Two cases of non-accidental head injuries and bruising of 14-week-old infants. A bruise was observed on Baby 1 two months prior to injuries; Baby 2 was in the care of their father at the time of the incident. Learning includes: advice on safe sleeping and safe handling needs to be provided to both parents; professionals need to consider how they can meaningfully engage with fathers, including those who do not live with the child; awareness of the impact of having a new baby on fathers as well as mothers; if information about a new baby is not shared directly with a health visitor, it cannot be guaranteed with current systems that all important information will be known by them; even a small bruise on an infant needs to be recognised as a potential warning injury by professionals; family members should not have unsupervised contact with their child in hospital if a non-accidental injury may be the reason for attendance. Recommendations to the safeguarding children partnership include: use learning from the next national child safeguarding practice review to explore what can be done to improve the involvement of fathers in work with families with new babies; undertake work to provide a better understanding of the role of fathers and the need to engage with fathers, and consider projects in other parts of the country; seek assurance from partner agencies regarding knowledge and use of the injuries in non-mobile babies policy.
      
    Serious Case Review No: 2022/C9295  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.      1       Child Safeguarding Practice Review STORK – babies with injuries  Contents 1 Introduction to the review Page 1 2 Process Page 1 4 Analysis and identification of learning Page 2 5 Conclusion and Recommendations Page 10  This report is strictly confidential. It must not be shared without the agreement of the  SCP (Safeguarding Children Partnership ). The disclosure of information (beyond that which is agreed) will be considered as a breach of the confidentiality of the children and agencies involved.    Introduction to the review 1. This review considers systems and practice within and between partner agencies in the Safeguarding Children Partnership (SCP) area specifically with regard to the assessment and safeguarding of infants where there are few known pre-disposing risks or vulnerabilities. 2.  In order to identify learning and good practice, and to consider the need for improvement action, the review reflected on two cases where babies were the subject of a serious safeguarding incident.   3. The learning identified is in relation to:  Bruises in non-mobile babies  Involving fathers  Late identification of pregnancy  Professional objectivity   Process  4. Following rapid review processes1 and consultation with the Child Safeguarding Practice Review Panel, the SCP identified that lessons could be learnt regarding the way that agencies work together to safeguard babies2 in the area.                                                              1 A rapid review is undertaken in order to ascertain whether a Local Child Safeguarding Practice Review is appropriate, or whether the case may raise issues which are complex or of national importance and if a national review may be appropriate. The decision is then made along with the national Child Safeguarding Practice Review Panel.    2  5. The CSPR was conducted in accordance with the requirements set out in:   The Children Act 20043 (as amended by the Children and Social Work Act 20174)  Working Together 20185  Local Multi-Agency Children’s Safeguarding Policy and Procedures   6. In order to identify learning and consider the need for improvement action, the review considered two cases where babies have been injured. Neither of the families considered were known to statutory agencies, other than a period where the mother of Baby 2 was known to children’s social care when she was a child.    Baby 1 was 14 weeks old when they suffered non-accidental head injuries. They lived with both parents and an older sibling. There had been no concerns identified about Baby 1 or the family prior to this, although around two months prior to the injuries a bruise was observed on the baby’s forehead. Baby 1’s mother had presented very late with the pregnancy and had requested a termination. This was not possible as a scan showed she was over 35 weeks pregnant.      Baby 2 was also 14 weeks old when they suffered non-accidental head injuries and bruising. Baby 2 was in the care of their father at the time of the incident. The parents were no longer a couple. The mother was known to CSC as a child. She told the midwives and health visitor that there had been controlling behaviour from the child’s father in their relationship.   7. Consideration of these cases enabled the review to focus on the systems that were in place and what works well in a strengths-based approach, alongside an exploration of where there may be learning for the system and for multi-agency practice.  8. In respect of the cases considered, personal family details will only be disclosed in this report where it is essential to the learning established during the review.   9. An independent lead reviewer6 was commissioned to work with a panel of local safeguarding professionals from the key agencies. The lead reviewer facilitated practitioner events,7 will speak to the families and produced this report. The lead reviewer and the panel collaborated on identifying the learning and writing recommendations from this CSPR.  10. Agency involvement at the time was considered by each individual agency through the completion of case specific chronologies, which included analysis and the identification of any single-agency learning. From these chronologies and the rapid review information, themes were identified for discussion with the professionals involved in the cases at practitioner events. The events also considered wider practice with infants and systems for assessing and safeguarding babies in SCP area. Analysis and identification of learning                                                                                                                                                                                                                     2 It was agreed that this learning review would be undertaken rather than individual child safeguarding practice reviews after consultation with the National Child Safeguarding Practice Panel in July 2020. 3 http://www.legislation.gov.uk/ukpga/2004/31/contents  4 www.legislation.gov.uk/ukpga/2017/16/contents/enacted  5 https://www.gov.uk/government/publications/working-together-to-safeguard-children--2  6 Nicki Pettitt is an experienced lead reviewer and has undertaken numerous Serious case reviews and CSPRs since 2009. She is entirely independent of all partner agencies.  7 This was by virtual meeting technology due to the impact of Covid-19    3  The review has established learning in the following areas and each theme will be considered in detail. Thematic analysis Involving and considering fathers Late identification of pregnancy, professional objectivity and bruising/marks in non-mobile babies.   Involving and considering fathers8   11. Learning has been identified nationally about the requirement for meaningful involvement with fathers by professionals working with children. In January 2020 the Child Safeguarding Practice Review Panel announced that they have commissioned a new national thematic review which will look at non-accidental injury in children under one. It is understood that one of the strands is about working with fathers. Fathers should always be considered and involved during the pregnancy, at the time of the birth and in the months that follow. There have been a large number of published case reviews where fathers or the partners of mothers are responsible for the death or harm of babies due to unsafe sleeping, shaking and other injuries. The second national review commissioned by the Child Safeguarding Practice Review Panel and published in 20209 states that infants dying suddenly and unexpectedly represents one of the largest groups of cases notified to the panel.  12. Professionals in both of the cases acknowledged that there is an expectation that information predominantly given to mothers is shared with fathers by the mother rather than directly being provided by the professionals involved. In the case of Baby 2, where the parents did not live together and where there was no clear plan at the time of the birth for what contact the father would have, there was a potential gap in systems for expected information sharing. This included key advice in regard to safe sleeping and safe handling not being shared with the father by any professional. This was by no means just an oversight in this case. It is an issue across the system.  Advice is provided verbally and in written form to mothers at key points during antenatal and postnatal care. A number of useful leaflets are provided for this purpose in SCP area, for example about coping with crying babies (ICON), immunisations, weaning, and safer sleeping.  However the advice and written information is largely provided to the mother and it is clear that this does not always filter through to all of those adults who are likely to have care of the child. In the case of Baby 2 it is now known that the baby was spending one night a week with their father from around six weeks old, and that there had been no professional contact with father. It is possible that no health promotion information had been shared with him.  13. There was also very limited professional contact with Baby 1’s father. This was described by those involved as common in cases where the provision of support is universal and that it can particularly be an issue with fathers/partners who work from 9 – 5, which are the hours that health visitors tend to visit families. It is also an issue when the parents are separated, such as in the case of Baby 2. Baby 1’s father was an experienced father as there was an older sibling. He was seen at a number of visits from the midwives and health visitor but was not engaged with directly other than small talk. Again, this is not                                                            8 This report refers to fathers but they could be mother’s partners, including in same sex relationships 9 Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm. 2020     4  unusual when the provision of support is universal. What was significant in this case is that the health visitor and midwives spoke to mother about how she felt about having another baby, particularly one that was due just a month after the pregnancy was identified. The same exploration was not undertaken with the father, despite Mother sharing with the midwives that her partner had not wanted any more children. There was no consideration of exploring the impact of a new baby with the father.  14. One of the obstacles to working with fathers/secondary carers is that during pregnancy and immediately after the birth it is the mother who is the midwife’s patient. Engaging with the father would complicate this relationship and simple things, such as storing information provided by the father on the pregnancy notes could potentially be a breach of data protection - although permission could be gained for this.  Engaging with fathers as well as mothers is good practice however and is more likely to provide a holistic assessment and intervention. In the cases considered in this review both fathers were known or known about and their details were correctly recorded. One lived with his family and was seen on occasion; one did not live with the mother and was not seen. This led to key information on safe sleeping and safe handling not necessarily being shared and limited knowledge of the child’s likely lived experience.  15. As well as posing a potential risk to children, fathers can also be a protective factor. For example fathers who do not live as part of the immediate family may be capable of caring for and protecting a child. Case reviews show that they are often overlooked by professionals10, often along with the wider paternal family.  Sandstrom et al11 made specific recommendations about identifying fathers and male carers, including: ‘being explicit with mothers about the importance of speaking to the father and including him in the process, while also ensuring that she would not be put at risk; speaking separately to the father rather than gathering information solely through the mother; and arranging separate home visits if necessary to explain the relevance of his involvement with the child, communicating a willingness to include him in decisions.’  The biggest issue reported by health visitors in regard to involving fathers is a lack of time, and that currently it is not a mandated contact or currently expected. It was stated during the review that it would be impossible with current caseloads to speak separately with all fathers on universal caseloads. It is acknowledged that it would take flexibility in the system and a change in the commissioning of the service to ensure that fathers and secondary carers are fully involved at this crucial time for their children. 16. In the case of Baby 2 Mother told the midwives that the relationship with the baby’s father had ended in part because he was jealous and controlling. She came across as confident and assertive and was adamant that the relationship was over. She felt it was important that the baby had a relationship with their father however. Questions were asked about this and Mother was clear that the baby’s father had never been physically aggressive and that she did not have concerns about him as a father. Around the time of the birth Mother had wondered whether the father should be present.  Both the midwife and the health visitor, who undertook an antenatal visit, spoke to Mother about this and it appears she decided against it. Good support was provided by both practitioners. Following the incident Mother told the police                                                            10 Hidden men: learning from case reviews. Summary of risk factors and learning for improved practice around ‘hidden’ men. NSPCC April 2015 11 Approaches to father engagement in home visiting programs. 2015    5  that the father had been at the hospital and had seen the baby right after the birth. The health visitor saw Mother and Baby 2 at home on three occasions. She enquired about contact between the baby and Father, and on the last visit, around seven weeks before the incident, Mother told her that the baby was staying for one night a week with his father and was very positive about this. She said that father lived with the paternal grandfather. The health visitor was not concerned as Mother reported that the plan was going well.  17. It is important for all professionals to be aware that difficulties can emerge after the birth of a child for fathers (or other secondary carers) as well as for mothers and in families where there were no previous concerns. This can include relationship issues, overwhelming concerns about the amount of responsibility that children bring, and a lack of confidence in the role. There is increasing evidence that fathers can suffer with a form of post natal depression12 which may have been an issue in these cases. The 2018 NICE guidelines on postnatal depression do not mention fathers, and awareness of this as an issue is low13. This is despite the fact that the numbers of men who become depressed in the first year after becoming a father is double that of the general population. Professionals need to be aware of this as a possibility, and consider it when engaging with families, particularly where there are pressures and stresses, as could have been the case in both families considered.  18. In neither case was any consideration given to how the father’s were managing with a new baby and the fathers were largely ‘invisible’ in the records.  It is potentially significant that both babies were just over 3 months old at the time of the injuries, as the research states that this is the time when father’s start to struggle most. Research shows that fathers feel isolated during the perinatal period as attention is understandably focused on their partner and new baby.  New parenthood is a time of stress and sleeplessness, and both parents are going to be more susceptible to anxiety and a decline in emotional wellbeing.14 This need to be acknowledged and addressed by the professionals working with the families.  19. In 2015 the NSPCC published a report called Hidden Men - Learning from Serious Case Reviews15.  It states that ‘men play a very important role in children’s lives and have a great influence on the children they care for. Despite this they can be ignored by professionals who sometimes focus almost exclusively on the quality of care children receive from their mothers and female carer.’ In order to ensure that fathers or partners are also acknowledged in work undertaken with mothers and children, there needs to be a review of systems and services, a commitment that organisations may have to provide additional or re-focused resources, and a cultural shift. The two cases considered in this review have identified there is a potential need for such changes across partner agencies regarding the role of fathers in families, and the need to engage with them when assessing, supporting and making plans for all children. This is necessary when they are living in the home or if they live elsewhere but have involvement with the child.                                                              12 Research available from the National Childbirth Trust (NCT) found that more than 1 in 3 new fathers (38%) are concerned about their mental health. It states that one in 10 fathers have PND and appear more likely to suffer from depression three to six months after their baby is born. 13 Community Practitioner magazine November 2018 and #HowAreYouDad? campaign  14 The Dad Project. NSPCC 15 https://learning.nspcc.org.uk/media/1341/learning-from-case-reviews_hidden-men.pdf    6  20. Research undertaken by The Fatherhood Institute along with the University of Worcester16 concluded that Health Visitors are well placed to engage with fathers of young children and their study provides strong evidence of the usefulness and benefits of training health and family practitioners in father-inclusive practice. It also reflects the need for providers of services to reconsider the need for out of hours’ services, as well as to assess how fathers’ needs and aspirations are acknowledged in leaflets, posters, and group sessions.  21. There was awareness amongst the professionals who were spoken to as part of the review that it is necessary to work with both parents and that father’s are important and significant. This awareness is in place and appears to make a difference when it comes to cases where there are known risks and vulnerabilities and where children are on a plan, be it child protection, child in need or early help. This is less evident in cases where there are no concerns and where the provision of services is universal. This is largely due to the limited time available for midwives and health visitors to spend on cases where there are no or few concerns. In both cases it was a shock to those involved that the babies were so significantly harmed, as there had been so little indication of potential risk.  Learning  Advice in key areas such as safe sleeping and safe handling needs to be provided and reinforced to both parents, including parents who do not live with the baby if they are to have contact.   Fathers need to be seen as equal parents in order to ensure that the needs and risks to a child are met and known.  Professionals need to give separate consideration to how they can meaningfully engage with fathers, including those who do not live with the child. This is a challenge in universal cases.   Professionals need to be aware of research on the impact of having responsibility for a new baby on fathers as well as mothers.  Late identification of pregnancy, professional objectivity and bruising/marks in non-mobile babies.  22. In the case of Baby 1, the mother had attended BPAS17 for a termination of pregnancy. She stated that she’d had a difficult pregnancy with her first child and that she did not plan to have any further children. The scan undertaken found that she was in fact just over 35 weeks pregnant and thus she was unable to have a termination. She was advised to seek urgent ante-natal care and her GP was informed (with her consent.) The midwives involved in the weeks that followed were aware of mother’s wish for a termination and explored with mother how she now felt about having a baby. They were reassured that while it had been a shock Mother was now happy and that her partner and wider family were supportive. This information was not shared with the health visitor, who was not aware until after Baby 1’s injuries that a termination had been requested. There is work being undertaken on the pathways for information sharing in the area.  Agreement has been reached that information should be shared when a termination had been sought and not received due to late gestation. Issues of consent have been                                                            16 Burgess, Jones, Nolan, Humphries 2015 17 British Pregnancy Advisory Service    7  identified and it is acknowledged that this will require a change to the local procedures, which is being considered.  23. There was some complexity to the case as Baby 1’s mother worked in a team in the community which included health visitors and family support staff, one of whom was the health visitor allocated to her. This may have had an impact on why Mother did not share the information about the termination, but it is also possible she may have assumed that, as the midwives knew and that the GP had been informed, the health visitor would be aware. Service users often make the understandable assumptions that information sharing between professionals is more effective than it actually is.18 During the antenatal appointment with the health visitor Mother shared her concern that she might not bond with the baby as she had so little time before it was due. The health visitor provided appropriate advice. This conversation made the health visitor think that Mother was open and candid and she had no concerns that Mother was might be concealing any information.  Likewise, the midwives had no concern that Mother would not share this information with the health visitor.  24. In the areas covered by the SCP there is no consistency regarding whether health visitors have access to GP or midwifery records.  Some GPs surgeries have SystmOne, which health visitors can access, others do not. If a health visitor has concerns about the well being of a child, they would access the GP information either on the system or by calling the GP. There was nothing about the case of Baby 1 at the time that would have led to such an action however. This means that the health visitor was responsible for baby 1 without the potentially significant information about the plan for a termination. Direct information sharing is important if it is known that there is a risk factor that could potentially be a safeguarding issue (in this case the request for a termination that was unable to be performed due to the late gestation.) All health professionals need to take responsibility for sharing information they are made aware of and should not assume that other professionals will have been told or will have access to the information.   25. In this case there were significant time pressures for the professionals involved as Mother had booked so late in the pregnancy. Even within normal time scales there are enormous expectations at the time of and immediately following a baby’s birth and limited time to complete all required tasks. It was acknowledged that health visitors need to be well informed about the family history and the potential risks when they take on responsibility for a child at around 10 days old, but realistically it is only if there are any concerns that there is a verbal handover between midwives and health visitors and checks made with the GP.  26. Immediately following birth, Baby 1 spent some time in the special care baby unit (SCBU). This was due to a concern about their breathing. It is known that there can be a negative impact on bonding between parents and their child when a new baby has to spend time on SCBU. A survey completed by Bliss (an organisation for the parents of babies born sick or prematurely) in 2018 showed that most parents felt their mental health got worse after being on the neonatal unit.  It is not known if this had an impact on Baby 1’s parents and their relationship with the child. The standard checks were undertaken with mother                                                            18 The Children’s Commissioner for England. Family Perspectives on Safeguarding and Relationships with Children’s Services. June 2010    8  following the birth and there was no indication of depression, and those professionals who visited after discharge observed a close relationship and good care from the mother and had no concerns.   27. An issue emerged for Baby 1 around eight weeks before the serious incident. A colleague of both mother and the health visitor was engaged in a text conversation with Mother. She was described as both a colleague and a friend. Mother told her that the baby was very unsettled when being cared for by anyone but her. She later said that the baby had a small bruise on the forehead from having ‘head butted’ Father while wiggling.  She wrote “it’s an innocent bruise but I feel that if people see it, I’ll be judged.” She also said that she was concerned it would result in a SAFER referral19. The colleague decided to go and see the mother and baby at home that evening.  She saw the baby who seemed happy and content and described the mark as very small and pale in colour. She also remarked on how strong the baby seemed when held and that the baby was trying to hold their head up and that this seemed consistent with the description of them head butting the father. The next day the colleague felt she needed some advice about what she knew so she approached a manager. Coincidently the manager had seen the baby that day as Mother and Baby 1 had come into the office. As she had not noticed the bruise, she felt there was no need for any action other than a plan to provide on-going support. The information about the bruise and how unsettled Baby 1 was, and the plan to support was not shared with the allocated health visitor, who in fact visited the family a week later. Mother also did not share any information with the health visitor about the bruise or how unsettled the baby had been.  28. This is potentially an example of ‘professional dangerousness’, a phrase proposed by Morrison20 in 1990 to describe the process where ‘professionals involved in child protection work can behave in a way which either colludes with or increases the dangerous dynamics of a family.’ This was expanded on by Sidebotham et al21 in 2016 where they explored the findings from a large number of serious case reviews and concluded that individual and systemic practice can come together to put a child at risk. In this case what turned out to be dangerous for Baby 1 was; a positive view of the fact that Mother had provided the information about the bruise which she did not need to do; a view, without seeking further advice, that the bruise could have occurred in the way described; the professional and personal relationships which led to a positive view of the mother and a wish not to subject her to the system that would be unleashed should a SAFER need to be put in; and the reluctance to think the unthinkable - that there could have been non-accidental harm inflicted on the baby of a colleague and friend.  29. The professional and friendly relationship between the mother and members of the team undoubtedly had an impact on the response to the bruise, which is understandable. It is difficult to be objective with a colleague and friend. The colleague described being worried which is why she felt she needed to take advice from a manager. The manager does not appear to have properly considered all of the information before deciding there was no cause for concern. This is being dealt with outside of this review. The single agency learning in this case has led to action to ensure that no members of staff are allocated a health visitor from the team where they work, to ensure that the objectivity of assessment is not compromised due to professional and personal relationships.                                                             19 SAFER is the name of the form used in the area to make a referral to children’s social care.  20 The Emotional Effects of Child Protection Work on the Worker. Tony Morrison  21 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014.     9  30.  It is positive that no assumptions were made that the mother of Baby 1 would be more able to cope without support than other mothers, and that it was recognised that additional support would be needed following the bruise. There is no evidence this support was provided however and as the information was not shared with the health visitor by her colleagues or by mother, they were unable to provide their own professional judgement in regard to the baby and the bruise, and they were unable to provide the additional support that it appears was required.  31. Before babies move on their own and move independently bruises are unusual. An American study22 found that babies that have serious non-accidental injuries have often received less serious injuries previously, so called ‘sentinel’ or ‘harbinger’ injuries. The study found that around a third of infants who had been abused had a previous sentinel injury. This was compared to none of the non-abused infants whose cases served as controls. The most common type of sentinel injury in children who were definitely abused was bruising (80%). This led the author to conclude that "detection of sentinel injuries with appropriate interventions could prevent many cases of abuse."  It is possible that in the case of Baby 2 the bruise reported by mother was a sentinel injury and an indicator that there were risks that needed considering.23   32. In the case of Baby 1 there was additional learning identified for partner agencies about the need to address, at the first possible chance, the supervision of contact between parents and babies in hospital if a non-accidental injury is part of a differential diagnosis24. EDT told the hospital that Mother could supervise contact between Father and the baby. This was before any consideration had been given to the timing of the possibly injury and who may be in the pool of perpetrators. This was not challenged at the time. The strategy meeting held just a few hours afterwards reversed this decision and it was agreed that all contact with both parents needed to be supervised. In this case this was not too much of an issue as at the time the baby was receiving 1:1 nursing and had a lot of medical attention, and the decision was changed quickly. In another case however this could put the child at risk. There has been action taken in relation to this particular incident.  Learning  The need for professional curiosity is essential when there are issues in a case that may lead to additional needs or risks, and professionals should have an open mind to ensure they do not make assumptions about how a family will cope.   Without information being shared directly when the responsibility for a new baby transfers to a health visitor, it cannot be guaranteed with current systems that potentially important information will be known by them.   When professionals are aware of even a small bruise on a very young child, they need to recognise it might be a warning injury.  They need to take action and make appropriate referrals, explaining to parents that they HAVE to do this and follow the Bruising in Non-Mobile Babies policy.                                                            22 Dr Lynn Sheets Children's Hospital of Wisconsin. March 2013.  23 Baby 2 also had a mark on their head which was identified by the health visitor at the new birth visit when Baby 2 was three weeks old. The mark was documented as being present since birth and considered to be a haemangioma. There is no learning identified in regard to this mark.  24 Differential diagnosis is a process where a doctor differentiates between two or more conditions that could be behind symptoms.    10   The benefits of employing support workers from within communities need to be balanced with the risks when there is a potential child protection issue for someone living and working in the area.   Family members should not have unsupervised contact with their child in hospital if a non-accidental injury may be the reason for the attendance.   Conclusion and recommendations   33.  Since the injuries occurred in these cases, the ICON25 programme has been launched in SCP area and professionals have been trained in the methods. ICON is a programme developed to help professionals provide advice and support to families in respect of coping with a crying baby to prevent shaking and abusive head trauma. This should help improve the provision of advice about safe-handling and is timely as OFSTED have announced that abuse of babies has increased by a fifth during the COVID pandemic. The programme needs to ensure that it includes the fathers or co-parents as well as mothers and ensure that those not living with the child also receive the advice and support. It is acknowledged that the response to COVID-19 in hospitals (current when this review was undertaken) makes this difficult due to the ban on visiting following a birth. This means the community response is particularly crucial.  34. The current policy in regard to Concealed Pregnancy is being reviewed by the local Partnership Procedures Group to consider what professionals should do if a mother presents very late in her pregnancy. This should also include what needs to happen if the delay in identifying the pregnancy means that a planned termination cannot take place. 35. Good relationships within and between agencies were noted and there is clearly a commitment to safeguarding vulnerable children in the area. The response to the referrals about the injuries were largely good and there are plans in place to protect both children going forward.  36. There has been good cooperation and engagement from agencies with this review process, which has allowed us to identify the learning.  It is recognised that actions have already been taken in relation to some of the individual agencies’ identified learning in this case, and that changes have been made.  37. The SCP is a new organisation that combines two previous Boards. The partnership is considering the learning from a number of reviews, to consider similarities and shared issues. The previous LSCB serious case review undertaken in 2017 highlighted the need to avoid assumptions about the protectiveness of parents, for example, which was an issue in this case.   Question for the SCP to consider: How can the partnership influence the necessary cultural and systemic changes across all partner agencies regarding the role of fathers and secondary carers in families?   Recommendation 1: The SCP to request that its partner agencies take the learning from the next national CSPR when it is published and explore further what can be done to improve the involvement of fathers in work                                                            25 ICON stands for I - Infant crying is normal, C – Comforting can help O - Okay to walk away and N – Never ever shake a baby    11  undertaken with families where there is a new baby in the area. They should then provide an update to the SCP on what changes they intend to make.  Recommendation 2: That the SCP asks commissioners to undertake a piece of work to provide a better understanding from professionals in partner agencies of the role of fathers, the need to engage with fathers and to consider projects in other parts of the country that are making a difference to all families.     Recommendation 3: That the SCP requests assurance from partner agencies regarding the knowledge and use of the Injuries in Non-Mobile Babies policy.  Recommendation 4: That the SCP considers that this review is published anonymously by area in the NSPCC library, due to the sensitivity in the case of Child 1.      