Death of a 1-year-9-month-old child in February 2012 as the result of severe brain damage. Police were unable to establish how the subject child sustained the fatal head injuries however medical evidence indicated that they were inflicted non-accidentally. Issues identified include: maternal history of depression; and concerns raised by father and paternal grandparents relating to an unexplained burn to subject child's hand and a bruise. Identifies analysis and learning, including: a focus on parental behaviour sometimes diverting professional attention away from the child; GPs treating episodes of maternal depression in isolation with insufficient attention to broader issues of family life, parenting capacity and child wellbeing; and need for professionals to remain alert to safeguarding issues and to think critically and reflectively whilst performing routine professional activities. Makes various recommendations.
      
 Title:  Serious case review relating to a child who died at the age of one year and nine months. LSCB: Kirklees Safeguarding Children Board Author: Carole Smith Date of publication: [2015]  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                         1        KIRKLEES SAFEGUARDING CHILDREN BOARD     SERIOUS CASE REVIEW RELATING TO A CHILD WHO DIED AT THE AGE OF ONE YEAR AND NINE MONTHS   Overview Report by Dr Carole Smith – Independent Author  Approved by KSCB November 2013  This report has been redacted to comply with a Reporting Restriction Order   January 20142   Contents (Paragraphs)  1.00 Introduction 2.00 Genogram 3.00 Reasons for the Serious Case Review 4.00 Terms of reference and the Serious Case Review process 5.00 Description of year: 1st July 2009 to end of December 2009 6.00 Description of year: 1st January 2010 to end of December 2010 7.00 Description of year: 1st January 2011 to end of December 2011 8.00 Description of year: 1st January 2012 to 28th February 2012 9.00 Analysis and learning: preliminary comments 10.00 Analysis and learning 11.00 Summary of learning 12.00 Good practice 13.00 Recommendations arising from this Serious Case Review 14.00 Conclusion 15.00 References      Abbreviations  CCG Clinical Commissioning Group CMHS Community Mental Health Services CSC Children’s Social Care Services ED Hospital Emergency Department IMR Individual Management Review KSCB Kirklees Safeguarding Children Board LCP Locala Community Partnerships MYHT Mid Yorkshire Hospitals NHS Trust PCT Primary Care Trust SCR Serious Case Review SHA Strategic Health Authority       3  SECTION ONE: INTRODUCTION  1.0  When the Chair of Kirklees Safeguarding Children Board (KSCB) made the decision to initiate this Serious Case Review (SCR) the relevant statutory guidance was contained in the 2010 version of Working Together to Safeguard Children: a Guide to Inter-agency Working to Safeguard and Promote the Welfare of Children (HM Government 2010). The Serious Case Review was thus guided by Working Together 2010, rather than by the Government’s more recent version of Working Together (HM Government 2013) which was effective from 15/4/13. However, as will become evident throughout this report the Review based its work on the principles for learning and improvement which are identified in the 2013 Guidance.  1.1  The requirement for Kirklees Safeguarding Children Board to conduct a SCR was, at the time, detailed in Chapter 8 of Working Together (HM Government 2010) and in the Local Safeguarding Children Board Regulations 2006. The purpose of a SCR as identified in Working Together is to:   Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children.  Identify clearly what those lessons are, how they will be acted on and what is expected to change as a result.  Improve intra and inter-agency working and better safeguard and promote the welfare of children.  1.2  In order to ensure the SCR identifies any lessons that should be learned and results in effective changes to protect children from harm, Working Together emphasises the importance of putting ‘the child’s daily life experiences and an understanding of his or her welfare, wishes and feelings’ at the centre of the Review (HM Government 2010: 8.1). The SCR Panel and independent author were mindful of this guidance and focussed on the child’s experience and needs insofar as they were able to identify and understand these.   1.3  In her review of child protection arrangements Munro (2011) recommends that Serious Case Reviews should adopt a systems theory approach to understanding why professionals and agencies respond to child protection concerns in particular ways. A systems perspective directs attention to the context of professional practice such that factors which impede effective professional judgement and decision making can be identified and changed. In summary, Munro and Hubbard (2011: 727) suggest ‘It has been realised that human error can be more effectively reduced by looking at the wider organisational factors that influence the individual and identifying which factors make it easier or harder for workers to perform well’: hence the particular emphasis on learning and improvement in Working Together (2013). This SCR has attempted to understand the context in which professionals practised and to reflect this in its identification of learning and recommendations for action.   1.4  It is important to recognise that this report has been written with the benefit of hindsight and its findings should be interpreted accordingly. The use of hindsight 4  may convey an impression of clarity and order with regard to retrospective description and analysis which was not available to professionals at the time of their involvement. As Munro (2011: 1.14) comments, ‘it is important to be aware how much hindsight distorts our judgement about the predictability of an adverse outcome.’ Similarly, it should be appreciated that the prediction of events is not a straightforward matter. It has been noted in national evaluations of Serious Case Reviews (Brandon et al 2008: 7) that the way in which complex risk factors interact in individual cases and under specific circumstances is difficult to predict. This SCR has tried to understand the nature of professional intervention and its organisational context at the time when agencies were working with the child who is the subject of this Review.  2.0  GENOGRAM RECORDING FAMILY COMPOSITION AND RELATIONSHIPS (not available for publication)  3.0  REASONS FOR THE SERIOUS CASE REVIEW  3.1  At the age of one year and nine months the subject child was taken by ambulance to their local hospital in a state of collapse and subsequently transferred to a specialist paediatric intensive care unit. Tests revealed that the child had suffered severe and unsurvivable brain damage and the child died on 28/2/12.  3.2  Although the cause of death was later identified as ‘head injury’, there remained uncertainty about how this had occurred. By September 2012, expert medical evidence was beginning to indicate that the child’s head injury had been caused non-accidentally. Medical experts subsequently agreed that non-accidental blunt force trauma to the child’s head had resulted in brain damage which led to the child’s death. Evidence available to West Yorkshire Police showed that the child had suffered the head injury at some time during the night or early morning of 26th and 27th February 2012 when at various times the child’s mother, her partner at the time (not the child’s father) and the child’s maternal grandmother were at the family home.  4.0  TERMS OF REFERENCE AND THE SERIOUS CASE REVIEW PROCESS  4.1  KSCB SCR Workstream and the decision to undertake a SCR  4.1.1  The SCR Workstream is a standing Panel of KSCB and its membership includes senior representatives from West Yorkshire Police, local NHS and Social Care service providers and commissioners, and Local Authority services. It is responsible for making recommendations to the Chairperson of KSCB about commencing SCRs in particular cases and for monitoring the implementation of multi-agency actions arising from SCRs to improve professional and organisational practice.   4.1.2  Working Together (2010: 8.18) places responsibility for deciding whether to initiate a SCR on the Chairperson of a Local Safeguarding Children Board following a recommendation from the Board’s Serious Case Review Panel or equivalent sub-group. The SCR Workstream of KSCB monitored information 5  about causation of the subject child’s head injury until available evidence indicated this was likely to have been caused non-accidentally. At that point in September 2012, the Workstream requested further information from agencies about their previous involvement with this case.   4.1.3  At its meeting on 13/11/12 the SCR Workstream of KSCB agreed that the criteria as identified in Working Together (HM Government 2010) for a SCR were met and recommended the completion of a SCR to the Chairperson of KSCB. However, at that time the Chairperson of KSCB did not have detailed information about the medical findings and expert opinion which had established the subject child was non-accidentally injured, or detailed information arising from Police enquiries into the case.  4.1.4  The KSCB Chairperson was aware that the Designated Nurse for Greater Huddersfield and North Kirklees Clinical Commissioning Groups had completed a Health Review (dated 16/5/12) following the subject child’s death, which had identified learning for health services and initiated remedial action. This Review had been considered by the KSCB SCR Workstream in May 2012. The KSCB Chairperson was therefore satisfied that work to improve service provision and professional practice in the health service would not be delayed pending the receipt of further information which she required to make a decision about conducting a SCR. This decision was made by the KSCB Chairperson on 6/3/13.  4.1.5  Working Together (HM Government 2010) states:   ‘When a child dies (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the death, the Local Safeguarding Children Board should always conduct a SCR into the involvement of organisations and professionals in the lives of the child and family. This is irrespective of whether local authority children’s social care is, or has been, involved with the child or family’ (HM Government 2010: 8.9, original emphasis).  4.2  The SCR Overview Panel  4.2.1  KSCB SCR Workstream established a SCR Overview Panel to conduct the SCR. The Overview Panel comprised independent senior professionals from relevant agencies none of whom had any direct involvement in providing services to the child and their family. The SCR Workstream also identified an independent Chairperson, and an independent author to write the overview report as required in Working Together (2010: 8.16 and 8.33). The independent chairperson was Bron Sanders who is also the independent chairperson of KSCB and the independent author was Dr Carole Smith neither of whom had any prior involvement with the agencies providing services to this family.   Chair of the SCR Overview Panel:   Bron Sanders holds a social work qualification (CQSW) gained in 1978, and Master of Business Administration (distinction), gained in 1998. She has over 30 years’ experience of children’s social care services in  five local authorities, working initially as a social worker, but then managing fieldwork, hospital and 6  residential services for children at a senior level, and ultimately at Head of Service level. She has considerable experience and expertise in relation to child protection services, and in leading children’s partnership bodies in strategic planning and service delivery and improvement. Currently, Bron Sanders is the Independent Chair for KSCB and East Riding Safeguarding Children Board.  Bron Sanders has not undertaken social work or management functions for Kirklees Council, and has had no previous involvement with this case.  Independent author of the SCR overview report:  Carole Smith’s qualifications are BSc (Sociology), M Phil (Social Work), Certificate of Qualification in Social Work, LLB, PhD. Between 1972 and 1994 she worked in the voluntary and statutory social care sectors as a social work practitioner, team leader and senior manager in services for children and families, including responsibility for child protection. From 1994 until 2011, she was a senior lecturer and later an honorary senior lecturer at the University of Manchester teaching, researching and publishing in areas relating to social work practice, law, social policy and statutory intervention with children and families, including issues associated with safeguarding children. She has considerable experience of working with Local Safeguarding Children Boards as an independent author for SCRs. Carole Smith has no involvement with policy or practice matters relating to KSCB or this case and is therefore able to take an independent view of the SCR process with regard to the child concerned. 4.2.2  The SCR Overview Panel was comprised of the following members:  Bron Sanders – Independent Chairperson  Associate Director for Safeguarding Children and Adults, Calderdale and Huddersfield NHS Foundation Trust  Manager, Kirklees Safeguarding Children Board  Director of Clinical and Operational Services, Locala Community Partnerships  Designated Nurse for Safeguarding Children, NHS Greater Huddersfield and NHS North Kirklees Clinical Commissioning Groups  Head of Care and Assessment, Family Support and Child Protection Service, Kirklees Council  Superintendent, West Yorkshire Police  Service Manager, Lifeline  Consultant Paediatrician and Named Doctor for Safeguarding Children, Mid-Yorkshire NHS Health Trust In attendance were:  Carole Smith – Independent Author  Safeguarding Children Co-ordinator, Kirklees Safeguarding Children Board 4.2.3  The SCR Overview Panel initially concluded that given its composition it would not require external expert advice although this decision would be reviewed if necessary. 4.3  Individual Management Reviews (IMRs)  7  4.3.1  IMRs refer to enquiries about intervention and service delivery, including inter-agency working, in agencies/services that have had a significant degree of involvement with children who are the subjects of a SCR and their families. Such enquiries should focus on what happened and why from a professional and agency perspective and are incorporated into an IMR report. They should aim ‘to look openly and critically at organisational and individual practice’ (HM Government 2010: 8.35) to identify learning, determine what improvements can be made and specify how such changes should be effectively implemented to protect children from harm. In this case the authors of IMR reports were expected to follow guidance in Working Together (HM Government 2010) and the Individual Management Review Handbook provided by KSCB.   4.3.2  In order to provide the SCR Overview Panel with comprehensive information about this case, IMRs including detailed chronologies, were requested and received from the following agencies/services:   Mid-Yorkshire Hospitals NHS Trust   Locala Community Partnerships   NHS England West Yorkshire Area Team and North Kirklees Clinical Commissioning Group   Family Support and Child Protection Service, Kirklees Council   West Yorkshire Police   West Yorkshire Probation Trust   Lifeline Kirklees 4.3.3  Additionally, summary reports were requested from the following agencies / services:   Kirklees Neighbourhood Housing / HOSS   NHS Direct  Local Care Direct  Specialist paediatric intensive care unit  Action for Children  Adult Social Care   Yorkshire Ambulance Service  South West Yorkshire Partnership Foundation Trust   4.4  The SCR process  4.4.1  The SCR Overview Panel met on five occasions between July and October 2013 and IMR report authors were briefed about issues relating to thorough completion of IMRs prior to the initial meeting of the Overview Panel. At the first meeting of the Overview Panel it was emphasised that the Panel should seek to understand professional intervention, decision making and inter-agency working from the perspectives of those who were involved at the time and should consider broader issues associated with the systems in which professionals were operating. Broader issues might include communication and recording systems, organisational characteristics, resources, professional knowledge, and 8  opportunities for supervision relating to safeguarding children. The independent author attended all meetings of the SCR Overview Panel.  4.4.2  IMR authors attended the first Panel meetings to discuss their enquiries and reports. This enabled the Panel to clarify and discuss learning issues arising from the IMRs and to request revisions where this was necessary. It was clear that IMR authors had based their enquiries on access to relevant written material, electronic records and interviews with appropriate professionals.  4.4.3  This SCR was completed according to guidance in the 2010 version of Working Together to Safeguard Children and professionals were involved insofar as they contributed to the completion of IMRs. However, in keeping with guidance about conducting SCRs in the 2013 version of Working Together which emphasises the full involvement of professional practitioners, the overview report author accompanied by representatives from the Overview Panel talked directly to some health visitors and managers from children’s social care Duty and Assessment Team about their involvement with this case. The overview report author emphasised to IMR report authors and professional practitioners that the purpose of the SCR was to identify how practitioners might best be helped to practice well rather than to find fault. This approach to learning and improvement is central to guidance about SCRs in the 2013 version of Working Together.  4.4.4  It was expected that IMR authors and the overview report author should consider and refer to relevant research and learning arising from previous SCRs completed by KSCB and national evaluations of SCRs.    4.4.5  The independent author and the SCR Overview Panel were satisfied that agencies had identified arrangements for discussing the SCR’s findings with IMR authors, and with managers and practitioners who had provided services to the subject child and their family.  4.4.6  The IMRs were quality assured by senior managers within agencies/services and subsequently by the SCR Overview Panel. The Overview Panel’s work, including that of the independent author, was quality assured by the KSCB Workstream, the Chairperson of which was a member of the Overview Panel and the SCR was approved by KSCB.   4.5  Important issues in identifying learning from this SCR  4.5.1  Some issues which appeared to be significant from early information available to the SCR Workstream assumed less importance as the Overview Panel conducted its enquiries and other information, while helpful for the learning of individual agencies/services, was not considered appropriate for publication. The SCR Overview Panel thus identified the following issues as requiring particular scrutiny in IMRs and during the Review and as being appropriate for inclusion in this report:   The child’s needs: were professionals sensitive to the child’s needs and aware of factors that might have a detrimental impact on the child’s 9  wellbeing? Were professionals knowledgeable about indicators of abuse and/or neglect and about what to do if they had concerns about a child’s wellbeing?  Mental health issues: to consider mental health concerns where relevant. How far were professionals aware of these issues and how did professionals evaluate their significance in terms of the mother’s parenting capacity and the child’s wellbeing?  Significant adults: to consider dates of changes in partners and whether these relate to incidents of mother’s depression/low mood. Were professionals sufficiently alert to the possible impact of changes in the mother’s partners on her mood and parenting capacity and did they explore the parenting capacity of the mother’s partners and their role in family life?  Parenting issues: to consider the impact of her own upbringing on the mother’s parenting capacity and her request for help with parenting. Were professionals sufficiently aware of the relationship between the mother’s experience of family life as she was growing up and her parenting capacity?  Information sharing and inter-agency communication: to consider whether key information was shared appropriately between agencies and professionals, whether the significance of information was clarified and understood and whether agencies and professionals responded effectively to information.   The organisational context: were there any factors in agencies / organisations which acted to impede good practice relating, for example, to resource issues, professional supervision and development, effective management oversight, communication and recording systems?  4.6  Time period to be covered by the SCR  4.6.1  The KSCB Workstream concluded that the most appropriate period to be considered by the SCR was from July 2009 when the mother’s pregnancy with the subject child began until late February 2012 which was when the subject child died.   4.7  Time-scale for completion of a SCR  4.7.1  Working Together (2010) requires all SCRs to be completed no later than six months from the date when the Chairperson of a Local Safeguarding Children Board makes the decision to hold a Review. The Chairperson of KSCB made this decision on 6/3/13 and this SCR has thus extended beyond six months. The SCR Overview Panel was concerned to ensure thorough reflection on learning arising from this case and did not wish to distort the SCR process by rushing its completion. However, the Panel was also aware that implementing learning from this SCR was already underway. The Designated Nurse Safeguarding Children for NHS Greater Huddersfield and NHS North Kirklees Clinical Commissioning Groups wrote a report dated 16/5/12 which identified learning arising from this case and action to improve practice. As will become evident throughout this report, most of the learning from this SCR has already been translated into actions for agencies/services and these have been implemented. As the 10  independent author I am satisfied that the delay in completion of this SCR has not adversely affected agencies’ responses to learning.  4.8  Involvement of family members in the SCR  4.8.1  The SCR Overview Panel considered it was important for representatives to meet relevant family members to explain the purpose of a Serious Case Review, to invite their views on services which had been provided and their effectiveness in helping the family, and to discuss any issues which might arise from publication of the Overview Report and Executive Summary.   4.8.2  Information about the subject child and family suggested that the following family members should be invited to participate in the SCR: the child’s mother, her former partner (who is the subject child’s father), the child’s paternal grandparents, the mother’s partner at the time of the child’s death and his parents and the mother’s parents and sister. The independent author and KSCB Safeguarding Children Co-ordinator were able to talk to all of the foregoing family members apart from the subject child’s maternal grandmother. Where family members’ commented on service provision and professional intervention over the period covered by this SCR, their observations are included in this report.  4.8.3  It should be acknowledged that conversations with the subject child’s family members included painful and difficult issues some of which were not directly related to service provision during the Review timescale. The SCR Overview Panel was grateful for the families’ willingness to participate in the Review process. However, the independent author and KSCB Safeguarding Children Co-ordinator explained to family members that given the purpose of a SCR, it would not be appropriate for its coverage and conclusions to respond to all the concerns which they expressed.   4.9  Issues relating to linguistic, cultural, diversity or equality issues  4.9.1  The subject child and members of their family were all white British and the SCR did not identify any issues associated with language, culture or religion that were relevant to service provision or professional intervention.  4.9.2  The subject child was healthy and developing normally up to the time of the subject child’s death. The subject child’s mother’s partners during the period covered by this SCR were both identified as being in full-time employment and the child’s mother had experience of higher education. The child’s mother was described by health visitors and staff in the Emergency Department of her local hospital as educated, confident and articulate and she was proactive in seeking services which she required from the local Children’s Centre. Although the subject child and members of their extended family lived in an area of high social deprivation according to the index of social deprivation (Department of Communities and Neighbourhoods 2010), the employment status and aspirations of individual family members did not suggest any issues relating to equality and diversity that were relevant to the SCR.  4.10  Parallel/related investigations, legal advice and media attention 11   4.10.1  The subject child’s death was notified to the then Strategic Health Authority (SHA) and logged on the Strategic Executive Information System as a Serious Incident. The Designated Nurse Safeguarding Children requested information from healthcare providers which had been involved with the family and completed a Health Review. In response to the Review healthcare providers identified recommendations and developed related action plans which responded to learning about healthcare provision in this case. The Designated Nurse’s Health Review and the resultant action plans are dated 16/5/12. Thereafter, the SHA and Primary Care Trust (PCT) agreed and monitored the implementation of actions through their own governance frameworks. As Clinical Commissioning Groups (CCGs) replaced SHAs and PCTs, implementation of the Health Review’s action plan was monitored through the appropriate CCG’s governance and risk process until this was completed. It is evident that following the subject child’s death, the Designated Nurse acted swiftly to review NHS service provision for this family and healthcare providers implemented remedial action in response to learning. Actions arising from her Health Review are discussed throughout this report.  4.10.2  A Coroner’s Inquest into the subject child’s death had not been held at the time of completing this report.  4.10.3  There were no ongoing criminal proceedings in respect of the subject child’s death during completion of the SCR.  4.10.4  The SCR Overview Panel did not consider it was necessary to have ongoing legal advice but this was available if requested.  4.10.5  In accordance with Government guidance the SCR Executive Summary, overview report and action plan would be published on the KSCB website at the conclusion of the SCR and remain there for at least twelve months. The SCR Overview Panel agreed to consult with media contacts in relevant agencies to develop an appropriate media strategy if this became necessary.   4.11  Understanding what ‘safeguarding’ means  4.11.1  Some members of the public may be confused about references to safeguarding children and child protection. Working Together (HM Government 2013) defines ‘safeguarding and promoting’ children’s welfare’ as follows:   Protecting children from maltreatment  Preventing impairment of children’s health or development  Ensuring that children grow up in circumstances consistent with the provision of safe and effective care; and  Taking action to enable all children to have the best outcomes  4.11.2  Child protection is part of safeguarding and promoting children’s welfare. In this report the term ‘safeguarding’ incorporates the definition above and includes protecting children from harm. 12   4.12  Preliminary note about the nature of this report  4.12.1  Statutory guidance requires that all SCR reports should be published but that, at the same time, ‘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’ (HM Government 2013: 71). It is evident that a report regarding enquiries into the death of a child is likely to include information which will be distressing to family members. This situation leads to two major consequences for readers of this report. First, the report has set out to provide anonymity to the child who is the subject of this SCR and to their family. Second, although the SCR Overview Panel had access via IMRs and other enquiries to detailed information about this case, the focus in this report is on the work of professionals and agencies over the Review period rather than on details about the child and family’s characteristics. Where possible I have avoided including personal information about members of the child’s family unless this is necessary to enable an understanding of agency involvement, professional practice and learning. Some information available to the SCR Overview Panel has been helpful in identifying learning for individual agencies/services, but the Overview Panel and independent author considered it was inappropriate to include these details in a published report.     SECTION TWO: DESCRIPTION OF AGENCY INVOLVEMENT WITH THE CHILD AND THEIR FAMILY OVER THE REVIEW PERIOD  5.0    Year 1: 1st July 2009 to end of December 2009  5.1  The community midwife completed a thorough assessment when booking the mother’s pregnancy with the subject child in October 2009. She recorded the identity of the child’s father and the mother’s earlier experience of depression. Because there was no evidence of maternal or child vulnerability, the community midwife did not initially refer the mother for an antenatal visit from the health visiting service although this service was notified of the mother’s pregnancy.  6.0    Year 2: 1st January 2010 to end of December 2010  6.1  In April 2010 the mother consulted her GP saying that she had been depressed for a few months and she was prescribed a month’s supply of anti-depressant medication. She did not return to the GP for assessment or a further prescription. The GP Practice was aware that the mother had previously experienced depression.   6.2  In May 2010, the mother’s community midwife contacted the health visiting service to report that the mother had separated from her partner (the subject child’s father) and her mood was low. A health visitor (HV1) visited the mother four days later and recorded that at this time the mother was undertaking a vocational programme of undergraduate studies and said she was well supported by family and friends. HV1’s records indicate that she was aware of the mother’s earlier experience of depression. 13   6.3  The mother’s pregnancy progressed uneventfully and she attended all her healthcare antenatal appointments.  6.4  The subject child was born in May 2010 and there were no recorded concerns about the mother’s care of her baby while in hospital. A community midwife visited the mother and baby at home on four occasions between the baby’s birth and the beginning of June 2010. Mother and the baby’s father were reconciled and the father was living in the family home. Community Midwifery records indicate that the father was supportive and was present for some of the home visits. During this time the baby was developing well and records suggest the mother was confident in her parenting role. Records also included observations about the mother’s wellbeing and indicated that she was ‘emotionally well’. At the beginning of June the community midwife transferred care of the mother and baby to the health visiting service and GP.  6.5  Records of the health visitor’s (HV1) first postnatal visit noted that the baby was healthy and developing well. Mother and baby were interacting appropriately. The mother reported that she had not experienced any tearfulness or low mood. HV1arranged to visit two months later to assess the mother’s mental health, but this and a subsequent visit met with no access. However, HV1 identified from the electronic health record that the mother and baby had accessed a local ‘drop-in’ well baby clinic on four occasions between June and early September where the baby’s health and weight had been recorded. HV1 checked with the relevant health visiting team and noted there were no concerns about the baby or mother’s wellbeing. At this stage the baby had received all appropriate immunisations. Under these circumstances HV1discontinued home visits but it was agreed that the health visiting team responsible for the ‘drop-in’ clinic would contact HV1 about any concerns or the need for further home visits.  6.6  The mother made her last visit to the ‘drop-in’ baby clinic in late September 2010. Records indicate that the baby continued to gain weight and was doing well. Between September and December the mother and baby also attended activities at the local Children’s Centre including baby massage and ‘stay and play’ sessions, and a healthy eating course.   6.7  In November, the baby’s immunisation programme was suspended because of two missed appointments. Automatic suspension by the electronic health system (SystmOne) attracts a proactive approach by Child Health and the immunisation team to increase immunisation uptake. At this time health visitors were not notified about suspensions, although routine notification has subsequently been implemented. The mother explained to representatives from the SCR Overview Panel that she had been very busy and overlooked the appointments. She attended an appointment in March 2011 when the baby received the (delayed) third dose of primary immunisations.  6.8  At some point after June 2010, the subject child’s father and mother had separated although the father and his parents continued to have contact with the child. Information available to the Overview Panel indicates that the mother met a 14  new partner around October 2010. He moved into the mother’s accommodation where she had been living with the subject child.  6.9  Information relating to this year indicates that the community midwifery and health visiting services had no concern about the mother and her baby’s wellbeing. The baby was developing well. Although the mother had sought anti-depressant medication from her GP in April, when midwifery and health visiting professionals asked her directly about her mood the mother did not report any symptoms of low mood or depression. Mother and baby regularly visited the ‘drop-in’ well baby clinic until September and spent a considerable amount of time at the local Family Centre. Records indicate that the mother took her baby for appropriate consultations with the GP and also contacted Local Care Direct and NHS Direct for advice when necessary. The only cause for (minor) concern was that the baby missed two appointments for their third immunisation after attending un-problematically for earlier immunisations. This was remedied by March 2011 when the delayed immunisation was administered.   7.0    Year 3: 1st January 2011 to end of December 2011  At the beginning of this year the subject child was just under eight months old  7.1  Early in March the mother took the subject child (aged approximately ten months) to the Emergency Department (ED) of her local hospital with blisters on three fingers of their left hand. The mother reported there was no evidence of blisters when the child had been put to bed the night before and she had only observed them on the morning of her attendance at the ED. The initial diagnosis was uncertain – a burn or reaction to insect bites. ED records note that the mother rejected the possibility of a burn but offered no other explanation. The child’s injury was assessed in the ED Review Clinic two days later where it was diagnosed as ‘definitely a burn’. A Review Clinic appointment was made for seven days later which was attended by the mother and child and a further appointment was arranged for a week after this.  7.2  As is usual practice, following recommendations from an earlier SCR, the ED notified the health visiting service and the family’s GP about the child’s attendance.  The Mid-Yorkshire Hospitals NHS Trust (MYHT) IMR identifies daily posting of such notifications. Records indicate that the notification concerning the subject child was received by a health visiting team administrator four days after the child was seen at the ED. However, because ED notifications were allocated for health visitor review at weekly team meetings, information about the subject child was not assessed by a health visitor until six days following its receipt by the team administrator. This was on 15/3/11. The notification gave no indication of any safeguarding issues but recorded ‘blisters to left index, middle and ring fingers consistent with burns but no obvious injury’.  7.3  The mother and child did not attend the last Review Clinic appointment. Prior to this appointment they visited a Walk-in Centre on 16/3/11 for attention to the child’s burn because the dressing had come off and the mother was concerned about possible infection. Walk-in Centre records note the mother was upset but was unable or unwilling to explain how the burn had been caused. The child was 15  distressed during the painful process of cleaning and re-dressing.  The Walk-in Centre referred the child to a Burns Unit at another MYHT site and the child was subsequently discharged from medical care. MYHT IMR notes that the Burns Unit had no record of the mother and child’s earlier attendance at the ED or the lack of any explanation for the child’s injury at that time.  7.4  When the child failed to attend the ED Review Clinic, a further appointment was issued but this resulted in non-attendance.  An ED receptionist contacted the subject child’s family and was reassured that mother and child had attended the Burns Unit. Although records indicate this was the case, the receptionist did not check the veracity of this information.  7.5  Five days after the subject child’s attendance at the ED and while medical review/treatment of the child’s burn was still ongoing, the child’s paternal grandmother arranged to speak to a health visitor. At this point the ED notification had not been reviewed in the health visiting team. HV2, who was not the family’s allocated health visitor, met the paternal grandmother on the same day as her request. The paternal grandmother explained that although her son and the child’s mother had finished their relationship her family maintained regular contact with the child. She reported her concern about the lack of an adequate explanation for the child’s burn although she noted that the child had received medical attention from the GP and she referred to a bruise near the child’s ear which had been observed a few weeks before and for which there was no explanation. The paternal grandmother observed that the mother’s new partner was living in the family home and the family had just moved into another area. On being advised by HV2 to report her concern to Children’s Social Care (CSC), the paternal grandmother said she could not risk the mother stopping her contact with the child as a consequence of contacting CSC.  7.6  Following this conversation HV2 planned to notify the appropriate health visiting team of the family’s move into their area; contact CSC and liaise with the GP to enquire about the child’s burn. The day after her conversation with the paternal grandmother HV2 passed on relevant information to the health visiting team, including the paternal grandmother’s concerns but was unable to discuss the situation with a social worker at CSC (Duty and Assessment Team).   7.7  Three days later (after the weekend) HV2 contacted CSC, Duty and Assessment. HV2’s records indicate that she told CSC about the paternal grandmother’s concern regarding the burn and that the GP had provided medical care. Although HV2’s records did not indicate that she told CSC about reported bruising to the subject child, HV2 told the IMR author that she remembered mentioning this to the social worker. CSC’s record of the same conversation identifies the paternal grandmother’s concern about the burn although this had received attention from the GP and her earlier observation of a bruise, the child’s previous non-attendance for immunisation and unspecific references to past domestic violence and difficulties with ‘access visits’. The CSC social worker also recorded that there had been no previous concern about the child’s health or development. HV2 and CSC’s records are in agreement about subsequent action: HV2 would liaise with the GP to ensure the child’s burn had received medical treatment and check the child’s immunisation status. HV2 had contacted CSC for 16  advice/consultation but it was agreed that if during HV2’s enquiries, any of the agencies/services expressed concern then HV2 should make a formal referral to CSC. At this point, the health visiting team had still not reviewed the notification about the child’s attendance at the hospital ED.   7.8  The day after HV2’s contact with CSC (15/3/11), a health visitor reviewed the ED notification. A health visitor had already been allocated to the family following contact from HV2. The following day HV3 contacted the family’s GP Practice and although unable to speak to the GP was told that the child’s injury was consistent with a scald to the hand and the child had attended all follow-up appointments (by 16/3/11 the child had attended all ED Review Clinic appointments). HV3 contacted the Practice again later that day and was informed that the child had previously been seen by two different GPs and they had no concern about the child’s health or development.  7.9  The community nurse from the Walk-in Centre had contacted HV3 to ensure the health visiting service knew about the child’s burn and understood that no explanation had been provided about its causation. The community nurse also informed the GP. HV3 visited the family on the same day following their consultation at the Walk-in Centre and met the mother, the subject child and the child’s maternal grandmother. HV3’s record of this visit indicates that she gave thorough attention to the mother and child’s wellbeing. She enquired about how the child’s burn had occurred but noted that the mother became distressed and offered no explanation. The mother’s sister had cared for the child the afternoon before the child’s attendance at the ED, but the mother had not observed blistering until the morning after. (Information available to the SCR Overview Panel also indicated that the mother had left the child in the care of her new partner for part of the evening but the child was in bed when she returned home). HV3 recorded that the mother had suspended her undergraduate studies and was working 2/3 days a week. (It became evident to the Overview Panel that the mother had complicated child care arrangements which included on occasions an unrelated child minder, her mother and sister and the child’s father and paternal grandparents). Her partner and family were reported to be supportive and the child stayed fortnightly for weekends with their paternal grandparents and father. HV3 observed the subject child crawling and walking with the support of furniture and interacting appropriately with the mother. Although the mother reported feeling stressed and low after the child’s burn injury, she said she was not depressed. There was no evidence relating to the child’s health or development to concern HV3.  7.10  The subject child’s father contacted the health visiting service and expressed concern about the child’s burn to HV4 who reassured him that the child was receiving appropriate medical treatment. HV3 phoned him back three days later when the father reported that he was concerned about the mother’s child care arrangements and had photographed the bruise previously reported by his mother to HV2. HV3 noted that she had not observed any signs of bruising/injuries and advised the child’s father to report his concern to CSC. HV3 provided contact details for CSC but there is no evidence that she checked whether the father had spoken to the Duty and Assessment Team. CSC Duty and Assessment has no record of contact from the child’s father. 17   7.11  HV3 visited the mother and subject child on three further occasions between March and early July. HV3’s records indicate that on each occasion she observed good interaction between the child and their mother, the child was supplied with plenty of appropriate toys and was reaching developmental milestones. There was no evidence of bruising or any injury to the child and HV3 had no concern about the child’s wellbeing.  7.12  At the last of these visits in June 2011 the mother said she was feeling low and sometimes cried during the day but she had discussed this with her doctor and was prescribed a one-month supply of anti-depressant medication.  7.13  Later in June the subject child’s immunisation schedule was again suspended due to a failure to attend appointments.    7.14  HV3 visited in July where she saw the mother. HV3’s records of this visit make no mention of the subject child although during interview for the IMR HV3 confirmed the child was seen. The mother reported being mentally well, although having some periods of tearfulness and low mood. During this visit the mother introduced information for the first time about the problematic circumstances in which she had grown up. Although the mother did not divulge this to HV3, her GP and MYHT records include reference to the mother’s family circumstances while she was growing up and earlier episodes of depression in 2001 and 2008 for which she had received treatment. HV3 went on extended leave shortly after this visit.  7.15  In August a GP saw the mother and recorded that the mother was no longer taking anti-depressant medication (following the prescription for a one-month supply in June) and was feeling well.   7.16  HV5 visited the family later in September to undertake a routine review of maternal mental health as required under the Healthy Child Programme (see Department of Health 2009). HV5 saw the mother and subject child; she recorded that the subject child looked well and their hand was fully healed. There were no concerns about the mother’s mental health, but HV5 offered advice when she observed the mother shouting loudly at the subject child during some minor temper tantrums. The mother reported that the subject child’s immunisations were up to date (HV5 did not notice that the child’s immunisation schedule had earlier been suspended due to non-attendance). The mother was about to start a parenting course at the local Children’s Centre and records indicate that she completed eleven weekly sessions between September and December 2011while on numerous occasions the child attended the Centre’s activity crèche. HV5 had no concerns about the mother or child’s wellbeing. The mother said she did not need health visiting support so HV5 discontinued further visits. However, although HV5 did not record any specific concerns about the mother’s or child’s wellbeing, she contacted the Children’s Centre in mid-October and requested to be informed if staff identified any parenting problems.   7.17  By December the subject child’s immunisations were up to date. The mother had taken the child for consultations with the GP where appropriate. 18   7.18  During this year the subject child suffered burn blisters to their hand for which there was no explanation, although the burn was appropriately treated. The child’s father and paternal grandmother expressed concern to health visitors about the burn, and a bruise which had been observed near the child’s ear some weeks earlier. A health visitor sought advice/consultation from CSC (Duty and Assessment) about the paternal grandmother’s concern. In June the subject child’s immunisation schedule was suspended for non-attendance, although by December outstanding immunisations had been completed. The mother’s GP prescribed a one- month supply of anti-depressant medication for her in June and she did not attend the GP Practice for a further prescription. During this year health visiting professionals detected no indication that the mother was depressed, although she admitted to occasionally feeling tearful and low. Apart from the subject child’s burn, health professionals’ records suggest that the subject child was well cared for and there were no concerns about health, development or wellbeing.  8.0   Year 4: 1st January 2012 to 28th February 2012 when the  subject child died  At the beginning of this year the subject child was approximately a year and eight months old.   8.1  In early January the mother reported to her GP that she had been feeling low and tearful for six months. The GP prescribed anti-depressant medication.   8.2  Ten days later (Friday 13/1/12) HV4 visited the family home to assess the mother’s mental health following information that a friend had contacted the local Children’s Centre expressing concern about the mother’s mental wellbeing. (HV5 was not working that day).The mother was very distressed and told HV4 she had felt low for months and her GP had recently prescribed anti-depressant medication. She reported being worried that she might reach the point of wanting to take an overdose but that although she was short-tempered with the child she would never cause harm. The family was in the process of moving house and the mother reported to HV4 that although her partner provided practical help with child care he was unsupportive and critical about her low moods. HV4 noted that the subject child was ‘clingy’ towards their mother and recorded the mother’s comments that the child did not like sharing her with her partner. Although the mother’s partner made allowances for the subject child’s behaviour, this had caused arguments. The mother stated that she had good support from her former and current partners’ parents and from her own family and friends. With the mother’s agreement HV4 made a referral to community mental health services (CMHS) and gave the mother contact details for the crisis mental health team if she needed immediate help. HV4 planned to review the situation after the weekend.  8.3  During the home visit (above) HV4 telephoned CSC (Duty and Assessment) with the mother’s consent to seek advice. The chronology and IMR do not contain a health visiting record of HV4’s conversation with CSC, but Duty and Assessment records note this contact as being for advice/consultation. CSC records include 19  concerns about the mother’s mental health, HV4’s referral to CMHS, arrangements for the mother to access the crisis mental health team over the weekend and the mother’s contact with her GP for anti-depressant medication. HV4 reported the mother’s comments that she would never harm her child, said she had no immediate child protection concerns and noted that she would visit after the weekend. The Duty and Assessment social worker concluded that support had been arranged for the mother and no further action was required unless circumstances changed.  8.4  HV4 visited again the following Monday and saw the mother and her child. The mother reported that she felt better and would continue taking anti-depressants, although she would not accept support from CMHS which she had found unhelpful in the past. Picking up the conversation she had previously started with HV3 in July 2011, the mother told HV4 about her very troubled childhood and the difficult circumstances in which she grew up. HV4 observed again that the subject child was very ‘clingy’, but otherwise appeared well and engaged in affectionate interaction with the mother. Mother’s consent was given for HV4 to contact her GP and HV4 strongly encouraged her to accept support from CMHS.  8.5  HV4 liaised with the community mental health team and expressed concern that the mother might not attend the appointment which had been sent to her. A second appointment would be made in the event of non-attendance, but otherwise CMHS could do little without the mother’s co-operation.  8.6  Ten days after HV4’s last visit, HV5 visited the family home as HV4 was on sick leave. The mother answered the door looking pale. She said she had been ill and refused HV5’s request to talk inside the house. HV5 noted that the subject child’s maternal grandmother was in the house.   8.7  Following HV4’s return to work five days later, she unsuccessfully tried to contact CHMS and the mother’s GP. When HV4 did talk to the GP she passed on information about the mother’s referral to CMHS. The GP confirmed the mother’s earlier consultation for depression. HV4 made a no-access visit to the family home and left a card asking the mother to contact her about arranging a visit.  8.8  The following day the mother saw her GP and reported that she was feeling well with no thoughts of self-harm or suicide. It was agreed that she would continue taking anti-depressant medication.  8.9  Two days later HV4 visited the family home and saw the mother (the subject child was reported to be with maternal grandmother). It was reported by the mother that her relationship with her partner had been strained. He had left home for a few days but returned when the mother requested this. The mother had withdrawn from her undergraduate course but was still working on a sessional basis. She informed HV4 that she was benefitting from the anti-depressant medication, felt better and did not need further health visiting or CMHS support. Given the mother’s report that she was now coping well, HV4 did not plan further involvement.  20  8.10  Information available to the SCR Overview Panel indicates that the subject child went to stay with her father and paternal grandparents over the weekend beginning (Friday) 24/2/12. The child had not been well and although had vomited over the weekend appeared to become progressively better. The child’s paternal grandmother returned the child to the family home on Sunday and reports suggest the child was reluctant to leave the grandmother when they arrived home. According to the mother she attended to the subject child twice during the night and early morning and she left the house early for work while the child was still asleep. The mother’s partner left for work about an hour and three quarters later, leaving the child in the care of maternal grandmother. When she went to check, the maternal grandmother found the subject child in a state of collapse in their cot and phoned for an ambulance. The child died from severe head injuries early the following day.  8.11  During this year the mother was again prescribed anti-depressant medication by her GP and shortly after she told HV4 that she had been feeling low for months and felt unable to cope. Information from two subsequent visits by HV4 and the mother’s further consultation with her GP suggested that her mental health was much improved and she continued to take anti-depressant medication. HV4’s observation of the child did not indicate any cause for concern about their wellbeing.   SECTION THREE: ANALYSIS AND LEARNING  9.0  Preliminary comments  9.1  It should be stated that the SCR Overview Panel and the independent author of this report concluded professionals could not have foreseen or prevented the subject child’s death.  Features identified by national evaluations of SCRs as being associated with (although not predictive of) serious injuries to children and child deaths – multiple missed appointments with health and social care professionals, poor home conditions, a history of domestic violence, substance misuse and neglectful parenting – were not apparent in this case.  9.2  Although there were indications of the mother’s mental ill-health, the mother sought and was given appropriate medication by her GP. The mother’s history or depression was recorded by midwifery and health visiting professionals, but they were not aware of her familial history and its association with her early depressive episodes in 2001 and 2008. The mother first mentioned her difficult childhood to HV3 in July 2011. Health visitors did not observe any evidence of the mother’s significant mental distress until January 2012 and following this the mother reported that she was coping well with the help of anti-depressant medication. Investigations by West Yorkshire Police have been unable to establish how the subject child sustained fatal head injuries, although expert medical evidence indicates that they were inflicted non-accidentally. However, information available to health and social care professionals was not such as to indicate the likelihood of any assault on the subject child. As Lord Laming observes, ‘It would be unreasonable to expect that a sudden and unpredictable 21  outburst by an adult towards a child or young person can be prevented’ (Laming 2009: 3).  9.3  Nevertheless, the SCR Overview Panel’s enquiries, assisted by IMRs from the agencies/services involved with this family, identified learning which is discussed below. Analysis and learning has been guided by the SCR Overview Panel’s assessment of areas for detailed scrutiny and investigation (see paragraph 4.5.1).   10.0  Analysis and learning  10.1  The child’s needs and indicators of abuse  The child’s needs: were professionals sensitive to the child’s needs and aware of factors that might have a detrimental impact on the child’s wellbeing? Were professionals knowledgeable about indicators of abuse and/or neglect and about what to do if they had concerns about a child’s wellbeing?  10.1.1  Some of the analysis and learning below relates to the subject child’s burn injury in March 2011. It should be clearly stated, however, that despite the attention given to this incident we do not know whether the burn was caused accidentally or not.   10.1.2  There is evidence from the IMRs that midwifery and health visiting professionals were sensitive to the subject child’s developmental, social and emotional needs. Records demonstrate that they observed and noted indicators of the child’s health, growth and development and the mother’s parenting. Health visitors recorded evidence of good parenting relating to the child’s presentation and demeanour, appropriate development, opportunities for play and affectionate interaction between the mother and child. A health visitor only observed the mother shouting loudly at the subject child on one occasion in September 2011and she offered appropriate advice about consistent and positive parenting.   10.1.3  During HV2’s conversation with CSC in March 2011 following the paternal grandmother’s expression of concern about the subject child’s burn, the focus was on whether the child had received medical treatment. This was appropriate but there is no evidence that the Duty and Assessment worker or HV2 considered the child’s developmental capacity (for example mobility and dexterity) in relation to the burn’s causation or thought about the impact of a burn on a very young child. This conversation was adult rather than child focused. Although HV3 asked the mother about causation of the burn, her evident distress about this and HV3’s subsequent experience of the mother as a competent and loving parent combined to diminish HV3’s concern. The mother’s presentation as a loving parent who was distressed about an apparently inexplicable burn diverted HV3’s attention from the subject child. It should be noted, however, that during HV3’s second home visit the mother reported information from the hospital Burns Unit. This suggested that the burn had been caused by immersion of the child’s fingers in a hot drink. There is no evidence that HV3 sought to clarify this information through direct contact with the Burns Unit or queried with the mother how this could have occurred without her knowledge. 22   10.1.4  When the subject child attended the hospital ED in March 2011 they were seen by a consultant in emergency medicine. After the mother rejected the possible diagnosis of a burn a second consultant offered to look at the injury but by this time the child’s hand was bandaged and the mother declined. The initial diagnosis was uncertain and indicated the likelihood of a burn or a reaction to insect bites. Records indicate that the first consultant questioned the mother thoroughly to try and understand how the injury might have been caused but could not identify an explanation.   10.1.5  ED staff appropriately applied the non-accidental prompt/trigger list introduced on ED cards in 2007. This requires a response to five questions and associated guidance directs a discussion of the case with a senior ED doctor if any of the questions are answered in the affirmative. A prompt also directs that a child under a year old should be seen by a senior doctor prior to discharge, regardless of diagnosis. The guidance above was followed in relation to the subject child. ED records and the IMR author’s interview with the first ED consultant indicate that the consultant made a decision not to refer the subject child to CSC based on applying the trigger list, which did not clearly suggest non-accidental injury, and observation of the child’s positive interaction with the mother.  10.1.6  A third consultant saw the subject child at the follow-up Review Clinic and when asked by the MYHT IMR author why he had not referred the child to CSC responded that he treated hundreds of children with superficial burns. On reflection he suggested that the approach to children with such injuries would now be different (see paragraph 10.1.8).  10.1.7  The MYHT IMR suggests that given the uncertainty of diagnosis and causation ED staff should have referred the child for a paediatric opinion. Additionally, there is no evidence that ED consultants considered the child’s developmental capacity (for example, mobility and dexterity) in relation to whether an accidental injury was likely. These are valid points but there is evidence that ED staff did think about the possibility of non-accidental injury, applied the trigger/prompt list, followed associated guidance and made a considered judgement to discharge the child without making a referral to CSC.   10.1.8  MYHT has introduced or improved several measures to enhance the emergency care of children and to help ED staff recognise and respond to indications of non-accidental injury. It has:   Introduced a Paediatric ED area in all hospitals, where children are assessed by paediatric-trained nursing staff who have an enhanced degree of safeguarding experience and a focus on the child’s welfare. Children are seen urgently by a doctor to reduce their waiting time and associated distress and are routinely referred for a paediatric medical opinion if non-accidental injury is suspected. Under these circumstances the Paediatrician would perform a full child protection medical examination. The MYHT IMR notes an expectation that ED staff would consult with CSC about the child’s history and current presentation. 23   Introduced a Bruising, Burns and Scalds Protocol (August 2011) which directs that when any professional identifies a suspected bruise, burn or scald to a baby who is not yet self-mobile, the case must be referred without delay to CSC, irrespective of any explanation that the parent/carer has provided and the professional’s own judgment about how the injury may have been caused. This Protocol is currently being revised to ensure that it provides clear and comprehensive guidance.  Maintained mandatory safeguarding training for all staff in line with a training strategy developed in 2009. The training strategy was informed by Safeguarding Children and Young People: Roles and Competencies for Health Care Staff (RCRCH 2006) and an intercollegiate document of the same title published in 2010.  Provided every member of staff employed by MYHT with a copy of NICE guidance on when to suspect child maltreatment (NICE 2009), and on a three-year cycle to coincide with mandatory training, circulated other relevant documents published by the Department of Health and NHS.  10.1.9  The Health Review carried out in this case notes the role played by the non-accidental prompt/trigger list and the Bruising, Burns and Scalds Protocol in alerting ED staff to the possibility of non-accidental injury and emphasising the importance of contact with CSC. It confirms that mandatory training should continue to include attention to the Protocol and communication with CSC when non-accidental injury is suspected. Additionally, the MYHT IMR includes the following recommendation to enhance health professionals’ awareness of possible non-accidental injury and appropriate action:  Recommendation for the Mid-Yorkshire Hospitals NHS Trust:   In order to provide clearer direction to professionals when dealing with a bruise, burn or scald in a non-ambulant child, the Safeguarding Team should re-launch the Bruising, Burns and Scalds Protocol to ensure all staff employed since the initial launch in August 2011 are aware of the Protocol. In addition, staff should be reminded of the NICE guidance ‘When to Suspect Child Maltreatment’ which indicates that an unexplained burn should prompt suspicion of child maltreatment.   10.1.10 The IMRs describe thorough arrangements for ensuring that professionals undergo regular mandatory training with regard to safeguarding children and that they are aware of their own agencies’ and inter-agency safeguarding procedures and guidance. Nevertheless there were issues relating to judgment and perception which evaded critical professional reflection in this case and which are unlikely to be resolved through measures to ensure procedural compliance.  10.1.11  First, when the subject child initially attended the ED, diagnosis of the burn was uncertain and as Munro (2011: 9) suggests ‘signs and symptoms (of abuse) are often ambiguous’. Although the Burns, Bruises and Scalds Protocol requires referral to CSC where babies are not self-mobile, at this time the subject child was reported by HV3 to be crawling and walking with the support of furniture. Advice provided to the independent author suggests that, under these circumstances, the subject child may not have been included under the Protocol. 24  Procedures and protocols all constitute rules of an if-then nature and cannot cover all eventualities. This emphasises the importance of nuanced professional judgment and reflection under frequently occurring conditions of uncertainty (Munro 2011). A systems perspective directs our attention here to the context of professional practice, including an organisational and professional culture that encourages learning and consultation and allows sufficient time for reflection.  This is relevant for all professionals in health and social care.  10.1.12  Munro (2011) and Brandon et al (2012) are critical of SCR recommendations that concentrate on introducing or strengthening protocols and procedures because they argue this does not encourage ‘deep’ learning and critical thinking but focuses instead on routine compliance. However, their view and my comments above should be considered in the context of practical imperatives that suggest procedural guidance should have a role alongside professional discretion. The named doctor on the SCR Overview Panel pointed out that in a busy ED environment where there is high staff turnover and safeguarding children is not the focus of professionals’ work, a protocol acts to raise awareness of safeguarding issues. He notes that since MYHT introduced the Protocol named safeguarding doctors have noticed an increase in contact from ED staff seeking advice about children’s injuries and appropriate onward referral to CSC.  10.1.13  Second, health visitors and an ED consultant commented on the mother’s educated, confident and articulate presentation and her evident distress about the subject child’s injury. These features may have distracted them from a focus on the child’s wellbeing. This may be a particular issue for community midwives and health visitors who have a duel mandate to assess and respond to both the child and mother’s wellbeing. Although a parent’s wellbeing is closely associated with their ability to provide good parenting, sufficient time and appropriate education and supervision should encourage professionals to retain a critical focus on the child.   10.1.14  Third, it may be thought that if ED staff had suspected child maltreatment (NICE 2009) and identified safeguarding concerns this would have alerted other professionals (the GP, health visitors and CSC) further down the line. This may be so but health and social care professionals should not derive a second-hand sense of security from the absence of recorded safeguarding concerns at the initial point of a child’s contact with services. Professional qualifying education and ongoing professional development should foster independent critical thought and a willingness to ask relevant questions, particularly as in this case when a very young child suffers a burn for which there is no explanation.   10.1.15  Fourth, the Healthy Child Programme (Department of Health 2009) places onerous responsibilities on the health visiting service for leading its operational implementation, including the early identification of safeguarding issues. National evaluations of SCRs show a significant proportion of children who were never referred to CSC and who thus fell below the radar for safeguarding intervention. In this context Ofsted (2008: 6) notes the crucial role for universal services in keeping children safe and comments ‘it is vitally important that these staff have the necessary skills and knowledge to identify and respond to signs of abuse’. Clearly, sufficiently manageable caseloads, appropriate professional education 25  and ongoing opportunities for professional development and reflective supervision should be in place for health visitors and other universal service providers. From a systems perspective the Government has recognized the importance of increasing capacity in the health visiting service and, importantly, of re-visiting and enhancing its model of professional supervision (Department of Health 2011).  10.1.16  In summary, this SCR concluded that professionals were generally sensitive to the child’s needs and aware of factors that might have a detrimental impact on the child’s wellbeing. They were knowledgeable about indicators of abuse and/or neglect and about what to do if they had concerns about a child’s wellbeing. However, a focus on parental behaviour sometimes diverted professional attention from the child and led professionals to be overly optimistic about parenting capacity. This professional tendency to optimism has attracted comment in national evaluations of SCRs (Brandon et al 2008; 2009; Ofsted 2010). Ambiguity about the signs and symptoms of abuse also means that awareness and action may not fit neatly into procedural frameworks and will require the application of professional judgment, reflection and consultation with colleagues.  10.2  Mental Health Issues Mental health issues: to consider mental health concerns in relation to relevant members of the family. How far were professionals aware of these issues and how did professionals evaluate their significance in terms of the mother’s parenting capacity and the child’s wellbeing?  10.2.1  Although health visiting records included reference to the mother’s early history of depression, it appears that none of these professionals were aware of the detailed circumstances relating to this. These details were however evident in the mother’s MYHT medical records and the GP Practice records. Midwifery and health visiting records did not indicate any episodes of maternal depression although the community midwife alerted the health visiting service in May 2010 about the mother’s low mood and HV3 recorded the mother’s reports of low mood and tearfulness in March (relating to the child’s burn), June and July 2011. It was not until HV4 made an urgent visit to the family home in January 2012, that the mother divulged the extent of her depression and said she had recently been prescribed anti-depressant medication by her GP.  10.2.2  It is clear from the records that midwifery and health visiting professionals were alert to maternal mental health issues and completed mental health assessments as appropriate (except following the birth of the subject child when HV1 had two no-access visits and knew the mother and baby were attending services at a well-baby ‘drop-in’ clinic). Community midwives and health visitors recorded that for the most part the mother presented as being emotionally well. During a conversation between health visitors and representatives from the SCR Overview Panel, health visitors commented that maternal expression of low mood and tearfulness is not uncommon during pregnancy and following a baby’s birth. They said there was nothing unusual about this mother’s presentation which would have differentiated her from most other mothers on a health visitor’s caseload. Reported episodes of low mood were not such as to raise any significant 26  concerns about parenting capacity, particularly as in all other respects (apart from the child’s burn injury) the subject child was observed to be well, reaching developmental milestones and as having an affectionate relationship with the mother.   10.2.3  When representatives from the Overview Panel met the mother’s second partner and his parents, they reported their suspicions that the mother was depressed. They thought it would have been helpful for the health visiting service to arrange consultation and support visits to both parents in cases of maternal depression. Health visitors reported to Overview Panel representatives that they would arrange joint maternal/paternal visits if they identified any cause for concern. However, in this case until January 2012, health visitors did not identify any evidence of maternal depression and although occasionally reporting low moods, the mother denied feeling depressed. Unknown to health visitors, the mother was seeking treatment for depression from her GP.   10.2.4  HV4’s urgent visit to the family in January 2012 was the first time that community health professionals became aware of the mother’s depression. Even so they remained unaware of previous episodes when the GP had prescribed anti-depressant medication. Records indicate that HV4 was alert to safeguarding issues, assessed the risk of harm to the child, liaised with the GP Practice, referred the mother to community mental health services and consulted CSC. Nevertheless, during two follow-up visits HV4 was reassured that the mother’s depression was lifting and at her last visit accepted the mother’s assertion that she did not need further health visiting support.   10.2.5  The Locala Community Partnerships (LCP) IMR comments that health visitors responded to incidents of concern as they arose and did not reflect upon the history of this case in relation to the mother’s mental health and parenting capacity. This seems to have been the case when HV4 dealt with the immediate issues arising from the mother’s depressive episode in January 2012 but later accepted the mother’s assertion that she did not require further support. Incident-driven practice has also been a feature of professional intervention identified in local and national evaluations of SCRs (Smith 2010; Ofsted 2008; 2010). Reflective supervision is again important in this context. However, health visitors were missing important information about this mother’s history of depression which was known to the GP and which might have alerted them to its significance in relation to parenting capacity.  10.2.6  The family’s GP Practice held information about the mother’s early periods of depression in 2001 and 2008 and about the family context in which these occurred. GP records also included three consultations for depression in April 2010 (when she was pregnant with the subject child), June 2011 (when the subject child was just over a year old) and January 2012 (when the subject child was about a year and eight months old. The Practice was also notified about the subject child’s ED attendance in March 2011. In March 2011 HV3 contacted the Practice to enquire about any concerns regarding the subject child and in January 2012 HV4 spoke to the GP about the mother’s mental health. There is no evidence that in January 2012, the GP told HV4 about the mother’s earlier episodes of depression. 27   10.2.7  There is no indication that Practice GPs considered the mother’s history of depression in relation to parenting capacity and the mother’s ability to meet her child’s needs or that they checked health visiting records on SystmOne to identify any concern about the mother and child’s wellbeing. The GP IMR notes that GPs routinely scrutinise only the last entry on a patient’s health record when they attend for a consultation. Larger GP Practices with part-time and/or salaried clinicians and multiple healthcare providers result in relatively little continuity in a GP’s contact with patients and their knowledge of a patient’s history.  10.2.8  As the independent author, I am concerned that the current system for the provision of GP services impedes continuity of knowledge and reflection about a patient’s history which may be relevant for understanding their current parenting capacity and potential safeguarding issues. Evidence in this case suggests that patient consultations are dealt with as singular events with little reference to history or social context. I have identified this as a problem in other SCRs. There are two possible responses to this learning. The most challenging is to encourage GPs to apply curiosity and intelligent reflection to their patients’ history and social circumstances when they attend for a consultation, and the second is to adopt a pragmatic approach. The latter concentrates on alerting GPs to potential safeguarding issues when they open a patient’s medical record. With the pragmatic approach in mind, work is currently underway to introduce a flagging system on GP records so that an indication of concern will appear on their screens when they open a patient’s health records. The following recommendation is designed to implement this arrangement.   Recommendation for NHS Greater Huddersfield and NHS North Kirklees Clinical Commissioning Groups:   SystmOne team should arrange for an alert/flagging/safeguarding node system to be available for use on GPs’ patient records so all children with concerns can easily be identified with regard, for example, to a failure to attend appointments, failure to attend for immunisations and other appointments such as psychology services when referrals are issued, attendance at hospital Accident and Emergency, parental mental health issues, parental substance abuse and domestic violence.  10.2.9  The most challenging response to learning with regard to GPs requires a broader approach to enhancing their critical and reflective capacity such that they are more likely to consider their patients’ presenting problems in relation to their medical history, social circumstances and potentially associated safeguarding issues. The SCR Overview Panel therefore supported the following local recommendation to improve GPs’ understanding of the relationship between parental mental ill health, parental substance misuse and domestic abuse, and potential safeguarding concerns. It also made a further national recommendation for all GPs which seeks to improve GPs’ thinking skills and awareness of the significance that singular consultations may have with regard to parenting capacity and children’s wellbeing when viewed in the context of a parent’s/carer’s medical history. Briefing sessions recommended below should enhance GPs’ alertness to particular issues, while the recommendation for NHS England seeks 28  to encourage ‘deeper’ learning so that critical thinking and reflection come to characterise the way in which GPs identify and respond to patient information in a safeguarding context.  Recommendation for NHS Greater Huddersfield and NHS North Kirklees Clinical Commissioning Groups:   Briefing sessions should be delivered to General Practice clinicians that focus on the increased vulnerability of children and young people when they are living in households where there is parental mental ill-health, parental substance misuse or domestic abuse.  Recommendation for NHS England:    NHS England should consider how best to enhance GPs’ ability to think critically and reflectively about a patient’s medical history in relation to the way in which this may affect parenting capacity and the identification of safeguarding concerns regarding children.  10.2.10  During two hospital appointments, the mother reported that she was tearful and low in mood. Mother was advised on both occasions to see her GP as he/she had previously treated the mother for depression. The MYHT IMR queries whether there were relevant Mental Health Pathways that would have been beneficial in monitoring the mother’s mental health at that time. The Health Review which was completed following the subject child’s death identifies the importance of introducing this Pathway and it has now been incorporated into the Euroking electronic records system.   10.2.11  This report has concentrated on the subject child’s mother’s mental health because reference to this was included in community midwifery, health visiting and GP records. However, it is also important that professionals should be alert to relevant features of a father’s/partner’s social and emotional wellbeing in relation to their parenting capacity and potential influence on a mother’s parenting. Professionals knew very little about the mother’s partners. Although the subject child’s mother did not report that her partners had any mental health or other significant wellbeing issues, there is no evidence that professionals were alert to these factors in the same way that they were about recording indications of the mother’s mental health.  10.2.12  In summary, the SCR identified evidence that community health professionals were generally alert to maternal mental health issues and their potential impact on parenting capacity. However, there is no evidence during 2011 when the mother reported low mood and tearfulness, that the health visitor associated this with mental health problems. Similarly, when HV4 visited the family in January 2012 a tendency to incident-driven practice meant that although attention was given to the child’s immediate safeguarding needs, there was no evidence that HV4 considered longer-term issues associated with parenting capacity. Health visitors’ assessment of the mother’s mental health was limited at least in part because they did not have full information about the mother’s mental health history (this is considered as a communication issue under paragraph 10.5). 29  Additionally, despite the current good practice emphasis on a father’s/partner’s potential impact on maternal wellbeing and parenting capacity (Department of Health 2009), there is no evidence that community health practitioners enquired about this aspect of family life. The proposed increase in health visiting capacity (Department of Health 2011) should allow more time for reflection under these circumstances and professional education and supervision are relevant in this context.  10.2.11  National evaluations of SCRs have identified a high incidence of mental health issues in parents where children have been seriously injured or died. Although the majority of parents with mental ill-health do not present a risk to their children (HM Government 2010: 9.30) and reference to mental ill-health includes a broad range of clinical conditions and severity, professionals should be alert to the possible impact of parental mental health issues on parenting capacity and children’s wellbeing.   10.3  Significant adults in the subject child’s life Significant adults: to consider dates of changes in partners and whether these relate to incidents of mothers depression / low mood. Were professionals sufficiently alert to the possible impact of changes in the mother’s partners on her mood and parenting capacity and did they explore the parenting capacity of the mother’s partners and their role in family life?  10.3.1 In May 2010 the community midwife contacted the health visiting service requesting an antenatal visit as the mother’s partner had left and she was low in mood. This health visitor clearly recognised the association between the mother’s separation from her partner and her low mood. Interestingly, just over a month before this community midwife’s contact with the health visiting service, the mother had consulted with her GP and been prescribed anti-depressant medication. Neither the community midwife or health visitor (HV1) was aware of this.  10.3.2  Community health records note the mother and her first partner’s reconciliation and his presence during some home visits following the subject child’s birth. It is not known when the mother separated permanently from the subject child’s father but health visiting records from March 2011 include details of ongoing contact between the subject child, their father and paternal grandparents. Information available to the Overview Panel indicates that the mother started a relationship with her second partner around October 2010, although this was unknown to professionals.   10.3.3  Health visitors never met mother’s partner and relevant information about his role in family life was gleaned indirectly from the mother. In September 2011 the mother reported that she and her partner had ‘differing views’ about parenting. The next health visitor contact was in January 2012 when the mother was acutely distressed. At this visit the mother reported that her partner provided practical help with the child but was emotionally unsupportive and critical of her low moods. She noted arguments resulting from the subject child’s unwillingness to tolerate her partner’s attention, although he made allowances for the child’s behaviour. 30   10.3.4  Although health visitors recorded the mother’s comments about her second partner’s attitude towards her and the child and noted differing views about parenting, there is no evidence that they explored these comments or reflected on their significance for the mother and child’s experience of family life. In January 2012 the mother’s observations about her partner’s critical attitude and difficulties with the subject child’s behaviour should have raised questions about the extent to which her partner was able to offer emotional support and the nature of his relationship with the subject child. There is no evidence that these issues were pursued during the health visitor’s subsequent home visits. At the mother’s request, further health visitor contact was suspended in February 2012 without any further discussion of family relationships.  10.3.5  It is clear that health visitors are responsible for giving a significant amount of information and advice to parents in addition to monitoring maternal and child health. This may impede their ability to adopt an exploratory and facilitating role when mothers indicate problems in parental and family relationships. When representatives from the Overview Panel spoke to health visitors, they were told that health visitors would make time to discuss problematic family issues. However, this will not happen unless health visitors recognise the significance of information in relation to the wellbeing of parents and children.   10.3.6  There is no evidence that during health visitor contacts with CSC (Duty and Assessment) in March 2011 and January 2012 either party to the conversation explored the role of the mother’s partner in family life, including his relationship with the mother and child. While the Duty and Assessment contact records identify the ‘family name’ and child’s full name, they do not include the full names of the parents/carers of a child who is the subject of a referral or professional contact for consultation/advice.  10.3.7  Although this section refers to professional awareness of the role of fathers/partners in family life and their potential impact on a mother’s wellbeing and parenting capacity, the Overview Panel was alert to the potential importance of other significant adults in this context. The roles played by extended family members and friends may exert varying degrees of influence on  parenting capacity, the social and emotional dynamics of family life and children’s wellbeing. Professionals should be alert to situations where significant adults outside the nuclear family play an important role in relation to parents’/carers’ and children’s wellbeing and be ready to explore this further where appropriate.  10.3.8  In summary, although the mother provided information to midwifery and health visitors about her partner(s), there is no evidence that these professionals (or CSC) explored its significance in relation to the quality of family life and the child’s wellbeing. A professional tendency to neglect the role of fathers/partners and to focus attention on mothers has been identified locally and in national evaluations of SCRs (Brandon et al 2009; Ofsted 2010). Similarly, there is evidence that GPs and health visitors accepted the mother’s assertion that she had good support from her extended family and friends without exploring this further.  31  10.3.9  The LCP IMR notes that some progress in identifying details about fathers and extended family members has been made. The parent health needs assessment template in the electronic health records should extend collection of this information since its expansion to incorporate ‘care and support circumstances and networks’. Similarly, the MYHT IMR notes that the Trust has been concerned to introduce systems to ensure identification and recording of household composition. To this end it has implemented the Unborn Child Safeguarding Integrated Care Pathway which identifies household composition and the Assessment Document for admission of all adult patients which triggers the collection of information about household composition and safeguarding concerns. The Euroking electronic maternity records system also has the capacity to record details about adult family members and children.   10.3.10  Although recording systems in the NHS are increasingly able to record details about household composition, is must be remembered that it is not simply the collection of information about family members/networks that is important but a professional ability to explore the significance of these for parents’ and children’s wellbeing.   10.3.12  The Healthy Child Programme best practice guidance (Department of Health 2009) emphasises the importance of involving partners/fathers and supporting them in their parenting role. It notes that a ‘father’s behaviour beliefs and aspirations can profoundly influence the health and wellbeing of both mother and child in positive and negative ways’ and insists that fathers should routinely be invited to participate in child health reviews and should have their needs assessed. For this to be accomplished health visitors’ contact with families will have to be more flexible, and paternal as well as maternal family relationships and roles will have to be at the forefront of health visitors’ minds.  10.4  Parenting Issues Parenting issues: to consider the impact of her own upbringing on the mother’s parenting capacity and her request for help with parenting. Were professionals sufficiently aware of the relationship between the mother’s experience of family life as she was growing up and her parenting capacity?  10.4.1  The SCR Overview Panel had difficulty in identifying evidence that health visitors were sufficiently responsive to the association between parental history/characteristics and a child’s wellbeing. The mother gave information to HV3 and HV4 about significant difficulties in her own childhood and experience of family life. It is now well understood that parenting capacity is influenced by a parent’s own experience of emotionally secure and consistent parenting (Brandon et al 2008). The mother’s comments should have led HV3 and HV4 to explore her experience of being parented and to reflect on her parenting capacity in this context. While we cannot know how far they thought about this, practical issues which are discussed below impeded their ability to pursue this further. Community midwives were unaware of the mother’s history and records indicate that although they made routine enquiries, the mother denied any problematic issues relating to her family.  32  10.4.2  The LCP IMR notes that HV3’s observations led her to assess the mother as warm, competent and caring. There is no evidence that she questioned this assessment in the light of later information about the mother’s difficult childhood experiences. However, following the mother’s disclosure about her childhood, HV3 left on extended leave negating the opportunity for further discussion of this issue.  10.4.3  During interview with the IMR author it was evident that HV4 was aware of the need to explore the mother’s disclosure about her childhood experiences in relation to her parenting capacity. However, HV4 did not want to put pressure on the mother during what was only her second visit and at that time (January 2012) HV4’s primary concern was to assess the mother’s mental health and the child’s safety. HV4 told the IMR author she had planned to discuss the mother’s comments at the next visit. Unfortunately, a period of sick leave interrupted this process and at a subsequent visit the mother made no reference to her family history and declined further health visitor contact. Although it is clearly difficult for universal service professionals to initiate conversations with parents about emotionally difficult topics, there is no evidence that HV4 attempted to re-open a discussion about the mother’s earlier remarks regarding her childhood. Reflective supervision would have been appropriate under these circumstances.  10.4.4  It is evident that the mother only shared information about her difficult childhood and family relationships with health visitors on two occasions (in July 2011 and January 2012). HV3’s perception of the mother as competent and caring and as willing to engage with healthcare professionals may have clouded her critical reasoning about the potential impact of the mother’s family history on her parenting capacity. Further reflection was not possible as HV3 left for an extended period of leave. Although HV5 reported to the IMR author that she recognized the importance of discussing the mother’s history further, there is no evidence that she tried to do so or recorded a concern about this by the time the mother declined further health visiting contact in February 2012.  10.4.5  In summary, although the subject child’s mother told HV3 and HV4 about her difficult childhood, they had little opportunity to explore this with her at the time. However, there is nothing in their records which identifies this as a matter of concern or as requiring further attention. It should be acknowledged that for the most part evidence available to community health professionals indicated that the subject child’s mother was a competent and caring parent. Visits to the family home and observations of the child suggested that the child was well cared for and meeting all developmental milestones. Given a busy working environment and evidence of competent parenting, it requires a high level of critical thinking and reflection (and the time to engage in this) to recognise the potential significance of parental family history in relation to parenting capacity.   10.5   Information sharing and inter-agency communication Information sharing and inter-agency communication: to consider whether key information was shared appropriately between agencies and professionals, whether the significance of information was clarified and understood and whether agencies and professionals responded effectively to information.  33  10.5.1  There is evidence of good communication between the community health professionals. In May 2010 the health visiting service were informed of the mother’s separation from her partner and low mood and this prompted a targeted visit to the mother by HV1. Similarly, HV3 appropriately shared with relevant health colleagues’ information about the subject child’s burn which at the time required the mother and child to attend for treatment appointments. The health visiting service also communicated appropriately with the mother’s local Children’s Centre to ensure that staff passed on information if there were any concerns.  10.5.2  Over the period of the Review six different health visitors either received information about the family or were directly involved as case managers in home visits. There is no evidence that this affected communication between health visitors and they clearly accessed the electronic recording system (SystmOne) to ensure they had relevant information arising from other health visitor contacts with the family.  10.5.3  A routine notification from the hospital ED about the subject child’s attendance with a burn injury in March 2011 was received by a health visiting team administrator four days later but was not reviewed by a health visitor until six days following its receipt. This delay resulted from several causes. First, ED sends paper notifications to an administrative hub from where they are distributed to health visiting or school nursing teams according to the child’s age. Second, the ED notification did not identify any safeguarding issues and the health visiting team administrator did not therefore consider it urgently for health visitor review. Third, as the LCP IMR notes, approximately 150-300 notifications from EDs are received daily by Locala. In this case the number of notifications was managed by allocating them for health visitor review at weekly team meetings. Although this issue relates as much to information management as it does to inter-agency and professional communication, it meant that HV2 was unaware of the child’s ED attendance and subsequent treatment at the time when she was listening to the paternal grandmother’s concerns and subsequently sought advice from CSC. Although the ED notification would not have heightened HV2’s concern, since it did not identify safeguarding issues, it would have provided accurate information about the child’s ED attendance and diagnosis.   10.5.4  The LCP IMR notes that the arrangement for paper ED notifications currently remains the same. However, work is underway to implement electronic notifications to expedite communication, health visitor review and appropriate follow-up where necessary. Learning in this context had identified the following recommendation:  Recommendation for Locala Community Partnerships:   A timescale for review of Accident and Emergency notifications by health professionals should be introduced into health visiting and school nursing operational guidelines.  10.5.5  Records indicate that at the mother’s initial visit to the ED, she was asked about any involvement from CSC and replied there was none. The MYHT IMR suggests 34  that it would have been good practice to check the veracity of the mother’s response directly with CSC given that the ED was dealing with an unexplained injury to a young child. Similarly, when an ED receptionist phoned the family to enquire about two missed appointments at the ED review clinic and was told the child’s burn was being treated by the Burns Unit at another MYHT site, there was no communication with the Burns Unit to confirm this. Although these instances were not significant in this case, they might well influence the course of events in other cases where parents/carers do not provide accurate information.   10.5.6  The MYHT IMR identifies changes in the hospital’s provision of ED services for children which should alert staff more effectively to the possibility of non-accidental injury and the necessity for inter-agency communication in this context. These changes have been discussed at paragraph 10.1.11. In relation to the ED receptionist’s failure to check information, the Health Review completed in May 2012 implemented action to incorporate this learning into training and to communicate it to relevant staff via hospital ED ‘Safeguarding Champions’.  10.5.7  The records of HV2 in March 2011 and HV4 in January 2012 indicate that their contact with CSC (Duty and Assessment Team) was in both cases for advice/consultation and CSC records suggest this was mutually understood. However, these contacts raise two issues regarding communication. First, HV2 passed on the concerns as related to her by the paternal grandmother and included the grandmother’s comment that the subject child’s burn had been treated by the GP. In fact the GP did not see the child for treatment but was notified about this by the hospital ED. It would have enabled a more focused conversation with CSC if HV2 had checked on the subject child’s treatment, immunisation status, the mother’s antenatal care and what was known about domestic violence and ‘no access’ before the contact with CSC. (The CSC records indicate that HV2’s reference to domestic violence and ‘no access’ relied on information from health visiting colleagues but the SCR Overview Panel’s enquiries found no evidence that domestic violence characterised either of the mother’s partner relationships during the period covered by the SCR).   10.5.8  Second, CSC’s records only refer to information provided by health visitors and give no indication of questions asked by the Duty and Assessment worker. The Overview Panel was concerned that there was no evidence in March 2011 of the Duty and Assessment worker asking about other adults living in the household, seeking further information about causation of the burn to the subject child or requesting clarification about HV2’s comments relating to domestic violence. All contacts to Duty and Assessment are screened by a manager before a decision about further action is ‘signed off’ and in this case there was no evidence that the apparent lack of information about important aspects of the child’s circumstances was challenged at this stage.  10.5.9  When representatives from the Overview Panel discussed this case with the two relevant managers from CSC Duty and Assessment, they were informed that it was routine practice for staff to ask probing questions when contacted for advice/consultation but that the pressure on this service made it difficult to record every detail of conversations with other professionals. Under these circumstances Duty and Assessment staff prioritised recording information and 35  agreed action. The Duty and Assessment team had reviewed this case following the subject child’s death and implemented action to ensure that whenever possible Duty and Assessment staff should record the full conversation between its staff and other professionals; that managers should record their reasons for decision making following a contact; that a conversation with professionals should not finish until there is a clearly agreed conclusion about responsibility for taking further action; and that professionals should confirm information and agreed action in writing following their contact with CSC Duty and Assessment. The representatives from the Overview Panel were satisfied that the Duty and Assessment Team had considered learning in this case and implemented appropriate action. The Overview Panel did not identify further recommendations to improve the communication practices of this service.  10.5.10  Communication from the GP Practice to other primary healthcare services was poor. This is an issue which has attracted attention in other local SCRs. In this case the Practice held information about the mother’s history of depression in 2001 and 2008 and her further consultations for depression in April 2010, June 2011 and January 2012. Additionally, the Practice had received a notification from the hospital ED in March 2011 about the subject child’s attendance with a burn injury. There is no evidence that GPs accessed SystmOne to check whether the health visiting service had any concerns about the child’s wellbeing or that at any time the GP initiated contact with health visitors. HV3 contacted the Practice to enquire about contact with the subject child following the child’s ED attendance and HV4 initiated contact in early February 2012 about the mother’s depression.  10.5.11  Over the period covered by this SCR it has been the practice for a health visitor link to have regular meetings with a GP Practice to discuss families and children where there are safeguarding concerns. The Overview Panel was advised that such meetings occur in most GP Practices six-weekly to three-monthly and were established in the mother’s GP Practice over the Review period. However, in this case the subject child was never discussed despite GP records about the mother’s history of depression and the subject child’s burn injury. Despite this being considered as an issue relating to communication, it is of course evident that professionals will not think to communicate if they do not recognise the importance of doing so. Learning suggests that GPs should be encouraged to take responsibility for identifying children and families for discussion with health visitor links rather than relying on the health visitor, who may have incomplete information, to do this. The alert/flagging model discussed at paragraph 10.2.7 where information indicating a safeguarding risk to children is clearly visible to GPs when they open a child or parent/carer’s health record, should enable GPs to more readily identify children about whom there are potential safeguarding concerns. Additionally, another model for alerting GPs to safeguarding issues – the Child Safe Global Trigger Tool (The Health Foundation 2010; Health Quality and Safety Commission 2013) which collates safeguarding information and acts to trigger further action where appropriate is currently subject to piloting and scoping arrangements in GP Practices. The following recommendation is designed to support these arrangements.   Recommendation for NHS Greater Huddersfield and NHS North Kirklees Clinical Commissioning Groups: 36    With the assistance of the alert/flagging system currently under development, GPs should adopt a proactive approach to identifying children and parents/carers where potential child safeguarding concerns may be indicated. This should inform consultation at meetings with the link health visitor so that healthcare information can be shared effectively and should also support piloting and scoping the introduction of a model - the Child Safe Global Trigger Tool – for safeguarding children in primary care.   10.5.12  GPs can currently access health visitors’ records on the shared electronic recording system (SystmOne) and could do so over the Review period. However, health visitors were unable to see GP’s patient health records on SystmOne. Had they been able and had they thought to do so, health visitors in this case could have developed a much better understanding of the mother’s depressive episodes over time and some understanding of her family background via access to her GP records. Recognising the importance of mutual information sharing, arrangements have now been made for health visitors to access adult and child GP patient records on SystmOne across Kirklees. This will rely on GPs obtaining patients’ consent. The following recommendation seeks to ensure the effective implementation of this measure.  Recommendation for NHS England West Yorkshire Area Team:   NHS England West Yorkshire should do everything it can to ensure that all Kirklees GP Practices routinely request that their patients consent to their health visitors having access to GP health records relating to children and their parents/carers.  10.5.13  In summary, although the Overview Panel identified evidence of good communication and information sharing, particularly between the community midwifery and health visiting services, the mother’s GP(s) were not proactive in communicating with health visitors. CSC’s contact records of conversations between CSC and health visitors lacked important information (for example, about the mother’s partner and his role in family life) and evidence of clarification (for example, about causation of the child’s burn and the child’s developmental capacity). Although health visitors contacted the GP Practice in March 2011 and January 2012, they did not make any enquiries about the mother’s family history or seek information from the GP about any previous episodes of depression. As I have noted, sometimes inter-agency/service communication depends on professional awareness that this is necessary to safeguard children and this in turn requires appropriate knowledge, reflection and a continued focus on the child.  10.6  Organisational features The organisational context: were there any factors in agencies / organisations which acted to impede good practice relating, for example, to resource issues, professional supervision and development, effective management oversight, communication and recording systems?  37  10.6.1  Although all the agencies/services involved with this case were reported to be very busy, the SCR did not identify any particular resource issues or organisational disruption that might have acted to impede good practice. When Overview Panel representatives met some health visitors involved with this family, they said that it was difficult but not impossible to make time for exploring problematic issues with families as well as delivering information and advice. The Government’s health visitor implementation plan (Department of Health 2011) recognises the importance of building capacity in the health visiting service to effectively implement the Healthy Child Programme best practice guidance. CSC Duty and Assessment managers reported that it was difficult to fully record conversations with other professionals when they telephoned for advice/consultation but they had emphasised to front line workers that they should do this as far as possible.  10.6.2  Ofsted (2008) emphasises the role of universal service professionals in identifying child abuse and neglect, particularly for those children on the margins of the child protection system. However, this remains a challenge given that professionals working in universal services will only ever see a relatively small number of child safeguarding cases in the population of children and families with whom they have contact. Significant factors identified by this SCR pointed less to resource issues or organisations’ structural features and more to issues associated with professionals’ knowledge, awareness and ability to maintain a focus on the subject child. In this context professional qualifying training, ongoing professional development and reflective supervision play an essential role in preparing and supporting professionals to complete their routine professional tasks while at the same time remaining alert to the possibility of safeguarding issues. As noted, protocols and procedures are tools for guiding professionals towards required actions but cannot replace professional judgment in ambiguous and uncertain circumstances.  10.6.3  The importance of regular supportive, challenging and reflective supervision has been mentioned above and this has been emphasised in national evaluations of SCRs and reviews of child protection arrangements (Laming 2009; HM Government 2010; Munro 2011; Brandon et al 2012). At the time of this SCR all LCP clinical staff who worked predominantly with children and were thus in a position to identify safeguarding concerns, were required to access a minimum of quarterly peer group safeguarding supervision and one individual safeguarding supervision session with a named nurse per year. These requirements included health visitors. Additionally, the LCP Child Protection Policy requires clinicians, including health visitors, to request individual safeguarding supervision with a named nurse child protection when working with families where there are ‘complex safeguarding or child protection concerns’. Clinicians can attend additional peer group supervision sessions as required and request individual supervision with a named nurse at their discretion.  10.6.4  The Government (Department of Health 2009; 2011) recognises the importance of reviewing supervision arrangements for health visitors in response to their role in implementing the Healthy Child Programme. At the time of writing LCP was acting to integrate clinical and safeguarding supervision with accompanying training for front-line practitioners so that they would know, as supervisors and 38  supervisees, what to expect from supervision. This will have the effect of enabling routine discussion of ‘low level’ safeguarding concerns that do not meet the threshold of ‘complex safeguarding or child protection concerns’ identified as requiring supervision in the LCP Child protection Policy. Staff will still be required to initiate supervision with the named nurse when they identify complex safeguarding concerns.   10.6.5  The SCR Overview Panel was concerned that health visitors did not seek supervision with the named nurse over the Review period. This would have been appropriate at least when health visitors were sufficiently concerned to contact CSC and when the mother declined further health visitor support in February 2012. The difficulty here is that for the most part health visitors must first be aware that particular circumstances warrant supervision and use their discretion to arrange it. Their critical thinking is not regularly and routinely challenged as should happen in specialist safeguarding services like CSC. LCP are currently reviewing supervision arrangements to ensure that they facilitate good practice. However, in universal services the significance of supervision for challenging and clarifying professional thinking without the prior identification of complex safeguarding concerns, remains a challenge that is not amenable to a ‘quick fix’ solution.  10.6.6  In summary, the SCR did not identify organisational or significant resource issues that impeded good practice in this case. All the agencies/services involved with the subject child recognised their safeguarding responsibilities and the organisations had sought to support good practice in this context. The early Health Review completed by the Designated Nurse for Greater Huddersfield and North Kirklees Clinical Commissioning Groups (2012) identified further action and implementation plans to improve practice which I have identified during the course of this report. At the heart of good practice must lie system arrangements that encourage professionals to be curious and to think critically, systematically and intelligently about what they observe (Brandon et al 2008; 2009; Munro 2011). This applies to organisations that design and provide qualifying programmes of professional education as well as to organisations in which qualified professionals will eventually work.  11.0  SUMMARY OF LEARNING  11.1  Much of the learning from this SCR was anticipated by the early Health Review completed in May 2012, which has already resulted in action to improve practice. Learning from the Health Review and subsequently from this SCR is summarised below:   When health or social care professionals become aware that a very young pre-verbal child has suffered an unexplained injury, they should ask questions about the child’s developmental capacity (for example, mobility and dexterity) in relation to the likelihood of its non-accidental occurrence. This should be undertaken with reference to local and national safeguarding procedures and guidance.  Professionals should look out for any loss of focus on the child’s wellbeing, which may be prompted by parental distress or other parent/carer 39  characteristics. They should remain alert to the possibility that their concern about a child’s wellbeing may be diminished by their positive perception of the ways in which parents/carers present themselves to professionals.  Although health and social care professionals should be familiar with evidence-based knowledge about the potential association between parental family history, mental health and parenting capacity they also need to recognise when such knowledge is relevant and can enhance their understanding in individual cases.  Professionals should remember that parenting capacity and the quality of family life are not only related to maternal wellbeing but also to the involvement and wellbeing of fathers/partners and sometimes of extended families and friends. When, as in this case, partners/fathers are relatively invisible, professionals need to adopt an inquisitive attitude about their role in family life. Similarly, professionals should explore parents’/carers’ assertions that they have good support from their extended family and friends.   Professionals need the time and opportunity to reflect on case histories so that they can better understand patterns and developments over time in relation to the assessment of parents’ and children’s wellbeing and future planning. They also need to think about how information from other agencies/services might contribute to a full understanding of case history.  The Burns, Bruises and Scalds Protocol used by MYHT needs revision so that it is clear and leads to effective practice and it should be re-launched to ensure that newly appointed staff are aware of this guidance.   GPs should be encouraged to consider repeated parental episodes of depression in relation to broader issues of family life, parenting capacity and children’s wellbeing. In this context they should ensure (within the constraints of patient consent) that other health care professionals, particularly health visitors, have access to relevant information. GPs should recognise the importance of proactively cross-referencing information with that held by community midwives/health visitors in relation to their role in a network of universal health care providers.  12.0   GOOD PRACTICE  12.1  Practice in relation to expected professional standards has been identified throughout this report. However, the following are notable instances of good practice:   When the mother attended the Walk in Centre following the subject child’s burn, the community nurse sought advice from the Burns Unit about the most appropriate treatment and informed the health visiting service and GP about the child’s attendance and the lack of an explanation for the child’s injury.  On receipt of information about the mother’s distressed condition in January 2012, the health visitor immediately made a home visit to assess the mother’s mental health and any safeguarding issues for the child.  13.0   RECOMMENDATIONS ARISING FROM THIS SCR  13.1  Much of the learning from this SCR has already led to changes which are designed to improve practice and which I have described above. Brandon et al 40  (2012) discuss the difficulty of identifying SMART recommendations that are at the same time amenable to implementation and audit while leading to learning that runs deeper than mere compliance with the latest procedures, protocols, messages from training, and role specifications. They note that the SCR process may constitute the most effective learning for the agencies/services involved and not all of this can be translated into recommendations. Not all of the recommendations arising from this SCR have been included in this report because either the identified learning has already led to remedial action or because to do so would require the disclosure of information which is inappropriate for publication. The remaining recommendations are listed below:  Recommendations for the Mid-Yorkshire Hospitals NHS Trust:   In order to provide clearer direction to professionals when dealing with a bruise, burn or scald in a non-ambulant child, the Safeguarding Team should re-launch the Bruising, Burns and Scalds Protocol to ensure all staff employed since the initial launch in August 2011 are aware of the Protocol. In addition, staff should be reminded of the NICE guidance ‘When to Suspect Child Maltreatment’ which indicates that an unexplained burn should prompt suspicion of child maltreatment.   Recommendations for NHS Greater Huddersfield and NHS North Kirklees Clinical Commissioning Groups:   SystmOne team should arrange for an alert/flagging/safeguarding node system to be available for use on GPs’ patient records so all children with concerns can easily be identified with regard, for example, to a failure to attend appointments, failure to attend for immunisations and other appointments such as psychology services when referrals are issued, attendance at hospital Accident and Emergency, parental mental health issues, parental substance abuse and domestic violence.   With the assistance of the alert/flagging system currently under development, GPs should adopt a proactive approach to identifying children and parents/carers where potential child safeguarding concerns may be indicated. This should inform consultation at meetings with the link health visitor so that healthcare information can be shared effectively and should also support piloting and scoping the introduction of a model - the Child Safe Global Trigger Tool – for safeguarding children in primary care.    Briefing sessions should be delivered to General Practice clinicians that focus on the increased vulnerability of children and young people when they are living in households where there is parental mental ill-health, parental substance misuse or domestic abuse.  Recommendation for NHS England West Yorkshire Area Team:   NHS England West Yorkshire should do everything it can to ensure that all Kirklees GP Practices routinely request that their patients consent to their 41  health visitors having access to GP health records relating to children and their parents/carers.   Recommendation for NHS England:   NHS England should consider how best to enhance GPs’ ability to think critically and reflectively about a patient’s history in relation to the way in which this may affect parenting capacity and the identification of safeguarding concerns regarding children.  Recommendation for Locala Community Partnerships:   A timescale for review of Accident and Emergency notifications by health professionals should be introduced into health visiting and school nursing operational guidelines.  14.0   CONCLUSION  14.1  Although I have noted earlier the Overview Panel’s conclusion that professionals could not have foreseen or prevented the subject child’s death, this does not mean that this SCR has not identified learning which should lead to improvements in practice.  14.2  At the heart of this learning, as has been identified in so many other SCRs, lies a professional ability to remain alert to safeguarding issues and to sustain a reflective capacity in the midst of routine professional activities. For those professionals who deliver universal services this is a significant challenge when they will come across safeguarding issues in a minority of their cases while occupying professional roles that bring them face-to-face with early signs of parenting problems and child abuse.   15.0  REFERENCES  Brandon, M., Sidebotham, P., Bailey, S., Belderson, P., Hawley, C., Ellis, C. & Matthew Megson (2012) New Learning from Serious Case Reviews: a Two-Year Report for 2009-2011, University of East Anglia and University of Warwick   Brandon, M., Belderson P., Warren, C., Howe, D., Gardner, R., Dodsworth, J. and Black, J. (2008) Analysing child deaths and serious injury through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005, London: Department for Children, Schools and Families  Brandon, M., Bailey, S., Belderson, P., Gardner, R., Sidebotham, P. Dodsworth, J., Warren, C. And Black, J. (2009) Understanding Serious Case Reviews and their Impact: a Biennial Analysis of Serious Case Reviews 2005-2007, London: Department for Children, Schools and Families  42  Department of Health (2009) Healthy Child Programme: Pregnancy and the First Five Years of Life  Department of Health (2011) Health Visitor Implementation Plan: A Call to Action  Health Foundation (2010) Evidence Scan: Global Trigger Tools, London: The Health Foundation  Health Quality and Safety Commission (2013) The Global Trigger Tool: A Review of the Evidence, Wellington, New Zealand: Health Quality and Safety Commission  HM Government (2010) Working Together to Safeguard Children, London: The Stationery Office  HM Government (2013) Working Together to Safeguard Children, London: The Stationery Office  Laming, H. (2009) The Protection of Children in England: A Progress Report, London: House of Commons  Munro, E. (2011) The Munro Review of Child Protection: Final Report, London: Department for Education  Munro, E. and Hubbard, A. (2011) ‘A Systems Approach to Evaluating Organisational Change in Children’s Social Care’, British Journal of Social Work 41:4, 726-743  National Institute for Clinical Excellence (NICE) (2009) When to Suspect Child Maltreatment: Clinical Guidance, London: RCOG Press  Office for Standards in Education, Children’s Services and Skills (2008) Learning lessons, taking action: Ofsted’s evaluation of serious case reviews 1 April 2007 to 31 March 2008, Manchester: OFSTED  Office for Standards in Education, Children’s Services and Skills (OFSTED) (2010) Learning Lessons from Serious Case Reviews: 2009-2010, Manchester: OFSTED.  Smith, C. (2010) Learning from Serious Case Reviews in Kirklees, Report prepared for KSCB   (The Health Foundation 2010; Health Quality and Safety Commission 2013)   43   Kirklees Serious Case Review – Child aged 1yr 9m – Recommendations from the Overview Report  KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG   Review Date   1  SCR023 Case summary: Child died 02/2012 aged 21 months. Death followed blunt force trauma leading to brain injury.  SCR 023/ 001 The Mid Yorkshire Hospitals NHS Trust (OR) Staff employed by the Mid Yorkshire Hospitals NHS Trust need to understand their professional responsibilities to ensure that appropriate actions and referrals are made when dealing with a bruise, burn or scald The outcome of this action will give clearer direction to professionals when dealing with a bruise, burn or scald in a non-ambulant child.  In order to provide clearer direction to professionals when dealing with a bruise, burn or scald in a non-ambulant child, the Safeguarding Team should re-launch the Bruising, Burns and Scalds Protocol to ensure staff employed since the initial launch in August 2011 are aware of it. In addition, staff should be reminded of the NICE guidance 'When the Suspect Child Maltreatment' which indicates that an unexplained burn should prompt suspicion of child maltreatment.  MYHT to be represented on the Wakefield LSCB  task and finish group to revise the Bruising, Burns and Scalds protocol    Protocol reviewed, revised and approved March 2014.  Patient Safety Bulletin forwarded as evidence     Task and Finish Group documentation  Evidence: Patient Safety Bulletin – Oct 2013    May-14       Green                 May-15 SCR 023/ 002 NHS Greater Huddersfield and NHS North Kirklees Clinical Commissioning Groups (OR)  GPs must be more proactive when receiving information about a child which indicates a safeguarding concern  SystemOne team should arrange for an alert / flagging / safeguarding node system to be available for use on GPs’ patient records so all children with concerns can easily be identified with regard, for Progress the flagging work and roll out to all GP practices in Kirklees Alert/Flagging system already under consideration for SystmOne records. Needs to be implemented in order for easier identification of safeguarding concerns for a child Agenda for SystmOne User Group meeting - 26/01/2014   Copy of presentation   Record of rep Mar-14     Green  May-15 Kirklees Serious Case Review – Child aged 1yr 9m – Recommendations from the Overview Report  KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG   Review Date   2  example, to a failure to attend appointments, failure to attend for immunisations and other appointments such as psychology services when referrals are issued, attendance at hospital Accident and Emergency, parental mental health issues, parental substance abuse and domestic violence.  and parents/carers, i.e. failure to attend for immunisations, attendance at A&E, parental mental health issues, and domestic violence.   attendance from each practice  SCR 023/ 003 NHS Greater Huddersfield and NHS North Kirklees Clinical Commissioning Groups (OR) When health or social care professionals become aware that a very young pre-verbal child has suffered an unexplained injury, they should ask questions about the child’s developmental capacity (for example, mobility and dexterity) in relation to the likelihood of its non-accidental occurrence. This should be undertaken with reference to local and national safeguarding procedures and guidance  With the assistance of the alert/flagging system currently under development, GPs should adopt a proactive approach to identifying children and parents/carers for consultation at meetings with the link health visitor so that healthcare information can be shared effectively.  GPs to discuss all children / families of concern with link HV  Meetings between GP practices & HV link to take place monthly or bi-monthly  Discussions between GP and HV Links and actions taken to be recorded in child’s records   This is part of the above ongoing work.   Letter advising all GP Practices re GP / HV Link meetings  Audit of the meetings   New Guidance for GP / HV Meetings  Mar-14  Green May-15 Kirklees Serious Case Review – Child aged 1yr 9m – Recommendations from the Overview Report  KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG   Review Date   3  SCR 023/ 004 NHS Greater Huddersfield and NHS North Kirklees Clinical Commissioning Groups (OR) All safeguarding training must incorporate the concept of ‘healthy scepticism’ and ‘respectful uncertainty’ between practitioners and families in all cases especially when disclosures about being a health professional are made by parents/carers  Briefing sessions should be delivered to General Practice clinicians that focus on the increased vulnerability of children and young people when they are living in households where there is parental mental ill-health, parental substance misuse or domestic abuse.  NKCCG / GHCCG – GP Practices / Practice reps to attend Practice Protected Time [PPT] briefings / workshops  All Greater Huddersfield CCG GP Practices attended the Practice Protected Time (PPT) where this was covered in detail  North Kirklees CCG GP Practices: flagging meetings underway Copy of presentations delivered x 3                   Copy of PPT Flyer  Copy of presentations                    Attendance lists Mar-14  Green May-15 SCR 023/ 005 NHS England, West Yorkshire Area Team (OR)  GPs should be encouraged to consider repeated parental episodes of depression in relation to broader issues of family life, parenting capacity and children’s wellbeing. In this context they should ensure (within the constraints of patient consent) that other health care professionals, particularly health visitors, have access to relevant information. GPs should recognise the importance of proactively cross-referencing information with that held by community midwives/health visitors in relation to their role in a NHS England, West Yorkshire should ensure that all Kirklees GP Practices routinely request that their patients consent to their health visitors having access to GP health records relating to children and their parents/carers GPs to encourage patients to allow HVs to share records This recommendation no longer applies as, nationally, there has been the introduction of a new electronic records management system, the Enhanced Data Sharing Model (EDSM). This gives the patient the control and they can now choose whether to share the full medical details with other health provider units (for example Health Visitors)                                   http://www.tpp-uk.com/latest-news-stories/systmone-enhanced-sharing-model-gets-full-roll-out-approval-3/   Mar-14 Green May-15 Kirklees Serious Case Review – Child aged 1yr 9m – Recommendations from the Overview Report  KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG   Review Date   4  network of universal health care providers.  SCR 023/ 006 NHS England (OR) This  national recommendation seeks to improve GPs’ awareness of the significance that singular consultations may have with regard to parenting capacity and children’s wellbeing when viewed in the context of a parent’s/carer’s medical history. NHS England should consider how best to enhance GPs’ ability to think critically and reflectively about a patient’s history in relation to the way in which this may affect parenting capacity and the identification of safeguarding concerns regarding children. Newsletter to be circulated across W Yorks, which includes learning from Safeguarding Serious Incidents  Standards and identifying risk Newsletter sent to CCGs for distributing across GP practices, which includes learning from Safeguarding Serious Incidents – April 2014                                                Work with CCG to ensure Level 3 safeguarding training is available and should help GPs to think reflectively. CCGs providing briefing sessions  Newsletter Apr-14 Green May-15 SCR 023/ 007 Locala Community Partnerships (OR) Notifications of children's attendance at Accident and Emergency departments must be reviewed within an agreed timescale to ensure an appropriate timely responses and information sharing when there is a possibility of non-accidental injuries. A timescale for review of Accident and Emergency notifications by health professionals should be introduced into health visiting and school nursing operational guidelines. All A+E notifications to be reviewed by a health professional in an agreed timescale which is set in the health visiting and school nursing operational guidelines  All information received from A +E departments must be viewed by a health professional within 3 days of receipt and signed and dated. Further reassessment of the family or young person's circumstances should be considered based upon the circumstances and professional judgement.                                     Timescale agreed and Supporting Families Teams Practice Process Guidelines (Locala, 2013) Aug-13 Green May-15 Kirklees Serious Case Review – Child aged 1yr 9m – Recommendations from the Overview Report  KSCB Ref Responsible Agency Lessons from SCR Recommendations Actions Required Agency Response / work undertaken Evidence / Outcomes Target Date RAG   Review Date   5  introduced into operational guidelines - 3 day timescale for health professional review following receipt of A+E notification agreed Guidelines ratified on 08.08.13                                 