Subdural haematoma suffered by Chris, a baby under six months old, in September 2015. Further examination revealed recent and old injuries including rib and leg fractures. Chris's injuries will have a life-long impact. Police are currently investigating the incident. Chris's mother is a migrant to the UK. Her husband, MH, is also a migrant. MF is the birth father of Chris and sibling, CS. Both MH and MF had access to the children. Family had contact with services including the GP, health visitors, midwifery and maternity services and the police. Police attended incidents involving the family on five separate occasions and notified children's services each time. Referrals were also made by maternity services and the health visitor following Chris's birth. Concerns included: domestic abuse; the family being victims of anti-social behaviour; mother's rough handling of CS during a medical appointment. Uses the systems methodology developed by the Social Care Institute for Excellence. Findings include: safeguarding children in migrant families could be improved by addressing cultural competence in understanding family dynamics and more effective use of interpreters; services are too reliant on self-report information from migrants due to a lack of robust historical health, social care and criminal records. Recommendations include: the LSCB should ensure that professional interpreter services are always used by agencies - the use of family members or others is not acceptable; LSCB should contact the relevant government department to highlight poor availability of historic health and social care records for migrants to the UK.
      
 Title:  Serious case review in the case of – Chris: period under review May 2013 to September 2015: overview report and LSCB response to SCR. LSCB: Liverpool Safeguarding Children Board Author: Liverpool Safeguarding Children Board 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.                            1  LIVERPOOL SAFEGUARDING CHILDREN BOARD  SERIOUS CASE REVIEW IN THE CASE OF - CHRIS   PERIOD UNDER REVIEW  MAY 2013 TO SEPTEMBER 2015     Overview Report  & LSCB Response to SCR - Final            2  CONTENTS              Page  1. Background and Introduction    3 – 7  2. Timeline of Agency Involvement    8 – 10 And key events  3. Summary Overview and Professional Narrative 11-13  4. Key Themes Identified      14 -15  5. Analysis of Agency Involvement and Learning 16 -19  6. Findings and Recommendations    21  7. Liverpool Safeguarding Children Board (LSCB) Response to the Findings of Serious Case Review   22  8. Addendum To Serious Case Review Report Chris – April 2017         23             3  1  INTRODUCTION AND BACKGROUND TO THE REVIEW  1.1 Key People Person Referred to as: Child Victim Chris Mother of Chris Mother Mother’s Friend (Father of Chris) MF Sibling of Chris CS Mother’s Husband MH  1.2 Incident Leading to the Review In early September 2015 police and ambulance service responded to a call saying that Chris was not breathing.  Chris was taken by ambulance to the local Children’s Hospital and was examined. Chris was under six months old at the time of the incident. A brain scan was undertaken which showed that Chris had experienced a subdural haematoma (bleed) to the left and right side of the brain.  Further examination revealed recent and old injuries including healing rib fractures and a healing leg fracture.   The severity of Chris’s injuries required emergency treatment and ongoing care in hospital.  The impact of Chris’s injuries will impact development and functioning throughout Chris’s life. 1.3 Confidentiality  Chris’s gender is not referred to in this report. Pseudonyms are attributed to other key individuals and to professionals who worked with Chris and their family.    1.4 Background to Chris and their family Chris was born by elective caesarean section.  Chris had no complications at birth and both mother and baby were discharged from hospital two days after Chris’s birth. Chris’s mother is a UK migrant who has lived in the UK since January 2012.  Mother is married to MH who is a UK migrant; the marriage took place in March 2013.  Other members of mother’s family live in the UK and it appears that she maintained contact with members of her family including her mother and brother during the period under review. She is reported to have a sister who lives in the local area.   From birth to the incident leading to this SCR Chris lived in rented accommodation with mother and sibling CS.  There appear to have been no other permanent members of the household although it is probable that both MF and MH spent time at the property and had access to Chris and CS. Mother had contact with health services before Chris’s birth in relation to her pregnancy and the birth of CS.  There were no safeguarding concerns about CS either before or after Chris’s birth.    4  In her contacts with maternity and midwifery services mother self-reported that she had a previous partner in her country of origin and also had a child within that relationship.  This was later confirmed as being accurate during the police investigation following the incident leading to this review.  Mother self-reported that there had been domestic abuse in this relationship. Mother had a number of consultations with health agencies during the period under review primarily in relation to ante and post-natal care.  She had experienced complications in pregnancy and discussed her concerns about continuing her pregnancies with the GP and with midwifery and maternity services. She did not attend an appointment made for her with midwifery and maternity services specifically to discuss her concerns. The review has heard conflicting information about mother’s ability to speak and understand English. In the majority of contacts with hospital and Health Visiting services mother was assisted by either a translator or by a ‘language line’ facility. However she was reported by her GP practice to be able to speak and understand English without the assistance of an interpreter.  When seen by services mother was often accompanied by a male friend who is referred to in this report as MF; when he was with her he appeared to always act as a translator for her.   Following police and social care investigations after the incident, MF has been confirmed as the biological father of CS and Chris. Other services were also aware of mother’s friendship with MF; he accompanied her to a number of consultations with her GP and was on occasion present at mother’s home when visited by HV.  Police were also aware of the relationship with MF due to their involvement in responding to incidents of domestic abuse and that there was a dispute between the two parties in relation to the paternity of one or both of the children. The relationship between mother and MF was known by professionals to be volatile and potentially violent and controlling.  During the period under review police were called to incidents within and outside the family home and in another public place on five separate occasions.  On each occasion risk assessments were carried out by police and, when one or both of the children was present, notifications were made to Careline.  On each occasion the risk rating attached to these incidents was ‘bronze’ or standard.  At a consultation with maternity and midwifery services in the early stages of her pregnancy with Chris mother said that MH was the father of both Chris and CS.  MH appears to be transient in the lives of mother and the children and there is no record of him being present at any of the contacts with professionals described in the multi-agency chronology. There is one incident involving police where MH makes a telephone call to report anti-social behaviour.  Some professionals were aware that mother was married but there was little or no enquiry or curiosity about MH and the role he played in the family.      5  1.5 Rationale for conducting the SCR Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board (LSCB) to undertake a review of a serious case in accordance with the procedures that are set out in chapter four of Working Together to Safeguard Children (2015).  A LSCB should always undertake a serious case review when a child dies or has been seriously harmed and abuse or neglect is either known or is suspected and there is cause for concern as to the way the authority, the Board or other relevant persons have worked together.   The purpose of the review is to establish what lessons can be learned from the case to improve safeguarding in the future, to improve inter-agency working and to better safeguard and promote the welfare of children in the local area.  This serious case review has been conducted under the guidance set out in Working Together to Safeguard Children (2015)1. The principles underpinning the review are that it:  Recognises the complex circumstances in which professionals work together to safeguard children;  Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  Seeks to understand practice from the viewpoint of the individuals and organisations; involved at the time rather than using hindsight;   Is transparent about the way data is collected and analysed; and  Makes use of relevant research and case evidence to inform the findings. The review was conducted on the basis that the overview report would be published in full.   1.6 The scope of the SCR The period under review is from May 2013 to June 2015.  Relevant background and contextual information prior to May 2013 is included in this report but is not subject to analysis.  1.7 Agencies Participating in the SCR   The following agencies have provided information and contributed to the SCR in accordance with Working Together to Safeguard Children (2015), Chapter 4 and the associated LSCB guidance and relevant learning and improvement frameworks.   Children’s Social Care (CSC)                                                            1 Working Together to Safeguard Children, Department for Education (Revised2 015)   6   Health Visiting Services (HV)  GP  Police  Children’s Centre  Primary School  Midwifery and Maternity Services  1.8 Methodology The review was commissioned by the Local Safeguarding Children Board who appointed a Lead Reviewer to undertake the review using a modified version of the systems methodology developed by the Social Care Institute for Excellence. 2  A multi-agency chronology was compiled to support the Serious Case Review which contains information about mother’s contact with agencies dating back to 2012. The lead reviewer held one to one and group conversations with professionals from all agencies included in the chronology.  NB: The review was unable to obtain detailed background information relating to mother prior to her migration to England.  In researching this SCR it has become apparent that it is not uncommon for migrants to the UK to present to services with no health, social care or other records and professionals from a range of agencies involved in this review have commented on the frequency with which they are working with only self-report information in these circumstances.  1.9 Research Questions Systems reviews do not set specific terms of reference.  The following research questions were posed by the LSCB to assist in providing focus to the review and constructing and shaping the findings. The LSCB asked the panel to address the following questions in the review: 1. What was the role played by services before and after birth? 2. How well did agencies communicate? 3. What issues does this case raise in relation to new communities including language and communication? 4. Are there are any issues for consideration in relation to the child’s siblings? 5. What are the issues in relation to domestic abuse3 raised by the case? 1.10 Review Team Members  A serious case review team was convened consisting of senior and specialist agency representatives from the local area to oversee the collation and analysis of information and outcomes of the review. The review was co-ordinated and managed by an independent lead reviewer with appropriate experience and training.                                                             2 http://www.scie.org.uk/publications/guides/guide24/ 3 https://www.gov.uk/guidance/domestic-violence-and-abuse  7    Position Organisation Service Manager Children’s Social Care Service Manager Careline (the ‘front door’ service for Children’s and Adult’s Social Care) Lead Nurse for Safeguarding x 2 Clinical Commissioning Group Head-teacher Primary School  Detective Chief Inspector Merseyside Police Lead GP for Safeguarding General Practice Business Manager LSCB Training Coordinator LSCB Education Coordinator LSCB Named GP for Safeguarding General Practice Executive Support Officer LSCB – Administration and Minute Taker  The independent lead reviewer chaired the review and attended every meeting of the review team.   The review team met on five occasions to oversee the review process, analyse data, report to the LSCB, draw conclusions from the material analysed and oversee the production of draft and final reports.  Written minutes of the review team meeting discussions and decisions were recorded by the LSCB Business Support Officer.  The review has used a systems based approach to analysing information and presenting the findings in the final chapter using recommended best practice in identifying improvement and learning.   The review team identified information to be provided by individual agencies.  This included all relevant documents and reports from services working with Chris in regard to assessments, plans and interventions.  1.11 Involvement of Family, Friends and Significant Others At the time of writing this report legal constraints prevent the review speaking to mother, MF and MH. 1.12 Criminal Proceedings  8  Police are currently conducting a criminal investigation into the incident that led to this SCR.  2 TIMELINE OF AGENCY INVOLVEMENT AND EVENTS  2.1 Involvement in 2013 In May 2013 CS was born by caesarean section with no complications.  One day after the birth of CS MF presented to the ante-natal ward and said that mother must leave hospital with CS as her father was dying. Staff advised against this due to surgery having taken place only 24 hours earlier.  Mother acted against medical advice and discharged herself.  Careline/CSC were notified of this event due to previous concerns.  The notification was recorded for information by Careline/CSC. Throughout June and July HV could not gain access to the family to conduct a birth visit for CS.  After three failed access visits HV telephoned Careline/CSC who advised her to telephone police. HV telephoned police who spoke to mother by phone following which a visit was arranged. When HV saw mother she explained that she had been visiting her family in another part of the country and was therefore not aware that HV was trying to contact her.  No concerns were noted by HV at this visit. At the end of July/beginning of August Police were called to two domestic abuse incidents involving MF on consecutive days.  The first incident involved MF causing disruption outside the family home.  Police attended and spoke to MF, it was noted that another male was present at the property who is recorded as being MF’s brother. A standard letter was sent by police following this incident. The second incident took place the following day when mother rang police to say that MF had entered the communal area of the property through an unsecured front door and had banged on the door to her flat and shouted abuse.  A friend of mother’s was present when police attended and translated for mother.  No complaint was made and police could see no sign that an offence had occurred.  MF had left the address by the time police arrived, he was later located and found to be intoxicated but complied with police requests for him to leave the immediate area. In November mother and MF attended a routine clinic appointment with CS for vaccinations.  During the visit mother and MF were noted to be arguing.  The practitioner noted some rough handling of CS and recorded this. The following week HV made a home visit and addressed this concern with mother who said that she had not intended to handle CS roughly and that she had been angry that immunisations had been given without her consent. 2.2 Involvement in 2014 In June police received a call from a member of the public reporting a verbal argument in the street where a young child was present.  Police attended the incident which involved mother and MF.  It was recorded as a verbal altercation about child access; no concerns were noted and MF complied with the police request to leave the scene.  9  In July HV made a home visit to conduct a one year development check on CS.  Mother reported that she had a male friend staying with her and that she was moving house soon.  CS’s development was recorded as age appropriate and there were no concerns. In August mother presented to her GP reporting that she was pregnant.  One week later mother presented to hospital with lower abdominal pain, she was assessed and advised to return in two weeks; mother did not attend the follow up appointment. Two weeks later mother again presented at hospital with bleeding and it was then confirmed that she was eight weeks pregnant.  At this consultation mother was asked about the father of the unborn child but was reluctant to discuss this; she was also asked about domestic abuse however she did not give a direct answer.  A Health Professionals4 letter was sent to her GP.  One week later mother discussed her concerns about the pregnancy with her GP and was referred to the local hospital; she failed to attend the appointment. Following two missed appointments with midwifery and maternity services mother was ‘booked in’ by the service in December.  At this appointment mother reported that MH was the father of the child.  The practitioner recorded that it was difficult for the practitioner to ask about domestic abuse as a friend, assumed by the review to be MF, was acting as interpreter. The notes record that Social Care were informed of the pregnancy due to previous information provided by mother in relation to domestic abuse, it is not clear how this information was sent.  There is a record in Social Care for three days later saying that an explanatory note is attached however that note is missing. 2.3 Involvement in 2015 In March mother was seen at ante-natal clinic.  During the visit she was asked about domestic abuse.  She said that she no longer saw MF.  Mother said that MH was the father of both the unborn and CS.  An interpreter was present at the consultation. One week later an incident was reported to police by MH. It involved a complaint about youths kicking a ball against the door or the family home. MH stated that the family were victims of anti-social behaviour.  This incident is recorded as being reported by a man with the same name as MH although he was recorded by police as being mother’s brother. In April Chris was born by elective caesarean section with no complications. During the following three months appointments were kept with the community midwife and Chris was seen by HV on three occasions and no concerns were noted. In July police were called to an incident at mother’s home address involving an assault on her by MF in which he slapped and scratched her.  Both Chris and CS were present at the incident.  The incident was recorded as being related to the paternity of CS and it was recorded by a police officer that MF is the father, although MH is unaware of this.  A referral was made to Careline.  This was logged by Careline and allocated to the Area Team for assessment.  MF was charged with assault and entered a plea of guilty to the offence of battery.  MF was given a community order, a fine and electronic tagging. This information appeared in the social care records.                                                              10  Nine days after this incident police were called to the address of MF who said that mother had been fighting with him and that they had been arguing about the children. Both parties had been drinking and mother had refused to leave the property. It is not clear whether there were children present at this incident. Two days after this incident police were again called to the address of MF, there had been a verbal argument and MF said that mother had punched him.  There were no visible injuries to either party and neither would provide any further information.   The same day an unannounced visit was made by a social worker to the family home at which they could not gain access and left a note for mother to make contact with them.  Nine days later mother made contact with the social worker, she was informed that an interpreter would be arranged and a further appointment would be made. Eight days after this police received a call to attend an incident at the address of MF involving an altercation between mother and MF.  Both children were present.  Mother and both children were taken to mother’s sister’s address. In early September the incident leading to this review took place.                     11   3  SUMMARY OVERVIEW FROM THE PROFESSIONAL NARRATIVE During the period under review Mother, CS and Chris had contact with a number of services including General Practice, Health Visitors, Midwifery and Maternity Services and Police (the latter in relation to domestic abuse incidents involving MF).   Throughout this time Chris’s mother appeared to have frequent contact with MF, and for at least some of this time they appear to have been involved in an intimate relationship. During this time Chris’s mother was also married to MH although it is not clear whether and when he lived at the family home (there was one occasion when he was present there to report an incident of anti-social behaviour to the police). Domestic abuse risk assessments were notified to the ‘front door’ service Careline.  The domestic abuse incidents were risk rated as ‘standard’ by police and were recorded as ‘for information only’. Maternity services first had contact with mother in October 2012 when she attended the Early Pregnancy Unit having reported that she was in pain, mother was around 7 weeks pregnant at this time.  Mother attended for booking later that same month which took place at a clinic specifically for non-English speakers.  Mother self-reported a previous pregnancy and a caesarean section.  The service did not have access to any previous health records from mother’s country of origin.   The maternity and midwifery service received a police notification of a domestic abuse incident between mother and MF in April 2013 and completed a health professional letter following this notification.   Given mother’s previous obstetric history an elective caesarean section was planned.  CS was born in May 2013 with no complications.  Within one day of CS’s birth MF came to the ante-natal ward and said that mother needed to be discharged because of a family emergency; mother confirmed that her father was dying and said that she wanted to leave hospital.  Staff were concerned due to this being a very short time after surgery and advised mother not to leave hospital.  They noted that everything had been fine before MF came to the hospital.  There is no record of any enquiry being made about domestic abuse. Mother insisted that she needed to leave hospital and did so with MF. A referral was made to CSC notifying of the self-discharge.   Following discharge from the hospital a home visit was conducted by a Community Midwife and no concerns were noted.  Twenty one days after leaving hospital mother was discharged with handover to the Health Visiting Service. When the HV first tried to visit mother she was unable to gain access on a number of occasions, the rented accommodation that the family lived in was a flat above a shop and she left cards for mother to contact her.  After several attempts the HV decided to telephone Careline as she was concerned about not seeing mother and CS following discharge from hospital.  Careline advised the HV to ring the police who would get in touch with mother on her behalf, she did so and police immediately telephoned mother.  Mother was very apologetic and said that she had been in London, the HV immediately went out to see her.    12  At the visit MF was present and was introduced as a friend who interprets for mother.  HV asked if MF was the father of CS but this was laughed off.  MF interpreted during the visit but HV felt that mother could understand quite a lot of what was being said to her. HV had four other conversations with mother during 2013, one of which was in response to a concern that mother had handled CS roughly during a clinic attendance.  HV spoke to mother about this, MF was present and interpreted for mother.  Other members of mother’s family were also present at the visit.  Mother said that she had not intended to handle CS roughly but that she was annoyed that CS had been given an immunisation without her consent.  HV observed mother handling CS at this visit and had no concerns, they discussed the family transferring to a new GP and that they were now living in a larger flat.  HV had no knowledge of previous domestic abuse incident involving MF and did not feel that there was anything negative about their relationship.  He appeared to get on well with mother and to be helping her, HV noted that he was always there. In contrast professionals did not see MH at appointments with mother nor was he seen at the family home. In June 2014 a member of the public called police to report that a male and female (mother and MF) were arguing in the street.  When police attended the scene it was confirmed as a verbal altercation over access to the children, the children were seen to be safe and well and MF was conveyed to his home address. Between June and August 2014 mother and CS had routine contact with the GP and in August mother presented to the GP saying that she was pregnant.  Two weeks later mother attended the local women’s hospital with lower abdominal pain and bleeding, a scan was unable to confirm the pregnancy due to the gestation period. At a further attendance, accompanied by MF mother was asked about the father of the unborn child but refused to provide this information, she was also asked direct questions about domestic abuse, but avoided answering these questions. A first booking clinic appointment was made which mother failed to attend for her first booking appointment; a consultation appointment had also been made to discuss mother’s concerns about the pregnancy which she also failed to attend. A further appointment was sent for mother to attend two weeks later in October which was rearranged by mother. A further appointment two weeks later she did not attend. Mother finally attended for booking in December, this was a face to face appointment with an interpreter present.  Mother explained that her late booking was due to uncertainty about whether to continue with the pregnancy and family illness. Careline were notified of the pregnancy due to the family being previously known to CSC regarding a domestic abuse incident which had been logged for information only.  In December mother was seen at home by the community midwife for a routine check and no concerns were noted, she was then seen again in clinic where an elective caesarean was arranged.  A further appointment was missed for which an interpreter had been booked.  Mother told the interpreter on the phone that she had forgotten the appointment.   In March 2015 mother was seen by maternity and midwifery services with an interpreter present.  Mother was asked about domestic abuse and about her relationship with MF; she stated that she was no longer in touch with MF and that the father of CS and the unborn  13  child was her husband and that there were no concerns about domestic abuse in that relationship. There were two further appointments with maternity and midwifery services in March and April where no concerns were noted.   In mid-April mother attended for a pre-operative assessment for the elective caesarean section.  She was admitted three days later and gave birth to Chris.  There were no complications and both mother and baby were discharged home two days later.  Usual post-natal visits were conducted and no concerns were noted about either Chris or CS.  In May care was handed to the health visitor. The review was unable to speak to HV2 about the SCR as she had left the service.  The records show that routine visits were made to assess and review Chris and that there were no concerns noted.                       14      4. KEY THEMES IDENTIFIED BY THE REVIEW  4.1 Family dynamics and inter-relationships, paternity Midwifery and maternity services and police made enquiries about the paternity of Chris and CS as both were aware of tensions in the relationship between mother and MF (it appears that this may have been linked to paternity disputes). Uncertainty regarding paternity was never formally confirmed to any professional (until after the incident).   It was noted that MF was frequently present at home address and at appointments and interpreted for mother.  Some professionals assumed that he was the father of the children, until mother reported that she was married to MH and was not in a relationship with MF.   4.2 Domestic Abuse 5 Police and midwifery services were aware of a history of domestic abuse with MF.  He was often present and did not afford opportunities for mother to be spoken to alone.  This was compounded by language issues, however professionals in health services did raise domestic abuse with mother.   There was a lack of a joined up approach re information sharing, particularly in relation to the last incident in July 2015. What specialist services domestic abuse services exist for non-English speaking victims in the local area? General practice guidance in relation to routine enquiry and first response to domestic abuse should be in line with NICE and Royal College of General Practitioners (RCGP) good practice guidance. 6 4.3 Management of Pregnancy Mother expressed some concerns about continuing with her pregnancies on a number of occasions.  This information was shared with midwifery and maternity services and a referral was made for consultation. Mother did not give the GP specific reasons for her concerns and did not follow up appointments to discuss this further, it is therefore difficult to interpret the significance of                                                            5 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/118153/vawg-action-plan.pdf 6 http://www.rcgp.org.uk/clinical-and-research/clinical-resources/~/media/Files/CIRC/Clinical%20Priorities/Domestic%20Violence/RCGP-Responding%20to%20abuse%20in%20domestic%20violence-January-2013.ashx  15  these concerns.  It is possible that this an indicator of sexual violence in the relationship, although this was never raised or discussed with any practitioner.  There is no specific guidance to general practice in this regard.  The panel has concluded that GPs should continue to follow NICE7 and RCGP guidance in respect of routine enquiry into domestic abuse and provide information and support/referral to specialist agencies as appropriate. 4.4 Working with migrant communities This review has been informed that there is a significant gap in the provision of historical health and social care records for UK migrants.  This results in professionals being unsighted on important aspects of personal history relating to both vulnerability and risk.  Practitioners observed that it is ‘almost impossible’ to obtain this information in the current system. There is a different view amongst professionals about mother’s ability to speak and understand English.  Mother was offered interpreting services for most of her consultations with professionals which is good practice.  There were occasions on which MF accompanied mother to medical and other appointments which could have restricted her opportunities to discuss the domestic abuse that she was experiencing in her relationship with him. 4.5 Hidden Males8 Professionals did not have a clear view about males in the family/network.  MF and MH both had access to the children however there was a lack of clarity about their roles in the family. There was no attempt by any agency to map the relationships or consider the impact of their involvement on the children.  Paternity issues were known by some professionals (is this sufficient reason to share information if no other concerns about the children), domestic abuse incidents highlighted the paternity issues however as the domestic abuse incidents were risk rated as low (and no MERIT risk assessment was conducted) information that was shared with Careline was recorded for information only.                                                                       7 https://www.nice.org.uk/guidance/ph50 8 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/hidden-men/  16       5. ANALYSIS OF AGENCY INVOLVEMENT AND AGENCY LEARNING 5.1 Midwifery and Maternity Services Services had little background information in relation to Chris’s mother as they did not have access to any historical health records from mother’s country of origin.  This necessitated them relying on self-report information provided by mother. In addition to a lack of historical health records the service recognised the additional needs presented by Chris’s mother as a migrant to the UK who appeared to have a limited command of English and required interpreters at her appointments and interactions with services (although this is not the view of all professionals involved with mother). Chris’s mother had two pregnancies during the period under review; she received routine ante-natal care in the form of assessment and monitoring, she also received emergency care in relation to PV bleeding during the early stages of her pregnancy with Chris.   Both children were born by elective caesarean and were born without any complications.  In summary the post and ante natal care received by Chris’s mother was of an expected standard.  Mother was seen at a clinic specifically for women who do not have English as a first language which is good practice. When MF presented to the ward the day after Chris’s birth saying that mother needed to be discharged staff did try to encourage mother to stay and warned that she would be leaving against medical advice.  However, mother took the decision to self-discharge.  This may indicate that MF was controlling and manipulating mother and it would have been good practice for staff to take the opportunity to ask mother about domestic abuse.  However it is also understandable that staff would be sympathetic when mother said that her father was dying and this may have influenced them in not asking about control and manipulation.  5.1.1. Learning and Actions Identified Domestic Abuse Policy and Risk Assessment for disclosures reviewed and updated. Internal IT systems changed to prompt for routine questioning and a field set to record this. Staff are aware of their responsibilities and through training.  Referral form has a specific field for Domestic Abuse and all referrals are reviewed by Safeguarding Staff to ensure that there has been a referral into the Local Authority, if appropriate.  17  Information sharing between Liverpool Women's NHS Foundation Trust and all three Liverpool MARAC’s and IDVA Services is deemed robust and is timely for the MARAC Meetings. All MARAC actions for midwifery and maternity services are completed and fed back as appropriate.  Maternity and midwifery services have strong links with ‘Ruby Project’ to support cases which although do not meet the high risk threshold, but still require support signposting to relevant agencies.  5.2 Health Visiting Services During the period under review the family received services from two health visitors, only one health visitor (HV1) participated in the review as the second (HV2) had left post.   Chris and CS received universal services in line with the Child Health programme.  HV1 demonstrated good practice following CS’s birth when she had been unable to gain access for a post birth visit by using police (this is usual practice locally) to make contact with mother. The HV1 met MF on several occasions, she was curious about his relationship with mother HV was unaware of historical domestic abuse that involved MF and the service does not appear to have received notifications of more recent domestic abuse incidents.   HV1 had no safeguarding concerns in relation to CS and there is no indication in HV2’s records that they had any concerns about Chris.    5.2.1. Learning and Actions Identified Domestic Abuse Policy reviewed and a recommendation put in that any Domestic Abuse referrals will generate a contact with the family. Communication issued via LCH bulletin to ensure that transfer in visits are completed as per LCH policy.   5.3 Police The relationship between Chris’s mother and MF was volatile and there were several police call outs to domestic abuse incidents between 2013 and 2015.  A number of these incidents involved police making referrals to Careline as either one or both children were present at the incidents.   Police provided timely and appropriate response to domestic abuse incidents and MERIT risk assessment and vulnerable child referrals were made as necessary. There is some confusion in the police records regarding people present at the scene of incidents, on one occasion MH appears to have been mistaken for another party.  There is learning here in relation to the confirmation of males present in the household.   18  5.3.1. Learning and actions identified Merseyside Police have welcomed the opportunity to take part in this Serious Case Review and welcome the findings following the review of our actions, systems and processes in respect of these tragic events. Police are pleased that the examination of the MeRIT risk assessment procedure and use of the Language Line facility is both robust and suitable to ensure all victims and witnesses receive suitable risk assessments in line with their needs and are also able to accurately provide or convey information to officers even if language barriers are present. This is reflected within the Community First strategy. Police note the learning outcome regarding the need to establish / confirm the identities of the males present within the household.  Merseyside police have a commitment to ensuring that every effort is made to correctly identify those individuals with whom they are engaging with and that records accurately reflect this. Whilst establishing the true identity of everyone police interact with is not as straightforward as it may at first seem, police will continue to strive to achieve this and ensure that records reflect this. This will be driven through the Force Strategy ‘Excellent Policing for the Communities of Merseyside’ part of which is our pledge to ‘Get it Right First Time’  , which includes the accurate recording of information.   5.4 General Practice Chris’s general practitioner provided services to mother, CS and Chris.  As is the case with other services the GP had no historical health information about mother and relied upon self-report information.   Mother discussed concerns about her pregnancy with the GP on more than one occasion, this may have been an opportunity to make further enquiries into the relationship with the father of the unborn child and whether there were any difficulties in the relationship. The GP did not discuss domestic abuse with mother as they were not aware of incidents that had taken place involving MF.  MF did attend some appointments with mother but there was no reason to suspect that the relationship was controlling or abusive.  5.4.1 Learning and Actions Identified The review heard conflicting information about mother’s ability to speak English. Analysis of GP records would indicate that a variety of interpreters drawn from friends and family were used on many occasions. It wasn’t clear how necessary these interpreters were. However from interviews held with GPs it was evident that, though non English speaking, the level of understanding was such that interpreters were not required. The finding is that the use of interpreters in general practice was not assessed appropriately. As illustrated in the review there is a need for professionals to develop culturally sensitive competencies to understand the family dynamics and language interpretation requirements.     19  Revise use of interpreters / language line as appropriate. Alert and code the records accordingly. NHSE are developing a policy statement on use of interpreters and interpretation in primary care.9 Once available this will be highlighted to all GP practice via established communication links between Named GPs and GP practices. GP providers are regulated by CQC. CQC require that GPs identify communication needs for the people who use their service and ensure you meet them  Those accompanying the mum were not appropriately identified. Their attendance was not challenged. There was evidence of in the GP records of previous episodes of domestic discord and police involvement. These episodes involved one key individual from this review who often accompanied mum to GP appointments.  Analysis of the GP records, and from conversations with clinicians in the practice, there was no evidence of friction between the two. Therefore there was no suspicion that there was anything untoward in the relationship.  However it is good practice for professionals to be clear that their interactions with patients are completely devoid of influence from others.  This involves an element of professional curiosity and will be influenced by many factors [time pressure / language difficulties /multitude of triggers to consider at any one time in a 10 minute consultation]. Always identify those who accompany patients and document accordingly. [READ codes available]. These will be used a prompt or reminder to explore, if necessary, any risks of adverse domestic situations.  RCGP guidance on domestic abuse will be reissued to all GP practice via established communication channels  The review highlighted a lot of good practice which should be celebrated and encouraged. For example - Follow-up on failure to attend / surgery and secondary care - Liaison with HV in practice over child development  This will be highlighted in the established training programme for GPs. Feedback will be given directly to the GP practice involved.  5.5 Careline/ CSC                                                            9 https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/03/it_principles.pdf   20  Careline received notifications of domestic abuse incidents directly from police and from maternity and midwifery services.  The domestic abuse referrals (PVP) were logged for information only as all were rated ‘bronze’ or standard risk and, within the current system, these cases are checked against information held on the core systems (Liquid Logic) to check whether there are any further risk factors, these may be additional concerns / involvement, or a record of a number of such incidents, each of which may result in further enquiries to be made.  In this context Careline followed the local procedure appropriately. There had been several contacts in 2013 / 2014 with Careline (CSC) that were low level domestic violence and all involved verbal-only disputes with no concern of  violence. In two incidents no children were identified by the Police as being present. The first contact to be allocated Children’s Social Care for a single assessment took place in July 2015.  A social worker attempted to contact mother to arrange a single assessment following a domestic incident in which she was assaulted by MF, for which he was charged and subsequently given a community sentence.  Mother was not available but responded to a message form CSC one week later to arrange an appointment.  This was delayed due the lack of availability of an interpreter.  By the time the incident leading to this SCR took place there had been no contact from CSC and no indication of when the single assessment was going to take place.  However at the time of the incident the commencement of the single assessment was not outside the statutory timeframe.  5.5.1. Learning and Actions Identified Domestic Abuse There is learning to be gained in relation to responding to the frequency as well as the severity of domestic abuse incidents.  In 2014/15 there were four domestic abuse incidents where the children were present, three of these took place within the space of 6 months.   The initial three recorded incidents were verbal only details in one of the incidents, children were not recorded as being present. In the third incident, the original VPRF1 form did not state children were present in the history, but this was amended in a later VPRF1 form.  There were no exacerbating risk factors that would warrant background checks being completed given the information shared by Merseyside Police, and no information held on Children Social Care records would highlight any concerns. Since 2015, a Merseyside BRAG rating was introduced which meant Police would check the low risk cases were not open, and if this was the case these DV incidents would be retained by Merseyside Police. The rationale for this was to reduce the volume of cases being referred to Careline (and other ‘front doors’ in Merseyside) so that resources could be used for higher risk cases. This initiative dovetailed with the Encompass – an initiative where schools were informed on any DV incident that the Police attended. Limited learning can be extracted from these earlier incidents, given the lower level concerns shared.  21  The only incident that involved any physical altercation was on 13th July 2015 – this involved an alleged slap to mother and resulted in a referral being generated and checks completed via the MASH process. Subsequent to the case being allocated to the Assessment Service on 23rd July, a further two DV incidents were recorded by Police involving further alleged physical altercations. These two incidents happened whilst the case was open to an area team. The last three incidents all involved alleged physical assault that should have resulted in the priority of the case being reviewed.    Allocation and Assessment There was a lengthy delay from referral/allocation for single assessment in late July to the serious incident on 2nd September 2015. The children had not been seen. The issue would be management oversight of single assessments at 10 and 35 days. In addition the worker was on holiday which highlights the issue of workers raising uncompleted work to a manager before going on holiday.   Assessment Service to ensure all single assessments have management oversight at 10 and 35 days and an alert in the electronic record system at 9 days to ensure the children have been seen and the assessment is progressing appropriately Social workers to raise incomplete single assessments with a manager before starting annual leave  6 FINDING AND RECOMMENDATIONS  6.1 Finding 1 - Domestic Abuse Information sharing in relation to domestic abuse incidents could be improved using existing systems.   6.1.1. Recommendation 1 (a)  The LSCB should be assured that all agencies are clear about information sharing requirements in relation to domestic abuse incidents.  (b) Police should conduct an audit of cases of domestic abuse incidents of victims who do not have English as a first language to establish whether this is a barrier to completion of the MERIT risk assessment.  Police should act on the findings of the audit to ensure equality of access to risk assessment for all victims. (c) The LSCB should be assured that the local domestic abuse strategy includes specific reference to migrant communities, the use of interpreters and the impact this may have on  22  disclosure and the pathway to specialist domestic abuse services for migrant and other victims who speak little or no English.  6.2 Finding 2 – Safeguarding children of migrant parents The review has identified two key issues in relation to safeguarding children in migrant families i.e. the cultural competence of the workforce in relation to understanding the family dynamics; the use of language interpretation services (see recommendations 1c). 6.2.1. Recommendation 2 The LSCB should be assured that current practice in relation to cultural competence and safeguarding is in line with national professional guidance and responsive to the needs of specific communities. 6.2.2. Recommendation 3 The LSCB should be assured that professional interpreter services are always used by agencies; the use of family members or others is not acceptable practice.  6.3 Finding 3 – Lack of robust historical health, social care and criminal records for migrants The review has identified a significant national issue in relation to the availability of health and social care records for migrants to the UK.  Services are reliant on self-report information upon which to base professional judgments and the provision of services.    6.3.1. Recommendation 4 The Chair of the LSCB should liaise with Chief Officers in partner agencies with a view to contacting the relevant government department to highlight this significant gap in the availability of historic health and social care records for migrants to the UK.  6.4 Predictability and Preventability The review has concluded that professionals involved in the case could not have reasonably predicted or prevented the tragic incident that led to this serious case review, however important learning has been gained from conducting the review and agencies have agreed an action plan that will be monitored via the LSCB process.      23               ADDENDUM TO SERIOUS CASE REVIEW REPORT  CHRIS – APRIL 2017   This addendum is an update to information provided in the main report primarily in relation to the conclusion of criminal proceedings and family involvement in the review. Criminal Proceedings Child Chris’s father was charged with the Grievous Bodily Harm (Section 18 wounding).  On 30th January 2017 he was found guilty of and sentenced to 13 years imprisonment.  Family Involvement in the Review Due to the progression of criminal proceedings, involvement of both mother (as a potential witness) and father (as the accused) was pended until conclusion of the criminal trial. Following sentencing of father it was concluded that no useful, further learning, would be gained from speaking with father.  Efforts were made to contact Child Chris’s mother, however these were unsuccessful.     24             Liverpool Safeguarding Children Board (LSCB)  Response to the Findings of Serious Case Review – Chris  Liverpool Safeguarding Children Board accepts the findings of the serious case review and has, along with individual agencies, responded to learning and actions identified.    In accordance with requirements (Working Together 2015: 74) LSCB’s response to the review findings of the Serious Case Review (SCR) Child Chris is detailed. Response to the SCR is provided against recommendations of the SCR.   Activity in response to the SCR has been progressed and monitored via LSCB and individual agency action and improvement plans. Individual agency responses to learning and actions identified are detailed within the body of the SCR.      SCR Recommendation 1: (a) The LSCB should be assured that all agencies are clear about information sharing requirements in relation to domestic abuse incidents.  (b) Police should conduct an audit of cases of domestic abuse incidents of victims who do not have English as a first language to establish whether this is a barrier to completion of the MERIT risk assessment.  Police should act on the findings of the audit to ensure equality of access to risk assessment for all victims.  (c) The LSCB should be assured that the local domestic abuse strategy includes specific reference to migrant communities, the use of interpreters and the impact this may have on disclosure and the pathway to specialist domestic abuse services for migrant and other victims who speak little or no English.    25  LSCB partnership arrangements, for sharing information in relation to domestic abuse incidents have been reviewed, revised and updated to clarify the arrangements for sharing information. The Multi Agency Risk Assessment Conference (MARAC) combined information sharing protocol clearly sets out the purpose and principles of sharing information between agencies at MARAC.   Supporting Community partners have developed a Domestic Abuse Referral Pathway which supports all professionals’ understanding of how to respond when a domestic abuse victim presents for support. The pathway includes contact information for a range of domestic abuse services so that those who experience domestic violence are able to access appropriate guidance, advice and support. Extensive contact information has also been drawn together which provides for victims, both men and women, and professionals, detail of how to contact support, services, refuges and help-lines locally, regionally and nationally.    LSCB has sought and received assurance, from Merseyside Police, through their undertaking of an audit, that victims who do not have English as a first language have not and continue not to receive a lesser service around safeguarding and support from front line officers. Merseyside Police and staff use a variety of mechanisms, including the use of current technologies on devices or mobile phones, and use Language Line services at scenes of incidents.   At time of SCR publication final review of a Liverpool Domestic Abuse Strategy is being completed. The strategy is to be agreed by relevant forums in May 2017 and received by LSCB in June 2017.    Recommendation 2 LSCB should be assured that current practice in relation to cultural competence and safeguarding is in line with national professional guidance and responsive to the needs of specific communities.  Recommendation 3 LSCB should be assured that professional interpreter services are always used by agencies; the use of family members or others is not acceptable practice.  A representative multi-agency task group has considered the information and guidance available to professionals, locally and nationally, in relation to cultural competence and safeguarding. The group has identified that guidance to support all professionals when responding to safeguarding concerns arising in migrant and diverse communities is extremely limited. Development of cultural competence guidance for multi-agency staff has commenced which will be communicated through workforce development ‘spotlight sessions’ supported by dissemination of practice guidance to all front-line staff.  Local practice across agencies, including Children’s Social Care, Merseyside Police, Merseycare and Education, has been reviewed in relation to working with diverse and migrant communities. Although practice remains in accordance with LSCB multi agency procedures, LSCB continues to work with agencies to further develop and improve practice. LSCB has implemented an audit of agency practice to ensure that agencies are assured that front line staff remain competent when and working with diverse and migrant communities and that the use of interpreters is in accordance with LSCB multi agency procedures. Findings of the LSCB audit continue to be used to support workforce development.             26   Recommendation 4 The Chair of the LSCB should liaise with Chief Officers in partner agencies with a view to writing to the Department of Health highlighting this significant gap in the availability of historic health, social care and criminal records.  In light of matters raised in this SCR the independent Chair of LSCB has written to the Department of Health highlighting a significant national issue in relation to the availability of health and social care records for migrants to the UK.  The letter affirms the review being informed, through consultation with a range of multi-agency professionals, as to the significant gap in the provision of historical health and social care records for migrants to the United Kingdom. This gap in information often results in professionals being unsighted on important aspects of personal history relating to both vulnerability and risk, often only being able to work with self-reported information.     As with all SCRs LSCB continues to develop more effective safeguarding practice by working closely with all professionals across the partnership. Learning from this and other serious case reviews, regionally and nationally, is regularly disseminated across agencies and multi-agency workforce development and learning opportunities continue to be made available for all staff.       