Death of a 3-year-old child, from an asthma attack. Child K1 had been diagnosed with brittle asthma and was on a child protection plan for neglect. Child K1 was living with their father and paternal grandmother who was the main carer at the time of death. Child K1's mother was suffering from depression and was unable to care for Child K1. Child K1's father was known to youth offending services, CAMHS and Connexions, and had a history of depression. Child K1 had had many health appointments related to asthma and had been admitted to hospital 9 times between 2013 and 2015 for asthma attacks. Learning includes: professionals need to take into account safeguarding concerns such as the impact of smoking and home environment; health professionals need to ensure they have a good understanding around the concept good enough care for a child with a chronic illness; consider the father's role in caring for a child; involving the housing provider in child protection meetings where there are rent arrears and neglect. Recommendations include: lead health professionals to be identified for all children with a chronic health problem with clear communication systems in place for information sharing. Uses a systems approach based on the Manchester methodology.
      
 Title:  Child K1: serious case review. LSCB: Manchester Safeguarding Children Board Author: Anne Morgan Date of publication: 2017  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.                               CHILD K1  SERIOUS CASE REVIEW This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 14th  December 2017     INDEPENDENT LEAD REVIEWER: Anne Morgan July 2017   MSCB Child K1 SCR Page i   Contents 1.0 INTRODUCTION .................................................................................................................... 1 2.0 RATIONALE FOR CARRYING OUT A SCR ............................................................................... 1 3.0 REVIEW PROCESS ................................................................................................................. 1 4.0 CHILDHOOD ASTHMA .......................................................................................................... 3 5.0 CASE SUMMARY ................................................................................................................... 7 6.0 ANALYSIS OF PRACTICE ...................................................................................................... 14 7.0 FINDINGS ............................................................................................................................ 20 8.0 ADDITIONAL LEARNING ..................................................................................................... 23 9.0 WERE THERE ANY AREAS OF GOOD PRACTICE? ................................................................ 25 10.0 RECOMMENDATIONS THE BOARD MAY WANT TO CONSIDER ........................................ 25 11.0 CONCLUSION .................................................................................................................... 26 12.0 APPENDICES ..................................................................................................................... 27       MSCB Child K1 SCR Page 1 of 27  1.0 INTRODUCTION  1.1 Child K1 was three years old at the time of death, following an asthma attack on the 21st June 2016. At the time, Child K1 had been diagnosed with brittle asthma and was on a Child Protection plan for neglect. Child K1 was living with father, and paternal grandmother who was their main carer at the time of death. 2.0 RATIONALE FOR CARRYING OUT A SCR 2.1 Two meetings in July and August 2016 of Manchester Safeguarding Children Board’s Serious Case Review (SCR) Panel were held to discuss the care provided to Child K1 before death in June 2016. A decision was made to recommend carrying out a SCR. This decision was ratified by the Independent Chair of Manchester Safeguarding Children Board (MSCB) in August 2016. This decision was based on the criteria as laid out in Working Together to Safeguard Children 2015 (Working Together)1, which refers to Regulation 5 of the LSCB Regulations 2006. Regulation 5 (2) states that;  “a serious case is one where:  (a) abuse or neglect of a child is known or suspected; and  (b) either;    (b)(i) the child has died; or (ii) the child has been seriously harmed and there   is cause for concern as to the way in which the… (agencies)… have worked   together to safeguard the child”.   “Cases which meet one of the criteria (i.e., regulation 5(2)(a) and (b)(i) or 5(2)(a) and  (b)(ii) must always trigger an SCR”. Child K1’s death met regulation 5(2) (a), abuse is suspected, and 5(2)(b)(i), the child has died 2.2 Following this decision an SCR was commissioned. There was a discussion about proportionality and the focus of the review. The panel agreed that the terms of reference and scope should concentrate on the impact of neglect on a child with asthma. The review is therefore focusing on that area but does also consider professional practice more generally.  3.0 REVIEW PROCESS 3.1 Scope and focus of the Serious Case Review 3.1.1. The SCR panel identified the following key areas to be explored as part of the review. They were:   To gain an improved knowledge of neglect and the role of smoking and poor home conditions (dirt, clutter) in exacerbating illnesses such as asthma, thereby increasing the risks of illness and death.                                                       1 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children March 2015 p 75: DfE MSCB Child K1 SCR Page 2 of 27   To gain an improved understanding of current research and findings around smoking and environmental factors and their effect.  To gain an improved knowledge of the management of cases where neglect factors may impact on chronic health conditions.   To gain a better understanding around the concept of when care is/is not good enough for the needs of a specific child and how this should inform case planning. 3.2 Time period to be covered 3.2.1 The review covers the period of time from the 1st January 2016 to June 30th 2016, but has used what was known of Child K1’s history prior to that time to inform review findings where appropriate.  3.3. Organisations involved in the Review 3.3.1 It was agreed that the following agencies would be required to contribute to the serious case review:  Children’s Social Care  New Charter Housing   Families First  GP Practice   Nursery   Early Help   Alder Hey Children’s Hospital NHS Trust (chronology for prior to period under review)  North West Ambulance Service   Central Manchester University Hospital NHS Foundation NHS Trust Acute and Community Services  Pennine Acute NHS Trust  Greater Manchester Police. 3.4 Methodology 3.4.1 Chapter 4 of Working Together2 identifies the purpose of a Serious Case Review and sets out the principles to be used for learning and improvement. It identifies that Serious Case Reviews and other case reviews should be conducted in a way which:   recognises the complex circumstances in which professionals work together to safeguard children;   seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;                                                        2 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of Children March 2015 children p75 DfE MSCB Child K1 SCR Page 3 of 27   is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings. Working Together also identifies the need for LSCBs to use a systems methodology in carrying out such reviews3 which should be ‘rigorous, objective analysis…in order to improve services and reduce the risk of future harm to children’...  3.4.2 This review was carried out in line with those principles and is proportionate to the case under review. The model used was a systems approach based on the Manchester methodology. Ms Anne Morgan was appointed to be the Independent author and chair of the review. Anne Morgan is an Independent Safeguarding Children Consultant with a background in paediatric quality assurance and safeguarding. She has extensive experience in carrying out reviews and is trained in the use of a systems approach. She was supported by a review team made up of senior Safeguarding Children Board representatives (Appendix 1) none of whom had any involvement in the case.  3.4.3 A chronology was produced by the agencies involved and the professionals working with the family identified. Professionals working with the family at the time under review were involved through practitioner groups and email correspondence where that was not possible. A separate meeting was held to gain background information from CAMHS. The final meeting with practitioners was used as an opportunity for them to review the findings and consider the recommendations. 3.4.4 The author and the Safeguarding Children Board Business Manager met Child K1’s paternal grandmother and mother to help inform the review process and their input has been incorporated into the final report. Child K1’s father did not feel able to contribute at that time.    4.0 CHILDHOOD ASTHMA 4.1 To understand the impact of asthma and professional concerns relating to the care provided to Child K1 it is necessary to understand what asthma is and what the expected management of asthma looks like. 4.2 Asthma 4.2.1 Asthma is a common chronic respiratory disease that can affect people of all ages which can start in childhood. Symptoms of asthma include a wheeze, breathlessness, chest tightness and cough. Symptoms can vary between one child and another and if left untreated it can be life threatening. Symptoms are usually episodic and may vary over time. 4.2.1. Asthma is triggered by many factors, including: viral infections; exercise; substances (called allergens) that cause allergic reactions, either aero-allergens (such as house dust mites, pollens,                                                         MSCB Child K1 SCR Page 4 of 27  fungal spores or animal dander) or oral allergens (such as eggs, fish, milk or nuts). Other triggers include medicines, including aspirin and non-steroidal anti-inflammatory drugs (NSAIDs), e.g. ibuprofen and naproxen, and environmental factors such as tobacco smoke, dust, fumes, and air pollutants, as well as climatic variation. 4.3 The Impact of Environmental Tobacco Smoke (ETS) (also called passive smoking second-hand or third-hand smoke)  4.3.1 There has been significant evidence available since the middle of the 1990s that exposure to environmental tobacco smoke has an impact on a child’s health as well as exacerbating childhood asthma4. ETS is the smoke a smoker breathes out and that comes from the tip of burning cigarettes, pipes, and cigars. It contains about 4,000 chemicals including carbon monoxide. Carbon monoxide makes it harder for oxygen to circulate round the body. In addition many of these chemicals are dangerous; more than 50 are known to cause cancer.  Each time children breathe in second-hand smoke they are exposed to these chemicals. Third-hand smoke is the smoke left behind in places where people have smoked previously. The harmful toxins found in third hand smoke can be found in the walls and furniture of a house, pillows and sheets, or even a child's hair after a caregiver smokes near the child.  4.4 Impact of ETS on a child’s health  4.4.1 Babies and children take more smoke into their lungs than adults. Because they are still growing and their immune system is not fully developed yet, they are at greater risk from the toxins given out in the smoke. They are more likely to get ear and respiratory infections and tooth decay and may miss more school than their peers who are not subjected to the effects of ETS. Infants have a higher risk of SIDS if they are exposed to ETS, particularly if co-sleeping.  4.4.2 Children with asthma are especially sensitive to ETS. It may cause more asthma attacks and the attacks may be more severe, requiring hospitalisation. This is because the chemicals in tobacco smoke irritate the airways and the lungs and trigger or exacerbate asthma reducing the body’s ability to circulate oxygen effectively5.  4.5 Psychosocial aspects 4.5.1There is a well-recognised link between asthma and psychosocial problems. In Sandberg et al6 18 month prospective study of children with asthma, the experience of an acute negative life event (e.g. death of a close family member) increased the risk of a subsequent asthma attack by nearly two-fold. The impact of an acute negative event was accentuated when it occurred in the context of chronic stress. Children exposed to high levels of acute and chronic stress showed a three-fold increase in risk for an attack in the two weeks that followed the acute event.  Four further studies                                                       4 Parental smoking and childhood asthma: longitudinal and case-control studies David P Strachan, Derek G Cook Thorax 1998;53:204–212 5 Asthma UK web-page access 13.03.2016 6 Asthma exacerbations in children immediately following stressful life events: a Cox’s hierarchical regression S Sandberg, S Jarvenpaa, A Penttinen, J Y Paton, D C McCann Thorax 2004; 59:1046–1051. doi: 10.1136/thx.2004.024604 MSCB Child K1 SCR Page 5 of 27  have reported that children exposed to domestic abuse were more likely than their peers to develop asthma7.  4.6 Epidemiology of asthma in the UK 4.6.1 The number of people affected by asthma in the UK is amongst the highest in the world.  According to Asthma UK and other sources, up to 5.4 million people in the UK are currently receiving treatment for asthma8.During 2011–12 there were over 65,000 hospital admissions for asthma in the UK, of these 25,073 were 0-14 years old.  4.7 Asthma deaths in the UK  4.7.1 Comparisons of international asthma death rates for 5- to 34-year-olds during 2001–10 show that the UK asthma mortality is one of the highest in Europe, and comparable with those for Australia, New Zealand and the USA9. Between February 2012 and 31 January 2013 there were 195 deaths due to asthma, of which 14% were aged 19 years and under10. The report “Why Children Die” 11  relates this higher percentage of deaths to differences in social equality found in the UK, good primary care services and the differing public health services and policies in other European countries. It identifies changes which could significantly prevent deaths in the longer term, improving health and quality of life. Tobacco control is one of the areas identified as being an important area for preventing disease and promoting health. Whilst the UK scores highly on population-based implementation of legislation and guidance (no smoking in public places, no smoking in cars where children are passengers, fostering regulations etc.) compared with many other European countries, health promotion in relation to smoking cessation has not been as effective. These factors need to be taken into account when considering the management of asthma. 4.8 Management of Asthma 4.8.1 The goal of management is for people to be free from symptoms and able to lead a normal, active life. This is achieved partly through treatment tailored to the person, and partly by people getting to know what provokes their symptoms and avoiding these triggers as much as possible. The NICE Guidelines 201312 clearly identifies the quality markers identified in diagnosing and managing asthma effectively (Appendix 2).  4.9 Asthma in Manchester 4.9.1 Central Manchester has the highest number of asthma admissions in children aged 0-14 in the country at 937 per 100,000 of the population. This compares to a national average of                                                       7 The relationship between intimate partner violence and children's asthma in 10 US states/territories. Breiding MJ, Ziembroski JS. Pediatr Allergy Immunology. 2011 Feb; 22 (1 Pt 2):e95-100. doi: 10.1111/j.1399-3038.2010.01087.x. E7   8 Health and Social Care Information Centre. Quality and Outcomes Framework: GP practice results. 2014. www.qof.hscic.gov.uk/index.asp pub 2010 Aug 24 9 Department of Health. An outcomes strategy for people with chronic obstructive pulmonary disease (COPD) and asthma in England. London: DH, 2011. www.gov.uk/government/publications/an-outcomes-strategy-for-people-withchronic-obstructive-pulmonary-disease-copd-and-asthma-in-england  10 The national review of asthma deaths (NRAD) 2011-12 complete ref 11 Cnattingius, S. The epidemiology of smoking during pregnancy: smoking prevalence, maternal circumstances, and pregnancy outcome. Nicotine Tob Res. 2004; 6(supp 2):S125-40.cited in Why children die: death in infants, children and young people in the UK Part A May 2014 12 Asthma Quality standard Published: 21 February 2013 nice.org.uk/guidance/qs25  MSCB Child K1 SCR Page 6 of 27  approximately 200 per 100,000 and has a clear correlation with levels of poverty, socio-economic deprivation high levels of smoking as identified in 'Why Children Die'13.  Asthma and Neglect 4.9.2 Neglect is defined in Working Together to Safeguard Children 201514 as “the persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health or development……. Once a child is born, neglect may involve a parent or carer failing to:   provide adequate food, clothing and shelter (including exclusion from home or abandonment);   protect a child from physical and emotional harm or danger;   ensure adequate supervision (including the use of inadequate care-givers);   or ensure access to appropriate medical care or treatment.  It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.  4.9.3 When concerned about neglect and whether it has an impact on a child’s asthma the neglect needs to be considered on a case by case basis. The assessment should take into account the care provided, based on the child’s health and development including any environmental and social economic factors that impact on that health and development as well as the carer’s ability to make the necessary changes. When considering neglect in relation to asthma and smoking the severity of the asthma will also need to be considered, as well as the care-giver’s ability to reduce or stop smoking and whether the asthma is triggered or exacerbated by the smoking.                                                            13 Why Children Die: Death In Infants, Children And Young People In The Uk Part A May 2014 Ingrid Wolfe Alison Macfarlane Angela Donkin Michael Marmot Russell Viner Royal College Of Paediatrics And Child Health National Children’s Bureau British Association For Child And Adolescent Public Health 14 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of Children March 2015 children p93 MSCB Child K1 SCR Page 7 of 27  5.0 CASE SUMMARY  5.1 Family Composition at time of K1’s death Age Relationship Ethnicity Under 4 Subject (Child K1) White British 20-25 Mother White British 20-25 Father White British 40-45  Paternal Grandmother White British  5.2 Summary of Case prior to Review Period 5.2.1 This period preceded the scope of the review; however, it may be considered relevant in relation to setting the scene in relation to the environment that Child K1 was living in. 5.2.2 Child K1 was born in August 2012. Child K1's mother was twenty-one years old at the time and their father, was sixteen. This was Child K1’s mother’s second child and Child K1’s father’s first. Child K1’s mother suffered from asthma and Child K1’s father with eczema.  5.2.3 Soon after Child K1’s birth both parents moved to live with K1's paternal grandmother. Child K1's mother at this time was depressed and unable to care for Child K1.   5.2.4 Children’s Social Care (CSC) became involved with the family at this time, supporting grandmother in caring for Child K1. The health visiting service also provided additional support to the family. 5.2.5 During December 2012 Child K1’s mother made several calls to the police reporting domestic abuse by Child K1’s father. He was not charged due to the retraction of allegations and lack of supporting evidence.  5.2.6 Child K1’s father was known to Youth Offending Services, Child and Adolescent Mental Health (CAMHS) and Connexions at varying times between 2012 and 2015. They worked with him to try and engage him in varying training schemes. Due to the birth of Child K1, and his “depression” for which he was treated this did not happen. He was however reported to be fully engaged with the support provided in relation to him being a parent. 5.2.7 In May 2013, following a referral from the health visitor, Child K1 was made a child in need. As part of the support package Child K1 was offered a nursery place which started in October 2013.  5.2.8 Child K1 was first seen for asthma on the 02/05/2013, when nine months old. Between August 2013 and August 2015 Child K1 attended A&E nine times with asthma; being admitted four times in respiratory arrest. Following the August admission Child K1 was diagnosed with “brittle asthma”. At an appointment with the Respiratory consultant at the Royal Manchester Children's Hospital (RMCH) in May 2015 Child K1’s grandmother reported that she had parental responsibility (she did not) and was Child K1’s main carer due to her son’s age. At this, and at all hospital attendances, Child K1’s grandmother inhaler technique was checked and she was advised to reduce MSCB Child K1 SCR Page 8 of 27  her and her partner’s smoking (reported to be 5 and 2 cigarettes respectively) due to the adverse effect on Child K1’s health. Child K1 was referred to the asthma nurse in May 2014. There is no discussion recorded in relation to Child K1’s father’s smoking.  5.2.9 Between June and December 2015 Nursery, Early Help and Housing raised concerns in relation to Child K1’s presentation and home environment.  5.3 Case Summary January 2016 to June 2016 (the period under review) 5.3.1 Child K1 was admitted to the North Manchester General Hospital (NMGH) on the 18/01/2016 following a respiratory arrest. The ambulance records noted that Child K1 had been short of breath for the previous six hours. Children’s Social Care were made aware of the admission. Child K1’s grandmother was taught CPR prior to discharge and the asthma nurse informed. Prior to this admission and subsequently not all Child K1’s appointments with the asthma nurse were kept. 5.3.2 Child K1 was seen at home on the 25/01/2016 by the health visitor and asthma nurse who made a referral back to Early Help identifying concerns relating to the environment and the impact it was having on Child K1’s health, the risk from sharing a room with grandmother and living in a smoky and cluttered environment. A referral was also made to the dental team and speech and language therapy. 5.3.3 On the 02/02/2016 Child K1 had a follow up appointment at the RMCH. No social concerns were identified, although Child K1’s grandmother’s smoking rate remained the same. On the same day Early Help visited the home. The worker could see Child K1 unsupervised downstairs. There was no carpet in the hall and a strong unidentified smell coming from the house, alcohol bottles were outside. An adult spoke to the support worker from an upstairs window and refused access. There had previously been difficulty accessing the family, in part because Child K1’s grandmother’s partner did not want a male support worker. Early Help referred the case back to Children’s Social Care. 5.3.4 On the 03/02/2016 the social worker (SW) did a home visit to assess conditions. Child K1 was clean and well presented. The house however needed to be cleaned. It smelt strongly of dog faeces. The social worker advised that the dog needed to be found a home and Child K1 provided with a bed. The SW also discussed their concerns that Child K1’s father may be using cannabis. The social worker was not allowed upstairs or allowed access to Child K1 and grandmother’s bedroom, which grandmother said was messy. The alcohol bottles were reported to be her son’s. The social worker attempted to arrange another visit but Child K1’s grandmother said she could not confirm a date due to the number of health appointments Child K1 had. 5.3.5 On the 10/02/2016 the social worker rang Child K1’s grandmother to arrange a home visit.  Grandmother said that her mother had just died. The social worker agreed to ring in a week’s time. The asthma nurse also rang and re-arranged their visit for the next week.  5.3.6 On the 11/02/2016 the social worker had supervision and raised concerns about grandmother’s compliance with care and the need to hold a strategy meeting. On the same day a warrant was authorised by the housing provider for ongoing rent arrears.  MSCB Child K1 SCR Page 9 of 27  5.3.7 Also on that date an ambulance was called by Child K1’s grandmother and Child K1 was taken the Emergency Department at NMGH where they were intubated and then transferred to RMCH Paediatric Intensive Care Unit. Child K1 was ventilated overnight before being transferred to a ward. Ambulance records note that Child K1 had been given antibiotics three days ago but these had not been started. They also recorded that Child K1 was in a dirty vest and no other clothes and that the house was dirty. A referral to children’s social care was made by the ambulance service. On the ward staff were concerned about Child K1’s father and grandmother’s attitude towards Child K1, especially their lack of response to K1's medical needs and contacted Children’s Social Care. The social worker advised the ward that a home visit needed to be carried out before Child K1 returned home. On the 16/02/2016 Child K1 was transferred to North Manchester General Hospital (NMGH) prior to discharge. On the 17/02/2016 the consultant’s records note that Child K1’s cubicle was dirty and smelling of smoke and that there were concerns regarding grandmother’s compliance with Child K1’s care. It is not clear whether this information was shared with Children’s Social Care although there was a conversation between the consultant and a social worker regarding their concerns in relation to Child K1. There was an agreement that Child K1 was to stay in hospital until a strategy meeting and/or a discharge planning meeting had occurred. Child K1’s grandmother was angry and upset about this decision and following discussion with the social worker Child K1 was discharged home on the 19/02/2016 with support from the community nursing team over the weekend.  5.3.8 On the 23/02/2016 the asthma nurse made a planned visit but was not allowed access although she saw Child K1 through the bedroom window. Child K1 was also not taken to the GP for follow up, despite being asked to contact the surgery in line with the asthma protocol. There is no evidence that this occurred following any of Child K1’s admissions 5.3.9 On the 24/02/2016 Child K1 was seen to be inadequately supervised by father by one of the nursery workers. A decision was made by the Nursery to talk to Child K1’s grandmother. The social worker was not informed. It was however highlighted at the Initial Child Protection Conference (ICPC).  5.3.10 On the 25/02/2016 the social worker rang Child K1’s grandmother and was told she couldn’t speak to her as it was her mother’s funeral that day. Attempts were made to contact Child K1’s grandmother later that week without success. The social worker carried out a home visit on the 02/03/2016. The house had been cleaned and clutter removed and good interaction was noted between Child K1 and Child K1’s grandmother.  5.3.11 The social worker contacted Early Help on the 04/03/2016 with a view to engaging their help in supporting the family. The case was accepted on the 08/03/2016. The plan included engaging Child K1’s father in Child K1’s care, providing financial advice and budgeting and helping with Child K1’s grandmother’s housing needs, monitor alcohol use within the household, to improve home conditions and support Child K1’s grandmother with Child K1’s care. The case was allocated to an Early Help worker on the 01/04/2016.  5.3.12 On the 10/03/2016 the eviction planned for the 11/03/2016 was withdrawn following payment of some of the rent arrears. MSCB Child K1 SCR Page 10 of 27  5.3.13 On the 14/03/2016 Child K1’s grandmother contacted the police to say her television had been stolen. She then realised it had been taken by her son and withdrew the complaint.  5.3.14 On the 04/04/2016 the social worker rang Child K1’s grandmother to arrange a home visit. She said the SW could not visit due to the large number of health appointments and that she needed help with a school placement as she had missed the deadline for this; the education case worker agreed to support Child K1’s grandmother who was informed and a visit planned for the next day. At that visit on the 05/04/2016 Child K1’s grandmother told the social worker that Child K1’s father was helping more, however the social worker noted that the condition of the house had deteriorated and that Child K1 whilst happy was grubby and was wearing dirty clothes. Child K1’s grandmother informed the social worker that K1”gets tired easily and lacks motivation”. She informed the social worker that she had a GP appointment late that day. The social worker advised Child K1’s grandmother that she needed to clean the house and that the social worker would visit the next day to ensure this had happened. Child K1’s grandmother was advised that due to the deterioration in care the social worker may need to proceed to a child protection conference. 5.3.15 Child K1’s grandmother attended the GP later that day (05/04/2016) following an NHS check invitation. She had a one month history of anxiety and panic attacks and had lost her mother two months ago. She was smoking 1-9 cigarettes a day, she was referred to the practice nurse for smoking cessation and for follow up by the GP. On the same day Child K1’s father also attended the GP. He is recorded as smoking 15 cigarettes a day and wishing to give up. He had stopped smoking cannabis a week ago. He was also suffering from anxiety with depression, and had had a low mood for the previous four to five years. He had been on antidepressants which he had stopped some time ago and was now requesting Mirtrazapine. This was prescribed and a referral made to the practice nurse for smoking cessation.   5.3.16 On the 06/04/2016 the social worker liaised with the support worker and advised that the case had escalated and was likely to go to an Initial Child Protection Conference. The SW also visited Child K1’s grandmother and informed her of the decision due to the ongoing concerns regarding the house and Child K1’s care. A strategy meeting took place on the 07/04/2016 and it was agreed to proceed to conference. Child K1’s mother was advised of current concerns and the plan for a child protection conference. 5.3.17 On the 18/04/2016 the Paediatric Consultant at NMGH invited professionals working with the family to a professionals meeting planned for the 04/05/2016 identifying in the invitation the concerns relating to Child K1. Invitees included RMCH and NMCH safeguarding nurses, the GP, social worker, the respiratory and asthma nurse and HV. This meeting was cancelled on the 20/04/2016 when the Paediatric Consultant was informed of the Initial Child Protection Conference planned for the 03/05/2016.  5.3.18 A planned visit by the social worker on the 20/04/2016 was cancelled by Child K1’s grandmother and re-arranged for the 25/04/2016. Improvements regarding the house cleanliness were noted and some decoration had taken place. Child K1’s father was reported to be helping more and was playing with Child K1 at the time of the visit. Child K1’s grandmother said she was not getting support from CSC and was feeling very stressed. She said that she was trying to reduce her smoking and was seeing the GP that day. The social worker completed the assessment and shared it MSCB Child K1 SCR Page 11 of 27  with Child K1’s grandmother. The recent bereavement and the impact of that on the family was not discussed or included within the report.  5.3.19 On the 03/05/2016 an initial Child Protection Conference was held. It was attended by Child K1’s grandmother, social workers, health visitor, asthma nurse, nursery and the police. A report was received from the GP and hospital consultant who were not able to attend. The consultant's report however clearly identified their concerns and the risks to Child K1. The conference decision was that Child K1 was at risk of significant harm and K1 was placed on a Child Protection Plan, category Neglect. This decision was unanimous. The main risk factors identified at the conference were the smoky environment within the house; fluctuating home conditions; the clutter and dirt within the house; the fact that Child K1 was co-sleeping with grandmother who was a smoker; the ongoing risk of criminality from Child K1’s father; and the fact that Child K1’s grandmother minimised professionals’ concerns. The plan also included a social work assessment of Child K1’s father and the support he was able to offer in caring for Child K1. The case was transferred to a different team and the social worker changed as Child K1 was now on a plan. At this time Child K1’s grandmother was reportedly smoking ten to nineteen cigarettes a day and Child K1’s father was smoking fifteen cigarettes a day. Child K1’s father was also being treated for depression. These facts were not included in the GP report or shared at the conference. The consultant from the RMCH was not invited and not aware of the concerns identified within the community. 5.3.20 On the 05/05/2016 the housing provider could not gain access to the property to carry out a planned gas safety check. They were also contacting Child K1’s grandmother at this time regarding her rent arrears. Further contacts were made in May without success.  5.3.21 The same day (05/05/2016) Child K1’s grandmother attended the GP surgery to see the practice nurse. She reported that she had cut down to about six a day; she was provided with nicotine replacement therapy. On a visit to the GP on the 10/05/2016 she informed the GP she was smoking ten to nineteen cigarettes a day. When this was discussed with Child K1’s grandmother as part of this review she reported that her smoking was fluctuating at this time due to stress.  5.3.22 On the 13/05/2016 a joint home visit was carried out by the previous and new social worker. The house condition was improved although Child K1 was still not in her own bed. When this was discussed with Child K1’s grandmother as part of this review, she reported that Child K1 would reach out for her in the night for comfort and did not want to sleep in a separate bed.  It was also agreed at the visit that the social worker would have more involvement with Child K1’s father to which he agreed. Child K1’s grandmother reported that she was unhappy with health staff saying at the conference that home conditions made Child K1’s asthma worse as Child K1 was not allergic to mites or dog or cat hair.  5.3.23 The core group meeting took place on the 16/05/2016. It was attended by the health visitor, nursery, social worker and Child K1’s grandmother. Grandmother reported that Child K1’s father was unwell. Some improvements were noted and a bed was now available for Child K1. Actions were identified to progress the plan and a referral was made to Families First15. The health visitor shared the outcome of the core group with asthma nurse.                                                       15 Families First is an intensive evidence based family support intervention MSCB Child K1 SCR Page 12 of 27  5.3.24 On the 19/05/2016 the Families First worker met with Child K1’s grandmother to agree a contract regarding Families First intervention. Within this plan were two items relating to Child K1’s father who was not at the meeting. One related to the Family First practitioner having an honest relationship with Child K1’s father in relation to his possible using or dealing of drugs; the other was to take on a more active role in the care of Child K1. At a further visit Child K1’s grandmother reported that she was not feeling well. She was grieving for her mother and reported that she was also stressed and anxious that Child K1 would be removed from her care. She cancelled the meeting for the following day. She also cancelled the asthma nurse’s visit planned for the 25/05/2016 and asked her to cancel the social worker’s visit planned for that day.  5.3.25 On the 03/06/2016 Child K1’s nursery contacted Children’s Social Care as K1 had a bruise on their arm. Child K1 had said “daddy hurt me”. The social worker arranged for a child protection medical and contacted the police for a strategy discussion. Following a visit to nursery the social worker reported that it was not a bruise but a scratch and having spoken to Child K1’s father and grandmother no further action was to be taken. On the same day, Child K1’s grandmother found out that Child K1’s father had tested positive for heroin and took him to a drug rehabilitation centre for advice and treatment. She cancelled a home visit by the Families First worker as she was too upset. The social worker received this information the following Monday (06/06/2016) and carried out a home visit that day with the Family First worker. The social worker saw Child K1’s father and grandmother and discussed the concerns that had been identified with them. The SW contacted the drugs team to check Child K1’s father’s attendance and the nursery to say that Child K1’s father was not to have unsupervised access to Child K1. The social worker also expressed concern with Child K1’s grandmother that Child K1’s bed had still not been assembled.  5.3.26 Both the health visitor and asthma nurse were in ongoing contact with the family during this time providing advice and support in relation to Child K1’s asthma, missed audiology and dental appointments and other general health and developmental concerns.  5.3.27 On the 13/05/2016 a second core group meeting was held. This was attended by Child K1’s grandmother, the social worker, Family First worker, asthma nurse and community nursery nurse (HV team).  Child K1 was reported to have a cough and cold and been prescribed medication by the GP; medicine advice was re-enforced by the asthma nurse. Child K1 was seen to be a good colour and breathing well. Child K1’s grandmother and Child K1’s father were reported to be engaging with Families First. Child K1’s grandmother had not assembled the bed, she said Child K1 would not sleep alone. She said she would stop Child K1’s bottle now K1 was feeling better and make appointments for audiology and the dentist.   5.3.28 On the 16/06/2016 Child K1 attended a clinic appointment and saw the respiratory medicine consultant. Child K1’s grandmother advised that Child K1 had been well until recently when the weather changed. Child K1 was prescribed a five-day course of steroids and advised to attend hospital if at all unwell. A bronchoscopy appointment was made for the end of June.  5.3.29 On the 17/06/2016, following attempts to contact Child K1’s grandmother by phone regarding rent areas and the need to do a gas safety check, a letter was sent advising her that a warrant would be authorised if payment was not received (no rent paid since March 2016).  MSCB Child K1 SCR Page 13 of 27  5.3.30 On the 20/06/2016 nursery contacted Child K1’s grandmother as Child K1 was unwell. They had provided medication for Child K1’s asthma in line with K1's healthcare plan but K1 was not responding, was clammy and continuing to cough. Child K1’s grandmother attended nursery and took Child K1 home. She is recorded as saying this was a sign that Child K1 was unwell. Child K1’s grandmother said at the meeting with the Review author that Child K1 was better in the evening. Child K1’s grandmother cancelled a planned visit with Families First as she reported being unwell.  5.3.31 On the morning of the 21/06/2016 Child K1 was unwell, coughing and not responding to their nebulisers. Child K1’s grandmother called an ambulance and Child K1 was taken by ambulance to North Manchester General Hospital. Child K1 was cyanosed and unresponsive. On arrival at hospital, despite intensive medical intervention, Child K1 was unable to be resuscitated. Child K1 was pronounced dead at 11.06 am. The Coroner and police were informed in line with sudden unexpected death in childhood procedures. No suspicious circumstances were identified at the hospital. The police and paediatrician carried out a home visit, recording that the house was cluttered, dirty, and smelt of smoke. All professionals working with the family were informed, as was Child K1’s mother.  5.3.3 A rapid response meeting was held on the 23/06/2016 to share information and manage bereavement support.      MSCB Child K1 SCR Page 14 of 27  6.0 ANALYSIS OF PRACTICE  6.1 Child K1’s admission to NMGH in January 2016 was the fifth admission in respiratory arrest. K1's hospital care was appropriate resulting in a quick recovery and discharge home. Pre-discharge training though should have included Child K1’s father. This ignoring of the fact that Child K1’s father had parental responsibility was a factor throughout Child K1’s life; and whilst Child K1’s grandmother acted as a parent she did not have parental responsibility. There is no evidence at this, or any other admission, that Child K1’s grandmother was referred to the GP for smoking cessation, although discharge letters did identify the need for Child K1’s grandmother to stop smoking. There is no evidence that father’s smoking was taken into account at any time. This was poor practice as it showed little thought of the impact of care being provided to Child K1 on their asthma. Both the failure to identify the need for Child K1’s father to stop smoking and the fact that the GP records were scanned but not linked to other family members meant that the GP was unlikely to pick this up as an action requiring attention. Had Child K1’s records been coded as a child with complex needs or a child of concern this may have occurred. 6.2 The follow up visit by the asthma nurse and health visitor was good practice and in line with national guidance. Smoking cessation was discussed in relation to Child K1’s grandmother and her partner but not in relation to Child K1’s father. This appears to be an issue ongoing in Child K1’s care. Neither smoking nor the environment were considered in the context of child protection (neglect), despite the significant risks of ETS, particularly when co-sleeping, and the impact of a dusty and dirty environment being explained to Child K1’s grandmother on numerous occasions. A referral was made to Early Help instead. The referral requested financial help for Child K1’s grandmother who was in rent arears, and emotional support in caring for Child K1. It also noted that Child K1’s father needed support following the breakup of his relationship. The referral to Early Help was in line with local protocol16 but did not take into account the input already received by the family and the impact of the smoking and environment on Child K1’s health. Nor did it take into account the complexity of the neglect and the need to identify the root cause rather than deal only with the practicalities. This is a common failing when analysing cases of neglect and identified in many SCRs. 6.3 On the 02/02/2016 the Early Help (EH) worker attempted a visit. The EH worker was not allowed access but was concerned regarding Child K1’s presentation and the state of the house and referred the case back to Children’s Social Care (CSC). The referral back to CSC was good practice, as was the visit carried out by the social worker the next day. The house appeared a little cleaner, but still smelt and no access was allowed to the upstairs area. Child K1’s grandmother refused to make an appointment for a further visit, citing health appointments as the reason. Whilst there may have been a number of health appointments for Child K1, their grandmother’s refusal to make an appointment showed an element of non-compliance with professionals, only allowing the contact she wanted with an agency to occur. Alcohol bottles at the property were reported to be Child K1’s father, however this was not checked with him (In April 2016 Child K1’s father informed his GP that he did not drink). A more assertive approach to Child K1’s grandmother and meeting with Child K1’s father to discuss the situation, including how best to manage the health appointments as well as the risks to Child K1 would have been appropriate. When the social worker followed up on the                                                       16 Draft Neglect Strategy for Children, Young People and Families 2016-2017 MSCB MSCB Child K1 SCR Page 15 of 27  10/02/2016 they were advised by Child K1’s grandmother’s that her mother, (Child K1’s great grandmother) had died and she didn’t want a visit at this time. This was understandable but a date should have been agreed for a future visit. 6.4 On the 11/02/2016 an ambulance was called and Child K1 taken to hospital (NMGH) with an asthma attack. The ambulance crew were concerned because Child K1 had not been given prescribed antibiotics by Child K1’s grandmother, Child K1 was in a filthy state, as was the house. Their referral to CSC was good practice, as was the referral following admission by ward staff when they became concerned about both Child K1’s grandmother and Child K1’s father’s attitude and behaviour on the ward. The social worker agreed a safety plan with the ward, which was good practice. This included Child K1 not being discharged from hospital until a home assessment had been carried out and discharge planning meeting held. 6.5 Following transfer to CMHT the cubicle Child K1 was being nursed in was recorded by the consultant to be dirty and smelling of smoke. The consultant noted that RMCH, NMGH and the asthma nurse were all concerned about Child K1’s grandmother’s compliance with Child K1’s care. The consultant requested a discharge planning or strategy meeting prior to Child K1 going home. This was good practice, however no action was taken when this did not happen and following Child K1’s grandmother insistence that she wanted to take Child K1 home, K1 was discharged home on the 19/02/2016 with follow up by the Children’s Community Nursing Team over the weekend. This followed a conversation between the ward and social worker and took no account of the concerns identified, or that a follow up home visit had not taken place by the social worker. Hospital staff did not discuss their concerns with the named nurse or doctor or escalate them in any way.  This was poor practice, as was the social worker’s agreement for Child K1 to go home without a follow up visit.   6.6 Sending Child K1 home without a discharge planning meeting or a strategy meeting was a missed opportunity to assess and analyse the risk to Child K1 with input from all the professionals working with the family. The handling of the situation gave Child K1’s grandmother mixed messages as to the level of concern identified by professionals and their expectation around her actions in relation to Child K1. This remained an issue throughout the case, with no effective action taken in relation to Child K1’s grandmothers non -compliance with Child K1’s care. Having a discharge planning meeting would also have been an opportunity to identify a lead health professional to have an overview of the case and identify what Child K1’s feelings were at this time.  6.7 Evidence provided by the ambulance service, the ward and the home visit suggested a level of neglect that should have led to a strategy meeting regardless of Child K1’s asthma and should have been held before discharge. This was poor practice and a missed opportunity to properly analyse the risks to Child K1.   6.8 Child K1 was not taken for an asthma follow up with the GP in line with the asthma pathway. There is no evidence that this was ever highlighted to other professionals working with Child K1 and was poor practice. Where children are not taken to health appointments there should always be consideration as to whether this is part of a bigger picture in relation to neglect. The asthma nurse was not allowed access to the home on the 23/02/16, a planned visit; concerns were raised at nursery about Child K1’s father’s supervision of Child K1 on the 24/02/2016; and the social worker MSCB Child K1 SCR Page 16 of 27  was unable to access the house until the 02/03/2016 (partly due to Child K1’s grandmother’s mother’s funeral on the 25/02/2016). Taking this all of this into account it still showed evidence of avoidance of professionals, non-compliance with treatment, and an increase in risk to Child K1, and following the concerns raised in hospital was further evidence of the need for a strategy meeting. Not initiating one was poor practice and resulted in considerable drift by children’s social care.   6.9 The hospital discharge letter to the GP in February 2016 did not truly reflect the level of concerns identified, and resulted in not all health professionals being fully aware of those concerns. During the time covered by this Review, there is also little evidence of any face to face liaison between the asthma nurse and health visitor with the GP; although updated copies of Child K1’s asthma plan were sent to the surgery. This case would have benefited from discussion and sharing of information in relation to Child K1’s care. At the time the asthma nurse had a caseload of 500 patients, including other children with a CP plan; and the service was replacing home visits by clinic visits or phone review due to demand on the service. This had an impact on the asthma nurse’s ability to carry out home visits and liaise effectively with all the other professionals involved. This would have affected the asthma nurse's contact with the GP, although there was liaison with the HV. Health visiting contracts included having a link health visitor and the need to liaise between GP and the named health visitor for a family when there are safeguarding concerns17. It would be good practice, particularly in situations of possible neglect relating to compliance to health needs, to liaise with the GP on a regular basis. This lack of liaison reflects the findings in the Child H review carried out by Bury in 201318 and would suggest the actions have not been fully embedded in practice.  6.10 The social worker made a planned visit on the 02/03/2016. The house was cleaner and uncluttered. However, Child K1 was still sleeping with grandmother and there was no evidence that grandmother had reduced her cigarette consumption. Good interaction was noted between Child K1 and grandmother, but there is no evidence recorded to say that the social worker saw Child K1 alone to find out their view on their care, or how much K1 was missing great- grandmother. It is not clear whether the social worker understood the implications of lack of progress in relation to Child K1 sleeping in a separate bed and Child K1’s grandmother stopping smoking and keeping the house clean; however it showed further evidence of that Child K1’s grandmother was unable to respond to Child K1’s needs and should have been acted upon more pro-actively and the situation not allowed to drift.   This needs to be taken in the context of a time when this Manchester social work team was under considerable pressure, with higher caseloads than elsewhere in the city and higher levels of child protection and neglect. The Locality involved has a higher level of deprivation and need, evidenced through Multiple Deprivation scores and other indicators. For example a breakdown of deprivation by income illustrates all but two wards in this area of Manchester have a higher percentage of income-deprived children than is average for the City. Four of the five wards with the highest percentage of income deprived children in the City reside in this part of Manchester. The social work teams in this area receive a higher rate of referrals and, at the point of involvement with Child K1, had average caseloads on the assessment teams of 27.8 (May and June data, 2016) and on the                                                       17 A Model of Good Practice GP-HV Communication Guidelines; HV Taskforce 3rdDec. 2012 18 The same NHS provider organisations were involved in that case MSCB Child K1 SCR Page 17 of 27  court and locality teams of 23.2. In the subsequent year there has been recognition of this demand and additional resource recruited to in this area of the city. Three social work teams now serve the community, leading to a reduction in caseloads with current figures being an average caseload of 21.8 on assessment teams and 18 on court teams in March 2017, marking a significant decrease. There is still further recruitment taking place into this area and there is a clear undertaking to ensure an average caseload across the area of 18.  Due to the changes that have occurred and continue to occur there is no finding in relation to drift. 6.11 Following discussion on the telephone on the 04/04/2016 when Child K1’s grandmother refused a visit, she identified that she needed help with arranging Child K1’s school placement. The social worker visited the next day (05/04/2016). The SW had followed up on Child K1’s school placement which was good practice. However the SW had not explored with grandmother why she had not applied for a school place in time; or considered this within the context of how able Child K1’s grandmother was to meet Child K1's needs. The condition of the house had deteriorated and Child K1’s grandmother was feeling unwell. She had a GP appointment that day for herself. The social worker advised that there would be a social work visit the next day and the house would need to be cleaned. It is not clear whether smoking cessation and co-sleeping were addressed. Nor was the impact of grandmother’s health on her ability to adequately care for Child K1.  6.12 The social worker advised Child K1’s grandmother that they may need to proceed to a child protection conference. The decision to consider proceeding to conference was good practice; however an opportunity to speak to the GP and get a clear picture of grandmother’s health and the impact it was having on Child K1’s health and development was missed. The visit by both father and grandmother to the GP should also have led the GP to considering the impact that their smoking and anxiety/depression were having on Child K1 and identified these concerns to the social worker. Throughout the period under review grandmother’s self -reporting in relation to her smoking was inconsistent and varied dependant on who she was talking to, although she was consistent in saying that she did not smoke within the house. Whilst her level of smoking may have increased at times of stress, particularly following her mother’s death, if health workers had liaised better it would have been clear as to how inconsistent her self–reporting was and the level of effort she was making to stop smoking.  6.13 On the 07/04/2016 a strategy meeting was held with the police and social worker. This was two months after the initial referral by the ambulance service and hospital had been made and reflected the ongoing drift in the case. No health or education professionals were invited. This failure to comply with Working Together Safeguard Children 2015 was reported by the review team to be common occurrence. In this case it was essential that health should have been at the strategy meeting as Child K1 had such significant health needs. This should have as a minimum included one of Child K1’s consultants and the GP who had significant information relating to Child K1’s father and Child K1’s grandmother. Had they been there the risk to Child K1 could then been more adequately assessed. The failure to invite them was poor practice. It is not however included in the findings as this has already been identified as a concern by MSCB and is being addressed. Child K1’s mother was advised of the concerns and the plan for a child protection conference. This was good practice, however there is no evidence that she was informed of the outcome. Not keeping Child MSCB Child K1 SCR Page 18 of 27  K1’s mother aware of the situation was poor practice as she had parental responsibility and had the situation deteriorated could potentially been considered as an alternative carer.  6.14 On the 19/04/2016 the consultant at NMGH contacted the social worker and various health professionals working with the family to arrange a professionals meeting. This included the safeguarding lead and was good practice. The consultant was advised on the 20/04/2016 that an ICPC was to be held the day before and therefore cancelled the professionals meeting letting those invited know of the conference. This information did not reach the consultant at RMCH and they were not invited by CSC. The consultant was unable to attend but wrote a comprehensive report for the conference. Had a professionals meeting taken place a much clearer understanding of the risks to Child K1 may have emerged, and whilst it was appropriate to cancel it did mean that neither consultant attended the ICPC and professionals did not have the opportunity to share information and agree a clear healthcare plan, which could have been incorporated into the Child Protection Plan.  6.15 On the 24/04/2016 the social worker made a planned visit to the family home. The Child Protection assessment was shared with Child K1’s grandmother but does not appear to have been shared with Child K1’s father. Whilst it was good practice to share the report with Child K1’s grandmother, the failure to involve Child K1’s father is a consistent theme running through this case and is replicated by all professionals working with the family at this time.   6.16 The Initial Child Protection Conference was held on the 03/05/2016 more than 15 days after the strategy meeting. This was not in line with Working Together 2015. Whilst it was quorate some key people were not invited or asked for reports. They included housing and the RMCH hospital consultant involved with Child K1. The GP report dealt with Child K1 but did not include relevant information in relation to Child K1’s grandmother or father which would have provided information which would have given a different perspective of the risks to Child K1, as would the housing report had it been requested. Housing were aware of a pattern in relation to rent areas and non-engagement by grandmother and could have supported CSC in their effort towards ensuring that the house was kept in an appropriate standard of cleanliness. This failure to access all the information available resulted in a lack of insight into the wider picture. In addition the child protection plan produced had a list of tasks but did not clearly identify the outcomes required, or what would happen if there were no improvements. This was not in line with good practice. “Signs of Safety” has now been introduced in Manchester and the author was assured that Child Protection Plans are now more outcome focused, this is not therefore included within the findings. Following the conference a new social worker was appointed in line with good practice guidance.  6.17 The joint visit on the 13/05/2016 by the old and new social worker was good practice. Child K1’s grandmother was unhappy with the health workers input at the conference, denying that home conditions had an impact on Child K1’s asthma as K1 was not allergic to mites, dogs, or cats (Child K1 had been tested for allergens). This assertion by Child K1’s grandmother showed that she either did not understand, or was failing to acknowledge the risks to Child K1 from smoking and a dusty environment, in that Child K1 did not have to be allergic to them for them to exacerbate their asthma. This had been an area of concern regularly raised with grandmother by the health professionals caring for Child K1. It would however have been good practice to clarify which was the case and re-iterate the risks. When discussed with Child K1’s grandmother as part of this review MSCB Child K1 SCR Page 19 of 27  she reported that she never smoked indoors and did not appear to understand the risks of ETS. The new social worker included Child K1’s father in the visit and told him of the intention to include him in the assessments. This was an action identified in the Child Protection Plan. This was the only time that there is any evidence Child K1’s father was being considered/assessed as a carer for Child K1. This was not however sustained as when the Family First worker attended the house on the 19/06/2016 and agreed a care plan with Child K1’s grandmother included within it were actions relating to Child K1’s father which were not agreed with him.  6.18 Following the child protection referral from nursery on the 03/06/2016 the proposed child protection medical should have taken place. A scratch can be an inflicted injury and this failure to believe Child K1, after speaking to their grandmother, is similar to the findings in an ongoing SCR in Manchester (Child G1) “where there was too great a focus on the individual injury rather than consideration of what the medical might or might not be able to contribute more widely to an understanding of the child’s experience”. This failure to go ahead with the CP medical was poor practice.  6.19 Although Child K1 was only three years old at the time of death, children of that age are able to communicate any concerns they may have with the adults working with them. There is little evidence that Child K1 was asked about daily life experience, or an understanding of asthma, and how Child K1 felt about not having contact with mother and great grandmother’s death. All of which must have been quite frightening and bewildering at times. A finding in relation to this is not included as both the Review team and the practitioners felt that this issue was being addressed through training and the introduction of signs of safety.  6.20 Following Child K1’s death there was no delay in initiating the Sudden Unexpected Death in Childhood procedure19 and professionals involved in Child K1’s death were informed in a timely way. Child K1’s mother was also informed promptly. This was good practice                                                             19 Working Together to Safeguard Children 2015 p85 DfE MSCB Child K1 SCR Page 20 of 27  7.0 FINDINGS 7.1 An overview of the questions asked within the scoping document have been identified and covered within Section 3 of this report. This identifies what asthma is and the impact of EST and dirty home conditions can have on a child’s health. The findings listed below therefore deal with how this impacted on the management of Child K1‘s care.  The headline findings are listed within the table and expanded on later in this section.  7.2 Professionals provided care in line with nationally agreed guidance, however this did not adequately take into account the safeguarding concerns (i.e. the impact of smoking and poor home environment) and the need to further escalate the case.    7.3 Health professionals have a lead role to play in ensuring that professionals working with a specific family have a better understanding around the concept of when care is/is not good enough for a child who has a chronic illness or disability and how this should inform case planning.  7.4 Neglect is a recognised category of abuse, however in this case the professional understanding was not sufficiently sophisticated as to the kind of behaviours that constitute neglect and their impact on children with chronic health conditions.    Additional Learning  8.1 Role of fathers – Child K’s father’s role in caring for Child K1 was not seriously considered or supported resulting in professionals being unclear of his ability to care for his child or receiving the support he may have required.  8.2 Information sharing between and within agencies was not always in line with good practice. This resulted in professionals not having all the information available when assessing the risk to Child K1.   7.2 Finding 1: Professionals provided care in line with nationally agreed guidance20, however this did not adequately take into account the safeguarding concerns (i.e. the impact of smoking and poor home environment) and the need to further escalate the case.   7.2.1 Child K1 would have had a predisposition to asthma in that both parents suffered from either asthma or eczema. Research identifies that this is more likely than to occur when children are subjected to ETS and stress (in this case domestic abuse between their parents) Child K1 was exposed to both from birth. It is not surprising therefore that K1 developed asthma at such an early age, or that it became problematic to manage. Whilst this information is widely known neither NICE guidelines21 nor the 2014 report by the Royal College of Physicians,22 consider these from a safeguarding perspective referring only to the need for educating parents. The guidance comes                                                       20 Asthma: Quality standard Published: 21 February 2013 nice.org.uk/guidance/qs25 21 Ibid 22 Why asthma still kills The National Review of Asthma Deaths (NRAD) Royal College of Physicians. Conﬁdential Enquiry report May 2014 MSCB Child K1 SCR Page 21 of 27  from a medical rather than a social model of care. Social policy on the other hand is now recognising the impact of smoking and there is now clear guidance in relation to foster carers with “smokers” not being approved for the care of children under five years of age, and having to smoke outside of the house for older children23. Since October 2015 it has also been illegal to smoke in the same care as a child24  and there is at least one published paper, albeit American, which clearly considers ETS in a child with asthma to be child protection in the same way as substance misuse and domestic violence25. In Child K1’s case social care failure to act effectively, and health professionals not effectively escalating their concerns to safeguarding leads within their individual organisations meant that there was a lack of clarity of the true risks involved and what could be done to alleviate them.  Professionals therefore need to be clear when smoking and a poor home environment puts a child at significant risk, have an agreed plan which includes both the impact of smoking and environment on the child as well as any other options available when no improvement in the child’s care occurs. This could include working with the City Council’s Environmental Team in relation to tenure compliance and enforcement in relation to social and privately rented housing. Since the review Public Health have had discussion with MSCB to ensure that the risk of tobacco smoke on Children’s Health is included within the “Safeguarding and Substance Misuse” Courses. This should ensure professionals are more aware and more able to effectively assess risk. Public Health have also agreed to collate information for non-health staff who work with families in relation to the risks of tobacco smoke to babies children and especially those who have asthma which would support that training. 7.3 Finding 2: Health professionals have a lead role to play in ensuring that professionals working with a specific family have a better understanding around the concept of when care is/is not good enough for a child who has a chronic illness26 or disability and how this should inform case planning. 7.3.1 The Munro review of child protection identified that managing cases of neglect can be problematic and difficult to manage27. It identified that the ‘safeguarding system’ and to some extent professional practice was geared to recognising emergency incidents rather than more enduring patterns of harm or risk and that there needed to be a continued shift in culture and practice to achieve earlier recognition of patterns of risk and harm, and earlier intervention to protect and safeguard the long-term needs of the child.  7.3.2 A chronic health problem, such as Child K1 had, adds an additional complexity and it becomes even more pertinent for a clear analysis and expert advice to be provided by health professionals.  This should clearly identify the impact of the neglect on the child’s health and development, enabling children’s social care and other professionals to understand the impact of the neglect on the child’s life. Child K1’s care was shared between two Hospital Trusts and whilst it transpired that the consultant paediatrician from NMGH felt that they were the lead professional this was not                                                       23 http://ukfostering.org.uk/becoming-foster-parent/your-circumstances/#sthash.WshvkpPL.dpuf viewed 20/03/2017 24  Children and Families Act 2014 25 Is Exposure to Second-hand Smoke Child Abuse? Yes Adam O. Goldstein published 2013, accessed on line February 2017 26 A Long Term Physical Health Condition (also known as a Chronic Condition) is a health problem that requires ongoing management over a period of years or decades. A Long Term Physical Health Condition is one that cannot currently be cured but can be controlled with the use of medication and/or other therapies. http://www.datadictionary.nhs.uk/data_dictionary/nhs_business_definitions/l/long_term_physical_health; accessed June 2017 27 The Munro Review of Child Protection: Final Report: A child-centred system May 2011 DfE MSCB Child K1 SCR Page 22 of 27  however made explicit to all professionals working with Child K1. Concerns therefore did not get the attention they warranted. This meant that whilst there was good input from the majority of health professionals involved there was no one clearly identified person to taking the lead in co-ordinating health information and explaining on an ongoing basis specifically when the care provided to Child K1 was not good enough and why. This was reflected in the discussion with Child K1’s grandmother she reported that she received advice that was sometimes conflicting and that recent events were not always known by all practitioners.   7.3.3 Medical professionals are best placed to identify how a child’s health or development, particularly one with chronic health needs, is being affected by the care provided. They are often unaware however of the significance of their input into multi-agency decisions about their care28 and because of the short notice for ICPC are rarely attend as was the case in Child K1’s case. This can mean their input can be diluted or misinterpreted with CSC getting mixed messages regarding the significance of the neglect. It is therefore important that medical staff are fully involved in the care planning for children where there are clear concerns regarding compliance with health care and the impact this may have on the child. It is important that reports are robust and where appropriate provide evidence and research to support their views as well as considering the impact, both positive and negative of the family on the child’s health and development. This lack of clarity and liaison between agencies is a finding that has been identified in another Manchester SCR (Child H1) and also as a concern nationally.  7.4 Finding 3: Neglect is a recognised category of abuse, however in this case the professional understanding was not sufficiently sophisticated as to the kind of behaviours that constitute neglect and their impact on children with chronic health conditions.   7.4.1 The Manchester Safeguarding Children Board Safeguarding Standard 2015 and their Strategy for Neglect December 201629 are written within the context of the higher than national average of neglect identified within Manchester and the number of children with a Child Protection Plan or Looked After for whom neglect has been identified. Child K1 without having asthma was not considered to meet those thresholds. The Neglect Strategy is however clear that warning signs and symptoms of child neglect vary from child to child and that by understanding potential indicators, professionals can respond to problems as early as possible and provide the right support and services for the child and their family.  7.4.2 Child K1’s diagnosis of brittle asthma, meant that when considering their care and whether that “was good enough” professionals needed to consider whether K1's carers were able to comply with their health care and keep them free of triggers such as EST, stress and a dirty home environment. Unless however this is explicitly identified by health professionals, then other agencies working with the family are unlikely to realise the significance or risk. This is an area often identified in SCR’s of children and young people who have additional needs30 but is even more difficult to manage when the concerns relate to such areas as smoking and obesity. Although the clear impact of both is fully documented, there is no clear guidance as to how to manage the                                                       28 Pathways to Harm, Pathways to protection :a triennial analysis of serious case reviews 2011-2014 Peter Sidebotham et al DfE May 2016 29 Manchester Neglect Strategy for Children, Young People and Families 2016-2019 p. 11 December 2016 MSCB 30 Pathways to Harm, Pathways to protection :a triennial analysis of serious case reviews 2011-2014 Peter Sidebotham et al DfE May 2016 MSCB Child K1 SCR Page 23 of 27  safeguarding issues successfully, the emphasis being on professionals’ focusing on health promotion and encouraging changes to adult behaviour. 7.4.3 This can disempower professionals when considering best how to manage those families where children are subjected to EST and where health promotion and support to the family have not worked. MCSB’s current strategy identifies the need for professionals to consider a broader set of circumstances which can only be pieced together through the accumulation of evidence until the legal threshold for care proceedings is met. The NSPCC screening tool is now included within that strategy31. The use of such a tool in Manchester at this time was not in place, had it been it could possibly have helped professionals identify the ongoing concerns and lack of change in Child K1’s care.   8.0 ADDITIONAL LEARNING 8.1 Finding 4: Child K1’s father’s role in caring for Child K1 was not seriously considered or supported, resulting in professionals being unclear of his ability to care for his child or receiving the support he may have required. 8.1.1 The Healthy Child Programme states that: “The contribution that fathers make to their children’s development, health and wellbeing is important, but services do not do enough to recognise or support them. Research shows 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.’ Maternity and child health services are used to working mainly with mothers, and this has an impact on their ability to engage with fathers. Fathers should be routinely invited to participate in child health reviews, and should have their needs assessed.’  8.1.2.Whilst the Healthy Child Programme and government policy both encourage the active involvement of fathers this has not always transferred into practice either in Manchester or elsewhere in the country apart from specific services available for teenage fathers (not available in Manchester). In this case it was apparent that Child K1’s father was initially involved in the care of his child. There is no evidence however that he was encouraged to continue his input and become fully involved with the professionals working with Child K1. His mother provided care to Child K1 from when K1 was a few weeks old. She attended hospital appointments and took responsibility for Child K1’s asthma plan. Grandmother informed professionals that she had Parental Responsibility (PR) and made excuses for Child K1’s father when he was not available or involved in Child K1’s care. In discussion with her as part of this review a Residence Order was never applied for and she was told it was unnecessary as Child K1’s father had parental responsibility. Professional's difficulty in engaging with Child K1’s father at times meant that there was little discussion with him in relation to his responsibility as a parent; and no clear insight into what he could positively or negatively contribute to Child K1’s care, no knowledge of his understanding in relation to Child K1’s asthma; or his thoughts in relation to smoking cessation.                                                       31NSPCC research has identified that the use of a screening tool over a period of time can enable professionals to better identify the level of neglect and changes that have occurred between one episode of screening and the next. National Evaluation of the Graded Care Profile Robyn Johnson and Richard Cotmore NSPCC Evaluation department 2015 MSCB Child K1 SCR Page 24 of 27  8.2 Finding 5: Information sharing between and within agencies was not always in line with good practice. This resulted in professionals not having all the information available when assessing the risk to Child K1. 8.2.1 Health Professionals - Whilst most health professionals communicated well, there was a lack of communication with the GP by the HV and asthma nurse; and between the paediatricians involved and acute and community services. The paediatrician at RMCH for instance being unaware of the home conditions and the social concerns until asked to attend the practitioner event. This combined with the lack of a known lead professional reduced the opportunity for an informed united front to be shown to grandmother in the management of Child K1’s care. Apart from the medical aspect of Child K1’s care the social concerns were not clearly identified on an ongoing basis between those health professionals caring for Child K1. This resulted in no clear plan in relation to smoking cessation for grandmother and father, and no way of identifying those times Child K1 was not seen for a scheduled appointment in either the hospital or community. A professionals’ meeting and supervision of complex cases would have been of benefit in this case. Currently there is little opportunity for this to occur, particularly in the acute setting. Professionals' meetings are not often held in Manchester, due to the wish to work fully with parents; this is a pattern found elsewhere in the country as well. However used effectively they can be of great benefit in clarifying and agreeing plans of action and providing a united front.  8.2.2. Another area where communication and information sharing was identified as difficult by practitioners related to the differing policies in place and systems of patient recording resulting in not all information being known to all practitioners. This is a national problem and in particular hinders communication between professionals working in different organisations, however it is also a recommendation of good practice identified in the London Asthma Standards32 and has been addressed elsewhere by the provision of honorary contracts and clear information sharing protocols being in place.  8.2.3 The housing provider involved with the family, were not invited to any CP/CiN meetings and there does not appear to have been any communication with them despite agencies being aware of the rent arrears and the condition of the house. This lack of involvement of housing with CSC in particular is a national problem and is not made easier by the outsourcing of local authority housing stock.   8.2.4 General Practitioners The RCGP’s guidance33 is very clear in relation to the role of GPs when working with CSC. The guidance states that: “GP’s have key roles in appropriate information sharing with children’s social care when enquiries are being made about children. GP’s and practice staff should make available to child protection conferences relevant information about a child and family, whether or not they are able to attend”.  In this case GP records did not link the family by address, resulting in the significance of parental attendance at the surgery not being considered in relation to Child K1 and their needs. This was                                                       32 London Children and Young People Strategic Clinical Network. London Asthma Standards for Children and Young People NHS England June 2015  33 Safeguarding Children & Young People A Toolkit for General Practice 2011 RCGP  MSCB Child K1 SCR Page 25 of 27  compounded by Child K1’s records not being EMIS coded in relation to their health and social needs and K1's multiple missed appointments not being highlighted. This resulted in the report to the Initial Child Protection Conference not including all the relevant information relating to Child K1‘s father and grandmother.  9.0 WERE THERE ANY AREAS OF GOOD PRACTICE?  9.1 Areas of good practice were identified within the analysis of practice; however of particular note is the prompt and very appropriate response by the ambulance service to Child K1’s home conditions on the 11/02/2016.  10.0 RECOMMENDATIONS THE BOARD MAY WANT TO CONSIDER 10.1 The MSCB ensure all agencies are aware of, and compliant with the current MSCB Neglect Strategy. 10.2 MSCB and Public Health prioritise staff training thus increasing knowledge around the management of smoking cessation, including how to reduce the impact of ETS on vulnerable children and adults.  10.3 Commissioners of Services ensure current education and advice in relation to asthma management be updated to comply with current NICE Guidance. 10.4 NICE be contacted and asked to consider whether the impact of ETS could be more explicitly recognised and linked to safeguarding within their Asthma Guidance.  10.5 Lead health professionals be identified for all children who have a chronic health problem or a disability in line with current good practice34, with clear and robust communication systems in place to ensure effective sharing of information.  10.6 Medical staff be reminded of the need to clearly identify the risks and impact on children when liaising with CSC; the need to provide clear evidence based reports which include parental strengths and weaknesses; and when unable to attend child protection meetings, ensure that their report and concerns are represented by another health professional.  10.7 The MSCB include as part of their audit programme a review of professionals’ engagement with all those with parental responsibility, with a particular focus on fathers’ and whether they are always appropriately included and involved in decision making relating to their child/children. 10.8 The MSCB to be assured that effective processes are in place to share and receive information from housing providers when any family assessments are being carried out.  10.9 The MSCB to seek assurance that a robust pathway is in place to support practitioners in primary care to participate in the child protection process and that this audited to assess improvement.                                                       34 National Service Framework for Children and Young People Standard 8: for Disabled Children and those with Complex Health Needs MSCB Child K1 SCR Page 26 of 27  11.0 CONCLUSION  11.1The incidence of childhood asthma in Manchester is the highest in the country, an unsurprising statistic when one considers the social and economic deprivation and the high incidence of smoking. It is therefore important to consider the impact of this on both families and the services providing support when caring for children with asthma and concerns in relation to possible neglect.  11.2 Child K1 was a well-loved little child who developed asthma at an early age, becoming severely unwell very quickly on a number of occasions. Child K1's grandmother acted appropriately to those acute occasions, calling 999 and initiating CPR. Child K1’s home environment however was not conducive to good asthma management, and whilst Child K1’s grandmother was provided with the support to enable change to happen, professional attempts to promote that change were largely unsuccessful.  11.3 Neglect is particularly difficult to manage, as it occurs over time and care can improve and then deteriorate. It is even more so when a child has a chronic illness or disability. In this case one aspect of neglect came from smoking. A habit that whilst socially unacceptable is not treated in the same way in the UK as many other harmful and addictive substances, the emphasis being on enabling smoking cessation. The assessment of the risk of neglect in such cases needs to be clear and explicit between both professionals and the carers and between professionals themselves, taking into account the risk of smoking triggering or exacerbating asthma on a child by child basis. In Child K1’s case unless there had been a period when they had not been exposed to ETS in particular it is impossible to identify the impact this had on their asthma.    MSCB Child K1 SCR Page 27 of 27  12.0 APPENDICES 12.1 Appendix 1  Review Team Members Role Organisation Designated Doctor for Safeguarding Children Manchester CCG Education Case Worker Manchester City Council Named Nurse Safeguarding Children Central Manchester University Hospitals NHS Trust  Detective Inspector Public Protection Division Greater Manchester Police Service Manager Social Work Team Manchester Council Assistant Director of Nursing Pennine Acute NHS Trust Locality Manager Integration and Prevention Manchester City Council Youth Justice Manager Manchester City Council Director of Revenues New Charter Housing Acting Designated Nurse for Safeguarding Children Manchester CCG  12.2 Appendix 2  NICE QUALITY STANDARDS FOR THE DIAGNOSIS AND MANAGEMENT OF ASTHMA Statement 1 People with newly diagnosed asthma are diagnosed in accordance with BTS/SIGN guidance. Statement 2 Adults with new onset asthma are assessed for occupational causes. Statement 3 People with asthma receive a written personalised action plan. Statement 4 People with asthma are given specific training and assessment in inhaler technique before starting any new inhaler treatment. Statement 5 People with asthma receive a structured review at least annually. Statement 6 People with asthma who present with respiratory symptoms receive an assessment of their asthma control. Statement 7 People with asthma who present with an exacerbation of their symptoms receive an objective measurement of severity at the time of presentation. Statement 8 People aged 5 years or older presenting to a healthcare professional with a severe or life-threatening acute exacerbation of asthma receive oral or intravenous steroids within 1 hour of presentation. Statement 9 People admitted to hospital with an acute exacerbation of asthma have a structured review by a member of a specialist respiratory team before discharge. Statement 10 People who received treatment in hospital or through out-of-hours services for an acute exacerbation of asthma are followed up by their own GP practice within 2working days of treatment. Statement 11 People with difficult asthma are offered an assessment by a multidisciplinary difficult asthma service. In addition, quality standards that should also be considered when commissioning and providing a high-quality asthma service are listed in related NICE quality standards.  