised following their assessment, they did not have any concerns and would place baby on Level 2 on the Continuum of Safeguarding Need. There were two plans documented in Maternity Services. A plan was documented on the paediatric liaison form for the Community Midwife and HV service to monitor and a meeting was to be co-ordinated by the Social Worker. This was inaccurate as during a conversation with the Social Worker, the agreed plan was the meeting would be coordinated by universal services. This was documented in a second plan.  86. Prior to discharge, mother was seen by the PMH Midwife and it was documented no pre-discharge meeting was required. This would have been an ideal opportunity to co-ordinate the plan. It was also noted mother’s case would be managed under Level 2 of the Continuum of Need, a plan of care was in place following discharge and the Safeguarding Midwife was aware of this second plan. The Community Midwife providing post-natal care was not aware of either plan. Midwifery Service’s information systems are not easily accessible for practitioners as a single record. This issue was raised during practitioner conversations. The PMH Midwife contacted CSC to discuss the referral made by the Community Psychiatrist. The second plan, as below, was different from the plan on the paediatric liaison form and was clearly documented within Maternity Service’s records by the PMH Midwife;   Mother and baby to remain under Community Midwifery care until twenty-eight days post-delivery.   Daily visits if discharged over weekend then twice weekly visits after, the Community Psychiatric Nurse to visit weekly.   Monthly review by Consultant Psychiatrist.   Social Care requested the coordination of a multi-disciplinary meeting at mother’s home to be attended by; Midwifery, HV Services and the Community Psychiatric Nurse to share information and any relevant concerns.  Page 27 of 52   The HV Service was messaged to contact the Maternity Unit, but never received the message therefore there was no further communication in respect of planning service intervention.   87. Communication between multi-agency practitioners was evidenced but interpretation and understanding of communication differed significantly resulting in no effective multi-agency response, planning or coordination. Crucially the key practitioners (HV and Midwife) allocated to provide the care for the mother and baby disclosed during the practitioner conversations they were not fully aware of the plans. The dissemination of the plans was not robust. There is no evidence the information was shared with the Community Midwife. Additionally, the STR Worker was allocated to encourage mother’s engagement through outreach work rather than a qualified Community Psychiatric Nurse to overview the case. The STR Worker is an unqualified support worker and developed a positive relationship with mother, but this case was more complex requiring overview by a qualified and experienced Mental Health Worker. The Mental Health and Midwifery learning summaries have made recommendations to strengthen these areas of practice.   Learning Point 11: The effective dissemination of safeguarding care plans to front line practitioners involved in the provision of care to new born infants and their mothers is crucial if infants are to be safeguarded. Frontline practitioners did not hold crucial information to support their intervention. The information cascade system failed in this case. All multi-agency workers including unqualified Mental Health Workers should have access to supervision and case monitoring processes.   88. Alcohol Use in the Post Natal Period The day after discharge (7th post-natal day) she was visited by the STR Worker who recorded mother was happy to be home and looked and reported feeling well. Mother had not arranged collection of her prescription from the Pharmacy but confirmed Baby A’s father would be picking up the prescription that day. Mother was open in her discussion and advised she had consumed alcohol the previous evening on discharge from the Hospital and her partner had agreed to care for the baby through the night. This was a significant issue and whilst the worker had asked for assurance that Baby A had been cared for by her father whilst mother had a drink of alcohol it was an indication that the mother may be relapsing into negative alcohol behaviours. The limitations in inter-agency communications and coordination meant this crucial information was not shared with other practitioners. On the 13th postnatal day a second event was documented by the Community Midwife that Baby A’s mother disclosed she had had a drink of alcohol for her birthday whilst Baby A was looked after by her father. It was her birthday the day after the Community Midwives visit.   89. These were two significant events in the post-natal period that could have alerted practitioners that Baby A’s mother was at risk of relapsing into the use of alcohol. However, the practitioners delivering care were not aware of Baby A’s mother’s alcohol misuse history and did not assess the disclosures to be of concern. They provided advice regarding the use of alcohol. During conversations, practitioners advised had they been fully aware of the maternal alcohol history this may have prompted further multi-agency communications and planning to assess and manage the risk.   90. Maternal Emotional and Mental Health Baby A’s mother’s emotional and mental health in the post-natal period was not stable. There were a significant number of written entries detailing her unstable emotional presentation. Whilst she was in hospital it was identified she was anxious and this was mostly considered as a normal reaction following the birth of a premature baby, her anxieties may well have escalated due to her mental health behaviours. She suffered from “social anxiety” so to remain in a ward with other women must have been a significant challenge for her and would have increased her anxiety levels. She was receiving her medication in hospital and was seen by Mental Health Services, so this would have helped her manage her emotions to some extent.   Page 28 of 52  91. On the 10th post-natal day it is positive mother rang the STR Worker as she was experiencing symptoms suggestive of panic and sobbing constantly. She had support from her own mother and sister at the time of call, but her prescription still had not been collected. She therefore most likely had not been taking her medication. The worker stressed the importance of the medication to help with anxiety and sleep and her mother agreed to collect the prescription. The STR Worker made a follow-up telephone call and mother reported she was feeling better. Mother shared her challenges at a visit the day after with the Community Midwife.  92. On the 16th post-natal day during a home visit by the STR Worker, Baby A’s mother reported feeling extremely tired as baby was sleeping all day and awake at night. She felt irritable and concerned that she may experience further deterioration to her mental health. The worker reiterated the importance of medication compliance as mother had not yet obtained her medication. There was confusion at the pharmacy in relation to her prescription which the worker resolved and the medication was collected the following day.  93. On the 22nd post-natal day mother was asleep, and her sister was minding the baby when the STR Worker visited, so the visit was rescheduled for 12 days later. The HV visited on the 23rd post-natal day and had concerns about mother’s emotional presentation. It was an unusual presentation in the HV’s professional experience as mother was always in her “pyjamas and yawning” during the HV contacts. The HV had some challenges in securing communication with Mental Health Services via telephone but eventually following an email to the STR Worker a plan was put in place for the worker to consult with the Consultant Psychiatrist. Mother already had a pre-planned appointment with the Consultant for 4 weeks later. This meant that the unqualified worker was left very much unsupported in her decision making regarding escalation of the case for earlier assessment. Unfortunately, the re-scheduled visit by the STR Worker was then cancelled due to competing commitments for the worker. The Community Midwife also documented on the discharge visit (27th post-natal day) that mother was “feeling anxious and obsessive-compulsive disorder was worse”. The Midwife had thought that mother was being visited by the Mental Health Service’s Home Treatment Team although there is no evidence that this provision was in place. The STR visited 9 days after discharge by the Community Midwife when it was noted mother “felt well in her mental health” although was physically unwell due to respiratory issues. Mum said she “had enjoyed time out walking the baby with her partner and was planning further trips out”. Clearly this period was difficult for Baby A’s mother with no consistent evidence that her mental health was consistently stable.   94. Her presentation (non-compliance with medication, presentation of OCD, excessive tiredness and anxiety), disclosures of alcohol intake were all indicators of an impending relapse. It would have been advantageous for this case to have been supported by a qualified Community Psychiatric Nurse which was a missing link. The Mental Health Services learning summary has made recommendations in respect of this. In addition, the only documented communication in this period between the front-line practitioners was by the HV to the STR Worker. More sharing of information at the time would  have been supportive but the case had been assessed as uncomplicated therefore was not subject to any formal planning safeguarding arrangements.    Page 29 of 52  SECTION 4: BABY A:  AN ANALYSIS  4.1 WAS RELEVANT HISTORIC INFORMATION ABOUT THE FAMILY/PARENTAL FUNCTIONING KNOWN AND CONSIDERED IN THE MULTI-AGENCY RISK ASSESSMENT, PLANNING AND DECISION-MAKING DURING THE PRE-BIRTH AND NEONATAL PERIOD?   95. Baby A’s mother had a complex family, relationship, health and social history up to the time of Baby A’s birth, which is documented in the review’s narrative. A pattern of behaviours and issues emerged resulting in significant periods of social and health instability for mother and her children. Mother presented with escalating mental health challenges which led  to a diagnosis of BPD. She exhibited risk taking behaviours including serious self-harm, attempted suicide, developed depression, anxiety and obsessive-compulsive disorder, had challenges in controlling her substance misuse behaviours, was homeless and became a victim of domestic abuse by numerous partners. She had some extended family support although these relationships were also documented on occasions as violent and unsupportive. Agencies could not secure mother’s engagement consistently in a planned way, although mother would seek support and care when in crisis for both herself and her children. There was some evidence mother’s engagement improved when she had outreach support. Mother also had a positive awareness of the needs of her children. When her situation was stable she was thought to be able to offer her children “good enough parenting” through shared care arrangements, with her children’s birth fathers. Following Baby A’s birth, mother appeared to have resumed full responsibility for the care of her baby and children with some support from her partner and extended family.   96. The review has been able to secure historic information from multi-agency partners which whilst not complete provides early insight into the maternal/family functioning following the birth of Child N in 2005. The information gathered following the death of Baby A, forms the multi-agency chronology used in this review. All agencies involved in this review held information in respect of significant factors relevant to the assessment of family functioning and parental capacity. This information when combined into the multi-agency chronology of significant events provided a good information base of the family’s history, patterns of behaviour, agency interventions and parental history. There was evidence of good levels of information sharing, risk management, planning and intervention through the MARAC process and again in recognising the need for early help through the Common Assessment Framework (hereinafter known as the CAF) around 2007. The information provided a narrative without analysis or understanding of the impact of safeguarding interventions for her or her children. The historic information was adult focussed and did not always provide a picture of how children experienced their daily lives, especially when their mother’s health was unstable and their social situation chaotic.   Learning Point 12: The historic information was mainly documented in a narrative form and little information was identified pertaining to the needs of the children, impacts on them or any effective analysis of the outcomes of intervention on the children. Can the LSCB and its partner agencies be assured that practice has improved and the outcomes of intervention with families in crisis are documented to support future intervention?.   97. The sharing of information between multi-agency partners is crucial in safeguarding work. A chronology of significant events is a central part of historic information sharing. It helps to: build a continuous assessment of parenting capacity; understand the impacts on the children in the family; assess a parent’s motivation to sustain change; develop a greater understanding of the strengths within a family; and identify the risk factors that may trigger a crisis. It has been an expectation of safeguarding practice for many years, that  agencies maintain chronologies of significant events for families when the main carer has social and health challenges as seen in this case and that this supports front line safeguarding practice.   98. The review process is not assured that multi-agency organisations had access to the range of historic information in the pre-birth and neonatal period that should have informed their risk assessment  and enabled focussed safety planning/intervention. There was evidence that some agencies/services did Page 30 of 52  not keep an effective chronology of significant events which was documented in the Primary School’s learning summary. This has been strengthened in practice within that service. In Maternity Services, differing service areas did not have access to all the information as a single record, resulting in a Community Midwife providing high levels of care without knowledge of mother’s mental health or substance misuse challenges. This also leads to a hypothesis that the use of accessible chronologies is not used on a regular basis in front-line maternity care.  Learning Point 13: The development of chronologies of significant events should be embedded in practice. This is an expectation of safeguarding practice, but the evidence reviewed does not demonstrate their use in supporting the assessment of parenting capacity and parental motivation to change. The use of safeguarding chronologies should be strengthened in single and multi-agency practice to more accurately understand the history.   Recommendation 7: The LSCB should seek assurance that all partner agencies have recording practice standards in place which include the use of both robust chronologies and impact analysis.  99. These deficits in information sharing and the lack of a robust chronology of significant events led to front-line practitioners engaging with Baby A’s mother with no significant knowledge of historic information to contribute to their understanding of her parenting capacity or her motivation to sustain change and provide effective and safe parenting.  4.2 WAS THE MULTI-AGENCY PLANNING ROBUST, APPROPRIATE, EFFECTIVELY IMPLEMENTED, MONITORED AND ADEQUATELY REVIEWED IN THE PRE-BIRTH AND NEONATAL PERIOD TO REDUCE THE RISK OF HARM TO THE INFANT?    100. Prior to the Consultant Psychiatrist making the referral to CSC towards the end of September 2016, support had been provided to the mother by the General Practice, Maternity and Mental Health Services. The services were working largely in isolation. Whilst there was some evidence of information sharing during this time, it was largely written information which included the ANCC form and the provision of formal feedback letters by Mental Health Services. There was limited direct communication between professionals addressing the issues of safeguarding. The direct communication was mainly, to meet the mother’s clinical needs. This included when the PMH Midwife contacted Mental Health Services in the ante-natal period to obtain a prompt assessment when her mental health had deteriorated, and mother couldn’t wait for an arranged appointment as she felt so poorly.  101. The information collated for this review indicates there were earlier opportunities for taking further action. At the point that mother’s pregnancy was confirmed, the GP Practice and Mental Health Services were aware that she had recently been admitted due to a deterioration in her mental health. Following discharge, mother was under the care of the Home Treatment Team. This team requested the Recovery Team should offer psychological therapies. Specialist treatment DBT was offered and she attended 4 sessions between February and April 2016. She was reviewed by a Recovery Team Psychiatrist at the beginning of March 2016, when she was known to be 6 weeks pregnant. However, her engagement with the therapy was poor and she was discharged back to the care of the GP and the Perinatal Midwifery Team in the middle of April 2016. In mid-May 2016, Baby A’s mother (16 weeks pregnant) was re-referred by the GP due to reported recent low mood and anxiety. She was assessed by an Assessment Team Psychiatrist who prescribed medication to assist with reported symptoms of depression. She did not want to engage with psychological therapies and a risk assessment indicated she did not pose a risk of harm to herself. She was discharged again back to the care of her GP and the Perinatal Midwifery Team. Direct communication to collate information held by both services and determine whether further action was needed to protect the unborn infant did not take place. This was a missed opportunity.    102. In March 2016, Mother’s attendance at the antenatal booking clinic clearly raised concerns which prompted the development of the ANCC form. In addition, Mother’s disclosure of her mental health Page 31 of 52  difficulties also prompted a referral to the PMH Midwife. However, subsequently the PMH Midwife had very limited involvement with mother due to the difficulties in engagement for her ante-natal care. This resulted in a missed opportunity to undertake further assessment, planning and consideration of the need for a robust multi-agency plan. An assertive outreach approach to support mother in engaging with the Specialist Midwife might have assisted at this point.   103. In September 2016 when mother missed the first appointment, the Recovery Team Psychiatrist adopted an assertive outreach approach through the STR Worker, after which she attended the second appointment. The referral to CSC by the Psychiatrist was the first point at which a formal multi-agency plan was agreed. The Social Worker assessed the case as being at level 2. It was understood the Consultant Psychiatrist had developed a robust plan of care for mother and mother and Baby A’s needs could be met through effective joint working by Community Midwifery, HV and Mental Health Services. The post discharge plan was agreed between the screening Social Worker and the PMH Midwife during a telephone discussion.    104. The STR Worker was contacted by the Social Worker and understood the case was to be managed at level 2. The worker understood the Community Midwife and HV would monitor mother’s wellbeing and the Social Worker would coordinate a multi-agency meeting. The Social Worker had a telephone discussion with mother who agreed to accept all support offered. The development of this multi-agency plan was not informed by the professional opinions of the Community Midwife, HV and Psychiatrist. Given that the Community Midwife and HV would be the practitioners assessing and monitoring mother and Baby A at home after discharge, their opinions should have been sought. The provision of early help support, or a pre-discharge planning meeting could have avoided this situation.   105. At the point of discharge, information sharing issues then resulted in neither the Community Midwife or the HV having a good understanding of the agreed plan. Neither practitioner was aware of the need for a multi-agency meeting to coordinate the safeguarding planning or the risks relating to mother’s history of alcohol misuse. Given these challenges, the plan could not be effectively implemented, monitored or reviewed.   106. Although the multi-agency plan (see para 86) appeared robust, its appropriateness was compromised by mum’s long history of alcohol misuse and inconsistent access to mental health services not being fully understood. In addition, the perceptions by the PMH Midwife and the STR Worker that mother’s mental health was stable at the point of discharge added to the deficits of the assessment process. A robust EHAT assessment would have improved the collation of  information which could have informed the decision-making process at the point of discharge.                                               107. In conclusion, this narrative of specific events has considered key events when more effective multi-agency planning could have been secured in the pre-birth and post-natal period. There was evidence that single agencies (Maternity and HV) undertook planning for their clinical intervention and there was some evidence of attempts by single agencies to work with the safeguarding concerns. However, the effectiveness of this work was disadvantaged by ineffective communication with front-line practitioners who were delivering the care, resulting in a lack of focus about the safeguarding plans required, and the risk of maternal mental health relapse resulting in possible increased alcohol use.   108. A multi-agency pre-birth protocol has been recently developed and was included on the LSCB website in April 2017. The focus of this is on the management of pre-birth concerns which have met the threshold for CSC intervention. Further guidance is required for multi-agency partners to support their assessment and intervention of early help in the pre-birth and post-natal period.  Recommendation 1: The LSCB should ensure the multi-agency pre-birth protocol is revised and re-launched. It should include the multi-agency arrangements for early help as well as statutory intervention in pre-birth cases. This should encompass the pathways for intervention, multi-agency service offers as well as the learning and supervision requirements for front line practitioners.  Page 32 of 52  4.3 TO WHAT DEGREE DID AGENCIES CHALLENGE EACH OTHER REGARDING THE EFFECTIVENESS OF THE RISK MANAGEMENT, PLANNING AND DECISION MAKING?  109. From 2009, there was a significant history of contacts or referrals being made to CSC due to concerns about domestic abuse, the impacts of mother’s difficulties on her children and about potential self-harm by Child M. There is no evidence that agencies making these referrals challenged the CSC decision making at any point. Mother was in receipt of Mental Health and GP Services at the point that she became pregnant with Baby A. She was seen by Mental Health Services at various points between the service becoming aware that she was pregnant and the date of the referral to CSC towards the end of September 2016. Mother was seen by a GP at the beginning of November 2015 and disclosed increasing low mood, a risk of self-harm and an increased alcohol consumption. The GP reviewed her medication and made an urgent referral to Mental Health Services which also advised of mother’s miscarriage three months previously. She was assessed by the Mental Health Assessment Team in the middle of November and admitted.   110. Mental Health Service information indicates ward staff contacted CSC the day after admission due to concerns about the possible negative impacts on her children. The concerns were regarding her alcohol intake and the children witnessing self-harm incidents. Mental health records noted feedback from CSC in that they had no concerns about the children as they lived with their fathers and this was accepted. However, Child M was living with her mother at this point and there was a shared care arrangement in place for Child N. There are inconsistencies in relation to this contact with the CSC chronology not referencing a contact on this date. Review of this contact has identified that expected practice within Mental Health Services would have been for a written referral to also have been submitted – this expectation has been reinforced by safeguarding leads.   111. In October 2013 Mental Health Services made a referral due to domestic abuse concerns and were advised that no action would be taken as mother was in a refuge and the children were living with their fathers. Therefore, the Mental Health Service information includes two occasions on which they received feedback from CSC that no action would be taken as the children were living with their fathers. This feedback was not challenged, nor the concerns escalated by Mental Health practitioners.         112. Following discharge from hospital in November 2015 and after limited engagement with DBT, mother was discharged back to the care of the GP and the Perinatal Midwifery Team in the middle of April 2016. In mid-May 2016, mother was referred again to Mental Health Services, medication was prescribed by a Psychiatrist at an assessment appointment and she was discharged back to the care of her GP and the Perinatal Midwifery Team. At this point, Baby A’s mother had been discharged by Mental Health Services twice in a one-month period, back to the care of her GP and the Perinatal Midwifery Team. The GP Practice received timely and detailed letters from Mental Health Service on both occasions. However, there was no direct communication between the partner agencies involved in her care on either occasion. Such communication would have provided opportunities to promote joint working, collate information and concerns, provide constructive challenge and to assess whether further action was required either to support mother or to safeguard her unborn baby. A hypothesis is likely that; due to differing Mental Health Teams 34 offering support at different points in her pregnancy, Maternity Service appointments being offered both for routine monitoring and with the PMH Midwife and GP contacts taking place, the totality of missed appointments and limited engagement was not fully understood. Silo working was seen in this case with each practitioner committed to doing their utmost to support mother but each working in isolation. Whilst Mental Health Services and the PMH Midwife were proactive in offering mother further appointments the information reviewed does not evidence she was challenged about her poor engagement with services, missed appointments or failure to consistently take prescribed medications until the appointment with the Recovery Team Psychiatrist towards the end of September 2016. The GP Practice learning summary notes that the importance of attending                                                            34 Assessment, Home Treatment and Recovery Teams  Page 33 of 52  appointments and complying with medications were reinforced with mother, particularly when she was seen during 2014.   113. Baby A’s mother received further support from the Mental Health Assessment Team between the end of June 2016 (22 weeks pregnant) and the beginning of August (27 weeks pregnant) at which point her mental health was assessed to be stable. This service ensured the Recovery Team would provide ongoing support prior to discharge. She was then seen by the Recovery Team Psychiatrist towards the end of September 2016, who advised her that a referral would be made to CSC.  This Psychiatrist challenged mother about her engagement with services and made a good quality and detailed referral requesting a pre-birth assessment. The Social Worker who screened the referral did not contact the Psychiatrist to discuss the referral. During a conversation, the Social Worker advised she used professional discretion and communicated with the STR Worker whom she felt would be able to contribute information of added value as her key worker, to the level of information contained within the referral. In addition, the referral was not assessed to be under Section 47 as the child protection drop box had not been ticked on referral.  It is not known whether the Psychiatrist would have challenged the plan agreed between the Social Worker, STR Worker and the PMH Midwife but a potential opportunity for challenge was missed at this point. It is expected practice the referrer is contacted by CSC; however, this may not always be a qualified Social Worker. The responder will be required to use professional discretion when deciding which practitioners are involved. This process is embedded in operational systems and its importance should be reinforced within Children’s Services.   Learning Point 14: CSC procedures include a requirement for screening responder to communicate directly with a referrer. This direct communication ensures that the referrer’s perspective and level of concern are fully understood and can provide opportunity for challenge by either the referrer or the responder. These communications can prove difficult considering the high number of referrals screened, differing organisational systems and the availability of the referrer when contact is attempted. Referrers should anticipate being contacted and ensure their referral includes information required to assist a CSC responder in making contact. Within CSC, the importance of the referrer being contacted should be reinforced.        114. It is expected practice the responder ascertains whether an EHAT assessment has been completed and if one hasn’t the rationale for not completing one. There is no evidence that the screening Social Worker raised completion of a EHAT with the STR Worker or the PMH Midwife or provided challenge on a EHAT not having been completed. During discussion, the Social Worker advised it is common practice for agencies to refer cases without having completed an EHAT or provided early help support. A hypothesis offered by the Social Worker was the differing perceptions of what CSC can offer and some agencies are anxious about managing early help cases and want to pass the risk to CSC. The Social Worker advised  her experience is that Midwives do not normally initiate a EHAT and refer pregnant women to CSC for a baby and family assessment. This perspective was supported by the data viewed and practitioner conversations held for this review. Currently around 40% of referrals received do not meet the threshold for intervention by CSC and a programme of work is already underway to manage this pressure. Workers who screen referrals provide a presentation at the multi-agency working together training on the work of the contact center and making effective referrals. Staff in the Contact Centre have a process in place to escalate any poor-quality referrals. However, it is expected practice that partner agencies have safeguarding leads with systems and processes in place to quality assure both contacts with and referrals made to CSC and the importance of these should be reinforced.     Learning Point 15: Practitioners can contact CSC to discuss a case, however they should understand that such contact does not constitute making a formal referral. The referral process requires submission of a completed CSC service request form. Practitioners should seek advice about making a formal referral if CSC do not feel the case meets their service threshold on discussion. All agencies have safeguarding leads in place to provide support on contacts, making referrals and escalating cases if necessary and should have effective quality assurance processes in place for these practices.  Page 34 of 52    115. The HV undertook a third home visit on the day prior to Baby A’s death in November 2016 and was very concerned about mother’s mental health.  Following this visit, the HV raised the concerns with the STR Worker by telephone and there was evidence of challenge by the HV. Following a constructive discussion between the two practitioners an action plan was then agreed.    116. There were two occasions in the postnatal period on which mother disclosed drinking alcohol and this was not challenged. The first disclosure was made to the STR Worker on the day after mother and Baby A had been discharged from hospital. Mother disclosed having had a drink the previous evening (on the day of discharge) and that father had agreed to care for Baby A during the night. It is not known if mother disclosed why she had had a drink, but it may have been an indicator that she was feeling under pressure. Mother was expressing her breast milk to feed to Baby A by bottle at this point and therefore required advice on management of this in light of drinking alcohol. This would not be an expectation of the STR Worker’s role. However, had there been early help support in place or a pre-discharge planning meeting and ongoing communication between the involved practitioners, this disclosure may have been shared prompting further action. Mother disclosed drinking alcohol for a second time to the Community Midwife six days after discharge from hospital, saying that she had a drink for her birthday and father had agreed to care for Baby A. The record entry notes that mother was aware to discard her breast milk and that mother reported feeling a lot better. Practitioner feedback was that the Community Midwife understood this to be the first alcohol mother had drunk.   117. Had the Community Midwife been aware of mother’s disclosure at antenatal booking clinic of drinking 30 units of alcohol weekly and the disclosure to the STR Worker, it is likely that this disclosure would have been viewed as concerning and prompted further action. The Maternity Service learning summary notes that the booking clinic disclosure should have prompted further assessment of mother’s alcohol use and the offer of support by a specialist Midwife. The HV was not aware of either disclosure or of mother’s history of alcohol misuse resulting in this risk factor not informing her assessment or intervention.     118. In conclusion, there was very limited challenge between the involved agencies regarding the effectiveness of risk management, planning and decision making. Positive challenge was evident both when the Recovery Team Psychiatrist recognised potential risks to the unborn baby challenging mother prior to making the referral to CSC and when the HV contacted the STR Worker on the day prior to Baby A’s death. Had the HV been aware of mother’s two disclosures of drinking alcohol, this challenge could have been stronger given an identified increased risk which may also have prompted a more robust response from mental health services given their understanding of mother’s alcohol use history. Missed opportunities for challenge at earlier points in the timeframe have been highlighted. Overall, it appears that the level of risk and the full history was not understood by practitioners with involvement during the timeframe and this became particularly significant during the antenatal and postnatal periods. The provision of early help support could have facilitated the collation of multi-agency information to inform a thorough understanding of mother’s difficulties enabling robust risk assessment processes and inter-agency communication through which constructive challenge may have been made.                 4.4 WERE THE RESPECTIVE STATUTORY DUTIES OF AGENCIES WORKING WITH THE INFANT, PARENTS AND FAMILY FULFILLED?       119. Statutory National Guidance, Working Together to Safeguard Children 35 (2013, 2015), references the critical importance of early help provision and clarifies the arrangements which should be in place. The St Helens Continuum of Need (EHAT Thresholds)36 references this guidance which requires                                                            35 HM Government (2013) Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children.  36 St Helens Safeguarding Children Board (2014) The St Helens Continuum of Need (CAF Thresholds). Page 35 of 52  safeguarding boards to provide additional guidance on early help assessment processes. This should include the provision of services and the thresholds for referral into Children’s Services. This additional guidance is contained within St Helens Council Think Family documents37 and the St Helens CSC Thresholds of Need.38     120. In November 2014, an Ofsted inspection39 was undertaken in the Local Authority and a final report published in January 201540. The report highlighted two priority and immediate actions in relation to early help which Local Authority Children’s Services were required to address. Firstly, the full implementation of the early help strategy including all partners undertake common assessments and strengthen the role of lead professional for children and families with emerging vulnerabilities. Secondly, to ensure clear understanding and implementation of thresholds across the Continuum of Need so that children and young people receive the right help at the right time. A priority and immediate action required by the LSCB was; to strengthen the challenge and focus on partner agencies playing an active role in the delivery of early help provision, ensure that the threshold for early help is understood and embedded in practice by partner agencies. The Ofsted report noted that early help service changes were already underway. These included a Local Authority restructure of its Early Help Services and location of the Priority Families Programme alongside the Early Intervention Service in June 2014. The report also noted that the Continuum of Need had been revised and re-launched in May 2014.   121. The EHAT was introduced as part of Every Child Matters ‘Change for Children’ programme41 2004 and is a national shared holistic assessment and planning framework. The aims of the EHAT are to;  help practitioners assess children and young people’s additional needs for services earlier and more effectively.  develop a common understanding of those needs and to agree on a process for working together to meet those needs.42  Completion of an EHAT with family consent is the first step in the provision of early help support by all agencies working with children and families on identifying additional support needs.   122. The Continuum of Need provides the overarching framework for St. Helens and outlines indicators for instigating the EHAT assessment process. It currently doesn’t clarify practitioner expectations if a family refuses to engage in the EHAT process. Working Together 2013 (page 13, S10) and Working Together 2015 (Page 14, S10) state that “the lead professional should make a judgement as to whether, without help, the needs of the child will escalate. If so, a referral into Local Authority CSC may be necessary”.   123. The Think Family suite of documents template catalogue includes all the templates required by practitioners to provide early help using the EHAT and templates to obtain feedback from children, young people and parents/carers on the support provided. The Think Family procedure provides multi-                                                           37 St Helens Council (2014) Think Family guidance documents. There are 5 documents- the Think Family Protocol, Think Family Brief Guide, Think Family Continuum of Need, Think Family Catalogue of Templates and the Think Family Procedure “Think Child, Think Adult, Think Family”. This was previously known as the child in need procedure.  38 St Helens Council (2014) St. Helens PSCYPS Thresholds of Need. 39 Ofsted inspection of services for children in need of help and protection, children looked after and care leavers and review of the effectiveness of the Local Safeguarding Children Board (2014). 40 Ofsted produces this report under its power to combine reports in accordance with Section 152 of the Education and Inspections Act 2006. This report includes the report of the inspection of Local Authority functions carried out under Section 136 of the Education and Inspection Act 2006 and the report of the review of the Local Safeguarding Children Board carried out under the Local Safeguarding Children Boards (Review) Regulations 2013.  41 Every Child Matters: Change for Children. 2004. HM Government. Every Child Matters: Change for Children set out the national framework for local change programmes aimed at building services around the needs of children and young people so that opportunities are maximised, and risks minimised. The framework highlights the fact that universal services which are provided to all children and young people have a crucial role to play in shifting the focus from dealing with the consequences of difficulties in children’s lives to preventing things from going wrong in the first place.  ADD information about the programme  42 Children’s Workforce Development Council. (2010). Overcoming obstacles. Barriers affecting practitioners’ engagement with the CAF process and lead professional. Page 36 of 52  agency practitioners and managers with detailed guidance on the management of cases at levels 2 and 3 on the Continuum of Need. It includes the action required if an EHAT is refused how to initiate an EHAT, the management of family action meetings and family action plans. There is inconsistent wording in the thresholds diagrams within the Continuum of Need and the Think Family procedure.  At the time of writing this report, the suite of Think Family documents was under review.   124. The St Helens Thresholds of Need references the 2014 Continuum of Need and Working Together 2013. This guidance clarifies the expectation that except for child protection (Section 47) referrals practitioners should have initiated a EHAT and provided support to the family prior to referring to CSC.    125. The Local Authority and LSCB have ensured that early help guidance has been developed with the Think Family documents providing a high level of detail on implementing early help processes.  However, the guidance documents do not refer to the use of the EHAT process in cases of unborn babies or infants, when Midwifery and Mental Health Practitioners are involved. A hypothesis could be that adult focussed practitioners might not identify the guidance as being relevant to their role. Research findings 43 identifies that there are national barriers to the implementation of the EHAT process across all agencies working with children and families. These include some practitioner groups viewing the completion of a holistic assessment of a child as daunting. It can be hypothesised that practitioners working primarily with adults, including Maternity Services and Adult Mental Health Staff may well have such anxieties.     126. Given that there is a range of guidance required for this area of practice, it is important that it is collectively easily accessible, and that support is available to practitioners, particularly if they are completing an EHAT or adopting the lead professional role for the first time. Such practitioners, when working under pressure and within resource constraints, are likely to find the guidance and undertaking early help work extremely challenging without effective support. All agencies are required by guidance to identify and respond to early needs and therefore should have internal support arrangements in place for front line practitioners.       127. In addition to the early help guidance documents, the LSCB has a 7-minute briefing on the Continuum of Need on its website. The LSCB training includes Lead Practitioners in practice seminars and the Working Together training includes an early help presentation. Working Together notes that staff working in Maternity and Adult Mental Health services have critical roles in safeguarding and require sufficient training to attain the required competences. Whilst attendance at LSCB training by these practitioner groups can be challenging, midwives are generally well represented at such training. However, there is recent evidence of Health Practitioners including Midwives not attending booked LSCB training with staffing difficulties or work commitments being cited as the rationale.    128. The LSCB has an Early Help Strategy 2016-201944 and the recovery plan developed following the Ofsted Inspection has been implemented. The actions included; the provision of support for practitioners using the EHAT process through the establishment of a Partnership Co-ordinator post within the CSC First Response Team and development of early help outcomes for inclusion in the LSCB dataset. More recent developments have been the implementation of the EHAT system and the establishment of an Early Help Panel. The EHAT system enables the electronic completion of an EHAT, and recording of subsequent meetings and action plans. Work has been undertaken to streamline processes where possible. The CSC referral form clarifies where an EHAT has been completed this should be submitted through the EHAT ICS transfer process instead of completing the referral form to request a service from CSC. However, feedback from the learning event was there were                                                            43 Children’s Workforce Development Council. (2010). Overcoming obstacles. Barriers affecting practitioner’s engagement with the CAF process and lead professional. 44 St Helens Safeguarding Children Board. Multi-agency Early Help Strategy for: Children, Young people and families in St Helens 2016-2019.  Page 37 of 52  challenges for some agencies in using the EHAT system including the requirement to record the same information on both the EHAT and internal information management systems.    129. Despite the significant work undertaken to develop operational and strategic guidance to support front-line multi-agency practitioner understanding of their early help responsibilities, practitioners involved in this case did not discuss instigating the EHAT process with mother. This included the PMH Midwife and the STR Worker who both understood that the case was to be managed at level 2 in the post-natal period. The Continuum of Need clarifies that a EHAT is required for cases managed at level 2. Level 2 criteria entail a child having additional needs which can be met by universal services working together and accessing targeted and specialist services when needed. Whilst this case met the service provision criteria, the level 2 indicators within the Continuum Charts guidance do not reference cases involving parental mental health, substance misuse or domestic abuse concerns – these concerns are referenced in the level 3 and 4 Charts.       130. In April 2017, a LSCB multi-agency pre-birth protocol was included in the safeguarding procedures and is therefore not currently referenced within the early help guidance and resources. This guidance will support practitioners in determining how to manage concerns about the welfare of an unborn baby when there are complex maternal health and social issues. Section 2 includes “perinatal/mental illness or support needs that may present a risk to the unborn baby or indicate that their needs may not be met” as a parental risk factor. Practitioner conversations identified that this guidance has not yet been implemented within Maternity Services.   Learning Point 16: Key issues that could have alerted involved practitioners to the need for a robust, coordinated response were the frequent missed appointments with all involved agencies, failures to accept interventions offered and the repeated failures to take prescribed medication. Whilst it is important to offer further appointments and support, consideration should also be given to the risks posed to an unborn baby by these issues and what further action is needed. Completion of an EHAT with parental consent facilitates holistic assessment and the provision of interagency early help support aimed at meeting identified needs and preventing escalation of the difficulties. Easily available and clear guidance on the early help responsibilities of all practitioners should be available to support them in this area of practice.                Recommendation 2: The LSCB and Local Authority to ensure all early help guidance addresses the issues identified in this review process. The revised guidance documents should be re-launched and made collectively available.   131. As early help support including an EHAT assessment had not been offered to mother prior to the referral made to CSC in September 2016, the case did not meet the service thresholds detailed in the CSC Thresholds of Need. This guidance is clear that CSC provide a service for cases at Levels 3 and 4 on the Continuum of Need. Section 7 of this guidance clarifies that expected practice prior to a referral for support at Level 3 being made is that an EHAT has been completed with parental consent and support services have been offered. A referral to CSC becomes appropriate where support offered through the EHAT processes at Level 2 has not met the child’s needs or where support has been refused and a referral to CSC has been deemed necessary. Discussion at panel identified that the Partnership Co-ordinator posts are now proving effective in supporting practitioners in completing an EHAT or undertaking the lead professional role for the first time and that this resource has been increased. Research findings 45 identifies practitioner feedback in that such support is highly valuable, especially for those new to the lead professional role.                                                                 45 Easton, C., Morris, M. and Gee, G. (2010). LARC2: Integrated Children’s Services and the CAF Process. Slough: NFER Page 38 of 52  Recommendation 3: The LSCB to seek assurance that partner agencies have in place a robust early help offer and the required systems and processes in place to enable effective early help work including in cases involving unborn children.        132. CSC had significant previous involvement with the family. Between May 2007 and December 2014, there were 13 contacts recorded on the CSC system. Within the timeframe of the review there was 1 contact recorded on the CSC system in relation to mother’s difficulties prior to the Psychiatrist’s referral in September 2016. This contact was made by the hospital in December 2014 and related to mother having self-harmed and being under the influence of alcohol. The recorded outcome was for a children and family assessment, however information reviewed has not identified that an assessment was undertaken.   133. Discussion with the Social Worker identified the last contact on the system prior to the Psychiatrist’s referral was in December 2014. However, as discussed previously there was an inconsistency in information. Mental Health Service records noted CSC were contacted in November 2015 after mother had been admitted to hospital and received feedback there were no concerns as the children were living with their fathers. It has not proved possible to locate this contact within CSC systems and the inconsistency remains unresolved. It can be hypothesised however, that not having access to the information (November 2015) would have affected decision making as it appeared that no concerns had been raised in 21 months as opposed to 10 months.  134. In April 2013, CSC completed a core assessment which included participation by the fathers of both Child M and Child N. Mental Health Services made a referral in October 2013, which was not progressed further as the children were living with their fathers. Practitioner feedback highlighted that contacts or referrals to CSC about parental issues when children are not residing with that parent are challenging to manage. There are consent issues to consider and as in this case, mother’s consent to share information about her mental health issues would be required before contact could be made with a father. It is likely the outcome of the April 2013 core assessment informed the CSC decision making on the referral received in October 2013.   135. Evidence received indicates that mother had contact with her children when they lived with their fathers and the core assessment (April 2013) concluded  they might return to mother’s care once she secured accommodation. The review has not been able to confirm that management of the referral received in October 2013 or the contact recorded in November 2015 by Mental Health Services included full consideration of the current care arrangements and possible impacts of mother’s contact with her children.   Learning Point 17: Referrals received about children living in shared care arrangements can be complex to manage. It is important that a safeguarding investigation clarifies what the current care arrangements are, whether they are permanent, what contact a child is having with the parent about whom concerns have been raised and whether that contact poses a risk. In order for CSC to be able to do this, referrers should ensure that a clear understanding of the care and contact arrangements and whether the parent has consented to the referral are included on the service request form. Partner agencies should ensure this through their internal quality assurance processes.   CSC should assure itself and the LSCB that this practice is standard when assessing such referrals.   136. The Recovery Team Psychiatrist who assessed mother for the first time towards the end of September 2016, clearly identified safeguarding concerns for the unborn baby and advised mother that a referral to CSC was going to be made. This referral was detailed and requested that CSC undertake a pre-birth assessment. Mother was distressed and left the consultation abruptly. The Psychiatrist arranged for mother to have further contact with Mental Health Services to clarify and reinforce the concerns.  Page 39 of 52  Good Practice 18: The Psychiatrist ensured that mother was contacted after she left the consultation abruptly by a Nurse to provide her with reassurance.   137. The Social Worker who screened this referral assessed the case should be managed at level 2 on the Continuum of Need by the agencies already involved working collectively. The Psychiatrist had provided an expert opinion on mother’s mental health difficulties and the likelihood of relapse, however the PMH Midwife and the STR Worker were positive about mother’s current mental health. Discussion between the Social Worker and the Psychiatrist could have provided further clarity for the Social Worker on the level of risk.  Early help could have been offered to mother and if refused or proved ineffective, the Social Worker may well have assessed the case at a higher level of need and meeting the threshold for CSC.           138. There is no evidence to indicate the need for an earlier safeguarding referral for the unborn baby was considered by practitioners. Maternity Services documented early concerns due to mother’s mental health difficulties and completed a ANCC form. However, these concerns did not then prompt further planning, assessment or intervention to provide early help support to mother. Mental Health Services and the GP Practice were aware at an early stage of mother’s pregnancy and had a good understanding of mental health and alcohol misuse history and could have considered making an earlier referral to CSC. It appears likely that practitioners were assured by mother’s presentation, her verbally expressed concern for her unborn baby and her agreements to follow advice. Her long-term history became lost. This type of compliance is frequently seen in complex safeguarding cases.          139. There was a negative impact on the provision of mental health care as mother disengaged from the Psychiatrist due to the referral to CSC being made. Planning through early help support or having made an earlier referral to CSC may have provided earlier opportunity to engage mother and may have avoided this distress at a late stage in her pregnancy.    140. Safe Sleep advice was provided the Community Midwife and the HV in accordance with internal guidance and Merseyside’s Child Death Overview Panel (hereinafter known as CDOP) multi-agency safe sleeping guidance (2015). 46 This guidance was re-launched in 2017.47 The multi-agency guidance includes an assessment tool which facilitates discussion on all risk factors and development of an action plan. Information received does not indicate that parental responses to the advice provided raised any concerns for practitioners or that practitioners observed any concerns at home visits such as inappropriate sleeping arrangements or a smoky atmosphere within the home.  141. Mother had several sudden infant death syndrome risk factors (hereinafter referred to as SIDS). These included two disclosures of drinking alcohol in the postnatal period, medication for mental health difficulties, disclosures of feeling very tired and smoking. The GP Practice understood mother to have reduced the number of cigarettes smoked whilst pregnant and recorded she had reduced this to four cigarettes daily in May 2016. Mother disclosed she smoked at the antenatal booking clinic in March 2016 and a referral was made appropriately to smoking cessation services. However no reference has been made to mother receiving support from this service. The review process has not identified if father also smoked. It was known he drank alcohol but that this was not problematic to him. Risk factors also for Baby A were her prematurity and the fact that she was less than 12 weeks old.    142. Practitioners who provided safe sleep advice were not aware of the potential risk of mother’s alcohol misuse history. She had disclosed binge drinking to the GP and to Mental Health Practitioners prior to becoming pregnant. She had also disclosed drinking 30 units of alcohol weekly to Maternity Services at antenatal booking, but this information had been “lost”. No evidence of mother drinking during pregnancy was identified and, when asked, she said that she was not drinking and had reduced her                                                            46 Merseyside CDOP. (2015). Multi-Agency Safe Sleeping Guidance. 47 Merseyside CDOP. (2017). Multi-Agency Safe Sleeping Guidance. Page 40 of 52  smoking due to concerns for her unborn baby. Not being aware of this important risk factor impacted particularly negatively in the postnatal period on the assessment of overall risk and provision of advice by the Community Midwife and HV.     143. Research findings evidence that the number of SIDS appear to have now stabilised as opposed to continuing to decline. The incidence is higher for young mothers with risk factors living in deprived areas of the UK than in the general population and efforts to reduce the rate within this group have had relatively little effect.48 Research findings49 evidence increasing levels of poverty thus potentially increasing the numbers of vulnerable families requiring support. Providing safe sleep advice where there are known risk factors is an extremely challenging area of practice which the development of multi-agency guidance by CDOPs have attempted to address.         144. A recent small scale qualitative research project has concluded that this group of mothers don’t engage consistently when safe sleep advice is provided through a traditional, didactic information-giving model.50  The findings indicate these mothers require an understanding not just of the messages but why they are important and a discussion tailored to their individual circumstances and beliefs which also enables gentle challenge of their own instinctive views as required to support them in making safer decisions in caring for their baby.   145. Further recent research51 identified that mothers with babies at higher risk of SIDS demonstrated reduced knowledge about the specific risk factors and that a targeted campaign of higher risk mothers is warranted. A rethink of the traditional models of health promotion through conversations to allow new innovations to engage families is also suggested.  Recommendation 4: The LSCB should seek assurance from CDOP and Public Health that the current provision of safe sleep advice to families with SIDS risk factors has been reviewed and options for more effective interventions explored considering recent research findings.                 146. In conclusion, significant challenges have been identified in relation to involved agencies meeting their statutory responsibility to safeguard the unborn baby through the provision of early help support or by identifying and acting to protect the unborn baby from likely or actual significant harm. Maternity Services identified that mother’s mental health posed a risk and an antenatal ANCC form was shared to inform the GP and HV, however the service didn’t undertake further assessment or offer early help support. A referral was made appropriately to the PMH Midwife; however, mother did not attend any appointments with this practitioner.    147. As concerns were raised about mother’s mental health during her pregnancy, she was referred appropriately to Mental Health Services by her GP and the PMH Midwife resulting in assessments and offers of psychological therapy. Unfortunately, mother’s engagement with support offered was limited with missed appointments and disclosures of non-compliance with prescribed medication. During the antenatal period, mother’s lack of engagement was not perceived to pose a safeguarding risk to the unborn baby until the appointment with the Recovery Team Psychiatrist.   148. Mother’s misuse of alcohol was not considered as a risk factor during her pregnancy. She disclosed drinking 30 units of alcohol weekly at antenatal booking clinic, however the information was not recorded on the ANCC or safeguarding documentation so didn’t inform future planning. Mental Health                                                            48 Anna Pease, Jenny Ingram, Peter S Blair, Peter J Fleming. (2017) Factors influencing maternal decision-making for the infant sleep. environment in families at higher risk of SIDS: a qualitative study BMJ Paediatrics Open Accessed- 07.09.17. 49 ADCS. (2016). Safeguarding Pressures Phase 5. The Association of Directors of Children’s Services Ltd. 50 Anna Pease, Jenny Ingram, Peter S Blair, Peter J Fleming. (2017) Factors influencing maternal decision-making for the infant sleep environment in families at higher risk of SIDS: a qualitative study BMJ Paediatrics Open Accessed- 07.09.17.  51 Anna Pease, Jenny Ingram, Peter S Blair, Peter J Fleming. (2017) Mothers’ knowledge and attitudes to sudden infant death syndrome risk reduction messages: results from a UK survey. ADC Online. Accessed 07.09.17. Page 41 of 52  Services and the GP Practice were aware of mother’s history of binge drinking but accepted mother’s assurances that she didn’t drink when pregnant. No evidence of mother having had a drink was identified during the pregnancy.     149. It is likely that Maternity Services staff did not fully understand the challenges for mother of living with a BPD and relied on Mental Health Services to address those needs. Multi-agency early intervention would have provided opportunities for discussions about mother’s mental health difficulties, how they might impact on her wellbeing and how to best meet her needs. Practitioner feedback has highlighted the screening Social Worker may also not have had a good understanding. At the point of the referral to CSC, including information on how this diagnosis might affect mother’s parenting capacity could have supported decision making.   Learning Point 19: Practitioners require an understanding of how a diagnosis of BPD might impact on parenting capacity. The expertise of Mental Health Service Practitioners both within individual cases and through the provision of multi-agency training can promote such understanding.                                     4.5 WERE THERE ORGANISATIONAL OR CONTEXTUAL OBSTACLES OR DIFFICULTIES IN THIS CASE THAT PREVENTED AGENCIES FROM FULFILLING THEIR DUTIES?  150. In September 2016, the HV Service transferred from a NHS Foundation Trust to the Foundation Trust already providing the Mental Health Services to mother. During conversations the HV highlighted significant challenges in contacting the STR Worker when there were substantial concerns about mother’s mental health, on the day prior to the incident. She was unable to contact the STR Worker by telephone, and was advised her call couldn’t be held. Therefore an email was sent to try to make contact. The situation was further complicated by a lack of administrative support to answer calls in the HV base main office at that time. The HV had to make several calls before being able to discuss her concerns with the STR Worker at around 4.30pm.    151. The NHS Foundation Trust providing the Mental Health and HV Services had recently undergone organisational change following successful tender bids to provide several additional services and was renamed to reflect these changes in April 2017. This organisation is implementing a new integrated electronic recording and information sharing system across the organisation. It is anticipated that this will be operational at the end of 2017. This change should facilitate improved joint working and information sharing in safeguarding cases involving both Mental Health and Community Health Practitioners, including HVs and School Nurses. Further workstreams are currently underway to facilitate greater integrated working within the new organisation.      152. The services actively involved in the delivery of care to mother in the postnatal period; Community Midwifery, HV and Mental Health Services were each utilising different electronic recording systems, in addition to which there were challenges posed by ineffective information sharing prior to Baby A and mother being discharged from hospital.   153. The Community Midwife was not aware of mother’s disclosure around her alcohol use at the booking appointment and reported not being made aware of the requirement for a meeting at mother’s home prior to discharging the family into the care of the HV. The Maternity Service learning summary notes the information sharing processes where there are safeguarding concerns at discharge have already changed.    154. A maternity paediatric liaison communication form was completed on the day of discharge to update the HV. This requested an early HV visit, clarified that the Community Midwife would provide regular care up to 28 days post-delivery and that CSC were involved for support only. It did not reference the agreed plan of care. This form was sent by fax to the HV Team and was received the next day. Page 42 of 52  However, it was not filed in the records or seen by the HV prior to the new birth visit 4 days after discharge.  Learning Point 20: Effective assessment and planning require access to all available information systems prior to contacts with children and families. The HV Service should ensure the systems and processes in place enable the timely inclusion of new information, particularly that related to vulnerability and risk issues.    155. At that visit, mother advised the HV that she was taking her medication for her mental health difficulties and that she felt better. Due to mother’s mental health issues, the fact that Baby A had been born prematurely and the feeding issues discussed, the HV undertook a second home visit 12 days later followed by a third visit on the day prior to Baby A’s death.        156. Both practitioners (Community Midwife and HV) were visiting the home without understanding the full situation or the agreed plan. Early help support, or a pre-discharge meeting would have avoided these difficulties and facilitated full discussion on the implementation of the plan including agreement on roles (including that of the STR Worker as a support worker) and responsibilities. The meeting would also have established communication processes between the three key practitioners involved in the post-natal period which would have facilitated the sharing of identified concerns. The review process has not identified any such communication between the practitioners aside from the telephone contact between the HV and the STR Worker on the day prior to Baby A’s death.                             157.  The GP Practice was involved in the antenatal period and utilising a different electronic system. Aside from receipt of the ANCC form, there was no communication between the GP Practice and Maternity Services in the antenatal period. The Practice did not have a regular Midwife who provided antenatal care at the surgery and advised that communication processes between these two services require improvement. Whilst Community Midwives provide antenatal care in GP Practices and record information electronically whilst there, this information cannot be viewed by the GP Practice.  158. Information from Mental Health Services to GP Practices is by letter with these normally being received about a week after appointments. The GP Practice learning summary noted that such letters were regularly received, provided detailed information and enabled a good understanding from the Mental Health Service perspective.     159. Whilst mother’s care was provided primarily by Maternity and Mental Health Services in the antenatal period, she was seen by practitioners from three different Mental Health teams (Assessment, Home Treatment and Recovery) during a period of 8 months. Maternity Service Practitioners included a range of professionals from; antenatal unit, delivery suite practitioners, post-natal ward and the PMH Midwife. The number of practitioners involved at different points over short time frame made it challenging for any one of these practitioners to fully assess mother’s needs and understand the overall picture. The limitations in involvement must also have made it extremely difficult for any one of them to establish a purposeful, working relationship with mother, particularly considering her frequent missed appointments and limited engagement, in relation to Mental Health Services, resulted in repeated discharges and re-referrals.   160. Research findings52 evidence that accurate assessment and a practitioner being able to establish a relationship with a service user which is both empathetic and purposeful are the two main factors which effect positive change. At the point of the referral being made to CSC, the Psychiatrist adopted an assertive outreach approach through involving the STR Worker. It can be hypothesised that earlier adoption of such an approach might have supported the earlier establishment of a working relationship which would have informed assessment processes.                                                                     52 McKeown, K. (2000). What works in Family Support with Vulnerable Families. Dublin: Dept. of Health and Children.  Page 43 of 52   161. The Maternity Service learning summary notes that the missed appointments with that service should have prompted further action in accordance with the trust’s non-attendance policy (hereinafter known as DNA) and recommended a policy review to ensure it is fully clear, particularly where appointments at specialist clinics are not attended.    Learning Point 21: Research findings53 evidence that parents with mental health problems offered services often didn’t access them and missed appointments. Health Practitioners sometimes step back in cases where engagement is poor but loss of support to the parent may in turn impact on the wellbeing or safety of the child. When parents with mental health problems don’t engage, practitioners should consider whether an assessment of the child is required.   Recommendation 5: LSCB to seek assurance that DNA policies contain clear guidance on the actions to be taken when adults with caring responsibilities (including those for unborn babies) fail to engage with services dealing with health issues that can adversely impact on parenting capacity. Key services requiring such clear guidance include Adult Mental Health, Substance Misuse and Maternity Services.    162. The Maternity and Mental Health Service learning summaries note a lack of management oversight and practitioners did not receive support through supervision. There was no Named Midwife in post at that time, therefore the organisational safeguarding leadership would have been compromised. The Maternity Service learning summary notes this post has now been recruited to and an action plan is in place to ensure that Specialist Midwives receive regular safeguarding supervision on complex cases. The Mental Health learning summary also noted that the STR Worker’s role in this case was not formally agreed at a multi-disciplinary team meeting and formalised in the resultant care plan. Actions are underway to resolve this issue.  163. The LSCB did not have a multi-agency pre-birth protocol in place whilst this case was ongoing which could have supported practitioners in their decision making. This protocol has since been developed and included on the LSCB website in April 2017.   164. Safe sleep advice was provided by Maternity Service Practitioners including the Community Midwife and by the HV in accordance with internal guidance and the CDOP safe sleeping guidance, launched initially in 2015. This guidance has been updated and re-launched in 2017.  The Mental Health learning summary includes a recommendation to ensure that Mental Health and Learning Disability practitioners working with families are aware of the key messages and can convey these to parents/carers.           165. Discussion with the Social Worker who screened the referral made by the Psychiatrist provided an insight into the challenges faced given the high number of referrals received and the fact that audit findings evidenced practitioners having only around 20 minutes to screen each one.   166. The Mental Health learning summary noted planned organisational change which will support future Mental Health service practice with pregnant women with serious mental health problems. Funding has been provided for the development of the Perinatal Mental Health Services through which local teams will support women during their pregnancy and for the first year after they have given birth.    167. The Psychiatrist at the learning event noted that previously there had been regular joint meetings held between Mental and Community Health Practitioners, facilitated by Mental Health Services which had been positively evaluated. The Mental Health learning summary includes an action to reinstate these meetings.                                                               53 NSPCC Parents with a mental health problem: learning from case reviews. Accessed 29.08.17 Page 44 of 52  168. In conclusion, practitioners were challenged by organisational and contextual issues whilst providing care and meeting their statutory responsibilities towards mother and Baby A. In the ante-natal period, the lack of management oversight and supervision within Maternity and Mental Health Services resulted in missed opportunities to review the support provided, ensure a child focus, discuss mother’s limited engagement, consider other possible actions including early help support and challenge practitioner opinion through reflection on the case. Mental Health Services are delivered by teams with specific remits and patients who fail to attend appointments are discharged back to their General Practitioner as per practice policy. In complex cases where patients frequently disengage and are re-referred, it is then challenging for any practitioner to secure an effective working relationship. Specialist Midwifery roles can enable continuity of care by that service, however mother did not attend these appointments and the response to this was not sufficiently robust.        169. At the point of discharge, the lack of either early help provision or the co-ordination of a pre-discharge planning meeting, accompanied by poor information sharing processes impacted negatively on the care  the Community Midwife and HV could provide in the post-natal period. Important risk information was not shared and neither practitioner was involved in the discharge plan decision making.    Recommendation 8: The LSCB should seek to understand the systems issues and barriers which impact on effective information sharing both within and between partner agencies.     170. Throughout the timeframe, practitioners were working within differing electronic recording systems with frontline practitioners not having a full and thorough understanding of mother’s history and challenges. The situation was further complicated by the absence of multi-agency pre-birth guidance at that time.                        Page 45 of 52  SECTION 5: CONCLUSION   171. The review has considered whether the death of Baby A could have been predicted or prevented. Table 1 provides an analysis of the interrelating risk factors.   172. Table 1: Analysis of interacting risk factors (focusing on factors known at the time of the event in November 2016)54 BACKGROUND HAZARDS KNOWN AT THE TIME SITUATIONAL HAZARDS KNOWN AT THE TIME  Maternal substance misuse (alcohol, cannabis, cocaine).  Maternal mental health challenges, BPD, obsessive compulsive disorder, anxiety, low mood, depression.  Maternal poor compliance with medication, treatment and therapy> no sustained improvement.  Maternal history: domestic abuse, child protection concerns – no assessment of capacity to change.  Deterioration in mental health prior to event.   Father works full time.   Incidents of family violence (maternal).  Unstable adult partnership relationships.  Maternal low to medium presentation BPD.  Maternal low to medium risk in presenting mental health behaviours.   Maternal experience of an unsettled baby vomiting all feeds back in conflict with professional opinion of settled baby.   In early stages of renewed relationship between parents: previous history father struggled with mother’s mental health.   No evidence of safety planning re alcohol use.  Midwifery ANCC documented, no further planning or intervention.  Maternal: multiple mental health behavioural issues.  13 contacts a with CSC (7-year period).  2 previous core assessments.   Non-compliance.   Specialist mental health support not escalated when maternal mental health deteriorated. Hidden or not appreciated  Paternal alcohol intake minimised.  2 incidents of maternal alcohol intake.  Conflicting opinion on Baby A’s presentation.   No evidence of maternal parenting capacity.  Joint parenting capacity (mother and father) not understood. STRENGTHS/PROTECTIVE FACTORS KNOWN AT THE TIME DANGERS KNOWN AT THE TIME  Positive relationships between adults with parental responsibility.  Adults focussed on needs of the children.  Supportive extended family network.  Mother child focussed when stable.  Safer sleeping advice given.  Maternal positive relationship with adult practitioners (MH, HV and Midwifery).    Expert Psychiatrist report detailing risks of exacerbation of alcohol intake in the post-natal period.   Interpretation of compliance issues.   Maternal mental health unstable in pregnancy. Hidden or not appreciated  Relationship between mother and maternal grandma could be volatile.  Evidence of Maternal Grandmother alcohol and cannabis use.  Some evidence of alcohol misuse in paternal family.  173. The review has identified the LSCB cannot currently be assured that multi-agency partnerships work cohesively and effectively with infants, children and their families to provide early help and protection where there is a history of a parental personality disorder/mental health issues and parental substance                                                            54 Acknowledgement to Ball K (NSPCC) for the use of the Analysis of interrelating risk factors methodology, SCR repository. Page 46 of 52  misuse. It has focused on the provision of early help in relation to a pregnant woman, who had two children within complex family dynamics. She had significant mental health, substance misuse and social issues and agencies struggled to secure her consistent engagement.   174. The first key area of learning relates to early help provision. There was significant health service intervention with Baby A’s mother during the antenatal period and all practitioners did their utmost to support her. However, no consideration was given to working under the Early Help / EHAT frameworks. This would have provided more opportunity to provide multi-agency early help support or to plan other action to safeguard the unborn baby prior to a referral being made to CSC at a very late stage in the pregnancy.   175. CSC had previously taken the lead in providing early help support within the Local Authority Area and there was a perception within some agencies that this remained the responsibility of the Local Authority through CSC. The statutory responsibility to monitor the provision of early help is a function of the Local Authority. However, all multi-agency partners have a responsibility to provide support through an effective early help offer. This includes early assessment, planning and intervention where there may be additional needs for an unborn baby. All agencies should be clear about their responsibility and their service offer within the early help framework. Critically the key universal services involved in the antenatal period are health providers who need to ensure they have the systems and processes in place to identify additional needs, assess the level of need and intervene appropriately. The causes underlying the lack of early help support in this case are multi-factorial and have been identified and analysed within the review.   176. Removing a baby at birth for child protection reasons impacts on attachment and bonding. But allowing a baby to be discharged from hospital to a family who are unable to provide appropriate care and protection can result in significant harm to, or even the death of, the baby. The importance of good, clear early or statutory pre-birth assessment is critical. Joint assessment of adults who are carers is essential to understanding both strengths and weaknesses.   177. An initial practice challenge is that the pre-birth process should be given equal weighting to the statutory child safeguarding systems. Pre-birth early help is crucial to inform the pre-birth statutory assessment process, normally undertaken at 20-24 weeks of pregnancy. However, this is a late stage to begin a complex assessment. To complete a good assessment, it is important to focus on parental engagement (both parents) and make use of the duration of the pregnancy to work with the family and with the professional network around them. It is here that the role of the Midwife/HV/GP is crucial as they can form a supportive relationship with the mother to enable her to recognise the importance of ensuring the baby is safe. Engagement with a family does not need to mean the Social Worker must see the mother throughout the pregnancy. It could mean that the Social Worker overviews the case, working closely with the front-line professionals throughout the pregnancy and post birth period.    178. The second key area of learning relates to assessment of parenting capacity. Mother’s complex history and how it might impact on her parenting capacity was not fully understood. The need for additional support services for her children who had lived within a context of domestic abuse and witnessed mother self-harming at times was not identified. The relationship between Baby A’s parents was not well understood and their joint parenting capacity wasn’t assessed. Whilst services including CSC undertook assessments, these weren’t informed by all available information. Mental Health Services and the General Practice held key risk information in relation to mother. Whilst there was some communication between agencies, there was no robust multi-agency communication or collation of all the known information.   179. A further key area of learning is in relation to the provision on safe sleep advice. This was given in accordance with single and multi-agency guidance and practitioners felt that mother understood the advice given and would follow this. Providing this advice and ensuring this results in the desired behaviours with parents where there are known SIDS risk factors is very challenging. Recent research Page 47 of 52  findings have identified the need to further develop this area of practice. The key issue being that how can we change parental behaviours, who have been given the information and appear to understand its content when caring for infants. Frequently parental behaviour in such cases is strongly influenced by complex factors such as alcohol misuse, drug misuse, mental illness and other significant social challenges.   180. The review finds that there were complex, interacting factors leading up to the death of Baby A, as is frequently documented in infant deaths in similar circumstances. Within the timeline there was not one identifiable factor that led to the death or one point in the timeline at which, had different action been taken, the death could have been prevented. The risk could have been predictable had there been robust multi-agency information sharing to inform the risk assessment, planning and intervention in the antenatal and neonatal periods.                            Page 48 of 52  SECTION 6: RECOMMENDATIONS  1. The LSCB should ensure the multi-agency pre-birth protocol is revised and re-launched. It should include the multi-agency arrangements for early help as well as statutory intervention in pre-birth cases. This should encompass the pathways for intervention, multi-agency service offers and the learning and supervision requirements for front line practitioners.  2. The LSCB and Local Authority to ensure all early help guidance addresses the issues identified in this review process. The revised guidance documents should be re-launched and made collectively available.  3. The LSCB to seek assurance that partner agencies have in place a robust early help offer and the required systems and processes in place to enable effective early help work including in cases involving unborn children.      4. The LSCB should seek assurance from CDOP and Public Health that the current provision of safe sleep advice to families with SIDS risk factors has been reviewed and options for more effective interventions explored considering recent research findings.  5. LSCB to seek assurance that DNA policies contain clear guidance on the actions to be taken when adults with caring responsibilities (including those for unborn babies) fail to engage with services dealing with health issues that can adversely impact on parenting capacity. Key services requiring such clear guidance include Adult Mental Health, Substance Misuse and Maternity Services.  6. The LSCB to consider how General Practitioner Practices can be supported in increasing their involvement within multi-agency safeguarding work.  7. The LSCB should seek assurance that all partner agencies have recording practice standards in place which include the use of both robust chronologies and impact analysis.  8. The LSCB should seek to understand the system issues and barriers which impact on effective information sharing both within and between partner agencies.                       Page 49 of 52  APPENDIX 1: COLLATED LEARNING POINTS & GOOD PRACTICE   1. Learning Point: Pregnancy and post-delivery is a critical time when at least 1:5 women will experience a deterioration in their mental health. Women with a history of mental ill-health are at significant risk of a deterioration therefore practitioners delivering care should be aware of how individual women may present and the triggers to activate a deterioration. The use of healthcare passports 55 is a way of enhancing understanding and communication between the woman, her family and practitioners/services.  2. Learning Point: Monitoring and assessing growth of new-born, pre-term infants is a core activity to ensure optimal growth. There is an expectation that all new-born infants are weighed, and the weight is then plotted on a growth chart which enables accurate interpretation of the data. All infants have growth charts in their parent held Child Health records, to support growth monitoring processes. Maternity and HV Services should ensure that growth assessment and monitoring are in line with the expected practice standards.   3. Good Practice: Education and the School Nursing Service were very responsive following the death of Baby A in providing Child M and Child O with bereavement support, in seeking expert help and ensuring follow up.  4. Good Practice: In 2006/07, whilst there was evidence of the challenges in managing the thresholds of child concern between multi-agency partners, there was positive evidence that the common assessment framework was being implemented in practice. It is positive that at that time the HV Service used this process to plan and provide a range of services to support mother and Child N.  5. Good Practice: In 2013, there was a cohesive response by the Police and multi-agency partners to the incidents of domestic abuse which included safety planning and the use of specialist domestic abuse services for mother.   6. Learning Point: There is a practice expectation that all relevant multi-agency professionals are contacted for information during a core assessment however in this instance key professionals were not involved. This should be embedded in practice and is not a recent expectation. The Local Authority should lead work on ensuring this area of practice is strengthened.  7. Learning Point: In complex family units, it is crucial the safeguarding investigation undertaken by CSC gathers information in respect of all the children in the nuclear and extended sibling group to build a jigsaw in respect of the impact of an event on all the children involved. All agencies should contribute to effective information sharing to enable CSC to effectively lead the investigation. All agencies should be assured their role in this process is robust.  8. Learning Point: GP Practices have ongoing responsibility for the health and wellbeing of their practice population, they have the potential to be a hub of information. Currently the review was informed that practices do not receive information directly from CSC, Midwifery or Education. Therefore, the information they hold on families is incomplete. There has been local work to strengthen their role in multi-agency safeguarding arrangements but improved information sharing needs to be a continual focus to ensure the full participation of GP practices in safeguarding arrangements.  9. Learning Point: The maternity ANCC form is used to share information between Health Practitioners when there are safeguarding concerns. It is a system that has been in place for many years and has                                                            55 A healthcare passport is a communication/information leaflet designed originally to facilitate and improve work with adults with learning difficulties in a NHS setting. Its scope can be extended for service users in other situations.  Page 50 of 52  recently (July 2017) been reviewed as a part of the standard operating process. It could be used to trigger the early help assessment tool (hereinafter known as the EHAT) in the pre-birth period. Early assessment, planning and intervention could then be used to inform the statutory social work assessment in either pre-birth or neo-natal period.  10. Good Practice: The Midwifery Service was proactive and person-centred in recognising mother’s deterioration and expediting her appointment to the same day, for review and assessment by Home Treatment Team Mental Health Services.  11. Learning Point: The effective dissemination of safeguarding care plans to front line practitioners involved in the provision of care to new born infants and their mothers is crucial if infants are to be safeguarded. Frontline practitioners did not hold crucial information to support their intervention. The information cascade system failed in this case. All multi-agency workers including unqualified Mental Health Workers should have access to supervision and case monitoring processes.   12. Learning Point: The historic information was mainly documented in a narrative form and little information was identified pertaining to the needs of the children, impacts on them or any effective analysis of the outcomes of intervention on the children. Can the LSCB and its partner agencies be assured that practice has improved and the outcomes of intervention with families in crisis are documented to support future intervention?.   13. Learning Point: The development of chronologies of significant events should be embedded in practice. This is an expectation of safeguarding practice, but the evidence reviewed does not demonstrate their use in supporting the assessment of parenting capacity and parental motivation to change. The use of safeguarding chronologies should be strengthened in single and multi-agency practice to more accurately understand the history.   14. Learning Point: CSC procedures include a requirement for screening responder to communicate directly with a referrer. This direct communication ensures that the referrer’s perspective and level of concern are fully understood and can provide opportunity for challenge by either the referrer or the responder. These communications can prove difficult considering the high number of referrals screened, differing organisational systems and the availability of the referrer when contact is attempted. Referrers should anticipate being contacted and ensure their referral includes information required to assist a CSC responder in making contact. Within CSC, the importance of the referrer being contacted should be reinforced.        15. Learning Point: Practitioners can contact CSC to discuss a case, however they should understand that such contact does not constitute making a formal referral. The referral process requires submission of a completed CSC service request form. Practitioners should seek advice about making a formal referral if CSC do not feel the case meets their service threshold on discussion. All agencies have safeguarding leads in place to provide support on contacts, making referrals and escalating cases if necessary and should have effective quality assurance processes in place for these practices.   16. Learning Point: Key issues that could have alerted involved practitioners to the need for a robust, coordinated response were the frequent missed appointments with all involved agencies, failures to accept interventions offered and the repeated failures to take prescribed medication. Whilst it is important to offer further appointments and support, consideration should also be given to the risks posed to an unborn baby by these issues and what further action is needed. Completion of an EHAT with parental consent facilitates holistic assessment and the provision of interagency early help support aimed at meeting identified needs and preventing escalation of the difficulties. Easily available and clear guidance on the early help responsibilities of all practitioners should be available to support them in this area of practice.    Page 51 of 52  17. Learning Point: Referrals received about children living in shared care arrangements can be complex to manage. It is important that a safeguarding investigation clarifies what the current care arrangements are, whether they are permanent, what contact a child is having with the parent about whom concerns have been raised and whether that contact poses a risk. In order for CSC to be able to do this, referrers should ensure that a clear understanding of the care and contact arrangements and whether the parent has consented to the referral are included on the service request form. Partner agencies should ensure this through their internal quality assurance processes. CSC should assure itself and the LSCB that this practice is standard when assessing such referrals.   18. Good Practice: The Psychiatrist ensured that mother was contacted after she left the consultation abruptly by a Nurse to provide her with reassurance.   19. Learning Point: Practitioners require an understanding of how a diagnosis of BPD might impact on parenting capacity. The expertise of Mental Health Service Practitioners both within individual cases and through the provision of multi-agency training can promote such understanding.               20. Learning Point: Effective assessment and planning require access to all available information systems prior to contacts with children and families. The HV Service should ensure the systems and processes in place enable the timely inclusion of new information, particularly that related to vulnerability and risk issues.    21. Learning Point: Research findings56 evidence that parents with mental health problems offered services often didn’t access them and missed appointments. Health Practitioners sometimes step back in cases where engagement is poor but loss of support to the parent may in turn impact on the wellbeing or safety of the child. When parents with mental health problems don’t engage, practitioners should consider whether an assessment of the child is required.                                                                 56 NSPCC Parents with a mental health problem: learning from case reviews. Accessed 29.08.17 Page 52 of 52   APPENDIX 2: BIBLIOGRAPHY.  1. Calder, M.C. (2003) Unborn Children: A Framework for Assessment and Intervention. In: Calder, M.C. and Hackett, S., eds. Assessment in Child Care Using and Developing Frameworks for Practice. Dorset: Russell House Publishing  2. Calder M., Hackett., et al (2013) Assessment in Child Care- Using and Developing Frameworks for Practice. 2nd ed, Russell House Publishing 3. Children’s Workforce Development Council. (2010). Overcoming Obstacles. Barriers affecting practitioner’s engagement with the CAF process and lead professional. 4. Corner, R. (1997) Pre-Birth Risk Assessment in Child Protection. Social Work Monographs, Norwich: University of East Anglia 5. Easton, C., Morris, M. and Gee, G. (2010). LARC2: Integrated Children’s Services and the CAF Process. Slough:  NFER 6. Hart, D. (2010) Assessment Prior to Birth. In: Horwath, J., ed. The Child’s World, Assessing Children in Need. London: Jessica Kingsley Publishers 7. HM Government (2013) Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children.  8. HM Government (2015) Working Together to Safeguard Children- a guide to inter-agency working to safeguard and promote the welfare of Children. Crown Copyright. 9. Hodson A., (2012) How research on pre-birth assessments should affect practice. Community Care 30.8.2012. Downloaded comunitycare.co.uk 27.8.17 10. McKeown, K. (2000). What works in Family Support with Vulnerable Families. Dublin: Dept. of Health and Children.  11. Merseyside CDOP. (2015). Multi-Agency Safe Sleeping Guidance.    12. Merseyside CDOP. (2017). Multi-Agency Safe Sleeping Guidance. 13. NSPCC Parents with a mental health problem: learning from case reviews. Accessed 29.08.17 14. Ofsted (2011) Messages from Serious Case Reviews. 15. Anna Pease, Jenny Ingram, Peter S Blair, Peter J Fleming. (2017) Factors influencing maternal decision-making for the infant sleep environment in families at higher risk of SIDS: a qualitative study BMJ Paediatrics Open Accessed- 07.09.17. 16. Anna Pease, Jenny Ingram, Peter S Blair, Peter J Fleming. (2017) Mothers’ knowledge and attitudes to sudden infant death syndrome risk reduction messages: results from a UK survey. ADC Online. Accessed 07.09.17. 17. RCPCH (2009) Using the new UK-World Health Organization 0-4 years growth charts. DoH. 18. SCIE Learning Together to Safeguard Children: a systems model for serious case reviews. 19. St Helens Council (2014) St. Helens CSC Thresholds  20. St Helens Council (2014) Think Family guidance documents. There are 5 documents- the Think Family Protocol, Think Family Brief Guide, Think Family Continuum of Need, Think Family Catalogue of Templates and the Think Family Procedure “Think Child, Think Adult, Think Family”. This was previously known as the ‘child in need procedure’.  21. St Helens Safeguarding Children Board (2014) The St Helens Continuum of Need (CAF Thresholds) 22. St Helens Safeguarding Children Board. Multi-agency Early Help Strategy for: Children, Young people and families in St Helens 2016-2019. 23. Welsh Government (2012) Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Model.      