Serious injury of 6 1/2-week-old twin babies, who were admitted to Somerset hospital and found to have serious head injuries and body bruising. Father was convicted of unlawfully and maliciously inflicting grievous bodily harm and received a sentence of 45 months' imprisonment, Mother was found not guilty of any offence. Mother and Father known to have had troubled childhoods and history of paternal mental ill health and conviction for violent offences. Family had contact with a number of services, including 7 local authority areas, 29 health agencies, 3 police forces and 7 housing authorities/agencies. A strategy discussion had been held by Somerset children's services and plans were in motion for a child protection conference at the time of the incident. Considers issues of: pre-birth assessments and rights of the unborn child; the role of police welfare checks; the need for professionals to challenge each other appropriately; working with mobile families who regularly cross organisational boundaries; and the use of research to inform practice. Makes interagency and various single agency recommendations covering children's social care, housing services, legal services, GPs and NHS Trusts and the police.
      
 Title:  Serious case review: overview report: in respect of Baby A and Baby B LSCB: Somerset Local Safeguarding Children Board Author: Jane Wonnacott and Gillian Earl Date of publication: 2013  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.                          Overview Report 19.03.13 Page 1 of 100   Somerset LSCB     Serious Case Review Overview Report   In respect of Baby A and Baby B    Report Authors Jane Wonnacott  BA MSc MPhil CQSW AASW Director In-Trac Training and Consultancy Ltd  Gillian Earl RGN RHV MA Associate In-Trac Training and Consultancy Ltd        Overview Report 19.03.13 Page 2 of 100  CONTENTS     Page 1 Introduction 3 2 The Serious Case Review Process 4 3 Family Context 8 4 Summary of Professional Involvement With The Family 9 5 Professional Involvement: North Somerset and Oxfordshire (0-19 Weeks’ Gestation) 14 6 Professional Involvement: Nottingham Pre Birth 16 7 Professional Involvement: Delivery and Hospital Post Natal Period 22 8 Professional Involvement: From Hospital Discharge to Serious Injuries 34 9 Thematic Analysis of Issues in this Case 47 10 Lessons Learnt 74 11 Conclusion 78 12 Overview Report Recommendations 80 13 Health Overview Recommendations 82 14 Individual Management Review Recommendations 86     Appendix 1: Terms and Reference and Scope of the Review 97         Overview Report 19.03.13 Page 3 of 100                                                  1. INTRODUCTION    Circumstances leading to this serious case review 1.1  Baby A and Baby B (twins) were admitted by ambulance to a Somerset Hospital at the age of six and half weeks and found to have serious head injuries and body bruising.  Mother, Father and the twins had recently moved to Somerset from Nottingham and were living with family in the area. Both parents were arrested and charged with Grievous Bodily Harm. The result of the criminal trial was that Father was convicted of unlawfully and maliciously inflicting grievous bodily harm, and received a forty five month prison sentence. Mother was found not guilty of any offence.  1.2  Mother and Father had received services in seven different local authority areas and had been in contact with a significant number of health providers, both during pregnancy and following the birth of the twins.  1.3  In view of these circumstances, the chair of Somerset Safeguarding Children Board decided that the case met the criteria for a serious case review under statutory guidance1, which requires that a review should be considered where a child sustains a potentially life threatening injury and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children.  1.4  As identified in Working Together to Safeguard Children (2010), where partner agencies of more than one LSCB have known about or have had contact with the child, the LSCB for the area in which the child is, or was ordinarily, resident should take lead responsibility for conducting the serious case review. Any other LSCBs that have an interest or involvement in the case should co-operate as partners in jointly planning and undertaking the serious case review. In this case at the time that the decision was made to undertake the serious case review the children were living in Somerset and the degree and extent of involvement by other local authorities had yet to be determined.   1 HM Government (2010) Working Together to Safeguard Children London: DCSF. Chapter 8 paragraph 8.11.    Overview Report 19.03.13 Page 4 of 100   1.5  Somerset Safeguarding Children’s Board, holding lead responsibility for conducting the review, made every effort to ensure that Nottingham LSCB were included appropriately in the review process. The steps that were taken to ensure this were: • An invitation to the individual management review authors to meet the serious case review panel (the Nottingham Children’s Social Care and Health authors attended). • An invitation to members of the Nottingham City Safeguarding Children’s Board to attend a Somerset serious case review panel (this was achieved via teleconference). • Two members of Somerset serious case review panel travelled to Nottingham to meet serious case review panel members. • The sharing of draft Overview Reports in advance for comment and feedback.  1.6  In addition all organisations submitting reports to the Somerset serious case review panel were offered an opportunity to review and offer feedback on the draft overview reports.     2. THE SERIOUS CASE REVIEW PROCESS  2.1 John Snell, Somerset Safeguarding Children Board Independent Chair, was appointed to chair the serious case review panel and oversee the process.   2.2 Members of the serious case review panel were: Somerset LSCB Co-ordinator  Somerset LSCB Deputy Chair  Service Director, Safeguarding & Care Designated Doctor Somerset and North Somerset Local Safeguarding Children Boards  Designated Nurse Somerset Local Safeguarding Children Board Detective Inspector Avon and Somerset Police    Overview Report 19.03.13 Page 5 of 100     Principal Educational Psychologist Somerset County Council   LSCB Audit Officer     2.3 Two experienced independent overview authors were appointed to prepare the overview report:  1. Jane Wonnacott, Director, In-Trac Training & Consultancy Ltd, a qualified and experienced social worker.  2. Gillian Earl, Independent Consultant and In-Trac Associate, an experienced safeguarding nurse consultant.   The authors attended panel meetings in order to ensure that the views of the panel were taken into consideration in the preparation of the final report.  2.4 The terms of reference and scope of the review were agreed and are appended to this report (Appendix 1).  2.5 Following a preliminary review of agency records it was agreed that individual management reviews would be required from: • Oxfordshire County Council. • Oxfordshire General Practitioner Services. • Avon and Somerset Police. • Nottingham CityCare Partnership (Health). • Nottingham City Children’s Social Care. • Northern Lincolnshire and Goole Hospitals NHS Foundation Trust. • Derby Hospitals NHS. • Nottingham University Hospitals. • Somerset Social Care. • Somerset GPs. • Somerset Partnership NHS Foundation Trust (formerly Somerset Community Health).    Overview Report 19.03.13 Page 6 of 100    • Derbyshire Social Care. • Somerset Health Overview Report.  2.6 The following additional information was requested and received : • Addendum Report Nottingham CityCare Partnership. • Addendum Report Nottingham City Children’s Social Care. • Telephone Strategy discussion minutes [Somerset Social Care & Avon and Somerset Police]. • Additional information from Avon and Somerset Police. • Typed transcript of telephone calls between the Nottingham social worker and Somerset Direct. • Recordings of telephone calls between Nottingham social worker and Somerset Direct.  2.7 The individual management reviews were scrutinised by the panel in order to ensure that they focused appropriately on the information and learning relevant to their organisation. A summary evaluation of the individual management reviews was completed for Somerset Safeguarding Children Board. Information from the reviews has been assimilated into this overview report.   2.8 Following further consideration it was agreed that an individual management review was not required from the following organisations, due to their limited contact with the parents during the review period or the historical nature of their involvement. Instead, reports and / or chronologies of prior involvement were requested from: • North East Lincolnshire Children and Family Service. • Somerset County Council Special Educational Needs Service. • Taunton and Somerset NHS. • NEMS Benefits Service. • Nottinghamshire Healthcare NHS Trust (Mental Health Services). • Derbyshire Police. • Nottinghamshire Police. • Thames Valley Police. • Cherwell District Council – Housing.    Overview Report 19.03.13 Page 7 of 100  • Nottingham Support Service 1. • Nottingham Support Service 2 (Floating Support Services and Central Access Point). • Hostels Liaison Group (HLG) Nottingham. • Charitable Hostel – Derbyshire.  • North Somerset Housing. • NHS Direct. • South Western Ambulance Service. • East Midlands Ambulance. • Weston Area Health Trust. • GP practices North Somerset NHS.  2.9 Additional papers considered by the panel to assist their understanding were: • Ofsted (2011) Inspection of Safeguarding and Looked After Children’s Services, Nottingham City.  • Ofsted (2011) Annual unannounced inspection of contact, referral and assessment arrangements within Nottingham City Council Children’s Services. • Nottingham Family Support Strategy February 2011. • A Guide for the Police, CPS and LSCB to assist with the liaison and the exchange of information when there are simultaneous Chapter 8 SCRs and Criminal Proceedings (April 2011). • Inspection report Somerset County Council Children’s Services (Ofsted 2011).  2.10  During the latter stages of the review process information was received from Somerset County Council Legal Department regarding the estimated timings and nature of the injuries to Baby A and Baby B. The information noted metaphyseal fractures present in both babies that were likely to have occurred sometime prior to the final serious injury.   Family Involvement 2.11  The Serious Case Review Panel was advised by Somerset Police that family members should not be contacted until after criminal proceedings had been    Overview Report 19.03.13 Page 8 of 100 completed. Letters were sent to both parents and paternal grandmother outlining the serious case review process, explaining that they could immediately submit any comment in writing to the serious case review panel.  Following conclusion of the trial Mother, grandmother and Father were again contacted and asked whether they wished to contribute to the review. Father did wish to see the overview author and he was therefore visited in prison and his views sought about the services provided to the family.     Putting learning into practice 2.12  As the review was not finalised until after the trial it was important that immediate action was taken by agencies to make any relevant practice improvements identified without waiting for the final overview report. The action plans that accompany this review do demonstrate that in most cases this happened. However, there were challenges in monitoring this process when the review was being led by one Local Safeguarding Children Board and many of the recommendations related to six other areas some distance away.    2.13  Somerset Local Safeguarding Children Board has made every effort to ensure that all relevant Boards are aware of the process of this review but each individual Board will need to take responsibility for monitoring progress of their own action plans.     3. FAMILY  CONTEXT   3.1   Both parents of Baby A and B are described as White British and both can be described as having troubled childhoods. They were subject of child protection plans.   3.2  Father has lived in the south west region for most of his life, only moving to Oxfordshire and Nottingham following his relationship with Mother. He had spent time in the care of Somerset County Council as a young person and there is some evidence of mental health problems. He was also known to the police following violent incidents resulting in a number of criminal convictions.     Overview Report 19.03.13 Page 9 of 100   3.3  Mother grew up in Derbyshire, where she was one of several siblings. There have been frequent suggestions that the Mother may have a learning disability but there is no evidence of any formal testing to confirm this.  Just prior to meeting Father she was living in a hostel in for vulnerable young women in Derbyshire and, following her relationship with Father moved to North Somerset where her pregnancy with the twins was confirmed shortly afterwards.      4. SUMMARY OF PROFESSIONAL INVOLVEMENT WITH THE FAMILY   4.1 Following confirmation of Mother’s pregnancy in North Somerset: •  Mother moved to Oxfordshire to stay with her brother, citing domestic violence from her partner. Mother reconciled with Father, was evicted from her brother’s home and moved with Father into a tent in Oxfordshire. Health, Children’s Social Care, Police and housing agencies had contact with the family at this point.  •  Mother and Father moved to Nottingham, moving in with a friend until they obtained their own accommodation. Nottingham Children’s Social Care, housing organisations and health agencies were all involved with the family during this pre-birth phase.  • Mother went into premature labour ten weeks before her estimated date of delivery and was admitted to hospital in Nottingham before being transferred to hospital in Grimsby (where the twins were born), due to the lack of Neonatal Intensive Care cots in Nottingham.  • The twins (together with both parents) were transferred to Derby hospital’s Neonatal Intensive Care Unit, then back to Nottingham where they were discharged into the community. • Within forty eight hours Baby A was re-admitted to hospital in Nottingham and discharged the following day. Nottingham Children’s Social Care continued to be involved. • A few days later without telling professionals that they were leaving Nottingham, the family moved to Somerset to stay with paternal grandmother. According to Father, their intention at this point was to find    Overview Report 19.03.13 Page 10 of 100    somewhere to live where they felt safer than they did in Nottingham.  • During the eleven days the family spent in Somerset they were visited by professionals from three services (Police, Health and Social Care) on seven occasions. A number of planned visits to the family were unsuccessful. The babies were also seen by the GP and in Accident and Emergency on one occasion prior to their final admission with unexplained injuries.  4.2 As demonstrated by the above history, Mother and Father have had contact with a number of services beyond universal provision, both prior to and during the period covered by this review. This has therefore been an extremely complex review involving seven local authority areas, twenty-nine individual health agencies, three police forces and seven housing authorities / agencies.    4.3 The picture is further complicated by Local Government reorganisations which have resulted in Father’s early records moving between North Somerset, the (then) Avon County Council and Somerset County Council.  Father was born in the administrative region of Avon County Council, an authority which had been created in 1974 and took over the government of the northern region of historic Somerset. In 1996 Avon ceased to exist and two new unitary authorities took over the government of the northern part of Somerset, North Somerset District Council and Bath and NE Somerset District Council.   4.4 Organisations that had contact with the family during the review timeframe:   Area Organisation Length of time involved. (From first to last contact) North Somerset  GP services   Two different practices involved at same time for Father: 3 months  NHS North Somerset Mother: 2 months 26 days  Father: 3 months  Weston Area Health Trust, including one visit to UBHT 2 weeks  North Somerset Housing 1 day   NADA  1 contact Oxfordshire Cherwell District Council Housing 2 months 19 days   Thames Valley Police 4 days  Child, Education & Families Directorate  1 month 6 days     Overview Report 19.03.13 Page 11 of 100   Oxford Health NHS Foundation Trust General Practitioner  Midwifery & Health visiting service 19 days between 1st and last contact  Primary Care records cover 2 months 3 days  Nottinghamshire   Nottinghamshire Healthcare NHS Trust 3 months 5 days (no physical contact)   Nottingham CityCare Partnership (Health) 3 months 12 days   Nottingham University Hospital NHS Trust 4 months 2 days   Hostels Liaison Group 2 weeks   Nottingham Housing Support Service 1 4 months 9 days   Nottingham Housing Support Service 2 24 days    East Midlands Ambulance Service NHS Trust 4 months     Nottinghamshire Police 14 days (no physical contact) re PMG 8.2.11  Children’s Social Care 4 months + 11 days NE Lincolnshire   Grimsby Hospital 9 days   Children’s Social Care 1 day (no physical contact)  Derbyshire   Derby Hospitals NHS Foundation Trust 9 days  Derbyshire Social Care 5 months 3 weeks  Derbyshire Constabulary Historical contact only  Charitable Hostel   4 months Somerset South Western Ambulance Service 9 days   Somerset Community Health (now Somerset Partnership Foundation Trust) 14 days    NHS Direct 5 months 3 weeks (three contacts)  Children’s Social Care 13 days   Taunton and Somerset NHS Trust Incident hospital 1 day   Avon & Somerset Police 9 months 4 days     4.5  The organisations which had the most extensive contact with the family during the timeframe for this review were those in the Nottingham City area. Within Children’s Social Care the family were first the responsibility of the screening and duty team, passing to the long term community team following the completion of the initial assessment.  A children’s centre was also involved, with a level 3 worker from the centre carrying out a parenting assessment. Level 3 workers within the centre carry a case load of Child in Need (CIN) cases and targeted pieces of work to be completed on cases that are open to Social Care.     Overview Report 19.03.13 Page 12 of 100                                                      4.6 The context for the delivery of services was identified by the Nottingham City Children’s Social Care individual management review author as a situation where the organisation ‘has experienced difficulties with recruitment and retention of staff within their screening and duty team which has meant that there have been a number of agency social workers and agency team managers, although it now has three permanent team managers in post. From August to December 2010, the teams were extremely busy, with a significant number of referrals.’ (para 1.5)   4.7 The Ofsted inspection of referral and assessment arrangements which took place whilst the family were in Nottingham (August 2011) noted improvements in the service and that social work vacancy rates were minimal as a result of senior managers ensuring the recruitment of suitably qualified workers to permanent positions.  The most recent Ofsted inspection of Safeguarding and Looked After Children’s Services (November – December 2010)2, also noted that workloads were manageable and that decisive action had been taken to identify and respond to increased referral rates in all key agencies.   4.8 Despite identified workload pressures in 2010, the Nottingham Children’s Services individual management review author also commented that: • The service is well resourced and well funded. • There are no cost issues in relation to the provision of parenting placements. • There is no hesitation in instigating either S47 enquiries or court applications and there are high numbers of children in care.  4.9 The individual management review author also identified current practice improvements relevant to this review:  • Re-organisation of the work. • Co-location of the safeguarding team (health and social care). • Named nurse now attending the management meetings. • Robust escalation policy (reviewed 2010). • Working together to integrate services.  2 Ofsted (September 2011)  Annual unannounced inspection of contact, referral and assessment arrangements within Nottingham City Council children’s services  http://www.ofsted.gov.uk/local-authorities/nottingham     Overview Report 19.03.13 Page 13 of 100                                                 • Proposed implementation of a joint supervision policy (health and social care).  4.10  The organisational context for Somerset Children and Young People’s Directorate during the time period covered by this review was that all child protection enquires would be filtered through ‘Somerset Direct’. Somerset Direct is a triage service and handles contacts from the public and professionals. There is a direct link for callers who consider their call has a child protection element. This service has been identified by a recent Ofsted inspection as:  ... an outstanding model. Managers are knowledgeable and supportive and set high work standards. The presence of qualified social workers and managers within this service is appropriate in determining appropriate thresholds for intervention3  4.11  The process within Somerset Direct is that when the telephone is answered, callers are directed to choose a direct link if their call has a child protection element. Calls are taken by advisors working closely with the social work team to identify if the contact has a child protection element or meets the Children’s Social Care threshold. The initial contact may result in a number of actions, including a referral, and is passed to the team leader of a local ‘pod’.  4.12  Teams in the Somerset Area Office are divided into four ‘pods’ composed of four to five social workers, senior social work assistants and support workers. Cases are allocated in turn to each pod. The pod meets every morning to discuss and manage their work. A new area manager came into post four days after the family arrived in Somerset.       5.   PROFESSIONAL INVOLVEMENT: NORTH SOMERSET AND OXFORDSHIRE  3 Ofsted (June 2011) Annual unannounced inspection of contact, referral and assessment arrangements within Somerset County Council children’s services   http://www.ofsted.gov.uk/local-authorities/somerset     Overview Report 19.03.13 Page 14 of 100       (0-19 weeks gestation)   5.1 Following confirmation of her pregnancy by a North Somerset GP practice, Mother was offered good medical care, but no social history was obtained by either the GP or the midwife although routine questions were asked about domestic violence. On each occasion she gave a negative response or indicated exposure to violence from her wider family.  5.2 Meanwhile Father was being treated by his GP for symptoms relating to his mental ill-health and he also informed the GP that his partner was pregnant.   5.3 Mother’s brother (Maternal Uncle) who lived in Oxfordshire called his own social worker concerned that Mother’s partner (Father) was very controlling and that Mother was very unhappy and isolated. Following ‘an alleged domestic abuse incident by Father’ and this call, Mother moved to stay with Maternal Uncle, a move facilitated by a voluntary domestic violence organisation in North Somerset.  5.4 On arrival in Oxfordshire Mother (now thirteen weeks pregnant) registered with a GP who recorded she had left her partner with the support of a Domestic Violence Unit. Mother was booked with the midwife, referred to a consultant obstetrician and Mother’s brother’s family health visitor was alerted.    5.5 Mother asked Father to join her in Oxfordshire, prompting her brother to follow the advice of his own social worker. The social work advice was that he should ask Mother to move out of his home. Despite Mother’s vulnerability there was no immediate assessment at this point by Children’s Social Care, seemingly due to the possibility that Mother would not be permanently resident in the area.  5.6 The local housing department in Oxfordshire decided that Mother was intentionally homeless and should return to the hostel in Derbyshire. Mother refused, moving with Father into a tent in the Oxfordshire area. Once the housing office became aware of this, bed and breakfast accommodation was arranged that night, and the couple advised to make a homeless application. This they did but, but due to still having a tenancy in North Somerset, they could not be offered    Overview Report 19.03.13 Page 15 of 100    housing in Oxfordshire.  5.7 During the time Mother and Father lived in the tent they were seen twice by Thames Valley Police.  Firstly, an anonymous member of the public spoke with a police community support officer on patrol and told them that Mother was pregnant with twins, had previous mental health problems, and was homeless and living in a tent with Father who had been violent to her previously. The police community support officer submitted an internal intelligence report which, due to its internal nature, did not trigger any multi-agency discussions.  5.8 On the second occasion they were alerted to the couple’s situation via an anonymous phone call to the police station, as well as from a member of the public to an officer on patrol. A Thames Valley police sergeant visited the campsite and spoke with the couple. He also spoke with Mother alone about domestic violence and asked her if she was okay and happy to remain with Father. She confirmed she was.   5.9 Communication between Health and Social Care in Oxfordshire appears confused by the fact that Mother was initially living with her brother who already had a social worker. The GP contacted social care and at this point appears to have assumed the same social worker was also working with Mother. No formal referral to Children’s Social Care was made by the GP due to Mother refusing her consent, although a letter of support to housing was offered.  No contact was made with the practice child protection lead, or a member of the safeguarding team, regarding the GP’s concerns. Should Children’s Social Care have received a referral from the GP, this is likely to have  prompted an initial assessment as it is clear that at this point Oxfordshire Children’s Social Care had begun to explore the potential vulnerability of Mother.   Evaluation of Practice North Somerset and Oxfordshire (0-19 weeks gestation)  Practice issues were: �   A focus by Health professionals on medical needs rather than a holistic assessment    Overview Report 19.03.13 Page 16 of 100 of both medical needs and social circumstances. The need to do this was particularly acute once it was confirmed that Mother was expecting twins, with additional stresses likely to result from a multiple birth.  �   A failure to make connections between Mother and Father although Father was registered at the same GP practice in North Somerset.  �   Although the GP in Oxfordshire liaised well with a number of different professionals, there was no co-ordinated plan in place.       6.  PROFESSIONAL INVOLVEMENT: NOTTINGHAM PRE-BIRTH   6.1    At approximately nineteen weeks pregnant Mother moved to Nottingham, presenting at Out Of Hours medical services with pregnancy related symptoms, and was referred to other health care professionals. Children’s Social Care teams in Oxfordshire and Nottingham received notification of Mother’s attendance at hospital.  She again presented at hospital in Nottingham three weeks later, and a referral outlining a number of risk factors was made by the Nottingham midwife to Nottingham Children’s Social Care requesting a pre-birth risk assessment. Nottingham confirmed to Oxfordshire Social Care that since Mother was remaining in Nottingham they accepted case responsibility. Oxfordshire Children’s Social Care therefore closed their case file.   6.2 Once it was recognised by the Oxfordshire health visitor that Mother had left the area but had not yet registered at a Nottingham GP surgery, she contacted her Trust’s named nurse who then appropriately contacted her safeguarding colleague in Nottingham to flag Mother’s name as a vulnerable pregnant adult.  6.3 On arrival in Nottingham there were challenges in pulling together a full picture of the family’s current situation, partly influenced by uncertainty as to where Mother and Father would be living and exacerbated by the fact that Mother appeared to be selective in the information she shared with each professional. The couple had contact with a number of housing services who demonstrated good practice by proactively working with the couple, for example, making appropriate and comprehensive referrals to Children’s Social Care outlining several risk factors,    Overview Report 19.03.13 Page 17 of 100                                                     including the likelihood that the babies would arrive early. There is also evidence of continued liaison with Children’s Social Care, including joint visits.    6.4 Mother informed the Nottingham social worker in the screening team that she had been on the ‘at risk register’ as a child and gave them the contact details of her social worker in Derbyshire. Derbyshire Social Care confirmed that Mother’s case was open to the learning disability team and that there had been limited recent involvement with her due to lack of engagement. No psychological assessment had been undertaken. Following completion of an initial assessment, the case subsequently transferred to the long term team within Nottingham Children’s Social Care and was allocated to a social worker whose role was to complete a core assessment.  6.5 Alongside the core assessment a PAM (Parenting Assessment Manual) assessment4  was commenced by the family centre in conjunction with the allocated social worker. Interviews carried out for this review have revealed that that during this process there was a degree of conflict between the two professionals involved.    6.6 At various times the social worker commented to other professionals that she thought the case might reach the threshold for child protection. For example, Derbyshire Children’s Social Care records note a request for information from the social worker saying Nottingham were initiating child protection procedures and considering care proceedings. Housing records also note that the social worker informed them that the case was ‘borderline child protection’.  However, supervision notes continue to document that the case was to be managed as ‘children in need’.   6.7 Meanwhile routine ante natal care was being provided by health. When Mother was seen by the Obstetric Specialist Registrar he referred Mother to the perinatal mental health team because he identified Mother as being ‘at extremely high risk of post natal depression’. Details of her current mental health status were not documented. Mother was not seen by this service, as she went into labour on the  4 A PAM assessment is a structured research based parenting assessment designed to be carried out by those who have been trained in its use.    Overview Report 19.03.13 Page 18 of 100   day of her appointment and, following later contact, failed to make any further contact or appointment.    6.8 Questions were appropriately asked of Mother during ante natal appointments about the possibility of domestic violence, to which she replied, ‘No, never’. However, it was not always possible to follow this up during subsequent appointments, due to Father’s presence.   6.9 During this period Mother and Father frequently reported problems with the downstairs neighbours. Father confirmed to this review that housing was a major source of stress. He has told this review that he did not feel safe in the flat as he believed there were gangs and prostitutes living on the floor below. Housing issues appear to have dominated much of the communication between the parents and the social worker, with Father sending numerous texts, often at night, complaining about their situation. The content of these text messages was not recorded within the social work file, highlighting the need to keep pace with new forms of technology and their relationship to traditional recording methods.  6.10  The Nottingham social worker did request information from Somerset Children’s Social Care regarding Father’s family background as it was known he had been in the care of Somerset as a young person. The files were recalled from Somerset’s archives and extracts sent to Nottingham from his family files, but there was no information about Father’s progress whilst in care, or relevant information such as his conviction for arson and referral for anger management sessions.   6.11  A core assessment record was completed within the time frame agreed with the Nottingham social worker’s manager. However, it repeated the details from the initial assessment and left most of the domains blank. It stated that the issues would be addressed in the ‘full core assessment’ and that a PAM assessment would be completed.  This does not appear to have been challenged by the Nottingham team manager and is a significant issue since later on Somerset Children’s Social Care assumed that a full core assessment had been completed, indicating the children were ‘in need’ rather than ‘in need of protection’.      Overview Report 19.03.13 Page 19 of 100 6.12  The same day that the core assessment record was completed, the health visitor initiated a safeguarding supervision file in respect of the family. The request contained relevant details of the family history, the fact a PAM assessment was ongoing and noted that there was a plan for a joint visit with a social worker. At this point, apparent discrepancies between the views of Health and Children’s Social Care start to emerge which were not explored by either party.  6.13  It was good practice that during this period the midwife referred and liaised with the allocated health visitor, giving information about the family history. The health visitor contacted the social worker who advised of the history, the PAM assessment and the fact that the parents had a tenancy support worker who was helping to furnish the flat. A joint visit was agreed between the social worker and health visitor, as well as an arrangement for a meeting to take place once the twins were born. In the event the joint visit did not take place as the social worker was unable to be there, but the family were visited by the health visitor and midwife.  6.14  During this period (which included Christmas) the parenting assessment continued, with Mother revealing more of her history and commenting that meeting Father was the best thing that happened to her, as he supported her after her Mother’s death.   6.15  At thirty one weeks of pregnancy, Mother was admitted to the labour ward via ambulance, accompanied by Father. On the same day the Nottingham social worker and the children’s centre worker continued with the PAM assessment whilst Mother and Father were on the labour ward.  Mother at this point was on a drip and the inappropriateness of this action does not seem to have been recognised by the workers nor challenged by staff on the ward.   6.16  Afterwards the children’s centre worker discussed the case with her team manager and concluded that it seemed the parents would be able to support each other but would need support from the children’s centre with their parenting. As housing was noted to be an issue, the children’s centre worker subsequently wrote to the housing organisation to point out the unsuitability of the current    Overview Report 19.03.13 Page 20 of 100 accommodation.   6.17  During Mother’s labour, there was communication between the hospital midwife, health visitor and perinatal mental health team. All were clear that Mother would still require assessment from the perinatal mental health team following the birth. The named midwife for safeguarding was also contacted by the ward and further information was obtained from Children’s Social Care noting that there was an ongoing assessment, that the category was Children in Need and there would need to be a discharge planning meeting.  6.18  Whilst in labour, Mother was transferred to Northern Lincolnshire and Goole Hospital (Grimsby) in accordance with the Trust’s in-utero transfer policy, due to no neonatal cots being available locally. A medical transfer letter to the Grimsby obstetrician stated ‘lots of social issues which have been explained to your midwifery staff’. The social worker was also informed.  6.19  On admission, a full history was taken from Mother and they were noted to have a social worker. Both parents were noted to be anxious and displaying slightly hostile attitudes towards care given so far.  6.20  Baby A and Baby B were subsequently born prematurely at thirty one weeks’ gestation, by emergency caesarean section. Both babies were small for gestational age and were transferred to the neonatal unit.   Evaluation of practice Nottingham Pre-birth  (Nineteen weeks gestation – birth at thirty weeks)  Practice Issues were:  �   Proactive work by Housing organisations who made appropriate and comprehensive referrals to Children’s Social Care.   �   An acceptable initial assessment by Children's Social Care, however, once the case passed to the long term team in Children's Social Care for a core assessment, there was a delay in allocation and an apparent lack of attention paid to the fact that the    Overview Report 19.03.13 Page 21 of 100 babies were likely to be born prematurely.  �   Confusion within Children's Social Care long term team as to the type and level of risk. The social worker referred to child protection procedures when talking to other agencies; however, supervision notes record that the case was Child In Need. It is possible that although the social worker expressed her own views to others, these views were modified during supervision with her manager. �   It was unacceptable that the core assessment consisted of the initial assessment, cut and pasted onto core assessment documentation. A serious omission was the lack of any systematic gathering of information about family history and an over reliance on self reporting by Mother and Father.  �   No assessment of the degree and extent of possible parental learning disability.  �   A lack understanding of the role of the parenting assessment (PAM) in relation to the core assessment.  The PAM is designed to complement (not replace) the core assessment but in this case there is no evidence of any assessment work at all apart from that related to PAM. This should have been picked up by the team manager in their supervision of the social worker, as should the implications of a degree of conflict between the children’s centre worker and social worker. �   Inappropriate behaviour in continuing the assessment process whilst Mother was in labour, and no challenge to this by hospital staff. �   Mother’s various presentations at emergency medical services was not identified as a pattern of help seeking which may have been a warning sign including anxieties about becoming a parent (Brandon, 2008)5.  �   Health professionals recognised vulnerabilities but at times appeared to be dealing with immediate health issues whilst passing over to Children’s Social Care the responsibility for managing safeguarding concerns.   �   Good practice by midwives who created an opportunity to ask about domestic violence when Father was not present.  �   An appropriate referral to the perinatal mental health team was made in respect of Mother although she went into labour on the day she was due to be seen and, following later contact, she failed to make a further appointment.   �   No discussion or referral by professionals to the community learning disability team, adult mental health services or substance misuse team to assess, assist and guide                                                  5 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner,. R. Dodsworth, J. Black, J., (2008) Analysing Child Deaths and Serious Injury Through Abuse and Neglect: What Can We Learn. London DCSF Research report DCSF-RR023      Overview Report 19.03.13 Page 22 of 100 interventions for promoting parenting capacity.  �   The tendency for both Mother and Father to respond affirmatively to any requests to attend appointments or fill in forms from professionals, may have encouraged over-optimistic assumptions about the extent of the parents’ understanding, level of engagement with professionals and capacity to put into practice any plans agreed (Cleaver and Nicholson 2008)6.  �   Little consideration by any agency of the stress being placed on the couple by the number of appointments they were expected to keep, often in one day.  A more co-ordinated approach may have reduced the negative impact of these demands and allowed a clearer assessment of the couple’s capacity to engage appropriately with professionals.  �   When the twins were transferred in-utero to Grimsby, it was not good practice for medical staff to state in the transfer notes, ‘lots of social issues which have been explained to you by midwifery staff’. The duty obstetrician responsible for Mother’s antenatal care at this time did not take full responsibility for ensuring that the safeguarding concerns, identified whilst at Nottingham, were appropriately documented and passed onto Grimsby, relying instead on midwifery staff to provide relevant information verbally.       7. PROFESSIONAL INVOLVEMENT:  DELIVERY AND HOSPITAL POST NATAL PERIOD     7.1                                                                                                                                                                    Whilst in Grimsby, hospital records indicate that the twins made progress and the parents were ‘attending to feeds and cares’. Father has spoken very positively to this review about the help and support that the family received from hospital staff during this time.  7.2 However, there were a number of significant concerns about the behaviour of the parents which were identified, not fully assessed, nor shared with the Nottingham social worker in writing. These concerns included hostility of Father towards staff, Mother missing feeds and parents having little insight into the responsibilities involved in caring for twins. These issues prompted a discussion with the hospital  6 Cleaver H, Nicholson D (2008) Parental Learning Disability and Children’s Needs: Family Experience’s and Effective Practice. Executive Summary DCSF    Overview Report 19.03.13 Page 23 of 100      safeguarding team who contacted the local social work office (North East Lincolnshire Children’s Social Care) but only regarding ‘money’, and a one-off hardship loan was made. The Nottingham social worker also asked the hospital to continue to supply food to Father, funded by Nottingham Children’s Social Care.  7.3 Liaison between the hospital and the Nottingham social worker was via telephone. The message conveyed to the hospital by the social worker was that there were ‘no child protection concerns’ and the twins were safe at the present time.   7.4 At nine days old Baby A and Baby B were transferred to Derby Hospital for continuing care nearer home.  The transfer documentation from Grimsby did set out issues relating to the social history and parental care of the twins in hospital, but this was not in a clear format and was only identifiable from disparate parts of the records. Verbal communication from Grimsby Hospital and the Nottingham social worker to Derby Hospital reinforced the view that this was a case of ‘Children in Need’.  7.5 On admission to the Derby Neonatal Intensive Care Unit the parents were accommodated at the Children’s Hospital. Staff on the Unit received a telephone call from the Nottingham social worker asking for items usually provided by parents to be given, along with meals for Father, due to benefit problems. When advised that meals were not provided to fathers, the social worker’s response to the hospital staff was that Social Care could not offer any funding for meals and asked for compassion to be shown. Health managers then agreed food would be provided.   7.6 The named midwife from Nottingham appropriately contacted Derby hospital advising the ward of the vulnerabilities of the parents, details of their social worker and that the babies should not be discharged without a discharge planning meeting.  7.7 The Nottingham social worker visited the parents in Derby hospital and spoke to ward staff who had increasing concerns about the ability of the parents to meet the needs of the twins. Following the social worker’s visit, Derby Hospital staff    Overview Report 19.03.13 Page 24 of 100   appropriately initiated Safeguarding Children & Young People – Risk communication and action planning paperwork, including the fact that the family social worker had told Grimsby hospital that the twins were ‘not a child protection issue’ and that both parents required a high level of support to meet both babies’ needs. The named midwife contacted the social worker to request a multi-agency meeting.  7.8 The family care sister informed the named midwife that a child in need status did not reflect the level of risk that the babies faced; they should be transferred into child protection and a strategy meeting held. The named midwife contacted the Nottingham social worker and contemporaneous records document that the social worker was noted to appear ‘aggressive’ in her manner. There is no indication that at this point the social worker was willing or able to assimilate the information from the hospital and consider whether this indicated a need to move from her view that the babies were not at risk and threshold for child protection enquiries had not been reached.  7.9 The Nottingham health visitor wrote a letter to housing supporting a request by Mother and Father to be re-housed.  7.10  Derby Hospitals Safeguarding paperwork was completed with a copy for Nottingham University Hospital. Adult risk factors were identified and also those for the babies (prematurity and low birth weight) with the section on risk being ticked under Neglect. Two days later the unit was contacted by Nottingham University Hospitals to say two beds on transitional care were available. Following discussion with the Nottingham social worker, the babies were transferred back to Nottingham. Derby Hospital faxed to Nottingham University Hospitals a copy of their safeguarding paperwork. On their return to Nottingham, the Nottingham social worker requested that the midwives noted information about parenting capacity, competence and any concerns to assist with a Child In Need assessment.  7.11  On the day the twins moved back to Nottingham at eighteen days of age, Nottingham University Hospitals Trust medical records record that a support    Overview Report 19.03.13 Page 25 of 100 worker within the hospital noted Mother and Father intermittently needed help with feeding and changing the babies. A number of concerns, new and old, were identified, including a report that Father had been rude to another patient in the ward by shouting and swearing about her, and was wandering the wards at night refusing to go home. Mother was noted to have left the babies in wet clothes and failed to feed them when they were hungry.  7.12  At this point, challenges to Mother and Father regarding their parenting appear to have triggered a number of complaints or threats of complaints against hospital staff.  7.13  The Nottingham social worker supported the parents in a complaint against the housing support service. This was despite the high level of support that the housing organisation had offered over and above that which might have been expected, given that the parents had no ties within the Nottingham area.   7.14  The babies were deemed by the hospital to be fit for discharge once a ‘social plan’ was in place. Meanwhile the social work intervention focused on housing issues, including a discussion between the social worker and their team manager about the possibility of s20 accommodation, as the social worker felt that the current accommodation was unsuitable and the babies would be at risk of significant harm. Social Care records show that the parents agreed the property was not suitable and were prepared to have the babies accommodated on a temporary basis and Father confirmed to this review that he would have agreed to the babies living with foster carers at this point. There appears to have been no discussion of the possibility of a parent and baby placement, but Father told this review that he would have welcomed such an opportunity to learn how to be a parent.   7.15  The parents were advised to make a homeless application, and the social worker and team manager decided to await the outcome of that application before deciding whether to accommodate the twins. The hospital  waited for Children’s Social Care to resolve the couple’s housing issues and a decision was made by midwifery management that Father could stay overnight with Mother and babies in    Overview Report 19.03.13 Page 26 of 100 a side room. The decision of the housing department was that they were not able to re-house the couple, resulting in increasingly anxious texts sent from Father to the social worker about the housing situation. He also complained that the social worker wasn’t helping them and they now wanted to return to Derbyshire.  7.16  The Nottingham social worker and a colleague from the team visited the parents in hospital and discussed their housing situation and advised them to make a housing application to Derbyshire. The senior midwife was given the team manager’s number to discuss with him the decision by housing not to re-house the parents. It was recorded in the social care file that the team manager discussed the situation with the service manager and s20 accommodation was thought to be inappropriate as the main issue was considered to be housing. The service manager asked for a home assessment and a discharge planning meeting was arranged for three days later.  7.17  The Safeguarding Children Service supervision file noted telephone contact between the named midwife (NUH) with the safeguarding children nurse specialist to discuss the management of the case and concerns that the main focus was on the housing issues. No focused risk assessment, review of the case records, or contact with previous units or an agreed joint action plan for attendance at the discharge planning meeting appears to have been undertaken in the light of their concerns.  7.18  The social worker was advised by Derbyshire Housing Department that Mother would be able to bid on properties in Derbyshire, but would not be accepted as homeless due to the Nottingham property. As a result the parents went to Derbyshire the same day, being away all day and not responding to attempts by the ward to contact them. The ward contacted the social worker who contacted the parents and advised the ward they would be back after 19:00 hours. They returned at 22:00 hours and made a formal complaint about the care the babies had received whilst they were away.   7.19  The social worker also received three texts from Father, the first complaining about the midwife, the second about revisiting housing and the third asking for    Overview Report 19.03.13 Page 27 of 100 bed and breakfast accommodation. The following day, further texts were received from Father regarding the housing issue.  7.20  The next day, the parents were still asleep at 09:15 hours and the babies not fed. Mother, when asked, said that she had fed them at 09:00 hours but no milk had been collected. At 13:30 hours, the parents were again found to be asleep in their room and needed prompting to feed and look after the babies.   7.21  The midwife discussed with the deputy ward sister and safeguarding midwife’s concerns regarding parenting skills, lack of concern re feeding times and general care for their babies. She was advised if there were concerns to raise them with the social worker. Her concerns were not shared at the discharge planning meeting.  7.22  The parents expressed concern that Baby B had a red mark noted on side of face and he was reported to be arching his back, following review by the neonatal doctor. No marks were seen and no medical problems identified. It is possible that the red mark may have been attributable to contact from the cot side and may have been an attempt to stop the twins’ discharge from hospital planned for the next day.  7.23  The discharge planning meeting, chaired by the team manager from Children’s Social Care, was a pivotal point in this case when there was an opportunity to assess the accumulating risks and develop a plan to keep the babies safe from harm. However, not all professionals invited to the discharge planning meeting had an in-depth knowledge of the family and two key practitioners (children’s centre worker, and midwife who had expressed concerns) were unable to attend. As a result relevant concerns were not shared during the meeting, with the main focus being housing issues, and the needs of the parents overshadowed those of the babies. The health visitor recorded the meeting as a ‘strategy meeting’, indicating differing views between professionals regarding the status of the meeting.  A plan of action noted in Children’s Social Care records agreed: • Discharge the following day (Saturday). • Social worker to go with parents and obtain equipment for the babies before discharge (£250 Grant).    Overview Report 19.03.13 Page 28 of 100 • PAM Assessment to be completed. • No midwife available to visit over the weekend. • Daily visiting from Monday shared between professionals. • Parents to be shown how to bathe and make up feeds prior to discharge. • Environmental health to visit flat next week to assess. • The case to be reviewed in one month.  7.24  Health staff attending later identified that there was a difference in opinion about the purpose of the meeting, risks identified, a difference in perception and they felt not listened to.   7.25  The social worker received a number of texts from Father that evening complaining about the heating, wanting to leave the flat and move into bed and breakfast, also enquiring about a promised pushchair.  Evaluation of Practice Delivery and hospital post natal period  (Birth - 4 weeks)  Identification of risk post birth: communication across Health and Social Care Following delivery at Grimsby Hospital, and then at Derby Hospital, a number of social and safeguarding concerns were identified by hospital staff.  Some of these were passed onto the Nottingham social worker while others were not, the level of communication possibly being influenced by the clear message from the social worker that there were ‘no child protection concerns’.  At times there appeared to be a lack of robust record keeping by health professionals in respect of concerns raised, which may have been influenced by the view expressed by the social worker that this was a Child In Need case. Alternatively, professionals may have been influenced by the threat of complaints made by the parents and social worker.   The social worker did request that hospitals noted the interaction between parents and babies, but contact by the social worker was via the telephone, apart from one visit to Derby. A visit to the hospital in Grimsby and a meeting with staff at an early stage would possibly have facilitated a fuller sharing of information, as would a more formal approach to planning with all three hospitals. Whilst distance was most likely a factor that made visiting    Overview Report 19.03.13 Page 29 of 100 difficult, this was a missed opportunity for some focused assessment and planning at a point where the babies were safe.   There seems to have been little consideration by the social worker of the significant concerns expressed by the hospitals, particularly in relation to parental failure to understand and respond to the babies’ needs for consistent basic care such as feeding and changing. There are clear indications of the ‘care conflicts’ described by Reder et al (1993)7, where parents’ own needs are such that they are unable to tolerate the needs of the dependent child.  Parental behaviours and inconsistent care of the babies in hospital would have suggested that care would be problematic in a home environment. There is no evidence of any assessment which included a focus on bonding within hospital, the parents developing relationship with the babies and its impact on attachment and risk once they were home.   Role confusion Because observations were being requested within a medical / nursing setting rather than one specialising in child protection, it was important to have specified the criteria by which concerns should be judged, including whether they indicated risk of significant harm. In addition there may have been the potential for role confusion in which tasks appropriate to one profession (social worker) were assigned to others (nursing staff) who had neither the skills nor responsibilities or time to carry them out8.    Documentation within hospital Although there is documentation about whether the physical needs of the babies were met there is no documentation about the couple relationship, the parental attitude to the pregnancy or the birth or their ability to provide warmth, stimulation and consistency. The midwives and nurses involved with the family during their extended stay in three hospitals would have observed valuable information about the parents’ attitude to their babies, their ability to provide a range of care, and the developing attachment relationship. In this case, such information was not fully documented, collated and shared with the social worker appropriately. This lack of robust documentation may have been influenced by the minimising of concerns by the social worker, poor communication and / or a lack of                                                  7 Reder, P. Duncan, S., and Gray, M. (1993) Beyond Blame: Child  Abuse Tragedies Revisited. London: Routledge. 8 Reder, P. Duncan, S., and Gray, M. (2003) Lost Innocents: A Follow-up study of fatal child abuse. Sussex: Brunner-Routledge page 84.    Overview Report 19.03.13 Page 30 of 100 understanding of professional roles, expectations and clarity of task.     Collaborative working Multi-agency working within this period was lacking structure and was insufficiently robust. There was, for example, lack of clarity regarding roles and responsibilities when practical issues such as finance, food and accommodation for Father and clothes for Mother were concerned, causing some tensions between hospital staff and the Nottingham social worker. The use of emotive language by the social worker was unhelpful (e.g. that parents should be ‘shown compassion and not left to starve’) and did not promote effective multi-agency working. Despite significant concerns at Grimsby / Derby hospitals, the request for a strategy meeting was not responded to appropriately by the social worker and there is no evidence that she discussed this request with her manager.  The perception of one hospital individual management review is that hospital staff lacked confidence in challenging the social worker and refrained ‘from voicing concerns when these had been ‘dismissed’ by others considered to be better qualified or to have more authority’ (Brandon et al 2008)9.  Working with hostile parents  Although it was the view of health staff at Grimsby and Derby hospitals that the case should be managed as child protection rather than Children In Need, once the babies transferred to Nottingham the approach within Children’s Social Care was case management under s17. There was a continued focus on housing issues, and potential risk was not assessed on the basis of a full knowledge of family history or the current response to the babies which was causing concern within the hospital. These concerns included parents being angry and aggressive as well as failing to attend consistently to the care of the babies, and the threat of complaints. Brandon et al (1998) identified situations where parental hostility resulted in workers becoming frozen which hampered their ability to reflect, make judgements and act clearly10. The social worker does not appear to have                                                                                                                                                                   9 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner,. R. Dodsworth, J. Black, J., (2008) Analysing Child Deaths and Serious Injury Through Abuse and Neglect: What Can We Learn. London DCSF Research report DCSF-RR023   Page 94 10 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardener, R., Dodsworth, J., Black, J. (1998) Analysing Child Deaths and Serious Injury Through Abuse And Neglect: What Can We Learn. London:  DCSF page 90 11 Munro, E . (2008) Effective Child Protection 2nd Edition London: Sage 12 Morrison, T. (1990) ‘The emotional effects of child protection work on the worker’ Practice 4 253-271 13 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner,. R. Dodsworth, J. Black, J., (2008) Analysing Child Deaths and Serious Injury Through Abuse and Neglect: What Can We Learn. London DCSF Research report DCSF-RR023   Page 93- 94 14 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner,. R. Dodsworth, J. Black, J., (2008) Analysing Child Deaths and Serious Injury Through Abuse and Neglect: What Can We learn. London DCSF Research report DCSF-RR023   Page 94 15 Sidebotham, P., & Weeks, M. (2010) ‘Multidisciplinary Contributions to Assessment of Children in Need’ in Horwath (ed) The Child’s World London: JKP    Overview Report 19.03.13 Page 31 of 100 discussed these concerns with her manager; neither was there an analysis of the response of the parents who, when challenged about the hospital’s concerns, deflected the social worker by making complaints about health and housing professionals.     During this period, complaints by parents were not collated and assessed as indicative of raising stresses and anxieties that may have impacted on capacity to parent. It is surprising that the social worker made a complaint to Nottingham Housing Support Service 1 on behalf of the parents, given the high level of support that Nottingham Housing Support Service 1 offered outside their remit. It is possible that this was indicative of a worker who was not receiving effective supervision designed to promote critical reflection, objectivity and consideration of the biases that may have been influencing practice (Munro 2008)11, (Morrison 1990)12.  The emotional impact on health staff of the complaints made against them (especially when the complaints appeared to be supported by the parents’ social worker), together with dealing with the challenging behaviours of both parents, especially Father, appears unrecognised and unacknowledged. Supervision with a safeguarding focus provided by someone with expertise in this area (in addition to midwifery supervision which has a different focus) may have identified an action plan to support and assist staff in managing the behaviours presented by the parents and kept the focus on the safeguarding, including appropriate documentation. Instead there appeared to be minimal contact with the family awaiting their transfer to another hospital.   The Nottingham University Hospital individual management review recommends that the ward manager (sister) should oversee complex safeguarding cases and it will be important that this overview includes an opportunity for reflection and management of emotional impact and the complex dynamics involved in child protection work.   Father confirmed to this review that housing was a major source of stress. He has told this review that he did not feel safe in the flat as he believed there were gangs and prostitutes living on the floor below. Housing issues were important as additional stressor but they were only part of the overall picture. In the days prior to the babies’ discharge from hospital in Nottingham; Children’s Social Care focused mainly on housing issues rather than pulling together an assessment which analysed the behaviour of the parents within the context of    Overview Report 19.03.13 Page 32 of 100 risk to the babies.   There were indications that the parents were extremely stressed and Father confirmed to this review that he would have agreed to the babies living with foster carers. However, because s20 was discussed with the team manager as a possible response to housing concerns, this was deemed an inappropriate course of action. It is unfortunate that the manager was not more probing at this point, prompting the social worker to reflect critically on the current information, particularly the response of the parents post birth.   There appears to have been no discussion of the possibility of a parent and baby placement but Father told this review that he would have welcomed such an opportunity to learn how to be a parent.   The discharge planning meeting The discharge planning meeting held at Nottingham Hospital was a pivotal point in this case. It continued the social work focus on practicalities rather than a comprehensive assessment of need and risk, although the health individual management reviews have identified that during the meeting, a number of differences were identified between professionals. There was evidence that: •  Historical and current concerns were not shared and discussed openly. • The format of the meeting was unstructured. • There were difficulties in keeping the focus on the babies’ needs, rather than housing and other practical issues. • The chairing did not allow health staff views to be valued and listened to. • The majority of professionals present were not in agreement with the outcomes of the meeting. • The CityCare Partnership safeguarding nurse tried hard to raise relevant concerns but felt ‘defeated’ and only slightly reassured that a daily visiting plan was in place and a review planned for one month rather than three months as proposed by Children’s Social Care. • The impact on staff present of having both parents and babies at the meeting.  The view of the social care staff at the meeting appeared to be that the parents were vulnerable and needed support, whilst health staff were concerned about their ability to    Overview Report 19.03.13 Page 33 of 100 parent and the potential for neglect the babies. This may not have been helped by the presence of both parents and the babies at the meeting, which could have stifled debate about current concerns by health staff. As identified by Brandon et al (2008)13, ‘sustained professional challenge was often found difficult in such cases with a difference of opinion or judgement rarely pursued to a satisfactory conclusion’ often due to lack of confidence, knowledge or experience. There is a need for ‘the importance of sustained and dogged professional challenge’ in such cases. As the staff attending were reported to be experienced and knowledgeable professionals, their behaviour during and after the meeting appears influenced by a lack of confidence in the process of escalating concerns, thus reducing the effectiveness of multi-agency working.   Research has identified that it is not enough for agencies to attend meetings in order to share information; they also may need to be proactive. It is for each agency to challenge other agencies where there is disagreement, and to bring to the attention of their own line management, and ultimately the line management within the other agency, any feelings that inadequate account has been taken of their view.14  This did not happen in this case.  Not all professionals invited to the discharge planning meeting had an in-depth knowledge of the family: two key practitioners (children’s centre worker and midwife expressing concerns) were unable to attend. As a result relevant concerns were not shared during the meeting, with the focus of the needs of the parents overshadowing those of the babies, whose needs appeared minimised. There was a fixed view that this was a Child In Need case and there was a lack of collation and evaluation of readily available information to identify and act on known risks to the babies (Sidebottom & Weeks 2010)15.  The safeguarding health staff present expressed concern as to the outcome of the meeting, but did not escalate these concerns or seek the advice and support of a more experienced colleague, such as the designated nurse or senior manager. In addition, the consultant neonatologist in charge of the twins’ care should have been involved in ensuring that any remaining concerns were resolved prior to the babies’ discharge (Laming Recommendation 70).  The decision to discharge the babies on a Saturday is very questionable given that these were vulnerable infants with identified social problems. Although acute health services offer    Overview Report 19.03.13 Page 34 of 100 a twenty four hour, seven day a week service, the full range of statutory services are not available and it has been documented that weekends can be a time of heightened risk for vulnerable children.      8. PROFESSIONAL INVOLVEMENT:  FROM HOSPITAL DISCHARGE TO SERIOUS INJURIES   8.1    On the Sunday morning after discharge the community midwife visited the family home and saw both babies. They were described as clean and well cared for with appropriate clothing and bedding. That evening Father sent a text to the social worker complaining of noise from the neighbours and asking whether the social worker had found them a pushchair.  A few hours later in the early hours on Monday morning, the Ambulance Service received a 999 call from the flat reporting that Baby A had breathing difficulties. Examination did not reveal any breathing problems but both babies were taken to Nottingham University Hospitals Accident and Emergency Department.  This was the first of two occasions where ambulance staff acted in a highly professional manner by taking both babies to hospital for examination.  8.2 Although no medical concerns could be identified, it was decided to admit both babies. Baby A was admitted to an Oncology Ward (due to pressure on beds) with Mother, whilst Baby B was with his Father in a parent’s flat within the hospital. Admission to the oncology ward was by no means ideal since staff there would not be used to assessing the implications of a sudden re-admission in circumstances such as these. The agreed plan was to contact the hospital safeguarding team the following morning.  8.3 Records at the point that Baby A and Baby B were re-admitted to hospital in Nottingham suggest that nursing staff were worried about the capacity of the parents to meet the babies’ needs.  Father informed the social worker by text of Baby A’s admission. She contacted the ward at 07:45 hours the morning after admission and asked staff there not to let the parents leave the ward. This was an unusual request, which they did not feel able to comply with, as no legal orders    Overview Report 19.03.13 Page 35 of 100      were in place. As a result the ward staff discussed their concerns about this request with the hospital safeguarding team.  8.4 Nursing concerns were appropriately raised with the social worker and the team manager. The team manager’s response was that nothing had changed since discharge and concerns had not been raised at the discharge meeting.   8.5 The named nurse appropriately relayed background information on the twins to the paediatrician with the result that the babies remained in hospital longer than would usually be the case. However, she did not escalate concerns to senior managers and/or call a professionals’ meeting, and appeared reassured by the social worker’s comments. Baby A’s consultant paediatrician was therefore subsequently reassured that a child in need plan was in place, resulting in Baby A’s discharge.   8.6 The continuing care sister was contacted with regard to Baby A’s admission as she had intended to visit the family home. It is noted in the health records that the social worker had expressed concerns to the continuing care sister that the house was cluttered, she had spent time cleaning up and that she had concerns regarding their discharge, despite the babies being at home less than twenty four hours prior to readmission. The social worker reported that the service manager had felt that discharge home, and not into foster placement, was appropriate. It was agreed that no home visit would take place whilst babies were in-patients.  8.7 Father sent a text to the social worker identifying that the paternal grandmother (in Somerset) had said the family could go and stay with her. He also sent a further text with paternal grandmother’s contact details and address. The social worker sent an alert to the emergency duty team, as the twins were to be discharged and their return to the home address planned. The social worker advised on the notification form that if the emergency duty team became involved and there were ‘concerns about parenting, to place twins in a place of safety’.  8.8 The Nottingham social worker contacted Somerset Children’s Social Care requesting a home visit to paternal grandmother’s to see her living conditions, due    Overview Report 19.03.13 Page 36 of 100  to concerns about Father’s upbringing. At this point there was some confusion between the Nottingham worker and Somerset Direct as to the best means for sending information. This was because the Somerset Direct worker had failed to explain that a secure e-mail facility was available. The Nottingham social worker therefore faxed to Somerset the initial assessment.   8.9 The information faxed to Somerset by the social worker only consisted of the initial assessment completed three months previously, and did not include sufficiently detailed information about past history or more recent observations regarding parental behaviour, or referrals made by other agencies. The lack of timely sharing of the core assessment meant that Somerset Children’s Social Care assumed that a core assessment had taken place and the twins had remained Children in Need rather than subject of section 47 enquiries.  Had Somerset seen the core assessment they would have been aware of its limitations.  8.10  At the same time the Nottingham social worker completed a CRIMMs form (request for police information) on paternal grandmother, authorised by another team manager and faxed to the Nottinghamshire Police Child Abuse Investigation Unit. There was delay of fourteen days in Nottingham Children’s Social Care ascertaining information from the Nottinghamshire Police regarding paternal grandmother, with the delay apparently caused by the fact that Mother and Father were moving out of the Nottinghamshire force area. The fact that the case had not been assessed as reaching the section 47 threshold meant that at no time had there been a request by the Nottingham social worker for a police check regarding the parents. A check would have revealed a number of violent incidents involving Father which could have informed the assessment process.    8.11  The twins were discharged from hospital that day, aged four weeks and four days.  The paediatric consultant was advised by the safeguarding nurse that a ‘tight package of care’ was in place with no need for a further discharge meeting. The social worker was informed of the discharge and the hospital records note that home visits were planned for Thursday and Friday. No discharge summary was completed and no conclusion of a written safeguarding plan in the notes.    Overview Report 19.03.13 Page 37 of 100  8.12  On the same day, three texts from Father and one from paternal grandmother were sent to the Nottingham social worker, complaining about the neighbour.  In one, Father said he was scared to go back to the flat and reiterated a request for bed and breakfast accommodation.  8.13  The following day, another Nottingham social worker spoke with Father about his concerns regarding his neighbour.  Father stated that his social worker was with him and assisting him with these issues. This social worker also recorded that the twins had not been linked on Care First (the IT system) to their parents, and were recorded as having Mother’s surname.  8.14  That day another text was sent by Father to the social worker, wanting to know what time she was visiting and reminding her to bring the pushchair with her. Father also apologised for being upset with her. The social worker visited the same day and saw both twins asleep in their cot. The flat was described as untidy with a smell of dirty washing (no washing machine) and parents stated they did their washing at their friend’s house. Mother and Father had not yet provided the social worker with their friend’s details, although asked. The following issues were noted: • Kitchen clean. • Tins of food in bedroom. • Bags of rubbish in front-room. • Mother and Father still talking of visiting paternal grandmother; asked to wait for agreement to go following CRIMMs check and welfare check on her.  8.15  Later that day the family visited the Children’s Social Care office to see the social worker and collect a pushchair. The twins were wrapped in a cotton blanket and their parents were advised by the social worker that the babies needed a whole blanket on top as quite cold outside.   8.16  The same day, the Somerset Direct social worker telephoned the Nottingham social worker to clarify what she wanted Somerset to do. The following was discussed:    Overview Report 19.03.13 Page 38 of 100 • No evidence for s47. • Discharge planning meeting held on discharge from hospital (date given). • Request for Somerset to visit daily and contact health visitor. • Police check on paternal grandmother and home visit.  8.17  Following discussion with the Somerset team leader it was agreed with the Somerset Direct social worker that it was not appropriate for twins to travel pre assessment, and that information shared by Nottingham indicated a high level of concern. The Nottingham social worker, when advised of this view, said that it would be difficult to stop the family visiting, and following a home visit the family had confirmed that they were adamant they wanted to move to Somerset the following week. The Somerset Direct social worker recorded that the Nottingham social worker seemed agitated and annoyed when advised that a manager would need to authorise a ‘welfare check’.  8.18  The same day, following discussion between the Somerset Direct social worker and team manager, the social worker contacted Nottingham Social Care to speak with a manager to advise that the four week old babies should remain in Nottingham pending assessment.  The Nottingham duty manager was not available and it was agreed that the duty senior would ring back (it is not documented that this happened).   8.19  At 11:00 the following morning (Thursday), the Nottingham Hospital continuing care sister visited the family flat with a student nurse. A musty smell was noted (a mixture smoke, possible damp and lack of cleanliness) with the kitchen door closed, and described by Father as ‘a mess’. Both babies were in a cot covered by a loose blanket and Mother was in bed. Several large vomit stains were noted on the sheet and both babygrows. The continuing care sister was advised that the sheets and clothes were in the wash and babies waking hourly for feeds. Four empty bottles were noted on the mantelpiece and she was told that bottles were being made up fresh for each feed. The continuing care sister discussed her observations and concerns with both parents and arranged a return visit to provide resuscitation training.     Overview Report 19.03.13 Page 39 of 100 8.20  Following the visit the continuing care sister attempted to speak with the social worker but was unable to make immediate contact. It then seems that the family must have travelled to Somerset (the immediate move possibly triggered by awareness of the concerns of the continuing care sister), as when the health visitor called later that day there was no reply. The paternal grandmother later confirmed with the social worker that the family were on their way. Following this no access visit, they contacted the Nottingham social worker and, once advised that the family had moved to the paternal grandmother’s, immediately liaised with health professionals in Somerset. This swift sharing of information ensured that the babies and parents were registered with a GP practice and were seen by the Somerset health visitor. However, the verbal information given by the Nottingham health visitor to her counterpart on Somerset did not include all the risk factors that were in the file and the file information did not arrive until after the serious injuries had occurred.   8.21  Somerset Children’s Social Care acted promptly in escalating the case to s47 and initiating a strategy discussion. However, the telephone strategy discussion did not include health colleagues which should have happened given the circumstances of two premature babies who had not yet reached their expected delivery date, with possibly complex medical needs. The decision at this point was to convene an initial child protection conference in fifteen working days, the delay designed to ensure all relevant information was gathered and analysed in order to inform decision making at that point.    8.22  A plan was put in place for daily visiting to the family and information was shared between the health visitor in Somerset and Children’s Social Care. The health visitor, for example, advised the Children’s Social Care team leader when they could not gain entry to the home for a planned contact following considerable attempts to gain entry. GP records were minimal with regard to the babies and when they were seen, no history was taken or enquiry made as to how the parents were managing following their move.  8.23  Two police ‘welfare visits’ were undertaken in the short time the babies were in Somerset and the babies were also taken to the emergency department at the    Overview Report 19.03.13 Page 40 of 100 hospital and seen by an on call GP. Mother described a history of the twins’ dark stools/pain and the GP discussed the babies with the paediatric senior house officer, who had no concerns. The paediatric senior house officer spoke to Mother, offered reassurance and arranged to ring her the next day. Information about this visit was faxed to the GP but not the health visitor, causing some confusion when the health visitor next saw the family and thought they were describing a hospital admission in Nottingham. Had the health visitor had the information about the history of dark stools she may have assessed the current symptoms that were being described to her (green stools) as underfeeding, and taken more urgent action.  8.24  Children’s Social Care sought legal advice on one occasion but the advice given was that the threshold for legal intervention had not been reached.  8.25  The Children’s Social Care team leader did discuss the case with the area manager and it was agreed that the arrangement for daily visits was sufficient. The team leader also advised during interview for this review that his ‘gut feeling was not great as there was no concrete evidence of what the needs were’. Within Children’s Social Care there was a delay in accessing historical information about Father since his files were located at another office. Once the files were retrieved seven days prior to the babies’ injuries, and information was given by the police regarding previous convictions, there is little evidence that this was analysed and consideration given as to whether the type and level of risk had changed.  8.26  Four days before the serious injuries, the health visitor contacted Somerset Children’s Social Care and advised that no one was at home for her planned visit. She had returned a short while later, again finding there was no one in and then had tried to contact their mobiles, which were switched off. She had then put a note through the flat door advising the family she would try again later.  8.27  The visit to the family the next day (Saturday) was by an experienced senior social work assistant who noted that one of the babies was ‘agitated’.  8.28  No contact was arranged for the next day (Sunday) and on Monday (13:30) the    Overview Report 19.03.13 Page 41 of 100 social worker made a planned home visit, finding there was no answer and no response to a telephone call. The situation was discussed with the team leader and following numerous attempted telephone calls, contact was made with the parents at 16:05 hours. As the social worker had had to respond to a placement breakdown and could not visit later that day, a visit was rearranged for 16:30 hours the following day.   8.29  At 07:09 hours on Tuesday morning ambulance control received a 999 call from Mother concerned that Baby A was not breathing. It is commendable that the ambulance crew took both babies to hospital since Mother disclosed that she planned to take baby B to see the GP as he had a bump on his head.   8.30  At 08:00 hours a referral was made to the Children’s Social Care emergency duty team by staff nurse from Somerset hospital.  They advised that neither child should leave hospital and to call the police if parents tried to take them.   Evaluation of practice From hospital discharge to serious injuries   Records at the point that Baby A and Baby B were re-admitted to hospital in Nottingham suggest that nursing staff were worried about the capacity of the parents to meet the babies’ needs.  These concerns were appropriately raised with the social worker and the team manager. The team manager’s response that nothing had changed since discharge and that concerns had not been raised at the discharge meeting, was inappropriate and maintained the ‘fixed view’ that this was a case of Children In Need. Records indicate that the manager failed to investigate in more detail why there might have been such a quick readmission, to really listen to the concerns of health staff or reflect on whether the discharge planning meeting had adequately addressed parental capacity to care for the babies. Further discussion with the social worker and a thorough analysis at that point would have included consideration of: • Increasing parental stress evidenced by the number of text messages to the social worker and Father’s attitude within hospital, including swearing at Baby B when feeding. • The lack of medical evidence for breathing difficulties and the possibility this was a    Overview Report 19.03.13 Page 42 of 100 cry for help from the parents.  The named nurse appropriately relayed background information on the twins to the paediatrician, with the result that they remained in hospital longer than would usually be the case. However, she did not escalate concerns to senior managers and/or call a professionals meeting, but appeared too easily reassured by the social worker’s comments. Baby A’s consultant paediatrician was therefore subsequently reassured that a Child In Need plan was in place, resulting in Baby A’s discharge. Communications between nursing and medical staff in order to ensure plans were in place for discharge demonstrated good practice (Laming 2003), but in this case there had been insufficient challenge of the practice within Children’s Social Care. The impression is that ‘exaggeration of hierarchy’ (Reder et al 1993)16 was operating, with the social worker perceived as being better qualified or having more authority.   There is evidence of lack of clarity by the Nottingham social worker regarding discussions concerning the possibility of s20 accommodation. The social worker’s comment to the continuing care sister that the service manager had not agreed that this was appropriate in a situation where the main issue was housing, does not fit with other Social Care records. These do not indicate that there was any formal discussion with the service manager to explore this option.  It was good practice that the continuing care sister attempted to contact the social worker following the concerns that she noted about the care of the babies two days after discharge.  However, telephone contact was not made until the next day and an e-mail sent two days later, by which time the family had moved to Somerset. The health overview report comments that the continuing care sister could have been more proactive and tried emergency numbers that could have alerted agencies that the family appeared to have fled (para 10.5). It is possible that the concerns of the continuing care sister had been picked up by the family and had triggered the sudden move to Somerset, and an understanding of the content of this visit would therefore be important in any analysis of risk. The concerns were eventually passed to Somerset by the Nottingham social worker and at this point did inform Somerset’s analysis and contributed towards the decision to commence section 47 enquiries.                                                  16 Reder, P., Duncan, S., and Gray, M. (1993) Beyond Blame: Child Abuse Tragedies Revisited London: Routledge.    Overview Report 19.03.13 Page 43 of 100  Following the continuing care sister speaking with the social worker, records note that an s47 would have been raised if the family had still been in Nottingham. This was followed by the Nottingham team manager having a discussion with the independent reviewing officer where it was agreed that if the family moved back to Nottingham, an urgent, initial child protection conference would be called. This suggests that the fixed view previously held, that this was a ‘Child in Need’ case, had shifted into child protection, influenced by the contact from the continuing care sister following her visit to the family, offering the social worker detailed information about her concerns.   At the point that the family moved there was delay of fourteen days in Nottingham Children’s Social Care obtaining information from the Nottingham Police regarding paternal grandmother, with the delay apparently caused by the fact that Mother and Father were moving out of the Nottingham force area. The fact that the case had not been assessed as reaching the section 47 threshold meant that at no time had there been a request by the Nottingham social worker for a police check regarding the parents. A check would have revealed a number of violent incidents involving Father which could have informed the assessment process.    It was appropriate for the Nottingham social worker to make contact with Somerset as soon as she became aware that the family were considering staying with paternal grandmother. However, the request for information centred on the capacity of the grandmother to provide an appropriate environment and did not clearly identify any concerns about parental capacity to meet the babies’ needs. Analysis of the conversation between the Nottingham social worker and Somerset Direct indicates that there was some confusion regarding appropriate methods for communication exchange. The Nottingham social worker did not fully understand the centralised contact system in Somerset and a Somerset Direct worker did not inform the Nottingham social worker that there was a secure e-mail system. This resulted in information being faxed through. When information was faxed to Somerset by the social worker, this only consisted of the initial assessment completed three months previously and did not include sufficiently detailed information about past history or more recent observations regarding parental behaviour or referrals made by other agencies. The                                                                                                                                                                   17 Munro. E (2008) Effective Child Protection 2nd edition. London: Sage page 145 18 HM Government. (2010) Working Together to Safeguard Children Para 5.83 19 Written feedback from Police SCR panel member and IMR author dated 9.11.11    Overview Report 19.03.13 Page 44 of 100 lack of timely sharing of the core assessment meant that Somerset Children’s Social Care assumed that a core assessment had taken place and the twins had remained Children in Need rather than subject of section 47 enquiries.  Had Somerset seen the core assessment they would have been aware of its limitations.  It was good practice that following a no access visit by the Nottingham health visitor and midwife, they contacted the social worker and, once advised that the family had moved to Somerset, immediately liaised with health professionals in Somerset. This swift sharing of information ensured that the babies and parents were registered with a GP practice and were seen by the Somerset health visitor. However, the information given verbally was only partial and did not contain all the information within the health visitor records recording possible risk factors. This would have influenced the Somerset health visitor’s assessment.  Liaison was also undertaken with the Somerset social worker and GP. Records were minimal with regard to the babies when reviewed by the GP, without a social history being undertaken or enquiry as to how the parents were managing following their move. As previously identified, professionals ‘need to make a clear, detailed record of events so that past history is available to be scrutinised’17 and for on-going risk assessment, including whether the babies or Mother are seen by another member of the practice.  Somerset Children’s Social Care acted promptly in escalating the case to s47 and this decision was confirmed as appropriate when information was received from the Nottingham social worker about the concerns of the continuing care sister.  However, there was a delay in accessing historical information about Father since his files were located at another office. Once the files were retrieved seven days prior to the babies’ injuries, and information was given by the police regarding previous convictions, there is little evidence that this was analysed and consideration given as to whether the type and level of risk had changed.  The telephone strategy discussion did not include health colleagues, which was unfortunate, given the circumstances of two premature babies who had not yet reached their expected delivery date, with possibly complex medical needs. It would have helped the planning process if this telephone meeting had been followed up within forty eight hours with a second face-to-face meeting to review the action plan agreed. This second    Overview Report 19.03.13 Page 45 of 100 meeting would have included all relevant professionals, information about Father’s previous convictions and ensured that the action plan remained appropriate, whilst further information was gathered, collated and analysed for the forthcoming conference.  It was reasonable for there to be a delay of fifteen working days in convening the initial child protection conference to ensure all relevant information was gathered and analysed in order to inform decision making at that point.  This is in line with government guidance.18  The Children’s Social Care individual management review records that legal advice was sought on one occasion but the advice given was that the threshold for legal intervention had not been reached. This advice was given as part of an informal discussion when the lawyer was in the building for another purpose.  At that point little was known about the background and there is no reason to argue the advice was not sound, based on the information given to the lawyer. However, the informal nature of the interaction meant that full consideration was not given as to the potential significance of missing information and whether an urgent, more formal review was needed when this was obtained.   There was evidence of good information sharing between the health visitor in Somerset and Children’s Social Care, for example, advising the Children’s Social Care team leader when they could not gain entry to the home for a planned contact on Friday, following considerable attempts to gain entry. There is no documented evidence of robust joined up working within primary health. For example, there is no record that when the babies and Mother were seen by the GP there was any consideration that the concerns about the social circumstances were known, further explored or discussed with the health visitor although an ‘alert flag’ (non-specific) had been added to their notes . The fact that the emergency visit to the out of hours GP at the hospital was not known to the heath visitor is significant, since it clearly led to some degree of confusion in the health visitor’s communication with the family. The health overview report also notes that had the health visitor had the information, she may have assessed the symptoms being described as underfeeding and taken more urgent action.   Two police ‘welfare visits’ were undertaken in the short time the babies were in Somerset. Whilst this demonstrates good multi-agency cooperation, the role, responsibility, purpose or focus of the police undertaking ‘welfare visits’ in these circumstances is unclear, since    Overview Report 19.03.13 Page 46 of 100 the case involved premature babies who had not yet reached their expected date of delivery. It would be a challenge for a non-medical professional to assess their health and wellbeing adequately, which also appears a relevant concern with regard to the visits undertaken by the student social workers over two Saturdays.  The police representative in the serious case review panel has advised there will invariably be occasions where the police may be required to assist in such cases by responding to concerns about the welfare of children expressed by another agency. This case has, however, exposed how little information the police staff had been provided with as part of the request to attend. The police role outside of normal office hours should only arise in three instances, firstly to execute police emergency child protection police powers, secondly to assist Children’s Social Care in executing an order of the court such as an Emergency Protection Order, or thirdly to support the Local Authority in their enquiries where a breach of the peace may occur. This is not force policy but a reflection of best practice as regards professional responsibilities and experience and, of course, a ‘golden thread’ of child protection awareness must run through everything police staff do.19 In this case none of those three criteria was met.  The visit to the family the next day (Saturday) was by an experienced senior social work assistant. Arranging a social work visit on a Saturday is commendable, and appropriate feedback to a manager was arranged. The possible explanation for the apparent ‘agitation’ of one of the babies was not explored and with the benefit of hindsight it is possible that the baby may have been in some discomfort from a fracture to his femur. Similarly it is possible that the ‘pain’ described by parents at the emergency hospital visit was due to more than bowel problems. This is not to criticise individual actions, as medical advice to the panel is that such fractures would be hard to detect, but it does reveal the limitations of daily visiting in protecting babies from harm.     No contact was arranged for the next day (Sunday) and due to work pressures and problems contacting the family, no further visits were completed prior to the serious injuries on Tuesday. It is unclear what the contingency plan was for such circumstances, where the agreed daily visits had not been achieved. It was known that the family at times were hard to reach (turning off telephones, not at home for planned appointments, and difficulty gaining access when the bell wasn’t working, dependant on other residents opening the    Overview Report 19.03.13 Page 47 of 100 communal entry door) which may have suggested the family’s disengagement with professionals. In these circumstances, it may have been appropriate to contact the area manager, although discussion did take place between the team leader and social worker.     9. THEMATIC ANALYSIS OF ISSUES IN THIS CASE     What was life like for the babies? 9.1   Although these were young, non-verbal infants, it is important that professionals were able to consider their experience of the world and the impact that this was likely to have on their growth and development.  The evidence within this review would suggest that for Baby A and Baby B, the world would have been an uncertain place with a lack of consistency in the care they were receiving, especially following their discharge from hospital.  At times, they would have felt warm, dry and comfortable and at others hungry and lacking physical and emotional warmth, with parents anxious and at times distracted from being able to meet their basic needs.    9.2 The babies were cared for in three different hospitals by their parents, with a number of concerning incidents noted which should have been referred more robustly to Children’s Social Care. The evidence suggests that their basic care needs were not consistently met by either parent and a variety of hospital staff had to step in to ensure their needs were attended to. Following discharge, they spent three days in the sole care of their mother and father and a further twelve days supported by paternal grandmother. Whilst in-patients, or in the care of their parents and later at paternal grandmother’s, there is no documentation of any assessment of the impact of these arrangements on the emotional development of either baby, although physical conditions are recorded.  A mother’s (or father’s) sensitive perception and acknowledgement of her (or his) infant’s emotional state, enables her (or him) to make sense of her (his) baby’s inner feelings and offer comfort appropriately; it appears unlikely that this happened and should have been noted as an important indicator for the future ability to care and emotional development of the babies.     Overview Report 19.03.13 Page 48 of 100                                                      9.3 As identified by Hart (2010)20 researchers have found that as early as two months, infants and mothers, while they were looking at and listening to each other, were mutually regulating one another’s interests and feelings. This provides the foundation for positive emotional and behavioural development and depends upon a close consistent relationship with a caregiver. In this case consistency would have been hampered by both the nature of the parental care they were receiving as well as the babies’ frequent hospital moves.   9.4 Following their discharge and whilst in the sole care of their parents, their standard of care quickly deteriorated and would have increased their level of discomfort as evidenced by: • Dirty bottles lying around. • Both babies found in soiled clothes and bedding. • Complaints by their parents about ‘excessive’ crying.   • Further attendance at hospital.   • Health professionals who identified that Baby A was being underfed – green stools, crying.   9.5 The culmination of these concerns appears to indicate increasing distress in Baby A, which may be factor contributing to re-admission to hospital with breathing difficulties.   9.6 Baby B did gain weight following discharge, whilst Baby A, just before and following the move to Somerset, was noted to have lost weight, presenting with green stools (which is likely to have been a sign of underfeeding) and was noted to cry a lot, causing concern and anxiety to his parents. Both babies may have already been suffering pain from an abusive incident.     The assessment process   The Significance of History 9.7 Both Mother and Father had significant involvement with statutory agencies as children and young adults. This was not systematically considered in relation to its potential impact on parenting capacity, from the time Mother was pregnant though  20 Hart D. (2010) ‘Assessment before Birth’ in Horwath, J The Child’s World London: JKP. Page 187    Overview Report 19.03.13 Page 49 of 100  to the serious injuries to Baby A and Baby B. There are differing reasons for this at various points in the case: • A focus on the medical aspects of pregnancy, resulting in social history not being explored either verbally or through scrutiny of medical records, for example, at the point the pregnancy was confirmed by the GP. • Poor record keeping resulting in significant information being either unavailable or partially known. For example, Father’s psychiatric history in Scotland which was partially recorded within the GP records and not shared with any other professionals. • Lack of a thorough core assessment in Nottingham which asked the right questions regarding family history, pulled together all known information and systematically analysed its meaning and impact. • Mobility of Mother and Father, resulting in information not always being available at the point of transfer. For example, the family history as known in Nottingham was not shared by the Nottingham social worker at the point Mother and Father moved to Somerset. • Information about Father’s history as a young person in Somerset being located in files in a different part of the County, which were not scrutinised to inform decision making immediately the family moved into the area. Even when Somerset Children’s Social Care received the files and information from the police regarding past convictions, there is no indication that the significance of this information was integrated immediately into the assessment of risk.  9.8 There is the impression that within Children’s Social Care in Nottingham there was a genuine desire to give the couple a chance to succeed. This was understandable, but it led to a situation where insufficient attention was paid to historical information which would have assisted an assessment of potential parenting capacity.  Despite the social worker and the team manager being in receipt of this knowledge, it was not deemed significant enough to explore in detail and used to inform an assessment of parenting capacity.  The focus instead was on practical issues, such as housing rather than the psychological capacity of the parents to parent the babies. An understanding of care and control conflicts    Overview Report 19.03.13 Page 50 of 100                                                  (Reder et al 1993)21 would have helped to identify that both parents’ past experiences were likely to impact on their capacity to respond to the needs of two demanding infants, without considerable support. Calder (2008)22 notes that care and control conflicts arise when:   ‘Parents’ own childhood experiences of adverse parenting leaves them with unresolved tensions which spill over into their adult relationships ...Their children are most at risk during the early months/years when they are most dependent and when they carry meanings for their parents associated with unresolved parental conflicts. This is compounded for parents living in stressful circumstances. Thus, an escalating scenario can develop in which stresses to the parental care-control conflicts come together over days and weeks and can lead to one precipitating and serious/fatal incident’ (p210)   9.9 The assessment may have shifted focus had s47 enquires been instigated and police checks (CRIMMS) been carried out. A check on Father would have revealed his violent background and, with the combination of already known factors relating to his childhood, would have alerted practitioners to potential risks once he became a father.    Quality of pre-birth assessments 9.10  A significant factor in this case was the lack of effective, pre-birth assessment, with a key factor being an apparent lack of understanding that the twins were likely to arrive early and therefore the usual timescales needed to be adjusted to take account of this. It is notable that one of the few references to this ‘potential early delivery’ in the records is by the housing worker, rather than professionals within health and social care.  9.11  The lack of effective pre-birth assessment was evident from the point that Mother presented as pregnant.  There was a lack of curiosity, by health professionals, regarding her social circumstances in the early stages of pregnancy and a lost opportunity to bring together significant information, in such a way that risks could  21 Reder, P., Duncan, S and Gray, M., (1993) Beyond Blame: Child Abuse Tragedies Revisited. London: Routledge 22 Calder, M. (2008) ‘Risk and Child Protection’ in Calder, M. (ed) Contemporary Risk Assessment in Safeguarding Children. Lyme Regis  Russell House.    Overview Report 19.03.13 Page 51 of 100                                                 be clearly identified.      9.12  If a screening risk assessment tool had been used by health professionals such as Greenland, C. (1987)23, Browne, K. & Saqi, S. (1988) or Whipple, E. And Webster-Stratton, C. (1991), the couple would have been quickly identified as likely to struggle with parenting, requiring an urgent and early referral to Children’s Social Care. Reder and Duncan’s (1999)24 examples of child abuse risk factors developed from these research studies provides a clear indication of the potential risks in this case. From the overall list several significant factors are present, namely:   • Parental history of abuse or neglect. • Learning difficulties or inadequate education.  • Fractured family including marital disharmony or violence. • Financial difficulties or poverty.  • History of violence or criminality. • Drug misuse. • History of suicide attempts / mental illness. • Poor use of medical care.  9.13  There is evidence at an early stage in this case of ‘interacting risk factors’,  Brandon et al (2008)25, that should have worried professionals and it is therefore of concern that health practitioners did not seek the advice of more experienced colleagues, such as the named or designated professionals.  9.14  According to the integrated chronology, the first health safeguarding referral was made by an Oxfordshire midwife, when Mother and Father were living in a tent when Mother was sixteen weeks pregnant. This was entirely appropriate since the midwife carried out a health and social care assessment in which Mother scored four, indicating a high risk. However, there is no record of this referral having been received and acted upon and no further follow up by the midwife to ensure her  23 Greenland, C. (1987) Preventing CAN Deaths: An International Study of Deaths Due to Child Abuse and Neglect. London: Tavistock   Browne, K. & Saqi, S. (1988) ‘Approaches to screening for child abuse and neglect’ in Browne, K., Davies, C., Stratton, P., (eds) Early Prediction and prevention of Child Abuse, Chichester: Wiley   Whipple, E., and Webster-Stratton, C. ‘The role of parental stress in physically abusive families’ in Child Abuse and Neglect 15: 279 - 91(1991) 24Reder, P., and Duncan, S. (1999) Lost Innocents: A Follow Up Study of Fatal Child Abuse. London: Routledge 25 Brandon, M., Belderson, P., Warren, C., Howe, D., Gardner, R., Dodsworth, J., & Black, J. (2008) Analysing Child Deaths and Serious Injury Through Abuse and Neglect: What Can We Learn. London DCSF Research report DCSF-RR023    Overview Report 19.03.13 Page 52 of 100                                                 concerns were dealt with. This was another lost opportunity to ensure that a comprehensive assessment took place pre-birth. It is significant that at this point it was alleged that Mother was addicted to codeine, yet no one explored this further and recognised the possible implications of this for both Mother and the unborn babies.  9.15  The Thames Valley Police individual management review highlights the fact that the general definition of a child within legislation (Children Act 1989 and 2004) is that of a young person under the age of eighteen, and does not include unborn children. The report indicates that this may have been a factor in a police officer failing to report concerns, as it was felt child protection concerns were only relevant once a child was born.   9.16  It was whilst the parents were living in Nottingham that there was the best opportunity for a thorough pre-birth assessment. The parenting assessment tool used within Nottingham is the Parenting Assessment Manual (PAM) which is particularly useful for work with parents with learning disabilities, although it does have a wider application.26  Whilst the PAM assessment is not pre-birth specific, it can be used in such circumstances, with domains 11-31 of the assessment being particularly relevant and domains 1-10 being completed post-birth (Dr Sue McGaw, PAMS Training Ltd, personal communication September 2011). Whilst it is understandable that PAM would have been seen as appropriate in this case, the pre-birth aspects of this assessment should have been completed alongside a thorough core assessment, which gathered and analysed information from the family and the whole network that had been involved with them over time.   9.17  Government guidance regarding specific issues to be addressed in relation to pre-birth assessments simply states that the same procedures and time scales should be followed when there are concerns about the welfare of an unborn child27. In this case, guidance was followed, in as much as a core assessment had been signed off as completed, however, the quality of this assessment was inadequate and it did not address any of the pertinent issues that should have been explored    26 Parent Assessment Manual developed by Sue McGaw, Special Parenting Service, Cornwall Partnership NHS Trust. 27 HM Government (2010) Working Together to Safeguard Children London: The Stationery Office     Overview Report 19.03.13 Page 53 of 100 in a timely manner pre-birth. The inappropriate sign off by the manager at this point has been commented upon within the Nottingham social care individual management review.   9.18  The Nottinghamshire individual management review has clearly highlighted the lack of pre-birth risk assessment. The numerous interacting risk factors in this case, alongside few protective factors, should have alerted professionals well before the birth that risks were significant and resulted in a pre-birth child protection conference. This should have prompted a fuller assessment utilising all known information, a baseline from which to measure future change and structured planning, focusing on the protection of the babies from harm.   9.19  The paucity of useful guidance (national or local), effective supervision or local training within Nottinghamshire regarding factors to consider in relation to pre-birth assessments, was likely to have contributed to a situation where good practice was not well embedded within the team. There is a comment in the Nottingham Children’s Social Care individual management review that one of the reasons the case was allocated to that particular social worker was because of her experience in this area of work. This appears to have led to a situation where her practice was insufficiently scrutinised by the team manager, particularly in relation to the implications of pre-birth assessments and multiple births.     9.20  It was wholly inappropriate to attempt to continue the PAM assessment whilst Mother was in labour, a situation which should not have arisen had there been a more thoughtful approach to the likely timescales within which a pre-birth assessment involving multiple birth needed to be completed.    Assumptions and learning disability 9.21  A major assumption that appears to have been made throughout work with this family was that both parents had a learning disability; there was a lack of precision in the terminology used, with a failure to distinguish between learning difficulties and learning disability.  Both parents frequently informed professionals that they had a ‘learning disability’, which professionals appeared to accept at  face value, without questioning this statement or looking for collaborating    Overview Report 19.03.13 Page 54 of 100 evidence.   9.22  In relation to Mother, this assumption seems to have started when she was a young person in Derbyshire and was referred to the learning disability team for assessment. Referral for an assessment was good practice if there was any doubt about her functioning; however, since she did not attend the appointment the exact nature of any learning disability was never determined.    9.23  The situation with Father is less clear, with him being represented by the official solicitor within current care proceedings. Terminology within the records is confusing regarding his intellectual ability. He did attend special school, but it is likely that it was the combination of a below average IQ and emotional vulnerabilities stemming from his background that led to the need for special education, rather than a learning disability alone.   9.24  In any event, lack of clarity in relation to both Mother’s and Father’s psychological functioning and imprecise reference within the records to ‘parental learning disability or difficulties’ may have diverted professionals from a focus on the potential risks to the babies. The use of the PAM assessment alone, without a concurrent core assessment with a focus on both risk and need, indicates an assumption that the main issue was parental learning disability, rather than a multiplicity of risk factors which were likely to impact on the parents’ capacity to provide safe care. It is far more likely that mental health issues and vulnerabilities as a result of past experience would affect parenting capacity, yet these issues were not the focus of the assessment process.      9.25  In this case, assumptions and lack of clarity led to the worst of both worlds, with neither the potential learning disability being assessed properly and appropriate supports put in place, nor a proper focus on assessment of risk.     Overview Report 19.03.13 Page 55 of 100                                                  9.26  Babies harmed  Parental support needs not identified  No psychological assessment  Assumptions both parents were learning disabled   Lack of focus on risk  Protection for babies not in place  Babies harmed   Assessing the need for accommodation under s20 9.27  As identified earlier in this report there was a level of confusion within Nottinghamshire Children’s Social Care about the possibility of accommodating the babies under s20. The individual management review rightly comments that it was inappropriate to consider section 20, when the main issue identified was housing and that ‘there appears from the record to have been no discussion regarding any concerns about the parents’ ability to care for the babies and that this factor was not part of any rationale for considering s20 accommodation.’28   9.28  At this point, it would have been appropriate to stop and consider whether the fact that the parents were apparently so willing to agree to accommodation was an indication of capacity to care safely for the babies. Reder and Duncan noted that having an awareness that families may give overt warnings of child abuse means that practitioners must be prepared to take seriously statements about not being able to cope or requests for the babies to live elsewhere. Such admissions need to be seen as an indication of the need for further assessment, which did not happen in this case (2003)29.   28Nottinghamshire Children’s Services individual management review para. 2.46 29 Reder, P Duncan, S (1999) Lost Innocents A Follow -Up Study of Fatal Child Abuse. London: Routledge.    Overview Report 19.03.13 Page 56 of 100                                                 9.29  By the time the parents had moved to Somerset, they gave the impression to professionals that they could manage the twins without support. It was recognised that this was a risky situation that needed further assessment, but the level of risk was not seen to be significant enough to prompt discussions with the parents regarding this assessment being within a residential setting.  The moment to identify this as a possibility had been lost prior to the move and did not form part of the information excange between Nottingham and Somerset.    Assessing the significance of allegations of domestic violence  9.30  Domestic violence can be expressed in a number of ways. It is very common for there to be more than one form of abuse occuring and it may have been going on for a period of time.  9.31  It is worrying that none of the agencies involved with Mother and Father undertook any assessment that included consideration of domestic violence and especially its potential impact on parenting. Consequences (2005)30 which may apply to either or both parents can include: • Loss of self confidence as a individual and as a parent. • Inability to bond and form a relationship with their child. • Feeling undermined as a parent and individual. • Feeling emotionally and physically drained with little to offer the babies. • Emotional distance between parent and child. • The potential to take out their frustrations on their babies. • Inability to deal with their babies’ behaviours.  The same guidance also identified that it was important not to solely focus on the mother as the only parent of the child and that the role of the father needs to be clarified and understood. It is also important to understand the dynamics of the perpetrator’s relationship to other members of the family and to consider any services required to meet the need for his behaviour to change and to support for Mother. In addition the utilisation of a Multi-Agency Domestic Violence Risk Identification threshold scale (2007), such as that developed by Barnardo’s, may have made this task easier for all the staff involved ensuring that the risk to  30 Lincolnshire ACPC (2004) Children who experience Domestic Violence Guidance: Lincolnshire    Overview Report 19.03.13 Page 57 of 100                                                                                                                                                                  Mother from the Father was appropriately assessed around domestic violence.31  9.32  All professionals working with families, where there is actual or potential domestic violence, must consider issues around confidentiality and safety. Professionals also need to be aware of each agency’s boundaries of confidentiality and be clear about roles and responsibilities. In addition, women must be given the opportunity to talk to professionals on their own, separate from the ‘perpetrator’, which did not always happen in this case. If this is not done, women may deny the violence because of the fear of the consequences (2004)32. The midwifery service did document when Mother was asked routinely about domestic violence, or when she was not asked due to the presence of Father, but other services and agencies did not.   9.33  When there is domestic violence in the home, small children and babies may not understand what is going on, but they often display signs that they are unhappy and feeling insecure. They may be more demanding and cry more, needing more attention and cuddles (2004)33. Following their discharge home, both twins appeared to be unsettled, resulting in Baby A’s re-admission to hospital shortly after discharge. On arrival in Somerset, excessive crying may have been influenced by underlying tensions or violence between the parents. Given previous allegations around domestic violence and the known impact on young children and babies, this area did not appear to have been considered within any assessment in either Nottingham or Somerset.   9.34  The National Health Service has introduced specific training and guidance (2005)34 for health professionals, to assist them to take a more pro-active approach to the problem. Starting with midwives (following prima facie evidence that pregnant women and their unborn child are at increased risk)35, the aim was to raise awareness throughout primary and secondary care about the true extent and cost of domestic violence, including asking routine questions regardless of whether or not there are signs of abuse, or whether domestic violence is  31 Barnardo’s (2007) Multi-agency Domestic Violence Risk Identification threshold scale. Can be found at    http://www.londoncp.co.uk/pdfs/supp_sg_dv_app1_riskmat.pdf 32 Lincolnshire ACPC (2004) Children who experience Domestic Violence Guidance: Lincolnshire 33 Childline (2004) Domestic violence information sheet. Childline: London 34 Department of Health (2005)  Responding to domestic violence: A handbook for health professionals 35 Department of Health (1998) Health Services Circular HSC 1998 / 211 Section 1    Overview Report 19.03.13 Page 58 of 100                                                 suspected. There is evidence and guidance that repeated enquiry at various intervals increases the ‘likelihood of disclosure’.This did not happen in this case and there was a lost oppprtunity to ask questions and document responses in order to inform all future assessment and plans.     Understanding the meaning of behaviour 9.35  Assessments in this case generally failed to move beyond immediate practical considerations to a more in-depth understanding of the psychology of the family and the meaning of parental behaviour. This was particularly the case in the immediate pre-birth and post-birth period in Nottingham.   9.36  For example, Reder et al (2003)36 identified that some parents made disguised admissions or ‘covert warnings’ of abuse of the child, which professionals needed to be able to translate and assess. These included expressed concerns for the child’s health, which was displaced to an innocuous problem often a few days before an assault. In this case a number of possible covert warnings were: • Two days prior to the twins’ first discharge, the parents expressed concern about a mark on the side of Baby A’s face, together with him arching his back (found to be well on examination).  • Following the discharge planning meeting, both parents were noted to be angry and aggressive towards staff and Father expressed anger at the poor care received on the ward. • Baby A was re-admitted to hospital less than 48 hours after his discharge, with difficulty breathing, and was found to be well on examination (it should be noted that it is possible that the breathing difficulties could have been caused by the action of the parents, such as shaking).  The potential significance of these incidents was not recognised by either health professionals or the Nottingham social worker.  9.37  In addition, the increasing anxiety of the parents, particularly Father, evident in the  36 Reder, P., Duncan, S and Gray, M., (1993) Beyond Blame: Child Abuse Tragedies Revisited. London: Routledge     Overview Report 19.03.13 Page 59 of 100                                                 texts to the Nottingham social worker, was not understood as a potential indicator of abuse. The fact that the parents were willing to agree to section 20 accommodation was not assessed as a potential plea for help and acknowledgement of their own fear that they could not care for the babies. The interview with Father during this review process has confirmed the initial view of the serious case review panel that he would have welcomed residential care at this time, particularly if this was a parent and child placement.  9.38  Another aspect of behaviour that needed further consideration as part of the overall assessment is the use of complaints by the family. Consideration could have been given as to whether these were used to regain a sense of control, or divert practitioners’ attention away from criticism of the parents’ capacity to parent. The failure to address the significance of complaints extended to consideration as to their impact on practitioners, and whether fear of being complained about could have influenced the likelihood that adverse aspects of parental behaviour would be highlighted. Whether or not this was the case is purely speculative, but there is no evidence that it was considered. The most appropriate place for consideration would have been within supervision (see paragraphs 11.56 - 57).  9.39  The issue of ‘disguised compliance’ has come to the fore, particularly following the serious case review into the death of Peter Connelly in Haringey.37 The second serious case review noted that:  ‘The un-cooperative, anti-social and even dangerous parent / carer is the most difficult remaining challenge for safeguarding and child protection services. The parents / carers may not immediately present as such, and may be superficially compliant, evasive, deceitful, manipulative and untruthful. Practitioners had the difficult job of identifying them among the majority of parents who are merely dysfunctional, anxious and ambivalent’. (para 4.2)   In this case, there is evidence that the parents superficially engaged with the Nottingham social worker and were at times positive in their texts to her about the  37 Haringey LSCB (March 2009) Serious Case Review Child ‘A’. Published by the Department for Education on 26th October 2010.    Overview Report 19.03.13 Page 60 of 100                                                 support she was providing. What is less clear is whether they deliberately manipulated professionals, or were so anxious and frightened about their  circumstances that when the help they were receiving did not address their immediate needs, they simply attempted to regain control by making their own decisions without consulting with professionals. The interview with Father would appear to confirm that the latter is the most likely explanation.   Recognising and responding to the vulnerability of young babies  9.40  The recent thematic report by Ofsted38 identifies the particular vulnerabilities of young babies and is clearly of relevance in exploring practice issues in this case. Findings from the Ofsted evaluation in relation to timeliness and quality of pre- birth assessments are in accord with the issues explored above. Other issues relating to an underestimation of the risks resulting from parents’ own needs and the need for improved assessment of and support for parenting capacity, are also relevant here.   9.41  Prior to the move to Somerset, there appears to have been little consideration of the fragility of the babies, combined with the parental stressors that were known to be present. It is hard to understand why, within Nottingham, the case was not considered to have reached the threshold for section 47 intervention either before, or immediately after, the birth of the twins. There was overwhelming evidence of factors that were likely to affect parenting capacity, combined with structural factors such as housing, and clear evidence that both parents were unable to consistently provide for the physical and emotional needs of two fragile premature babies.       9.42  Once the family moved to Somerset risks were recognised, but the task was how best to respond whilst gathering and analysing all the relevant information. This is of particular relevance, given the current medical view that the babies are likely to have received the injury to their femurs either before or during the time they were in Somerset. Protecting the babies at this point was a particular challenge in the light of legal advice that the threshold for court action had not been met.     38 Ofsted (October 2011) Ages of concern: learning lessons from serious case reviews Reference. 110080    Overview Report 19.03.13 Page 61 of 100                                                 9.43  The response to instigate daily visiting appears reasonable. However, in this case the exact purpose of the visits was not sufficiently clear and they did not achieve the desired result in identifying any cause for concern or preventing the final injuries. It is possible that the visits, in fact, increased the parent’s anxiety at this point.  9.44  Whether or not any professional should have identified that the babies were injured is debatable. Dale et al (200539) note that the degree to which infants experience pain is a contentious issue and quote David (2004)40:  Fractures cause two kinds of pain. One is acute pain resulting from the forces applied to the bone and the pain resulting from the bone breaking. The other is ongoing pain in the days and weeks after a fracture has occurred. The immense variability means that over-confident assertions are worth avoiding … in infancy, rib fractures and metaphyseal limb fractures often produce no detectable ongoing pain at all ... the point is that caution is required before concluding that a reasonable carer should have known that something was seriously amiss in a child with rib or metaphyseal fractures.     It therefore seems likely, that in this case, professionals would not have been able to identify definitively the fact that the babies were being harmed, and the health visitor would not have picked up the injuries on examination.  However, as identified elsewhere in this report, there were a number of interacting factors which were indicative of heightened risk to the twins.    9.45  The ambulance service in Somerset did immediately recognise the vulnerability and potential injury to both twins despite only having been called out in respect of Baby A. This, followed by the exemplary work of the emergency medical team in Somerset (health overview report para 10.16), will have prevented further harm.   Communication within and across organisational boundaries 9.46  Communication across boundaries was particularly important to consider in this  39Dale, P., Green, R., and Fellows, R., (2005) Child Protection Assessment Following Serious Injuries to Infants. Chichester: Wiley. 40 David, T. J. (2004a) ‘Avoidable pitfalls when writing medical reports for court proceedings in cases of suspected child abuse’ Archives of Disease in Childhood 89. 799-804 page 802    Overview Report 19.03.13 Page 62 of 100 review, due to the highly mobile nature of the family. The panel were struck by the capacity of the family to move swiftly, often long distances, without the knowledge of practitioners working with them. This clearly provided many challenges in the sharing of information.    9.47  It was apparent that a factor affecting the efficient transfer of information was a lack of understanding between practitioners of the different systems in places in different parts of the country, and the need to clarify what these are when attempting to transfer information. The conversation between the Nottingham social worker and Somerset Direct clearly demonstrates that the Nottingham social worker was unfamiliar with the system in operation in Somerset, and that the Somerset Direct worker was not sufficiently aware that this might be the case. The resulting irritation on both sides is evident from the transcript of the conversation and did not facilitate the smooth flow of information.      Quality of information 9.48  Assessments will only be as good as the information on which they are based. In this case, throughout the period covered by this review, all known information failed to be gathered, collated and analysed in such a way that risks could be identified. There are a number of factors that appear to have inhibited this process that relate to communication between professionals.  9.49  The mobility of the family was undoubtedly a factor affecting the quality of information used to inform assessments and decisions.  Within Oxfordshire, and in the very early stages of work in Nottingham, the impression from the records is that since this was likely to be a transient family there was little to be gained by beginning a concerted attempt to gather and evaluate all known information. Similarly, although social workers in Somerset requested information from Nottingham, there was no speedy follow up in order to ensure this was received quickly and, likewise, Nottingham did not ensure that all relevant history was passed on in a timely way. Workers in all organisations were likely to have been influenced by the fact that this family tended to move from one place to another rapidly and without warning.             Overview Report 19.03.13 Page 63 of 100                                                 9.50  Communication depends upon one party recognising the importance of the information they hold and the other party asking the right questions. The child protection literature has consistently identified the tendency of professionals to ‘hold on to their beliefs about a family, despite new evidence that challenges them’ (Munro 2008)41. In this case, the definition of the family as one where parents were vulnerable, having possible learning difficulties and needing support, pervaded work throughout the pre-birth and immediate post-birth phase and was most noticeable in the lack of good quality information and analysis informing the core assessment and discharge planning within Nottingham.  This, combined with treating information received discreetly and failing to consider any fresh developments in the context of what was already known about the family (Reder el at (1993)42, meant that any new alerting information about the babies’ safety was dealt with in isolation and, as a result, thresholds of concern were not reached.  9.51  A different picture may have emerged if the most recent events had been collated and integrated with the previous concerns already identified. This accumulated knowledge would have raised an awareness of the increasing risk, so that these concerns reached a critical threshold which would have determined a different response in Nottingham, such as section 47 enquiries, prior to the family’s move to Somerset. With the benefit of hindsight, this appears to have happened once the family had already left, influenced by the quality of the safeguarding information shared by the continuing care sister with the social worker.  9.52  The lack of section 47 enquiries within Nottingham, combined with the knowledge that a core assessment had taken place, meant that even though Somerset had not seen the core assessment it was possible to make the assumption that the family’s circumstances had been fully explored and there had been no need within Nottingham to escalate the case to section 47. Sight of the core assessment would have revealed its limitations and may have prompted a speedier gathering and analysis of information by Somerset Children’s Social Care.  9.53  The quality of information received will also be influenced by the clarity of  41 Munro, E. (2008) Effective Child Protection London: Sage page 137 42 Reder, P Duncan, S. And Gray, M (1993) Beyond Blame: Child Abuse Tragedies Revisited. London: Routledge Page 87    Overview Report 19.03.13 Page 64 of 100                                                                                                                                                                  communication from one professional to another, regarding what is required. The failure to check that each party is attributing the same meaning to the information being conveyed has been identified as a feature in other reviews.43 In this case, it is not clear that requests for information or tasks to be carried out by others were always understood in the same way by all involved.  On a number of occasions, professionals were given the task of monitoring the parents; for example, the midwives on neonatal units and the daily visiting plan agreed in Nottingham and Somerset following discharge from hospital. In the first instance, health staff were left to monitor the parents’ early parenting skills by ‘reporting any concerns’, however, they were not made fully aware of the nature of the concerns or the factors to be observed, resulting in little ‘quality information’ being offered to the social worker. In the second instance, the plan identified ‘daily visiting,’ but no criteria were identified for what would constitute success or failure of the plan.    Sharing information across Health Trusts  9.54  A common thread which affected the ability to understand fully the significance of previous history, was that of professional records which were either not completed well enough or available at relevant and appropriate times. Professionals ‘need to make a clear, detailed record of events so that past history is available to be scrutinised’ to inform any future interventions. Patterns can be detected only if practitioners have written down a precise account of what happened’ (Munro 2000 quoted Horwath 2010)44. The Health overview report identifies (para 10.15) that insufficient information was made available to each new set of health professionals involved, leading to evidence of the ‘start again syndrome’. For example, following the babies’ discharge from hospital and the family’s move to Somerset the late transfer of the health visiting records inhibited previous concerns about the parents’ ability to care for their babies from being used to inform assessments.  9.55  In this case, practitioners were often making decisions on complex matters without the benefit of previous records influenced by the number of times the family moved and the significant number of different professionals seen. At times, practitioners were wholly dependent on verbal information offered by the parents  43 Reder, P. and Duncan, S. (2003) ‘Understanding Communication in Child Protection Networks’ Child Abuse Review 12 82-100 44Horwath, J. The Child’s World London: Jessica Kingsley Publishers. Page 81    Overview Report 19.03.13 Page 65 of 100                                                 without the benefit of collaborative evidence from health records. The transfer of medical records across boundaries is dependent on patients registering with a new GP when they move to a new location. The GP then has to request their previous records, a process which may take a number of weeks to complete which, in cases such as this, was not helpful.  However, if the professionals involved had discussed their concerns with a named or designated professional, the exchange of information across health boundaries could have been more speedily and effectively managed.  9.56  In this case, information sharing across Health Trusts was complicated by the number of times the babies moved from hospital to hospital. The evidence points to a lack of consistency in the way that information was transferred, plus the time taken to assimilate this information and use it to understand the particular circumstances of the babies.  9.57  Adult Health services, such as Community Learning Disability, Substance Misuse or Mental Health services could have brought specialist knowledge concerning the nature and extent of any ‘alleged’ learning disability, substance misuse or mental health problems. However, although there was an attempt in Nottingham to involve the perinatal mental health team because of concerns that Mother was at risk of post natal depression, there was no overall assessment of her mental health needs. In relation to Father, the information known to the GP in North Somerset that he had received mental health services in Scotland, and comments relating to post traumatic stress, were not highlighted in communications with others when the family moved. An early referral to adult health services may have been able to offer particular interventions or provide access to relevant services, including focused assessment; thus there was a missed opportunity in this case (Horwath 2010)45.   The role of meetings in the communication process 9.58  The discharge planning meeting has been identified as a pivotal moment in this case. It was an opportunity for practitioners to bring together all known information and use this to inform a plan, aimed at promoting development and keeping the  45 Horwath, J. The Child’s World London: Jessica Kingsley Publishers. Page 345    Overview Report 19.03.13 Page 66 of 100                                                                                                                                                                  babies safe. However, this meeting was not attended by all the key people who had worked with the parents (i.e. children’s centre worker and midwife) and the process of the meeting was such that health practitioners did not feel their concerns were heard. The fact that a meeting has taken place might reassure professionals, evidenced by the social work team manager dismissing subsequent concerns when the babies were readmitted, because they had not been raised at the meeting. However, attention needs to be paid to the quality of the meeting process and in this case it seems that ‘groupthink’46 was evident, with a pressure on those with a divergent opinion to conform to the dominant view.  At the time, these concerns were not appropriately escalated to the designated nurse or senior manager. Making sure that not only the right people attend such meetings, but also that all opinions are sought and heard and that there is reflection after the meeting as to whether any further action is needed, is crucial to the effective use of such meetings in safeguarding children.    9.59  The review also raises issues about the need to ensure that all relevant information is used to inform strategy discussions. In Somerset there was no health presence at the initial strategy discussion, which meant that vital health information regarding two premature babies with considerable health needs was lost. The Somerset Children’s Social Care individual management review highlights the need to ensure that there is clarity needed, as to when such a discussion needs to be face to face, rather than via the telephone. Consideration also needs to be given to ensuring the right people attend such discussions / meetings in line with government guidance and that such discussions should include ‘children’s social care, the police, health and other bodies as appropriate’47.    Partnership working  Professional challenge – relationships across the network 9.60  Approximately half of all serious case reviews are in relation to babies under one year of age, underlining the importance of effective universal services provision for young children, for example, health visitors and Early Years services such as  46Janis (1982) quoted in Munro (2008) Effective Child Protection London: Sage.  Page 148 47 HM Government (2010) Working Together to Safeguard Children. DCSF-00305-2010. Para 5.56     Overview Report 19.03.13 Page 67 of 100                                                                                                                                                                  children’s centres (2010)48. In this case, a high number of health professionals was involved with the family from different health organisations, across a number of counties, with key professionals expressing concerns about the parents (antenatally and postnatally). Their voices and opinions were not heard by the Nottingham social worker and team leader, who appeared not to value alternative views, or treat them with respect and therefore utilise the expertise of the whole network effectively. This is demonstrated by: • Minimising of concerns raised by ward staff at Grimsby during the discharge planning meeting. • The safeguarding nurse feeling ‘defeated’ during the discharge planning meeting (IMR Addendum Report page 7).  • Minimising concerns when Father was reported to have sworn at Baby B, whilst staying in hospital accommodation. • The social worker in making and supporting complaints from the family against professionals.  9.61  Polarisation between agencies can have a negative impact on working together and result in the potential for staff to withdraw from their safeguarding role to the detriment of the child and family. It is relevant to highlight that three different hospitals were asked by the Nottingham social worker to document concerns and pass them to her. None did this effectively and this may have been influenced by culture and the personalities involved. This may have also impacted on the health professionals involved, who did not discuss or escalate their concerns with managers.   Using expertise 9.62  Research undertaken by Ward et al (2010)49 identified that many parents reviewed, who had harmed their children, were ‘struggling with mental health problems, drug and alcohol abuse and domestic violence. Several birth fathers had criminal convictions for violence. Few had supportive partners, friends or family members who could help with neighbourhood factors and housing problems, compounding parental problems - all factors present in this case. The  48 Brandon, M., Bailey, S., and Belderson, P. (2010) Building on the learning from serious case reviews: a two year analysis of child protection database notifications 2007 – 2009. Research brief DFE-RB040 49 Ward, H., Brown, R., Westlake, D., and Munro, E. (2010) ‘Infants suffering or likely to suffer, significant harm: A prospective longitudinal study. Research Brief DFE-RB053 page 3    Overview Report 19.03.13 Page 68 of 100                                                 research also identified that assessments demonstrated an unfocused multi-agency approach, often influenced by a lack of clarity around roles, responsibilities and expectations.    9.63  In this case, there were several instances where it was unclear what was being expected, for example, in the case of ‘monitoring’ within hospital and daily visiting when the babies were discharged. The role of welfare checks was raised within the Avon and Somerset Police individual management review and is an example of the need for greater clarity regarding roles and expectations. Police would not have the expertise to assess the wellbeing of premature babies with substantial health needs, yet the term ‘welfare check’ implies this is the case. It is also unclear whether the student social worker, conducting one of the daily visits, would know what to look for in relation to health and development of the twins.  The plan developed at the strategy meeting for daily visiting appears without clarity of purpose, or agreed criteria for judging the safety and wellbeing of the twins or consideration as to who was the right person to be undertaking the task.   9.64  The need to recognise and use expertise effectively has been recognised in other reviews. Brandon et al’s study (2005)50 of serious case reviews in Wales noted that: ‘The barrier to the collation and analysis of relevant information often appeared to be a failure to recognise and understand expertise rather than a lack of communication … skilled use of expertise and consultation in a coordinated manner could result in more rigorous assessments and promote greater professional trust, confidence and challenge.’  Using expertise requires receptivity and respect for what others can bring to the discussion, as well as robust relationships across the professional network. Both were compromised in this case.  The expertise within the health community was not fully utilised.  The observation by the Nottingham Housing Support Service 1 worker that the babies were likely to be born prematurely seems to have been forgotten, and there is evidence of a difficult relationship between the Nottingham  50 Brandon, M., Dodsworth, J., and Rumball, D. (2005)  ‘ Serious Case reviews: Learning to Use Expertise Child Abuse Review 14 160-176 (2005)     Overview Report 19.03.13 Page 69 of 100                                                 social worker and the children’s centre worker, which may have affected the quality of analysis.    9.65  Recent research has raised questions concerning the acceptable threshold for significant harm, particularly where neglect and/or emotional abuse are key issues. It notes ‘If the welfare of the child is indeed the paramount consideration, then both practitioners and policy makers need to ask far more stringent questions, concerning what constitutes acceptable and unacceptable levels of parenting in a civilised society.’51 In this case, there appeared to be a difference in professional / agency opinion about whether the babies were in need, or in need of protection. This was especially evident when housing and health professionals expressed child protection concerns and made appropriate referrals, whilst the Nottingham social worker and team leader held the fixed view that they were children in need. Whilst Children’s Social Care does have lead responsibility for child protection, there is a need to use escalation/dispute resolution processes effectively, in order to ensure that there is a proper debate concerning thresholds where opinions differ. The Nottingham Children’s Social Care individual management review author informed the serious case review panel that considerable attention has been paid to the use of escalation processes and the Ofsted inspection of safeguarding (January 2011) noted good partnership working and that a dispute resolution policy is in place. The individual circumstances of this review indicate that the Local Safeguarding Children Board will need to ensure that the scrutiny processes focus on consistency and effectiveness of the application of dispute resolution procedures.    Working with mobile parents 9.66  As identified above, these were highly mobile parents with the capacity to move long distances at short notice. This demanded organisational skills, as to travel with such young babies on public transport would not have been straightforward. However, mobility affected the quality of information sharing and potentially the commitment of professionals to comprehensive information gathering and analysis of this information, when it seemed likely that the family would move.  51 Ward, H., Brown, R., Westlake, D., and Munro, E. (2010) ‘Infants suffering or likely to suffer, significant harm: A prospective longitudinal study. Research Brief DFE-RB053 page 7     Overview Report 19.03.13 Page 70 of 100                                                 There is little evidence that the underlying reason behind their mobility was adequately explored or incorporated into an assessment of risk. The focus continued to be on practical matters, such as housing (which was of course important), rather than also considering the psychological perspective; i.e. what was the meaning of their behaviour?  9.67  Closure was identified by Reder et al (1993)52 in approximately 50% of the child deaths they studied. This involved such behaviour as parents at times shutting themselves away from professionals by refusing to open the door, or failing to keep appointments, as in this case. Another way in which families ‘closed off’ was through ‘flight’, in which parents moved home repeatedly, often at short notice and without telling the professionals involved. This behaviour was identified to be primarily an issue of control, with parents feeling that they had so little influence about what was happening in their lives they could gain control by attempting to shut professionals out. Consideration of how far this dynamic was present in this case would have enhanced an understanding of parenting capacity.   9.68  At times, there is evidence that practitioners unwittingly exacerbated the problem by encouraging movement to another area, believing this was in the best interest of this family or others in their network. The NADA worker, for example, supported Mother in obtaining train tickets to go and stay with maternal uncle 1 and the conflicting needs of maternal uncle 1’s family and Mother in Oxfordshire, resulted in the Oxfordshire social worker advising maternal uncle 1 to evict her.  9.69  Systems and resources also contributed to mobility, with Mother being transferred to Grimsby hospital because of the lack of specialist cots in Nottingham. Whilst well meaning, the transfer of Mother and the twins again, from Grimsby to Derby then back to Nottingham, increased the likelihood of lost information and consistency in the care and assessment of the twins and the parents. As identified in the Health overview report (para 9.19), unborn babies / children should not be transferred to other hospitals without proper documentation and transfer of full social information and direct telephone communication made to the receiving on-call community paediatrician / paediatric consultant. If such documentation is not  52 Reder, P., Duncan, S., and Gray, M. (1993) Beyond Blame: Child Abuse Tragedies Revisited. London: Routledge Page 99    Overview Report 19.03.13 Page 71 of 100                                                 received, the consultant in charge (or nominated deputy) of the case, should contact the referring hospital to request such documentation is forwarded. The use of Named or Designated health professionals should also be considered as a resource for effective information sharing between different organisations, regarding any safeguarding concerns. Following full consideration of this issue, the health overview report recommends that when infants are transferred out of area to access specialist medical care, further transfers should be limited to transfer back to the local area.   The role of supervision 9.70  The importance of effective supervision in child protection work is well documented in government guidance and reviews53 54. In this case, there is little evidence that supervision enabled the reflection and critical thinking required, or encouraged the appropriate use of professional challenge where appropriate.  9.71  Within Oxfordshire, there is no evidence that supervisors encouraged the social worker for maternal uncle 1’s family to think more broadly about the potential risks to Mother’s unborn child. This, combined with the GP’s lack of consultation with named professionals, meant that all known and relevant information was not brought together by Children’s Social Care and passed to Nottingham.  9.72  Of particular concern was the quality of supervision provided to the Nottingham social worker who had the most contact with the family. The lack of focus on an assessment of risk within supervision has been appropriately highlighted by the Nottingham individual management review, which recommends that supervision case discussion records be amended to include a section on ‘current assessment of risk, if any’. This does not, however, address an issue which emerges from the integrated chronology, which is the way in which the social worker was interacting with others and her apparent anxieties about the case. It is noticeable from the chronology that she was informing others that the case was likely to be child protection, or even moving towards care proceedings, yet the supervision records almost immediately following these conversations do not include any discussion about these views and simply refer to this being designated Child In Need.  It is  53 HM Government (2010) Working Together to Safeguard Children. DCSF -00305-2010. Paragraphs 4.50 and 4.51 54 Munro, E. (2011) The Munro Review of Child Protection Interim Report: The Child’s Journey.  Page 53    Overview Report 19.03.13 Page 72 of 100                                                                                                                                                                  possible to speculate that the social worker projected her anxieties outwards, rather than being encouraged to name and explore these within supervision. The impact of anxiety on child protection practice has been well documented over many years,55 with Munro (2011)56 noting that, ‘The emotional dimension of working with children and families plays an important part in how social workers reason and act’. The social worker concerned had only recently returned to work after a two year absence, and there is little evidence that consideration was given as to the personal impact of this case on her, particularly since she was receiving a number of texts form the family outside usual working hours. The dynamics of the relationship between the worker and the family and the information this could contribute to an overall understanding of the case, do not seem to have been explored.   9.73  Supervision did not adequately address the impact of professional relationships. There is evidence from the chronology that the social worker came across at times to others as aggressive, highlighting the challenge for supervisors in really knowing the level of interpersonal skills being employed by their supervisees. This is particularly the case in social work, where so much work takes place out of sight of the supervisor.  Within health, although there is now evidence that hospital staff did not feel that they had a good working relationship with the social worker, supervision was not used to explore how to manage this appropriately and ensure that it was not having a detrimental effect on practice.   9.74  The Nottingham Social Care individual management review identifies that social work practice in this case was below the standard that would have been expected and immediate management action was taken to ensure that operational issues identified in the practice of the social worker and the team manager were immediately addressed. It is also important to acknowledge that all agencies have a responsibility to challenge practice when they have continuing concerns about case management, including the option to escalate their concerns to senior managers within their agency.   9.75  Although in midwifery ‘supervision’ is not typically the mechanism used to manage  55 For example: Morrison, T.(1990) ‘The emotional effects of child protection work on the worker’ Practice 4 (4) 253-271   56 Munro, E. (2011) The Munro Review of Child Protection Interim Report: The Child’s Journey.  Para 3.17    Overview Report 19.03.13 Page 73 of 100                                                 conflicts between a midwife and other professionals (a midwife would generally initially discuss such conflicts with their line manager, the ward sister), they could thereafter seek support and advice from a safeguarding nurse. This appears not to have happened in this case.    9.76  The role of ‘informal supervision’ between health professionals who do not access supervision on a regular and formal basis, poses a particular challenge for child protection supervisors. Staff contributing to multi-agency assessments, such as the midwives and neonatal staff, requires support and regular supervision to ensure that any anxieties they may hold about either the task or process are identified and supported. To enhance any such multi-agency work, staff involved need to have a clear structure, to fully understand each other’s roles and responsibilities and to feel confident to challenge any decisions made they do not agree with. In such cases, supervision may need to be directive as well as reflective, to ensure that the responsibility for the family is shared by all the professionals involved. Appropriate supervision should have monitored and challenged any concerns identified about professional and family collusion, with appropriate intervention as necessary (Horwath 2010)57.  9.77  All professionals delivering universal services have key roles to play, in the identification of children who may have been abused or neglected and those who are likely to be, thus helping to build up a picture of the child’s situation and alert the appropriate professional if there is a concern. When health professionals are unsure of what action to take or options available to them, they should seek the support of either the named or designated professionals, which did not appear to happen in this case.  9.78  Named professionals have a key role in promoting good professional practice within their organisation and providing advice and expertise for fellow professionals. They usually have specific expertise in children’s health and development, child maltreatment and local arrangements for safeguarding and promoting the welfare of children and would have been a valuable source of advice and support. Whilst designated professionals are a vital source of  57 Horwath, J. (2010) The Child’s World London: Jessica Kingsley Publishers. Page 107    Overview Report 19.03.13 Page 74 of 100 professional advice on safeguarding children, their services were not fully accessed in this case. This was a missed opportunity by the named professionals, especially following the discharge planning meeting and Baby A’s admission to hospital shortly after his first discharge.     10. LESSONS LEARNT 10.1  Many of the lessons from other reviews, in relation to babies under one year, apply in this case. In particular there is evidence that assessments failed to identify the interaction of a number of risk factors that should have concerned professionals. The presence of mental health problems (Father and Mother), history of violence (Father), substance misuse (Mother’s codeine use – Father’s previous amphetamine use), possible domestic violence and parents who had received compromised parenting themselves, was not properly assessed and did not result in a coherent plan to protect the babies. The issue for this review is why did this occur, what lessons can be learnt and what can be done to improve practice in the future.  10.2  Important factors appear to have been a lack of understanding of the implications of a multiple birth, the likelihood that the babies would be premature and the possibility of medical complications making the babies more vulnerable.  The delay in completing a robust pre-birth assessment was therefore particularly significant and resulted in over-optimism that the parents would be able to provide safe appropriate care. Caring for twins provides a number of challenges and for these parents, with their own vulnerabilities and needs, a comprehensive pre-birth assessment should have highlighted the risks and resulted in a coherent multi-agency plan before they were born. There are indications that the parents themselves were aware of their own limitations and immediately after the birth would very likely have agreed to section 20 residential assessment. This option was not considered as the focus was on the inappropriateness of using section 20 for what was perceived to be housing rather than a child protection issue. This option was again not considered in Somerset, this time because the parents were not requesting it and appeared to be coping with support.  The importance of listening to parents who are giving clear warnings through their behaviour that    Overview Report 19.03.13 Page 75 of 100                                                 they are not coping needs to be recognised, as a failure to respond at that point may mean the opportunity for intervention is lost.      10.3  The issue of the right of unborn babies to protection is fundamental here. Government guidance in Working Together to Safeguard Children 2010 does note that the same procedures should be followed when there are concerns about the unborn child. However, there is nothing in the guidance to support good practice in relation to pre-birth child protection processes, nor to highlight any issues that should be considered in relation to multiple births. The Thames Valley Police individual management review helpfully highlights the fact that child protection legislation only applies to children once they are born and suggests that this should be amended to protect the rights of the unborn child.    10.4  At no time, particularly pre-birth, were professionals explicitly utilising any frameworks to assist them in identifying risk. The PAM assessment’s primary focus was on parental functioning and in conjunction with a good core assessment may well have contributed to an understanding of risk. However, there was no core assessment, the PAM assessment was not finished and in fact, some key modules can only be completed after birth, when parenting can be observed. Ward et al (2010)58 suggests that utilising a simple methodology developed by Jones et al (2006)59 and underpinned by research evidence has proved a useful means of identifying which children are at greatest risk of suffering significant harm in the future.  Another useful framework both pre and post birth may have been the signs of safety approach60, which understands safety as ‘strengths demonstrated as protection (in relation to the danger) over time61. The explicit use of such frameworks may have assisted in the consideration within Nottingham and Somerset as to whether the threshold for legal intervention had been met.  10.5  One response to the concerns in the case was to set up a daily visiting schedule both in Nottingham and Somerset. The plan for daily visits needs careful  58 Ward, H., Brown, R., Westlake, D., and Munro, E. (2010) Infants Suffering, or Likely to Suffer, Significant Harm: A prospective longitudinal study. DfE Research Brief DFE-RB053. 59 Jones, D., Hindley, N., and Ramchandani, P. (2006) ‘Making Plans: Assessment, Intervention and Evaluating Outcomes’, in Aldgate, J., Jones, D., and Jeffery, C. (eds) The Developing World of the Child. London: Jessica Kingsley Publishers 60Buffa, J., and Podesta, H. (2004) ‘Partnership and Risk Assessment in Child Protection Practice Protecting Children 19 (2) 36-48 61 This is fundamental to the signs of safety approach developed by Andrew Turnell and Steve Edwards. See: www.signsofsafety.net.     Overview Report 19.03.13 Page 76 of 100 consideration as, unless the purpose and limitations of the visits is clear, it may result in a false sense of security across the professional network. As this case demonstrates, it is likely that the babies had already suffered fractures to their femurs during the period that visits had occurred and the schedule did not prevent the final severe head injuries.  In fact it is possible that the visits themselves raised the parents’ anxieties. Where daily visiting is taking place it is important that the purpose is made explicit to families and the professionals who are carrying them out and there are clear contingencies in place if visits are not achieved.  10.6  Linked to the issue of the visits are a cluster of issues relating to ensuring the right people with the right qualifications and experience are carrying out tasks.  The police officer asked to carry out a welfare check had eight months operational service and was asked to undertake a potentially complex task and their opinion as to the welfare of the babies is likely to have been given considerable weight by others. As a result of this case and others, Avon and Somerset Police are working on a protocol which will clarify the role of welfare checks and who should be charged with carrying them out.   10.7  Other issues have emerged concerning roles within the system, including ensuring that the right people (i.e. those with direct knowledge of the parent’s capabilities) attend discharge planning meetings and the need for strategy discussions to include health personnel, particularly where there are young babies with medical issues.  10.8  The need for professionals to challenge each other appropriately has been a feature of many serious case reviews. In this case there appear to have been a number of factors that prevented constructive challenge at various points, most notably during the time the twins were in hospital post birth. The prevailing social work view that this was a situation of ‘Children in Need’ was not adequately challenged by nursing staff who, having seen the parents’ daily interaction with the babies, had serious concerns about their capacity to parent. The overriding impression was that there was a reluctance to challenge social workers who were perceived to have more expertise in child protection matters and the perceived    Overview Report 19.03.13 Page 77 of 100                                                 ‘aggressive’ communication style of one social worker compounded this view. This was particularly crucial at the point of the discharge planning meeting when, despite escalation polices within the LSCB, the disquiet of nursing staff only emerged as a result of information gathering for this review. LSCBs, therefore, need to take steps to move beyond policies and procedures in this area and take steps to examine the health of interagency relationships on a regular basis.      10.9  This case has clearly highlighted the challenges associated with working with mobile families who regularly cross organisational boundaries. As well as the practical issues relating to information transfer, as evidenced by problems in the transfer of information between Nottingham and Somerset Children’s Social Care, the review has also identified that mobility needs to be treated as information in its own right. In this case, for example, it is possible that the sudden move to Somerset was because the continuing care sister in Nottingham was unhappy about the standard of parenting.  The reason for mobility therefore needs to be questioned and understood within the context of an assessment of risk.  Professionals also need to be careful not to increase mobility inappropriately, such as when Mother was encouraged to move from North Somerset to her brother’s home in Oxfordshire.  Additionally, in this case, the lack of suitable cots resulted in vulnerable babies moving through three hospitals in the first few weeks of their life.  10.10  The importance of reflecting, throughout any assessment on the dynamics of family/professional interaction, is evidenced throughout this review. At times, the parents appeared to be engaged with professionals, drawing them in as a source of support, mainly with practical matters. On other occasions, they were openly hostile, using the complaints system apparently to deflect professionals from questioning too deeply in areas they did not wish to explore. In addition, there is evidence that they also gave clear warnings to professionals that they did not feel able to cope with the babies; warnings that were not apparently heard. There are also indicators that the phenomenon of ‘closure,’ identified by Reder et al (1993),62 may have been apparent with professionals finding it hard to access the family towards the end of the time frame for this review. Relationships with the  62 Reder, P., Duncan, S., and Gray, M. (1993) Beyond Blame: Child Abuse Tragedies Revisited. London: Routledge    Overview Report 19.03.13 Page 78 of 100 family were therefore complex. There is little evidence that supervision in any agency enabled professionals to reflect on the dynamics of the relationship they had with the family and the meaning of their behaviour.  10.11  The need for effective supervision is therefore a key lesson from this review. Effective supervision would have enabled professionals to stand back from the day to day case management, focus on the risk factors present in this case and consider their likely impact on outcomes for the babies.  Effective supervision would also have focussed, whilst the babies were in Nottingham, on the dynamics of family/professional relationships as well as relationships between professionals and the impact these may be having on outcomes. It is possible that the perceived style of communication of the Nottingham social worker hid an underlying anxiety about this case and there is no evidence that this was explored properly in supervision with her manager.    10.12  One important lesson particularly relevant within health agencies is the need to use consultation with named and designated professionals, combined with escalation processes if necessary, when there is concern regarding the actions of others within the professional network and constructive challenge has not resulted in the desired outcome.      10.13  One final lesson is the need to ensure that all professionals are aware of relevant research and use this in their work. In this case, knowledge of well documented risk factors in relation to the vulnerability of infants, parents’ history and current behaviour would have assisted decision making.     11. CONCLUSION   11.1  In this case, Baby A and Baby B were injured whilst living in a family situation which, when all the facts are taken into account, could have predictably led to a less than optimal outcome. Whilst the severity of the injuries could not have been predicted, there were clear signs that Mother and Father were struggling to provide the care needed by two vulnerable, premature babies. An important issue    Overview Report 19.03.13 Page 79 of 100 is therefore whether there were opportunities to prevent the injuries?   11.2  The most obvious opportunity was during pregnancy In Nottingham when a comprehensive pre-birth assessment would have revealed family histories  indicative of parents who, at best, would need a great deal of support to care for twins. The combination of a twin pregnancy, two vulnerable parents, Father’s history of violence and few support structures should have led to a structured assessment of risk prior to the birth.  11.3  The second opportunity to prevent the injuries was during the immediate post birth period when the parents were giving clear signals that they were finding it difficult to cope. A combination of a discharge planning meeting that did not include information from concerned health professionals, and a failure to really listen to what the parents were saying, both verbally and through their actions, meant that there was a focus on practical issues such as housing, rather than potential risk. Health staff remained concerned, but failed for whatever reason to escalate their concerns to senior management.  11.4  The final opportunity was following the parent’s sudden move to Somerset, when the earlier failure to conduct a full assessment resulted in a paucity of relevant information being passed to Somerset. Although the case at this point was immediately identified as high risk, again historical information that should have been available about Father was not integrated into the ongoing assessment, nor did it inform a discussion with the legal team regarding whether the threshold for legal intervention had been met. Although there was well co-ordinated professional activity providing intensive visiting to the family at this point, it is likely that both babies had already received some injuries. It is possible that the final serious injuries could have been prevented by greater clarity regarding the purpose of the welfare visits and a more intrusive approach by professionals. However, it cannot be assumed that this is the case.   11.5  The main conclusion must be that the failure to prevent the injuries stemmed from the cumulative effect of a number of organisations over time failing to integrate all known information about the family, recognise risk including the particular issues    Overview Report 19.03.13 Page 80 of 100 relating to a multiple birth and work together effectively across professional and area boundaries. That said, it should be noted that this was a particularly challenging situation due to the number of moves, some of which were precipitated by organisations themselves. Managing such cases requires strong effective management, supervision and support for professionals to enable them to stand back, reflect and identify risk whilst working with constantly evolving complex situations on a day to day basis.   11.6  The most important element of any review must be whether it has a positive impact on future practice. Individual management review authors have considered their involvement in this case and made many recommendations for practice improvement which have been accepted by senior managers and are in the process of being addressed. A number of additional recommendations are made by this overview report which require either a multi-agency approach to service improvement or a shared vision of good practice across LSCB member agencies. These relate to pre-birth assessment practice, staff supervision, inter-professional relationships and use of research to inform practice. It is the view of the serious case review panel that these recommendations address key issues which are at the heart of practice issues in this case.     12. OVERVIEW REPORT RECOMMENDATIONS    All LSCBs involved with this review are asked to consider the recommendations from the overview report, health overview report and individual management reviews relevant to their area. The chair of Somerset Safeguarding Children Board will write to the chairs of Nottingham, Derbyshire, North East Lincolnshire, Oxfordshire and South Somerset and North Somerset, in order to bring to their attention the findings of this review and invite them to develop and monitor action plans which will address the lessons learnt.  12.1  LSCBs should review their pre-birth assessment guidance to ensure that it highlights the particular risks that need to be considered in the case of multiple births and the need to gather and analyse all relevant historical information.     Overview Report 19.03.13 Page 81 of 100  12.2  LSCBs should ensure that an audit of pre-birth assessments takes place, in order to ascertain whether they are fit for purpose, in line with the guidance and adequately analyse the potential risk to the unborn child.    12.3  LSCBs should review supervision arrangements across the partnership and establish, implement and audit a core standard for safeguarding supervision. The standard should:   •     Focus on the quality of supervision delivery. • Take account of differing governance arrangements, supervision cultures and organisational structures for the delivery of supervision. • Take account  of Working Together to Safeguard Children (2010 para 4.51) and promote a style of supervision which: � Keeps a focus on the child � Avoids drift � Maintains a degree of objectivity and challenges fixed views � Tests and assesses the evidence, based on assessments and decisions � Addresses the emotional impact of work.  12.4  LSCBs should ask agencies to review their internal escalation and resolution processes and ensure that policies are combined with regular activity to evaluate and review the health of relationships at the front line and first line manager level.   12.5  LSCBs should review and monitor single agency or multi-agency safeguarding training strategies to ensure the promotion and embedding of relevant research, in relation to the assessment of risk and young babies, the importance of cumulative histories in analysing risk and working with resistant and/or mobile families.   12.6  Somerset LSCB should raise with the appropriate Government department, the issue that unborn children currently do not have the same right to protection in law as children post-birth, and ask that Government child protection guidance should adequately address the rights of the unborn child.             Overview Report 19.03.13 Page 82 of 100 13 HEALTH OVERVIEW RECOMMENDATIONS    It is recognised that only the Somerset Local Safeguarding Children Board and partners can implement an action plan; however, it is highly recommended that these recommendations are disseminated to all NHS Clusters and Local Safeguarding Children Boards for both their consideration and implementation as standards of good practice.  13.1  NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to request them to recommend that NHS Trusts have in place, a policy for multi-agency pre-birth planning between 18-20 weeks gestation, where there is recognition of parental risk factors and/or safeguarding concerns to the unborn/newborn child • Early identification of high-risk families must include a holistic evaluation of any risk factors to unborn children, particularly where there is known domestic violence and parental mobility.   • There should be recognition of the likelihood of early delivery for all pregnancies but particularly when the mother is expecting twins.   • Safeguarding concerns to the new born child should be identified through holistic assessment by 18-20 weeks gestation and a multi-agency pre-birth planning meeting held to develop a pre-birth plan with additional measures in place in the event of premature birth.  • GP record keeping policies should require all vulnerable families’ records to be ‘flagged’ with born/unborn children. Record keeping policies should be amended to include unborn child in line with the Children Act 1989 despite foetuses having no legal status.   13.2  NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to request them to ensure that all health provider services have a Did Not Attend/Missed Appointment policy with reference to children where there are safeguarding concerns across all    Overview Report 19.03.13 Page 83 of 100 health specialities, including where children and pregnant mothers may attend.   • All NHS Providers to have in place a Did Not Attend/Missed appointment policy for all health services accessed by antenatal mothers and children  13.3  NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to request them to recommend that all Obstetric/Neonatal health services should review policies to ensure clinical need, vulnerability and safeguarding concerns are included in the decision making for hospital transfer and discharge, ensuring both family history and documentation are provided in a timely manner, and there is clarity of purpose for discharge planning and strategy meetings.  • When unborn infants are transferred out of area in order to access specialist neonatal care, further transfers must be limited to transfer back to the local area to promote continuity of care, information sharing and child protection planning. All transfers should be made on the basis of clinical need only.  • Unborn babies/children should not be transferred to other hospitals out of area when there is no identified clinical need for this transfer. Where transfers are required for a clinical need proper documentation and transfer of full ‘social information should be made by direct telephone communication to the receiving on-call Community Paediatrician/Paediatric Consultant. If this is not received, it should be ‘chased up’.  • Where there are safeguarding concerns, weekend/bank holiday discharges should be avoided if possible to minimise the involvement of staff that are unfamiliar with highly complex families, avoiding ‘start again’ assessments. There must be clarity of the status of all professional and discharge meetings with appropriate attendance from all agencies. Professionals with key information who consider they should attend should request an invitation. The meeting should incorporate: • good preparation    Overview Report 19.03.13 Page 84 of 100 • practitioners prepared and empowered to challenge decision making • good minutes including appropriate and timely distribution  13.4  NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to ask them to recommend that NHS Trusts review information sharing pathways and escalation policies to ensure health professionals are clear about their duty to share information when there are child protection concerns, and the process to escalate these concerns, to include the secure and prompt transfer of information when families move out of area.   • Health professionals must be clear about their duty to share information, escalate cases and refer to Children’s Social Care, if necessary, without the consent of parents where the welfare of children or UNBORN children is likely to be compromised. Designated and Named professionals should facilitate this if necessary.   • There must be careful and concise sharing of concerns about parenting ability and risks to the unborn child between agencies and health services when families move areas.   • All practitioners are accountable for their practice and must challenge other agencies’ decisions when required. Designated Professionals must be accessible for advice and support to assist staff to use the escalation process where there are appropriate concerns.   • There must be consideration of a clear policy for prompt and secure transfer of children’s health records to the receiving authority for both children in need or subject to a child protection plan. Transfer of information through Named Nurses should also be used.  • When new services are set up to provide urgent care services such as the acute care GP, there must be consideration of the pathways for information sharing to health visitors on attendances by children.    Overview Report 19.03.13 Page 85 of 100  13.5  NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to ask them to recommend that early identification of high-risk families must include a holistic assessment, targeted history taking and the evaluation of the risks and protective factors to the unborn children. • Sufficient consultation time for all health professionals should be allowed for holistic and complete history taking especially at first contact, and ‘patterns’ of behaviour and risk factors noted where there are concerns. Every effort should be made to confirm information given in a history independently and to contact/receive information from previous health workers responsible for parents, unborn babies and children, where they may be parenting concerns.  • Nursing observations as to parental management skills and their behaviour is an important CONTRIBUTION to a ‘Parenting Assessment’ but because of the artificial environment of a hospital setting cannot replace it. There needs to be clarity that such information does not form a complete formal parenting assessment as understood by other agencies.  • There should be consideration of the appropriate policy for admission of children with faltering growth/neglect in specialist children hospitals to an appropriate ward with due regard to safeguarding concerns  • Where parents are recorded as having ‘learning difficulties’ early ‘baby handling’ teaching skills should be instigated with sufficient time for reinforcement of lessons.  •  Professionals should expect to see and check vulnerable children and not be inhibited by parental excuses to not disturb, particularly when ‘serious neglect’ issues are identified.   13.6  NHS Somerset Director of Nursing will write to the Strategic Health Authorities Directors of Nursing to ask them to recommend that all NHS    Overview Report 19.03.13 Page 86 of 100 Trusts review their training materials and give consideration to the need to be amended such that the learning points which have emerged are clearly embedded in professional training.     14. INDIVIDUAL MANAGEMENT REVIEW RECOMMENDATIONS    Derby Hospitals 14.1  That medical and nursing staff are supported and developed by a programme of further specific training in identification of attachment issues in the NICU environment, adult risk issues, parenting assessment, recording and communication of concerns.  14.2  Safeguarding team to facilitate involvement of learning disability liaison nurse or safeguarding adult officer with LD background in cases of concern where parents have a learning disability   14.3  That Derbyshire County Council Children and Younger Adults Department review the protocol for sharing information with other Local Authorities to ensure a timely response    North Lincs and Goole Hospital 14.4  To review the protocol and name of the child protection care pathway   14.5  To review the current level 3 safeguarding training to increase course content in relation to recognition and impact of parental learning disability   14.6  Develop specific child development training for staff groups working on neonatal units across the hospital sites   14.7  Develop a formal communication process for transfer / handover of care from midwifery to neonatal units ensuring the inclusion of all family / social history   14.8  Develop a timely records transfer process between midwifery and neonatal unit to ensure no loss of information    Overview Report 19.03.13 Page 87 of 100  14.9  Develop a process of parental assessment for parents of children on neonatal units    NHS North Somerset  14.10  Safeguarding Training for all GPs to encompass their role as gatekeepers of information, and that they need to take a more holistic view of patients as parents.  14.11  GP training is audited on an annual basis   14.12  Pre-birth planning arrangements are audited    Nottingham Support Service 2 14.13  All Access Point staff undertake in house safeguarding training    Nottingham Support Service  14.14  Work between agencies to be further examined internally and areas for improvement identified   14.15  Handling of complaint: there is evidence to indicate that communication between the Social Worker and Manager was good through the investigation and the complaint was resolved to everyone's satisfaction. However, records of the contact could be better, which needs to be addressed with Manager of Nottingham Support Service 1.   14.16  Contact following on from the complaint was with the Manager but records are not clear. This will be addressed with Manager    Nottingham University Hospitals NHS Trust 14.17  Complete the planned update of the existing Trust policies (Safeguarding Vulnerable Adults; Mental Capacity Act)   14.18  Update the In-utero Transfer Guideline to include safeguarding      Overview Report 19.03.13 Page 88 of 100 14.19  Update the Trusts Transfer & Discharge policy to include safeguarding   14.20  Have a debriefing meeting between NUH and Social Care once the SCR is completed to identify lessons learned regarding the interagency relationship   14.21  At that meeting it should seek solutions to the need for formal communication regarding risk issues, particularly category and severity, between Social Care and NUH   14.22  Produce guidance clarifying roles and responsibilities for ward staff regarding parenting observation and assessment   14.23  Ensure that all staff attend safeguarding training according to Trust Policy   14.24  Ensure that the nature of the individual’s safeguarding responsibility is reviewed at annual appraisal (appraisers therefore need to be trained accordingly)   14.25  Re-emphasise the need of internal escalation to the responsible consultant when there are safeguarding difficulties   14.26  Ensure that the staff who attend Discharge planning meetings are the appropriate staff and that they understand their role and understand that the organisation should support discharge only when it is satisfied that a satisfactory plan is in place   14.27  Ensure that where care is provided at home by NUH staff that there are clear roles and responsibilities in place for escalating safeguarding concerns   14.28  Ensure that the staff of the Family Health Directorate, have Learning Disabilities training   14.29  Continue its current work on Information Governance and address this issue particularly with the family health team      Overview Report 19.03.13 Page 89 of 100 14.30  The Family Health Directorate should work with their neonatal consultant team to review how they discharge their responsibility on the postnatal wards for babies with social concerns which are often outside the overview abilities of medical registrars   14.31  The Family Health Directorate should ensure that the feeding charts identify who has fed and provided care to babies on our wards   14.32  The Family Health Directorate should emphasise to its ward managers their oversight role in cases of complex social issues, in particular where non-registered staff have been involved   14.33  The Family Directorate should re-emphasise the importance of adhering to policy for parents being resident of the wards   14.34  The Family Health Directorate should work with the Obstetric team to review how the outcome of referrals to the perinatal mental health team is communicated to the mother’s NUH record   14.35  The Family Health Directorate should re-emphasise to its staff the importance of adhering to its In-utero transfer policy with respect to completing incident forms   14.36  The Safeguarding team should address training issues in those areas where communication with them was not timely   14.37  The Safeguarding documentation should be reviewed to ensure that the paperwork supports ready access to the correct ‘Risk’  Information  14.38  ED should explore what processes they have in place to deal with patients who present with complex social issues and are not already known to Social Care locally   14.39  The Family Health Directorate should ensure that there is appropriate advise/support given to the safeguarding team should issues arise that they    Overview Report 19.03.13 Page 90 of 100 cannot manage.    Nottingham CityCare Partnership 14.40  Nottingham CityCare Partnership will arrange training for frontline staff in relation to Parents with Learning Disabilities and the impact upon children.   14.41  The Nottingham CityCare Partnership Named Nurse for Safeguarding Children will ensure that all the Safeguarding Children Nurse Specialists and the Domestic Abuse Nurse Specialist in the Safeguarding Children Service are fully aware of the Escalation Process where there may be immediate concerns for the safety and well being of a baby, child or children and know what immediate action to take   14.42  A review of the Escalation Process by Nottingham City Safeguarding Children Board    Nottinghamshire Healthcare NHS Trust 14.43  That the ‘trilogy of risks’ are added to the screening tool for post natal depression   14.44  That the Trust’s DNA policy is used in all directorates   14.45  All Perinatal Mental Health Practitioners have a knowledge of the usage of the CAFs    Nottingham City C&F 14.46  Where families have been known to previous local authorities, Social Care team managers will ensure that background information is sought from those authorities prior to authorising a Core Assessment   14.47  In the case of pre-birth assessments where there are identified safeguarding risks / indicators, an initial planning meeting to commission the assessment must be chaired by a CTM or a CSCTM. This meeting should allocate key tasks, record risks and identify the timescale and review process.      Overview Report 19.03.13 Page 91 of 100 14.48  All contact with a Service User, even via text message, will be recorded and form part of the child’s case file   14.49  An electronic recording system is developed for the family community teams which complements and has a clear interface with the social Care Carefirst and Castle systems.   14.50  Supervision case discussion records will be amended to include a section on ‘current assessment of risk, if any’   14.51  All discharge planning meetings will consider a current assessment of risk   14.52  Social Care will develop a policy regarding highly mobile families   14.53  The outcome of a CRIMMs check will be copied directly to the team manager who must make a written acknowledgment on the file that he/she has read the contents and a managerial view of risk.   14.54  Training is developed in respect of pre-birth planning and rolled out across social care and family community teams.   14.55  Concerns about individual issues of competence should be addressed within the appropriate line management arrangements.    Oxfordshire Health NHS Foundation Trust  14.56  To improve the level of knowledge regarding Child Protection processes for General Practitioners   14.57  To improve communication between Midwifes, General Practitioners & Health Visitors  14.58  To formalise the process to follow up complex / high risk pregnant women who do not attend appointments / move out of area  14.59  Social Services telephone calls to be managed by the respective Named General    Overview Report 19.03.13 Page 92 of 100 Practitioner   14.60  Improved use of General Practitioner codes and flagging system   14.61  To ensure that all staff working in a PHCT have received a commensurate level of Safeguarding training  14.62  To ensure that the correct advice is given to patients who present as ‘homeless’     Oxfordshire County Council: Children, Education & Families Directorate 14.63  Domestic Abuse training and guidance is reviewed to ensure that the cycle of abuse and reconciliation is adequately reflected and that an understanding of reactions to abuse are included.  14.64  The ‘pre-birth referrals’ procedures and protocol for children moving across boundaries are reviewed and updated to ensure that pre- birth cases are referred quickly and not held open without active assessment or support being provided . 14.65  Where a third party moves in to a household where there is active CEF involvement guidance is developed to assist practitioners in knowing when to refer to the assessment team.  14.66  An audit and dip sample of referral recording and address checks is undertaken . 14.67  CEF to explore how the relevant aspects of the course ‘Principles of learning disability support’ can be delivered to CEF staff.    Thames Valley Police 14.68  Thames Valley Police to review the initial training of PCSOs to ensure the inclusion of guidance on how to correctly record and refer (internally) safeguarding concerns.   14.69  Thames Valley Police to circulate a bulletin to PCSOs containing guidance on how to correctly record and refer (internally) safeguarding concerns.      Overview Report 19.03.13 Page 93 of 100 14.70  Thames Valley Police to review their Domestic Abuse Policy and Operational Guidance to ensure sufficient guidance is provided in relation to what may constitute an ‘incident’. (Any changes to be published)   14.71  Thames Valley Police to issue a bulletin to the Domestic Abuse and Child Abuse Units reminding them to create a CEDAR record whenever an intelligence report results in further Police action and in particular a referral to another agency.   14.72  Thames Valley Police to review the management of intelligence reports once received within the Child Abuse Investigation Units, Domestic Abuse Units and by the Vulnerable Adult Co-coordinators to ensure compliance with the ‘Management of Police Information’ guidance in terms of creating an audit trail.   14.73  Thames Valley Police to review their Child Abuse Investigation Policy to ensure it contains reference to the importance of considering the welfare of unborn children. (Any changes to be published)    Somerset County Council Children and Young People’s Directorate 14.74  If another local authority or agency requests a welfare visit or other task, expectations for this visit or task should be agreed and sent out in writing.   14.75  Somerset Direct (SD) should always advise the caller of the secure email facility.   14.76  Somerset Direct should always clearly identify advisors by their full name, whilst ensuring personal security.   14.77  Somerset Children's Social Care should have clear guidance relating to failed home visits including contingency and reporting arrangements.   14.78  Somerset Children's Social Care, in conjunction with LSCB partners, should set out clear criteria relating to welfare visits specifying roles and responsibilities.   14.79  Somerset Children's Social Care should in consultation with partners clarify:   ●When a strategy meeting must be face to face     Overview Report 19.03.13 Page 94 of 100  ●When it is appropriate to have a telephone conference  ●When a respective specified agency (e.g. health) must be included in the strategy.   14.80  Somerset Children’s Social Care, through the Somerset LSCB, to share the above with the South West procedures group as examples of good practice.    Avon and Somerset Constabulary 14.81  All ‘Welfare checks’ should be carried out be qualified Child Protection professionals with police attendance reserved for occasions only where police powers are required.  14.82  Where 5.1 is not possible, by virtue of the fact an emergency check is required, a strategy discussion should take place between a CAIT supervisor and the agency before the checks are carried out. The risks can then be analysed and a considered plan agreed prior to the visit taking place. The officer attending should ideally be a CAIT officer; if another member of staff attends they should receive a briefing direct from the CAIT supervisor. The results of the visit should then be subject of a further strategy discussion.   14.83  Protocol agreed between Social Services and police to reflect procedures to follow in the event of emergency checks being required by police.   14.84  ISO procedure to be introduced into Force Communications to reflect an appropriate response to such requests in the future.   14.85  All Avon and Somerset Constabulary staff likely to come into contact with the public to receive appropriate child protection training, including risk indicators of abuse. This should be by delivery of the existing NCALT training module in the first instance.   14.86  Where a need for an Initial Child Protection Conference is highlighted there should be ability to fast track those where children are at most risk.   14.87  All police contact with children about whom there are concerns should be    Overview Report 19.03.13 Page 95 of 100 reflected in a comprehensive intelligence report that should be submitted in a timely manner and shared with CAIT staff for analysis.    Taunton & Somerset NHS Foundation Trust 14.88  Clinical case to be used in the Trust ongoing Safeguarding training programme.   14.89  Recommendations from this SCR to be incorporated into Trust Safeguarding procedures and audit programme as appropriate.  14.90  Learning from this SCR to be used Trust ongoing Safeguarding training programme.    Somerset County Council Legal Services 14.91  Submit e-mail to every lawyer within the Social Care team, strongly urging them to maintain a record of any conversation with client(s) where it could be construed that legal advice has been given (even if no matter subsequently arises as a result of that advice).   14.92  Message to instruct that where such records are created, they should be added to the Norwel case management system on every occasion in the event that a legal matter does arise (i.e. the Service is formally instructed to take further action).   14.93  The format of any such record is to be at the discretion of the lawyer providing the advice, provided that it clearly details any recommendations provided, even if that recommendation is to take no further action at the time. The recommended (but not mandated) format is an e-mail to the recipient of the advice as soon as is practicable after the event.    Somerset Partnership NHS Foundation Trust 14.94  A review of the processes currently in place to ensure professional records of high risk cases are transferred swiftly between organisations must take place. Consideration must be given to how information from outside Somerset is obtained in order to guarantee the seamless provision of key services to families; consistently delivered, ensuring children remain safeguarded.     Overview Report 19.03.13 Page 96 of 100  14.95  A Significant Event Audit meeting should take place with the health visitor team involved in this case. The Area Manager, Locality Safeguarding Children Nurse and Named Nurse should attend to discuss all the issues in this case and to identify any individual learning required from the individuals involved.   14.96  The lessons learnt from this review must be disseminated to the individuals concerned, the health visiting team and the wider organisation, illustrating the concerns identified and reiterating best practice processes. The relevant local and national policies and guidelines should be referenced and their usage reiterated to all staff.       Overview Report 19.03.13 Page 97 of 100     APPENDIX 1: TERMS OF REFERENCE AND SCOPE OF THE REVIEW    The terms of reference for the review were agreed by the panel chair. The timescale for the review was established as being from the time Mother moved to North Somerset, met Father, became pregnant and up to the point that the twins were admitted to hospital with serious injuries, and non accidental injury was established to be the most likely cause.    It was agreed that the overall aim of the serious case review process would be as described in Working Together to Safeguard Children 2010,  i.e. to • Establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children. • Identify clearly what those lessons are, both within and between agencies, how and within what timescales they will be acted on and what is expected to change as a result. • Improve intra-agency and inter-agency working and better safeguard and promote the welfare of children.    Authors were also asked to consider the earlier childhood history of the parents in order to understand the attributes they brought to parenting.  Each author was also asked to assess whether any information their organisation held about either parent, which lies outside the prescribed timescale set out above, was relevant to the issues raised and lessons learnt.   Authors were asked to construct a comprehensive chronology of involvement by the organisation and/or professional(s) in contact with the child and family over the period of time set out in the review’s terms of reference. Where an agency had relevant contact with the alleged perpetrator, it was specified that the chronology should also cover these actions and should ask whether everything was done which might reasonably have been expected to manage effectively the risk of harm posed by the alleged perpetrator[s] to the child.    Overview Report 19.03.13 Page 98 of 100     Report authors were asked to consider the following key questions:  •   Were practitioners aware of, and sensitive to, the needs of the children in their work and knowledgeable both about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare?  • When, and in what way, were the child(ren)’s wishes and feelings ascertained and taken account of when making decisions about the provision of children’s services? Was this information recorded?  • Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare?  • Where appropriate, what are your agency’s thresholds for instigating Initial Assessments, Core Assessments, multi-agency strategy discussions and Section 47 investigations?  What guidance do staff have in completing these assessments? • What guidance and protocols does the agency have in respect of families with accommodation difficulties, where there are child protection concerns? • What guidance and protocols does the agency have in respect of families who are highly mobile and move across agency geographical boundaries and where there are child protection concerns? • What guidance and protocols does the agency have for working with non-compliant families and the issue of ‘missed’ visits and appointments and where there are child protection concerns? • What arrangements are in place for hospital discharge meetings for families where there are child protection concerns? • What expectations regarding visiting does your agency have for children (including seeing the child awake) and families where there are child protection concerns? What visits were defined in plans for this case and was the visiting pattern adhered to? • What were the key relevant points/opportunities for assessment and decision making in this case in relation to the child and family?  Do assessments and decisions appear to have been reached in an informed    Overview Report 19.03.13 Page 99 of 100 and professional way? • When did your agency learn of the pregnancy of Mother? • Was risk identified and responded to appropriately in your organisation’s planning and intervention? • How has the organisation made decisions regarding pre-birth planning?  What training, advice and guidance is available to staff and what protocols and procedures informed the judgements made? • What are the agency’s protocols and criteria regarding parenting assessments?  How are parenting issues identified and required outcomes agreed, implemented and monitored? • Did actions accord with assessments and decisions made? Were appropriate services offered /provided, or relevant enquiries made, in the light of assessments?  • Was communication within your organisation, and between your organisation and others, timely and effective in this case? • Were there any issues in communication, information sharing or service delivery between those with responsibilities for work during normal office hours and others providing out of hours services?  • Where relevant, were appropriate child protection or care plans in place and child protection and/or looked after reviewing processes complied with?  • What training and guidance is available to staff working with parents who have, or may have, a learning disability?  What evidence is there of guidance and protocol being followed in this case? • What training is provided for staff in your organisation regarding child development, especially regarding new born infants? • Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability of the child and family and were they explored and recorded?  • Were senior managers or other organisations and professionals involved at points in the case where they should have been? • Was the work in this case consistent with each organisation’s and the LSCB’s policy and procedures for safeguarding and promoting the welfare of children and with wider professional standards?     Overview Report 19.03.13 Page 100 of 100 • Were there organisational difficulties being experienced within or between agencies? Were these due to a lack of capacity in one or more organisations? Was there an adequate number of staff in post? Did any resourcing issues such as vacant posts or staff on sick leave have an impact on the case?  • Was there sufficient management accountability for decision making?       