Death of an infant girl in 2020 found to be an accident, linked to an unplanned unsafe sleeping environment. Ruby was on a child protection plan due to risk of neglect when she died. Learning focuses on: awareness of a parent's history; considering and involving fathers; assessing wider family members who play a key role in supporting or safeguarding a child; sharing concerns about the impact on a child of changes of circumstances; the impact of alcohol and substance misuse on children and unborn babies; safer sleeping advice; using virtual technology for key meetings; strengths based models of assessment and planning; avoiding over-optimism and losing focus on the child; knowledge of multi-agency safeguarding procedures and professional confidence in challenging when they are not followed. Recommendations include: promote the involvement of fathers; ensure that the implementation of sleep assessments includes bespoke explicit and detailed safer sleep advice, including an explanation of why vulnerable babies are more at risk of sudden unexpected death in infancy (SUDI); ensure that key meetings such as child protection conferences being held by video conference or telephone have the optimum involvement of parents; ensure that professionals have the knowledge and confidence to challenge other agencies, including the use of escalation policies; consider how to ensure that accurate information about medication being prescribed to a pregnant woman is available to all health professionals working with the family.
      
    Serious Case Review No: 2022/C9248  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.   1    Child Safeguarding Practice Review Ruby REVIEW REPORT             Contents 1 Introduction and summary of the learning Page 1 2 Process Page 1 3 The child being considered Page 2 4 Learning identified Page 2 5 Conclusion and recommendations Page 16  1     Introduction and summary of the learning from this review1 1.1 This Child Safeguarding Practice Review (CSPR) was undertaken in order to find learning through considering practice and systems with the family of a young baby who died in 2020. The child will be referred to as Ruby2.  An inquest3 found that Ruby’s death was accidental.  Ruby was on a Child Protection Plan (CPP) due to risk of neglect when she died.   1.2 Learning was identified in the following areas by considering this case:   Awareness of a parent’s history    Considering and involving fathers   Assessing wider family members who play a key role in supporting or safeguarding a child   Sharing concerns about the impact on a child of changes of circumstances    The impact of alcohol and substance misuse on children and unborn babies   Safer sleeping advice   Using virtual technology for key meetings   Strengths based models of assessment and planning   Avoiding over-optimism and losing focus on the child   Knowledge of multi-agency safeguarding procedures and professional confidence in challenging when they are not followed   1 It was agreed to remove any indicator of the area where Ruby lived. However the learning will be widely disseminated locally.  2 The name Ruby was chosen by the Partnership to provide anonymity for the child and family. The family support this choice.  3 A parallel police investigation was undertaken in regard to Ruby’s death. No further action is being taken.   2   2       Process  2.1  It was agreed that the review would be undertaken using the Significant Incident Learning Process (SILP) methodology, which engages frontline staff and their managers who were involved in the case being considered, avoids hindsight bias or individual blame, identifies opportunities for improvement within systems for safeguarding children and promotes good practice. An independent lead reviewer was commissioned to undertake the review4. Due to Covid-19, engagement with professionals was via video technology.  2.2  The lead reviewer spoke to Ruby’s mother who was supported by her mother, Ruby’s maternal grandmother (MGM). The learning identified from this engagement is included in the report where relevant.  There was no involvement with Ruby’s father during the pregnancy or after her birth.  Her mother identified him following Ruby’s death. He has been informed of the learning from the review. The man who was thought to be the sibling’s father at the time did not engage with the review.  3       The child being considered  3.1 Ruby was vulnerable due to her mother’s history of serious mental health difficulties and domestic abuse in her relationship with the man thought to be her older child’s father5. Ruby’s mother had been known to services as a teenager due to family relationships, substance misuse and what we can now see was a risk to her of abuse through exploitation. When Ruby’s sibling was born, a child in need plan was made. The concerns were largely in regard to domestic abuse between the sibling’s parents, emerging parental substance misuse concerns and the potential for a relapse in the mother’s mental health.  3.3 During the pregnancy with Ruby, a child and family assessment was undertaken by CSC. There were a number of concerns at the time after the mother left her mother’s home with her child and accepted a tenancy in another town where she had no family support. There were potential risks from new acquaintances of the mother, on one occasion the sibling was found alone on the street and was taken into police protection6. There were a number of missed appointments and allegations of mother’s increasing alcohol7 and substance use. Both unborn Ruby and her sibling were made the subject of Child Protection Plans.  4 Learning  4.1 The review has identified learning following consideration of the following areas of practice that were identified during the rapid review process, highlighted within the agency reports, discussed at the learning events and from speaking to family members.  Areas of learning  Knowing the history Child’s lived experience Impact of Covid-19 Professional challenge of self and others     4 Nicki Pettitt is an experienced safeguarding professional and lead reviewer who is entirely independent of the Partnership and all agencies  5 Following Ruby’s death it was established that he was not the father.   6 The Children Act 1989 section 46 empowers a police officer to remove a child to suitable accommodation or prevent the removal of a child from a hospital or other place in which that child is being accommodated. When these powers are exercised, the child is considered to be in police protection  7 Problematic alcohol use is evident. There does not appear to be a clear pattern of use however which had an impact on the assessment of this by those involved at the time  3         Knowing the history  4.2 A large number of case reviews completed in recent years have highlighted the importance of considering, understanding and sharing details of a parent’s history if it may have an impact on the care of their child. It is known that when children and young people are subjected to difficult experiences, it can have an effect both at the time and when they become parents themselves. Research into Adverse Childhood Experiences (ACEs) states that the more additional ACEs a child experiences and the longer they experience them for, the worse their physical, mental and social outcomes are likely to be. This includes the possibility that their own children will be known to safeguarding services, and that their longer-term mental health will be adversely impacted8. In respect of Ruby’s mother, there was good awareness across agencies of her significant mental health history and other more recent and current vulnerabilities.  4.3 During the pregnancy with Ruby’s older sibling it was apparent that the relationship between the baby’s parents was abusive. The sibling spent time on a child in need plan, which Mother largely cooperated with. The plan closed when the couple’s relationship ended, and although there were concerns in the year that followed these were not felt to meet the threshold for CSC involvement. It appears however that these concerns were not considered together but as individual incidents, meaning they did not meet the recognised threshold. Had they been considered together, along with the known history, there may have been the need for a social work assessment. The national Safeguarding Practice Review Panel’s Annual Report published in May 20219 states that ‘the recognition of cumulative neglect and its impact continues to be a key challenge for practitioners’ nationally. The fact that the mother and child were living with the maternal grandmother was also seen as a protective factor for Ruby’s sibling. When the mother left the grandmother’s home where the family had been living, and secured a tenancy in a different town, concerns for Ruby’s sibling, and then unborn Ruby, began to escalate.   4.4  Those professionals who know Mother well described her as naive and trusting. She was also said to be impulsive. Her move, early in the first Covid-19 lockdown, was not well planned and was advised against by her family and the professionals involved. The move led to a number of changes of professionals, including the family GP, health visitor, community and hospital midwifery care and mental health professionals. The mother told the review that this was particularly difficult for her. The review found evidence of good information sharing at the time of the move, including verbal handovers that highlighted current concerns and the background to the case. The exception to this was due to Mother not immediately registering with a new GP. When she did it took a significant amount of time for the records to transfer, with the new GP not actually receiving the family records until after Ruby died. There is no evidence that any other professional informed the GP of the family history.  4.5  Delays in receiving GP records are an issue across the area and have been highlighted in other case reviews nationally. The GP surgery that the mother and Ruby’s sibling registered with asked Mother to fill out a new patient information form. While a good starting point, this relies on the parent providing accurate and honest information, and the right questions being asked. The review has found that the form completed in this case was not the most up-to-date version and did not include a question about whether there was social work involvement with the family. This question was relatively recently introduced onto the form in the area to provide   8 For some adults who have experienced ACEs, there may be protective factors and individual levels of resilience so negative outcomes should not be assumed. However they always need to be considered on a case by case basis.    9https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/984767/The_Child_Safeguarding_Annual_Report_2020.pdf  4  an indicator to the GP surgery about whether they needed to prioritise information seeking about a family newly registered at their surgery. Work has since been undertaken to ensure the GP surgery involved are using the correct form and discussions are underway about the requirement that they have an administrator with specific responsibility for safeguarding.  4.6  There is little doubt that many of those working with them knew the maternal family well. There was an admirable commitment to ensuring that Ruby’s mother was not labelled by her history, but a recognition that she required support (from family members and potentially professionals) to enable her to positively parent her children. Mother told the review that she had excellent support from a number of professionals, including the children’s social worker. Less was known by professionals about the relevant males. Ruby’s mother had separated from the man she believed was the father of the sibling by the time she became pregnant with Ruby, but he had on-going involvement due to his contact with his child and what appears to be a degree of mutual dependency between them.  Private law proceedings in respect of the sibling had been instigated by the mother around the time of her move, as she wanted to ensure that there was a clear plan for contact, which had not always been the case. The police and CSC were occasionally involved due to allegations made by both parents about the other one’s care of the child, on-going domestic abuse and contact disputes. The social worker told the review she was unsuccessful in her attempts to engage with the sibling’s father, this is disputed by the father. There was limited involvement with him in the assessments and plans. The social worker remembers inviting him verbally to meetings and that he chose not to attend. This was not recorded, and it appears no letter or formal invitations were sent other than to the Initial Child Protection Conference, which he did not attend.   4.7  For family members who do not engage, putting information in writing can be helpful. The man thought to be the sibling’s father claimed that his mother was supportive, but reportedly he resisted her being approached by professionals. This appears to have been accepted by professionals as a lack of interest by him in his child’s care, and it seems that his intimidating behaviour to them and reportedly to Ruby’s mother also had an impact. His probation officer shared with the review that he told her that he was very concerned about his child however and that she made contact with children’s social care about this, requesting that his concerns were robustly explored. Reportedly as the concerns about her care of the sibling were denied by the mother, no further action was taken. The probation officer did not use the escalation policy to challenge this, as she was not aware that this was a possibility. The other agencies involved tend to rely on CSC to make contact with fathers who do not live with the child, and there was no evidence of any challenge about the lack of involvement from Ruby’s sibling’s father, even when she was on a CP plan and core group meetings were being held. A recommendation has been made to ensure that all professionals take responsibility to both involve fathers and challenge their colleagues if there is no involvement, even when this seems to be complex or difficult.  4.8  Professionals were not confident about who the father of Ruby was. Mother said that she was not sure and that she was reluctant to find out – stating that her experience with the sibling’s father had made her wary of further contact disputes. She did give a name to a number of professionals, including the midwife, but was very clear they were not in a relationship and that she had no on-going contact with the man in question. This was accepted by those involved and mother’s wishes were respected.  Ruby’s mother experienced domestic abuse both in her childhood and in her past relationship/s, and the professionals working with her were aware of this. It is right that professionals are sensitive to this issue and respectful of the mother’s wishes regarding information sharing with partners/ex-partners. The World Health Organisation states that medical professionals must guarantee security and confidentiality to 5  women who may be subjected to domestic abuse10, and this is established practice in the UK. Those involved with Ruby’s mother during her pregnancy did not feel that it would be appropriate to pressurise her to disclose who the father was or might be. This does pose a dilemma to professionals however, who would want to involve a child’s father in assessments and plans and key meetings such as child protections conferences.  4.9 It was clear that Ruby’s mother had a lot of support from her family, but that she wished to be more independent and less reliant on them. There was professional concern about how she would cope as a single mother of two young children, as her mood was ‘low’ and she was known to be isolated in her new home, particularly during the Covid-19 lockdown.  Due to her history of mental health concerns Ruby’s mother was on antidepressants and anti-psychotic medication11. It is believed that she stopped taking the antidepressants after the pregnancy with Ruby was confirmed. The review has identified however that there was not a clear overview of what medication Ruby’s mother was prescribed or taking, other than from her self-report. This appears to be a systemic issue that needs further exploration.  Both the GP and the psychiatrist were prescribing to Ruby’s mother, and it would have been helpful if there had been a review of this when Ruby’s mother was referred for obstetric care and to the substance use and domestic abuse midwives. Ongoing mental health support was provided and this continued following her move. Although she was considered to be mentally well in recent years, it is good practice that at the time of a new pregnancy that this support remained in place. 4.10 As well as considering the history of the parents, it is important that professionals consider any known predisposing risks from wider family members who have caring responsibilities for a child. MGM was a critical part of the plan following Ruby’s birth, with the expectation that she, along with other maternal family members, would provide support and monitor the mother’s mental health for four weeks. The review has found this was not straightforward and that there were some concerns shared at the time about this support and the wider family’s own issues.  Learning:  There remains a need in the area for professionals to consistently consider and apply the impact of cumulative harm and a parent’s own history to the current situation.   Father’s should not be missed or an after-thought – at every meeting father’s need to be considered as a potential risk or protective factor to a child. The wider paternal family should also be considered as well as the maternal side. All professionals have a responsibility to engage with fathers or question any apparent lack of engagement from other agencies. This includes putting key information in writing.     If an expectant mother is taking prescribed medication from her GP and a psychiatrist, it is good practice to seek permission to speak to the prescribers.   When relying on the support provided by wider family members to reduce any risk to a child, it is important to make checks and assess their suitability for the role.    Child’s lived experience 4.11 When there is a parent who is vulnerable, as Ruby’s mother was, it can be difficult to vigilantly consider the child’s lived experience while providing support and advice to the parent.  Mother’s own needs could dominate conversations with and between professionals. An awareness of and focus on the risks to the child from the parent’s vulnerabilities is essential.  In  10   https://www.who.int/news-room/fact-sheets/detail/violence-against-women  11 Aripiprazole and Sertraline 6  this case there were concerns about the impact on the children of maternal mental health, drug and alcohol use and domestic abuse. Along with this there were the added risks of a move to a new area where there was no support from family and a need for new professional involvements. This was particularly concerning during a pandemic where a number of services were not actively providing support such as play settings and group family support.  4.12 Ruby’s sibling was also spending time with the man thought to be her father, yet very little was known about him or her life experience when staying with him. The focus of professionals, including when considering if a child protection plan was required at the ICPC, was on Ruby’s mother’s care. Ruby’s sibling had lived for much of her life with her MGM along with her mother. In March 2020, her mother’s decision for them to move out and get a flat would have been a big change for the child. Although her mother stated that difficult tensions in the home were making it untenable for them to remain living with extended family, this would still have been a big adjustment for Ruby’s sibling, who was used to living with a number of adults. There were benefits to Ruby’s sibling and mother from living with MGM, which included support with child care and financial support. MGM was also able to facilitate contact between Ruby’s sibling and their father.  The move placed more responsibility on Ruby’s mother to care for herself and her child, and coincided with her pregnancy. Although the distance between her previous home with MGM and her new property was not excessive, the public transport available was slow and limited. The plan was mostly based around family members travelling to the new home however as this was thought to best meet Ruby’s siblings needs.  4.13 Following Ruby’s mother’s move with sibling to their new home in another town, there were increasing concerns about the company that mother was keeping. Information was shared that she appeared to be allowing her accommodation to be used by people who were drinking and taking drugs. Home visits by a number of professionals, including the police, described men asleep or ‘passed out’ in the living area. Despite this, the mother was always described as sober and able to care for Ruby’s sibling.  Ruby’s mother had a history of being exploited when younger and those who knew her believed she would struggle to say no to those who wished to use her in this way. Ruby’s mother told the review that her child was not at risk and that any visitors only came after the child had gone to bed.  4.14 Not long after the move there was police involvement due to a domestic abuse incident between Ruby’s sibling’s parents. Both made allegations of assault against the other, and police officers were concerned about mother’s demeanour – describing her as erratic and extremely distressed. She said that she was not taking her medication due to her pregnancy and this was understood to be the reason for her behaviour. Due to these concerns it was agreed by the police that Ruby’s sibling remain in her father’s care that day, as her mother was felt not to be able to look after herself and certainly not a two year old. The police informed the Safeguarding HUB, the IDVA service (as the DASH was medium risk) and an email was sent to the midwifery service, the health visitor and to a named social worker who was listed on the system, despite it not being allocated at the time. No further action was taken by the Safeguarding HUB following the police referral. However a later referral was received from Victim Support about the same incident, sharing concerning allegations made by Ruby’s mother about physical assaults from Ruby’s sibling’s father. A worker from the safeguarding HUB had spoken to Ruby’s mother and suggested a Child and Family (C&F) Assessment be undertaken by a social worker but she declined to give consent for this, only agreeing to an early help assessment.  4.15 This was the second time that Ruby’s mother had refused a C&F assessment in as many months. It does not appear that the HUB considered all other known history when agreeing 7  that early help was appropriate at this stage.  This incident, combined with the known concerns, met the threshold for a child protection response for Ruby’s sister, who had been present at the time of the domestic abuse. Ruby’s mother wanted her community midwife to lead on the early help support. The planned ‘team around the family’ included mother’s mental health nurse and Ruby’s sibling’s health visitor, as well as mother and MGM. There was a plan to involve Family Action & the area Family Support, but the response to COVID 19 limited what was available.  4.16 All assessments and meetings in regard to early help plans at the time had to be held virtually and this had an impact on their effectiveness.  The community midwife in this case contacted the HUB with concerns about the recommended early help plan, particularly with the limited opportunities for face to face contact at the time. The HUB advised that either the midwife or mother refer again if concerns increased.  4.17 There is evidence that Ruby’s mother was exploited financially by at least one of her new associates and there were concerns shared that Ruby’s mother was drinking and using drugs. Professionals reflected that Ruby’s mother was sometimes ‘out of her depth’ when having to deal with difficult situations. An example of this was when she allowed a friend and her children to stay at her accommodation. The friend was escaping domestic abuse and her children were open to children’s social care in another area. There was no evidence of the professionals involved with the other family considering the impact on Ruby’s sibling of these guests. In fact there was a safety plan in place for these children that supported the move. There was also no communication with Ruby’s sibling’s allocated social worker, who only found out about the plan on a home visit.  At the time there should have been robust planning for all of the children in the home that considered the impact on them all of Ruby’s mother’s decision to provide refuge to her friend. The impact on the child/ren of inappropriate visitors and guests in their home needs to be considered, shared and part of planning, particularly where drug and alcohol abuse features, as it did in this case.   4.18 An incident where Ruby’s sibling was taken into police protection following her being found alone on the street in May 2020 should have indicated worries for her care and supervision however.  (This incident is considered further below.) The observed warm relationship between Ruby’s sibling and her mother led those who knew them to underestimate the impact on the child of the house guests as well as Ruby’s mother’s vulnerability.  4.19 It was in August 2020 that Ruby’s mother was seen at the hospital and was described by staff as unkempt, disinhibited and behaving erratically. When interviewed she stated that she was drinking around half a litre of vodka plus wine and cider on a daily basis with the friend who was living with her temporarily. It emerged during the review that those involved at the time did not entirely believe that this was actually the case, but there is no evidence that this disbelief was explored with mother or that they had any idea why she would lie about something as serious as this. It was not until the care proceedings on Ruby’s sister following Ruby’s death that hair strand testing was undertaken, which confirmed long term drug and alcohol use, but not at the time of the child’s death.  At the time of the hospital presentation a breathalyser was negative and mother refused a blood test for drugs. Although she later informed the substance use midwife that she had used cocaine and cannabis once during the pregnancy. At the time it appears there was no consensus amongst the professionals involved regarding what levels of alcohol and drug misuse were suspected.  4.20 The response to mother’s disclosure was a child protection conference in respect of unborn Ruby and her sister, as there was recognition that both children would be at risk of neglect due to the vulnerability of Ruby’s mother, her risky associates and friends, her chaotic 8  presentation and behaviours, the isolation resulting from having moved away from her support network and her reported heavy drinking. This was a good decision and application of thresholds. A funded nursery place for the sibling and a referral to substance misuse service, a substance misuse service, were part of the plan following the conference.  A core group was formed and was responsible for the plan. There was a lot of evidence to suggest that alcohol use was an ongoing issue for the mother throughout her pregnancy with Ruby.  This is not reflected as a significant issue in either of the Child and Family assessments completed or in the Child Protection Plan following the ICPC in September 2020 however. This was likely due to optimism from those involved about mother’s ’honesty,’ the fact that she had not been seen under the influence of alcohol, and her reported determination to stop drinking. However the involvement of the substance misuse midwife was positive and they provided both challenge and support to Ruby’s mother.   4.21 Following Ruby’s death there was a rapid post-mortem. There were however delays in the initial toxicology testing, due to Covid-19. This led to the issue being taken to the GOLD group12 to fast track the tests - due to the need to have information to effectively protect Ruby’s sibling and to limit the impact of the delays.  A further round of toxicology was then required to consider the impact of the prescribed medication that Ruby’s mother was taking at the time. In the meantime the on-going safeguarding of the sibling was being considered and there was challenge from partner agencies in respect of this.  Learning:   Any change of circumstances or sharing of concerns must consider, first and foremost, the impact on the child. Professionals need to balance supporting a vulnerable parent with clear child focused challenge about the potential for a negative impact on the child.    Professionals need to be clear about the impact of chaotic alcohol and substance misuse on children and unborn babies, including on the parent/carers ability to protect their child from harm.    Consideration should always be given to who is in the family home when considering a child’s lived experience. Even if the parent is thought to not be using drugs or alcohol, if the parent allows the home to be used for drinking and drug taking it is a child protection matter.      Impact of Covid-19  4.22 It was the view of the rapid review meeting that was held shortly after Ruby’s death that there was no evidence to suggest that the Covid-19 pandemic directly caused or contributed to the tragedy, although it was acknowledged that it did exacerbate some of the issues faced by this family and the professionals involved. This CSPR has also found this. All agencies needed to adapt their practice swiftly to ensure that they were able to provide services to all vulnerable families, including Ruby’s. The pandemic undoubtedly had an impact on the engagement of professionals with the family, on the ability of some services to make complete assessments rather than basing them on self-reporting, on the need to reinforce case specific advice regarding issues like safer sleeping whilst ensuring Covid-19 safe practice for staff and service users alike.     4.23 The second national review commissioned by the Child Safeguarding Practice Review Panel and published in 202013 states that infants dying suddenly and unexpectedly represents one of  12 A Gold Group can advise, guide or otherwise support the management of an effective response to an identified incident, crime or other matter and is chaired by a senior police officer. It is positive that in this case the toxicology was fast tracked.   13 Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm. 2020  9  the largest groups of cases notified to the panel.  In light of this, engaging with parents about safer sleeping and safer handling is important both before a child is born and afterwards.  Unsafe sleeping environments are one of the infant care factors most commonly associated with Sudden Unexpected Death in Infancy (SUDI)14  along with co-sleeping on a sofa or in a bed, including after drinking alcohol and/or taking drugs15, and co-sleeping with babies who are premature or low birth weight and where there was poor antenatal care and where there was use of alcohol or drugs during pregnancy is a greater risk.  The last point is particularly important in this case.   4.24 Provision of advice regarding safer sleeping is provided verbally and in written form (e.g. a leaflet) at key points during antenatal and postnatal care and is expected practice nationally. It isn’t straightforward however. The Lullaby Trust state that ‘for some in more vulnerable situations, additional support in understanding and implementing safer sleep practices is required.’ The Serious Case Reviews that were considered in the Child Safeguarding Practice Review Panel’s report suggested that largely parents do not find the interactions with professionals about safer sleeping meaningful and that they tend to think that the goal is to follow the advice most of the time, rather than always. The report concludes that a more sophisticated multi-agency practice model (“prevent and protect”) is needed to support families living in challenging circumstances to ‘understand the reasons behind the safe sleeping advice and anticipate reasons why this might not always be easy to follow consistently.’  This was likely to have been required by Ruby’s mother, even as an experienced parent. The challenge of managing two children alone added to the potential risks, along with mother’s drinking during the pregnancy. There is evidence that safe sleeping advice was given was in the hospital and that the community midwife discussed safe sleeping with Ruby’s mother twice postnatally, including on her first home visit to Ruby where she saw two Moses baskets that were for the baby to sleep in.  The social worker also observed the sleeping arrangements.   4.25 The Lullaby Trust published a recent survey in March 2021 which showed ‘a concerning indication that lockdown restrictions combined with the increased pressure placed on public health services by Covid-19, means less support and information for new parents, which is putting babies at risk.’ In Ruby’s case there was a lot to consider in the days following her birth. There was a multi-agency focus on the plan for support from family members with the care of both children, and the need to monitor mother’s mental health due to the increased risk of a postnatal breakdown. There is a clear protocol for unborn babies that are subject to a CPP that a ‘birth plan’ is completed by the core group and that this considers both the hospital stay and the discharge from hospital. When the child is subject of a child protection plan, as Ruby was, a discharge meeting should be held following the birth which includes the key professionals and the family to discuss the expectations of all, including the professional visiting schedules. This did not happen in this case as those involved at the time felt there was an appropriate plan in place in respect of baby Ruby and her family. There is no expectation of specific consideration in either the birth plan or at a discharge meeting of the consideration of safer sleeping. Those involved in this case reflected that a leaflet and checking where a baby is supposed to be sleeping is not enough when a parent and their children are vulnerable.   4.26 A neighbouring area has implemented ‘sleep assessments’ which start during the pregnancy and are completed by midwives following the child’s birth. They take into consideration particular circumstances and vulnerabilities. There is a plan to implement these in the area. This review has made a recommendation to ask that this is extended to ensure that all   14 https://www.lullabytrust.org.uk/research/evidence-base/  15 Toxicology results following Ruby’s death showed no recent consumption of alcohol or illegal substances by her mother.  10  professionals, not just midwives, are aware of the need to reinforce safer sleeping advice to the more vulnerable families and where there are particular risks, as there were in this case.   4.27 The home move during the pandemic had worried professionals. The substance misuse midwife was particularly concerned due to the new area being known for its high level of substance misuse.  When the mother then missed a number of appointments with her, and was said to have no money immediately after getting benefits - requiring a referral to the food bank, the midwife spoke to the social worker, questioning whether a strategy meeting was required and whether the child in need plan was sufficient. When this was not agreed there was no formal escalation by the midwifery service or any consideration of formally requesting a strategy meeting.   4.28 The social worker recognised Ruby’s mother’s on-going vulnerabilities and her involvement following the CPP being made focused on the need to make the home a safe place for the children, and mother’s need to enforce a ‘closed door’ policy.  Covid-19 was very difficult for the family, as their relatives were some distance away and the mother felt isolated and restricted.  The professionals involved recognised that it was a balance between ensuring that Ruby’s mother was developing friendships in the new area but ensuring that those attending the home were not a risk to the children. Local support services had very limited offerings due to the pandemic.  Key professionals remained involved however and there was no impact on this case of health staff being redeployed to Covid-19 duties.  Initial support was provided by the Universal health visiting service (with a transfer when Ruby’s mother and sibling moved home in March 2020.) Strengthening Families took over the health visiting role after a child in need plan was made in June 2020. They undertook a number of direct visits to Ruby’s mother, and developed a good relationship. This allowed the strengthening families worker to challenge mother, including about the risk to her unborn baby from drinking. There was a verbal handover from the community midwife service in respect of Ruby when she was 10 days old and the Strengthening Families worker was informed there were no concerns about the baby.   4.29 For any mother the postnatal period is a vulnerable time where they require high levels of support. A study published in May 202116 acknowledges that a lack of social support increases the risk of depression in new mothers and that this was exacerbated by the Covid-19 lockdowns. It was fortunate for Ruby’s mother that it was during the period between full lockdowns that Ruby was born, and the core group were able to put a package of support from family members in place for Ruby and her mother and sibling. Those involved were aware of the potential vulnerabilities that could lead to deterioration in mother’s mental health and the concerns about her excess drinking during the pregnancy.   4.30 Maternal alcohol use and substance misuse were at the centre of the assessments and discussions between Ruby’s mother and substance misuse service. It was recognised that she was likely to be under reporting or denying use, and that this might not be the full picture. She stated that after the hospital admittance that she was not drinking at all. They were also aware that her changing her prescribed medication during the pregnancy may have led to symptoms that she was using alcohol or other substances to manage. However due to the Covid-19 pandemic face to face appointments were not occurring in all cases and for Ruby’s mother contact was completed over the telephone. This lack of face to face contact limited the ability of substance misuse service workers to assess firsthand her demeanour and any potential intoxication.    16 Communication Across Maternal Social Networks During England’s First National Lockdown and Postnatal Depressive Symptoms.  Myers and Emmott. University College London 11  4.31 Covid-19 risk assessments were undertaken regularly by all relevant agencies in the area. Most were designed to specifically consider the ability of professionals to visit and undertake work in a service user’s home.  In the case of CSC this case was Covid-19 risk assessed regularly, and was described as ‘dynamic’ and considered the changing needs of the family. In August for example the visits from the social worker increased to weekly due to concerns about the mother’s drinking. The review acknowledged the fine line between ensuring that professionals are safe but also the need to see the most vulnerable children at home, and appreciates that it was positive practice that face to face visits continued to Ruby’s sibling and then Ruby herself.   4.32 When the Initial Child Protection Conference (ICPC) was held in respect of unborn Ruby and her older sibling, there were technology issues that had an impact on the process, particularly for Ruby’s mother. The meeting was held via Teams technology, which all the professionals had access to. Ruby’s mother was unable to access the meeting via video however and had to dial in. This meant that she could not see who was speaking. She was reportedly distressed by this at the time. The IRO did not postpone the conference due to this, as they believed it was in the best interests of the children for the conference to proceed. The IRO told the review that Ruby’s mother had a clear understanding of the concerns, was able to voice her views and was involved appropriately in the conference.    4.33 Ruby’s mother was at a further disadvantage at the conference as the ICPC report (which takes the form of a child and family assessment) and proposed plan was not written in advance of the meeting and was therefore not shared with her, as is expected practice. They were also not shared with the other professionals in advance of the Conference, as is the procedure. This deficit was not challenged by any professional, including the IRO. The social worker allocated to Ruby and her sibling was new to the team and the role, and had started just before the first lockdown. This was the first time she had taken a case to an ICPC. The system should ensure that the lack of a report is challenged prior to or during the conference, particularly where there are new staff who require information and support when completing tasks for the first time.   Learning:  Safer sleeping advice needs to be robust and bespoke for families where there are additional vulnerabilities. It needs to consider in detail the increased risks in each case and involve the multi-agency professionals working with the child and family.     When undertaking important meetings virtually or by telephone, such a child protection conference, there needs to be optimum planning, pre-meets and recognition of the difficulties this may bring to vulnerable service users. The planning needs to include support to enable them to attend and be fully prepared for the meeting, including seeing the key reports in advance.   Professional challenge of self and others.  4.34 Signs of Safety was used in this case to consider both the strengths and the risks.  The positive aspects of the mother’s care of sibling and then Ruby were based on this, which is good. The strengths identified included breast feeding, positive interactions, a clean home, and so on. This needed to be balanced with the child’s lived experience however, which considered the disruption due to mother’s lifestyle, lack of supervision and care due to alcohol and substance misuse, and the risks posed by visitors to the home. The focus of signs of safety is on how strengths can become safety over time to reduce the risk of the dangers/harms identified. In this case there was the planned use of the family network as part of the safety plan. It is important that there are clear bottom lines however, with robust testing of the plan which 12  includes the skilful use of authority and a transparent focus on risk. This should ensure that the multiagency team around the child considers evidence and avoids over-optimism, including regarding what strengths and protection family members may bring to the case. Practice in this area is said to be evolving and improving.   4.35 Ruby’s mother and the extended family network were aware of the concerns of professionals. The social worker reported that she related these back to the impact on sibling and that both the physical and emotional impact was considered. This was not entirely the case however. When Ruby’s sibling was found wandering the streets alone in May 2020. Her mother’s explanation was too readily accepted by those who were working closely with her.  The police, on the other hand, arrested her mother for child neglect and imposed bail conditions that prevented her caring for her child for a number of weeks. Concerns were noted by the police about Ruby’s mother’s presentation and attitude towards Ruby’s sibling at the time. The review has found that there were discrepancies in the accounts given; including how long Ruby’s sibling was actually missing for. However there were also issues with the information sharing regarding the incident. For example the social worker emailed one of the officers in attendance for further information and he did not share the concerns about Ruby’s mother’s presentation that were included in the report from the night. It was known however that there was evidence of heavy alcohol use at the property, and a male was present at the time who was known to the police due to his drug use. This detail does not appear to have been considered by professionals who decided that a child protection response was not required at the time, and there was limited sharing of the information with other professionals. Even without the required information being shared by the officer involved, the incident was seen in isolation. For example information was available that Ruby’s mother had missed a number of antenatal appointments (eleven in all) and this was not considered.    4.36 It is also of significance that the police had been called the night before the missing incident. They had been told that the adults in the house were drinking and taking drugs. There was a systems issue identified in that the police notification was completed the day after the incident but not signed off by a police manager until two days after the incident as it was a bank holiday weekend, so it was not placed onto the CSC system until after the response to the missing incident had been decided. There is no evidence the response was reconsidered in light of this additional information, or that the officers involved in the second incident considered what had happened the previous night. This lead to decisions being made without the full information and incident led practice. the area Police have been asked to consider how they can ensure that information is shared in a timely way on bank holiday weekends.   4.37 The knowledge and combination of the two police notifications may have led to a more robust response. As well as this, the learning event discussion highlighted that very few professionals are aware that a strategy meeting should always follow a child being made subject of police protection. Ruby’s mother was spoken to by those involved from CSC following the incident and a degree of optimism about what happened and mother’s role in not supervising the toddler was evident. Mother gave what was considered to be a plausible explanation to the social worker and the email from the police officers involved at the time did not provide information to dispute this. MGM was present during the conversation with CSC and was pledging support which was reassuring to CSC. MGM was caring for Ruby’s sibling while mother was on bail for the matter and she appeared fine despite her ordeal. Professionals reflected that it can be hard to challenge family members when they are articulate and professionals have a good relationship with them, as was the case with Ruby’s mother and grandmother. A strategy meeting would have ensured that all of the available information was considered. It is also helpful to go back to the professional source of the 13  information or concerns to discuss the conclusion of any assessment to ensure it fits with what actually happened at the time. It is acknowledged that the police later decided to take no further action in this matter, which along with the email correspondence at the time also provided reassurance to CSC. It should always be remembered however that the criminal justice system works to a different standard of proof than is required when considering a safeguarding response.  4.38 There were practice issues that could have been challenged by those working with the family at the time. This included the lack of multi-agency meetings and absence of recordings/minutes of those that were held. Some professionals are clear that some meetings, for example child in need meetings, were held, but acknowledge that there is no evidence that this was the case. There is also no evidence of management oversight in respect of the lack of evidence of key meetings. Even the most experienced practitioners should consult procedures to clarify what is expected and focus thinking when deciding on a course of action. All professionals need to be aware of the expectations when there is a plan in place for a child including the frequency of meetings, the requirements to provide reports and record the outcomes, and the production of a plan which is also shared with the family. If there is any doubt or disagreement, advice should be sought from others within organisations, such as safeguarding leads, senior managers, child protection conference chairs and legal services. They can then be clear about when a challenge is required if these expectations are not met.   4.39 In order to ensure that a safeguarding system is able to provide professionals with the ability to challenge and address concerns, there also needs to be good information sharing and seeking. Small things like the need to use a team email address instead of a direct email for a professional were identified as learning, as when a professional is off, key information can be lost, meetings can be missed and professionals can then be kept out of the loop for future meetings. This was an issue for the mental health worker and the substance misuse service worker. There were other areas identified in this case where information was not shared as would be expected. For example, in July 2020 the police informed CSC that they had received a call alleging that Ruby’s mother had been using amphetamines while caring for her child.  The police undertook a welfare check and reported that two other adults in the home were clearly under the influence of substances but that there was no evidence that Ruby’s mother was under the influence of any substances or alcohol and her child was asleep in bed at the time of the visit. There is no evidence this was shared with other professionals by CSC. Had the other professionals involved in the case been aware of this allegation, and the police involvement the night before the incident where the sibling had been out alone, there may have been a challenge or escalation of concern requesting a safeguarding response.   4.40 After Ruby’s death there were concerns about how her mother was coping. It was understandable that she was shocked and grieving, and consideration was given to the impact of this on her care of the older child.  Some of the professionals involved also struggled with the death of Ruby, which is completely understandable.  Circumstances such as these can have an impact on decision-making in respect of surviving siblings and the review was told that some of the professionals involved at the time were worried that concerns about Ruby’s mother’s mental state may have had an impact on the focus on the sibling’s needs following Ruby’s death. The Strategy Meeting held to discuss Ruby’s death decided that Ruby’s sibling should remain in her mother’s care but that a family member would supervise at all times.  The fact that the previous plan had not been adhered to was discussed.  It was stated by Children’s Services that this plan was more enforceable as a ‘bottom line’ and that the family had reassured CSC that they would adhere to it this time.   14   4.41 It was initially agreed that there should be no unsupervised contact between Ruby’s sibling and her mother, however the plan then changed and it was decided that Ruby’s sibling could return to her mother’s sole care. The review was told that the decision making was undertaken almost entirely by CSC without seeking and hearing the views of other professionals, particularly those working in adult mental health where there were serious concerns about the on-going contact and the proposed plan for reunification. CSC dispute this, but mental health professionals involved at the time told the review they were only aware of what was happening because the family told them. This was challenged at the time, but the concerns were apparently not responded to. This was likely due to the amount of tasks that needed to be prioritised by CSC, including taking legal advice. It would have benefited the case if the Partnership escalation policy had been used by other agencies about these concerns. Care proceedings have since been undertaken in respect of Ruby’s sibling.  4.42 It has also been identified during the course of this review that staff involved in cases that require a child safeguarding practice review need support and regular updates on the processes that are being undertaken. When a child has died or is seriously injured, there needs to be responsive structures in place to support staff through this ordeal that does not rely on self-referral for welfare support. Health agencies have a robust debrief process in place for staff following a death or significant incident, including debrief meetings after events held as part of a CSPR, however this is not in place for all agencies which can lead to anxiety. A recommendation has been made in relation to this issue.    Learning  Strengths based models of assessment and planning for children need to have a clear focus on risk and ensure that all available information is considered when deciding on the safety plan for a child.    Written safeguarding procedures need to be considered by professionals at key points in a case. This includes when there is an incident, when a case requires a strategy meeting or a conference, and when there is a disagreement between agencies.   All professionals need to be confident about what is in the multi-agency safeguarding procedures. This includes expectations about frequency of meetings, requirements to provide reports, recording of meetings, production of a plan, and so on. This confidence will ensure that they challenge colleagues when expectations are not met.   Professionals need to ensure that having a positive relationship with family members does not lead them to lose focus or be over optimistic about the potential for harm to a child.  5  Conclusion and recommendations  5.1 Ruby’s death was a tragic accident, linked to an unplanned unsafe sleeping environment. The Partnership recognised however that there were lessons to be learned for the way that agencies worked together in this case and the way that they engaged with Ruby’s mother in respect of her predisposing vulnerabilities and the risks these might pose to her children.  5.2 There has been a high degree of cooperation and engagement from agencies in the area with the review, including the completion of single agency reports that identified learning and made appropriate and timely action plans. These have resulted in changes being made, like those identified above for the GP surgery, and substance misuse service reviewing their Covid-19 procedures for pregnant service users. Learning regarding both assessments of family members and the need for balance within strength’s based practice are included in the CSC agency report. Much of the wider learning identified within this report has been 15  addressed by the single agency actions plans. For example children’s social care are working to ensure that gaps in case recording are identified and rectified.   5.3 The purpose of providing additional recommendations is to ensure that the Partnership are confident that any areas identified as being of particular concern and not included in the single agency plans, are addressed.  In respect of Recommendation 4, the review is aware that this is an issue that has been identified in other case reviews in the area, and remains an ongoing concern. The Partnership aspires to ensure that there is robust and persistent challenging of professionals in cases where there are concerns about professional practice with a child and family. A recommendation was made in a recent serious case review. Ruby’s case shows that this remains a concern and the partnership are asked to make renewed efforts to ensure improved practice in this area.  Recommendation 1: The Partnership to make promoting the involvement of fathers a key focus of its work.   Recommendation 2: The Partnership to ensure that the implementation of Sleep Assessments in the area includes bespoke explicit and detailed safer sleep advice, involves all adults who will have responsibility for the care of the baby, and that all professionals working with the family are aware of and reinforce the sleep plan. The plan should include the advice that it must be adhered to all of the time and includes an explanation of why vulnerable babies are more at risk of SUDI17, using case specific information.  Recommendation 3:  The Partnership to request that the relevant partner reviews both expectations and practice to ensure that key meetings such as child protection conferences being held by video conference or telephone ensure the optimum involvement of parents.   Recommendation 4: The Partnership to ask partner agencies to reconsider how they ensure that professionals have the knowledge and confidence to challenge other agencies, including the use of the escalation policy, as this case shows that this issue remains a concern. Consideration needs to be given to all key meetings, such as child protection conferences, promoting positive challenge.    Recommendation 5: The relevant partner agencies to be asked to consider how they can be sure that accurate information about medication being prescribed to a pregnant woman, is available to all of the health professionals working with the family.  Recommendation 6: The Partnership to request that clear protocols are developed by all partner agencies to ensure that staff working with a child who dies, or is the subject of review, receive timely and ongoing information and support until the conclusions of any investigations or processes.    17 Sudden unexplained death of an infant 