Serious non-accidental head injury of a 3-month old girl, in December 2012, resulting in a life changing brain injury. Baby H lived with mother, father and four older siblings/half-siblings; the family had been living in the county where the incident occurred for a number of months. Both parents experienced turbulent childhoods. Father had nine children prior to meeting mother, some of whom had been removed from his care and adopted; mother had been known to children's social care and child and adolescent mental health services (CAMHS). Family were known only to universal services prior to Baby H's birth, at which time a referral to children's social care was made identifying a number of concerns relating to mother's vulnerabilities, including her age, the family's recent move to the area and having no electricity. Mother was taking medication prescribed for anxiety and had reported taking an overdose prior to the incident. Prioritises four findings, including: insufficient consideration of mental health issues in the context of parenting capacity; insufficient support for professionals working with challenging behaviour; and reliance on personal relationships and knowledge to obtain services of partner agencies. Identifies additional learning, including how well the Mental Health Capacity Act 2005 is embedded in relation to the assessment of 16- and 17-year-olds. Uses the Social Care Institute for Excellence (SCIE) Learning Together systems model.
      
 Title:  Serious case review: Baby H. LSCB: North East Lincolnshire Local Safeguarding Children Board Author: David Peplow 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.                          North East Lincolnshire  Local Safeguarding Children Board        Serious Case Review  Baby H       Commissioned April 2013          1   Foreword from Independent Chair of NE Lincolnshire LSCB This serious case review was commissioned following an assault on a young, premature baby whilst in the care of her parents. This assault resulted in the infant sustaining a life changing brain injury.  It was my responsibility, as the Independent Chair of NE Lincolnshire’s LSCB, to decide whether this dramatic event in the life of Baby H, should be reviewed under the auspices of a serious case review (SCR), or by other means. It was my considered opinion that an SCR was appropriate and would provide the best route for sharing learning.  In particular, I was struck by the characteristics of this little baby’s family and the need for assurance that both universal and specialised services in NE Lincolnshire and neighbouring Lincolnshire had understood their needs and responded appropriately. This meant that the SCR process was more complex, as close collaboration was required between two local authority areas, each of which has its own “culture” and mechanisms for multiagency working. The SCR was commissioned and ‘owned’ by NE Lincolnshire, whilst liaising closely with Lincolnshire, which had known this family for a longer period.  I commend this report for its robust analysis and transparency. The report attempts to move beyond a description of what happened and when, and addresses the fundamental questions of why certain decisions and actions were taken, based on the situation at the time, rather than looking back with hindsight.  This SCR has also embraced the opportunity to create a “window on the system” through the scrutiny of this particular case. In other words, this report explores the systems, arrangements and professional relationships which exist both within and between NE Lincolnshire and Lincolnshire, which may have an impact on other children and families, beyond this case.  To achieve this, NE Lincolnshire LSCB exercised courage and creativity in embracing an SCR methodology which was hitherto unfamiliar to professionals in both LSCB areas and which was developed by the Social Care Institute for Excellence (SCIE). This methodology allows themes and messages to ‘emerge’ through the process, rather than being determined by prescribed terms of reference. This requires all those involved in the review process to collaborate and trust their collective professional judgement to identify the key issues and turning points in the case.  The Review Team is also enabled to use its local knowledge and understanding of the realities of local practice to provide a commentary on what a single case can tell us about the wider system.  It’s only fair to say that this SCR process was, at times, a challenge to those involved. They needed to grapple with a new style of reviewing at the same 2  time as applying their professional expertise and insight to this particular case. However, members of the Review Team and Case Group rose to the challenge.  With hindsight, I accept that it may have been a false economy to abbreviate the introductory training for this new SCR methodology, as offered by SCIE. However, this decision was not made recklessly. On the contrary, it was made in the context of limited financial resources and the time capacity of all those involved. However, I would advise other LSCBs, using the SCIE methodology for the first time, to invest as much time as they can afford in the introductory training.   This report contains a detailed description of the methodology used. This is not ‘padding’, but is essential to understand the theoretical base, which informed the analysis and learning in this case review.  Despite (and perhaps rewarded by) the challenges of employing a new style of SCR, what has been produced is a strong report. At the conclusion of the review, those who had contributed to it reflected that it had provided significant individual professional learning, as well as influencing wider agency practice. As the review progressed, early action was taken to address any indications of weakness in the wider system.   Perhaps unusually for an SCR, this review has not exposed dangerous practice, critically poor judgement or professional oversight. That’s not to say that practice cannot always be improved. Whilst some may therefore consider that an SCR was a disproportionate response to the circumstances of this baby, the opposite is true.   Despite the heightened political and media interest in SCRs, many of which have led to serious criticism of individuals and their agencies, their purpose is not simply to highlight poor practice. SCRs are a vehicle for examining individual cases and the wider system to learn valuable lessons, including those which can be drawn from reliable and good practice.  The LSCBs for both NE Lincolnshire and Lincolnshire are presented with “findings” from this review, which, when carefully considered and acted upon, will strengthen local arrangements for safeguarding children and young people.   And this will fulfil the purpose of this serious case review.   Sue Woolmore Independent Chair NE Lincolnshire LSCB  31 January 2014   3      CONTENTS  Chapter  Page    1 Process 6  Introduction 6  Policy Context 7  Publication 7  The Reviewers 8  Methodology 9  The Review Team 11  Structure of the Review, Parameters and Mandate 13  The Case Group 14  Involvement of the Family 16  Limitations and Delays 17    2 Case Summary 18    3 Appraisal of Practice 20  Professional decision-making in relation to MH staying with FH 21  MH’s mental health and the professional response 22  Professional responses to MH’s first pregnancy 22  Family move to Grimsby 23  Premature birth of Baby H and removal of Baby H from NICU against medical advice 23  Social Care involvement following referral by named midwife 24  Professional responses to further mental health difficulties reported by MH 25  Professional responses to an anonymous referral to Children’s Social Care 25  Call to out of hours medical services and subsequent ambulance call 25    4 The Findings 27  Analytical process for establishing systems findings 28  In what way does this case provide a useful window on our systems? 28  Findings for the safeguarding system 30  Finding A  Family – Professional Interaction 30  Finding B  Family – Professional Interaction 33  Finding C  Management systems 37  Finding D  Response to Incidents 40 4   Chapter  Page    5 Agency Responses and Learning at the Fringes 43  Mental Capacity Act 43  Health visitors and School nurses 43  Maternity Services Cross Boarded Transfer 44  Call out of Staff 45  Police Recording of Information about Children 45  Strategy meetings 45    6 Summary 46    Appendix 1 Findings and Questions summary 47     References and Bibliography 50  Addendum 52                                5       CHAPTER 1 - PROCESS  Introduction  This serious case review concerns a non accidental head injury, resulting in a life changing brain injury, sustained by a three month old baby born prematurely in North East Lincolnshire. The Chair concluded that the most appropriate response to the case was to conduct a Serious Case Review. It was known that the family had moved from the Lincolnshire area into North East Lincolnshire (NEL) and had been resident in NEL for a comparatively short time (approximately six months) prior to the incident which triggered the consideration for an SCR .  Working Together to Safeguard Children (ibid) gives guidance as to which LSCB should take lead responsibility.  Paragraph 8.13: Where partner agencies of more than one LSCB have known about or have had contact with the child, the LSCB for the area in which the child is or was normally resident should take lead responsibility for conducting the SCR. Any other LSCBs that have an interest or involvement in the case should co-operate as partners in jointly planning and undertaking the SCR. In the case of a looked after child, the local authority looking after the child should exercise lead responsibility for conducting the SCR, again involving other LSCBs with an interest or involvement.  Therefore North East Lincolnshire LSCB took lead responsibility for conducting the SCR, as the child in question was normally resident in that area.  Lincolnshire agencies contributed to the serious case review as the parents and some of the children had been previously known in their area.  In March 2013 a new version of Working Together to Safeguard Children (HM Government 2013i) was published. This did not change the guidance regarding primacy for the decision to initiate an SCR being with the LSCB for the area in which the child is normally resident (serious case review check list). It also states that the LSCB should ensure that there is appropriate representation in the review process of professionals and organisations who were involved with the child and family.      6   The Family Structure at time of incident  The titles follow a format used by the commissioning LSCB when conducting reviews, the initial H being a sequential designation and is unrelated to the name of the baby. Policy Context Whilst in the process of commissioning the SCR the LSCB was aware that a new permissiveness, in terms of review process, was imminent. As such the review process has taken account of the March 2013 version of Working Together to Safeguard Children (ibid). The underpinning regulations as to when to conduct a serious case review were unchanged and both versions rely on Regulation 5 of the Local Safeguarding Children Boards Regulations 2006. Publication The 2013 version of Working Together to Safeguard Children outlines within the serious case review check list the requirement for publication. “All reviews of cases meeting the SCR criteria should result in a report which is published and readily accessible on the LSCB’s website for a minimum of 12 months. Thereafter the report should be made available on request. This is important to support national sharing of lessons learnt and good practice in writing and publishing SCRs. From the very start of the SCR the fact that the report will be published should be taken into consideration. SCR reports should be written in such a way that publication will not be likely to harm the welfare of any children or vulnerable adults involved in the case.”  With this in mind some of the family detail is limited to protect the privacy of vulnerable children and their families. Title Age at Incident Relationship to Subject Baby H 3 months Subject MH 18 years Mother of subject FH 34 years Father of subject Sibling 1 1 year Full sibling of subject Half sibling 1 7 years Half sibling of subject Half sibling 2 6 years Half sibling of subject Half sibling 3 5 years Half sibling of subject 7   The Reviewers Working Together to Safeguard Children 2013 says: “The LSCB must appoint one or more suitable individuals to lead the SCR who have demonstrated that they are qualified to conduct reviews using the approach set out in this (Working Together 2013) guidance. The lead reviewer should be independent of the LSCB and the organisations involved in the case.”  In this instance two reviewers were appointed, both fulfilled the independence criteria and both had been accredited by the Social Care Institute for Excellence (SCIE) as reviewers in the Learning Together methodology (Fish, Munro and Bairstow 2008ii). The reviewer who held the contract with North East Lincolnshire took a lead responsibility for authoring the report, whilst the second reviewer assisted with facilitation of the Review Team and Case Group activity, report amendments feedback and as “critical friend” for the lead reviewer. The Social Care Institute for Excellence also took a role in providing supervision for the reviewers and quality assurance of the overall process and report. This is to ensure that the Learning Together model is applied to reviews in a consistent way and to support reviewers. Working Together 2013 sets out the way in which all case reviews should be conducted as follows: • Recognises the complex circumstances in which professionals work together to safeguard children. • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did.  • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight. • Is transparent about the way data is collected and analysed. • Makes use of relevant research and case evidence to inform the findings.  8  Methodology  In response to new requirements from Chapter 4 of Working Together 2013 (idem) to utilise systems thinking in case reviews, the independent chair of North East Lincolnshire LSCB asked SCIE to tender for undertaking a case review using the SCIE Learning Together model (idem). The SCIE Learning Together model for undertaking case reviews uses systems thinking as a methodology, it is a tried and tested model with over 60 case reviews having been undertaken in the UK and internationally. The process differs in a number of respects to the previous Serious Case Review arrangements, as set out in the previous version of Working Together, and elements of the final report look quite different.  Learning Together was developed by SCIE using approaches developed in other high risk areas of work such as aviation and health. It uses a facilitated process to learning from practice that looks at the whole system as a set of related activities rather than only looking to find learning around one case. It engages the professionals involved to explore not just what happened but why they acted in the way they did, why things made sense at the time and what it can reveal about things that are working well in the wider safeguarding system and what might need to change. Distinctive about this approach is that it endeavours to understand professional practice in context, identifying all the factors in the system that influence the nature and quality of work with families and make it more or less likely that the quality of practice will be good or poor. Solutions then focus on redesigning the system where necessary to minimise adverse contributory factors. In this way the aim is to strive to make it harder for professionals to do safeguarding poorly and easier to do so well. The process involves having a ‘Review Team’ made up of senior managers across the local partnership led by two lead reviewers who engage those people who were directly involved in the case in a collaborative process of dialogue, as well as drawing on the formal documentation (files, reports, minutes of meetings) as a source of data.  A fundamental part of the approach is to talk with staff to understand what they thought and felt at the time they were involved in the case, avoiding hindsight as much as possible. It is vital to try and make sense of what factors contributed to their understanding at the time and to the decisions they made. These key people are called the ‘Case Group’ and input is initially gathered from them via individual conversations. The Review Team collate data from the conversations and other documentation, and then develop the story identifying some key practice episodes which are examined in depth with the whole Review Team. These Key practice episodes are not every encounter with professionals but rather those periods of time the Review Team see as most significant to the case. An episode could be a short single event or a longer period of time. The detailed examination is in order to draw out findings which are about the whole system and not specific only to the case. The Case 9  Group members are also given the opportunity to discuss, correct, amplify and challenge the factual accuracy and interpretations of the sense that the reviewers make of the case.  Further information on the SCIE Learning Together Model can be found at http://www.scie.org.uk/children/learningtogether/index.asp Specific training is offered by SCIE to assist Review Team participants to understand the model and its academic rigour. This is normally done by way of a three day foundation course. The reviewers engaged are both foundation course trainers for SCIE. This option was not taken up by the commissioners; however a morning’s introduction to the methodology was delivered by the lead reviewers to an audience of both the Review Team and senior managers from the two LSCBs involved in this case. This lack of training has had an impact on the Review Team and slowed some of the processes as time was taken at the start of each meeting to explain the process and task that was due to be completed. This also led to additional meetings being required. 10  The Review Team  Name Agency and Title Role David Peplow Independent Reviewer Lead Reviewer Jenny Myers Independent Reviewer Co Reviewer Helen Willis North East Lincolnshire LSCB Coordinator Review Champion Paula Whitehead Lincolnshire LSCB Manager Review Champion (for part of the review) Toni Geraghty Lincolnshire LSCB Legal advisor to the LSCB Review Team Member Penny Sheardown North East Lincolnshire Head of Looked After Children and Disability Review Team Member Craig Ferris North Lincolnshire and Goole NHS Foundation Trust Head of Safeguarding Review Team Member Julie Choudry North East Lincolnshire Children’s Health Provision, Named Nurse Safeguarding Children Team Review Team Member Karen Philpott Humberside Police Crime Management Branch             Detective Sergeant Review Team Member Sarah Glossop North East Lincolnshire Designated Nurse Review Team Member Roz Danks North East Lincolnshire Education Head of Access and Education Welfare Services Review Team Member Joy Gilbert Lincolnshire Community Health Service Named Nurse Safeguarding Children Review Team Member 11  Liz Bainbridge Lincolnshire Partnership NHS Foundation Trust. Consultant Nurse Safeguarding and Mental Capacity (Named Nurse) Review Team Member Sheridan Dodsworth Lincolnshire Children’s Services Head of Service, Children with Disabilities Review Team Member Jan Gunter South West Lincolnshire Clinical commissioning Group Designated Nurse for Safeguarding Children and Adults (Lincolnshire LSCB) Review Team Member Elaine Todd United Lincolnshire Hospitals NHS Trust. Named Nurse for Safeguarding (Children and Young People) Review Team Member  The Review Team was made up of senior representatives from across North East Lincolnshire and Lincolnshire who had no direct dealings with the case being reviewed. They worked with the lead reviewers to analyse material collected and contribute to information about organisational context, strategy, resources and local policy.    As explained in the introduction above the review was commissioned by North East Lincolnshire LSCB as the child in question was normally resident in that area.  Lincolnshire agencies contributed to the serious case review as the parents and some of the children had been previously known in their area. An element of this contribution was to have representatives as part of the Review Team.  The size of the team was larger than the range suggested by the model, this was in order to be as inclusive as possible across the two authority areas but bought with it some challenges in managing meetings as the process is highly collaborative and needs the input from all the team.   There were also some logistical difficulties as the meetings were held on the premises of the lead LSCB local authority and it proved challenging for some of the Lincolnshire representatives to arrive on time for meetings. As each meeting would start with a briefing about the task ahead (in lieu of the foundation course, see above) this was problematic. This matter was escalated to the Chair of Lincolnshire LSCB by the Chair of NE Lincolnshire 12  LSCB and the obstacles were overcome. These comments should be set against a backdrop of the new permissiveness of SCR process which is a challenge for all those involved. Commissioners, reviewers and other participants continue to learn about what works well in delivering reviews that meet the five requirements outlined in Working Together 2013 (idem)  The Review Team actively participated in the structured conversations with the Case Group, the identification of key practice episodes and contributory factors and the overall findings. This report is the shared responsibility of the Review Team in terms of analysis and conclusions.  Quality assurance has been provided to the lead reviewers through direct supervision by SCIE. However it should be noted that due to capacity issues and the maternity leave of the Head of Learning Together at SCIE the quality assurance of the first iteration of the report was delayed. Structure of the Review, Parameters and Mandate The Review Team met on six occasions and an additional two meetings with the Case Group. They worked on information from conversations, key practice episodes and contributory factors, and then formulated this information into findings. The Lead reviewers and Review Team use a number of data sources, these include the Review Team constructing chronologies from internal agency documents. These were then merged into a single consolidated chronology which was made available to the Review Team. Other documentation is analysed either by the Review Team member or a lead reviewer. The conversations are a key source of data generated by individual discussion with the Case Group (see below). The input of the lead professionals within the Review Team is also required to assist with the local context, policy and procedure. The lead reviewers will also take account of previous reviews and other published research. Although some historical information was relevant and covered in the chronology, the core time period the review appraised was from 6th December 2010 until the end of December 2012. This is from the time MH first stayed with FH to the initiation of a police investigation into the trigger incident. Many reviews in the past have examined involvement of services over many years, a “rule of thumb” with Learning Together reviews is for the period under consideration to be between one and two years. This is so that the system, the policies and procedures and professional practice are similar enough to how business is conducted now in order to provide a useful and relevant “window on the system”. (Vincent 2004iii) The methodology does not require formal terms of reference so that the review can follow whatever emerges from documents and conversations, and what was important for professionals and the family at the time. This leads to 13  a more open style of enquiry rather than one constrained by a pre-determined terms of reference.  In addition to the writing of various documents, the process involved a number of steps outlined below. The meetings are rigorous and involve professionals in detailed discussion about standards of practice, policy and procedure and being tasked with additional enquiries.    • Introductory meeting with both Boards • Introductory meeting with Review Team • Introductory session with Review Team and Case Group • Conversations with the Case Group • Review Team meetings to re construct the case and the narrative around the story and accuracy • Review Team to agree and identify Key practice episodes • SCIE supervision • Review Team meeting Draft findings • Draft report • Review Team • Case Group consultation • SCIE quality assurance of the final report  • Feedback to the LSCB   The Case Group The Case Group comprised of 22 people. The members of the Case Group are the staff who worked with or made decisions about the family, and who had individual conversations with members of the Review Team. They were collectively briefed on the methodology and then met with the Review Team for two sessions to share in the analysis, the identification of contributory factors, and to comment and contribute to the final report.  Not all members of the Case Group were able to participate in all stages of the process due to other parallel processes and proceedings. (See Involvement of Family, below).  There were two staff members who had moved on, one took part in a telephone conversation, the other did not respond to contact from the Review Team. (See Limitations and delays, below)  The systems approach uses sources of data to learn more about how people saw things at the time they had any involvement in the family and with their colleagues. It also explores with them through structured conversations what factors were affecting their work. This is known as ‘local rationality’ and those involved in the case play a major part in the review, by exploring how and why practice unfolded the way it did and highlighting the broader organisational context.   14  The professionals involved in the conversations were able to give open and insightful feedback about their views and how things seemed to them when they had contact with the family. One significant factor was that whilst a number of professionals had contact with the family, very few had known them for any length of time or had intensive involvement with them.  Conversations were held with staff from:  Children’s Social Care • Social worker (Lincolnshire –had left) • Social worker (Lincolnshire) • Social worker (North East Lincolnshire) • Principal social worker (North East Lincolnshire)  Education • Head teacher of nursery school (Lincolnshire) • Primary school child protection coordinator together with Head teacher (North East Lincolnshire)  Police • Police officer (PC) response team (Humberside Police covering North East Lincolnshire) • Two Police officers (DS) public protection team (Humberside Police covering North East Lincolnshire)   Health • Parenting practitioner (Lincolnshire) • Two Health visitors (one from each area) • Children and adolescent mental health service social worker (Lincolnshire) • Children and adolescent mental health service nurse (Lincolnshire) • General practitioner together with practice manager (North East Lincolnshire) • Staff nurse neo-natal Intensive care unit (North East Lincolnshire) • School nurse (Lincolnshire) • Nursery nurse (North East Lincolnshire) • Consultant paediatrician (North East Lincolnshire) • Senior staff nurse, children’s ward (North East Lincolnshire)  Housing • Housing officer (Lincolnshire) • Housing officer manager (Lincolnshire) 15  Involvement of the Family Understanding how events unfolded from the point of view of the family was seen as a very important element of this review, as it is with any case review. As well as considering the parents MH and FH there was exploration by the Review Team to establish if there was a member of the extended family who could usefully contribute to the review. The conclusion was that there were no additional family members who could add to the review. This case review was conducted whilst parallel processes were also underway, that is both care proceedings and a criminal investigation. A list of questions was compiled to assist those involved in other processes to understand what type of information was sought. On 3rd October 2013 a meeting took place with representatives from the commissioning LSCB (NEL), a representative from NEL legal department, the Police and the Crown Prosecution Service (CPS). There were clear and strong representations from the Police and CPS regarding involving the family in the review prior to the conclusion of the pending criminal proceedings. It was also felt that some of the Case Group who may be giving evidence should be not attend any planned plenary session prior to the conclusion of those proceedings. This advice was put to the Review Team. There was not total agreement that the advice should be followed without some additional challenge. The matter was referred to the Independent Chair of the owning/commissioning LSCB who concluded that on this occasion the advice of the Police and CPS should be followed. The review was aware of the guidance regarding parallel processes that was produced by the CPS and the Association of Chief Police Officers (CPS, ACPO April 2011iv); however that document was prepared prior to review process such as Learning Together being used for Serious Case Reviews. With this in mind a cautious approach was considered the best route at this time, recognising the gap this introduces in the available data.  The family members will be approached at a later time as it is felt important to invite involvement and to be able to consider their perspective regarding professionals’ involvement with them. The Review Team also considered if the children could be approached, those thought old enough are also potential witnesses in other proceedings. So as with the adults, it was not considered appropriate to speak to them whilst other proceedings are ongoing. Of course they may decide they do not wish to participate.  It has been hard to ascertain in any depth what life was actually like for the children living in this family as they had not become well enough known to the wider universal services and schools in their new area when the premature birth of Baby H took place. Nor has it been possible to gain the perspective of the MH and FH.  16  Limitations and Delays A Practice Supervisor had moved on and did not respond to messages left, her notes were accessed and were seen to be correct in that they summarised the case and confirmed agreed actions. A Lincolnshire social worker had left and was contacted, she agreed to a telephone conversation with the Review Team member who contacted her and recalled some things about the case. She declined further involvement. The Family have not been spoken to (see above).  The Review Team worked hard to familiarise itself with the new SCIE Learning Together methodology. On reflection this was an ambitious ask and at times has caused tension and anxiety as the analysis took longer to complete than originally anticipated and planned. An additional meeting was required in order to complete the analysis of the events being focused on.  Whilst the lead reviewers attempted to address the lack of understanding and at times confidence in the model there is some significant learning for SCIE and the commissioners in making sure that in the future, particularly around Serious Case Reviews using new methodologies, the training of the Review Team is considered as part of the commissioning process. In addition there needs to be clarity in the contracting as to what size of review is being commissioned as this impacts on the size of the Review Team, Case Group activity and timescales for completion.   Additionally the complexity of having a slightly larger cross authority/LSCB Review Team, the differing organisational culture and approaches, and the difficulties in getting dates and times agreed to meet in order to get full attendance also impacted on timescales. As the completion date was extended the review was still live during a period when the lead reviewers had pre- arranged holidays. However there was no period when both reviewers were not available.  The meeting referred to above in the “Involvement of the Family” section also advised that the report should not be published before the conclusion of criminal proceedings. 17  CHAPTER 2 – CASE SUMMARY  This case involves a significant non accidental head injury, resulting in a life changing brain injury, sustained by a three month old baby (Baby H) born prematurely at 31 weeks and 6 days gestation and who had spent several weeks in hospital in a specialist neo natal unit (NICU).   Baby H lived in a blended family consisting of the birth mother, MH, who was 18 years old, father, FH (34), an older sibling who was one, and three half-siblings from their birth father’s previous relationship. The family had recently moved from Lincolnshire to North East Lincolnshire and at the time of the injury had only been in their new county for a number of months. At that time they were in receipt of universal services, which is the normal health, education and housing services it would be expected that a young family would use.  FH had a turbulent childhood and has 6 older children from previous relationships. Some of those children were removed from his care and were adopted. Whilst resident in Lincolnshire FH had a further 3 children  with a new partner and when that relationship came to an end, and following private law court proceedings in 2009, he secured the residency of those three children; the family were known to children’s services at the time. FH was Father to 9 children prior to meeting MH.  MH had been known to Children’s Social Care and Children and Adolescent Mental Health Services in Lincolnshire and had a turbulent childhood with a history of her allegedly suffering abuse, including an allegation of historic abuse which was being investigated by a neighbouring police force. None of the abuse allegation had been substantiated.  Whilst Baby H was a patient on NICU the named midwife made a referral to NEL Children’s Social Care, for a request for Service identifying a number of concerns in respect of MH including her being a vulnerable young adult with care of five children, the recent move to a new area and having no electricity. The suggested action needed was to undertake an assessment of need and assessment of home conditions, with possible services required being to ascertain if any risk to children within the home in view of previous concerns. There was an anxiety on the ward about FH’s possible reaction to the referral and it was not discussed with him in case he became aggressive.  The parents became frustrated at not having the baby home but professional advice to them had made it clear that the professionals needed to be reassured that the parents had the capacity to care and feed the baby confidently and that sufficient support was going to be provided by social care. The consultant had told the parents that he would call the police if Baby H was taken home contrary to his professional advice.  There was a series of around 30 telephone calls made to the ward in a short period of time by FH during which he repeatedly asked to know what had 18  been said about him in the referral made to social care. Following this, MH came to NICU with an adult not known to the staff and took Baby H, the hospital security staff were contacted but were unable to intervene and the police were called.   The police attended the family home and MH agreed to return with Baby H to the hospital. The police officer noticed that MH was quite young and had a feeling something was not quite right.   The baby was later returned voluntarily and a strategy meeting was called. MH said that there had been a misunderstanding about taking Baby H home. This was contrary to the hospital’s view that the situation had been clearly stated. At the strategy meeting it was decided to initiate a further assessment and family support through Children’s Social Care. Baby H was discharged home some days later.  On 7th December 2012 Children’s Social Care had a referral from an anonymous caller expressing concern about the children. This was investigated by social care, the children were all seen and no immediate concerns identified. There was no evidence of the disturbance reported.  The following day there was contact with the GP out of hours service by MH concerned about the Baby H and advice was given over the phone. At 6.22 the next morning, an ambulance attended the house as Baby H was having a seizure.   Baby H was taken to the emergency department and then to a children’s ward. It became apparent from the medical interventions that there was a serious head injury.  Initially it would appear that there were many aspects of the case for the Review Team to explore to understand the circumstances leading up to and surrounding the serious incident and whether more could have been done to prevent it.  Specifically the review wanted to know more about:   • The quality of assessment of MH’s own mental health needs including her mental capacity • The professional decision making process by which MH came to be living with FH. • Whether there was significant focus given to the needs of the children in the family • The differing views of the impact of FH’s aggressive and difficult behaviour and the risk he posed to his partner and the children • Whether neglect of the children or sexual exploitation of MH was a feature in the case • The level of support that the family had received in both counties, including the transition arrangements from one authority to another 19  • The support given to a very young mother and the impact of having a premature baby on her capacity to parent safely given her mental health CHAPTER 3 – APPRAISAL of PRACTICE  This case review has looked in detail at the circumstances leading up to the serious injury to Baby H.   It is important to remember that despite the parents’ previous histories, including concerns about MH’s mental health and FH’s aggression, this family was only receiving universal services for the majority of the period under review. Previous proceedings taken by FH had secured residence of his three children and the professional views observed about the family whilst they were living in Lincolnshire were that they were a tight and coping family unit.  Appropriate contact had been made in regard to the first pregnancy of MH with maternity services and the nursery school was providing advice and support to the parents before they moved to the next county. Although there were low level concerns about neglect the children were not markedly different to other children living in similar circumstances in the community. The transition from Lincolnshire, where the family were users of universal services, to knowledge about the family in North East Lincolnshire was adequate and before the birth of Baby H the family were accessing new local services including maternity ante-natal, general practitioner, schools and housing appropriately.  In relation to whether the relationship between MH and FH was violent or exploitative the professional view (explored during the conversations) was that, despite the age difference, it was not. There had been concerns when MH moved in with such an older partner and professionals appropriately assessed the nature of their relationship. This was explored in detail by the Review Team. However, it was evident that there was a growing differing professional view of the behaviour and risk posed by FH by those who met him in North East Lincolnshire, with health professionals finding him obstructive and difficult to manage. It appeared the stresses on the family were increasing following to the referral to Children’s Social Care (CSC) without discussion with FH and the growing concerns about their parenting capacity of a premature baby. There were no concerns with regards to potential physical assault of the children.  The impact of the move, the birth of a premature baby and the stresses of having a number of young children with a very young and potentially isolated mother with emerging mental health issues has been considered by the review and the key incident that raised further concerns and involvement of CSC was the removal of Baby H from NICU. The professional response to this has identified some learning around the potential seriousness of the removal of a baby from NICU and the need to ensure that in future it is seen to indicate the potential for harm. It has been reported to the review that this has led to the paediatrician changing practice and he would now view such an episode as a significant indicator of likely future harm. 20   There is significant evidence that there was good professional practice at the universal level of services in this case. There is however some learning particularly to individual agencies and, “at the fringes”, together with some findings for consideration by the LSCBs.  Professional decision-making in relation to MH staying with FH  Prior to December 2010, MH had been living with relatives. She was known to both social care as a child in need, and was accessing CAMHS services. In December 2010 she was arrested following a breach of the peace. On her release from custody, her immediate return to where she had been living was not considered appropriate. MH therefore suggested she could stay with a friend, FH, who was 32 and had three children. They soon began having a relationship, and MH was seen as an informal carer for the children.   The review considered in detail the professional response to MH’s decision to stay with FH, and the subsequent relationship that developed between them, particularly in the light of MH’s age and mental health problems. Firstly, this review considered whether MH’s local authority area (at that time, Lincolnshire County Council) should have provided alternative accommodation for MH. The review considered local policy and procedure and explored the relevance of the “Southwark Judgement” (R v London Borough of Southwark HM Publications. 2008.v  Shelter, Legal Services 2009vi). It was found that practice in this situation was not lacking, policy and procedure was followed (Lincolnshire County Councilvii) and concerns regarding the relationship and choices made were appropriately escalated and considered during supervision. Alternative accommodation was available but MH declined to attend the relevant appointment. Secondly, the review considered professional responses to concerns regarding the age difference between MH and FH and the possibility of an exploitative relationship. The review found evidence that there had been multi-agency consideration of possible risks arising from the relationship, social care having discussed the situation with police. There was no evidence of any criminal offences taking place, so the police had no powers to act and there were no other powers to compel MH to live elsewhere, appropriate steps had been taken to offer alternative accommodation. Finally, this review considered whether, given MH’s mental health problems, which included self reported symptoms of psychosis, consideration should have been given to her capacity to make the decision regarding living with FH. After extensive consideration of the Mental Capacity Act 2005 (HM Government Legislation 2005viii), it was the view of the Review Team that it was not reasonable to have expected professionals involved in the case to apply this legislation in this case. However, these discussions did highlight a wider discussion regarding the Mental Capacity Act, and the extent to which it is embedded in work with young people more generally. There was a strong view that there is general 21  learning for both LSCBs with regards to the application of the MCA. In order that learning is not lost this aspect is considered further in the section of this report ‘Agency responses and learning at the fringes’. MH’s mental health and the professional response  The Children and Adolescent Mental Health service (CAMHS) continued working with MH by having regular meetings with her and considering what else might help her. She was offered an inpatient place for further assessment but she declined. The professional opinion was that there were not grounds for a compulsory admission.   There was some professional concern that MH may not have shared the extent of her mental health history with FH. A core assessment was carried out by Lincolnshire Children’s Social Care (February 2011) this assessment does not reveal any overt concerns with regard to children. A decision was made that FH should be given the information about MH’s mental health history. There was some delay between the decision and sharing the information but it was done and there were no adverse events in the intervening period.   Professional responses to MH’s first pregnancy  In spring 2011, MH became pregnant with her first child. The first record of this pregnancy was when she appropriately accessed maternity services on 17th May 2011; records show “gestation unknown”. MH was still an open case as a ‘child in need’ at this point.  It was agreed that preparations for the birth were good and any required assessment would be opened at 20 weeks. When this stage was reached, no such assessment was thought necessary. In August 2011 MH’s case was closed to social care.  MH had been seen to enjoy her time with the boys and the previous assessment to explore the impact her presence may have on them had raised no concerns. MH was invited by CAMHS to a session about pregnancy and attachment but declined. MH made it clear to CAMHS that she did not want further appointments. She was discharged and a summary letter sent to the GP.   At this point, MH and FH were seen as a functional family and became recipients of the universal services connected with pregnancy, a new baby and young children. The review found this to be an appropriate professional response.  In November 2011, MH gave birth to her first child – Sibling 1. Health visiting services were provided, and saw the family in the clinic and at home. The parents were proactive and sought advice. When MH reported low mood, she was offered, and accepted, a series of listening visits.   In February 2012 MH reported to the Health Visitor that she was pregnant again. The couple told the Health Visitor and housing officials that they planned to move to Grimsby. The termination of tenancy form showed the 22  reason simply as ‘Other. They told the health visitor that they wanted a new start.  Family move to Grimsby  In June 2012 the family started to access services in Grimsby. They were not an ‘invisible family’. A family not registering with a GP, children missing from a school roll or persistently not attending and homelessness would be seen as causes for concern (SET LSCB. 2011ix). However, this was not the case with this family.  The review considered this period in detail but concluded that, as they were not in receipt of enhanced services at the time of the move, there was nothing which should have been done by any of the services who had previously worked with the family. Statutory records were appropriately transferred by the GP and education. It was discovered that the non-statutory records from nursery education were given to MH to pass on to a new setting; this was discussed by the Review Team in some detail. This would not be policy or acceptable for statutory records, however it was a practical solution in these circumstances. The extent of this as a regular practice was not known as this lies outside of the statutory framework. There was no evidence that the family moved to avoid any professional attention as they were open about the fact they were moving and quickly engaged with services in the new area. They were able to access housing, education, maternity and GP services without any difficulty. This is the expected response.  Premature birth of Baby H and removal of Baby H from NICU against medical advice  Shortly after the move, on the 20th August 2012, a new baby was born (Baby H), she was premature at 31 weeks and 6 days gestation. Baby H was admitted to the neonatal intensive care unit (NICU).  During the baby’s stay in hospital MH revealed something of the past involvement the family had with social services. Social care in the previous area was contacted and previous records and reports viewed, in accordance with good practice. The new local GP held the transferred records and viewing of these GP records should have been part of this enquiry into previous agency involvement (Think Family Toolkit. DCSF, 2009x) (finding A). During this period FH exhibited challenging behaviour in the ward towards a range of professionals. Professionals at the ward had concerns about MH and FH’s ability to care for Baby H, and in particular MH’s ability to care for five children at such a young age. The named midwife appropriately made a referral to Children’s Social Care, but did not feel able to discuss this with MH or FH based on perceptions of FH’s aggressive behaviour. Professionals in 23  NICU were distressed by this challenging behaviour, and felt that their supervision arrangements did not sufficiently support them in dealing with this.  The pattern whereby some health professionals may not be supported to deal with challenging behaviour is discussed in more detail in Finding B.  The challenging behaviour escalated regarding a wish to take Baby H home, with numerous phone calls made to the ward by FH. On the 16th September 2012 Baby H was taken from the NICU against medical advice. There was a good response to this aspect of the incident with ward staff ensuring that the parents had the supplies they would need to care for Baby H, as well as security and the police being notified of the incident. Police officers attended the home and were able to persuade MH that she should return with Baby H to the hospital, police officers provided the transport.  MH revealed to the officer that she was depressed and had recently taken an overdose of her prescribed medication. Despite this being recorded by the police officer, submitted to the police public protection team and shared at the strategy meeting, no action was taken either to refer MH to mental health support services, or to consider the child protection issues entailed by a suicidal parent. Police records show that the details shared were that MH had been suffering from post natal depression and had been prescribed Amitriptyline (medication for anxiety) and that she had disclosed that she tried to take an overdose a few days previously. She had stated that she did not wish to harm herself now and declined any help. The hospital was informed of this information.   The strategy meeting minutes are lacking in detail and it is not clear now whether these concerns were discussed, or what action (if any) was agreed in respect of this.  This is problematic practice given government guidance (Think Child, think parent, think family 2012xi).  The reasons underlying this are considered in Finding A.  The removal of Baby H from the ward prompted a strategy discussion. MH’s explanation that the removal of Baby H had been as a result of confusion, and a ‘spur of the moment’ decision was accepted by the meeting, this meeting was not attended by the doctor who had given clear advice to MH about what was required before discharge of Baby H. The absence of this information may well have been why MH’s explanation was accepted. The Review Team thought that this was poor decision-making: the removal of a baby from hospital against medical advice should have been considered as an indicator of poor parenting capacity. At this meeting, information from the Police regarding MH’s overdose was not shared. The meeting was poorly administered and did not comply with policy or guidance. The reasons for this are discussed further and are further explored in the findings section. (Finding C). Social care involvement following referral by named midwife 24  Following the referral from the named midwife, the case was opened to Children’s Social Care as a Child in Need case. The Review Team felt that this was appropriate given the concerns presented in the referral. A social worker conducted home visits appropriately, and did not have sufficiently serious concerns about the family to initiate child protection procedures. Professional responses to further mental health difficulties reported by MH A few weeks after the birth, MH visited her GP and reported feelings of anxiety. The GP prescribed an anxiolytic drug. Despite reporting that he had considered whether this could be post-natal depression, the GP did not appear to consider MH’s mental health in the context of her being a young mother of five, with a recent newborn, and did not signpost her to further support. The reasons underlying the failure to ‘Think Family’ are explored in Finding A. Some detailed work was undertaken by the Review Team to understand what information would have been available to the GP via the computer system (SystemOne). Appropriate back record conversion had been taken place when records moved onto the computer. This examination of the records illustrated the difficulties that can be encountered in using the system, particularly in a short space of time such as at a GP appointment. It was discovered that the CAMHS discharge letter had been scanned onto the system but was marked as an “admin event” one of 191 such events, rather than “clinically relevant”, of which there are 42 entries. Even if the letter were included in this later category the examination of so much data would be time consuming. SystemOne is known to be problematic in some situations and members of the Review Team are taking this forward (see Agency Responses and Learning at the Fringes below).  Professional responses to an anonymous referral to Children’s Social Care On Friday 7th December 2012 an anonymous referral was made to Children’s Social Care. The information was that there was a disturbance at the family home of Baby H. The allocated social worker was unable to attend immediately, however the principal social worker took the decision to undertake the visit himself, within a short time frame from the initial call.  The visit was conducted at 5pm that day, during which the principal social worker saw all the family members, the half siblings were asleep in the front room and a bedroom, Baby H and sibling 1 were seen in the kitchen area, sibling 1 awake and Baby H asleep. There was no evidence of the described disturbance. The worker left after the checks and told the family that a social worker would be in touch the following week. Call to out of hours medical services and subsequent ambulance call 25  On 8th December 2012, MH called the out of hours medical services, describing Baby H as being snuffly with some colour change to her face. The Review Team considered that appropriate advice against the available information was given with further advice to call back if there were further concerns or changes. No further calls were made. At 6.22 am on 9th December an ambulance attended baby H who was having a seizure, Baby H was taken to hospital where appropriate examinations took place. It was disclosed that Baby H had been twitching for around 12 hours; a non-accidental head injury was diagnosed following a computed tomography scan and interpretation of the images. This resulted in a timely multi-agency investigation. A police officer responded to (and dealt well with) the call from social care. The officer contacted had not been on duty at the time, and it was noted by the Review Team that there had been a reliance on personal relationships to call the officer. Whilst this did not have an adverse effect on the investigation this process is further examined in the findings (finding D).  As part of the review process it was noted that the hospital report on the CT scan varied to the report (given as a second opinion) by the hospital that Baby H was later transferred to. As is routine, the hospital completed a serious incident investigation in relation to the workings between Radiologists and Paediatricians. In summary the investigation determines a correct report was offered but that the report interpretation by the Consultant Paediatrician could have been better understood to support care management if a verbal discussion between Consultant Radiologist X and Dr B had taken place. A number of actions were identified to facilitate improvement in internal processes. The action plan was supplied to the lead reviewer and is shown as completed. 26  CHAPTER 4 – THE FINDINGS Moving from the case-specific to general systems issues The Learning Together model for case reviews has three core principles which must be adhered to for it to be considered a Learning Together review.  Very briefly they are: to gather data whilst avoiding hindsight bias; to appraise and explain practice; and finally to move away from the case specifics identifying system wide learning. These systems issues are not presented as recommendations but as findings. This last part is a fundamental shift from previous review styles and the associated recommendations. However, a study of recommendations arising from Serious Case Reviews (Brandon et al 2010xii) calls for a curbing of ‘self perpetuating and proliferation’ of recommendations.  Therefore the findings are accompanied with a series of questions and considerations for the LSCB rather than a pre written action plan.  Given the requirement in Working Together 2013 (idem) for the LSCB to publish a response outlining actions already taken and those planned for the future this approach is more challenging for the LSCB. A Serious Case Review plays an important part in efforts to achieve a safer child protection system, one that is more effective in its efforts to safeguard and protect children. Consequently, it is important to understand what happened and why in this case and then to go further and reflect on what this reveals about underlying gaps and inadequacies in the child welfare system. When the gathered data is examined we ask ourselves what the case has revealed about six underlying patterns or typologies, they are lines of enquiry and are as follows:  • The use of tools, what has been learnt about tools (computer systems, forms and so on) and their use by professionals? • Family - professional interaction, what patterns of ways that professionals are interacting with different family members are discernable, and do they introduce risk into our system? • Management systems, are any elements of management systems a routine cause for concern in any particular ways? • Response to incidents/crisis, are there any particular issues about patterns of how professionals respond to incidents? • Longer term work, were any patterns identified about ways of working over a longer period with children and families? 27  • Innate Human biases, are there common errors of human reasoning and judgement evident that are not being picked up through current set ups? Not all the typologies will have a finding associated with them but are designed to allow for structured enquiry as to what the data has revealed. This consistency of process across all Learning Together reviews will allow for a bank of findings to be built up and assist in later analysis of findings across a range of reviews. Analytic process for establishing systems findings The aim of a Learning Together case review is to use a single case as a ‘window on the system’, to uncover more general strengths and weaknesses in the child protection system. A four-stage process of analysis is used to articulate how features of the case can lead to more general systems learning. The first is to look at how the issue manifested in the case specifics, this will mostly be presented as one example, even if there are several such examples. This will come from the analysis of the reconstruction of the unfolding case and examination of key practice episodes. The second step is to consider whether the issue observed in this case is ‘underlying’. That is, that it is not a ‘quirk’ of the case, but is likely to represent practice in other cases and by other practitioners. The third step is to consider how geographically widespread and numerically prevalent the issue is within the system. Sometimes it is not possible within the scope of a review to adduce the data. The sources for these steps will be information from the Review Team and Case Group, any performance data, national research and other reviews in a variety of combinations. In this review, it has not been possible to obtain some of the data requested to populate these steps – this has been highlighted where relevant. The last step is to articulate why this issue matters, what are the risks to the safeguarding system. Based on this finding, questions and considerations for the LSCB are formulated.   In this case there are findings which may have manifested in one of the two LSCB areas, but it would be useful for the other LSCB to consider if there is a similar issue in their area. In what ways does this case provide a useful window on our systems? Reviewing this case not only provides an opportunity to establish what happened in the case, and why, but also what this tells us about general strengths and weaknesses in the child protection system.  At the beginning of the period under review, the family was perceived as ‘coping’. Later events suggest that they may have been ‘just coping’. This case provides an example of how universal services such as GP and health visiting services, and specialist health services, work with families with multiple needs, but who do not meet thresholds for statutory children’s 28  services. It also provides useful insights in to service responses when these levels of need escalate, and a swift response to an incident is required. This review has prioritised four findings for the Board to consider: Finding Category Finding A:  A tendency for professionals not to consider mental health issues in the context of parenting capacity, means that a full understanding of parental needs is not reached, and potential risks to children not identified  Family-professional interaction Finding B: The provision of support for some health professionals in North East Lincolnshire, in relation to the emotional toll of working with challenging behaviour is not sufficiently embedded in organisations leaving some staff feeling vulnerable. Family-professional interaction Finding C:  In North East Lincolnshire the process of strategy meeting minute taking and appropriate information sharing is not as robust as it should be and falls below the standards of “Working Together”  Management Systems Finding D:  In North East Lincolnshire there is a reliance on personal relationships and knowledge to obtain services of partner agencies, which creates a weakness within the safeguarding system.   Communication and collaboration in response to incidents  29  Findings for the safeguarding system. The order the findings are presented in should not be read as an order of importance. That is a matter for the LSCBs.  Finding A: A tendency for professionals not to consider mental health issues in the context of parenting capacity, means that a full understanding of parental needs is not reached, and potential risks to children not identified  (Family – Professional interaction)  It is well recognised that working effectively with parents with mental health problems requires a holistic approach, often referred to as a ‘think family’ approach (e.g. SCIE, 2012 idem). This is in two main ways. Firstly, the impact of parenting on a parent’s mental health must be considered; the stresses of parenting can precipitate or exacerbate mental health issues. Secondly, it is important to consider the impact of the parent’s mental health on the child’s safety and wellbeing, including the possibility that the parent may harm their child. The implications of “Think Family” are far reaching and extend to both universal and targeted services working with adults, children and families and working across all sectors (Think Family Toolkit. 2009 idem)  This case has identified a pattern in which key professionals may not be ‘thinking family’, meaning that a full understanding of mental health issues and their impact on parenting capacity may not be reached, and potential safeguarding issues not identified.  How did it manifest in this case? There were several instances in this case in which professionals failed to ‘think family’.   A few weeks after the premature birth of Baby H, MH attended her GP and described feelings of anxiety. The GP, in response to specific questions posed by the Review Team, said that he had considered post natal depression but felt that she was experiencing stress and anxiety, and prescribed an anxiolytic medication. The GP did not seem to consider MH’s symptoms in the context of her being a mother to five children, including a premature newborn. The GP did not appear to consider additional support that MH may need, or issues for the welfare of the children in this situation, signpost MH for further support.    The NICU staff were aware that MH was taking this medication, as an enquiry was made regarding the compatibility of this medicine and breast feeding. However, there is no evidence that there was any enquiry as to why MH was taking this drug, meaning that staff at this unit were also not taking in to account MH’s mental health issues.   A final instance occurred when Baby H was removed from the NICU against medical advice six days after the GP attendance. During the journey back to 30  the hospital MH told the police officer that she was taking medication for depression and had taken an overdose. This information was recorded and submitted to the public protection team; however there is no evidence of escalation or further consideration as to how this could impact on MH and family, or that this information was shared with other members of the multi-agency group.  It is unclear in this case whether the injuries to Baby H were influenced by MH’s mental health difficulties. It is also not possible to say whether these injuries could have been prevented, had there been greater awareness of MH’s mental health difficulties across the professional group. However, these episodes highlight a potential weakness in practice, which warrants further consideration.  How do you know it is underlying? The Review Team reported that there is an underlying practice norm whereby professionals deal with the ‘presenting issue’ rather than taking a holistic view of a person, and their potential needs, including as a parent. This is supported by national research evidence (e.g. SCIE, 2012 idem). In this case the lead professionals from the Review Team were clear the focus of the NICU staff is the patient, Baby H. The review observed that the GP worked in a similar, narrowly focused when he was spoken to and the notes examined. He dealt with the symptoms presented by his patient MH, and there was no evidence that he gave consideration to wider family circumstances. In Review Team discussion it was felt that this was likely to be the norm given the work load and time constraints in General Practice.  There was a strong feeling from the Review Team that this was an important issue and this finding is the result of discussion about maternal mental health, the use of risk assessment and the link to risk management.  How widespread is the pattern? Research evidence suggests that a failure by professionals to think holistically about the needs of parents with mental health problems and their children is an issue across a range of professions, and across the country (e.g. Tompsett et al. 2009xiii) and has been identified as a factor in analyses of Serious Case Reviews (Brandon et al. 2012xiv).   How prevalent is the issue? No specific work was done by the Review Team to understand the prevalence of this issue in North East Lincolnshire. More generally, research evidence suggests that between one in four and one in five adults will experience a mental illness during their lifetime. At the time of their illness, at least a quarter to a half of these will be parents (SCIE, 2012, idem). Whilst not all parental mental illness represents a safeguarding concern for children, this nevertheless suggests that parents with mental illness represent a significant group.   The shift in children’s and adult social care policy and guidance, which now places greater emphasis on supporting adults in their parenting role, would 31  also strongly suggest that this issue is widespread and prevalent on a national basis.  The main policy in England: No Health without Mental Health, the Troubled Families Initiative, Community Budgets, Think Local Act Personal, Putting People First and the March 2013 Working Together guidance which provide the framework for children’s services to support the child and the family would support this view.  Why does it matter? Parents with mental health problems can experience difficulties in parenting, which affects the welfare of their children. Conversely, the stresses of parenting can exacerbate or precipitate mental health problems in adults (Falkov, 1998). Professionals working with adults therefore need to be aware of the adult’s role as a parent, in order to: a) Fully understand the needs of that person b) Consider how parental difficulties may impact on children, including any safeguarding issues that they may raise.  If professionals do not do this, opportunities to safeguard children, and to support parents to perform their parenting role to the best of their abilities, may be missed. It is important to identify and support adults who are experiencing problems who are parents or carers and ensure support is co-ordinated.  This case has suggested that some key professions are not taking this approach, meaning that potential opportunities to identify risks to children may be missed.  Finding A: A tendency for professionals not to consider mental health issues in the context of parenting capacity, means that a full understanding is not reached, and potential risks to children not identified  (Family – Professional interaction)  It is important to identify and support adults who are experiencing mental health problems who are parents or carers and ensure support is co-ordinated. Professionals working with adults need to be aware of their role as parents so that potential opportunities to identify risks to children are not missed.  • Has the LSCB identified this as an issue previously and/or did the board do work around the Think Families agenda? • Is this agenda embedded in front line practice? • Are professionals equipped to recognise multiple vulnerabilities and compounding risk? • Does the LSCB have access to data which would assist in assessing the prevalence of the issue?   32  Finding B: The provision of support for some health professionals in North East Lincolnshire, in relation to the emotional toll of working with challenging behaviour is not sufficiently embedded in organisations leaving some staff feeling vulnerable. (Family – Professional Interaction)  Providing support to children and families is inherently relational: practitioners cannot simply ‘deliver’ services, but instead work with families to ‘co-produce’ outcomes. When families are very hostile to professionals, this can present significant difficulties. Firstly, being unable to form a constructive relationship with a family can inhibit the worker’s ability to provide the support the family needs. Secondly, if professionals are not sufficiently supported, experiencing this hostility can exacerbate stress and ‘burnout’ (Mor Barak et al. 2009xv). Working with challenging families can be particularly difficult and anxiety-provoking for practitioners who enter families’ home environment, as illustrated by the following quote from Ferguson’s research: “Safeguarding literature, policy and practice discussions largely ignore the core experience of doing the work. Little attention is given to where it is performed, and in particular, the practice of home visiting and the emotions and challenges of accessing children it gives rise to.” (Ferguson 2009xvi)   This case suggests that the support given to some health professionals does not sufficiently recognise the emotional toll of working with challenging behaviour, and the subsequent impact on relationships with particular families, and practitioners’ morale more generally. This can have an adverse impact on staff’s working relationships with families, and leave them feeling vulnerable and demoralised.  How did it manifest in this case? In this case the documentation provided by the Review Team and information from some of the conversations showed that there was a high degree of challenge and ’hectoring’ behaviour from the family but in particular the man within the family.  Whilst Baby H was being cared for on the NICU, FH displayed challenging behaviour towards members of staff on the ward. This behaviour pattern manifested on one occasion as a series of around 30 calls made by FH to challenge the ward’s decision that Baby H was not yet ready to be discharged. This behaviour had a negative impact on the ability of staff to work with the family: a referral was made to children’s social care, but MH and FH were not informed due to staff fears that this would lead to an aggressive response from FH.  The health visitor who worked with the family after Baby H was discharged also reported finding FH’s behaviour challenging and intimidating. FH was present ‘in the background’ at all visits, was verbally aggressive to the health visitor when she attempted to speak to one of the older children, and seemed to ‘undermine all information and advice given’. The health visitor undertook visits to the house with a colleague, because of her anxiety about visiting the home.  33   The review heard from some Case Group workers from NEL that this behaviour impacted upon practice as it inhibited meaningful, child centred discussion between the professional and the parent. This led to the professional feeling overwhelmed, anxious and fearful.  Within health visiting there was information from the caseworker that she felt anxious in respect to working with safeguarding families this was because she was ‘newly qualified’. The caseworker had been working within the health visiting Provision for over a year when the incident took place.   The health staff in this case were supervised and supported in line with their usual arrangements, and there is evidence that the health visitor had safeguarding supervision in respect to the case, in line with Children Health Provision Safeguarding Children Supervision Protocol. However, both NICU staff and the health visitor felt insufficiently supported to deal with the challenging behaviour presented by FH. This was particularly the case for the health visitor, who was visiting the family in their home, which left her feeling anxious and vulnerable.  How do you know it is underlying? Discussions with the Review Team and Case Group suggested that the support given to staff in this case was in line with normal procedures, and so the vulnerability felt by staff is unlikely to be a ‘quirk’ of this case.  From discussion with the Review Team it was apparent that in the ward setting of NICU such behaviour was seen as unusual. However there was acknowledgement that there was a lack of process to offer support to the practitioners or to escalate the matter.  With regard to health visiting, it was felt that encountering challenging behaviour in home visits was relatively common, and that the routine supervision and support provided to health visitors did not adequately recognise this. This may be in part due to changes to expectations on newly qualified health visitors.  Upon entering the role newly qualified health visitors have a period of preceptorship (minimum of 6 months) with a qualified health visitor (preceptor). Historically, newly qualified health visitors did not take any safeguarding cases for the first 6 months, giving them the opportunity to first gain expertise in universal working and families. This has now changed, and health visitors who have been qualified for less than 6 months are now also given safeguarding cases as part of their caseload.  Newly qualified health visitors were also expected to attend safeguarding children supervision every 3 months, which is in line with the expectation placed on those health visitors which have been qualified over a year. However, this case raises a question of whether this is adequate to support practitioners in dealing with challenging behaviour from families in which there are safeguarding concerns. 34    How widespread is the pattern? Working with challenging behaviour is a feature of work for all professionals dealing with families who may be in times of stress and crisis, which can be particularly the case in families where there are safeguarding concerns. The supervision and support arrangements for health visiting, including the changes to when safeguarding cases are added to caseloads, are based on national guidelines. It is therefore likely that the issues raised by this case may be present at a national level.   Although there is not yet research evidence to support this, it is interesting to note that the Institute of Health Visiting is currently conducting a ‘State of the Nation’ survey of health visitors, in which one of the areas explored is the adequacy of support and supervision arrangements.   How prevalent is the issue? Within the hospital setting there is only a view regarding the NICU. In this ward it was felt that instances of challenging behaviour are relatively rare. Therefore, any response to this issue would need to proportionate to incidence.  Regarding health visiting in the community, the review does not have statistics to show the prevalence of challenging behaviour, and of course different professionals may take a different view of the same situation. There is however evidence that resistant and aggressive behaviour is a feature in a number of Serious Case Reviews. Whilst this review has not worked to put a numerical value to the issue, Ferguson (2010xvii) offers some assistance: “We have failed to acknowledge the sheer scale of resistance and hostility that professionals have to bear”.  35   Why does it matter? Working in conditions in which they feel intimidated can leave professionals unable to undertake their professional role. The implications in the short term are that workers may struggle to form productive relationships with families, and may focus on their own emotional responses to the situation, and as such practice could suffer, rendering the safeguarding system less safe. Over the longer term, a lack of support to deal with challenging behaviour can exacerbate stress and burnout.  It is essential that management and supervisory arrangements in child protection cases facilitate authoritative practice, challenging and supporting the worker and ensuring overall managerial accountability.   Finding B: The provision of support for some health professionals in North East Lincolnshire, in relation to the emotional toll of working with challenging behaviour is not sufficiently embedded in organisations leaving some staff feeling vulnerable. (Family – Professional Interaction)  Staff who do not feel able and supported to deal with challenging behaviour from parents can struggle to establish productive relationships with families in the short term, and may suffer from anxiety and low morale in the longer term.  There are real dangers for practice if we do not recognise the impact of working with these types of pressures and provide staff with the appropriate support at all stages of their career.  Training programmes, supervisors and managers need to acknowledge the stresses of working with such cases and provide appropriate support and guidance.  • Has the LSCB previously considered this issue? • Does the LSCB have any additional data that would confirm or refute that this is an issue for staff and in what settings? • Does the LSCB know if staff locally has been equipped to work with resistant, aggressive or violent parents both in single agency and partnership working? • How might the LSCB help practitioners overcome this obstacle to effective practice? • Protocol changes has been introduced by the Named Nurse, (safeguarding children team NEL), as a result of the SCR. How might the board monitor the impact of this? • Are the principles of these documents transferable to other professions?   36   Finding C: In North East Lincolnshire the process of strategy meeting minute taking and appropriate information sharing is not as robust as it should be and falls below the standards of “Working Together” (Management Systems)  Strategy meetings are a key part of the child safeguarding system, and represent a key opportunity for agencies involved with young people to share information and determine potential risks. It is therefore highly important that the business of a strategy meeting is properly and accurately recorded. Discussions will take place, information shared and decisions made about how to progress a case to safeguard a child. Those matters must be recorded in an enduring form. Therefore minutes should be taken, circulated in a timely way and agreed for accuracy by the participants.   The minutes should record agreed actions and who is responsible, again accurate recording is vital so that the progress can be tracked. Action points will have been agreed with a view to assisting in the understanding of the child’s situation and to strengthen the safeguarding process. Therefore a failure to meet this standard renders the system less safe.  The importance of ensuring high standards of record keeping in relation to strategy meetings is reflected in both national and local guidance. This guidance further states that the responsibility for maintaining these standards should sit with children’s social care. The expected standards at the time of the case can be found in Working Together to Safeguard Children 2010 at paragraph 5.56 and onwards.   The North East Lincolnshire LSCB policies and procedures says at paragraph 3.82 “The strategy discussion should be convened and led by local authority children’s social care and those participating should be sufficiently senior and able, therefore, to contribute to the discussion of available information and to make decisions on behalf of their agencies. “and at 3.84 “…Any information shared, all decisions, should be clearly recorded using the appropriate forms.”  “Working Together” published in March 2013 does not alter this responsibility for social workers and their managers. This guidance states that ‘Social workers and their managers should... record agreed decisions in accordance with local recording procedures; and follow up actions to make sure what was agreed gets done’ (p. 34).  How did it manifest in this case? A strategy discussion took place following the removal of Baby H from hospital contrary to the medical advice, and was attended by representatives from social care, police and health. This meeting discussed MH’s reasons for removing Baby H from the ward, and agreed a number of subsequent actions. A police officer was responsible for chairing the meeting, and producing and distributing minutes. The subsequent distribution of minutes was not carried out in a timely way and there was no process to agree the accuracy of the minutes or to monitor the delivery of the agreed actions. 37   This process placed the lead with police; this is not in accordance with either version of Working Together or the local policy. Actions would be agreed but there did not seem to be any robust process to ensure that the recording reflected the discussion or to ensure delivery of actions.  In this case there was no evidence that the failure to check accuracy and distribute the minutes contributed to any negative outcome. In this instance, it appears that all parties carried out their agreed actions despite a lack of monitoring. However, this practice raised concerns for the Review Team about its potential impact on other cases.     How do you know it is underlying? The Review Team reported that a lack of agreed process for agreeing accuracy of minutes, and monitoring actions as outlined above, was the normal practice in the area at this time. The delegation of responsibility for administration and monitoring to staff from the police was also reported to have become normal practice at the time. This suggests that this practice was not unusual to this case, but is likely to have occurred in relation to all Strategy Meetings.   How widespread is the pattern? As this was the normal practice it pertains to all such meetings that were taking place in North East Lincolnshire.   Evidence from other Learning Together case reviews suggests that difficulties in relation to administration of key meetings in the child protection process are also being experienced elsewhere in the country.  How prevalent is the issue? The review has requested data on the number of Strategy Meetings that took place using this process, that is whenever there is reasonable cause to suspect that a child or young person is suffering, or is likely to suffer significant harm, there should be a strategy discussion involving Children's Social Care and the Police and other agencies as appropriate (e.g. Education and Health), in particular any referring agency, but this data has not been provided.  Between October 2012 and October 2013, 549 Section 47 enquiries were conducted in North East Lincolnshire (Source: Characteristics of children in need in England, 2012-2013, Department for Educationxviii). Given that strategy meetings are the first step before initiating a Section 47 investigation; this would suggest that at least 549 strategy meetings were held, as some result in decision not to conduct an enquiry. This means that a substantial number of cases are likely to be affected by poor record keeping and action monitoring in relation to strategy meetings.     38  Why does it matter? Strategy meetings are a highly important element of the child protection process, convened in response to serious concerns about a child. It is therefore essential that accurate records of discussions and actions are taken, distributed, and followed up. National guidance suggests that children’s social care is best positioned to undertake this role. Failure to comply with these standards suggests that key actions, which formed part of a plan to keep children safe, may not be completed.  The review found that there is a lack of clear process in relation to administration of strategy meetings in North East Lincolnshire. Actions would be agreed but there did not seem to be any robust process to ensure that the recording reflected the discussion or to ensure delivery of actions. In addition, responsibility for administration has come to be placed with police; this is not in accordance with either version of Working Together or the local policy.     Finding C: In North East Lincolnshire the process of strategy meeting conduct, minute taking and appropriate information sharing was not as robust as it should be and fell below the standards of “Working Together 2010” (Management systems)  A local process for strategy meetings had been adopted which was not in accordance with statutory guidance or local policy. It was apparent that this deviation had resulted in a process that fell below the standards expected in the guidance.  • Is the LSCB confident that statutory guidance and local policy is being complied with? • How are minutes checked for accuracy and progress of actions monitored? • Has the Multi-Agency Safeguarding Hub (MASH) addressed the issues identified? • Did the LSCB agree to this procedural deviation?  • Are there systems in place so that if a local variation of guidance seems to be suitable it is considered and agreed by the LSCB? • Is key information being consistently and accurately shared with partners?    39   Finding D: In North East Lincolnshire there is a reliance on personal relationships and knowledge to obtain services of partner agencies which creates a weakness within the safeguarding system. (Response to incidents)  Effective safeguarding requires clear local arrangements for collaboration between professionals and agencies (Working Together to Safeguard Children 2013). For our multi-agency protection system to be reliable, and work in all cases, arrangements for obtaining advice and input from other services need to be embedded within procedures and routine practice, rather than dependent on personal relationships between individual professionals.  This review has suggested a pattern whereby staff requiring input or advice from another service, for example specialist Child Abuse Investigation Team (CAIT), are not following procedures for contacting relevant members of staff, but are relying on personal relationships to gain the required input. This is not a reliable way of working, and can lead to undue reliance on particular staff members to deal with enquiries from other teams.  How did it manifest in this case? Following Baby H’s weekend admission to hospital, and diagnosis of a non-accidental head injury, an appropriate decision was taken to initiate a multi-agency Section 47 investigation. The hospital contacted social care services, who in turn required out-of-hours input from a specialist CAIT officer.  The social care staff member believed there to be a police call out list, but was unable to locate it. This staff member therefore called an officer known to him. Despite not being on duty at the time, this officer responded to the call, and the investigation proceeded in a timely manner.   This review has established that there is not a call-out list for contacting specialist CAIT officers. Instead, the established procedure is for members of staff to contact officers through the main Police switchboard. However, this was not known to the social care member of staff at the time.   In this case, the decision to contact a member of the CAIT team who was not on duty did not adversely affect the outcomes of the case. However, this occurrence raised questions about normal practice in these situations.   How do you know it is underlying? The CAIT officer involved confirmed that his receiving calls whilst off duty, as occurred in this case, was a common occurrence. Members of the Review Team also confirmed that they had believed there to be a call out list, and were unaware of the process for contacting specialist CAIT officers out of hours.  This suggests that this practice was not restricted to this particular case, but was likely to happen in other, similar cases. However, it is important to note 40  that the Review Team immediately sought clarity on the correct procedure, and have taken actions to ensure that this is followed in future.   How widespread is the pattern? No specific work on how widespread the issue is has been undertaken. However some of the Review Team confirmed that such reliance on personal relationships to obtain a service from specialists both within agency and across agencies existed in their service and area. This was the case not only when such service were needed out of hours but was also during core working hours. This was not the case across all service areas by either agency or local authority/LSCB. But had sufficient resonance with some of the Review Team that it was identified as an issue worthy of more exploration.  How prevalent is the issue? The evidence base is limited; however the CAIT officer who was a member of the Case Group confirmed that this was a very frequent occurrence for him as an individual, and that on most ‘off duty’ weekends he would take calls of some type. The Review Team gave examples of similar issues occurring in ‘in hours’ services. 41   Why does it matter? In order to safeguard children effectively, it is important that input and advice from relevant services, including specialist services is obtained in a reliable and timely way.   Reliance on personal relationships to obtain this input, rather than using established procedures, creates a weakness in the system such that it could cause delays in obtaining the help and advice needed. It also has the potential to put a disproportionate work load onto certain individuals, and disrupt their ability to carry out their normal duties, leading to ‘unplanned abstraction’ of particular individuals from their usual jobs.     Finding D: In North East Lincolnshire there was a reliance on personal relationships and knowledge to obtain services of partner agencies which creates a weakness within the safeguarding system. (Response to incidents)  For our multi-agency protection system to be reliable, and work in all cases, arrangements for obtaining advice and input from other services need to be embedded within procedures and routine practice. Agencies need to have in place robust systems of communicating details of on-call specialist practitioners to front-line practitioners.  By not following an agreed protocol to obtain out of hour’s services and specialist services in hours from partner agencies the system becomes weak with potential for delays. There is also a “knock on” to the agency concerned in that there is an unplanned abstraction from normal duties, can further weaken the system.  • Does the LSCB recognise this scenario as problematic? • Does the LSCB agree that this matters? • Is the LSCB satisfied that the arrangements between partner agencies for obtaining services of other agencies both in and out of normal hours are well understood and properly implemented and monitored? • The LSCB should note that the Review Team took action immediately in this instance.    42  CHAPTER 5 - AGENCY RESPONSES and LEARNING at the FRINGES During the course of the review some issues came to light that were addressed by the agency concerned. A record of these follows. Mental Capacity Act This review raised a question of the capacity of MH to make good judgements and decisions. This led to a discussion of the Mental Capacity Act 2005 and how well embedded it is in relation to the assessment of 16 and 17 year olds was considered in detail.  A member of the Review Team expressed the view that “the MCA 2005 is not robustly integrated or embedded across Lincolnshire’s services for children in practice, training, policy and procedure. Whilst there is abundant evidence that the children’s views and their competency (which for 16 and 17 yr olds is now replaced by capacity) are considered, the transition from implementation of the MCA in 2007 has not been robust across the country with adults (as per reason for the select committee) let alone 16 and 17 year olds who are covered by other acts and competency frameworks.”   The House of Lords has established a Select Committee on the Mental Capacity Act 2005. The terms of reference of the inquiry ask the Committee to “consider and report on the Mental Capacity Act 2005”. Evidence to date is suggesting wide spread non-compliance. However this is in relation to all ages and not specifically with regards to those who are 16 and17 years old.  The fact that a Select Committee has been established in the first instance, would suggest this is a National issue and it seems reasonable to suggest this is a matter for both LSCBs to consider further, that is likely to be the case once the Committee reports. Lincolnshire Community Health Services NHS Trust has raised awareness of MCA being considered and applied if appropriate to all 16 and17 year olds receiving care. It has been disseminated by Team Brief. This goes to all staff members and is described as a robust system and also through the Champions Network across all services. Lincolnshire Partnership NHS Foundation Trust have now commenced mandatory training for CAMHS staff entitled “competency and capacity” to ensure that children under 16 and those over 16 are assessed under the appropriate legislation and case law regarding decision making. Health Visitors and School Nurses Children’s Health Provision North East Lincolnshire Council has put in place two protocols since the commencement of the SCR.  The first is the Safeguarding Children Supervision Guidelines for newly qualified health visitors and school nurses, which also includes those school 43  nurses who have moved from a non-safeguarding caseload to a safeguarding caseload.  Within the protocol there is an expectation that newly qualified case holders receive supervision with their named supervisor from the safeguarding children team every 8 weeks, over the period of a year. The number of families the case holder is expected to hold within the first year is negotiable, but there is an expectation that they will hold some cases as soon as they qualify as a health visitor. This number is negotiable in conjunction with their Team Leader and their named safeguarding supervisor, and is always based on their skills and confidence. The protocol also stipulates that their named supervisor will ‘mentor’ them in respect to writing reports/ statements that are of a safeguarding nature. Within this year there is also a requirement for the case holder to attend two mandatory study days delivered by the safeguarding children team which aims to discuss assessment and analysis of safeguarding cases. Children’s Health Provision (NELC) has also embedded clinical supervision for all case holders which occurs every 3 months with their Team Leader. This is in addition to the PARD (Performance, Appraisal, Review, and Development) which they complete/review with their Team Leader twice a year.  The second protocol in place is the Process for the Transfer of Safeguarding Records within and outside the locality, which stipulates the accountability of the case holder when the child has ‘moved in or moved out’ of the area, and the standard expected of the case holder to ensure that liaison and communication occurs from the transferring case holder to the receiving case holder. It was also recognised that the sharing of CAMHS information from the GP within SystemOne needs to be consistent and a defined process developed and shared. This is an area of work which the Named Nurse and the Designated Nurse have arranged to work on. CAHMS presently do not use SystemOne so it can be unclear if the service is presently working with a child, therefore communication between all services is essential. It would be useful if the work being undertaken by the Designated and Named Nurse could give clarity and clear guidance that this communication process is efficient and workable, especially between CAHMS and Children Health Provision. Maternity services cross border transfer Although United Lincolnshire Hospitals (ULHT) NHS Trust maternity services had an informal process in place for the cross-border transfer of information for those families with whom there were safeguarding concerns (i.e. Midwives would verbally hand over concerns to the ongoing region's Named Midwife), this was not a documented process. As a result of this review, ULHT's Named Midwife has devised a formal process which incorporates the use of a 'handover proforma' which will be forwarded to the ongoing region's Midwifery 44  team (with a copy retained for the medical records); thus making the process more formal and robust. Northern Lincolnshire & Goole Hospitals NHS Trust (NLaG) is currently developing a transfer in / transfer out policy for maternity cases that book with the Trust. It is likely to be finalised in early 2014. Call out of staff The system for North East Lincolnshire out of hours Social Care contacting the Police has changed and now all calls go to the central Police number and work is allocated to the appropriate officer.  Humberside Police, who cover an area wider than NEL, are in the process of ensuring that all local authority Children’s Services  within the Humberside Police area are aware of the call out procedures in order to avoid unnecessary delay due to an over reliance on individual contacts who may not be available when off duty. Police recording of information about children The Humberside Police juvenile form only allows for the main subject and their parents/carers’ details and this was completed by the attending officers and submitted to the PPU for consideration. They are to review the form to include siblings and other children present at the address in order that consideration may be given to their welfare. This is an ongoing action by Humberside Police.  Strategy meetings The police were recording minutes of the multi agency strategy meetings despite being a participant of the meeting. This resulted in information being omitted from the minutes, which were not checked and confirmed as being accurate by all agencies. Since this has been identified as a potential risk, the Principle Social Worker, Children’s Services now record all strategy meeting minutes. A recent Audit by Police shows that there was a considerable gap in minutes being received by police and that no system was in place to agree accuracy or monitor the completion of agreed actions. 45  CHAPTER 6 - SUMMARY  A sound rationale existed for making the decision that this case should be reviewed and that a Serious Case Review was appropriate. There was a need to examine in detail multi-agency working and cross border working. The matters for specific examination are outlined in the report (page 13).  The review was approached with rigour and an open mind, although the fact that there is a review can tend to lead to a mind set that there must be significant problems to uncover. In fact the Review Team concluded that most of the practice that was explored was sound and of the expected standards.   The Review Team identified that the family had experienced a set of stressful events and situations in close proximity to the premature birth of Baby H. These included life events which are identified as being significant stressors, such as changes in residence, social circumstances and schools, pregnancy and financial issues (Holmes & Rahe (1967) Social Readjustment Rating Scale). In addition there was the trauma of a premature birth and the stressors that brings.  It is important that professionals working with a family at such a time of stress and change work with the family to identify the situation and its impact and therefore target support and intervention to reduce the impact of the stressors and increase the resilience of the family unit.  Working with children and families is complex and some areas were found where the system was weak and could be strengthened. These are addressed in the findings.  The assault on Baby H was unprecedented in the context of this family’s history. This dramatic event could not have been predicted by the professionals working with them.  By strengthening the multi- agency system we endeavour to make it easier for professionals to do the right thing in all cases. 46   Appendix 1. Findings and Questions – Summary  Finding A   A tendency for professionals not to consider mental health issues in the context of parenting capacity, means that a full understanding is not reached, and potential risks to children not identified  (Family – Professional interaction)  It is important to identify and support adults who are experiencing mental health problems who are parents or carers and ensure support is co-ordinated. Professionals working with adults need to be aware of their role as parents so that potential opportunities to identify risks to children are not missed.  • Has the LSCB  identified this as an issue previously and/or did the board do work around the Think Families agenda? • Is this agenda embedded in front line practice? • Are professionals equipped to recognise multiple vulnerabilities and compounding risk? • Does the LSCB  have access to data which would assist in assessing the prevalence of the issue?  Finding B  The provision of support for some health professionals in North East Lincolnshire, in relation to the emotional toll of working with challenging behaviour is not sufficiently embedded in organisations leaving some staff feeling vulnerable. (Family – Professional Interaction)  Staff who do not feel able and supported to deal with challenging behaviour from parents can struggle to establish productive relationships with families in the short term, and may suffer from anxiety and low morale in the longer term.  There are real dangers for practice if we do not recognise the impact of working with these types of pressures and provide staff with the appropriate support at all stages of their career.  Training programmes, supervisors and managers need to acknowledge the stresses of working with such cases and provide appropriate support and guidance.  • Has the LSCB previously considered this issue? • Does the LSCB have any additional data that would confirm or refute that this is an issue for staff and in what settings? • Does the LSCB know if staff locally has been equipped to work with resistant, aggressive or violent parents both in single agency and partnership working? 47  • How might the LSCB help practitioners overcome this obstacle to effective practice? • Protocol changes has been introduced by the Named Nurse, (safeguarding children team NEL), as a result of the SCR. How might the board monitor the impact of this? • Are the principles of these documents transferable to other professions? 48  Finding C   In North East Lincolnshire the process of strategy meeting conduct, minute taking and appropriate information sharing was not as robust as it should be and fell below the standards of “Working Together 2010” (Management systems)  A local process for strategy meetings had been adopted which was not in accordance with statutory guidance or local policy. It was apparent that this deviation had resulted in a process that fell below the standards expected in the guidance.  • Is the LSCB  confident that statutory guidance and local policy is being complied with? • How are minutes checked for accuracy and progress of actions monitored? • Has the Multi-Agency Safeguarding Hub (MASH) addressed the issues identified? • Did the LSCB  agree to this procedural deviation?  • Are there systems in place so that if a local variation of guidance seems to be suitable it is considered and agreed by the LSCB? • Is key information being consistently and accurately shared with partners?  Finding D: In North East Lincolnshire there was a reliance on personal relationships and knowledge to obtain services of partner agencies which creates a weakness within the safeguarding system. (Response to incidents)  For our multi-agency protection system to be reliable, and work in all cases, arrangements for obtaining advice and input from other services need to be embedded within procedures and routine practice. Agencies need to have in place robust systems of communicating details of on-call specialist practitioners to front-line practitioners.  By not following an agreed protocol to obtain out of hour’s services and specialist services in hours from partner agencies the system becomes weak with potential for delays. There is also a “knock on” to the agency concerned in that there is an unplanned abstraction from normal duties, can further weaken the system.  • Does the LSCB recognise this scenario as problematic? • Does the LSCB  agree that this matters? • Is the LSCB  satisfied that the arrangements between partner agencies for obtaining services of other agencies both in and out of normal hours are well understood and properly implemented and monitored? • The LSCB should note that the Review Team took action immediately in this instance. 49  References and Bibliography  i Working Together to Safeguard Children: a guide to interagency working to safeguard and promote the welfare of children. HM Government. March 2013.  ii Fish, S. Munro, E. Bairstow, S. (2008) Learning Together to Safeguard Children: developing a multi-agency systems approach for case reviews.  iii C A Vincent Analysis of clinical incidents :A window on the system not a search for root cause. London 2004  iv CPS, ACPO (2011) A guide for the Police the Crown Prosecution Service and Local Safeguarding Children Boards to assist with liaison and the exchange of information when there are simultaneous chapter 8 serious case reviews and criminal proceedings  vJudgments - R (on the application of G) (FC) (Appellant) v London Borough of Southwark (Respondents) http://www.publications.parliament.uk/pa/ld200809/ldjudgmt/jd090520/appg-1.htm  vi Shelter Children’s Legal Service briefing Responding to youth homelessness following the G v LB Southwark judgment http://www.shelter.org.uk/__data/assets/pdf_file/0005/231269/G_v_Southwark_briefing_revised_Nov_11.pdf  vii Lincolnshire Children’s services policy 1.1.10 Family and Friends Policy and 5.2.1 Homeless 16/17 year olds protocol.  viii Mental Capacity Act 2005 http://www.legislation.gov.uk/ukpga/2005/9/contents  ix Southend, Essex and Thurrock LSCB procedures. Essex 2011   x Department for Children, Schools and Families. 2009. Think Family Toolkit, Improving Support For Families at Risk, Strategic Overview. Department for Children, Schools and Families. 2009.  xi Social Care Institute for Excellence. Think child, Think parent, think family. London 2012.  xii Brandon, M et al, Department of Education, September 2011. xiii Tompsett, H., Ashworth, M., Atkins, C., Bell, L., Gallagher, A., Morgan, M., and Wainwright, P. The child, the family and the GP: Tensions and conflicts of interest in Safeguarding Children. DCSF Research Briefing. London: HMSO.  50                                                   xiv Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C., and Megson, M. (2012) New learning from serious case reviews: a two year report for 2009-2011. London: HMSO.   xv Mor Barak, M.E. et al. (2009) ‘The impact of supervision on worker outcomes: a metaanalysis’, Social Service Review, vol 83, no 1, pp 3−32.  xvi Ferguson, H. (2009) Child Protection Practice. Palgrave Macmillan Publishing.  xvii Ferguson. H (2010) Walks, Home Visits and Atmospheres: Risk and the Everyday Practices and Mobilities of Social Work and Child Protection. British Journal of Social Work  xvii https://www.gov.uk/government/publications/characteristics-of-children-in-need-in-england-2012-to-2013   See also:  Social Care Institute for Excellence. Mental Capacity Act 2005. At a Glance 05. London 2010.  Nursing Times.Net. A guide to Risk Assessment. 2003.  Lincolnshire JSNA. Teenage Pregnancy. Lincolnshire County Council. 2011  Ash Villa. LPFT.NHS.UK  Dekker, S . A Filed Guide to Understanding Human Error. Ashgate publishing Ltd. Farnham. 2010  Munro, E. The Munro review of child protection: final report: A child centred system. London TSO, 2011                 51                                                                                                                                               Addendum to overview report Contribution to SCR from the parents of Baby H  Both parents of Baby H were invited to meet with members of the SCR Review Team, so that they could contribute to the process and contribute their experiences to the learning from this case.  Baby H’s mother didn’t take up the invitations which were sent to her, despite several attempts by the Review Team to engage with her.  On 22 April 2014, two members of the SCR review team met with the father of Baby H (referred to in the overview report as FH). It should be noted that FH has not been convicted of any offence against Baby H.  The purpose of this meeting was to create an opportunity for FH to share his views about the kind of support which was offered to his family, prior to the head injury to Baby H and whether the subsequent assault on his daughter could have been predicted or avoided. This was also an opportunity for FH to contribute any learning from his family’s experience, which could strengthen child protection processes.  This was a difficult meeting for FH, who was unable to accept that the serious case review was an independent process. His main concern was his separation from his children, including Baby H, which he described as unjust and very painful to him.  FH identified specific professionals who he felt had been particularly helpful and respectful. This included the health professionals who responded to Baby H’s serious injuries and he felt that she owed her life to them. He also acknowledged the police officer who came to arrest him when the children were initially removed, following Baby H’s injury. The officer concerned had removed the handcuffs from FH and allowed him to hug his children goodbye and then to have a cigarette before being taken to the police station. These gestures were appreciated by FH.  In broader terms, FH described having greater respect for older professionals whom he believed had more life experience to bring to the role. He described a low opinion of younger professionals, and particularly any who he believed weren’t parents themselves.  FH explained that he had challenged professionals in some meetings, alleging that they were “no better” than him. FH spoke of his need to feel respected by professionals dealing with him, if he was to reciprocate with mutual respect.   FH questioned whether his cultural background, from a traveller heritage, had influenced the way in which services had treated him. He believed that he may have been treated more negatively because of this. 52                                                                                                                                               With regard to strengthening the child protection system, FH described the need for professionals to have training about the impact of mental health issues on parents. Indeed, FH suggested that he himself had been unaware of the impact of his wife’s mental health issues on her capacity to parent safely.  In terms of the assault and subsequent brain injury to Baby H, FH described not knowing what could have been done to prevent this, including any intervention from agencies.     53                                                                                                                                                   Lincolnshire Safeguarding Children Board  Response to SCR H                                  1  This serious case review concerns a non-accidental head injury, resulting in a life changing brain injury, sustained by a three month old baby born prematurely in North East Lincolnshire.  The case was considered by North East Lincolnshire Safeguarding Board (NELSCB) and their independent Chair concluded that the most appropriate response to the case was to conduct a Serious Case Review.  The methodology used by North East Lincolnshire was the SCIE learning together systems model.  This approach endeavours to understand professional practice in context, identifying the factors in the system that influenced the nature and quality of work with families.  As the family had previously lived in Lincolnshire it was important for Lincolnshire Safeguarding Children Board (LSCB) to work closely with North East Lincolnshire's Board and contribute to the review.  NELSCB concluded the review in April 2014 and the final report was thereafter presented to Lincolnshire Safeguarding Children Board on 22 May 2014 when the relevant findings to Lincolnshire were accepted.  Whilst only Finding 1 was found relevant to Lincolnshire practice, Lincolnshire SCB has taken the opportunity below to respond to the other three findings of the review to explain how these issues are addressed in our area.  An action plan has been developed which is based on the findings of the review and the relevant action and learning from the case will be monitored by LSCB through to completion.  Finding (1)  A tendency for professionals not to consider mental health issues in the context of parenting capacity, means that a full understanding is not reached, and potential risks to children not identified  Although this finding was not attributed directly to practice in Lincolnshire, the LSCB acknowledge it is important to identify and support adults who are experiencing mental health problems who are parents or carers and ensure support is co-ordinated.  Professionals working with adults need to be aware of their role as parents so that potential opportunities to identify risks to children are not missed.  All Lincolnshire agencies involved in this review have established single and multi-agency training and policies and procedures which identify mental health issues in the context of parenting capacity.  The LSCB Section 11 audit and external moderation provides audit information on this issue.  The LSCB has an established framework for multi-agency audit and accordingly an audit on this issue will form part of that annual audit programme to ensure continuing assurance to the LSCB.   2  Finding (2)  The provision of support for some health professionals in North East Lincolnshire (Lincolnshire) in relation to the emotional toll of working with challenging behaviour is not sufficiently embedded in organisations leaving some staff feeling vulnerable.   Whilst this finding was not applicable to practice in Lincolnshire and was not experienced in this case by Lincolnshire practitioners as a general principle, LSCB recognise staff who do not feel able and supported to deal with challenging behaviour from parents can struggle to establish productive relationships with families in the short term, and may suffer from anxiety and low morale in the longer term.  There are real dangers for practice if we do not recognise the impact of working with these types of pressures and provide staff with the appropriate support at all stages of their career.  Training programmes, supervisors and managers need to acknowledge the stresses of working with such cases and provide appropriate support and guidance.  In Lincolnshire the issue of working with hostile and challenging families featured in a previous serious case review and has resulted in the role out of continual  LSCB training, and the development of a  policy around working with difficult to engage families.    Finding (3)  In North East Lincolnshire the process of strategy meeting conduct, minute taking and appropriate information sharing was not as robust as it should be and fell below the standards of “Working Together 2010”   This Finding was not applicable to practice in Lincolnshire.  In Lincolnshire there are clear (Lincolnshire) LSCB policies and procedures including business processes around Strategy Discussions which are adhered to.  As the lead Child Protection Agency,  Audits are completed on a quarterly bases by Lincolnshire Children's Services reviewing the quality and consistency of strategy discussions.  There are regular meetings of core LSCB members reviewing the strategy discussion processes and how they are working for the staff and partners in Lincolnshire.  All agencies are aware of the requirement to actively engage in Strategy Discussions and good engagement is demonstrated.          3   Finding (4)  In North East Lincolnshire there was a reliance on personal relationships and knowledge to obtain services of partner agencies which creates a weakness within the safeguarding system.   This Finding was not applicable to practice in Lincolnshire.  Lincolnshire Safeguarding Children Board is satisfied that the arrangements between partner agencies for obtaining services of other agencies both in and out of normal hours are in place and are effective.   All agencies have robust working relationships with their partners and are clear about their roles and responsibilities.  This has been tested and verified by regulatory inspection.  The LSCB has an escalation policy in place which can be invoked should any partner agency have concern about the level of response of another partner. 4  