Summary of a review into the death of 1-year-old girl in July 2012, as the result of non-accidental injury. C2 sustained injuries whilst in the care of mother's partner, A2. A2 was convicted of murder and sentenced to life imprisonment. Family were known to a significant number of agencies including a number of health services in different hospital settings. In the month prior to her death, C2 attended hospital with a head injury and what was identified as a possible bite mark, considered to be non-accidental. A Section 47 investigation was progressed but assessments did not involve all agencies with knowledge of the family and the case was closed. A2 had a previous conviction for criminal damage and possession of an offensive weapon, relating to an incident of domestic abuse with an ex-partner. Identifies lessons including: insufficient professional curiosity; lack of professional challenge; and need for robust and clear escalation procedures where there is disagreement between agencies. Makes recommendations including the review of the arrangements for taking photographs of possible injuries to ensure medical staff have access to this service at all reasonable times.
      
 Title:  Serious case review Family V: executive summary. LSCB: Lincolnshire Safeguarding Children Board Author: David Ashcroft Date of publication: 2014  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                              SERIOUS CASE REVIEW FAMILY V  EXECUTIVE SUMMARY       Report by David Ashcroft, Independent Overview Report Author      6 February 2014      Version 02/14  1    Introduction  1. This is the Executive Summary for the Serious Case Review commissioned by Lincolnshire Safeguarding Children Board into the case of Child V (C2).   2. C2 was born on 9th May 2011. She died on 31st July 2012 as a result of injuries sustained when in the care of her mother’s partner, who was charged with murder and subsequently convicted and sentenced to life imprisonment in November 2013. She lived with her mother (A1); elder half-sibling (C1); and from March 2012 with her mother’s partner (A2); who was also the father of her half-sibling (C3) who was born 4th August 2012, a few days after C2’s death.  3. There are two main incidents covered by this SCR.  This first was in early June 2012 and the second was at the end of July 2012.  These are referred to as Episode 1 and Episode 2 in this report.  4. Episode 1: C2 was brought by ambulance to Boston Pilgrim Hospital A&E Department on 1st June 2012 following a call to the 111 service by her mother concerned about a possible head injury.  She was subsequently admitted to the Children’s Ward and was examined by the Consultant Paediatrician, CON2, the following day.  CON2 identified a possible bite mark that he considered could be the result of Non Accidental Injury (NAI).  C2 was subsequently discharged to the care of her maternal grandmother, A3.    5. A referral was made by CON2 to children’s social care Emergency Duty Team (EDT) who spoke to staff and the family on the phone but did not attend the hospital.   6. C2 was the subject of a strategy discussion between social care and the police on 3rd June and a Section 47 investigation was agreed. The possibility of a non-accidental cause for the bite mark was not followed up robustly.  A decision not to proceed to an Initial Child Protection Conference was made on 12th June, although the case remained open to Lincolnshire Children’s Services as a Child in Need for the completion of the core assessment.  Subsequent investigations and the assessment were progressed, but did not involve all agencies with knowledge of the family.  There was contact with the family and the children were seen, but recording on the social care ICS system was limited. Workers observed positive parenting and discounted the possibility of non-accidental injury without checking this with the Consultant concerned. The case was closed by Children’s Social Care by 24th July, although health were concerned about this.   At several points there were missed opportunities to escalate or resolve some of the differences of view.  Version 02/14  2  7. Episode 2: C2’s principal carer, A2, called emergency services at 16.39 on 28th July as she was not breathing normally and was reported to have fallen off the settee.  C2 and C1 had been in his sole care as their mother was at work.  8. C2 was taken to Grimsby Hospital by emergency services in a critically ill condition. Appropriate medical interventions were undertaken to treat her presenting conditions, but a CT scan was inaccurately reported as normal.  She was subsequently transferred to Sheffield Children’s Hospital and died there early on 31st July.  Investigations conducted at Sheffield, including a further CT scan, revealed a deterioration in her condition and significant brain injuries and by 17.00 on 29th July it had been concluded that there was a high likelihood of NAI due to “shaken baby syndrome”. A2 was subsequently arrested at Sheffield Children’s Hospital and charged with murder.  Undertaking the Serious Case Review  9. At a meeting of the Lincolnshire Safeguarding Children Board’s (LSCB) Serious Case Review Sub-Group, on the 10th September 2012, the panel recommended unanimously that this case met the criteria under Working Together 2010, to undertake a Serious Case Review (SCR). The Independent Chair of the LSCB, Chris Cook, confirmed his decision that this case should be the subject of a Serious Case Review on the same day.  An independent author, Mr David Ashcroft, was commissioned on 8th November to undertake the review.   10. The timespan for the Review was from C2’s birth (9/5/11) to her death (31/7/12).  11. This case is notable for the large number of different agencies and services that came into contact with the family.  In particular health services were accessed at a number of different hospital settings. Individual Management Reviews and short information reports were requested from, and completed by, the following agencies: Lincolnshire County Council, Children’s Social Care (CSC) Lincolnshire Police Nottinghamshire Police (short report) Lincolnshire Probation Trust United Lincolnshire Hospital NHS Trust (ULHT) for midwifery services and Pilgrim Hospital, Boston Lincolnshire Community Health Services (LCHS) NHS Lincolnshire (General Practice) East Midlands Ambulance Service (EMAS) North Lincolnshire and Goole Hospitals NHS Foundation Trust (NLaG) for Diana, Princess of Wales Hospital, Grimsby (DPoW) Sheffield Children’s Hospital Foundation Trust (SCHT) NHS Direct (short report) Lincolnshire County Council Education and School (short reports) Nottinghamshire County Council, Children’s Social Care (short report) Version 02/14  3  LIVES First Responder Service (short report)  12. A comprehensive integrated chronology of the case was compiled from the details supplied by each agency.  The Overview Report sets out a summary of the key events and analyses these in detail in order to learn the lessons from this review.   13. A Health Overview Report (HOVR), bringing together the analysis and issues across the health organizations involved, was also commissioned.  This benchmarked the clinical practice described in the IMRs against the expectations of commissioned services and evidence of best practice, and also explored how effectively health organizations had communicated with each other and with agencies beyond health as part of the inter-agency response to the family up until C2’s death.  14. The Overview Report was compiled based on the information and analysis collected through the IMR process. It is intended for publication as the account of the learning from this case. The Overview Author has presented for discussion and challenge key themes and lines of enquiry to the SCR Panel.  This Executive Summary highlights the key learning from this SCR.   Learning and Actions already taken  15. Agencies have already considered some of the action points arising from this case and taken appropriate and prompt management action to address obvious shortfalls in process and operational capacity. This is positive and appropriate to ensure that learning and improvement does not wait for the completion of the formal serious case review process.  Actions already taken include:  • Agreement between Children’s Social Care and Lincolnshire Police and health agencies to ensure that there are suitable staffing arrangements for strategy discussions to take place outside normal business hours; • Revised arrangements for Public Protection Unit (PPU) cover outside normal working hours; • Revised arrangement for urgent checks through the Police National Database (PND) for placements of a child by Children’s Social Care; • Revised arrangements within the police for accessing Scene of Crime Officers (SOCOs) to take photographs to allow the appropriate recording of injuries to children; • Aide memoire for Strategy Discussions issued April 2012 by CSC to ensure that all children in a family should be considered; • Revisions to the Connected Persons Procedure (relating to the placing of children with family members or friends as an alternative to foster care) issued in September 2012; • Serious Untoward Incident Report commissioned by NLaG in respect of the reporting of the CT scan at Grimsby Hospital as normal.  Conclusions Version 02/14  4   16. It is the conclusion of this Serious Case Review that the death of C2 was neither predictable nor preventable.   The subsequent trial of A2 has established that he was responsible for the murder of C2.  The judge concluded that A2’s failure to tell the truth meant that the medical teams spent time investigating other possible causes of her injuries. The judge also made clear that A1 was completely exonerated of any involvement.  17. Although there are lessons to be learnt from this case there is no evidence that any different circumstances would have modified or changed A2’s behaviour and actions, or that the outcome for C2 could have been different.  However, there were discrepancies and differences in the information known by agencies; in the history reported by the family; in the judgments reached in good faith by professionals.  None of these suggest unequivocally that there was a clear risk of significant harm that should have been acted upon differently, for example by removal of C2, at the time of episode 1, although the opinion of CON2 that there was an unexplained bite mark should not have been discounted.  Opinion on this injury should have been clarified with CON2 as part of the S47 investigation.   The failure to challenge the differences of view, or to escalate them to resolution, and to use multi-agency processes constructively to test information and agree a plan focused on the child’s best interests, together with the gaps in recording, were all missed opportunities to ask more searching questions. These are of concern and provide important lessons from this Serious Case Review.   18. At episode 2 the injuries sustained by C2 were life-threatening, and there is evidence of prompt and appropriate action to treat her by a series of teams and interventions. In general interagency liaison worked well, including with the transfer to South Yorkshire services in Sheffield. What was not picked up during episode 2 was some of the information that might have increased the probability that NAI was considered of greater likelihood at an earlier stage.  This would not have changed the outcome for C2, but reveals the importance of maintaining a clear focus on safeguarding issues.  19. Episode 1 More attention to, and evaluation of, a range of safeguarding questions in June 2012 might have enabled agencies to be more alert to possible risks to C2 and also to her siblings and therefore to have developed a proactive relationship with the family that was focused on the possible risks to all three children, including the unborn C3.   20. This more proactive relationship with the family could have been through a Team around the Child (TAC) approach, a Child in Need (CiN) plan or through a Child Protection Plan (CPP).  Had CON2’s view been accepted that the bite mark was a NAI or at least unexplained, a child protection conference might have been called and more detailed information about the family could have been gathered and more fully evaluated.   It would certainly have presented a more complex picture to Version 02/14  5  support work with the family, but it is in my view unlikely that the case would have met the threshold for implementing a CCP even after discussion at conference, given what was known at the time.  Holding an ICPC, however, might have established with the family the nature and level of the concerns shared by agencies and why these were potential risks, and placed the whole history of C2 short life in a clearer context. This would have supported closer working with the family.  Instead, a more optimistic view of the risks developed during June, it was decided that a Child Protection Conference was not justified and the case was closed a few days before the final episode and C2’s death, without a TAC or CiN plan.   While this is missed opportunity there is no firm evidence that it would have affected A2’s behaviour or actions, or would have protected C2 more effectively.  21. Greater professional curiosity and better exchange of information might have challenged the varying accounts and explanations provided by A1 and A2 in order to evaluate better whether there were safeguarding risks and how these might have been managed.  This might have probed more closely the assumption of parental responsibility by A2 in his presentation to health agencies, and the degree to which he provided the history of C2’s injuries and well-being to professionals even when not present at the reported incidents..   22. Episode 2 C2 was seriously ill and her condition critical from the time of the 999 call on 28th July.  The emergency response was timely and appropriate to her presenting symptoms, but did not adequately consider the safeguarding implications of the case and of information provided by A1 and A2 in a number of separate comments.  Medical opinion from both DPoW and Sheffield suggests that it is unlikely that C2 would have recovered.  However, there was a failure to incorporate information about her previous episodes of hospital admission and possible injury or to question the likelihood of NAI, which was compounded when the initial CT scan at DPoW Hospital was incorrectly reported.  23. Overall, the case illustrates weaknesses in the robust, prompt and sceptical appreciation of safeguarding risks across several agencies, which should have placed a proper professional curiosity alongside the positive parenting observed, and the immediate priorities of care and treatment that were correctly put in place.  The case illustrates that, in circumstances where there are different views and opinions, and not sufficient challenge and curiosity, safeguarding processes need to prompt the critical evaluation required to assess risks clearly and to decide on an appropriate course of action.    24. Where there is clear evidence of significant harm there are robust processes for deciding on a course of action to protect children.  What this SCR indicates is that children can come to harm where there are few obvious signs and where only hindsight suggests information that might have given rise to greater concerns. Appropriate procedures and process were in place – to gather information, to Version 02/14  6  conduct a strategy discussion, to escalate concerns – but these were undermined by inconsistencies in recording, failures to challenge and check information, and by a lack of focus on the child(ren.  25. Although there is no evidence to conclude that this would have predicted or prevented C2’s death, there were weaknesses in the handling of this case by both individual workers and agencies.    There are as a result several areas where lessons should be learnt from this Serious Case Review.  These are: • Lack of professional curiosity, particularly in relation to the accounts given of the injuries to C2; • Discrepancies in information not challenged through checking with agencies involved; • The need for a prompt response, in person, to both the family and health staff when concerns are raised, especially out-of-hours;  • The need to have clearly understood and safe discharge arrangements • The need to hold prompt, inclusive strategy discussions;  • The need for robust and clear escalation when there is disagreement between agencies; • Consistent and regular supervision to challenge and question the emerging picture; • Recognition of safeguarding risks alongside clinical interventions, particularly when treating seriously ill children.  In addition there should have been more explicit recognition by all agencies that there might be safeguarding risks for both C1 and C3 if there were concerns about C2.  There seems to have been little consideration of the family dynamics and the fact that A2 was a relatively new part of the household, about whom there had been previous concerns of violent behaviour.  26. Overall, there should have been greater focus on the child, and consideration of the risks to, and experience of, a young child who it is now known had suffered a series of unexplained injuries about which different accounts had been given.  Recommendations  27. A number of specific recommendations have been made arising from the IMRs and these are contained in the SCR Action Plan published with the full report.  28. The Lincolnshire Safeguarding Children Board is recommended to consider how it can reinforce the need for a critical and probing safeguarding mindset across all staff and agencies, so that staff are equipped be alert to potential safeguarding risks in all situations.  29. The Lincolnshire LSCB should consider the findings from this report as part of its Learning and Improvement Framework and review to what extent further audit and Version 02/14  7  training work is required to address the issues identified.  30. That urgent consideration should be given to the arrangements for taking photographs of possible injuries to ensure that this service is available at all reasonable times where there are safeguarding concerns.      David Ashcroft Independent Report Author 5 February 2014  Version 02/14  8 