Death of an 11-month-old boy in September 2011, as the result of a head injury. Father said the injury took place when Child K was knocked over by the family dog. Medical opinion was that the injuries were not consistent with this explanation and that non accidental injury was a likely cause of death. At the time the case review report was written no charges had been brought. Child K lived with mother and father at the time of the incident; father was Child K's primary carer. Father was known to children's social care in relation to his older child with another partner. Paternal history of: neglectful parenting; anger management; Attention Deficit Hyperactivity Disorder (ADHD); depression; domestic abuse perpetration; substance misuse; a serious health condition; criminal activity and imprisonment. Child K attended hospital in December 2010 with an injury to his ear; Child K was referred to a medical registrar in the acute medical team with concerns about possible non-accidental injury but was subsequently discharged with no cause of the injury identified. Issues identified include: failure to properly consider the significance of earlier injuries and weight loss; father's sense of isolation as the main carer of Child K, particularly as he found it difficult being the only man in baby and toddler groups; and lack of consistency in the health visitors work with the family. Recommendations include: safeguarding board should consider what action it can take to promote the involvement of fathers in baby and toddler groups; the Named Doctor for Safeguarding Children should ensure that paediatricians are provided with additional guidance regarding the need to consider and record possible causes of injuries; and the Head of Midwifery should ensure agreements are made with neighbouring hospital trusts when a woman is going to receive postnatal care from a different Trust to the one where she received ante-natal care or gave birth.
      
 Title:  Serious case review: concerning Child K: overview report. LSCB: Barnsley Safeguarding Children Board Author: Peter Ward 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.                             Barnsley Safeguarding Children Board  Serious Case Review Concerning Child K  Overview Report   Author of Overview Report – Peter Ward, Independent Social Work Consultant  6 June 2012   Overview Report concerning Child K    Page 2 of 115 Table of Contents             Page 1 Introduction  6 1.1 Purpose of the Review  6 1.2 Circumstances leading to decision to carry out a Serious Case Review  6 1.3 Scope and Terms of Reference of the Review  7 1.4 Contributors to the Review and Methodology  10 2 Details of Family  13 2.1 Family Composition  13 2.2 Relevant Family Information  13 2.3 Information provided for this Serious Case Review by FK  13 2.4 Information provided for this Serious Case Review by MK & her family  14 2.5 Discussion with "FK's Previous Partner"  17 2.6 Comments from IORA and SCR Panel to issues raised by family members  17 3 Summary of Agencies Involvement  18 3.1 Description of Agencies Providing IMRs and Reports  18 3.2 Chronological summary of agency involvement – Background  20 3.3 Birth of "FK's first child" – 1st Child Protection Review Conference   21 3.4 1st Child Protection Review Conference – 2nd Child Protection Review Conference - Information relating to "FK's first child"   22 3.5 Removal of "FK's first child" from Child Protection Register – Final Separation of FK and "his previous partner"  25 3.6 Final Separation of FK and "his previous partner" End of Period Covered by Review  28 Overview Report concerning Child K    Page 3 of 115 3.7 Information relating to "Child K's sibling" and Child K - Background (April 2008 – April 2009)  34 3.8 MK and "her child's" move to Sheffield – Birth of Child K (April 2009 – October 2010)  34 3.9 Involvement with Child K, "his sibling", MK and FK from the birth of Child K until he sustained the injuries that led to his death (October 2010 – 26 September 2011)  38 3.10 27 September 2011 onwards  45 4 Analysis   53 4.1 Introduction  53 4.2 ToRs 3 & 4 What were the key relevant points / opportunities for assessment and decision making in relation to Child K and his family?  Do assessments and decisions appear to have been reached in an informed and professional way?   Did actions accord with assessments and decisions made?  Were appropriate services offered / provided, or relevant enquiries made in the light of the assessments?  53 4.3 ToR 1 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?  75 4.4 ToR 2 Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare?  76 4.5 ToR 5 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?  77 4.6 ToR 6 Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of 78 Overview Report concerning Child K    Page 4 of 115 disability relating to Child K and his family?  Were they explored and recorded?  4.7 ToR 7 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?  79 4.8 ToR 8 Were there any 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 sick or on leave have an impact on the case?  80 4.9 ToR 9 Was there sufficient management accountability for decision making?  86 4.10 ToR 10  Were senior managers or other organisations and professionals involved at points in the case where they should have been?  87 4.11 ToR 11 Establish whether there are any overlapping issues between this review and the Child H, Child L Serious Case Reviews and, if so, what has been put in place to address the issues?  88 4.12 ToR 12 What was the agencies' involvement with anger management for FK?  90 4.13 ToR 13 Provide a commentary on the context of drug usage by FK and was this likely to have impacted on the family and the care of Child K.  91 4.14 ToR 14 Was the information sharing and passing of referrals between agencies, with prior knowledge of FK, adequate and appropriate?  92 4.15 ToR 15 Had referrals been made for domestic violence between FK and "his previous partner".  Were agencies sufficiently aware of this and the potential 94 Overview Report concerning Child K    Page 5 of 115 impact on Child K and his family?  4.16 ToR 16 Establish whether the large number of health visitors contributed to concerns not being addressed adequately with regard to the care of Child K.  95 4.17 ToR 17 Establish whether there are protocols in place which identify actions agencies should have /will take if birth parents do not take a child to appointments and another family member attends and if this contributed to concerns not being adequately addressed in relation to child K.   96 4.18 ToR 18 How effective was the multi-agency response to "Child K's sibling" in terms of safeguarding their position.    96 4.19  Challenge of IMRs 99 5 Conclusions  100 6 Recommendations 106  Appendices 1 Genogram 108 2 Integrated Action Plan 109 3 Abbreviations 134 4 References 135  Overview Report concerning Child K    Page 6 of 115 Introduction  1.1 Purpose of the Review  1.1.1    This Serious Case Review (SCR) was commissioned in compliance with regulation 5(1) (e) and 5(2) (a) & (b) (ii) of The Local Safeguarding Children Boards Regulations 2006 which came into effect on 1 April 2006. In accordance with the guidance issued in Chapter 8 of ‘Working Together to Safeguard Children – A guide to inter-agency working to safeguard and promote the welfare of children’ (HM Government 2010), this Overview Report has been undertaken by an Independent Author and completed in accordance with the terms of reference set out in section 1.3 of this report.  1.1.2 Working Together to Safeguard Children 2010 states that a SCR should be undertaken when a child dies and abuse or neglect is known or suspected to be a factor in the death. The purpose of this Review is to:  � establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children; � identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and  � improve intra- and inter-agency working and better safeguard and promote the welfare of children. (Working Together to Safeguard Children 2010, 8.5)  1.1.3 Consequently this report is not intended to be a judicial opinion or to apportion blame but to consider, with the benefit of hindsight, whether there are lessons to be to be learnt from this case in relation to the way in which professionals and organisations worked together to safeguard and promote the welfare of Child K. The Review also sets out to identify clearly what the lessons are, and as a consequence improve intra and interagency working and better safeguard and promote the welfare of children.  1.2 Circumstances leading to decision to carry out a Serious Case Review  1.2.1 Child K was born in October 2010 and lived with both his parents.  He died in hospital on 28 September 2011, aged 11 months.    1.2.2 Child K was admitted to hospital in Barnsley on 28 September 2011 having reportedly collapsed at home when in the care of his father.  He was described as going ‘floppy’ and was unconscious when he arrived at hospital.  FK reported that on 27 September 2011, Child K had been knocked over by the family dog and had hit his head on the concrete step. The parents did not seek medical attention that day although Child K was described as sleepy and had a runny nose and he was given Calpol.  Also on 27 September 2011, a member of the public had contacted the Health Visiting Service and reported that she was concerned about a child (who turned out to be Child K) because he had bruising to his face.  The member of the public reported to the health visitor that she had advised FK Overview Report concerning Child K    Page 7 of 115 to seek medical attention. The health visitor advised the member of the public to ring Children’s Social Care if she was concerned.  1.2.3 Following Child K’s arrival at hospital, on 28 September 2011, emergency medical treatment was provided, he was thoroughly examined and a CT scan was carried out.  Child K was found to have a number of bruises around his head and neck and a CT scan showed skull fractures on 2 sites and a small subdural haematoma.  Arrangements were made for Child K to be transferred to the Paediatric Intensive Care Unit (PICU) at Sheffield Children’s NHS Foundation Trust (SCNFT) and the transfer was undertaken by EMBRACE, SCNFT’s specialist transport service.  On arrival at SCNFT Child K was taken straight into x-ray for a repeat CT scan.  This confirmed that there was severe damage to the brain and he had coned (the lower part of his brain had herniated, i.e. pushed down into the top end of the space occupied by the spinal cord).  Child K was transferred to the intensive care unit where he continued to be in a critical condition.  Due to progressive deterioration in his condition, the decision was made with MK and FK to withdraw treatment. He was taken off the ventilator and handed over to MK to cuddle at 19:25 hours and was certified dead at 19:50 hours.  1.2.4 Medical opinion was that the injuries sustained by Child K were not consistent with the explanation given by FK and that non accidental injury (NAI) was a likely cause of death.  This view was supported by initial Post Mortem investigations which showed that Child K had three fractures to his head, a brain bleed, which was not in the locality of the fractures and haemorrhaging to his eyes.  As a result of the above information, a meeting of the Serious Case Review Sub Group of the Barnsley Safeguarding Children Board (BSCB) was held on 21 October 2011, and a decision was made to recommend that a Serious Case Review be undertaken in accordance with Chapter 8 of Working Together to Safeguard Children.  The Chair of the BSCB accepted this recommendation on 28 October 2011.   1.2.5 Following the initial post mortem investigations, further specialist post mortem investigations have been sought in relation to the injuries to Child K’s skull, brain and eyes.  At the time of writing this report the specialist reports have not all been received.  Throughout the period that this Serious Case Review has been undertaken, FK has been on Police bail having been arrested in connection with Child K’s death.  At the time of writing no charges have been brought.     1.3 Scope and Terms of Reference of the Review  1.3.1 It was initially determined by the SCR Panel that the period of the Review would be from July 2009, when it was indicated that MK and FK had begun their relationship, until 1 October 2011, three days after Child K died.    1.3.2 Information was provided to the initial SCR Panel meeting, on 21 October 2011, that FK had had previous involvement with other agencies, notably South Yorkshire Police (the Police) and Sheffield Children Young People and Families – Social Care (Sheffield Social Care), in respect of issues Overview Report concerning Child K    Page 8 of 115 relating to domestic violence, anger management and substance misuse and it was recommended that these should be explored, within the IMRs, as identified in the Terms of Reference below.    1.3.3 On 26 October 2011, the Head of Safeguarding and Welfare at Barnsley Children, Young People and Families – Social Care (Barnsley Social Care), requested by letter to the Chair of Sheffield Safeguarding Children Board (SSCB) that consideration be given to the appointment of an author for an Individual Management Review on the basis that partner agencies of Sheffield Safeguarding Children Board namely Sheffield Children’s NHS Foundation Trust (SCNFT) and Children’s Social Care have been involved with the care of child K and his father.  1.3.4 Subsequent enquiries revealed that FK had an older child,  whose name had been placed on the Child Protection Register in Sheffield following their  birth in June 2007.  It was therefore decided to extend the time period of the Review to begin when this child was born and the scope of the Review to consider agency’s involvement with "this child" and their mother.  Although FK separated from "his previous partner" around January 2009 it is clear that he continued to have a substantial amount of contact with both "her and his first child".  Therefore Sheffield agencies’ involvement with "FK's previous partner" has been considered for the full period covered by this review.  "FK's previous partner"  is aware of the death of Child K; she was informed by letter that a SCR was taking place and the Manager of Safeguarding Services in Barnsley visited her to explain the Serious Case Review Process and the extent to which the review has considered issues relating to her.  Although numerous references are made to "the previous partner" in this Overview Report these are in the context of her being the partner of FK and mother of "FK's first child".  Records in her name, such as medical records, have not been considered as part of the review.    1.3.5  BSCB made contact with the Local Safeguarding Children Boards (LSCBs) in Nottingham, Nottinghamshire and Derbyshire all of whom confirmed that MK was unknown to them.  Based on this information, the SCR Panel decided to include information about MK in the SCR only after the date she moved to Sheffield.  1.3.6 The following Terms of Reference were agreed: 1 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?  2 Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare?  3 What were the key relevant points / opportunities for assessment and decision making in relation to Child K and his family?  Do assessments and decisions appear to have been reached in an informed and professional way?  Overview Report concerning Child K    Page 9 of 115 4 Did actions accord with assessments and decisions made?  Were appropriate services offered / provided, or relevant enquiries made in the light of the assessments?  5 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?  6 Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability relating to Child K and his family?  Were they explored and recorded?  7 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?  8 Were there any 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 sick or on leave have an impact on the case?  9 Was there sufficient management accountability for decision making?  10 Were senior managers or other organisations and professionals involved at points in the case where they should have been?  11 Establish whether there are any overlapping issues between this review and the Child H, and Child L Serious Case Reviews and, if so, what has been put in place to address the issues?  12 What was the agencies' involvement with anger management for FK?  13 Provide a commentary on the context of drug usage by FK and was this likely to have impacted on the family and the care of Child K.  14 Was the information sharing and passing of referrals between agencies, with prior knowledge of FK, adequate and appropriate?  15 Had referrals been made for domestic violence involving FK.  Were agencies sufficiently aware of this and the potential impact on Child K and his family?  16 Establish whether the large number of health visitors contributed to concerns not being addressed adequately with regard to the care of Child K.  17 Establish whether there are protocols in place which identify actions agencies should have /will take if birth parents do not take a child to appointments and another family member attends and if this contributed to concerns not being adequately addressed in relation to child K. Overview Report concerning Child K    Page 10 of 115  18 How effective was the multi-agency response to safeguard any other children.  1.4 Contributors to the Review and Methodology  1.4.1 Peter Ward, the Independent Overview Report Author (IORA), has a background in social care and has worked in management and front line social work.  He is qualified to degree level in social work and has a post-graduate diploma in management studies.  He is now the Director of a Social Care Consultancy and as such undertakes investigations and other consultancy work on an independent basis.  Since 2005 he has been involved in several Serious Case Reviews as an IORA, Individual Management Review (IMR) Author or Panel Chair.  His appointment is in accordance with the guidance at 8.33 in Chapter 8 of ‘Working Together to Safeguard Children 2010’ which states that:  “The overview report should be commissioned from a person who is independent of all the local agencies and professionals involved and of the LSCB(s).  The overview report author should not be the chair of the LSCB, the SCR sub-committee or the SCR Panel.”  1.4.2 The chair of the BSCB is Simon Hart.  The independent chair of the Serious Case Review Panel for this Serious Case Review is Paul Sharkey who is an Independent Safeguarding Consultant and a qualified social worker of 25 years experience.  He has worked as a practitioner and at middle and senior management in both the statutory and third sector in the child protection and safeguarding arenas.  He has chaired five Serious Case Reviews since 2002 and has been the Overview Author for six SCRs during this period.  He achieved Independent Author and Chair accreditation in March 2010 with the (former) National Safeguarding Delivery Unit of the Department for Children, Schools and Families (now the Department for Education).  He has an M.A. (distinction) in Child Care Law and Practice from The University of Keele and a Masters in Public Administration (MPA, distinction) – the Public Sector MBA - from the University of Warwick Business Hospital School.  Mr Sharkey has had no previous involvement with any of the agencies associated with this SCR and can therefore claim to be independent.  Mr Sharkey’s appointment is in accordance with the guidance at 8.16 in Chapter 8 of ‘Working Together to Safeguard Children 2010’ which states that:  “The Chair of the SCR sub-committee should be an experienced person and could be the independent Chair of the LSCB, or a member of the LSCB. The Chair of any SCR Panel should not be a member of the LSCB(s) involved in the SCR, an employee of any of the agencies involved in the SCR or the overview report author. The SCR Panel Chair can be the independent LSCB Chair, someone from another LSCB which is not involved in the SCR or from an agency which is not involved in the case.”  1.4.3 In addition to the chair the following people were members of the SCR Panel:  Overview Report concerning Child K    Page 11 of 115 � Assistant Executive Director, Safeguarding Health and Social Care, Barnsley Children Young People & Families (CYP&F) � Head of Children’s Social Care, Barnsley CYP&F � Head of Safeguarding and Welfare, Barnsley CYP&F � Assistant Director, NHS Barnsley � Designated Nurse Safeguarding Children, NHS Barnsley  � Medical Director and GP Representative, NHS Barnsley  � Designated Doctor Safeguarding Children, BHNFT � Public Protection Unit Manager, South Yorkshire Police � Assistant Director Nursing, Directorate of Nursing Clinical Governance and Safety, South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) � Lead Nurse Children and Young People, Sheffield Teaching Hospitals NHS Foundation Trust (STHFT) � Sheffield Safeguarding Children Board (SSCB) Board Manager (Panel member from 26 March 2012 onwards)  1.4.4 The SCR Panel met on 21 October 2011, 14 December 2011, 23 January 2012, 26 March 2012, 27 April 2012 and 24 May 2012 in connection with this SCR.  The author of the Overview Report was not a member of the Serious Case Review Panel but attended all the Panel meetings, with the exception of the one on 21 October 2011, in connection with writing the Overview Report.  Legal advice was available to the SCR Panel from the Assistant Borough Secretary (litigation) within Barnsley Metropolitan Borough Council.  1.4.5 The SCR Panel received and considered IMRs from the following agencies: � Barnsley Hospital NHS Foundation Trust (BHNFT) � Barnsley Children, Young People and Families – Education (Barnsley Education) � Barnsley Children, Young People and Families – Social Care (Barnsley Social Care) � NHS Barnsley – Health Overview Report � NHS Barnsley - Primary Care (Primary Care) � Sheffield Children’s NHS Foundation Trust – Health Visiting (Sheffield Health Visiting) � Sheffield Children’s NHS Foundation Trust  - Hospital Services (SCNFT) � Sheffield Children Young People and Families – Social Care (Sheffield Social Care) � Sheffield Teaching Hospitals NHS Foundation Trust (STHFT) � South West Yorkshire Partnership NHS Foundation Trust (SWYPFT) � South Yorkshire Police (The Police) � Yorkshire Ambulance Service (YAS)  1.4.6 The authors of the Individual Management Reviews are all independent in accordance with the guidance at 8.33 in Chapter 8 of ‘Working Together to Safeguard Children’ which states that: Overview Report concerning Child K    Page 12 of 115 “Those conducting management reviews of individual services should not have been directly concerned with the child or family, or have been the immediate line manager of the practitioner(s) involved.”  1.4.7 The IMR from BHNFT was written by a Named Nurse for Safeguarding Children and the Named Doctor for Safeguarding Children both of whom are employed by BHNFT.  The named nurse had no involvement with the care of Child K but the named doctor is Paediatric Consultant 2 who was briefly involved in providing some information about Child K to the Police and Barnsley Social Care the day after Child K died.  Details of this are outlined in this Overview Report.  Furthermore, the named nurse who co-wrote the IMR for BHNFT had a period of extended leave whilst the review was being undertaken and some work was carried out by another named nurse.  This colleague had a phone conversation with the health visitor on 28 September 2010 following Child K’s admission with the injuries that resulted in his death later that day.  Details of this phone conversation are outlined in this Overview Report.  Neither the named doctor nor the named nurse have attempted to provide an analysis of their actions in respect of the case and the IORA is satisfied that the authors of the BHNFT IMR are sufficiently independent from the case.     1.4.8 A comprehensive integrated chronology of agency involvement and significant events for the period June 2007 to October 2011 has been compiled from the chronologies provided within the IMRs.  This has been analysed by the SCR Panel.    1.4.9 The Overview Report author undertook this review by making reference to the terms of reference, IMRs and other reports listed above and through discussions at SCR panel meetings and face to face, telephone and email communication with IMR authors and panel members including a meeting with IMR authors on 11 November 2011.    1.4.10 In addition the SCR Panel considered which family members should be involved in the review and how and when to involve them.  The Panel decided that MK and her parents and FK and his mother would be invited to meet with the IORA and the Designated Nurse for Safeguarding Children from NHS Barnsley (hereafter referred to as the Designated Nurse).  A meeting subsequently took place with FK on his own and MK and her parents together at their respective homes.  FK’s mother was present in the house when the meeting took place with FK but she did not take part in the meeting.  These meetings took place in March 2012, whilst the Police were still investigating Child K’s death.  Prior to the meeting, the IORA consulted with the SCR Panel representative from South Yorkshire Police to ensure that the meeting would not impact upon possible criminal proceedings.    1.4.11 In writing this Overview Report, the IORA has been mindful of the revised approach to the evaluation of SCRs described by the National Director, Development and Strategy for Ofsted in a letter dated 14 December 2011 to Directors of Children’s Services and LSCBs.   Overview Report concerning Child K    Page 13 of 115 2. Details of Family  2.1 Family Composition    Child K Date of Birth October 2010, Date of Death 28 September 2011  Relationship to Child K Date of Birth Referred to as Ethnic Origin Mother June 1985 MK White British Father  August 1984 FK White British Maternal Grandmother Not known  White British Maternal Grandfather Not known  White British Paternal Grandmother Not known  White British         A genogram of the family is included as Appendix 1 of this Overview Report.  2.2 Relevant Family Information   2.2.1 This review considers the previous family units of FK and MK.    It is understood that MK moved to Sheffield in April 2009 and lived with "family" for a year before MK and FK moved to the Barnsley area in April 2010 by which time MK was pregnant with Child K.  Child K was born in hospital in Sheffield but lived his entire life in Barnsley with both parents.  FK lived with a previous partner at the start of the period covered by the review and with MK and Child K at the end of that period.  In between times he lived with "a family member" for a period of time.     2.3 Information provided for this Serious Case Review by FK  2.3.1 A number of times during the meeting with FK he said that his memory was not very good and that MK would be able to provide more accurate information about who provided services and when things happened.    2.3.2 FK said that he moved to the Barnsley area with MK prior to Child K’s birth.  He thinks this was in June 2010.  Prior to that, MK and FK had each been living "with members of their respective families".  He was in a previous relationship for 5 years before they split up and then he was single for a while before meeting MK.  2.3.3 FK spoke very positively about living with MK and Child K when he was born.  FK added that he and MK did not go out drinking or clubbing but did family things like going fishing and to the zoo.  2.3.4 MK worked and FK looked after Child K.  He went to a session at the library once but felt uncomfortable as he was the only Dad there.  FK said that he felt that professionals tried to include him but that it would be better if more men attended and it should be targeted at men as well as women.  FK added that he thought he went to the Antenatal Clinic once with MK but that they did not attend antenatal classes.   Overview Report concerning Child K    Page 14 of 115  2.3.5 When asked, FK said that he could not remember seeing a Health Visitor at all after Child K was born but he added that his memory is not good.  He did however talk about the two hospital attendances that Child K had in December 2010.  Regarding the attendance at BHNFT he said that Child K had a rupture in his throat which caused bleeding in his mouth.  Regarding the admission to SCNFT FK said that Child K had swung his head while MK had been holding him and had bashed on her head and hurt his ear.  He said that hospital staff had assessed them as a family and observed how they cared for Child K and had realised that Child K was well loved.   He stated that the hospital said they would contact MK and him regarding results of blood tests and to arrange a scan of Child K's ear but they did not do so. Consequently the family had to ring SCNFT themselves after Child K was sent home.  2.3.6  When asked about how he felt the family had been treated during previous social care involvement he said the social workers were “spot on” and visited regularly.  He stated he was involved in all the meetings held with Social Care, and commented “It’s obviously not nice but we dealt with it and did what was asked.”   2.3.7 FK also talked about the situation when Child K collapsed and was rushed to BHNFT in September 2011.  He explained that staff at Barnsley Hospital said they were stabilising Child K to transfer him to Sheffield.  However, when he arrived at Sheffield a Doctor said there was nothing that they could do for Child K.  This was a shock because staff at BHNFT had seemed positive.  FK did not feel that staff at BHNFT had done anything wrong but felt that they were not specialists.  FK also commented that Child K was developing bruises whilst he was in the care of the hospital staff; he added that Child K bruised easily and that he and MK had previously told the Health Visitors this.  2.3.8 Talking about the present time FK stated that he saw a Counsellor once before Christmas but will get back in touch with his GP and request that he is referred to a Counsellor again.  2.4 Information provided for this Serious Case Review by MK & her family  2.4.1 MK said that in April 2009 she returned to Sheffield.  MK did not really see anyone from the Health Visiting Service until after Child K was born and she was living in Barnsley.  MK observed that the Red Book talks about developmental assessments but different areas undertake these at different times.  MK wanted to know why this was, so the Designated Nurse briefly explained.  2.4.2 MK said that she moved to Barnsley in April 2010 but she was booked in to give birth at STHFT and she continued to receive antenatal care from Sheffield midwives, which was her choice, although she told them that she had moved to Barnsley.  A health visitor visited after Child K was born; MK pointed out that to the IORA and Designated Nurse that this was six months after she had moved to Barnsley.  MK said that at this visit the health visitor told MK that HV4 would be her named health visitor but HV4 Overview Report concerning Child K    Page 15 of 115 never made any visits to her home.  On one occasion a visit was arranged, which MK thinks was probably for the six week check.  She waited in all day but no-one came so she finally rang up and got through to an answer machine.  After this, a different health visitor tried to visit without an appointment but MK was out and when she returned home she found a card through the door.   MK attended clinic approximately every six weeks until she returned to work and this is the only place she ever saw HV4.  The IORA asked MK if she felt that she received enough support from the health visitors and she responded that she did not feel that she needed extra help.  However she also commented that no health visitor ever came to check how Child K was after his discharge from SCNFT when he had a haematoma on his ear.  With hindsight MK wishes that the health visitor had followed this up.  When Child K was in hospital with the haematoma to his ear, HV4 rang MK to see if he was okay.  HV4 also phoned MK on the day Child K was admitted to hospital the last time to see if she was alright.  2.4.3 MK’s family member said that MK and FK had had two dogs and she questioned why HV4 never went to the house or checked to make sure everything was alright.   2.4.4 With regard to the haematoma on Child K’s ear, MK said FK and her have been questioned since child K's death as to why they attended hospital in Sheffield instead of Barnsley and she explained it was because they were more familiar with Sheffield.  MK said that the consultant told them Child K might have mild haemophilia and that a follow up appointment would be made for him.  However there was no follow up after discharge so MK phoned up for the test results and was told by a nurse that no follow up was required.  2.4.5 MK compared the lack of follow up at SCNFT with a situation, the previous week, when MK attended BHNFT with Child K because he was coughing up blood.  On that occasion blood tests were undertaken and someone rang with the results two hours after they arrived home with Child K.  MK added that she was happy with the explanation the doctors at BHNFT gave as to why Child K had coughed up blood.  Whereas no-one from SCNFT ever gave her an explanation as to why Child K had the haematoma.  2.4.6 MK herself told the IORA and the Designated Nurse that she believed the haematoma had been caused when she was holding Child K and he had banged his ear against her head.  2.4.7 MK considered the maternity care she received to have been “really good”.  During the pregnancy she saw the GP in Sheffield as she was depressed and feeling really tired; the GP referred her to the Mental Health Service at STHFT where she was prescribed anti-depressants but she was reluctant to take these.  A community midwife then checked MK’s iron level which was found to be low.  She started to take iron tablets for the low iron level and her mood lifted so she never took the anti-depressants.  The counsellor from STHFT rang to follow up with MK to ensure all was well.  In May 2010 MK felt dizzy and her blood pressure was low so she was signed off work for three days.  Overview Report concerning Child K    Page 16 of 115 2.4.8 MK changed her GP to one in Barnsley around June 2010 and at her new patient health check her blood pressure was found to be high.  The GP said the community midwife would check this again.    2.4.9 FK attended the first scan with MK but was unwell on the day of the second scan so MK’s mother accompanied her.  FK did not attend antenatal clinic appointments.  He also felt uncomfortable attending playgroup and reading sessions as he was the only man there.  2.4.10 MK felt that there were good facilities at the Children’s Centre where there was singing for babies, messy play and positive parenting with the outreach workers.    2.4.11 When MK went back to work in May 2011 FK looked after Child K on Monday and Tuesday; he then stayed with MK’s parents on Tuesday night and Wednesday. FK did not want to go to groups with Child K because he was the only man there and he does not drive. However he took Child K to the park on Mondays and Tuesdays.   2.4.12 When Child K was at BHNFT after his collapse in September 2011 there were two paediatricians present and she said that Child K had only been walking for one week and was unsteady on his feet.  MK felt that one of the paediatricians seemed shocked by this and looked sideways at the other one, who said it is quite normal.  This made MK lose faith in the paediatrician who had seemed shocked and they then questioned his judgement.  2.4.13 MK said that the family were put in a room at BHNFT where they waited while Child K was given medical treatment.  The IORA asked if they had been kept up to date with what was happening with Child K.  MK responded that they wanted staff to be caring for Child K rather then coming to them to explain what was happening.  2.4.14 MK said that one of the doctors at SCNFT said that he knew there was no hope for Child K when he saw the first scan.  Given this MK questioned why he was transferred to SCNFT.  She felt it might have been better to have let the family have more time with him at BHNFT rather than medics spending time stabilising him and transferring him to SCNFT if it was inevitable that he was not going to survive.  The family also felt that they were given some conflicting information as they were told that Child K was stable before he was transferred but he then deteriorated during the journey to Sheffield.  2.4.15 MK said that everything felt rushed at the hospital and wishes that the second CT scan had been carried out at BHNFT rather than SCNFT as then the family could have had longer with Child K.  MK added that she would like the opportunity to speak to the paediatrician as she has a list of questions and would like to have the medical evidence explained to her.  It was questioned whether the Police would be prepared for the paediatrician to meet with MK at this stage as criminal proceedings are ongoing.  It was agreed that the Designated Nurse will liaise with the paediatrician and the Family Liaison Officer (FLO) regarding this issue.  Overview Report concerning Child K    Page 17 of 115  2.4.16 MK said that the current FLO has been good and has a gentler manner than the previous one.  However the previous FLO gave straight forward answers.  MK was unhappy with one aspect of the way she and FK had been treated by the Police the day after Child K died.  They both attended the Police station to be interviewed and were told that they were likely to be about two hours.  MK thought they would both be interviewed at the same time by different officers. However they were interviewed one at a time and her interview lasted four hours.  Consequently FK was waiting on his own throughout this time.  MK said that if she had known FK was going to be waiting like this she would have arranged for someone to sit with him whilst he waited.  She added that she has good family support but FK has “naff” support.  2.4.17 Although MK has been living in Sheffield since Child K died she has continued to be registered with the GP surgery in Barnsley.  The GP has checked that she is okay and has given support but has not been intrusive.  MK has found this approach “really good”.  2.4.18 Finally MK referred to two things that have happened recently that have concerned her.  Firstly she said that Sheffield Social Care have taken over from Barnsley.  The IORA agreed to discuss this with Barnsley Social Care.  Secondly MK explained that she was told she could return to work but after a few days was suspended.  She understands why she is suspended but she is unhappy that she was incorrectly told that she could return.    2.5 Discussion with "FK's Previous Partner"  2.5.1 The Manager of Safeguarding Services for Barnsley Metropolitan Borough Council explained the purpose and process of a SCR and the extent to which this SCR would contain reference to her and "her child".  The Manager of Safeguarding Services also explained the publication arrangements for the Overview Report and Executive Summary including the fact that they will be fully anonymised before publication and that publication is unlikely to take place for some time as there are matters still to be resolved.  2.5.2 "FK's previous partner" was given several opportunities to ask questions but did not have any at that time.  Before leaving the Manager of Safeguarding Services invited her to make contact if she wanted to ask any questions after the meeting finished.   2.6 Comments from IORA and SCR Panel to issues raised by family members  2.6.1 It was difficult to establish exactly what session FK was referring to when he said he went to a session at the library.  The IORA believes that he was talking about a toddler and baby group which he went to after Child K was born.  One issue identified in this review is a difficulty organisations sometimes experience engaging with fathers and other male carers.  This will therefore be addressed within this Overview Report. Overview Report concerning Child K    Page 18 of 115   2.6.2 The comments made by MK and FK that SCNFT did not contact them as promised with the result of blood tests need to be investigated by SCNFT.  2.6.3 After her relocation to Barnsley records show that MK did not change GP until September 2010, not June 2010 as she told the IORA and Designated Nurse.  This was four to five months after she moved and she had not told her previous GP that she had moved address.  The Health Visiting Service in Barnsley would not have become aware that MK had moved into their area until after MK changed GP.   2.6.4 The issue of Child K’s transfer to SCNFT was discussed at the SCR Panel meeting on 26 March 2012.  It was explained that BHNFT is not a specialist children’s hospital and it was necessary to transfer Child K to the specialist hospital where appropriate facilities were available and to ensure that as much as possible was done to save his life.   2.6.5 In response to MK’s request to meet with the consultant paediatrician at BHNFT the Designated Nurse consulted with the Police and the consultant paediatrician.  Subsequently the consultant paediatrician met with MK in early May 2012.   2.6.6 In response to the concern raised by MK in paragraph 2.4.18, the author of the Barnsley Social Care IMR told the IORA on 19 March 2012 that the relevant manager within Barnsley Social Care was aware that there had been a problem with information sharing between Barnsley Social Care and Sheffield Social Care but that this was being resolved.  The IORA contacted MK that same day and passed this information onto her.  2.6.7 Family members who have contributed to this SCR, will be contacted by BSCB before publication of the review and will be given the opportunity of meeting with someone to discuss the report.  3. Summary of Agencies Involvement  3.1 Description of Agencies Providing IMRs and Reports  3.1.1 BHNFT provides a range of in patient and out patient health services within Barnsley and the surrounding area.  The services which had contact with Child K and his family during the period covered by the review were the community midwifery services following Child K’s birth, the Children’s Assessment Unit, in connection with one hospital attendance in December 2010 and the emergency department at the hospital in connection with the incident that led to Child K’s death.    3.1.2 "Child K's sibling"  was seen in the Children’s Assessment Unit at BHNFT in September 2011 following the death of Child K.  This was the only contact the BHNFT had with "this child" and there was no contact with "FK's first child".  3.1.3 Child K was only 11 months old at the time of death and was never in receipt of educational provision.   Overview Report concerning Child K    Page 19 of 115  3.1.4 Barnsley Social Care delivers the Local Authority’s statutory social care services within Barnsley Metropolitan Borough.  Child K was not known to Barnsley Social Care until he was admitted to hospital with the injuries that led to his death.  The IMR from Barnsley Social Care considers the services provided from that point onwards.  3.1.5 The Primary Care IMR considers the family’s contact with General Practice during the period covered by the Serious Case Review.  This includes contact with GPs in Sheffield and Barnsley, background information when MK lived in Derbyshire and historical information relating to FK.   3.1.6 Sheffield Children’s NHS Foundation Trust (SCNFT) is a dedicated paediatric Trust.  The Trust provides inpatient and out patient hospital based services including paediatric medicine and surgery, radiology, transport services and paediatric intensive care on a regional basis.  In addition, in April 2011, nursing and health visiting services across Sheffield were transferred to the Trust as part of the integration of Community Health Services.  3.1.7  SCNFT have provided two IMRs for this SCR.  One considers the hospital based services provided and the other considers health visiting services the vast majority of which were provided before the integration of Community Health Services in April 2011 which resulted in Nursing and Health Visiting Services being transferred to SCNFT.  SCNFT did not provide any health visiting services to Child K as he lived in Barnsley throughout his life.  3.1.8 Sheffield Social Care delivers the Local Authority’s statutory children’s social care services in Sheffield.    3.1.9 STHFT is a large acute Trust which comprises five adult hospitals and adult community services, including midwifery services.  MK received antenatal care from STHFT in respect of her pregnancy with Child K who was born in one of the Trust’s hospitals.  MK received postnatal care from BHNFT as she was living in the Barnsley area by the time Child K was born.  In addition to the provision of maternity services in respect Child K, STHFT was involved with FK from 2007 until November 2009 in respect of treating a viral infection.  3.1.10 SWYPFT provides a range of community, mental health and learning disability services across a number of Local Authority areas in South and West Yorkshire.  Through most of the period covered by this review, in the Barnsley area, these services were provided by NHS Barnsley, Care Services Direct but in May 2011 NHS Barnsley, Care Services Direct was taken over by SWYPFT.  SWYPFT’s involvement with the subjects of this review was limited to providing health visiting services in respect of Child K from November 2010 onwards.    3.1.11 South Yorkshire Police had several contacts with FK from the start point of the review until December 2009.  After that time there was no further Overview Report concerning Child K    Page 20 of 115 involvement from South Yorkshire Police until September 2011 when officers were alerted that Child K was in cardiac arrest and was being taken to hospital.  Officers were then involved in investigating the incident in which Child K had sustained these injuries.  3.1.12 YAS provide an ambulance service across the whole of Yorkshire.  During the period covered by this review YAS had contact with Child K on the day he died.  Chronological summary of agency involvement   3.2 Background  3.2.1 "FK's first child" was the first child of FK and "his previous partner" who were living together as a couple.  As a result of "the partner's" history a Common Assessment Framework (CAF) was completed by a community midwife in which led to Sheffield Social Care undertaking a pre-birth assessment and starting a Core Assessment prior to "the child's" birth.    3.2.2 Although this SCR considers events from the birth of "this child" onwards, STHFT maternity records in respect of the birth of "the child" have not been accessed.  Maternity records are held under the name of the mother and as "the previous partner" is not part of Child K’s family, the SCR Panel took the view that it was not appropriate to seek access to her records unless there was a compelling reason to do so.  The SCR Panel was informed by staff from STHFT that the maternity care provided to "the partner" was of a high standard and that the undertaking of a CAF and subsequent events demonstrated good practice as evidenced by the fact that an assessment took place in hospital prior to discharge.  Consequently the SCR Panel decided that the likely benefits of detailed consideration of the maternity records were outweighed by the confidentiality issues involved.  Furthermore, the majority of the contacts that maternity services from STHFT had with "the partner" were prior to period covered by this review.  3.2.3 Background information provided to this SCR shows that FK has a history of Attention Deficit Hyperactivity Disorder (ADHD) as a teenager, with associated anger management issues, drug use, including heroin and criminal activity.  He has been imprisoned three times in relation to crimes committed in order to maintain his drug habit and contracted "an infection" as a result of his drug use.  Records suggest that he was last released from prison in June 2005 and was successfully detoxed in 2006.  Information provided to this review does, however, indicate that FK has used cannabis and amphetamines during the period covered by the review.  3.3 Birth of "FK's first child"– 1st Child Protection Review Conference - Information relating to "the child"  3.3.1 Following "FK's first  child's " birth, mother and baby remained in hospital whilst a five day assessment was undertaken by the ward and a pre-discharge meeting was held.  It was agreed at this meeting that "the child" would be discharged from hospital to the care of their parents and that a Overview Report concerning Child K    Page 21 of 115 Child Protection Conference would be convened.  Discharge took place the following day, and a social worker visited the family "four days later" to share the Core Assessment. The Child Protection Conference was held "two days later" and was attended by FK and "his previous partner".  It was decided that "the child's" name would be placed on the Child Protection Register in the category of neglect.  3.3.2 Over the next three months, prior to the first Child Protection Review Conference; the social worker visited the family home on eight occasions; three of which included a Core Group meeting.  In June the health visitor received communication and a handover record from the community midwife.  The Health Visiting Services first postnatal contact with the family, also took place when HV1 attended a Core Group meeting at the family home and carried out a postnatal contact.  Both parents and "the child" were present and HV1 documented information about all three people.    3.3.3 The social worker recorded that at the Core Group meeting, FK said that he had delayed some medical treatment for himself to ensure that he was able to support "his partner" and be involved in parenting "the child".  This relates to treatment he required for "an infection".  Preparation for the treatment began "next month" but the actual treatment did not begin until "the following year"  The author of the STHFT IMR has written that assessments made prior to the treatment commencing showed that FK had a history of intermittent drug use and custodial sentences.  There is no indication that staff in the Infectious Diseases Team were aware of his history of ADHD or of any issues relating to anger.  3.3.4 The health visitor made four further visits to the family home prior to September; these included attendance at Core Group meetings.  "FK's previous partner and child" were seen at all these visits but FK was only present on two occasions and it was recorded that he was now working full time.  Records for all the contacts that the health visitor and social worker had with the family during this period refer to "the child"  developing well and there being no concerns about their well being. In July both the social worker and HV1 made records referring to FK being involved in the care of "the child" but needing to increase his confidence.  3.3.5 In August the Police received two calls concerning FK and/or "his previous partner" the first of which has no bearing on or relevance to this review.  The second incident was when "the partner" contacted the Police and reported that FK had assaulted her and hit her in the mouth.  FK was arrested for common assault, interviewed and released following advice from the Crown Prosecution Service that there was insufficient evidence for a charge to be pursued.  "The child" was present at the house when this incident took place and police officers completed the necessary paperwork to alert other professionals.  Records suggest that "the partner" was intoxicated at the time of this incident but FK was sober.  Although this was the first recorded domestic incident between "the parties" during the period covered by the review, it is recorded that, prior to the birth of "their child" they told the health visitor about an incident that had taken place the previous year which they described as an “overheated argument”.    Overview Report concerning Child K    Page 22 of 115  3.3.6 In August the social worker visited the family home where FK, "his partner and child" were all present.  A discussion took place regarding the two domestic incidents and a written agreement was made with FK and "his partner" that they should not drink alcohol whilst caring for "the child" who should not be exposed to “any domestic incidents”.    3.3.7 Three days later, Sheffield Social Care received information from a member of the public alleging that a couple who were staying with "a members of FK's extended family" may pose a threat to " the child" when they stayed there overnight.  The social worker spoke to FK and "his partner" who stated that they were not aware that the couple posed a risk to children but signed a written agreement that "their child" would not stay at "this" home whilst further assessments were undertaken.    3.3.8 The following day HV1 visited FK, "his partner and child" although FK did not stay for the whole visit.  "The partner" told HV1 about the two domestic incidents and also about the situation with the couple staying with FK’s "extended family".  HV1 discussed details of the home visit with the child protection supervisor and was advised to liaise with the social worker.  It is unclear from the records whether there was any communication between HV1 and the social worker about these issues.     3.3.9 In September a MAPPA meeting was held regarding the couple "who may pose a risk" staying with FK’s "extended family".  It was agreed that they would leave" within 3 weeks" and that "the child" would not visit the address until after they had left.  Later records state that they left "5 days later".  Also on "the same date" the first Review Child Protection Conference was held and it was agreed that "the child" would remain on the register for a further six months due to the concerns that had emerged about FK associating with persons posing a risk.    3.4 1st Child Protection Review Conference – 2nd Child Protection Review Conference  - Information relating to "FK's first child"  3.4.1 Following the Review Child Protection Conference in September, the next contact with the family was "five days later" when a Core Group meeting was held at the family home.  HV1 recorded that both parents were present and "the child" was thriving, sociable and interacting well.  HV1 also recorded that "the child" had an abrasion on their right ear which had been caused by a ring which was being worn by FK.  FK stated that he was upset about this and was no longer wearing rings as a result.  The record of this Core Group meeting does not contain any reference to the abrasion to the ear so it is unclear whether or not the social worker was aware of it and whether it was raised as an issue at the Core Group meeting.  3.4.2 "A week later", HV1 discussed "the child" with the child protection supervisor.  This is the first of several occasions when it is recorded that Sheffield Health Visitors discussed "the child" with the Child Protection Supervisor.  Initially this was because they were on the Child Protection Register.  Subsequently, when "the child" ceased to be on the Child Protection Register they were vulnerable and met the criteria for Child Overview Report concerning Child K    Page 23 of 115 Protection Supervision as in the Safeguarding Children Supervision Policy for Clinical Staff in Sheffield.  3.4.3 Following on from the Core Group both HV1 and the social worker continued to have frequent contact with the family and reports continued to be positive about "the child's" development and the relationship between FK and "his partner".  When the social worker visited "the partner" and FK in September they talked about the possibility of getting married in the future.  3.4.4 Three weeks later, FK contacted the Police and stated that "his partner" was attacking him.  When the Police attended the property there was no sign of a disturbance and FK had no visible injuries.  FK admitted having taken drugs and he was taken to "a family member's" home.  The Police recorded that "the child" was upstairs in their cot, had not witnessed the incident and appeared happy.  The incident was assessed, by the Police, as standard and Sheffield Social Care were informed.  Later that day "the partner" contacted the out of hours service within Social Care to inform them of the incident.  She stated that she wished to end her relationship with FK.    3.4.5 A Core Group meeting took place the following day and again it was reported that "the child" was developing well with good weight gain.  FK was not present and the main focus of the meeting was the incident from the previous day, with "the partner" stating that she was unsure whether she wanted to resume the relationship with FK.  It was agreed that SW2 would visit FK to ask him to sign a child protection agreement pending having a mental health assessment.  It was also agreed that contact between FK and "the child" was to be facilitated by "another family member".  Finally there is reference to "the partner" having another dog and both dogs being in a cage during the meeting.  The health visitor recorded that concerns were expressed to "the partner" about the dogs.  This was the second time that the health visitor discussed, with "the partner", the potential danger of dogs with young children.  The first time was prior to the "child's "birth.   Sheffield Social Care have no record of this core group meeting although the health visitor record suggests that the social worker did attend.  3.4.6 As a result of the incident, FK saw his GP who prescribed antidepressants and "8 days later"  FK told HV1 that he had seen a social worker and did not require a mental health assessment. Sheffield Social Care have no record of the social worker seeing FK during that period and it is not possible to verify whether there was a contact during the period in question.  In October, the social worker carried out a home visit and has recorded that FK, "his partner and child" were all present; FK and "his partner" stated that they had split up for a few days but were now back in a relationship and also that FK was going to assist more with household tasks.  3.4.7 Through November and December HV1 and the social worker continued to have contact with the family and Core Group meetings took place.  FK and "his partner" were both taking antidepressants and it was recorded that Overview Report concerning Child K    Page 24 of 115 they were feeling well.  "The child"  was reported to be thriving although in  December the social worker recorded that they had recently been unwell with a viral infection and the parents had taken appropriate action by taking them to the GP.  3.4.8 The first recorded contact with the family next year was made by the social worker in January. The social worker visited the family home where "the partner and child" were present.  "The partner" stated that she and FK had separated because FK wanted to have his own space.  She added that "their child"  was to continue to have contact with FK and she would promote this.  A Core Group meeting was held one week later but it is unclear from the IMRs provided to this SCR whether FK was present at that meeting.  At the Core Group meeting it was noted that "the child's"  assessment had been completed and they were developing well and thriving but possibly had a squint in their left eye and would be referred to Orthoptics.  In February the social worker visited "the partner and child" at home again.  "The partner" reiterated that she and FK were separated; but that they were working together in order to promote contact.  3.4.9 In February, in between the Core Group Meeting and the social worker’s visit to "the partner and child", FK was stop searched by the Police and found to be in possession of cannabis.  He was arrested and given a warning.  Because this incident occurred in the street and no child was present Sheffield Social Care were not notified of the incident and therefore the social worker had no knowledge it.  3.4.10 In February a letter was sent from STHNFT to FK to inform him that his treatment for "an infection" was to commence in March.    3.4.11 A Review Child Protection Conference was held in February which was attended by both FK and "his partner".  It is recorded in the Sheffield Health Visiting IMR that FK and "his partner" said at the Review Conference that they might resume their relationship.  It was acknowledged that "the child" was developing well, growing and thriving and had a good attachment to their parents, both of whom were able to meet their needs.  It was also acknowledged hat there had been some Police involvement with FK and "his partner" as a result of the domestic incidents but it was felt that these were a reflection of the immature behaviour of "both parties" and were not of significant concern.  There was unanimous agreement at the review conference that "the child's" name would be removed from the Child Protection Register.    3.4.12 The SSCB manager has provided the IORA with information that it was known by members of the conference that the father was about to commence treatment for "an infection" but the consequences of this was not discussed and there was no information provided that this could have an impact on his mood or behaviour and so should be a factor in the decision making.  The SSCB manager has also confirmed that no child in need plan was made as this was not felt to be necessary but that universal services would continue to provide services.  However, since 2009 all Child Protection plans that end are followed up by a Child in Need Plan so this would not be the case again.  Overview Report concerning Child K    Page 25 of 115  3.5 Removal of "FK's first child's" name from Child Protection Register – Final Separation of FK and "his previous partner" - Information relating to "FK's first child"  3.5.1 Following "FK's first child's" removal from the Child Protection Register the only professional having regular or frequent contact with the family was HV1.  "The child" remained an open case to Sheffield Social Care until July but there was no further direct contact between Sheffield Social Care and the family during this period although in May and July the Police made Sheffield Social Care aware of incidents involving the family and these will be described at the appropriate place in this summary.   3.5.2 HV1 visited "FK's partner and child" in March, just over a week after the Review Child Protection Conference and recorded that there were no concerns and that "the partner" was to attend clinic or request a home visit if needed.  The next contact HV1 had with "the partner"  was in March when HV1 phoned her  because she had not taken "the child"  for the Orthoptic appointment. It was agreed that "the partner" would phone for a new appointment. The next time "the child"  was seen by anyone from the Health Visiting Service was in April when "the partner"  took them to the Community Forum Clinic.  Again it was recorded that they were thriving and gaining weight.  3.5.3 FK commenced his treatment for "an infection" in April and the author of the STHFT IMR explains that a letter was sent to FK’s GP that day to outline details of the treatment.  In the STHFT IMR it is written that: “It was identified that as part of FK’s treatment he could suffer significant emotional side effects and for that reason he was referred to an adult social worker linked to the specialist clinic (employed by Sheffield City Council).  It was noted that the social worker would normally continue to monitor patients throughout the course of their treatment, but in this case the social worker was identified as leaving the service and a further appointment to the post had not been made; therefore support services were requested from the GP in this letter.”   3.5.4 The author of the Primary Care IMR states that this letter asks if services are available should the patient need them.  The IMR author explains that FK’s mood was assessed by the GP who did not feel any other support was required.    3.5.5 From the start of FK’s treatment in April to his discharge in November next year he attended 15 out patient’s appointments at STHFT; initially he was seen weekly but as the treatment progressed this was reduced.  There were also 10 times when he failed to attend for appointments but these were followed up and he attended rearranged appointments.  At these appointments, amongst other things, there was discussion about how FK was feeling emotionally and on six occasions he described emotional issues such as feeling ‘snappy’ and/or anxious.  In addition, in November he reported financial stress and the possibility was raised of him seeing the social worker if this was not resolved at the next appointment.  However, in the event he did not feel it necessary to see the social worker.  More detail Overview Report concerning Child K    Page 26 of 115 about these appointments will be provided at relevant points in this summary of agency involvement.  It is clear from the records that there was discussion about how the treatment was affecting FK’s relationship with "his previous partner".    3.5.6 Whilst FK was receiving treatment the Infectious Diseases Team wrote to his GP on three occasions and phoned the GP surgery once.  There was no communication from the GP to the Infectious Diseases Team.  The Health Visiting Service did not have contact with the Infectious Diseases Team or the GP in connection with FK’s treatment whilst it was taking place.  3.5.7 In May FK contacted the Police and said that he had been forced to flee the premises.  Shortly after this, FK spoke to the call handler again and said that it was family business and he did not require the Police.  Nevertheless, officers were dispatched to the premises and spoke to FK who stated that it had been a verbal argument only.  The Police reported this incident to Sheffield Social Care who undertook screening checks and decided that no further action was required.    3.5.8 In June HV1 carried out a home visit to the family and reported that FK looked thin and pale having started his medical treatment.  It appears that HV1 was unaware, until this visit, that FK had resumed a relationship with "his previous partner".  It also appears that HV1 was unaware of the incident in May that had resulted in Police involvement.  3.5.9 Records indicate that, after this date, FK and "his previous partner" continued to live together until January 2009.  3.5.10 In June FK had an out patient’s appointment in relation to his treatment. It is recorded that he was feeling ‘snappy’ and was advised that this was due to the treatment.  FK responded that it was manageable.    3.5.11 At 18:09 hours on 8 July 2008 YAS received a 999 call in which it was explained that "FK's first child"  had sustained a laceration to the forehead when a wallpaper stripper had fallen from a security gate in the house and hit them on the head.  The caller stated that "FK's previous partner" was her aunty.  An ambulance took "the child" to SCNFT and YAS staff informed the Police of the incident.  Officers attended the family home and found that the injury was not of a serious nature; they completed a Gen 118a “Concern for a Child” form1 as they took the view that the incident did not meet the threshold for child protection but that other agencies should be made aware it.  "The child"  attended the emergency department at SCNFT with "their mother" and was found to have a 4cm cut on their forehead but that there were no abnormal neurological signs.  The wound was closed with glue and "the child" was discharged home with written and verbal advice.                                                1 This form is used by South Yorkshire Police to inform Children’s Social Care when they attend an incident that does not warrant instigation of Child Protection Procedures but there are some concerns regarding a child.   Overview Report concerning Child K    Page 27 of 115 3.5.12 Sheffield Social Care received a Police notification of this incident on 14 July 2008, six days after it had occurred, and it is recorded in the Sheffield Social Care IMR that the explanation given for the injury was accepted by the Police and medics.   The social worker contacted the Health Visiting Service on 15 July 2008 to speak to HV1 to seek an update on "the child".  HV1 was on annual leave and the social worker informed HV3 of the injury.  It is recorded within the Sheffield Health Visiting IMR that HV3 would discuss this with HV1 on her return from leave, which she did.  It is also recorded that the social worker informed HV3 that Sheffield Social Care were to close the case and this was done on 21 July 2008.  HV1 tried to visit "FK's previous partner and child" at home on 29 July 2008, without an appointment, but no-one answered the door.  3.5.13 Also in July, FK had an out patients appointment regarding his treatment.  It is documented that he was feeling bad tempered, and that there was discussion of possible triggers and options.  "Later that month" the Nurse Practitioner from the infectious diseases team sent a letter to FK’s GP to provide an update on the treatment given.  After this, FK continued to attend out patient’s appointments approximately once/month.  He did not attend a planned appointment in October but attended the following day and explained that his non-attendance had been due to a family death.  At these appointments FK typically reported that he was feeling short tempered and there is consideration to the impact this is having on his relationship.  At an appointment in November FK reported financial stress and the possibility was raised of him seeing a social worker at his next appointment if this had not been resolved.  This was mentioned in a letter sent to FK’s GP that day.  At a subsequent out patient’s appointment in December FK said that he had not yet needed to contact the social worker about financial issues.  3.5.14 In August the Police were alerted to a disturbance outside FK’s flat.  It appears that FK was inside the property with "his previous partner" and had locked her outside following an argument.  By the time the Police arrived access had been gained to the flat.  Police officers spoke to all parties involved and submitted the necessary domestic violence paperwork which led to Sheffield Social Care being informed of the incident.  Sheffield Social Care state that they undertook screening checks although there is no record from Social Care or Sheffield Health Visiting Service to suggest that the Health Visiting Service was informed of the incident.  3.5.15 In September HV1 visited the family home and found it to be empty.  This was the first time HV1 had tried to see the family since an unsuccessful home visit two months earlier in July.  The last time HV1 had seen the family was nearly four months previously in June.    3.5.16 Following the attempted home visit in September, HV1 contacted Child Health to try to find a new address and an address was identified in a different area of Sheffield.  The Health Visiting Team covering the new area was notified of this.  A letter from the Health Visiting Team in the new area was sent to arrange a home visit for October 2008 but this had to be rearranged.  The visit eventually happened later in October when HV4 visited.  Therefore in total there had been a gap of nearly five months, Overview Report concerning Child K    Page 28 of 115 since June, when there had been contact between the Health Visiting Service and the family.   At one point during the visit FK left the room and HV4 raised the issue of domestic abuse with "his partner" who responded that she was safe and happy and there was no ongoing domestic abuse.  HV4 felt that "the child" was  making progress with their development and interacting well with their parents.  It was agreed that "the child"  would be taken to the clinic each month.  The author of the Sheffield Health Visiting IMR has explained to the IORA that this refers to the Well Baby Clinic organised by the Health Visitor which enables the Health Visitor to assess the child and family in venues outside the family home.   3.5.17 "FK's previous partner took their child" to the clinic in November and reported that they had been unwell the previous week with an ear infection but had now recovered having received treatment from the GP.  Clinic staff observed "the child" to be bright and playful and recorded that "the partner" was well and coping.  It was agreed that "the child"  would attend clinic again in early January but "the partner" phoned the health visitor that day to say that they could not attend due to a viral illness and the appointment was rearranged.    3.5.18 In December HV4 discussed "the child" in child protection supervision.    3.5.19 In the early hours of January next year Police were "contacted about a domestic abuse incident".  Police officers attended the property where all was calm.  FK was taken to another address for the night and the situation was assessed, by the Police, as standard.  Officers completed all necessary paperwork to enable details of the incident to be shared with partner agencies.  However, Sheffield Social Care do not have any record of receiving information about this incident.    3.6 Final Separation of FK and "his previous partner"– End of Period Covered by Review - Information relating to "FK's first child"  3.6.1 "FK's first child" was due to attend the rearranged clinic appointment in January but did not do so.  HV4 phoned "the previous partner"  to find out why she had not attended and was told that she was presenting herself as homeless because she and FK had split up and the tenancy was in his name.  HV4 said that she would phone again two days later which she did.  "The previous partner"  informed HV4 that she and "her child" were both well, were staying with a friend and had an appointment with the Homeless Assessment and Support Service (HASS).  HASS is a multi-disciplinary service that works with homeless families to ensure that they have access to health and other services when they may be at their most vulnerable.  One week later, "the previous partner" phoned HV4 to inform her that she was now in bed and breakfast accommodation with "her child".  HV4, in turn, contacted HV5 in the homeless team and gave a verbal handover of "the child", including that they had been subject to a child protection plan but that there were no recent concerns.  HV5 visited "the previous partner and child" in bed and breakfast accommodation; HV5 completed a HASS assessment, gave her contact details and information regarding local GPs and arranged to visit again when they had moved into interim accommodation.  The next visit from HV5 took place on in February when Overview Report concerning Child K    Page 29 of 115 "the child" was observed to have a small bruise on the side of their face.  "The child's mother" said this bruise had been sustained when they had fallen out of bed; she added that she now had a cot for them.  HV5 accepted this explanation.    3.6.2 The author of the Sheffield Health Visiting IMR has informed the IORA that The HASS Health Visitor was aware that there was a history of domestic abuse between "the child's mother" and FK and also a previous partner. The HASS Health Visitor did address the issue of domestic abuse with "the child's mother" who identified that there had been no recent events and that she had no current contact with FK. The Health Visitor did not see FK at the properties whilst visiting but if she had been aware of any current domestic abuse she would have reassessed the situation and taken appropriate action.    3.6.3 Following FK and "his previous partner's" separation in January, FK failed to attend out patient’s appointments, in respect of his treatment for "an infection" , on 3 occasions in January and February. He was contacted by telephone in January but attempts to contact him on 3 occasions in February were unsuccessful.  FK eventually attended for an appointment in February; he explained that he had not attended the previous appointments because of problems in his relationship and had not received letters or phone messages because he had moved out of the family home.  It is recorded that when FK attended the appointment he was with his partner but the identity of the partner is not recorded.  Other IMRs provided for this SCR suggest that FK had not met MK by this stage but it is possible that this partner is someone completely different.  Subsequently FK failed to attend two appointments in March.  FK was due another out patient’s appointment in April but he cancelled this due to being unwell.  He was sent another appointment and attended in April where he said that he felt well now his treatment had stopped and although he had some raised anxiety he was coping.  Medical investigations were completed to confirm whether FK’s treatment had been effective and he was advised by the nurse practitioner to see his GP should he have any concerns.  In May FK was contacted by telephone and informed that his treatment had been successful, although further investigations would be required in six months time to confirm this.  3.6.4 In April 2009 HV5 carried out a home visit to "FK's previous partner and child" and undertook a CAF in order to apply for a two year nursery place for "the child".  Later in the week HV5 discussed "the child" in child protection supervision.  This was the last contact that HV5 had with "FK's previous partner and child".  The next record in the IMR from Sheffield Health Visiting is nearly two months later, on 28 May 2009 when a member of the public contacted HV6 and reported that a young family had moved into the area and a ‘baby’ could be heard crying late at night for prolonged periods.  HV6 made enquiries and established that the family in question was "FK's previous partner and child".  3.6.5 Following further enquiries, and discussion between HV6 and Sheffield Social Care, HV6 carried out a joint visit to "FK's previous partner and child" in June 2009 with a support worker from a housing agency.  They Overview Report concerning Child K    Page 30 of 115 found the flat to be sparsely furnished but with essential items in place, including a stair gate.  HV6 felt that "the child" was developing as expected and "the mother" was handling them confidently and with affection and was prioritising their needs.  "FK's previous partner" stated that "the child" stayed overnight at "family member's" every two weeks.  It was agreed that the support worker from the housing agency  would support "the previous partner" in decorating and furnishing the property and applying for funding for a washing machine and cooker and would also accompany her to a local toddler group.  A GP appointment was arranged for 19 June 2009 and HV6 also arranged to visit that day to review "the child's" progress.  After the visit HV6 contacted Sheffield Social Care to discuss the visit; it was agreed that there were no current concerns that required Social Care involvement but that an enhanced health visiting service would be delivered.    3.6.6 When HV6 made the planned visit the property was clean and tidy but there was no change in the furnishing.  "The child" was seen to be dressed appropriately and steady growth was demonstrated.  At the end of the meeting HV6 arranged to meet again next month to review progress with housing, look upstairs, clarify FK’s address, inform "his previous partner" of the outcome of the two year nursery application and review her feelings of depression.  3.6.7 Before this next planned visit from HV6, Sheffield Social Care received an anonymous referral expressing concern that "the child" could be heard continually crying, a number of people smoked cannabis at the property and arguments could be heard between "the previous partner" and her partner.  The social worker spoke to the support worker from the housing agency  who reported that the property was clean and tidy.  The support worker also said that "the previous partner" had said she was not in a relationship with FK but she allowed him to spend time at the property to ‘normalise’ things for "the child".  Records from HV6 suggest that a social worker from the screening team tried to contact HV6 but that they did not manage to speak to one another.  A social worker then visited "the previous partner and child" and undertook an initial assessment which resulted in a decision that the complaint had been malicious.  In the Sheffield Social Care chronology it is written that there was no mention of whether FK was living at the property.     3.6.8 Two days after the social worker had carried out an initial assessment, HV6 made her next planned visit.  No further progress had been made with furnishing or decorating the house but "the previous partner" had received funding to repair the washing machine and buy a cooker.  It is recorded that she told HV6 about the visit from Sheffield Social Care following an anonymous referral and said that she thought the referral had probably been made by FK because he wanted to resume his relationship with her and she had said no.  At the end of the visit it was agreed that HV6 would arrange another visit in three to four weeks but no date was set.    3.6.9 Four weeks later, HV6 wrote to "the previous partner" to arrange a visit in August 2009 but when HV6 visited that day there was no reply at the door, the curtains were closed and the letterbox sealed.  HV6 did manage to Overview Report concerning Child K    Page 31 of 115 contact her by phone later that day and she apologised for missing the visit, saying that she had forgotten about it and also that "the child" had been allocated a nursery place.  A subsequent visit planned for later in the month was cancelled as "the previous partner" reported that she had swine flu and "the child" was staying with FK.  The next face to face contact between HV6 and "the previous partner" was in  September 2009 when HV6 dropped off a home safety pack and briefly saw "the child"  at the door and the next visit of any substance was later in September when HV6 undertook a planned home visit.  At this visit "the previous partner"  referred to "her child" having met FK’s girlfriend but she added that the relationship had now ended.    3.6.10 In September FK failed to attend an out patient’s appointment in connection with his treatment.  This should have been his first appointment since he was told in May that treatment had been successful but that further investigations would be required in six months time.  After further failed appointments in October and staff being unable to contact FK by letter or phone he was discharged from the service. The GP was informed of FK’s discharge in November  3.6.11 There is no record of HV6 seeing "FK's previous partner or child" during October 2009, but HV6 did have telephone contact with her and liaised with the support worker from the housing agency and with the nursery  3.6.12 In November Sheffield Social Care received an anonymous referral relating to "FK's previous child".  Sheffield Social Care spoke to the HV6, the GP and the support worker none of whom raised any concerns and social workers visited "FK's previous partner and child" and undertook an initial assessment.  After completing the investigation, Sheffield Social Care closed the case.  3.6.13 During the social workers’ visit "the previous partner" told them that she and FK had been considering resuming their relationship but that they had since fallen out over money and decided not to do so.  She indicated that she did not want to have contact with FK but that FK had contact with "his child" and she did not mind this continuing.  3.6.14 "Six days later FK's previous partner" contacted the Police and stated that she had been assaulted by FK, who she described as her partner.  She initially requested an ambulance but then changed her mind and no ambulance attended.  FK was arrested for assault occasioning actual bodily harm; he admitted causing damage to the property but said that both parties were involved in a scuffle; no further action was taken against him.    3.6.15 It is recorded in both the Police and Sheffield Health Visiting IMRs that a member of staff from Sheffield Social Care visited the property whilst the Police were present and this member of staff was made aware of the situation at the time.  It is also recorded in the Sheffield Health Visiting IMR that the social worker made HV6 aware of the incident 2 days later.  Sheffield Social Care have reported that this incident was addressed within the initial assessment that was undertaken as a result of the anonymous referral. Overview Report concerning Child K    Page 32 of 115  3.6.16 The author of the Police IMR states that officers ensured that the appropriate domestic violence forms were completed and shared with the PPU.   3.6.17 Following the incident in November, HV6 made two unsuccessful attempts to contact "FK's previous partner"  by phone and then wrote to her to arrange an appointment.  However, when HV6 visited on the scheduled date there was no reply.  Eight days later HV6 saw "FK's previous partner and child"  in the street; it is recorded that the child looked well and clean and when HV6 discussed the recent incident with FK "his previous partner" said she was okay and had not seen FK for about two weeks.  HV6 arranged to carry out a home visit in December 2009 and following this visit recorded that "the child" was developing well and attending a local playgroup and nursery.  "FK's previous partner" reported that she had not had contact from FK for a month.  After this visit HV6 had a lengthy conversation with the housing agency support worker regarding progress with "FK's previous partner" and "his child's" challenging behaviour. It was documented that "the child" was not reported to have seen their dad but did go to their grandparent's home at weekends.  3.6.18 In December FK was arrested in the street for possession of cannabis and a warning was issued.  3.6.19 HV6’s next planned visit to "the previous partner" was in mid-February 2010 but she cancelled this. HV6 then made contact with a housing support worker who explained that there were no outstanding housing issues and the agency was to end their involvement.  The support worker raised some issues about "the previous partner's" lack of engagement and not being consistent with strategies to manage "her child"   who, in turn, was displaying some aggressive behaviour.  The support worker also informed HV6 that "the child"  had not seen their father but had had contact with "another family member" .    3.6.20 When HV6 visited next it is recorded that "the child "  was developing well and having contact with their father every weekend at "another family member's" home.  Because the housing agency were closing the case "the previous partner"  agreed to HV6 making a referral for Family Support.  This was done in March when HV6 visited and completed a CAF which was signed by "the previous partner".  During the visit HV6 heard, what sounded like, an adult moving around upstairs.  "The child" pointed upstairs and said what HV6 thought was “Daddy”.  "The previous partner" however implied that "the child" had said “trousers”.  3.6.21 During the completion of this SCR, HV6 told the author of the Sheffield Health Visiting IMR that she did not ask who was upstairs because of "the mother's" response to "the child's" comment and because of previous violence between the couple.  However HV6 added that she planned to ask who had been upstairs at the next contact and subsequently did so.  3.6.22 After the home visit in March HV6 contacted the nursery and was told that "the previous partner" had authorised FK to collect "their child"  from Overview Report concerning Child K    Page 33 of 115 nursery and he had done so the previous week.  HV6 contacted Sheffield Social Care and was told that there was no child protection agreement in place with regard to contact between "the child"  and their father.  3.6.23  In March HV6 visited "the previous partner and child" with a family support worker.  When asked about FK and the previous visit, "the previous partner"  said that FK had been collecting his belongings, explaining he had a new partner and was living in Barnsley. She  added that she felt okay about this and felt safe around FK.  FK had reportedly separated from "his previous partner"  about four months before she moved into this property so it is unclear what belongings he would have had at her house.    3.6.24 In April 2010 "FK's previous partner" took "her child" to the emergency department at SCNFT. It was reported that "the child" was playing in the garden of one of their mother’s friends with a plastic see-saw. They stood next to the see-saw as they pressed the seat down and the seat is reported to have flipped back up and hit them in the face.  On examination they had a small graze/bruise on the upper gum and a small graze to the bridge of the nose.  It is recorded in the Sheffield Social Care IMR that they were contacted by SCNFT following this hospital attendance and were told that "the child" had been discharged with written advice and that the injury was thought to be consistent with the explanation.  The author of the Sheffield Social Care IMR explains that the hospital contacted Social Care because "the child" had previously been on the Child Protection Register.  This was in line with a process in place at that time and no action was taken by Sheffield Social Care.  12 days later the Health Visiting Service received a discharge summary regarding this hospital attendance.  3.6.25 In June 2010 HV6 attempted to undertake a pre-arranged visit to "FK's previous partner and child" but there was no reply.  HV6 then spoke to the family support worker who reported regular contact with them including a visit the previous week.  The family support worker reported that "the child" appeared calmer.  HV6 was due to see them in July 2010 but "the previous partner" cancelled the appointment due to other commitments.  Also on that date HV6 was told that the family support worker had closed the case and was no longer involved with the family.  It appears that this was closed without any prior discussion with HV6.  Subsequently, HV6 spoke to the deputy head at "the child's" nursery to discuss the family history and their speech development.  3.6.26 In July HV6 carried out a home visit to "FK's previous partner and child" and completed a "health development" questionnaire.  This was the first time HV6 had seen "the child" since March.  HV6 was informed that FK had paid for floor covering in the living room and was helping out practically, rather than providing child support. "The previous partner"  said she was happy with this arrangement and was on good terms with FK.  She said again that FK has a new partner, who is pregnant.  She added that the new partner has a child and they do not live in Sheffield.  "The partner" stated that "her child" stays with FK from Friday to Sunday and she feels this is a positive arrangement.  HV6 told the author of the Sheffield Health Visiting IMR that she asked "the previous partner" where FK was living and she said that she was not sure of the address. Overview Report concerning Child K    Page 34 of 115   3.6.27 HV6 involvement with "the previous partner and child " continued throughout the remainder of the period covered by this review but there are no further references to FK after this visit in July, although he was continuing to have contact with "his child".    3.6.28 Although there are no further references to FK after July it is recorded in the YAS IMR that in October the Police contacted YAS and requested that they attend "the previous partner"  who had been assaulted and had sustained a large lump on the top of her head.  The author of the YAS IMR explains that staff that attended the incident remembered there being children in the property but Social Care were not notified and the YAS staff do not recall whether hospital staff were informed about the children.  YAS staff did, however, ensure that the children were not left alone when "the previous partner"  was taken to hospital.  There is no information to indicate who had assaulted her or where the assault had taken place, therefore there is no evidence to suggest that FK was involved.   The Police have been unable to find any record of this incident.    3.6.29 The child care setting that "FK's first child" attends had FK named as their father and records that indicated that there had been previous Family Support Team intervention.  They were aware of limitations placed on FK’s contact with "his child"  since the death of Child K but had no information about limitations to contact prior to that time.  This is consistent with information in other agencies which demonstrates that, until Child K’s death, there was no concern that FK might pose a risk to "his first child"   3.7 Background Information relating to "Child K's sibling" and Child K  3.7.1 "MK's first child" was born in the Midlands. It is recorded in the medical records that the pregnancy was unplanned and that MK split from the child's father soon after the birth and moved to another address in the Midlands.  This SCR has confirmed that MK "and her first child" were not known to the LSCBs in either of these two areas and based on this information it was decided that IMRs would not be sought from agencies in either county.  However historic records provided in the Primary Care and SWYPFT IMRs suggest that there were no significant health issues for MK "or her first child" and no concerns in relation to Safeguarding Children.  3.8 MK and "her first child's" move to Sheffield – Birth of Child K 3.8.1 MK and "her first child" moved to Sheffield between April and June 2009 when they moved into the home of "family members".  YAS, the Police and Sheffield Social Care all report that they had no contact with MK or "this child" until after Child K sustained the injuries that led to his death.  3.8.2 It is recorded in the Primary Care IMR that MK met FK in July 2009 although it is unclear where this information has come from.    3.8.3 MK and "her first child" registered with a GP in Sheffield in June 2009 and the GP surgery informed the Health Visiting Service that they had moved in to the area.  HV8 visited the family home when "the child"  was 14 months old and a nursery nurse visited the following day to complete the 6 – 13 month assessment and Family Health Profile.   Overview Report concerning Child K    Page 35 of 115  3.8.4 MK told HV8 that she had recently separated from the father of "her child" and had returned to live with her "family",  whilst information provided in the medical records suggests the separation had occurred soon after "the child's"  birth.  MK also explained that she worked three days/week at a nursery in the Midalnds and that she took "the child" with her twice/week and they stayed in Sheffield with "family" on the third day.  MK also told HV8 that she supervises "her child's"  contact with their father but there is no explanation of this in the health visiting notes.  HV8 believes they would have asked why contact was supervised but cannot remember the response.    3.8.5 HV8 documented that there were no domestic abuse, mental health, alcohol or drug issues.  The nursery nurse recorded that the lounge area of the house was clean and tidy, that "the child"  was developing as expected and that MK had the support of close family.  MK and "her child"  did not present as being vulnerable and it was decided that the core offer of the Health Visiting Service would be delivered to the family.  No further home visits were planned but MK was given details of how to contact the local Health Visiting Team and clinic.  There is no documentation to indicate that "the child" attended a Well-Baby clinic in the area and no information to suggest that the Health Visiting Service had any further direct contact with MK or "her child"  whilst they lived in Sheffield although a health development questionnaire was completed and filed in the Family Health Record in 2010.  MK herself told the IORA and Designated Nurse that HV8 visited twice soon after she moved to Sheffield but that there were no further visits after this.  3.8.6 The first GP consultation was in September 2009 when "MK's first child" attended with an ear infection.  "The child"  also visited the GP Practice in December 2009 with eczema when they were seen by GP12 and February 2010 when they were seen by Practice Nurse 2.  "The child" also had two consultations with the GP during 2010; these were in May for an Upper Respiratory Tract Infection and July for another ear infection.  The Primary Care IMR does not contain any details of these consultations other than a record in the chronology that they occurred.  3.8.7 In February 2010, eight days after "MK's first child"  was seen by the Practice Nurse at the GP Practice, they were taken to the Emergency Department at SCNFT with a history of screaming and holding their genitalia when passing urine.  It was documented that they had become unwell nine days before with fever and screaming on passing urine and was treated with antibiotics for an ear infection.  Fever and ear pain is said to have subsided as did the screaming with passing urine, but the latter had recurred in the four days prior to the hospital attendance.  This history is consistent with the report in the Primary Care IMR of attendance at the GP Practice in February.  3.8.8 The author of the SCNFT IMR has written that when "the child"  was examined, they were noted to have some redness and it was thought that they either had an infection or a urinary tract infection.  Attempts to collect a urine sample from "the child" for investigations were not successful so Overview Report concerning Child K    Page 36 of 115 they were discharged home with painkillers and a fungal cream and arrangements were made for the urine to be collected at home and handed in at a later date.  3.8.9 Nine days later, "the child" was taken back to the Emergency Department at SCNFT by MK.  The presenting complaint on this occasion was fever and ear-ache and it was reported that they had been unwell for about three days. "The child had some redness" and red swollen tonsils and red ear drums. This time they were thought to have tonsillitis or infection but urinary tract infection was still a possibility since their urine was yet to be examined. They were given some antibiotics and discharged home to continue treatment with the fungal cream and for MK to collect a urine sample.    3.8.10 Discharge summaries relating to both hospital attendances were sent to the Health Visiting Service and it is documented on the second of these that MK had been trying to obtain a urine sample from "her child" for five days.   There is no record of a urine sample being provided to the hospital or of "the child"  attending the hospital again.  Furthermore, they did not have another appointment with the GP until May 2010.    3.8.11 In February 2010, in between "the child's" attendance at the GP Practice and their first attendance at SCNFT Emergency Department, MK was referred to STHFT for a termination of pregnancy and was initially seen two days later.  This referral came after MK referred herself to Sheffield Contraception & Sexual Health Service which was part of Sheffield NHS Primary Care Trust at that time. Documentation states that part of MK’s decision to terminate her pregnancy was that she was unable to cope with another baby at that time. It is also documented that she was upset but sure of her decision and that she had support.  However there are no further details about the support.    3.8.12 Later in February, in between "the child's" two attendances at SCNFT, MK contacted the gynaecology department to state that she was unsure of her decision to have a termination and she was offered further counselling and a follow up appointment, which she attended.  Subsequently, MK booked for pregnancy care and, after completion of a booking history, it was deemed appropriate for the midwife to be the lead professional, as the pregnancy was low risk.    3.8.13 A full social history was taken at the pregnancy booking.  FK was detailed as the father of the unborn baby and MK said that they were not in a relationship or living together at that time.  Information was recorded that FK already had a child, who lived with their mother, and also that FK had Attention Deficit Hyperactivity Disorder (ADHD) but there was no exploration of how this affected his day to day ability.  No information was recorded about FK receiving treatment for "an infection" , his previous drug use or his involvement with Sheffield Social Care during his relationship with "his previous partner".  MK was asked about domestic abuse and responded that she had not experienced it in her relationship with FK.  MK was also asked about mental health and said that she had no previous mental health issues.  The author of the STHFT IMR explains that when Overview Report concerning Child K    Page 37 of 115 the father of an unborn child is named no further routine checks are undertaken by the midwife, unless there are specific concerns raised within the social or medical history that warrant further investigation.  Consequently no enquiries were made about FK’s history.    3.8.14 STHFT faxed an antenatal contact/hospital referral form to the Health Visiting Team.  FK was named as the unborn baby’s father and it was written that MK and FK were not together.  3.8.15 Whilst this SCR was being carried out MK told the IORA and Designated Nurse that she moved into a property in the Barnsley area in April 2010 and it is recorded in the chronology from STHFT that she told the midwife this at the time.  However it is recorded in the IMR from the Sheffield Health Visiting Service that "KF's previous partner" told HV6, one month earlier, in March 2010, that FK had moved to Barnsley to live with his new partner who was pregnant.  Despite moving to Barnsley in April 2010 MK did not register with a GP in the Barnsley area until September 2010, just one month before Child K was born and the Health Visiting Service in Barnsley were not made aware of the family’s arrival in their area until September 2010.    3.8.16 Through her pregnancy MK had frequent and regular antenatal appointments, predominantly with the same midwife.  For the majority of appointments MK attended on her own but on one occasion she attended with "another family member".  Records suggest that FK did not attend any antenatal appointments with MK although MK and FK both told the IORA and Designated Nurse that FK had been present when MK had her first scan.  Maternity care for MK continued to be provided by STHFT after her move to Barnsley and MK was booked to deliver her baby at hospital in Sheffield.    3.8.17 In June 2010 MK had a consultation with GP11 due to ‘low mood’.  She was referred to the Maternity Mental Health Team where she was seen and assessed.  According to information in the Primary Care IMR, MK’s mental health showed evidence of mild to moderate depression, and also evidence of low self-esteem.  In the STHFT IMR it is recorded that MK was reviewed by a clinical manager for maternal mental health services in July 2010 and it was recorded that she exhibited strong features of clinical depression and that a follow up appointment was planned for four to five weeks time.  The author of the Primary Care IMR states that MK was seen in the Maternity Mental Health Team in August.  The author of the Primary Care IMR also explains that it was suggested that MK go on anti-depressant medication but that her mood and sleep pattern improved with treatment with iron tablets and she never did go on anti-depressant medication.  Information provided by MK to the IORA and Designated Nurse confirms that her feelings of depression during the pregnancy were short lived and that she did not take any anti-depressants.  3.8.18 In the Primary Care IMR it is recorded that, through counselling by the Perinatal Mental Health Unit, it emerged that MK had mental and physical difficulties with this pregnancy, suffering from dizzy spells, headaches and low blood pressure.  Also that her sleep pattern was poor and she worried Overview Report concerning Child K    Page 38 of 115 that the unborn baby (Child K) may suffer from ADHD inherited from FK.  MK herself reported to the IORA and Designated Nurse that she only felt dizzy on one occasion during the pregnancy and as a result was off work for three days.    3.8.19 A home visit was undertaken by an STHFT midwife in September 2010 to ascertain if home conditions were suitable and whether appropriate preparations had been made for the birth of the baby.  By this time MK was living in the Barnsley area and the author of the STHFT IMR explains that the midwife to whom MK was allocated had arranged for a colleague who lived near MK to perform the home visit as this area was not routinely covered by Sheffield community midwives. The author of the STHFT IMR further explains that home birth assessments were introduced into practice following a previous SCR and that the assessments are seen as an opportunity for midwives to ensure home conditions are suitable for a newborn baby with appropriate equipment in place and it also provides midwives with an opportunity to assess any changes to family circumstances.   3.8.20 In September 2010, a Health Visitor Transfer Summary Sheet was completed by HV8 as MK and "her first child" had moved out of the area.  The only information documented on the summary was “routine health visiting”.  No mention was made of MK being pregnant.  3.9 Involvement with Child K, "his sibling", MK and FK from the birth of Child K until he sustained the injuries that led to his death (October 2010 – 26 September 2011)  3.9.1 Following the birth of Child K in October 2010 MK stayed in hospital for two days during which time normal postnatal care was provided.  MK and Child K were then discharged  to the care of community midwives employed by BHNFT.  In accordance with current STHFT hospital policy a telephone call was made to BHNFT to inform them of the discharge of MK and Child K and to provide a verbal summary of the care provided.  Also, as part of routine practice the postnatal midwifery care records, baby chart, daily postnatal observation chart and a discharge summary report generated following input from the midwife on PROTOS (an electronic midwifery recording system) were sent home with MK for use by Barnsley midwives.  A copy of the discharge summary was also sent to the GP.    3.9.2 It appears that BHNFT was not provided with a social history for the family and did not gather this during visits to the family.  The authors of the BHNFT IMR explain that midwives in Barnsley usually gather a social history during the antenatal period and consequently do not routinely gather such information post-natally.  3.9.3 Following Child K’s discharge home, community midwives from BHNFT visited the family home on four occasions (days 3, 5, 7 and 11 of life) before transferring the care of MK and Child K to the health visiting service.  These four visits were all undertaken by different community midwives.  The authors of the BHNFT IMR state that MK was reported to be postnatally well and coping well with the care of Child K who she was Overview Report concerning Child K    Page 39 of 115 breastfeeding.   The IMR authors explain that a social history would normally be taken in the antenatal period but in this case Barnsley midwives did not undertake any antenatal visits because they did not know about the family until after Child K was born.  It appears that they did not record a social history when they visited the family after Child K was born and made no record of who was present at the contacts other than Child K and MK.   3.9.4 The first contact with the family from health visitors from SWYPFT was in November 2010 when Child K was 12 days old.  This was the day after the final visit from a midwife.  Based on information contained within the BHNFT and SWYPFT IMRs it appears that no written information was passed from the Barnsley midwife to the health visitor despite the fact that the midwife should complete a discharge form and pass a copy of this to the health visitor.      3.9.5 This visit in November was also a ‘movement in’ visit in respect of "MK's first child".  The author of the SWYPFT IMR explains that a ‘movement in’ visit occurs when a family with a child or children aged 0-5yrs registers with a local GP and that, in this case Barnsley Child Health Services became aware of the family movement into Barnsley in September 2010.  There was therefore a gap of nearly two months before the visit took place.  The health visiting service had received a written summary of previous health visiting involvement which did not highlight any concerns about their development or the care they were receiving.    3.9.6 The visit in November 2010 was carried out by HV1 but the allocated case holder for the family was HV4.  This situation arose because HV1 was moving to a different Health Visiting Team whilst HV4 should have transferred into the team covering the area in which Child K lived, in October 2010 but did not actually do so until December 2010.  3.9.7  The author of the SWYPFT IMR states that during the birth visit, HV1 noted that this was a two parent family.  The author adds that details of the father were not recorded and there is no documentation which identifies that questions were asked about any previous relationships. There is no information recorded about the attachment in relation to the mother or bonding between mother and child. The Maternal Mental Health Care Pathway was not in place at this time.  Two weeks later, in November 2010, MK took Child K to clinic where Child K was weighed and was found to be just below the 98th centile.    3.9.8 Following this clinic attendance, the only contacts that health services had with "MK's first child", until after Child K died, were in June 2011 when they saw GP5 as they had tonsillitis and July 2011 when they saw GP 6 with post viral sinus congestion.  On the second of these occasions "the child" was taken to the surgery by "another family member".     3.9.9  In December 2010 FK attended an appointment with GP4; this was a routine follow up regarding his treatment for "an infection" .  This was the first appointment that FK had attended in relation to this since he had become non-compliant with treatment in November 2009.  It was confirmed Overview Report concerning Child K    Page 40 of 115 that FK was cured of "his infection" but was potentially a risk to himself and his partner due to his failure to continue follow up. This appointment in December 2010 was FK’s only contact with health services during the period from October 2010 onwards.    3.9.10 In December 2010 Child K visited GP1 for a six week check which showed no abnormalities; in particular the mouth was examined and found to be normal.  MK had a postnatal examination by the GP at the same time as Child K’s six week check; it was noted that she was breastfeeding and her mood was recorded as being good.  The only GP appointments that MK had after this were for "routine health care".  3.9.11 The day after the six week check, MK returned to the GP with Child K as he was coughing up blood.  On this occasion Child K was examined by GP2 who referred him to the Child Assessment Unit (CAU) at BHNFT.  GP2 wrote a letter for the hospital in which Child K was described as a well baby with no previous problems, who is breastfeeding and thriving.  The letter stated that no other signs of bleeding or bruising had been noted; it did not highlight any safeguarding concerns and asked the Paediatrician to “please advise”.    3.9.12 Child K arrived at the paediatric unit at 19:00 hours on that day in  December 2010 with both parents.  He was seen by a paediatric registrar who took a medical and family history and undertook a full clinical examination.  MK and FK reported that Child K had had a cough for three days and at approximately 17:30 hours he had coughed a couple of times and blood had come from his mouth.  The registrar described Child K as having a “snuffly” nose and recorded him having “raw mucous membrane on left of soft palate”.  The registrar’s recorded diagnosis was “Viral URTI” (upper respiratory tract infection) – and that K had “coughed up blood due to burst blood vessel in pharynx”.  The registrar documented that this was discussed with parents and blood tests were arranged.  Child K was discharged home at 23:30 hours with advice to return if concerns were ongoing or his condition deteriorated.   An electronic discharge letter was completed which included a summary of the admission, diagnosis and details of the blood results.     3.9.13 Information about this hospital attendance was sent from the hospital to the Health Visiting Service via SystmOne four days later.  This was opened by the administrator in the Health Visiting Team two days later and forwarded to HV4 who became aware of the incident at 12:11 hours that day.  A discharge summary from BHNFT was scanned into the Health Visiting Records on SystmOne later that day and opened by HV4 four days later.   3.9.14 In December 2010, before the health visiting team became aware of Child K’s attendance at hospital, HV3, a Health Visitor Bank Nurse working with the service, made an unsuccessful planned visit to the family home to undertake Child K’s 6 to 8 week contact. HV3 undertook the visit due to the fact that HV4 had only been with the team for 2 days and had been allocated a caseload of approximately 380 cases including around 12 where Safeguarding Children was an issue.  Child K was almost eight weeks old at the time of this visit and the author of the SWYPFT IMR Overview Report concerning Child K    Page 41 of 115 explains that, at that time, it was in keeping with policy to carry out a check between six and eight weeks of age.  However in January 2011 the Health Visiting Service adopted the ‘Healthy Child Programme 0-5 Years Health Visiting Standards’ which clearly identifies that a contact of this nature should be undertaken at six weeks.  3.9.15 Three days after this unsuccessful visit, MK took Child K to the Emergency Department at SCNFT with a three day history of a swelling of his right pinna (outer aspect of the external ear).  Records show that MK did not provide any suggested explanation for the swelling but told the registrar in the Emergency Department that Child K had woken three days earlier with a slight swelling of the pinna and this had worsened rapidly.  Records also show that MK told the registrar about Child K’s attendance at BHNFT a few days previously.  3.9.16 The Emergency Department registrar was of the view that the swelling was either a haematoma,  a blood containing swelling which usually develops from small blood vessels bursting following blunt trauma or a seroma, a swelling containing fluid called serum which may occur following trauma or surgery or may be spontaneous.  The Emergency Department registrar referred Child K to the Ear Nose and Throat (ENT) surgeons so that the swelling could be drained. The Emergency Department registrar wrote in the notes that if the fluid drained from the swelling was found to be bloody, NAI should be considered.  3.9.17 Child K was then reviewed by an ENT registrar (ENT1) who was also of the opinion that the swelling could be a haematoma or a seroma and who arranged for Child K to be admitted to a ward to be prepared for theatre to drain any fluid it contained.  The ENT registrar spoke with MK who provided a similar history to that given to the Emergency Department registrar although on this occasion MK stated that the swelling had occurred two days previously.  3.9.18 The following day, Child K was taken to surgery and a blood stained fluid was drained from the swelling and, after discussions in ENT, child protection concerns were raised.  As a result of these, the next day a junior doctor in ENT referred Child K, by phone, to a medical registrar in the acute medical team, to look at child protection issues.  Child K was still an in-patient at SCNFT at this time.  The author of the SCNFT IMR explains that the specialty teams are aware that they can refer children directly to social care, but they do not have the expertise to do child protection medicals and therefore established practice is that they refer to the medical team. The IMR author adds that this arrangement is not peculiar to SCNFT but occurs in other hospitals across the country.  3.9.19 Also on that date ENT1 contacted BHNFT and obtained the results of a clotting screen which had been carried out when Child K had been seen earlier in December 2010; these were normal.  ENT1 also contacted HV4 to ask about any concerns the Health Visiting Service had in relation to Child K. Records show that HV4 phoned back and explained that there had been nothing abnormal detected at the birth visit other than dry skin and that the parents had acted on advice to attend the GP with this issue.  HV4 Overview Report concerning Child K    Page 42 of 115 also informed ENT1 that Child K had only been seen once by a health visitor and the family were not home for the six to eight week assessment that HV3 had tried to undertake.  There is no evidence to suggest HV4 and ENT1 discussed the possibility of contacting the designated or named doctor for advice or of referring Child K to Children’s Social Care and no such contacts were made.  3.9.20 At 17:20 hours on that day a medical specialist registrar, MSPR 1 saw Child K and reviewed the history.  MK again said that she noted bruising on the right pinna on 3 days before and it was documented that MK said the colour of the bruise was lighter the next day and swelled up on day two.  MK also told MSPR1 that Child K had been seen at BHNFT after coughing up blood which was attributed to a cut on his palate (roof of the mouth).  It was documented that Child K was breastfed, although it is recorded in the chronology prepared for this SCR that, when Child K was seven days old, MK told the midwife that the breastfeeds were being topped up with formula milk.  MK added that Child K had bruised more when his blood investigations had been carried out in BHNFT.  Finally, MK was quoted to have said that Child K was noted to have a cut inside the pinna of his right ear soon after birth which had healed after treatment from the GP but that this cut had reappeared.  However, there is no record in the Primary Care IMR for this SCR of Child K seeing the GP at a few days of age or of ever seeing the GP because of a cut in his ear.  The first contact with the GP had been when Child K was 31 days old as a result of dry skin around the ears and on the legs.  3.9.21 MSPR 1 discussed two possible causes of the swelling on Child K’s ear.  These were, swelling following minor trauma due to a clotting disorder or swelling due to forceful trauma.  MSPR1 explained that either way, further investigations were needed and arranged for a more detailed clotting screen to be done the next day.  From the examination of Child K that was carried out by MSPR1 in December 2010, it was documented that Child K had a small fading bruise on the radial (lateral) aspect of his right forearm near the elbow.    3.9.22 The following day Child K was reviewed on the ward round by MSPR2.  Child K was examined and said to be doing well and the plan was for a clotting screen to be done and Child K to stay overnight.  The blood test was carried out but the sample clotted so no results were obtained.  MSPR 1, reviewed Child K at 20:00 hours with both MK and FK and explained this to them.  3.9.23 The following day Child K was reviewed by the ENT team and declared fit for discharge home from ENT point of view.  He was also seen by MSPR 1 during which, the difficulty with bleeding Child K was discussed. The outcome of this discussion was to discuss with the Paediatric Medical Consultant whether Child K could be discharged home to come back in a couple of weeks for the bloods to be repeated but in the event blood was obtained that day for the tests which were normal.  Child K was discharged home that day, but there is no documentation regarding who discharged him and time of discharge.  The plan at discharge, as documented in a discharge summary created by ENT2, was for follow up to be arranged by Overview Report concerning Child K    Page 43 of 115 the medical team.  However, there is no record of any medical follow up arrangement being made by the medical team.  This is consistent with the statement made by MK to the IORA and Designated Nurse that she was told that a follow up appointment would be made but this never happened.  3.9.24 Two days after Child K was discharged, he attended the ENT dressing clinic for removal of stitches and was discharged from ENT follow up.  3.9.25 It is clear from the above, lengthy account of Child K’s admission to SCNFT that, although ENT staff referred him to the acute medical team because of concerns about the possibility of NAI, this was not thoroughly investigated by the acute medical team and Child K was discharged without anyone identifying the cause of the swollen pinna.  3.9.26 Shortly after the phone conversation between HV4 and ENT1 in December 2010, HV4 left a message on MK’s mobile phone asking her to make contact to arrange the six to eight week assessment.  The next day MK phoned HV4 in response to the phone message left by HV4 the previous day.  MK explained that the haematoma on Child K’s ear had been drained.  An appointment for the six to eight week assessment was made for a later date but MK phoned HV4 again on to explain that Child K was still an in-patient at SCNFT and she would call again when he had been discharged.  The author of the SWYPFT IMR identifies that the phone call from MK was logged at 13:00 hours but the visit had been arranged for 10:30 and there is no indication as to whether a visit had been attempted at that time.  The author also identifies that HV4 did not contact SCNFT to confirm whether Child K was still an in patient.   3.9.27 Child K received his first primary immunisation in January 2011 and the next contact between the family and the Health Visiting Service took place in February 2011 when he was weighed at clinic and his weight was recorded as 7.35 kg.  The following week, HV4 carried out the six – eight week assessment.  It is written in the SWYPFT IMR that the six – eight week assessment was carried out by HV4 during a visit to the family home but MK told the IORA and Designated Nurse that HV4 never visited her home and this assessment was carried out when she took Child K to clinic.  Either way this was the first time that HV4 had met the family.  Child K was 16 weeks old by the time the six to eight week assessment was carried out and the delay was recorded as being due to Child K having been in hospital and a changeover of health visitor.    3.9.28 Aside from the lengthy delay in carrying out the six to eight week assessment visit the author of the SWYPFT IMR raises a number of concerns about how it was carried out.  These include the scorecard for the Edinburgh Postnatal Screening not being completed and no record of the relationship between Child K and either parent being discussed.  At this assessment Child K’s weight was recorded as 7.29 kg which is 0.06 kg lighter than the previous week.  The author of the SWYPFT IMR identified that Child K’s weight had fallen from just below the 98th centile in November 2010 to just above the 75th centile at this visit.  However, this is not recorded in the case notes.  Overview Report concerning Child K    Page 44 of 115 3.9.29 Later in February 2011 "MK's first child" started attending a local children’s centre one day per week and this continued for five months until they moved to a nursery school.  The IMR from Barnsley Education reports that no significant events or incidents occurred over this period.  Staff at the centre considered that MK and FK were affectionate and attentive with "their  child" and communicated well with centre staff.  3.9.30 In March 2011 Child K attended for his third primary immunisation and one week later, HV2 weighed Child K at the clinic where his weight was recorded as 7.94 kg.  This was an increase of just 0.65 kg from the 6 - 8 week assessment six weeks earlier which meant that Child K’s weight had now fallen below the 75th centile.  HV2 did not make any mention of the drop in centile or of any bonding or attachment issues.  3.9.31 In April 2011 MK attended a weaning session presented by a nursery nurse and later that month  Child K attended clinic for a six month assessment.  This assessment was carried out by HV4 who had previously seen Child K at the six to eight week assessment.  Maternal wellbeing was discussed during this assessment and the postnatal depression screening was undertaken. As was the case at the six to eight week assessment the scorecard for the Edinburgh Postnatal Screening was not completed and there is no recorded information in relation to the attachment or bonding in relation to Child K and MK was provided.  At this assessment Child K weighed  8.55 kg and was back on the 75th centile.  3.9.32 Children’s Centre staff informed MK about support groups and programmes that were available and MK chose to attend the Positive Parents Group which was held over a six week period commencing in May.  Childcare was provided with this group and Child K attended all sessions and presented no issues for the staff.    3.9.33 In June 2011 student HV1 saw MK and Child K in clinic where Child K’s diet was discussed.  MK expressed concern that Child K “develops red marks easily on his skin when he bumps into things which disappear quickly”.  The author of the SWYPFT IMR considers that this statement would have presented an opportunity for safeguarding supervision.  3.9.34 The final direct contact that the Health Visiting Service had with Child K was in August 2011 when he attended clinic aged 41 weeks, the only information documented about this visit was Child K’s weight which was 9.9 kg.  3.9.35 "MK's first child" started at nursery in September 2011and attended in the afternoon from Monday to Friday each week.  Both FK and MK attended the initial meeting for new parents and were inquisitive about the setting but did not raise any concerns.  Nursery staff’s perception was that "Child K's sibling" was initially very shy and close to MK and FK and took time to settle.  The author of the Barnsley Education IMR considers that "the child's" behaviour was typical of a child who had not spent a great deal of time in a child care setting.  Child K was usually present when "his sibling" was brought to and collected from nursery and therefore nursery staff often Overview Report concerning Child K    Page 45 of 115 saw Child K.  However, they never had any concern about the appearance of either child or the behaviour of MK and FK.    3.9.36 Neither the Police nor Barnsley Social Care had any contact with the family after their move to Barnsley until after Child K sustained the injuries that led to his death.  3.10 27 September 2011 onwards   3.10.1 At 12:30 hours on 27 September 2011 the nursery received a phone call from a friend of MK and FK in which they were informed that "Child K's sibling"  may be late as there had been an accident involving Child K.  Nursery school records indicate that "the sibling" was a little bit late but there is no record as to who brought them to the nursery or whether Child K was in attendance.  3.10.2 At 14:00 hours on 28 September 2011, HV5, who worked in the same team as HV4, documented information about a phone call taken from a member of the public at 17:10 hours on 27 September 2011.  This member of the public was also a service user of HV4’s and the record was placed on the record of the member of the public.  The text of the record reads as follows: ‘T/C from (name of member of the public) at 17:10 hrs on 27/09/11(the member of the public) was upset because she had seen a child with his Dad in the street who had scratches on his face which looked red and angry and in her opinion needed to be checked by a Dr. She told the Dad this and he stated he was going to take the baby to the GPs when his mum returned home from work. (The member of the public) rang for reassurance that she had done the right things but she did not know the name of the baby and didn’t want to “get involved”. Advised she could ring the police or social care duty team if she wanted to report what she had seen anonymously. (The member of the public) preferred not to do this as she felt sure the child’s Mum would go to see the GP when she got home. Reassured and advised to ring back in the morning if she found out any more information and we could help any more.’  3.10.3 On 29 September 2011 this information was entered on Child K’s record.  3.10.4 It is unclear from the SWYPFT IMR exactly how and when the Health Visiting Team became aware that the child referred to by the member of the public was Child K.  It seems probable that this was established by finding out, from the hospital, the identity of the child who had been admitted that morning.  3.10.5  In the course of undertaking this SCR the author of the SWYPFT IMR has spoken with HV5 who has provided additional, more detailed information about the telephone call.  Interviews carried out by the author of the SWYPFT IMR have also revealed that HV5 contacted HV4 during the evening of 27 September 2011 and informed HV4 about the phone call from the member of the public.  No record was made of the phone call between HV5 and HV4.  Overview Report concerning Child K    Page 46 of 115 3.10.6  On 28 September 2011 Child K was admitted to BHNFT by ambulance, was subsequently transferred to SCNFT and died that evening.  Numerous contacts were made by a range of agencies and these are described in detail below.  As far as possible they are described in the order they occurred but in some cases there is no accurate record of the time.  There are also some discrepancies in the records of different agencies as to when discussions took place and what information was exchanged.  3.10.7 At 10:00 hours YAS received a 999 call from an adult male for Child K who was apparently unwell.  An ambulance was dispatched to the address given, which was the family home.  At 10:15 hours the ambulance left the scene to convey Child K to hospital and nine minutes later Child K arrived at BHNFT following which YAS EOC informed YAS Clinical Team Leader regarding the seriousness of the call and the crew’s concerns for the injuries to Child K.  3.10.8 Attending YAS staff completed a referral to Children’s Social Care and made the YAS Safeguarding Team aware of the incident.  Barnsley Social Care have no record of receiving a phone call from YAS although a member of clerical staff remembers receiving the call and believes that it was about the same time as the calls from the Health Visiting Service.  The member of clerical staff in Barnsley Social Care believes the details of this call were passed on to social work staff but none of the social workers who were on the ‘duty’ system that day, remember being told.  The Barnsley Social Care IMR also refers to a follow up fax received from YAS at 13:34 hours.  None of the social workers on ‘duty’ that day had any recollection of having ever seen, or known about this fax.  3.10.9 The author of the Barnsley Social Care IMR explains that this fax was filed on Child K’s record on the Local Authority’s ‘R’ drive, which is where items are stored which cannot be scanned onto ‘ERIC’, the computerised information system used by Barnsley Social Care.  The fax was scanned and filed on the ‘R’ drive on 30 September 2011, two days after it was received and this is likely to have been done by the member of clerical staff as this would be usual practice.  There is no record on ERIC to link Child K’s ERIC record to this fax held on the ‘R’ Drive although there is a record of a subsequent fax received from the health visitor on 30 September 2011.  Consequently, a person looking at Child K’s ERIC record would not be aware that a fax had been received from YAS.  3.10.10 At 10:36 hours the Police received a call from YAS to advise them that Child K was in cardiac arrest and being taken to hospital.  Police Officers attended at the hospital to ascertain the nature of the child’s injuries.  They were told by medical staff that the parents’ account was that he had been knocked over by the family dog, sustaining injuries.  It is recorded in the Police IMR that officers were told by staff at the hospital that, in their opinion, the injuries were compatible with the initial explanation given.  The author of the Police IMR has told the IORA that a consultant said that Child K had a small bruise which did not seem to be suspicious.  There is no reference to this discussion in the BHNFT IMR but it is recorded that Child K had  “a number of bruises on his forehead”.      Overview Report concerning Child K    Page 47 of 115 3.10.11 At 11:15 hours Staff Nurse 1 in the Health Visiting Team received a call from the member of the public who had contacted HV5 the previous evening.  The member of the public reiterated the information she had given the day before but is recorded as stating that the baby’s face was “smashed in” which father had stated was because the baby had “fallen down the bottom step”. The member of the public informed Staff Nurse 1 that she had seen an ambulance take the child from the house that day. Staff Nurse 1 advised the member of the public to ring Social Care and gave the telephone number of the Children’s Social Care duty team.  Staff Nurse 1 left HV5 a message about this phone call in the message book.  3.10.12 According to the SWYPFT IMR, HV4 contacted Barnsley Social Care 15 minutes later, at 11:30 hours, and informed a social worker (SW2) of the situation with Child K.  HV4 apparently told SW2 that Child K had a fractured skull and bleed on his brain and he was being stabilised before transfer to SCNFT.  The Barnsley Social Care IMR records three phone calls, in quick succession from the Health Visiting Service to Barnsley Social Care.  The first of these was taken by a member of clerical staff and it is probable that the second was also taken by the same person.  Social worker 2 may well have taken the third but the recording does not have that social worker’s initials and it is the individual’s practice usually to initial such records.  There appear to be some discrepancies around the time of the calls, with Barnsley Social Care records having everything later than other agencies do.  In the Barnsley Social Care IMR it is written that the first contact from the Health Visiting Service was recorded as being at 15:17 hours but could have been received up to half an hour earlier.  The Health Visiting Service had it recorded as being made nearly four hours earlier.  3.10.13 Having been informed by YAS of Child K’s admission to hospital, Police Officers attended BHNFT to ascertain the nature of the child’s injuries. They spoke to MK and FK and also to the Emergency Department consultant. They were told by the Emergency Department consultant that the parents’ account was that Child K had been knocked over by the family dog, sustaining injuries. At that point, the officers were told by the Emergency Department consultant that Child K had been unconscious when he was admitted to hospital but had been resuscitated and was now sedated whilst further tests were being carried out.  The Emergency Department consultant also told officers that Child K had some bruising on his forehead but the Emergency Department consultant did not think it was anything serious. The report from the Police Officers states that, in their opinion, there was nothing suspicious about the account of the accident and hospital staff brought nothing suspicious to their attention.      3.10.14 An officer attended the family house where Child K had allegedly been knocked over by the dog and Barnsley Social Care was updated at that point.  The author of the Barnsley Social Care IMR has written that the case recording states explicitly that at that stage the Police were not regarding the injuries to Child K as suspicious and they would contact Social Care again if that view changed.    Overview Report concerning Child K    Page 48 of 115 3.10.15 The record written by the Emergency Department consultant describes Child K’s condition on arrival briefly, noting that breathing was inadequate and needed support with bag and mask ventilation followed by anaesthetic input.  This record makes no mention of any discussion with the Police.  The record written by the Anaesthetist notes inadequate breathing requiring intubation and ventilation.    3.10.16 In mid afternoon the named nurse at BHNFT received a phone call from HV4 in which HV4 explained that a phone call had been received the previous day from the member of the public.  The SWYPFT IMR doesn’t include any record of HV4 phoning the named nurse but it does record that the named nurse phoned the Health Visiting Team and undertook to try to get an update of Child K’s progress.    3.10.17 Having received information from HV4 the named nurse at BHNFT made enquiries from the Emergency Department and consultant paediatrician at the hospital.  The named nurse then spoke to the social worker to ensure that Barnsley Social Care were aware of the situation.  It is written in the BHNFT IMR that SW1 said that Barnsley Social Care were aware of the situation but that Police stated that it was not suspicious.  The named nurse expressed concerns to the contrary based on the information provided by the health visitor about the phone call from the member of the public and the nature of the injuries.  The named nurse suggested that the social worker should immediately speak to the consultant paediatrician who had seen the child and could give a full account of the injuries and reported history.  3.10.18 Shortly after this, the consultant paediatrician did speak to the social worker; the consultant paediatrician recorded that the following points had been discussed during the phone conversation: 1. "Child K’s CT scan results and poorly condition.  2. Parents being made aware of Child K’s condition and informed that a referral had been made to Children’s Social Care.   3. The social worker confirmed that the family were not known to Barnsley Social Care. 4. The social worker was informed that a letter and CT scan had been sent to the Consultant Radiologist at SCNFT requesting his expert opinion.  The social worker was given his contact details and advised to ring him if needed as the consultant paediatrician was not working for the following few days. 5. The social worker was made aware of the health visitor and neighbour’s concerns 6. The social worker was made aware that FK was the only person to have witnessed Child K’s accident".  3.10.19 The IMR from Barnsley Social Care also states that the social worker had phone conversations with the named nurse and the consultant paediatrician at BHNFT and states that these were at 16:00 hours and 16:10 hours respectively.  Unlike the record in the BHNFT IMR, the one in the Barnsley Social Care IMR of the conversation between the social worker and named nurse does not refer to any discussion about whether or not the injuries might be suspicious.  The record, in the Barnsley Social Overview Report concerning Child K    Page 49 of 115 Care IMR, of the conversation between the social worker and consultant paediatrician largely covers the same points as those in the consultant paediatrician’s notes but two points are of particular note.  Firstly, it is recorded that the social worker told the consultant paediatrician that the Police were not treating this as suspicious at the time and the consultant paediatrician responded that this was rightly so as there were still a number of questions to be answered.  Secondly, there is no reference in the IMR from Barnsley Social Care to the consultant paediatrician telling the social worker about "a sibling".  As a result of the information contained within the BHNFT IMR the author of the Barnsley Social Care IMR has checked again with staff within the social work team and they are certain that no-one mentioned another child to them at the time. The author of the Barnsley Social Care IMR considers it likely that if the social worker had known about the existence of another child in the family then this would have been recorded, even if a decision had been made not to try to see the child.   3.10.20 Following the phone call between the social worker and the consultant paediatrician, the social worker discussed the case with the team manager and assistant team manager.  The content of their discussion is recorded at the end of the contact in as follows:  “Awaiting the outcome of current Police investigations and updates from Paediatric staff with regards to K`s condition/injuries. At this time Police indicate they are investigating circumstances but are not currently treating this as suspicious.  Police and medical staff will update Dept which will then inform Social Care decision making and any actions required.  Discussion with Team Manager and agreed above.”  3.10.21 This was the last contact that the assessment team had regarding this case on 28 September 2011.  3.10.22 On arrival at BHNFT Child K was taken to the Emergency Department where resuscitation attempts continued led by the emergency department consultant and anaesthetic consultant.  Meanwhile the paediatric registrar started taking a history from FK.    3.10.23 An urgent CT scan of Child K’s head was undertaken and this was reported on by the radiologist as showing skull fractures on two sites and a small subdural haematoma.  Initial full blood count and clotting studies were planned.  3.10.24 A consultant paediatrician attended the Emergency Department and examined Child K.  The consultant paediatrician took a history from the parents and maternal grandmother which Paediatric Registrar 2 transcribed onto the Child Protection Pack.  Because the nature of the injuries was unclear, the family were told that Social Care would be notified.  Later that same day Paediatric Consultant 1 and Paediatric Registrar 2 went through the notes and discussed the case.  Social Care, the Police, the health visitor and the named nurse for safeguarding children were all informed and Paediatric Consultant 1 wrote to the paediatric Overview Report concerning Child K    Page 50 of 115 radiologist at SCNFT requesting the radiologist’s opinion in interpreting the CT scan in the light of the history provided by MK and FK.  3.10.25 Paediatric Consultant 1 told the author of the BHNFT IMR that his instinct was that due to the circumstances of the injury being unclear, the bruising, and few witnesses, the possibility of a NAI should be considered.  He felt, however, that he could not say this with any certainty and required the opinion of the consultant radiologist.  He stated, however, that he was clear that a multi-agency process needed to be followed as NAI was to be considered as a possibility and that it was clear that he was considering the possibility of NAI based on his actions and the documentation used.    3.10.26 The paediatric registrar at BHNFT contacted a paediatric consultant at SCNFT to secure a bed within the Paediatric Intensive Care Unit (PICU).  The paediatric consultant told the author of the SCNFT IMR that the paediatric registrar was advised to contact the neurosurgeons prior to contacting EMBRACE, SCNFT’s specialist transport service in order to establish how urgent the transfer needed to be.  In the event, however, the CT scans were not immediately available to the neurosurgeons and the EMBRACE team attended BHNFT on the understanding that the neurosurgeons would be in touch once they had seen the scans.    3.10.27 The neurosurgical registrar and paediatric consultant at BHNFT identified from the CT scan that Child K had two skull fractures and a small subdural bleed (a bleed on the surface of the brain) but that the brain was normal.  Based on this diagnoses it was agreed that Child K did not require a very urgent transfer to the PICU at SCNFT but could be transferred by EMBRACE.  When the paediatric consultant at SCNFT reviewed the scan at around 14:00 hours he identified findings consistent with severe cerebral oedema (brain swelling).  The consultant radiologist then reviewed the scan and agreed that there was evidence of severe cerebral oedema.  This information was passed onto the EMBRACE consultant who was told that Child K still did not require a very urgent transfer but that there may be problems with raised intracranial pressure (ICP – pressure within the head).  3.10.28 Prior to leaving BHNFT the EMBRACE team told the paediatric registrar that they had noted blood on the tip of Child K’s penis when they were catheterising him.  This blood had not been noted when Child K was examined by the paediatric consultant at BHNFT.    3.10.29 The EMBRACE team from SCNFT left BHNFT with Child K at 16:30 hours on 28 September 2011 in order to transfer Child K to SCNFT.  During the journey Child K’s condition deteriorated and the ambulance stopped for treatment to be given.  Child K was then transferred urgently to SCNFT where, on arrival he was taken straight into x-ray for a repeat scan which confirmed that there was severe damage to the brain and he had coned (the lower part of his brain had herniated, i.e. pushed down into the top end of the space occupied by the spinal cord).    3.10.30 From x-ray, Child K was transferred to the intensive care unit where he continued to be in a critical condition. Due to progressive deterioration in Overview Report concerning Child K    Page 51 of 115 his condition, the decision was made with MK and FK to withdraw treatment. He was taken off the ventilator and handed over to MK to cuddle at 19:25 hours and was certified dead at 19:50 hours. Child K was transferred to the bereavement suite at 23:40 hours, the police were informed the same night and the coroner the following day.  Throughout this period, Child K’s parents were regularly updated.  3.10.31 During the evening of 28 September 2011 the consultant paediatrician on call at SCNFT contacted the out of hours duty social worker in Barnsley Social Care to inform the social worker that Child K had died and to gather some background information. The consultant paediatrician mentioned that Child K had a "sibling" and it is recorded in the Barnsley Social Care IMR that this was the first time that social workers had been aware of this.  The paediatrician and social worker agreed that the paediatrician would contact the Police and speak to MK and FK about the whereabouts of "the sibling" and would then contact the social worker with this information.  After the call to the paediatrician ended, the social worker contacted the senior manager on call.  After various phone calls it was established that the "sibling" was staying with "family members" but would be collected by "other family members" and taken to their home address, where the social worker and Police would undertake a safe and well check.  It is recorded in the IMR from Barnsley Social Care that initially there was a difference of opinion between health staff at SCNFT and staff from Barnsley Social Care as to whether "the sibling" should be seen that night, given the late hour and the degree of risk.  Finally, though the visit did go ahead and "the sibling" was seen asleep.  3.10.32 On 29 September 2011 the Assessment Team within Barnsley Social Care picked up the case and it was allocated to SW1 who commenced an initial assessment.  In the afternoon of 29 September 2011 a post mortem examination was carried out and a strategy meeting was held.  The strategy meeting was attended by the Police and Barnsley Social Care but health representatives were unable to attend and the Police asked BHNFT to provide a report to assist the post mortem.     3.10.33 Both Paediatric Consultant 1 and Paediatric Registrar 2, who had attended to Child K on 28 September 2011 were on leave the following day and the request for a medical report came to Paediatric Consultant 2.  Paediatric Registrar 2 had dictated a medical report before going on leave and had passed it on a secretary to type.  The report was still in draft form but, having undertaken various checks, Paediatric Consultant 2 made a copy, clearly marked as a draft, available to the strategy meeting.  Paediatric Consultant 2 also returned a phone call to SW1 and expressed the view that the history was unusual and the injuries significant and that Paediatric Consultant 2’s initial thought was that non accidental injury was a significant possibility.  3.10.34 The outcome of the strategy meeting was that there should be a child protection medical examination of "the sibling" , that the Police would interview MK and FK that afternoon and that Barnsley Social Care would speak to them the following day.  Barnsley Social Care would also make enquiries with Sheffield Social Care in view of information that had been Overview Report concerning Child K    Page 52 of 115 provided about FK’s ex partner.  Following the meeting SW1 contacted MK, FK and "other family members"  to advise that contact for both MK and FK needed to be supervised by another adult.  3.10.35 SW1 also contacted "the sibling's" nursery school to inform staff of Child K’s death, and advise them that contact needed to be supervised and that additional support may be needed when "the sibling" returned to nursery.  Records from the nursery suggest that "the sibling" attended the nursery everyday that week except for Friday 30 September 2012 but there are no records about who dropped them off or collected them.  Staff at the nursery told the author of the Barnsley Education IMR that no significant changes were noted in "the sibling's" behaviour.  3.10.36 The author of the SWYPFT IMR has written that on 29 September 2011 the named nurse at BHNFT telephoned the Health Visiting Team to inform them that Child K had died and that FK had been taken into custody and "the sibling"  had been removed from the family home and placed in care.  HV5 was informed of this situation.  By contrast, the report from Barnsley Social Care makes it clear that " the sibling" was not placed in care but was staying with "other family members".  3.10.37 On 30 September 2011 Paediatric Registrar 3 undertook a full child protection medical of "the sibling".  A "family member" and SW1 were also present.  No concerns were identified and the general physical examination was normal although the paediatric registrar identified grazes on "the sibling's" back and left arm, bruises on both knees and two very faint bruises on each side of the lower abdomen.  "These were" attributed the grazes and bruised knees from playing football the previous day but could not explain the faint bruises on the lower abdomen.  "The sibling" was asked about these bruises and said that they could not remember how they got them but they had not been hurt by anyone.  The authors of the BHNFT IMR state that the paediatric registrar has not written a specific comment about the abdominal bruises.  In addition to the physical examination, a blood count and clotting studies were undertaken and the results were within normal limits.  The findings were discussed with Paediatric Consultant 3 after which "the sibling" was discharged to the care of "a family member".  3.10.38 Also on 30 September 2011, Barnsley Social Care and the Police continued their investigations and communicated with each other.  A decision was made that FK should not have contact with "Child K's  sibling" until the position was clearer and that contact between MK and "the sibling" should be supervised.  3.10.39 None of the IMRs have any record of action in respect of this case on 1 October 2011, the last day of the period covered by this review.  4. Analysis  4.1 Introduction  Overview Report concerning Child K    Page 53 of 115 4.1.1 This review considers the actions of 11 agencies over a period of over four years and consequently a wealth of information is available for analysis.  IMR authors and the Independent Overview Author were asked to analyse agency involvement against 18 Terms of Reference.    4.1.2 In order to make the analysis manageable and meaningful Terms of Reference 3 and 4 are addressed first, by considering the key points and opportunities for assessment and decision making and the appropriateness of the action taken.  This is by far the longest section of this analysis. The actions of organisations are then analysed against the other 16 Terms of Reference.  Inevitably there is some overlap between the various issues and many of the interactions that professionals had with the family and with each other raised points that are relevant to more than one of these issues.  The IORA has tried to address points in the most relevant place and to cross reference where a point is discussed under more than one issue.    4.2 ToRs 3 & 4 What were the key relevant points / opportunities for assessment and decision making in relation to Child K and his family?  Do assessments and decisions appear to have been reached in an informed and professional way?   Did actions accord with assessments and decisions made?  Were appropriate services offered / provided, or relevant enquiries made in the light of the assessments?  4.2.1 Throughout the period of 4¼ years that this review covers there were numerous opportunities for assessment and decision making in relation to the various parties considered in this review.  These can be divided into a number of broad themes which is how they are considered here, firstly considering issues relating to FK and "his previous partner" (in the context of his relationship with her) and then MK and "her first child" when they were in Sheffield and finally Child K, "MK's first child"  MK and FK when they lived in Barnsley.  Within each thematic section issues are considered largely chronologically.  Issues relating to "FK's previous partner" and FK (in the context of their relationship)  Child protection of "FK's first child"  4.2.2 Although the period prior to the birth of "FK's first child" is outside the period covered by this SCR and the SCR Panel decided that "FK's previous partner's" maternity records should not be included in the STHFT IMR it is appropriate to comment that, on the limited information available, it appears that professionals acted appropriately in light of what was known about "the previous partner".  Action was taken before "FK's first  child" was born in order that they could be protected from birth and their name was then on the Child Protection Register for approximately nine months until February 2008.  Overview Report concerning Child K    Page 54 of 115 4.2.3 There are issues in FK’s history which should have led to some concerns about his capacity as a father.  However the author of the Sheffield Social Care IMR has identified that, whilst assessments did consider FK and his drug and criminal history, they largely focused on "his previous partner's" history.  Furthermore, where information was collected about FK this relied almost entirely on self-reporting from him and information was not verified in any other way, such as by the social worker contacting other agencies.  This was a shortfall in the thoroughness of the assessments that were undertaken at that time.  4.2.4 Whilst acknowledging that there should have been a more thorough assessment of FK, the IORA agrees with the author of the Sheffield Social Care IMR that it is questionable as to whether the information relating to FK alone would have been enough to warrant social care involvement, assessment and a Child Protection plan.    4.2.5 Whilst "FK's first child's" name was on the Child Protection Register the social worker and health visitor were the main professionals involved with the family; records suggest that they had an adequate level of involvement and that Core Group meetings took place every month as required.  4.2.6 The two Review Child Protection Conferences were key points for assessment and decision making.  It appears that the main reason for the continuing registration of "FK's first child" at the first review conference was the concerns that had arisen in August 2007 when it came to light that a couple, who may pose a risk to children, were staying with "extended family members".  This was dealt with promptly and with an appropriate level of concern; a Multi-Agency Public Protection Arrangements (MAPPA) meeting was held and FK, "his previous partner and family" were left in no doubt that it was not acceptable for "the child" to visit "these family members" whilst this couple were living there.  The situation was then monitored and the couple soon left the property.  The first Review Child Protection Conference was held on the same day as this MAPPA meeting and continued registration was agreed to enable the situation to be monitored.  This was a sensible approach.  4.2.7 By contrast the IORA has some concerns about the decision in February 2008 to remove "FK's first child's" name from the Child Protection Register and not to instigate a Child In Need Plan.  The IORA accepts that the level and number of incidents of concern that had occurred whilst "the child" had been on the Child Protection Register did not warrant continued registration.  However, the IORA considers that there were two issues that should have received greater consideration at the Review Conference in February 2008.  Firstly, prior to "the child's" birth the main concern had been about "their mother's" capacity to care for and protect a child.  The first eight months of "the child's" life suggested that FK and "his previous partner" together could provide adequate care but they had separated one month before the Review Conference and there had been very little opportunity to assess the impact this separation would have on "the child" or on their parents’ ability to care for them.    Overview Report concerning Child K    Page 55 of 115 4.2.8 Secondly, having delayed his treatment for "an infection" in order to help with caring for "his child", FK was due to start his treatment.  It was known and discussed in Core Groups that the treatment was likely to cause him to feel unwell.  The IORA considers that it would have been appropriate to have considered the likely impact of the treatment on FK’s parenting and mood and to consider whether further support could be provided to the family.  Although FK and "his previous partner" had separated, the impact of the treatment on FK was still an issue because he was having contact with "his child" and they had indicated that they were thinking about resuming their relationship.  4.2.9 Notwithstanding the above comments, the IORA acknowledges that no safeguarding concerns have emerged regarding the care provided to "FK's first child" after they were removed from the Child Protection Register which suggests that the decision was appropriate.  Support provided once "FK's first child" was removed from the Child Protection Register  4.2.10 Because Sheffield Social Care effectively ended their involvement with the family when "FK's first child's" name was removed from the Child Protection Register the only service having any sort of planned contact with the family was the Health Visiting Service.  It is unclear exactly what health visiting package was intended to be provided to the family during this period although the author of the Sheffield Health Visiting IMR indicates that it was an offer of universal services including the health visitor having monthly contact.  However between March 2008 and January 2009, when "FK's previous partner and child" became homeless health visitors saw "the child" at home three times and in clinic twice.  Therefore contact was, on average, approximately once every two months which does not accord with the plan of monthly contact but is a significantly greater amount of contact than would be provided under the core programme.  4.2.11 The author of the Sheffield Health Visiting IMR expresses the view that when "FK's first child" was first removed from the register a more defined package of support should have been put in place earlier.  The IORA agrees that it would have been appropriate for the health visitor to have assessed the family’s support needs at the time of the child's removal from the register and clearly agreed the level of support that would be provided.  The IORA is pleased to note that since 2009 all Child Protection plans that end in Sheffield are followed up by a Child in Need Plan as this provides a period of transition.  Domestic Incidents  4.2.12 There were two domestic incidents of relevance to this review.    4.2.13 In the first of these incidents, in August 2007, FK allegedly hit "his previous partner" who was reported to be intoxicated.  On being informed of these incidents Sheffield Social Care took action in a timely fashion with a social worker visiting to discuss the incidents with "both parties".  Sheffield Social Overview Report concerning Child K    Page 56 of 115 Care then made a written agreement with "the previous partner" and FK that they would not drink alcohol whilst caring for "their child".  Whilst the timeliness of the response should be commended, the IORA is concerned about the use of a “written agreement” in this way for two reasons. Firstly, the IORA questions how realistic it was to expect the parents not to drink alcohol at all whist caring for "their child"  Secondly it is unclear how this agreement was to be monitored or what the sanctions would be if the parents did not comply.  There are no references to this written agreement at a later date, even when there was further alcohol misuse and/or domestic violence.   The author of the Sheffield Social Care IMR has written that since this time the agency has recognised that child protection agreements are not a useful way of working with families as there is no way to monitor their effectiveness.  Practice now encourages all agreements to be incorporated into a child’s plan where all agencies sign up to it, and this has proven to be a more effective way of working together with families and professionals.     4.2.14 The other domestic incident that occurred was in October 2007 and on this occasion FK alleged that "his previous partner" was attacking him.  However when the Police visited there were no signs of any disturbance but FK was found to have been taking drugs.  This incident took place in October 2007 the day before a planned meeting and much of the meeting was spent discussing it.  FK was not present at the meeting and "his previous partner" reported that they had separated and FK was staying with "a family member".  However when the social worker visited the family home 15 days later "the previous partner" and FK were both present and said they were back together.  Although the author of the Sheffield Social Care IMR states that social work assessments took place after each domestic incident there is no indication of how this episode was addressed even though it occurred only two months after they had signed a written agreement that they would not drink alcohol whilst caring for "their child"   Learning Lessons, Taking Action (Ofsted, 2008) is a report of the evaluation of 50 SCRs.  One of the key messages from Learning Lessons, Taking Action is that “Agencies responded reactively to each situation rather than seeing it in the context of the case history.”  This is an example of such behaviour as Sheffield Social Care did not relate the domestic incident in October 2007 back to the assurances made by "both parties" two months earlier.  4.2.15 In addition to these two domestic incidents, there were four more during the remainder of the period covered by this review; in May 2008, August 2008, January 2009 and November 2009.  FK contacted the Police in connection with the first two of these incidents, both of which appeared to have involved verbal arguments.  "FK's previous partner" contacted the Police in connection with the third and fourth incidents and on both occasions stated that FK had hit her although the last incident was the only one where there was any evidence of an injury.  4.2.16 Of these four incidents, the first three occurred whilst FK and "his previous partner" were living together although the third was on the day they separated.  The fourth incident occurred 10 months after they had ceased Overview Report concerning Child K    Page 57 of 115 to live together and apparently after FK had commenced his relationship with MK.    4.2.17 The Police recorded who was present at the second, third and fourth of these incidents and in each of these, they followed necessary procedures and made Sheffield Social Care aware of the incident.  After the third incident they removed FK from the property and at the time of the fourth incident he was not living at the property anyway.    4.2.18 The author of the Police IMR has written that when Police Officers attended the incident in May 2008 they made the judgement that it did not meet the criteria of a domestic incident because no crime had been committed; consequently they did not submit the necessary domestic violence forms to the PPU which would have allowed the information to be passed to partner agencies. The author of the Police IMR explains that the officers were mistaken in their judgement and subsequent action.  Despite this comment, it is recorded in the Sheffield Social Care IMR that on 2 June 2008 a report of this incident was received from the Police.    4.2.19 Police Officers only made reference to the parties being under the influence of alcohol or other substances on one of these four occasions.  This was the January 2009 incident when it was recorded that both "parties" had been drinking.  The Police had previously identified that "the previous partner"  had been under the influence of alcohol during one of the incidents they had attended and FK had been under the influence of drugs during another of the incidents.    4.2.20  Sheffield Social Care had knowledge of three of these incidents, May 2008, August 2008 and November 2009 but there is nothing contained in social care records to indicate that they were aware of the incident in January 2009. The incidents in May and August were brought to their attention via police reports whilst the incident in November 2009 was self reported by "the previous partner". Sheffield Social Care informed the SCR that they undertook screening checks following the incidents in May and August and that the incident in November 2009 was addressed via the Initial Assessment undertaken as a result of an anonymous referral received a few days previously. The outcome of the assessment into the incident was recorded within this Initial Assessment. It is the understanding of the IORA that, with the exception of November 2009, Social Care did not complete Initial Assessments in respect of the reported domestic incidents and limited their assessment to screening checks which were reliant on the information provided by the police.  The IORA questions how Social Care were able to adequately assess the seriousness of each incident in the absence of contact with the family and contact with all involved agencies via an Initial Assessment.   4.2.21 All of these incidents were relatively minor and were spread out over a number of months. Nevertheless it is clear that the relationship between FK and "his previous partner" was punctuated by a number of domestic incidents for which one or other felt the need to involve the Police. The IORA has some concern that Sheffield Social Care responded to each Overview Report concerning Child K    Page 58 of 115 incident in isolation rather than in the full context of the case and as a result questions whether they were given sufficient consideration.  Injuries to "FK's first child", including hospital attendances  4.2.22 Over 2½ years between four and 34 months of age "FK's first child" sustained four minor head injuries, two of which resulted in them attending the Emergency Department at SCNFT.  The author of the Sheffield Health Visiting IMR concludes that health visitors were not sufficiently rigorous in considering the likely cause of some of these injuries.  The authors of the Health Overview Report consider that the injuries could have been genuine accidents that occurred as described but could also have been “Harbinger injuries”, (a term to describe an accumulation of minor incidents giving rise to a level of concern, including frequent A&E attendances).     4.2.23 "FK's first child" was only four months old when they sustained an abrasion to their right ear in 2007.  It has been difficult for this SCR to establish many details about this injury or how practitioners decided that it was not a possible NAI.  Neither the health visitor nor social worker who were working with the family at that time are still working in Sheffield and they have not been interviewed in connection with this SCR.  Therefore the IMR authors have been dependent on written information.  The author of the Sheffield Health Visiting IMR has recorded that the abrasion was seen and discussed at a Core Group meeting but the social worker who attended the core group meeting has not made any record of the abrasion.  The records from the health visitor do not describe the size or shape of the abrasion or whether there was any consideration of referring "the child" for a medical opinion.  The Sheffield Health Visiting IMR does suggest that FK’s explanation that the abrasion had been caused by his ring was readily accepted.    4.2.24 Any injury to a non mobile infant should be a cause for concern and it is important that practitioners display ‘respectful uncertainty’ when investigating such injuries.  In 2009, two years after "FK's first child" sustained the abrasion to their ear the National Institute for Health and Clinical Excellence (NICE) published guidance for health professionals on when to suspect child maltreatment.  Pages 8 and 9 of the quick reference guide list a number of alerting features that should prompt health professionals to suspect child maltreatment and these include situations where a child who is not independently mobile sustains, amongst other things, lacerations and abrasions without a suitable explanation.  Also in 2009 Sheffield Safeguarding Children Board issued a document “Section 47 Protocol for Responding to Concerns About Injuries or Abuse in Infants under 1 Year” a readily accessible internet based document designed to help practitioners to decide if there may be cause for concern and to outline the procedures to be followed where concerns are identified.  4.2.25 When HV5 noticed a small bruise on "FK's first child's" face during a visit in 2009 "the previous partner's" explanation that "the child" had fallen out of bed was accepted.  HV5 did not remember this incident when the author of the Sheffield Health Visiting IMR asked about it but did remember that "the child" was very active and boisterous.  This was only the second time that Overview Report concerning Child K    Page 59 of 115 HV5 had seen "the child" and their mother which raises a question as to whether HV5 was sufficiently familiar with the history to accept the mother's explanation without further enquiry.  The author of the Sheffield Health Visiting IMR draws attention to a question posed by Brandon et al, “For a child who is otherwise meeting developmental milestones might a parental explanation for injuries be too readily accepted?” (Brandon et al 2010)  4.2.26 On both occasions that "FK's first child" was taken to hospital, in  2008 when they had a laceration on their forehead and 2010 when they had a small graze/bruise on the upper gum and a small graze to the bridge of the nose, medical staff assessed the injuries as being accidental injuries that were consistent with the explanations given by the mother.  Information provided in the SCNFT IMR is that it was documented that there were no concerns about NAI.  This suggests that possible NAI was considered and discounted.  Whilst FK was present when "his child" sustained the first of these injuries there is no suggestion that he was present when the second was sustained.  4.2.27 Sheffield Social Care closed this case shortly after they were informed of "the child's" first hospital attendance, in 2008, and although the social worker had phoned the Health Visiting Service to request an update there is no record of this being received.  It appears that the case was closed without any contact with the family and without the update being received.      4.2.28 The IORA does not wish to overstate the potential significance of these injuries and it is important to emphasise that, even with the benefit of hindsight there is no information to suggest that any of the injuries sustained by "the child" were NAIs.  It is, however, worthwhile emphasising the importance of treating all such incidents in the context of the family history and not viewing each one in isolation.  In order to do this it is essential that thorough records are kept detailing the injury and how decisions about the likely cause and any necessary action were reached.  The IMRs provided for this SCR do not include any information to suggest that practitioners considered "the child's" previous history when assessing injuries they sustained.  Furthermore, the IMRs show that the records about the abrasion to their ear were insufficient.  Medical treatment for FK    4.2.29 The IORA has discussed that, despite the social worker and health visitor being aware that FK was due to start treatment for "an infection" , this was not considered when the agencies were considering "other issues in the family" and these services did not communicate with the Infectious Disease Team as would have been appropriate.  It is also important to consider whether the treatment impacted on "other family members" and how this was dealt with at the time.  4.2.30 Whilst FK was being treated, every out patient’s appointment provided an opportunity to assess how he was coping with the treatment and how it was impacting on those around him.  It is clear that FK did identify, on six occasions, that he was being affected emotionally and there was some Overview Report concerning Child K    Page 60 of 115 consideration of how this was affecting "his previous partner" but no consideration of whether it was having any impact on "other family members"  4.2.31 Although the GP assessed FK on one occasion there is no indication that this was done with any consideration for the welfare of "other family members" and there was no communication from the GP to the Infectious Diseases Team or to the health visitor.  4.2.32 The health visitor only saw FK twice whilst he was receiving the treatment.  The first of these visits was in June 2008 and there is a comment in the record that FK had started his treatment and looked thin and pale but there is no indication that there was any discussion about his mood.  Furthermore it is clear that there was no communication between the health visitor and the Infectious Diseases Team and the health visitor was never made aware that FK reported feeling ‘snappy’ and anxious.  4.2.33 The author of the STHFT IMR considers that communication with FK’s GP was excellent but acknowledges that there should probably have been some direct contact from the infectious diseases team to the health visitor.  The IORA acknowledges that the Infectious Diseases Team did make the GP aware of the likely side effects of the treatment but, as with the health visitor, there is no indication that the GP was informed about FK describing himself as ‘snappy’ and anxious.  4.2.34 The author of the STHFT IMR also identifies that staff in the Infectious Diseases Team were of the understanding that Children’s Social Care were involved with the family.  In that case, they should have made contact with Children’s Social Care when FK commenced his treatment.      4.2.35 It is not possible to say how much FK’s treatment affected his behaviour and whether it had any impact on " other family members"  However it is a concern that the Infectious Diseases Team, the GP and the Health Visiting Service did not communicate more with one another and work together.     4.2.36 The author of the IMR from STHFT considers that the assessments undertaken by the Infectious Diseases Team were appropriate at that time.  However the IMR author adds that there is now a wealth of literature that suggests that adult services should be more involved in the identification of children at risk and some changes are required in order to undertake accurate assessments of families in these services.  The IMR author describes changes that have been made within STHFT since this incident to improve staff awareness of the need to have regard to the welfare of children.  The IMR author states that, as a result of these changes, the number of referrals to community professionals is increasing considerably and there is the potential for a negative impact where by professionals become ‘swamped’ with routine letters and referrals that it can become difficult to highlight those at significant risk.  This is addressed in the recommendations of this review.  Assessments after "FK's previous partner" became homeless  Overview Report concerning Child K    Page 61 of 115 4.2.37 When FK and his "previous partner" separated in January 2009, she became homeless and moved, with her child, into bed and breakfast accommodation.  This resulted in another change of health visitor to HV5 who worked within the HASS.  This was a significant time of change and was therefore a key time for assessment.  The involvement of HASS was appropriate due to the vulnerability of homeless people and it is clear that assessments were carried out to support "the previous partner and put arrangements in place for "re-housing"  4.2.38 HV5 saw "the previous partner and child" three times over a period of nine weeks up to April 2009.  However it is unclear what further involvement HV5 planned to have because eight weeks later, when a member of the public contacted HV6 and reported concerns about a family, that turned out to be "the previous partner and child", HV5 did not know that they had been re-housed.  There is no indication that HV5 had tried to visit "the previous partner and child"  during that eight week period.  4.2.39 HV6 and a support worker from a housing agency worked together to assess the home situation when "the previous partner and child"  were re-housed and HV6 liaised with Sheffield Social Care.  This appears to have been a thorough assessment which resulted in a comprehensive package of support including the involvement of the support worker and an enhanced health visiting service.  Delivery of this enhanced health visiting service was not without some difficulties; for example, "the previous partner" and HV6 agreed in July 2009 that HV6 would visit again in three to four weeks but she was out when HV6 tried to visit and there was actually a period of nearly three months until September 2009 before the next visit.  In both November 2009 and February 2010 the health visitor and support worker experienced some difficulty contacting "the previous partner".  4.2.40 Anonymous referrals expressing concerns about "FK's first child's " wellbeing were received by Sheffield Care in June and November 2009.  In both instances there was a prompt response to the referral and an Initial Assessment was carried out.  However the basis on which Sheffield Social Care decided that the referral in June 2009 was malicious is unclear.  Records suggest that HV6 only got to know about this referral because "the previous partner" told HV6 about it.  This suggests that there was no communication from the social worker to the Health Visiting Service about the referral.     Assessment of FK in Sheffield  4.2.41 Previous SCRs in Barnsley and elsewhere have identified that professionals paid insufficient regard to fathers and other male caregivers when working with families and this was considered by Brandon et al, in pages 51 – 54 of “Understanding Serious Case Reviews and their Impact, A Biennial Analysis of Serious Case Reviews 2005 – 07” (2009).  More recently Ofsted, in its annual reports concerning the evaluations of serious case reviews, have made several references to practitioners not involving fathers and failing to adequately consider their needs.  It is explained in this report that FK was included in assessments carried out but that these assessments relied on self-reporting.  There are also comments from Overview Report concerning Child K    Page 62 of 115 professionals about FK being involved in caring for "a child".  These records suggest that FK was involved in the care of "his child"  and that professionals were attuned to discussing his involvement and role.  Records also suggest that, whilst FK and "his previous partner" were living together, she presented a positive picture of her relationship with FK.   4.2.42 As stated above, FK and  "his previous partner" separated and it appeared that professional input to the family was entirely directed at "the partner".  There is no indication that either the social worker or health visitor visited FK’s " home address" or offered any support to FK.    4.2.43 Following FK and "his previous partner's'" later separation in January 2009 FK again lived "with a member of his family". Sheffield Social Care had ceased their involvement with the family six months before this and there was no reason for them to be made aware that FK and "his previous partner" had separated.  However, the IORA is of the view that the Health Visiting Service should have had contact with FK in order to support him and also to ensure that the care being received by "his child" and the home environment were suitable.  As it is, neither HV5 nor HV6 ever met FK during the period covered by this review.     4.2.44 The author of the Sheffield Health Visiting IMR refers to there apparently being very little focus on FK’s parenting capacity.  The author highlights the need to involve and support fathers, including non-resident fathers and points out that this is especially important when it is known that the father is a significant carer for the child(ren).  The author draws attention to the Child Health Programme 2009 where it is written that “Fathers should be routinely invited to participate in child health reviews and should have their needs assessed.”    4.2.45 An incident in August 2009 is worthy of particular note.  The author of the Sheffield Health Visiting IMR has written that HV6 contacted "the previous partner" to arrange a visit and was told that she was unwell so "her child" was staying with FK and "his extended family".  HV6’s response was to carry out the visit the following week when "the previous partner" was better.  This would have been an ideal opportunity for HV6 to have arranged to visit "the child" with FK but this opportunity was missed.  Issues relating to MK and "her first child" when they were in Sheffield   Assessment of "MK's first child" in Sheffield  4.2.46 The visit from HV8 to MK and "her first child" in June 2009 provided the first opportunity for any agency in Sheffield to assess this family.  It is unclear what information Sheffield Health Visiting, received from their previous authority or if there was any communication between the services.  It is also unclear exactly what MK meant when she said that she supervised contact between "her child" and their father and whether she was referring to a formal arrangement whereby contact had to be supervised for the safety and well being of the child.  The IORA shares the view of the author of the Sheffield Health Visiting IMR that HV8 should have been more inquisitive about this issue and enquired further.  This Overview Report concerning Child K    Page 63 of 115 statement could have been an indication that there were child protection issues in respect of "this child" and this should have been clarified.  However, enquiries carried out for this SCR did not reveal any safeguarding concerns relating to "this child".  Hospital attendances for "MK's first child"  4.2.47 It is the view of the author of the SCNFT IMR that assessment and decision making around "MK's first child's" two attendances at hospital in 2010 was undertaken in an informed and professional manner.  The IORA is satisfied that there is no evidence that hospital staff should have taken further action and does not consider it necessary to make a recommendation around this issue.  MK’s pregnancy with Child K  4.2.48 MK was well supported in considering whether to have a termination of her pregnancy and when she was unsure about her decision to have a termination she received further counselling.    4.2.49 The author of the STHFT IMR explains that when the father of an unborn child is named no further routine checks are undertaken by the midwife, unless there are specific concerns raised within the social history that warrant further investigation and, in the case of MK’s pregnancy with Child K, no enquiries were made about FK’s history.  The author of the STHFT IMR states that there was no exploration about how FK’s ADHD affected his day to day ability.   Although other records suggest that ADHD was not a significant issue for FK by the time MK was pregnant with Child K, the IORA considers that it would have been appropriate for staff within maternity services to have made enquiries in order to appropriately assess whether FK’s ADHD may have an impact on the baby.     4.2.50 Although MK stated that she was no longer in a relationship with FK, when she booked for pregnancy care and there is no mention of him being present at any antenatal appointments, it now appears that MK and FK were together as a couple throughout the pregnancy.  Furthermore MK and FK have both said that FK attended the first scan that MK had in connection with this pregnancy.    4.2.51 Potentially significant information about FK was that he was the father of another child, that he was receiving treatment for a viral illness, that he had a history of substance misuse and that there was domestic violence in his relationship with his previous partner.  None of this information came to the attention of midwifery services during MK’s pregnancy with Child K.  Information that FK was the father of another child was known to the maternity service at STHFT but was recorded within the records of "his previous partner" as it related to her pregnancy.  Information about FK’s treatment for "an infection" was known to the infectious Diseases Team within STHFT but not to the maternity service.  4.2.52 The author of the STHFT IMR addresses this issue and identifies practical and ethical reasons why such information is not routinely shared within the Overview Report concerning Child K    Page 64 of 115 Trust.  The IMR author has written that midwives rely on the information that is provided to them by the women they care for and that whilst it is easy to check medical records (such as GP and hospital records) for the women that they care for, midwives will not have access to the records for the father of unborn babies.  The IMR author also makes the point that these reasons are not unique to STHFT but will apply nationally.    4.2.53 It is the case that working with and engaging with fathers is a national issue and that many agencies need to bring about organisational and cultural change.  Within maternity care, in 2011 the Royal College of Midwives issued guidance to midwives entitled “Involving Fathers in Maternity Care” and “Top Tips for Involving Fathers in Maternity Care”.  In 2010 the Fatherhood Institute produced “The Guide for New Dads” which is given to new fathers to encourage them to become involved with their children and to provide information, including information about keeping children safe.  4.2.54 The author of the STHFT IMR explains that the format of the midwifery records had been changed which is aimed at gathering a similar social history for fathers as is currently done for mothers.  The IMR author considers that this will be an improvement on the current situation but points out that it still relies on accurate and truthful information being obtained from women themselves, particularly in relation to the father.  Furthermore, the IMR author states that it is difficult to see how, without significant investment in the sharing of information which is currently held within individual agencies on different incompatible systems, there will be a robust solution to this problem should parents deliberately withhold or provide false information.  4.2.55 The IORA recognises that this issue of gathering information about the parents of unborn children to be a difficult issue nationally and acknowledges the efforts that have been made in Sheffield to improve the quality and quantity of information gathered about fathers.  There needs to be a balance reached between allowing information to be collected so that people with a history of behaviour that may pose a risk to children can be identified whilst not being overly intrusive.    4.2.56 Another area of concern in relation to maternity care for MK relates to her mental health.  Information provided in the IMRs from Primary Care and STHFT each provide an incomplete account of the services and treatment provided in respect of MK’s mental health.  Looking at the records together, and in conjunction with information provided by MK to the IORA and Designated Nurse, it appears that MK had two appointments with the Maternity Mental Health Team, approximately one month apart.  At her first appointment it was suggested that she begin a course of antidepressants but she was reluctant to do so and by the time of her second appointment her mood had improved enormously, apparently as a result of taking iron tablets.  It appears that the midwife did not receive a copy of a letter sent by the Maternal Mental Health Specialist to the GP in which MK’s assessment was summarised.  The author of the STHFT IMR points out that, without correct information the midwife would be unable to assess the risk to the child and make any necessary referrals for support.   Overview Report concerning Child K    Page 65 of 115  4.2.57 Apart from being named as the father of Child K, FK is invisible in respect of agencies’ contact with MK and "her first child"  during this period.  Information provided by MK and FK when they met with the IORA and Designated Nurse suggests that they were in a relationship with one another throughout MK’s pregnancy and that this relationship continues to the present time.  Furthermore, the information suggests that they were living together from around April 2010, six months before Child K was born.    4.2.58 It is to be commended that MW1 ensured that a home visit was carried out, prior to the birth of Child K even though the family were no longer living in Sheffield.  However the IORA takes the view that the informal arrangement of using a midwife who lived nearby was not appropriate.  Instead the IORA considers that it would have been appropriate for MW1 to contact midwives in Barnsley to inform them of MK and to ask if they would undertake a home visit.  If BHNFT had responded to the effect that they did not undertake home visits MW1 could have further explored this with her manager and decided on the next step.  It is not unusual for mothers to choose to give birth at a hospital outside the area in which they live and therefore it is to be expected that there will be other occasions when midwifes in Sheffield are providing antenatal care to women who live elsewhere.  Consequently the IORA considers that appropriate arrangements should be put in place so that midwives understand their responsibilities in respect of initiating pre-birth visits.  A further point is that health visitors in Barnsley are now required to carry out an ante natal visit for all pregnancies.  This expectation was not in place at the time of Child K’s birth but, if it had been, health visitors would not have been able to fulfil this requirement because they would not have been aware of the family and the impending arrival of Child K.     4.2.59 It should be recognised that these shortfalls were partly the result of a unusual set of circumstances.  Although MK moved home when she was less than half way through her pregnancy she did not change her GP until only a few weeks before Child K was born.  Indeed her GP remained unaware that she had moved home until shortly before Child K was born.  Consequently the health visitors responsible for "MK's first child" also remained unaware that the family had moved and therefore they did not inform Barnsley health visitors of "this child" until shortly before Child K’s birth.  Issues relating to Child K, "MK's first child", MK and FK when they lived in Barnsley   Postnatal midwifery involvement following birth of Child K     4.2.60 The authors of the BHNFT IMR comment that the care provided by midwives after Child K was discharged home was what would be routinely expected following a normal delivery without complications but that the visits would not usually all be undertaken by different midwives.  BHNFT’s standard is that a woman should see three or fewer different midwives postnatally and this is audited on a three monthly basis.  Of 20 women whose service was audited in the period when a service was provided to Overview Report concerning Child K    Page 66 of 115 MK, two saw one midwife, eight saw two, 10 saw three and none saw more than three.  There is no clear documented reason why four different midwives visited Child K and MK postnatally but one visit took place over the weekend and one midwife from the team was on sick leave throughout the period in question which placed added pressure on the team.  Given that the midwifery service monitors continuity of care on a regular basis and that it is unusual for a woman to see more than three midwives postnatally the IORA has not made a recommendation about this issue.        4.2.61 Although the authors of the BHNFT IMR describe the care provided to be that which would be routinely expected they also identify that the information available to the community midwives was substantially less than would usually be the case.  This is because the information that BHNFT received from STHFT about the family was not as extensive as the information that BHNFT would usually aim to gather in the antenatal period.  In particular midwives in Barnsley will routinely ask questions about social history and the family situation in the antenatal period, including asking about domestic abuse, mental health and substance misuse.    4.2.62 Midwives in Sheffield had undertaken a family history during the antenatal period but this information was not shared with staff from BHNFT when care was transferred to Barnsley.  Furthermore, the authors of the BHNFT IMR state that referrals into BHNFT from other areas are often made without any social history being provided.  The author of the STHFT IMR has written that the phone call that was made to BHNFT to inform them of the discharge of MK and Child K was in accordance with current STHFT hospital policy.  4.2.63 The IORA is concerned that BHNFT were not notified of the family’s transfer until MK and Child K were discharged from hospital and that the information relating to the social history and MK’s referral to the maternity mental health service was not transferred.  Whilst this might be usual practice it is the IORA’s view that it does not afford the best care to the family.  The IORA would argue that, if it is deemed necessary to gather a social history then surely it is important to ensure that professionals providing a service to the family are aware of the social history.    4.2.64 Women have the right to choose the hospital in which they want to receive antenatal care and give birth and this SCR does not suggest that patient choice should be diluted.  However it is important that arrangements are put in place to minimise any possible difficulties arising from the change of care provider that can then occur when the mother and baby return home.  First Contact from Barnsley Health Visitor  4.2.65 The first visit from a Health Visitor to Child K took place at an appropriate time, one day after the final visit from the Barnsley midwife when Child K was 12 days old.  However the health visitor had only received verbal handover information from the midwife, not a written discharge form as is required.  Records of this visit suggest that the health visitor did not gather some of the information required by the Health Needs Assessment and this Overview Report concerning Child K    Page 67 of 115 resulted in an incomplete understanding of the family which could have impacted on the assessment of the level of risk.  The author of the SWYPFT IMR specifically comments that no details were recorded about FK and there is no information recorded about his previous relationships.  Also there is no information recorded about the attachment of either child to MK.  The IORA notes that there is no indication that HV1 discussed the potential danger of the family dog with MK and FK.    Lesion inside Child K’s mouth – attendance at BHNFT CAU  4.2.66 When MK and FK took Child K to the GP in December 2010, the GP acted appropriately by referring Child K to the Child Assessment Unit (CAU) at BHNFT and asking the paediatrician to advise.  It is of note that this attendance was only one day after GP1 had carried out a six week check of Child K and had not identified any abnormality when checking the inside of the mouth.  4.2.67 Following a thorough examination the paediatric registrar concluded that Child K had a “Viral URTI” (upper respiratory tract infection) and had “coughed up blood due to burst blood vessel in pharynx”.  The authors of the BHNFT IMR explored with the paediatric registrar his understanding of safeguarding children and have recorded that the paediatric registrar said he would be particularly alert to safeguarding issues if he had known that there were previous concerns or if the history and examination did not fit.  The view of the authors of the BHNFT IMR is that the paediatric registrar’s diagnosis of “burst blood vessel” would not be a common one but there was nothing in the notes he has written to point to a different or more sinister explanation.  The author of the Primary Care IMR, however, comments that there was never a satisfactorily answered explanation for the bleeding in Child K’s mouth  4.2.68 This hospital attendance has been the subject of much discussion at SCR Panel meetings and concern has been expressed about the diagnosis made by the paediatric registrar.   Whilst there is no evidence that the raw mucous membrane on Child K’s soft palate was an NAI it is fully accepted that it was a very unusual presentation in a young child.  The IORA accepts the opinion of the authors of the Health Overview Report that because of the unusual presentation there should have been discussion with the consultant paediatrician and consideration should have been given to admitting Child K overnight to allow further investigations and enquiries to be made and to consider the possibility of NAI.  With hindsight this was a missed opportunity.  Admission to SCNFT in December 2010    4.2.69 It must be concluded that when Child K presented at SCNFT in December 2010 with an injury to his ear, there should have been a strong suspicion that he may have suffered an NAI and this should have been thoroughly investigated before he was discharged.  From the information provided in the SCNFT IMR it is clear that the registrar in the Emergency Department considered that the injury to Child K’s ear may be an NAI.  Staff in the ENT Team also had concerns about the cause of the injury and consequently Overview Report concerning Child K    Page 68 of 115 Child K was referred to the Medical Team specifically for that team to look at child protection issues.  However when Child K was examined by members of the Medical Team they appear not to have considered NAI and Child K was discharged without sufficient investigation into the cause of his injury.  The author of the SCNFT IMR addresses this issue in considerable detail and identifies failings on the part of the SPRs in the Medical Team not to have considered the possibility of NAI, the staff nurse in the Medical Team for not considering NAI and the ENT team for not questioning why the Medical Team had not properly considered NAI.  However, the author of the SCNFT IMR is unable to identify why these failings occurred.  The staff members concerned were experienced staff members with considerable experience in Safeguarding Children.  One issue that was raised during the carrying out of the IMR was whether the ENT doctors had communicated their concerns about NAI sufficiently clearly.  This is addressed in the SCNFT IMR with a recommendation that will tighten the referral process to the acute paediatric medical team.  The author of the SCNFT IMR also reports that Child K was in hospital during the winter flu season and both Medical SPRs reported that they were very busy and felt that this might have impacted on the care provided to Child K.  This point is considered in the analysis of Term of Reference 8.  4.2.70 It was appropriate for ENT2 to contact BHNFT and the health visitor for information about Child K.  The author of the SCNFT IMR explains that, whilst ENT2 could have contacted Children’s Social Care, it is the usual practice of this trust for other specialty professionals who have child protection concerns to pass these on to the acute medical team. Hence it is not unusual for ENT 2 not to have contacted social care personally.    4.2.71 The author of the SCNFT IMR has explained to the IORA that specialist doctors do not usually refer concerns to Social Care because they are not trained to carry out child protection investigations and these will still have to be carried out by the medical teams.    4.2.72 Considering this incident with the benefit of hindsight it is difficult to understand how the doctors with the medical team failed to realise that there were possible Safeguarding concerns in relation to Child K’s injury.  Child K was a non-mobile infant of less than two months of age and the primary reason that ENT staff referred him to the medical team was so that possible NAI could be investigated.  The suggestion that this was not made sufficiently clear on the referral is a matter of great concern.  The author of the SCNFT IMR has told the IORA that the system usually works well and she cannot explain why things happened as they did this time around.    4.2.73 Once HV4 became aware that Child K had been discharged without a full investigation of a possible NAI there was a responsibility on HV4 to challenge and if necessary to make a referral to Social Care.  In reality HV4 did not even see Child K for a further seven weeks.  4.2.74 With hindsight Child K’s admission to SCNFT in December 2010 seems to have been a very significant event.  It is impossible to know what would have resulted from a thorough investigation of the cause of the haematoma Overview Report concerning Child K    Page 69 of 115 but it is not unreasonable to suggest that it may have led to a very different outcome for Child K.    4.2.75 In addition to the haematoma, the potential significance of the bruise on Child K’s arm should not be disregarded.  Child K was a non-mobile infant and therefore this bruise should have resulted in some concern from medics and an attempt to establish how it had been sustained.  Records suggest that this was not pursued.  4.2.76 The IORA notes that a case review has been carried out in Sheffield regarding another child who was in SCNFT at the same time as Child K in December 2010 and that action has been taken as a result of that review to raise awareness and understanding of medical staff in relation to Safeguarding Children.  The IORA agrees with the recommendation to tighten up the referral process made in the SCNFT IMR.  Six – Eight week assessment of Child K by the health visitor  4.2.77 The six – eight week assessment of a baby is an important opportunity for health visitors to assess the development and well being of babies.  At the time of Child K’s birth, health visitors in Barnsley worked to a policy that this assessment should be carried out between six and eight weeks of age.  However, in January 2011 they adopted the “Healthy Child Programme 0-5 years Health Visiting Standards which require such a contact to be carried out at six weeks.  Therefore, if HV3 had managed to visit Child K in December 2010, as planned, this would have been just inside the eight week limit in place at that time for this visit.  No criticism can be levelled at the Health Visiting Service for the assessment not going ahead on the day of the planned visit and there was then a further unavoidable delay as a result of Child K being admitted to hospital.  However the subsequent delay of approximately seven weeks between Child K being discharged from hospital and HV4 actually undertaking the six - eight week assessment is a matter of concern.  Such a delay would be unacceptable in any circumstances but is of particular concern given that Child K had had two visits to hospital, including a period as an inpatient due to what may have been an NAI.  It is also a concern that the delay in carrying out the assessment was recorded as being due to Child K being in hospital and a changeover of health visitor when Child K had only been in hospital for five days and had been discharged seven weeks before the visit took place.  Furthermore HV4 had been working in this Health Visiting Team for eight weeks and had been the allocated health visitor for Child K throughout that time.    4.2.78 A further concern relates to where this assessment took place.  Following MK’s statement that it happened at clinic not at her home, the assistant director of nursing at SWYPFT made further enquiries and established that this was indeed the case.  Therefore HV4 never had an opportunity to assess Child K in his home environment or to assess the suitability of the home.  Furthermore this leads the IORA to question when this assessment would have been carried out if MK had not taken Child K to the clinic.    Overview Report concerning Child K    Page 70 of 115 4.2.79 It is also necessary to consider the quality of the six - eight week assessment that was carried out.  The author of the SWYPFT IMR has identified that HV4 did not complete the scorecard for the Edinburgh Post Natal Screening of MK and there is no record to indicate that HV4 discussed the relationship between Child K and either parent or identified that Child K’s weight had fallen from just below the 98th centile in November 2010 to just above the 75th centile at this visit.  The IORA cannot be sure whether these issues indicate that the assessment was not sufficiently thorough or are the result of inadequate record keeping but either way they are an additional cause of concern on top of the delay in the completion of the assessment.  4.2.80 Managers within SWYPFT have investigated why the six – eight week assessment was incorrectly recorded as having taken place at the family home when in fact it took place at clinic.  They have found that when practitioners record details of a contact on SystmOne there is a drop down menu to record the location of the contact.  However if practitioners do not use this drop down menu the location of the previous contact is automatically retained for the new contact.  This has been identified as a weakness in the system and it has been rectified.  When recording details of a contact, practitioners must now use the drop down menu to record location, before they can progress to the next page of the record.  Concerns about insufficient growth velocity  4.2.81 The issue of Child K’s weight is addressed in the IMR from SWYPFT and the Health Overview Report.  Having dropped to just above the 75th centile at the time of the delayed six - eight week assessment it continued to drop and had fallen below the 75th centile by the end of March 2011 before climbing back to the 75th centile one month later.  The authors of the Health Overview Report refer to guidance that was in place at the time which states that one trigger for Primary Care Assessment is when “weight has fallen across 2 centile spaces when weight is above the 9th centile”.  However, in the case of Child K, evidence suggests that health professionals did not even note that there was a potential issue of concern, let alone take the action required by the guidance.  The absence of any assessment as a result of Child K’s weight falling more than two centiles is of greater concern when one considers that this occurred in the weeks immediately after Child K was in hospital in December 2010.  Incident that led to the death of Child K  4.2.82 The IORA and SCR Panel consider that the response from HV5 when the member of the public phoned on 27 September 2011 was inadequate and inappropriate.  The member of the public expressed a clear and apparently cogent description of Child K’s condition which should have led HV5 to have concerns about Child K’s well being.  Having received this information HV5 had a responsibility for taking action and it was insufficient simply to suggest that the member of the public could ring the Police or Social Care.  The member of the public had acted responsibly by contacting “the authorities” and having done so should not then have been expected to make further phone calls.  The author of the SWYPFT IMR Overview Report concerning Child K    Page 71 of 115 considers that by failing to take responsibility for referring the concerns into Barnsley Social Care the health visitor breached the local Child Protection Procedures and a Local Work Instruction for Health Visiting Services.    4.2.83 It seems to the IORA that there were two factors that may have mitigated against HV5 taking responsibility for referring Child K into Social Care at this stage.  Firstly, the phone call was taken at 17:10 hours, 10 minutes after the health visitor should have finished work for the day and, therefore, it is quite possible that the health visitor was about to leave the office.  Secondly, the member of the public either could not, or did not want to, provide the name of the baby, which made it more complicated to take action.  However, neither of these factors constitutes an acceptable reason for not taking action.  Concerning the fact that the phone call was made outside normal office hours, the author of the SWYPFT IMR points out that the Professional Code of Conduct requires a Nurse to reasonably execute a duty of care at all times to uphold public confidence (NMC, 2008).   Regarding the reluctance of the member of the public to provide the name of the baby the author of the SWYPFT IMR considers that with more persuasion and reassurance about anonymity, the member of public may, at the very least have divulged where the baby lived.  The IORA agrees with this view.    4.2.84 The report “The voice of the child: learning lessons from serious case reviews” (Ofsted, 2009) highlights a number of occasions when adults, including members of the public not related to the child, have raised concerns about a child and these have not been taken sufficiently seriously.  The report concludes that LSCBs should “consider how they can better engage the general public in safeguarding children.”  The authors of the Health Overview Report draw attention to a new Hospital scheme which has been established by the National Society for the Prevention of Cruelty to Children (NSPCC) which allows members of the public to anonymously report concerns about a child by text.  This is in addition to the more traditional telephone helpline provided by the NSPCC.  The authors of the Health Overview Report explain that, within Barnsley, posters have been developed which advertise this texting service and these have been circulated for display in public areas to all GP Practices, General Dental Practices, Pharmacies and Opticians as well as public areas in BHNFT.  Whilst the development of the NSPCC system is to be welcomed it must not be allowed to absolve local agencies from acting responsibly when they are made aware of safeguarding concerns.    4.2.85 It is unclear from the SWYPFT IMR why HV5 informed HV4 of this phone call during the evening of 27 September 2011. However, once this information was shared both health visitors shared the responsibility for not taking action.    4.2.86 The author of the SWYPFT IMR also makes the point that HV5 should not have told the member of the public that she could phone HV4 the following morning to ascertain whether the child had been taken to the GP.  This is because it would be a breach of confidentiality to give such information about a service user to a member of the public.  Overview Report concerning Child K    Page 72 of 115 4.2.87 When the member of the public, phoned the Health Visiting Team on 28 September 2011, the staff nurse, like HV5 the previous day, failed to take professional responsibility for referring the case into Social Care.  By this time, Child K was already on his way to hospital by ambulance so there was little that could be done.  Nevertheless, it was important that Social Care were informed of the incident and it should not have been left to the member of the public to do this.  It is unclear from the records whether the member of the public named Child K, or referred to him having a sibling during the phone call to the staff nurse.  If it was evident at this stage that there was a sibling this should have been a further reason for the Health Visiting Team to make Social Care aware of the situation.     4.2.88 YAS staff acted appropriately by conveying Child K to hospital with his mother and informing both the Police and Barnsley Social Care of the incident.  It is unclear whether the phone call from YAS to Barnsley Social Care made reference to there being another child in the household, as would have been advisable, but the child was referred to in the fax that was sent to back up the phone call.  4.2.89 Having been informed of Child K’s admission to hospital, Police Officers also acted appropriately by visiting the hospital to seek further information and by discussing the case with Barnsley Social Care.  It is unclear whether Police Officers were aware, on 28 September 2011, that Child K had a sibling.  However, the Police had not had any previous contact with the family and had not been present at the house when Child K had been taken to hospital.  4.2.90 Although Police Officers sought information from the hospital about the extent of Child K’s injuries the IORA notes that the account within the Police IMR of what they were told about the injuries is substantially different to the account within the BHNFT IMR of the injuries.  In addition, the message the Police took from the hospital and passed on to Barnsley Social Care was that the injuries were compatible with the explanation given by the parents and were not suspicious.  However Paediatric Consultant 1 was of the view that NAI should be considered a possibility and the named nurse expressed concern to the social worker about the Police stating the injury was not suspicious.  4.2.91 In an addendum to the BHNFT IMR, the Named Doctor for Safeguarding Children at BHNFT has written that the Emergency Department consultant “would undoubtedly state that child K was seriously unwell at time of presentation, based solely on the fact that his spontaneous breathing was insufficient, and he needed support with ventilation”.  However, in the absence of any written record from the Emergency Department consultant about contact with the Police it is not possible to know what the Emergency Department consultant actually said about the seriousness of the injuries.  4.2.92 The Named Doctor for Safeguarding Children at BHNFT has also written in the addendum that neither the Emergency Department consultant nor the Anaesthetist “made any comments in the notes about whether they think the injury was accidental or non-accidental” and that “this would usually be Overview Report concerning Child K    Page 73 of 115 for the paediatrician to indicate once a fuller history and examination had been taken.”    4.2.93 Whilst it is not possible to know exactly what was said to Police Officers at BHNFT on 28 September 2011 it is clear that their understanding that the injury was not serious and the cause of it not suspicious was at odds with the reality of the situation.  Furthermore it is clear that this view affected how Barnsley Social Care considered the case during the rest of that day.  The IORA is satisfied that this apparent misunderstanding did not have any bearing on the tragic outcome for Child K or on the ultimate welfare of "his sibling" but on another occasion the outcome could have serious consequences.  Therefore the IORA is of the opinion that the Police, BHNFT and Barnsley Social Care need to develop a protocol around the sharing of information when a child attends hospital and there are possible safeguarding concerns.  This needs to address how, when and by whom, information should be shared and should support all disciplines to cope with the uncertainty that exists with such situations.  4.2.94 Barnsley Social Care had never had any contacts with, or information about, this family prior to 28 September 2011 and therefore when contacts were received that day they had no history relating to the family or details about who was in the family.  By the time the first contact was made with Barnsley Social Care, Child K was already at BHNFT receiving emergency medical care.  Consequently there was no immediate action for Barnsley Social Care to take in relation to Child K.  However there was a role for Barnsley Social Care in considering whether action was required to safeguard "the sibling".  4.2.95 It is clear from the information provided to this SCR that the relevant social work team within Barnsley Social Care received several contacts about this incident on 28 September 2011. HV4 contacted the team three times; YAS made a referral by phone and backed this up with a fax; an officer from the Police Public Protection unit, the named nurse from BHNFT and a consultant paediatrician also from BHNFT spoke to the social work team once each.  Despite this total of seven phone contacts and one fax, by the time social work day time staff went off duty they remained unaware of the existence of "the sibling"  and believed that Child K’s injury was not being treated as suspicious.  Because of these two factors, the out of hours Social Care service was not told about the family and nothing had been done to check on the well-being of "the sibling".  It is apparent from the Barnsley Social Care IMR that there were some organisational and resource issues that impacted on the handling of the information that was received on 28 September 2011.  These issues are considered in the analysis of ToR 8.  The issue of safeguarding "the sibling"  is considered in greater detail in the analysis of ToR 18.  Care and Treatment Provided to Child K in Hospital  4.2.96 The authors of the BHNFT IMR conclude that the overall management and care of Child K whilst he was in the emergency department was of a good and safe standard.  One issue is that an out of date child protection medical pack was used.  The significance of this is that the up to date pack Overview Report concerning Child K    Page 74 of 115 in use at that time provided a trigger for doctors to explicitly include their professional opinion and to make it clear that this was a professional opinion.  The authors of the BHNFT IMR explain that, in the case of Child K, the use of the out of date pack did not lead to a clearly identified opinion section in the report sent to Social Care.  The authors of the BHNFT IMR explain the action that has been taken to ensure that no further out of date packs are in use and has strengthened arrangements to ensure that unused packs are destroyed when a new version is produced.  4.2.97 The author of the SCNFT IMR has concluded that the difference in interpretation of the CT scan did not make a difference to the outcome for Child K as, even when the cerebral oedema was identified the advice remained that he did not require a very urgent transfer.  Nevertheless it is important to ensure that the interpretation of scans is of the best possible quality and therefore it is necessary to consider what can be done to minimise the risk of a repeat.  The author of the SCNFT IMR refers to "another SCR" where there was an issue with an out of hours radiologist refusing to undertake a scan on the child.  This led to a recommendation that BHNFT and SCNFT needed to come to an arrangement to ensure that CT head scans carried out at BHNFT are interpreted by a paediatric radiologist.  The authors of the BHNFT IMR conclude that, where a child is to be transferred to SCNFT, radiology images should automatically be sent electronically to SCNFT so that any of the Hospital 2 clinicians likely to be involved in ongoing care can be assured they will have access to all relevant images without delay or confusion.    4.2.98 The statement in the BHNFT IMR that EMBRACE staff noted blood on the tip of Child K’s penis was a matter of some concern to the SCR Panel as the extent or cause of this blood was not addressed in any IMR.  The Assistant Executive Director, Safeguarding Health and Social Care, Barnsley CYP&F made enquiries of the investigating police officer who had seen the injury, was not concerned about it and described it as a tiny scratch that a child of that age might well have caused himself with a fingernail.  In light of this the IORA is satisfied that it is not an issue that requires further consideration in this SCR.    4.2.99 The care provided to Child K at SCNFT is considered to have been of a good standard, appropriate to his condition and consistent with policies and procedures.  There is no suggestion that any different action could have been taken that would have led to a different outcome for Child K.    Action taken after Child K had died  4.2.100 Relevant actions after Child K died relate to the welfare of "the sibling". This is addressed in the analysis of ToR 18.  4.3 ToR 1 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?  Overview Report concerning Child K    Page 75 of 115 4.3.1 One would anticipate that staff working in the organisations involved in this SCR should be 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 and certainly there are many examples of these factors being demonstrated.    4.3.2 However there were also some occasions when opportunities were missed, including the following:  4.3.3 As has already been described neither MSPR 1 nor 2 appreciated the significance of the information available to them when they assessed Child K when he was in SCNFT in December 2010 with the haematoma on his ear.  During the interviews, both SPRs were quick to identify the risk factors and indicators of abuse , however due to reasons which neither of them could explain, their assessment of Child K’s injury was limited to the possibility of a clotting disorder despite documentation in the case notes by the ENT surgeons about their safeguarding concerns.  Similarly the health visitors in Barnsley did not raise any concerns about this injury and did not challenge the staff at SCNFT about the decision to discharge Child K without fully investigating the possibility of NAI.     4.3.4 There is no evidence that the Health Visiting Service in Barnsley recognised that Child K had lost weight or took the action required by the guidance in place at the time.    4.3.5 The Health Visiting Team in Barnsley did not respond appropriately when a member of the public reported that she had seen a child with an apparent facial injury on 27 September 2011.  It appears that the health visitor who took the initial call did not appreciate the severity of the injuries.  The health visitor and staff nurse both tried to place responsibility for contacting Social Care onto the member of the public rather than taking professional responsibility for doing this themselves.  4.3.6 The Infectious Diseases Team at STHFT, Sheffield Social Care, Sheffield Health Visitors and FK’s GP all failed to consider the potential impact on "FK's first child" of FK’s treatment for "an infection" and no arrangements were put in place to ensure that this was monitored.  The various agencies did not communicate sufficiently well with one another about this.   4.3.7 On one occasion, YAS staff did not fully appreciate the potential impact of domestic violence in the family home and did not share information with Children’s Social Care as they should have done.  4.4 ToR 2 Did the organisation have in place policies and procedures for safeguarding and promoting the welfare of children and acting on concerns about their welfare?  4.4.1 All the organisations that contributed to this SCR have provided information about the policies and procedures that they have for safeguarding and promoting the welfare of children and acting on concerns Overview Report concerning Child K    Page 76 of 115 about their welfare.  These include the South Yorkshire Child Protection Procedures agreed by the Local Safeguarding Children Boards across South Yorkshire as well as specific policies and procedures within individual organisations.   4.4.2 This SCR has already commented upon the failure of the Barnsley Health Visiting Service to follow the guidance relating to inadequate weight gain in the Barnsley Primary Care Trust document “Assessment & Management of Weight Faltering (Failure to Thrive)”.  A further issue about this guidance is that it was issued in 2005 and was six years old and overdue for review by the time the service had involvement with Child K in 2011.    4.4.3 The most significant failings in this case – the failure to investigate Child K’s haematoma in December 2010 and the inadequate health visiting service provided to Child K – did not result from a lack of policies or procedures but, respectively, from a failure to identify possible signs of abuse and a failure to follow procedures.  4.4.4 STHFT is worth particular consideration as this trust primarily provides services to adults, not children.  Section 11 of the Children Act 2004 placed a duty on many organisations, including NHS foundation trusts such as STHFT, to ensure that “their functions are discharged having regard to the need to safeguard and promote the welfare of children”.  In the STHFT IMR it is explained that the Trust has a ‘Safeguarding Children Policy’ (STHFT 2011).  The Lead Nurse, Children and Young People at STHFT has confirmed to the IORA that this policy was introduced in January 2008 and updated in December 2009 and February 2011.  Prior to 2008, STHFT relied upon the South Yorkshire Child Protection Procedures when dealing with such issues.  The involvement of the Infectious Diseases Team with FK was in 2007 – 2009 and was therefore during the initial development and implementation of this policy.    4.4.5 The STHFT policy that requires community midwives to carry out a home visit before a child is born was introduced following a previous SCR in 2008.  The purpose of this visit is to enable midwives to ensure that the baby is discharged to suitable home circumstances.  Whilst the IORA believes that the midwife should have liaised with Barnsley midwives regarding this visit it is encouraging to learn that this policy has become embedded in practice.  4.5 ToR 5 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?  4.5.1 A small number of events identified within this case occurred at times outside normal working hours.  4.5.2 In October 2007 Sheffield Social Care and the Police liaised appropriately about a domestic incident involving FK and  "his previous partner" .  Information was appropriately passed onto day time staff within Sheffield Overview Report concerning Child K    Page 77 of 115 Social Care and was followed up by the allocated social worker the following day.  4.5.3 Child K’s attendance at the CAU in BHNFT in December 2010 took place in the evening but this does not appear to have had any detrimental impact.   4.5.4 The phone call to HV5 from the member of public expressing concern about the well being of Child K was made after 5.00 pm and the IORA has considered whether this might have had an impact on the way that the health visitor responded.    4.5.5 Child K died during the evening and the out of hours social care team became involved.  They had not been briefed by the day time service because at the end of the day Barnsley Social Care staff were unaware that Child K had a sibling and they understood that the injury to Child K was not considered to be suspicious (this is addressed in detail in the analysis of ToR 18).  When the out hours social care team were informed, by SCNFT, of the death of Child K the response was appropriate and there is no suggestion that the absence of information from the day time staff had an adverse affect on how the out hours team responded.    4.5.6 The Paediatric Medical Consultant at SCNFT described having spent a considerable amount of time dealing with arrangements regarding safeguarding "the sibling".  She felt that this was not ideal as she was on call out of hours and had other responsibilities to deal with.  She told the author of the BHNFT IMR that this would have been avoided if there had been a social worker on site.  The SCNFT IMR does not make any recommendations about this.  The IORA has sought further information from the author of the SCNFT IMR to try to establish if this is an ongoing problem relating to a deficit in the out of hours service.  In response the IMR author informed the IORA that she believes that social workers from Sheffield Social Care come to the hospital, even out of hours and therefore she believes this problem arose because Child K was from Barnsley.  In the absence of more detail from SCNFT the IORA does not consider this to be a priority issue for the SCR to pursue.  However, if SCNFT consider this to be a significant problem they should discuss the matter with Barnsley Social Care.  4.6 ToR 6 Was practice sensitive to the racial, cultural, linguistic and religious identity and any issues of disability relating to Child K and his family?  Were they explored and recorded?  4.6.1 All the children and adults whose records have been accessed as part of this SCR are white, British with English as a first language.  For the most part, the agencies that have contributed to this review had recorded these basic details about the family members with whom they had contact.  However the author of the SWPFT IMR has identified that the ethnicity of MK was not recorded on SystmOne and there were no details relating to FK.  Overview Report concerning Child K    Page 78 of 115 4.6.2 Several agencies, including Primary Care, SWYPFT, Sheffield Social Care and Barnsley Social Care do not have a record of the family’s religion.  Where information relating to religion was recorded, family members were mainly described as either “Church of England” or “Christian”.    There are no records in any of the IMRs to suggest that the family held strong religious beliefs that impacted on their daily lives or required services to be delivered in a particular way and no indication that the hospital chaplain was involved when Child K was dying.  4.6.3 The only known issue relating to Child K or any of the family members that could be regarded as a disability is FK’s childhood diagnoses of ADHD.  The Health Overview Report contains useful information about ADHD, including the difficulty that doctors face in making a clear diagnosis and the differences of opinion that exist regarding the extent to which the condition persists into adulthood.  The Health Overview Report also identifies challenges with the transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) and concludes that “there continue to be gaps in provision for some young people once they have left Children’s Services with GPs continuing to monitor and prescribe medication for ADHD without specialist advice or support.”  4.6.4 It is clear from the IMRs that most agencies were unaware of FK’s history of ADHD.  Given that he had not had any treatment for ADHD since he was 16 years of age, which was six years before the birth of his first child,  and nine years before he moved to Barnsley with MK the IORA is not surprised by this and does not consider it to be a failing on the part of the agencies.  MK told maternity staff at STHFT about FK’s ADHD when she booked for her pregnancy.  The IORA expresses the view that maternity staff should have made further enquiries about this at that time.   4.6.5 With regard to cultural identity the IORA believes that a possibly significant factor that was overlooked was that FK was the main carer for Child K and "his sibling" once MK returned to work, three days a week, in May 2011.  With the benefit of hindsight it can be seen that FK may have been isolated and lacking support when he was caring for the children.  He had moved away from his home area, was not able to drive and he himself told the IORA and Designated Nurse that he found it difficult to go to groups such as baby and toddler groups as he felt awkward being the only man there. The IORA does not have any recent figures about the number of families with pre-school children where the mother is the only bread winner and father cares for the children.  Nevertheless it is safe to say that this is still a relatively unusual situation and the vast majority of people taking children to groups such as baby and toddler groups, are women.    4.6.6 It is interesting to note that that the Barnsley Education IMR report that "Child K's sibling" attended sessions at the Children’s Centre “with Child K, MK and occasionally (the IORA’s emphasis) FK.”  Furthermore, even after MK had returned to work she attended a Positive Parents Group at the Children’s Centre but FK did not.  There is no indication that either the Children’s Centre or the Health Visiting Service were aware that FK was the children’s main carer, or that there was any discussion with him about what support he might need. Overview Report concerning Child K    Page 79 of 115  4.7 ToR 7 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?  4.7.1 Much of the work carried out with the families involved in this review was consistent with policies and procedures for safeguarding and promoting the welfare of children and with wider professional standards.  Examples include the following:  4.7.2 During the first few months of "FK's first child's" life the social worker and health visitor were the main professionals involved with the family; records suggest that they had an adequate level of involvement and that Core Group meetings took place every month as required.  4.7.3 The first time "this child" attended hospital they were transported by ambulance which had been requested by FK and as per procedure YAS alerted the Police to the hospital attendance.  Police officers who attended did not feel that the incident met the threshold for Child Protection but did feel that other agencies should be made aware of what had occurred.  Consequently they completed a Gen 118a Concern for a Child Form which was also in line with procedure.    4.7.4 Health Visitors in Sheffield had regular child protection supervision in respect of "FK's previous partner" as required by the Safeguarding Children Supervision Policy for Clinical Staff in Sheffield.  Sheffield Health Visitors also demonstrated good practice by having discussions with FK and "his previous partner" about the potential danger that dogs can pose to young children.  4.7.5 Occasions when work was not consistent with policy and procedures for safeguarding and promoting the welfare of children, and with wider professional standards included the following:  4.7.6 HV5 did not know that K3 and "his previous partner" had been re-housed in 2009.  In addressing this, the author of the Sheffield Health Visiting IMR states that, on occasions in the past the Housing agency have not informed HASS when a family have moved out of interim accommodation into a permanent address.  She adds that this practice has improved and currently HASS and Housing meet on a monthly basis to share information regarding vulnerable families who are homeless and this has resulted in improving communication between these services.    4.7.7 The community midwives from BHNFT did not complete a written discharge form when handing care of Child K on to the health visitors.  4.7.8 There were several ways in which the service provided by SWYPFT was not consistent with policy and procedures and with wider professional standards.  These have been addressed in detail and include the omissions at the initial visit from the health visitor, the substantial delay in carrying out the six-eight week assessment, HV4 never visiting the family Overview Report concerning Child K    Page 80 of 115 home, the failure to recognise and monitor Child K’s weight loss and the unacceptable response to the member of the public who phoned to express concern about an injury to a child, which turned out to be Child K.    4.7.9 The occasion described in the analysis of ToR 1 when staff from YAS did not appreciate the potential impact on a child of a domestic incident between adults resulted in staff failing to act in accordance with policies and procedures.  4.7.10 Good professional standards include keeping acceptable records.  Sheffield Social Care’s records contain no reference to the abrasion to FK's" first child's" ear, although the health visitor has recorded that it was discussed at a core group meeting in September 2007 which was attended by the social worker.  In addition Sheffield Social Care do not have any records relating to the core group meeting held in October.  These omissions suggest a shortfall in the Sheffield Social Care record keeping for this case.    4.7.11 The author of the SWYPFT IMR found that record keeping within this case was not of a good standard, with omissions in relation to basic record keeping standards.  Specifically the record keeping of the initial home visit was insufficiently thorough, there was a delay in making a record of the phone call from the member of the public on 27 September 2011 and the six-eight week assessment was incorrectly recorded as a home visit when it had taken place at the clinic.  This last point has raised a concern about SystmOne.  4.7.12 The Emergency Department consultant at BHNFT did not make any record of having spoken to the Police following Child K’s admission on 28 September 2011.  4.8 ToR8 Were there any 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 sick or on leave have an impact on the case?  4.8.1 When FK received treatment for "an infection"  the adult social work post in the team was vacant.  Consequently FK did not receive social work support whilst he was receiving the treatment.  It is impossible to know what level of support FK would have received if there had been a social worker in post or to establish whether this would have made a difference to the identified failure of adult and children’s services to talk to one another or to assess the impact of FK’s treatment on "his first child".       4.8.2 This SCR has identified a significant failing when Child K was taken to SCNFT with a swelling to his ear in December 2010 but the possibility of it being caused by NAI was not investigated.  There are two organisational issues that may have contributed to this outcome.  Firstly, it is reported that MSPR 1 felt that the ENT doctors did not communicate their concerns about NAI clearly.  However, even without a clear statement from the ENT Overview Report concerning Child K    Page 81 of 115 department, it should have been clear to the medics that Child K’s injury was suspicious and needed to be investigated as a possible NAI.  Nevertheless, the IORA welcomes the recommendation made within the SCNFT IMR that telephone referrals from other specialties to the acute paediatric medical team should be backed up by a written referral.  4.8.3 The second issue raised as a contributory factor relates to the capacity within the service.  It is reported in the SCNFT IMR that this admission took place during the winter flu season which is a time when a large number of children attend the hospital with respiratory problems.  Both Medical SPRs reported that they were very busy and felt this may have impacted on the care provided to Child K.  The author of the SCNFT IMR believes that, whilst the increased workload may have been a contributory factor to the substandard care Child K received, it is unlikely to have been a major contributory factor and no recommendation is made about increasing capacity.  However as noted above action has been taken as a result of another review to raise awareness and understanding of medical staff at SCNFT in relation to Safeguarding Children and further recommendations are made in this SCR.     4.8.4 Significant organisational difficulties have been identified with the Health Visiting Service in Barnsley and these impacted on the service provided to the family once they moved to Barnsley.  The author of the SWYPFT IMR identifies the following issues: � The movement of Health Visitors � High caseload numbers within an area of mixed deprivation � Staff working reduced hours � Staff on maternity leave � HV4 being the only full time permanent member of staff within the team to which they moved � Unclear lines of accountability in relation to management and leadership � The merger with SWYPFT � The introduction of a new electronic records system  4.8.5 These issues contributed to the situation whereby Child K and his family saw three different health visitors and a student health visitor, the lack of any follow up after Child K was discharged from hospital in December 2010 and the lengthy delay before the six – eight week assessment was completed.  The IORA believes that it is highly likely that these organisational difficulties impacted on the quality of the service delivered by individual health visitors.  4.8.6 The author of the SWYPFT IMR has made five recommendations which address specific organisational and practice issues and has also recommended that “an overall review of the Health Visiting Service is undertaken which includes a robust consideration of the management and leadership structure within Health Visiting.”  It is recommended that this review is undertaken by someone independent of the service and is completed by December 2012.    Overview Report concerning Child K    Page 82 of 115 4.8.7 Significant work has already been taken by SWYPFT to improve the Health Visiting Service in Barnsley. The following actions have been taken: � A service redesign group has been established. � A case file weighting tool is now in use. � A case file audit has been undertaken. � An analysis of case load is under way and a policy is in development with regard to prioritizing case loads. � A SystmOne record keeping group is addressing the technical and practical aspects of record keeping � The team leaders have a defined role with clear lines of accountability and support from a professional lead. � A new manager has been appointed with a strengthened job description. � A local safeguarding children action group in Barnsley SWYPFT is monitoring the actions and this is overseen by the SWYPFT safeguarding children’s committee. � There has been a realignment with The Safeguarding Children’s Team has been repositioned to the Corporate Directorate to ensure a direct link to the nurse director and leadership structure  4.8.8 The IORA is reassured that SWYPFT are taking appropriate action in response to the findings of this SCR and wishes to emphasise the importance of these changes being seen through to a conclusion in order to ensure that the organisation can deliver a safe Health Visiting Service within Barnsley.  4.8.9 Barnsley Social Care had no knowledge of Child K and his family until he was on his way to hospital on 28 September 2011.  However, during that day they received seven phone calls and a fax about him from four different agencies.  Organisationally, the initial contact about a case, before it has been accepted as a referral, will be taken by a member of the Business Support Team, who are clerical staff, not qualified social workers.  Once information is entered on the computer system it appears directly on the work desk of the duty officer, who is a qualified social worker.  4.8.10 In the case of Child K, the phone call and fax from YAS were both received by a member of the Business Support Team and the investigation suggests that neither were brought to the attention of the duty social worker.  This is of significance as the fax is the only contact where it is known for certain that reference was made to "Child K's sibling".  4.8.11 The author of the Barnsley Social Care IMR has found that there were organisational difficulties being experienced by the Business Support Service supporting this Assessment Team on the day in question. The minimum number of staff normally required to cover reception is two but on this occasion, due to staff sickness and leave there was only one person available in the afternoon.  Furthermore this person had additional management responsibilities across several operational teams as well as being the initial point of contact with the service for the public and other agencies.    Overview Report concerning Child K    Page 83 of 115 4.8.12 The author of the Barnsley Social Care IMR goes on to explain that there have been reductions in the number of Business Support Staff over a number of years as a result of the Gershon Report and more recent pressures following the reduction in local authority budgets.  As a result the Business Support Service provided within social work teams is adequate provided everyone is in work but there are difficulties covering for sickness and leave.  The IMR author goes on to make four recommendations which are directly related to improving the service that business support staff can provide to social work teams.  4.8.13 A further difficulty identified within Barnsley Social Care concerns where the fax from YAS was filed.  It could not be filed on ERIC, the computer based system that associates such documents with the service user’s case records and because of this it was filed on a different computer drive with no reference to it on Child K’s case records.  The outcome of this is that the fax was effectively lost.  The author of the Barnsley Social Care IMR has made three recommendations to address this issue.   4.8.14 The author of the Barnsley Education IMR identifies that the nursery had previously undertaken home visits for new parents but that these had ceased due to resource issues.  The IMR author suggests that Early Years settings should review the potential value and feasibility of re-introducing home visits to new parents in order to help build up a picture of a child’s situation.  There is, however, no evidence that the lack of a home visit from the nursery made any difference to the management of this case or the outcome for Child K.    Communication issues between agencies  4.8.15 Many of the organisational difficulties identified in this review related to poor or no communication between organisations.  Much of this has been considered in this analysis and so will only be mentioned briefly here.  4.8.16 As reported with regard to ToR 7, there was an organisational difficulty whereby the housing agency did not always communicate appropriately with HASS when people were re-housed.  This is being addressed and the situation has improved.  4.8.17 On one occasion YAS did not inform Sheffield Social Care of a domestic incident involving MK's previous partner.  "A child" was known to be present in the household but the professionals involved did not appreciate the potential impact of domestic violence on a child.  4.8.18 Although the Police made Sheffield Social Care aware of the domestic incidents that occurred between FK and "his previous partner" in May 2008, August 2008 and January 2009, records suggest that Sheffield Health Visiting Service were not made aware of them.  Given that there was no involvement from Social Care at that time, and the Health Visiting Service was providing an enhanced package of care to the family it would have been beneficial for the service to have been informed of these incidents.    Overview Report concerning Child K    Page 84 of 115 4.8.19 A service manager from Sheffield Social Care has provided the IORA with information about the “Joint Investigation Team” that was established in September 2009.  This is a joint venture between Sheffield Social Care, South Yorkshire Police and Sheffield Domestic Abuse Partnership and the purpose is to improve the efficiency and effectiveness of both the police and social workers in responding to safeguarding issues for children and young people.  It is intended to make the best use of the respective skills of both police officers, social workers and the multi-agency team in the investigation of allegations or suspicions of child abuse, information sharing and assessing domestic violence referrals to the Police.  The domestic violence protocol, delivered by the Team, ensures that every domestic violence notification/incident attended by the Police is reviewed and risk assessed daily by a multi-agency group including practitioners from Police, Social Care, Health, Sheffield Domestic abuse and the Multi-agency Support Team (MAST) to ensure that information is shared, that joint planning is agreed and matters are progressed in a timely way by the most appropriate agency.  It is anticipated that if this team had been in existence when the Police made Sheffield Social Care aware of the domestic incidents that occurred between FK and "his previous partner" then the health visitor working with the family would have been made aware of the incidents at the time and would have been in a position to take any appropriate action.  4.8.20 The SCR Panel considered the development of the “Joint Investigation Team” as an example of good practice and within the Panel it was questioned whether a similar initiative should be developed within Barnsley.  In response the Assistant Executive Director for Safeguarding, Health and Social Care provided information about a multi-disciplinary response to domestic abuse referrals that is being developed by Barnsley’s Stronger Families Project.  This project will promote effective information sharing and will have a dedicated worker from the third sector who, with colleagues, will work directly with families where domestic abuse is a feature. The role will also take on an awareness raising role and provide learning opportunities for staff particularly around working with children who have experienced domestic abuse within their families. The team will also provide a consultative and supervisory role to colleagues working in the community.  This project is currently being piloted within one area of Barnsley.  4.8.21 There was no communication between Family Support and the health visitor when the Family Support Worker ceased involvement with FK's " "previous partner and child "in July 2010.   4.8.22 The Infectious Diseases Team, Health Visiting Service and GP did not have sufficient communication about FK’s treatment for "an infection" and there was no communication with Children’s Social Care.  4.8.23 As described in the analysis of ToRs 3 and 4, there were difficulties with communication from the Maternal Mental Health Specialist and the community midwife when MK was pregnant with Child K.  As the result, the midwife was not informed of the outcome of MK’s mental health Overview Report concerning Child K    Page 85 of 115 assessment which could have affected her capacity to accurately assess the risk to Child K and make necessary referrals for support.  4.8.24 After MK and FK moved from Sheffield to Barnsley they changed GPs and their medical records were transferred to their new GP.  However important information that FK’s "first" child, had been on the child protection register and that there had been several domestic incidents between FK and his previous partner were not included in FK’s medical record and therefore were not available to health professionals in Barnsley.  In fact FK’s medical record did not even make mention of the existence of "his first child".  4.8.25 Communication from Sheffield Midwives to Barnsley Midwives in connection with Child K’s birth and discharge from hospital was in accordance with usual practice and with procedure.  Nevertheless the IORA remains concerned that Barnsley midwives were not aware of the family until after Child K was born and did not receive information about the family’s history.  Consequently the IORA makes recommendations to both STHFT and BHNFT to improve their information sharing processes when a woman is due to receive postnatal care from a different Trust to the one from whom she has received ante natal care and/or with whom she has given birth.     4.8.26 Contrary to procedure, Barnsley midwives did not provide any written handover information to the Health Visiting Service.  Furthermore information held in the GP records was not shared with the health visitors providing care to Child K and "his sibling".  4.8.27 Barnsley Social Care were not informed of Child K’s admission to hospital with a haematoma although with hindsight, it is abundantly clear that there were grounds for a much more thorough investigation of the cause of this injury and that Barnsley Social Care should have been involved.  It appears that this failure of communication was the result of the acute medical team at SCNFT not investigating the injury as a possible NAI and a lack of concern from the health visitor.  4.8.28 The author of the Barnsley Education IMR questions whether the level of communication between health care professionals and those working within early years settings is at a level which enables concerns about children to be developed. The IMR author recommends that this is reviewed.  4.8.29 HV5 should have contacted Barnsley Social Care on 27 September 2011 when the member of the public phoned up and expressed concern about Child K.  When HV4 contacted Barnsley Social Care after Child K had been admitted to hospital the following day, HV4 should have told the social worker that Child K had a sibling living at home.  4.8.30 After Police officers attended BHNFT on 28 September 2011 they believed that Child K’s injuries were not serious and the cause was not suspicious.  It appears that there was some miscommunication between the Police and the Emergency Department consultant.  This issue is addressed in detail in this report.  Overview Report concerning Child K    Page 86 of 115  4.9 ToR9 Was there sufficient management accountability for decision making?  4.9.1 The organisations that have provided IMRs largely identify that management accountability for decision making was sufficient.  On occasions staff sought management input in relation to specific issues.  For example, the author of the SCNFT IMR states that staff appropriately sought advice from a consultant when there were difficulties getting a urine sample from "Child K's sibling" during their first attendance at the Emergency Department of SCNFT.  There are also examples of decisions being taken and/or ratified at a pre-determined level of seniority.  For example, in Sheffield Social Care, assessments were signed off by managers “in line with local procedures” whilst in the Police, risk assessments were carried out by departmental Sergeants.    4.9.2 On the day that Child K died, The Assistant Team Manager on the Assessment Team in Barnsley Social Care signed off the decision to await further information following a discussion with the Team Manager at the end of the normal working day and the IMR author states that this is usual practice.  Furthermore, the EDT worker contacted the on-call senior manager on hearing that Child K had died and had a sibling and they made the decision together that "this child" should be seen that evening. The social worker then spoke with the manager a number of times during the evening.  At both hospitals Child K’s care was consultant led and decisions were taken at the appropriate level.  4.9.3 Two areas are identified in the IMRs where there was insufficient management accountability and these are areas where other failings have been identified throughout the analysis.  The first of these relates to the care provided to Child K when he was admitted to SCNFT in December 2010.  Management accountability was another area where it appears that there may have been difficulties as there is no documentation to suggest that there was any input from the supervising consultant. However, this is unclear as MSPR1 has said that Child K was discussed in handover with PMC1 and therefore it is unclear if the problem was with a lack of management accountability or poor record keeping.  If the case was discussed with a consultant then it is even more of a concern that the possibility of NAI was not recognised by staff.  4.9.4 With relation to SWYPFT, the analysis of ToR 8, above, identifies a significant number of organisational difficulties facing the Health Visiting Service.  These include issues around management accountability.  Concerns relate to management accountability for the Health Visiting Team as a whole and the author of the SWYPFT IMR provides information about the structure of the service at that time, the size of caseloads and the movement of individual health visitors between teams.  The author of the SWYPFT IMR also identified that the team leader had been unaware that the six – eight week assessment of Child K was so late in taking place.  In fact the Team Leader had no knowledge of Child K prior to his death.  Overview Report concerning Child K    Page 87 of 115 4.9.5 It is pointed out in the SWYPFT IMR that health visitors are not case managed and therefore team leaders will not have a detailed knowledge of health visitors’ caseloads.  Nevertheless, the team leader does have a responsibility to ensure that a child’s welfare, development and safety needs are being met.  It is the view of the IORA and SCR Panel that Child K did not receive the level or quality of service to which he was entitled and that this was not identified or addressed by anyone in a managerial position. This suggests that the organisation did not fulfil its responsibilities under Section 11 of the Children Act 2004 which states that “Each person and body to whom this section applies must make arrangements for ensuring that – their functions are discharged having regard to the need to safeguard and promote the welfare of children.”  It is acknowledged that since Child K’s death SWYPFT have changed the arrangements for managing health visitors.  This has included strengthening the team leader role, with respect to the supervision of health visitors, to ensure that SWYPFT is fulfilling its responsibilities under Section 11 of the Children Act 2004.   4.10 ToR 10  Were senior managers or other organisations and professionals involved at points in the case where they should have been?  Senior manager involvement 4.10.1 Occasions when senior managers should have been involved in the case are largely addressed in the above analysis regarding management accountability for decision making.  In addition the IORA considers the following issues to be significant.    4.10.2 All the health visitors in Sheffield accessed child protection supervision whilst being involved with the provision of care for FK's "first child" and their family and this was good practice.  However the IMR author questions whether there was sufficient in-depth analysis of the family’s situation.  As examples, the author explains that the minor facial injuries that were observed, were not all documented in the supervision records and also that little emphasis was placed on FK’s parenting, although he had frequent regular contact with "his first child".     4.10.3 As stated above, it would have been appropriate for the paediatric registrar who examined Child K at BHNFT on 10 December 2010 to have consulted with the consultant paediatrician who was on duty that evening.  4.10.4 With respect to Child K’s first admission (to SCNFT), MSPR 1 reported that the case was discussed with PMC1 as was the normal practice. Child K was however not seen by PMC1 prior to discharge.   Involvement of other agencies 4.10.5 There were several occasions when other organisations or professionals should have been involved.  These have been addressed in the analysis of ToR 8 in the context of communication between agencies.  4.10.6 There were also the following occasions when organisations appropriately involved others and worked effectively together. Overview Report concerning Child K    Page 88 of 115  4.10.7 The Police informed Social Care of the domestic incidents.  4.10.8 There is evidence of good joint working and communication between Sheffield Health Visiting, Sheffield Social Care and a housing agency when HV6 first became involved in June 2009.  Concerns had been expressed by a member of the public about a baby crying, the health visitor identified who this was, consulted with Social Care, carried out a joint visit with a worker from the housing agency and fed back to Social Care.  Subsequently HV6 liaised with Sheffield Social Care, the nursery and the housing agency and instigated Family Support, when they ended their involvement.  HV6 also liaised with Sheffield Social Care on occasion.  4.10.9 Medical staff from BHNFT and SCNFT worked well together following Child K’s admission with the injuries that resulted in his death on 28 September 2011  4.11 ToR 11 Establish whether there are any overlapping issues between this review and the Child H, Child L Serious Case Reviews and, if so, what has been put in place to address the issues?  4.11.1 Child H died in September 2010 at seven weeks of age and was the subject of an SCR commissioned by BSCB which was completed in June 2011.  Child L died in February 2011 at five weeks of age and was the subject of an SCR commissioned by BSCB which was completed in March 2012.    4.11.2 There are the several similarities between the circumstances of Child H, Child L and Child K and these include the following: � None of the children were known to Social Care prior to sustaining the injuries that led to their death. � All three children died as a result of severe traumatic brain injury believed to be the result of an NAI.   � Both families were white, British and were not felt to have any particular needs relating to their religion, race, language or ethnicity.    4.11.3 In the case of Child H the father has been convicted of murder and in the case of Child L the father has been charged with murder but has not yet stood trial.  In the case of Child K a criminal investigation is ongoing and the father is currently on bail.    4.11.4 In the cases of both Child H and Child K there had been previous concerns in relation to the care of an older child of one of the parents and also issues relating to domestic violence with one of the parents.  However the agencies which had contact with Child K knew nothing about these earlier concerns and therefore were not in a position to consider them when making decisions about services for Child K and "his sibling".       4.11.5 Child L and Child K were both born in hospitals outside Barnsley and, following discharge home, postnatal midwifery care was provided by midwives in Barnsley.  The circumstances were somewhat different as MK Overview Report concerning Child K    Page 89 of 115 was not known to Barnsley midwives prior to the birth of Child K whereas the mother of Child L had received some antenatal services within Barnsley and, consequently was known to the community midwife.  Nevertheless, in the case of Child L it was found that community midwives had not completed a discharge form when passing the care of Child L onto the Health Visiting Team.  It was determined that the failure to complete this paperwork was due to it not being included with the discharge information provided by the hospital.  Child K was born in a different hospital to Child L but once again a discharge form was not completed by the community midwife.  A recommendation was made in the Child L SCR to address this problem but this post dated the birth of Child K.  The recommendation requires community midwives to “have readily available to them and use all the required paperwork needed to be completed antenatally and postnatally to meet local record keeping standards”.  The IORA anticipates that this recommendation will also address the failure to complete a discharge form in the case of Child K and therefore a further recommendation has not been made regarding this issue.  4.11.6 In the case of Child K, however, there were additional difficulties which resulted from all antenatal care and the birth taking place outside Barnsley.  These are addressed below.  4.11.7 An important finding in the Child L SCR was that no-one had discussed the dangers of shaking a baby with Child L’s parents and that, whilst at one stage this was done routinely, this is no longer the case.  Recommendations were made to ensure that midwifery and health visiting leads meet to discuss who will take responsibility for this task and that a procedure to address this omission is written and disseminated by April 2012.  The authors of the Health Overview Report describe the multi-agency actions that have now been taken to ensure that parents are informed by Children’s Centre staff, midwives and health visitors about the risks of shaking a baby and safe sleeping, at set times both antenatally and postnatally.    4.11.8 Another key finding in both the Child H and Child L SCRs concerned a lack of engagement of professionals with male carers in the child’s life.  This is also evident on a number of occasions in this SCR.  For example, FK was included in assessments in Sheffield prior to the birth of "his first child" but these assessments relied on self-reporting.  After FK and "his previous partner" separated, health visitors did not have any contact with FK even though he was having frequent contact with " their child" who was on an enhanced package of support from the Health Visiting Service.  When Child K was born, midwives and health visitors in Barnsley had very little information about FK and did not seek to gather more information.  There is also no indication that health visitors ever assessed FK’s child care skills or were aware that he was the main carer for both Child K and "his sibling" during the days that MK was at work.  By contrast, there was good engagement with FK in Sheffield whilst he was living with "his previous partner and the child" was on the Child Protection Register.  Both the health and social worker consistently made reference to FK being present during visits and records suggest that he was included in discussions and assessments. Overview Report concerning Child K    Page 90 of 115   4.11.9 Several recommendations have been made to ensure that midwives and health visitors gather more information about fathers and other significant male carers and also that they record who is present at visits.  However, whilst it is relatively straightforward to implement procedural changes there needs to be a cultural shift so that professionals understand that a key part of their role is to safeguard children and that, in order to do so, they need to take a pro-active role in gathering information about the individuals involved in a child’s life and to take action if they have any concerns about the way any of those people are caring for the child.    4.12 ToR 12 What was the agencies' involvement with anger management for FK?  4.12.1 ToRs 12 – 15 inclusive, concern historical issues relating to FK.  In considering these ToRs it is important to note that, prior to the death of Child K, no one ever identified that the father of "his first child" was also the father of Child K and consequently no information relating to FK as the father of "his previous child" or partner of "his previous partner" was available to agencies working with MK and FK in Barnsley.   There is no evidence to suggest that midwifery staff in Sheffield or Barnsley or health visitors in Barnsley asked whether FK had any other children from previous relationships.  However the BHNFT records from Child K’s attendance at CAU in December 2010 did name "the previous child" and refer to them as being FK’s child.  It would have been relevant for health visitors to have known about "this child"  as they reportedly visited MK and FK’s home on a frequent basis.  4.12.2 The IMR from Primary Care contains information about FK’s history in which it is written that one aspect of his ADHD was ‘low frustration tolerance’.  There is little reference to specific assistance being given to FK to manage his anger although reference is made to him being prescribed Ritalin which, in 2001 when he was 16 years old, he used “as a tranquiliser”, when he became angry.  It is clearly stated in the Primary Care IMR that FK had not received any intervention, with regards to anger management, since he was 16 years old.  This was six years before the birth of his first child, and nine years before he moved to Barnsley with MK.  4.12.3 None of the other agencies that have provided IMRs to this SCR had any knowledge of FK having received help with anger management in the past and therefore their only knowledge of FK’s ability to manage his anger was their own observations during contact with him.    4.12.4 Between them, the agencies that have contributed to this review are aware of six domestic incidents involving FK during the period covered by this review.  These took place in August 2007 (MK had been drinking), October 2007 (FK under the influence of drugs) May 2008 (just after treatment for "an infection" began), August 2008, January 2009 (MK and partner had both been drinking) and November 2009 and all involved FK and "his previous partner".  Some of these were reported as being verbal only, although on one occasion the partner sustained a bleeding nose.  FK was not prosecuted in connection with any of the incidents.   Overview Report concerning Child K    Page 91 of 115  4.12.5 Although FK described himself as feeling “snappy” at some of the out patient’s appointments in connection with his treatment, there is no evidence that these feelings resulted in him becoming angry with anyone.  4.12.6 None of the Barnsley agencies involved with the family identified any issues regarding FK having difficulty managing his anger.  MK and FK both denied that domestic abuse was an issue when they were asked by the paediatric registrar in the Emergency Department and although there is evidence of domestic incidents between FK and "his previous partner" there is no evidence of any such incidents in the relationship between MK and FK.  4.12.7 In summary, although information provided to SCR Panel at the start of the process was that FK had a history of anger management problems it appears that agency involvement with anger management was restricted to work done with him as a teenager and this ended at least six years before the start of the period covered by this review.  None of the agencies involved with the family during the period covered by this review were involved with anger management with FK.   4.13 ToR 13 Provide a commentary on the context of drug usage by FK and was this likely to have impacted on the family and the care of Child K.  4.13.1 Information provided by FK and reported in the Sheffield Social Care and Primary Care IMRs suggests that FK used drugs, including heroin and crack, extensively as a teenager and this led to his involvement in criminal activity which resulted in him spending time in prison.  Having relapsed after he served a custodial sentence, FK sought help and successfully underwent a drug rehabilitation programme which he completed over a year before the birth of "his first child" and the start of the period covered by this review.  4.13.2 There is no information to suggest that FK used hard drugs at all during the period covered by this review.  On two occasions, in February 2008 and December 2009, FK was found by the Police to be in possession of cannabis whilst away from home and without any children present and in October 2007 when Police were called to FK and "his previous partner's" home in October 2007 to attend to an alleged domestic incident they found him to be under the influence of a drug believed to be speed.  "A child" was present in the home during this incident and therefore could have been affected by it but officers removed FK to protect "the child".  There is no evidence of any drug use by FK after he was living with MK.  4.13.3 The possibility that FK was frequently under the influence of drugs whilst in the presence of his children cannot be excluded but there is no evidence that this was the case.    4.14 ToR 14 Was the information sharing and passing of referrals between agencies, with prior knowledge of FK, adequate and appropriate? Overview Report concerning Child K    Page 92 of 115  4.14.1 In considering this term of reference three distinct periods need to be considered.  Firstly, when agencies became involved because "his previous partner" was pregnant with FK’s child did they receive sufficient information about FK’s history?  Secondly, when MK presented as pregnant with FK’s child what knowledge did maternity services have of FK and thirdly when MK and FK moved to Barnsley with "MK's first child"  and Child K was appropriate information shared with relevant Barnsley agencies?  When agencies became involved because "his previous partner" was pregnant with FK’s child did agencies receive sufficient information about FK’s history?  4.14.2 This Overview Report has already explained that an assessment was undertaken prior to the birth of "FK's first child" but that the focus of the assessment was on "his previous partner" and although information was gathered about FK this relied almost entirely on self-reporting from him.  Having made that point, it is worth noting that FK was open and honest about his diagnoses of ADHD and his history of drug use and therefore the information that agencies held about FK at that time was largely accurate.  When MK presented as pregnant with FK’s child what knowledge did maternity services have of FK?  4.14.3 Earlier paragraphs of this report explain that maternity staff only had limited knowledge of FK’s history during MK’s pregnancy with Child K and they did not identify that the father of Child K was also the father of "his first child"  The reasons for this are also explained and explored in the aforementioned paragraphs.    When MK and FK moved to Barnsley with "MK's first child" and Child K was appropriate information shared with relevant Barnsley agencies?  4.14.4 Because it was never identified that FK was the father of both "his first child" and Child K no agencies in Barnsley were given any information about FK’s history when the family moved to Barnsley.  In addition the social history that was gathered by midwives in Sheffield was not passed on to midwives in Barnsley.  This is addressed in earlier paragraphs of this Overview Report.  4.14.5 HV6 in Sheffield was aware of some of the domestic incidents and was told by "FK's previous partner" in March 2010 and July 2010 that FK was living in Barnsley with his new partner who was pregnant.  On one of these occasions HV6 was also told that FK’s new partner had "another" child.  The author of the Sheffield Health Visiting IMR considers, based on the documentation in the Family Health Record, that FK was a significant carer for "his first child" and in view of the complex history, it would have been appropriate for HV6 to liaise with the Health Visiting Service providing care for "Child K's sibling" and family. The IMR author points out that the NSF for Children, Young People and Maternity Services makes reference to the fact that the role of fathers in parenting is often over looked (DOH 2004) and adds that, if HV6 had liaised with the Health Visiting Service in Overview Report concerning Child K    Page 93 of 115 Barnsley this would have provided an opportunity for the health visitor involved with the family of "MK's first child" and Child K to take account of the history in their risk assessment.  4.14.6 Notwithstanding the above comments it is important to be realistic about the practicalities of sharing information in this case.  HV6 had not been told the name of FK’s new partner or where he was living.  Therefore, at that stage, there was little in the way of information that HV6 could have provided to the Health Visiting Service in Barnsley.  Even if HV6 had ascertained the name of FK’s new partner or where they were supposedly living, MK & FK both remained registered with a Sheffield GP until September 2010 and "MK's first child" was on the books of the Sheffield Health Visiting Service until September 2010.  Therefore, if HV6 had contacted health services in Barnsley in either March or July 2010 this would not have led to the family being identified.  MK also received antenatal care in Sheffield throughout the pregnancy and although she told the midwifery service in April 2010 that she had moved to Barnsley she also told staff delivering her maternity care that she was no longer in a relationship with FK and, as far as can be ascertained, he was not present during any appointments.    4.14.7 In theory, the most effective way of ensuring that relevant information is passed on when a person moves from one area to another is through the medical record.  However, this Overview Report has already made reference to the lack of communication between the GP and Health Visiting Service and also that FK’s medical record did not contain information about the domestic incidents between "him and his previous partner "or the fact that FK’s older child had been on the child protection register.  Therefore, even if communication between the GP and Health Visiting Service had been better, this important information would not have come to the attention of the Health Visiting Service.  4.14.8 If Sheffield Health Visiting Service had maintained some contact with FK after he separated from "his previous partner", as the IORA has suggested they should have done, then this may have enabled the service to have had useful information about FK which maybe could have been provided to the Barnsley Health Visiting Service when FK and MK moved there.    4.14.9 It is also important to keep the concerns about FK in perspective.  Without wishing to minimise the seriousness of domestic violence, the domestic incidents between FK and "his previous partner" were relatively few and far between and did not all involve physical violence, FK was not always the perpetrator and none of them resulted in a prosecution.  Furthermore there was never an occasion when FK was suspected of causing any harm to "his first child" and, as far as the IORA can ascertain, agencies in Sheffield had no concerns about FK caring for "the child".  Therefore, whilst it would have been best practice for information to have been passed onto Barnsley health visitors the IORA considers it unlikely that any additional service would have been provided.  4.15 ToR 15 Overview Report concerning Child K    Page 94 of 115 Had referrals been made for domestic violence between FK and a previous partner.  Were agencies sufficiently aware of this and the potential impact on Child K and his family?  4.15.1 As has been stated earlier in this analysis there were six reported domestic incidents between FK and "his previous partner"  during the period covered by this review.  The Police, Sheffield Social Care, Sheffield Health Visitors and the GP with whom FK, "his previous partner and child" were registered each knew about some or all of these incidents.  4.15.2 This report has already explained that HV6 in Sheffield was told that FK had moved to Barnsley with a new partner who was pregnant and the report has considered whether HV6 could have taken action to make Barnsley health visitors aware of FK’s history.  4.15.3 This report has also explained, that the history of domestic violence was recorded in "his first child's" medical records but not those of FK.  Therefore, once FK moved to a new GP practice this information was no longer available to his GP.  4.15.4 Sheffield Social Care had not had any involvement with FK or " his previous partner" for some months prior to him moving to Barnsley with MK.  Therefore, in the absence of any enquiry to Sheffield Social Care from another agency they were not in a position to share information about the domestic violence.    4.15.5 The Police were never called to attend any domestic incidents between FK and MK.  Indeed they were not called to any incidents involving MK through the entire period covered by this review, or any incidents involving FK after November 2009.  Consequently they had no opportunity to identify that the father of Child K had previously been involved in domestic violence.   4.15.6 Because no-one identified the father of Child K as being the same person as the father of "his first child" and previous partner of "their mother" no agencies working with the family of MK, FK, "MK's first child"" and Child K had any awareness of the previous domestic incidents between FK and "his previous partner".  4.16 ToR 16 Establish whether the large number of health visitors contributed to concerns not being addressed adequately with regard to the care of Child K.  4.16.1 This term of reference was included because it was clear from the initial reading of records that several different heath visitors had been involved in the care of Child K in Barnsley.  The IMRs have shown that, in addition to this, there were seven different health visitors involved with "FK's first child" in Sheffield during the period covered by the review.  Consequently in addressing this term of reference the IORA will also consider the impact of the large number of health visitors involved with "FK's first child".  Overview Report concerning Child K    Page 95 of 115 Health visitors involved with "FK's first child" in Sheffield  4.16.2 Seven health visitors are referred to in the Sheffield Health Visiting IMR of which four were the allocated health visitor for "FK's first child" at different times.  Of the others HV2 and HV7 each saw "the child" once at clinic whilst HV3 took a phone call from a social worker whilst the allocated health visitor was on annual leave.  4.16.3 Each change of allocated health visitor was the result of a change of address for "this child". Throughout the period covered by the review whilst each health visitor was allocated to "the child" they provided continuity of service.  "FK's previous partner" never told the health visitor that she was moving home; instead on one occasion the health visitor tried to visit and found the flat empty, on another "the previous partner and child" failed to attend clinic and on the third a neighbour reported a disturbance.  Consequently, there was never a planned change of health visitor.  Nevertheless there is evidence that verbal handovers took place from one health visitor to another.    4.16.4  When "the previous partner and child" were in homeless accommodation they were provided with a health visitor who works in HASS.  This is a specialist service that ensures families have access to health and other services when they may be at their most vulnerable.   4.16.5  There was a short period of time, following "the previous partner and child" leaving interim accommodation and moving into their own tenancy, when the Health Visiting Service were not in touch with the family. During telephone discussion between the Sheffield Health Visiting IMR author and HV5 it was clarified that sometimes the housing agency have not informed HASS when a family have moved out of interim accommodation into a permanent address. This practice has improved and currently HASS and the housing agency meet on a monthly basis to share information regarding vulnerable families who are homeless and this has resulted in improving communication between these services.    4.16.6 The IORA concludes that the involvement of several health visitors was not due to any difficulties with service delivery but was the result of several changes of address.  This process was well managed and does not require any changes in policy or practice.    Health visitors involved with Child K and "his sibling" in Barnsley  4.16.7 In several places in this analysis there are references to significant problems that have been identified with the Health Visiting Service that was provided to Child K and his family.  One aspect of this was that there was no continuity in the provision of the service that was provided.  Nevertheless the problems which have already been identified in this report were much greater than the use of several different health visitors.    4.17 ToR 17 Establish whether there are protocols in place which identify actions agencies should have / will take if birth parents do not take a child to Overview Report concerning Child K    Page 96 of 115 appointments and another family member attends and if this contributed to concerns not being adequately addressed in relation to child K.  4.17.1 This ToR was included as early reports suggested that there were occasions when Child K was presented at medical appointments with a family member other than his mother or father.  The SCR Panel wanted to investigate whether this was a feature of the care of Child K and whether it impacted on how concerns were addressed.    4.17.2 A more detailed consideration of this issue, through the IMRs has shown one recorded incident when "another family member" took Child K to a GP appointment.  This was in June 2011 after MK had returned to work and the "family member" cared for Child K on a regular and frequent basis.  In addition, there was an occasion in July 2011 when "Child K's sibling" was taken to the GP by "another family member". Both of these attendances were due to the children being unwell with infections.  At least one of Child K’s parents was present each time he attended hospital or was seen by anyone from the Health Visiting Service.  4.17.3 Agencies contributing to this review have reported that there are no protocols in place which identify actions agencies should have or will take if birth parents do not take a child to appointments and another family member attends.  However, there is no indication that this was an issue of concern in this case or that the two occasions when Child K was taken to the GP by family members contributed to concerns not being adequately addressed in relation to Child K.  4.18 ToR 18 How effective was the multi-agency response to "Child K's sibling" in terms of safeguarding their position.   4.18.1 This ToR was included due to concerns that there may have been a delay before agencies took action to safeguard "Child K's  sibling" after Child K was admitted to hospital on 28 September 2011.  Consequently in addressing this ToR, the IORA has considered the events of 28 September 2011 onwards.  4.18.2 "The sibling" was at home with MK, FK and Child K on the morning of 28 September 2011 when Child K became unwell and the ambulance was called.  They remained at home with FK when Child K and MK were taken to BHNFT in the ambulance.  It appears that they were then taken to nursery as usual.  There is no record of who collected them from nursery but it appears that they were staying with a "family member" during the evening of 28 September 2011 whilst MK and FK were with Child K at BHNFT and then SCNFT.  Agencies did not give active consideration to the welfare of "the sibling" until the evening of 28 September 2011 after Child K had died.  Given that Child K’s injuries are believed to be the result of NAI it is important to consider whether anything could or should have been done differently.  Overview Report concerning Child K    Page 97 of 115 4.18.3 There are two main issues to consider in respect of the above; firstly, when were various agencies aware of the existence of "the sibling" and secondly, when were agencies aware that Child K’s injuries may be the result of an NAI.    4.18.4 Four agencies contacted Barnsley Social Care about Child K during the day of 28 September 2011; SWYPFT, the Police, YAS and BHNFT.  However, according to the Barnsley Social Care IMR, social workers remained unaware of the existence of "the sibling" until the evening of 28 September 2011 when a social worker in the Emergency Duty Team was contacted after Child K died.  It is therefore worth considering what knowledge each of the agencies, which contacted Barnsley Social Care, had about "the sibling" and what they told Barnsley Social Care.  4.18.5 HV4 from SWYPFT was aware of "the sibling" when HV4 contacted Barnsley Social Care on 28 September 2011 to refer Child K.  HV4 should have informed Barnsley Social Care of the existence of a "sibling" in the household but it appears that this was not done.  The SWYPFT IMR does not provide any reason for why HV4 did not tell Barnsley Social Care about "this child".    4.18.6 YAS staff who attended the house following the 999 call saw a young child present and were aware that this child remained at the house with an adult male when Child K and MK were conveyed to BHNFT.  YAS staff contacted Barnsley Social Care by phone to inform them of the injuries to Child K and of his conveyance to BHNFT.  They also sent a referral form by fax.  It is unclear whether "the sibling" was mentioned in the phone conversation but there is reference to them in the fax.  It appears that this fax was only seen by a member of clerical staff on the day that it arrived in the social work office and the information about "the sibling" was not brought to the attention of the social workers.  It is the view of the author of the Barnsley Social Care IMR that the reference to "the sibling" was not in a very obvious way that would have focussed attention on them at a time when so much else was going on.  The referral form is a standard form used by YAS which includes a specific section for YAS to provide details of any other children on the scene.  In the form sent to Barnsley Social Care in connection with Child K the box in this section headed ‘Name’ was completed with “X year old child ”.  Although YAS staff did not have a name for "the sibling" and their  age was incorrect the IORA considers that it should have been clear to Barnsley Social Care that another chid had been present.  4.18.7 It is unclear whether the police officer who contacted Barnsley Social Care during the day on 28 September 2011 was aware that Child K had a "sibling".  However, the Police had not had any previous contact with the family and had not been present at the house when Child K had been taken to hospital.  4.18.8 BHNFT records clearly state that Paediatric Consultant 1 told the social worker about "the sibling" during the afternoon whist Child K was in the hospital.  The Social Care records confirm that there was a phone call between these two professionals but do not contain any record of Overview Report concerning Child K    Page 98 of 115 Paediatric Consultant 1 referring to "the sibling" and the author of the Barnsley Social Care IMR is of the view that this would have been recorded if the information had been provided.    4.18.9 Considering all the above, it is clear that Barnsley Social Care was informed of "the sibling" during the day of 28 September 2011 but that this information was overlooked.  It is also clear that the health visitor missed an opportunity to inform Social Care of "the sibling" when this should have been done.  In addition there remains a clear and irresolvable difference of view as to whether Paediatric Consultant 1 told the social worker about "the sibling".   4.18.10 It is also necessary to consider what action, if any, Barnsley Social Care should have taken during the day time on 28 September 2011 if they had become aware of "the sibling".  The author of the Barnsley Social Care IMR states that there was uncertainty as to whether Child K’s injury was non-accidental and considers that, during the afternoon of 28 September 2011, when Child K was obviously critically ill then even if the social work team had known about "the sibling" they may well have decided not to try to see them at that time.  4.18.11 Information in this Overview Report provides a confused picture as to whether or not there were concerns about the cause of Child K’s injuries.  The IORA accepts that during the day time on 28 September 2011 no-one was sure about how Child K had sustained his injuries and it was possible that they had been sustained accidentally as described by his parents.  Nevertheless, the IORA does not believe it was possible, on 28 September 2011, to rule out the possibility of NAI.  Consequently, the IORA is of the view that, if Barnsley Social Care had been aware of "the sibling" they should have considered whether action was needed to safeguard them and, at the very least, should have contacted the nursery and health visitor to gather more information about them.  Therefore it is the view of the IORA that the failure of the health visitor, and possibly others, to inform Barnsley Social Care about "the sibling"  and the failure of Barnsley Social Care to properly process the fax from YAS, delayed appropriate action being taken to safeguard "the sibling".  4.18.12 By the time Barnsley Social Care’s Emergency Duty Team became aware of "the sibling", during the evening of 28 September 2011, Child K had died.  SW4 from EDT liaised with a senior manager and took prompt action to ensure that "the sibling" was safe and well.  This resulted in good joint work between Barnsley Social Care and the Police.  4.18.13 Action taken on 29 September 2011 to safeguard "the sibling" was appropriate and proportionate.  This includes arranging and holding a strategy meeting, informing the nursery of the situation, making arrangements for "the sibling" to have a medical the following day and advising the family that any contact MK and FK had with "the sibling" should be supervised by another adult.    4.18.14 The authors of the BHNFT IMR consider that the medical assessment of "the sibling" on 30 September 2011 was comprehensive and well Overview Report concerning Child K    Page 99 of 115 documented on an up to date pack.  The IMR authors draw attention to the lack of commentary about how the bruises on the abdomen were interpreted. They acknowledge that the bruises were probably overlying bony prominences and could have been caused accidentally by a tight belt, for instance but state that the examining doctor at the time should have been explicit.  The IORA shares the concern that no possible explanation was provided for these bruises.  This medical assessment was being undertaken as a result of the death of "the child's" sibling in circumstances where there was suspicion that the death may have been the result of an NAI.  In such circumstances it is imperative that the doctor undertaking the examination explicitly comments on any injury identified, however slight it may be.  Following discussion at the SCR Panel and with the Named Doctor for Child Protection at BHNFT, the IORA makes a recommendation in connection with this.  4.18.15 In summary, it is the view of the IORA that there was a delay in safeguarding "the sibling" on 28 September 2011 as a result of poor or missed communication about their existence and the seriousness and possible cause of the injuries.  Once Barnsley Social Care became aware of "the sibling" and of the concerns of the consultant paediatrician at SCNFT, appropriate action was taken in a timely fashion to safeguard them.  However the possible cause of faint bruises identified at the medical assessment were not adequately explained in the medical report.    4.19 Challenge of IMRs  4.19.1 All of the IMRs produced for this review follow a set format specified by BSCB.  As a result they are all well structured with a shared introduction explaining the background to the review and the reason it is being undertaken.  They also contain a clear statement as to the time period for the review and the key issues to be addressed as set out in Terms of Reference produced by the Serious Case Review Panel.  They include sections to summarise the agency’s involvement with the family and to analyse that involvement.  Individual chronologies were written on a standard template to enable continuity and to facilitate the compilation of the integrated chronology.  The IMRs have all been signed off at an appropriate level within the organisations.  4.19.2 Primary aims of SCRs are to learn lessons and to take action that will improve services in the future.  In order to achieve these aims it is essential that all the IMRs provide a thorough analysis considering each and every one of the Terms of Reference identified by the SCR Panel.  It is also essential that the IMRs draw out the key lessons to be learned and make recommendations based on these lessons.  The IORA and SCR Panel have worked to ensure that all the IMRs follow such a framework.  4.19.3 The SCR Panel and IORA provided substantial challenge to the performance and practice of agencies throughout the SCR with the result that IMRs were revised on a number of occasions.  This challenge was provided in SCR Panel meetings and in individual discussions that the IORA had with IMR authors.  In some cases this challenge was the result of the IORA or SCR Panel members believing that the analysis within the Overview Report concerning Child K    Page 100 of 115 IMR needed to be strengthened and on other occasions it was because information in one IMR was inconsistent with information in another.  4.19.4 Examples of incidents where the IORA and SCR Panel have provided challenge to IMRs include the following: � Decision making in respect of de-registration of "FK's first child" Sheffield Social Care response to domestic incidents between FK and "his previous partner" � Communication between adults and children’s services in respect of FK’s treatment for "an infection"  � Pursuit of a urine sample for "the sibling" � Gathering and storing information about fathers during pregnancy  � Communication between midwifery services when a pregnant woman receives antenatal care and/or gives birth with one Trust but is going to receive postnatal care from a different Trust  � Insufficient response from BHNFT to lesion inside Child K’s mouth  � Location of six-eight week assessment of Child K  � Communication between BHNFT and the Police regarding Child K’s injuries on 28 September 2011  � The inadequate explanation for the faint bruises found on "the sibling's" abdomen at the medical assessment following Child K’s death   5. Conclusions  5.1 This SCR was commissioned following the tragic death of Child K and has involved detailed consideration of agency involvement with the family of MK, FK, "Child K's sibling" and Child K.  The findings suggest that there were incidents that should have resulted in agencies having concerns about Child K’s welfare as early as December 2010.  Such concerns should, in turn, have led to a different course of action in which case the tragic death of Child K may have been avoided.  In view of the events of 27 and 28 September 2011, the two hospital attendances in December 2010 appear hugely significant.  With regard to the first of these, when Child K was referred to BHNFT by the GP with a lesion in his mouth, the presentation was very unusual and it is suggested that the registrar should have sought the opinion of the consultant and also that consideration could have been given to admitting Child K whilst further enquiries were made and the possibility that it was an NAI considered.    5.2 With regard to the occasion when Child K attended SCNFT with a swelling to his ear, it is clear that this should have been investigated as a possible NAI and that this was recognised by the doctors in the emergency department and the ENT surgeons but was overlooked by medics.  Furthermore, this highly suspicious presentation occurred only eight days after Child K’s aforementioned attendance at BHNFT with the lesion inside his mouth.  This error was, at least in part, the result of an error of professional judgement but it has also led to a recommendation about internal referral processes, which is addressed in the recommendations.   5.3 It is very easy, with the benefit of hindsight, to criticise the actions of agencies and individuals who work under great pressure and have to make Overview Report concerning Child K    Page 101 of 115 difficult decisions, often based on relatively little information.  In her Review of Child Protection Professor Munro (2011) wrote that:  “It is important to be aware how much hindsight distorts our judgment about the predictability of an adverse outcome. Once we know that the outcome was tragic, we look backwards from it and it seems clear which assessments or actions were critical in leading to that outcome.”  5.4 The IORA fully shares these views but considers that hindsight is not required to identify that a possible NAI should have been investigated when Child K was admitted to hospital in December 2010.  5.5 There were numerous problems with the health visiting service provided to Child K and his family in Barnsley.  There was no continuity as to who provided the service, the initial visit was insufficiently thorough, the six – eight week assessment did not take place until Child K was 16 weeks old and even then took place at the clinic rather than at the family home, staff did not identify that Child K’s weight had fallen by more than two centiles and the policy regarding insufficient growth velocity in infants was out of date.  Furthermore, when a member of the public alerted a health visitor to Child K’s injuries on 27 September 2011 the health visitor did not take appropriate action.    5.6 These substantial problems with the delivery of the health visiting service have resulted in significant action being taken as a matter of urgency and several recommendations within the SWYPFT IMR including the need for an overall review of the Health Visiting Service.  It is essential that this is undertaken without delay.   5.7 Although the above issues are the major concerns to have emerged from this SCR, other lessons have also been learned that will help to improve practice.  The following issues have emerged in relation to services provided to Child K and his family.  5.8 Pregnancy care given to MK in connection with Child K was generally of a good standard although there was insufficient communication between the maternal mental health team and the midwifery service.  There was also a complete lack of contact with FK and very little information gathered about him.  When MK booked for pregnancy care, she told midwives that she was no longer in a relationship with FK and he did not attend antenatal appointments, although both MK and FK report that he did attend for the first scan.  MK named FK and provided some history about him although she did not include some important information.  Given the increased awareness of the importance of fathers to the wellbeing of young babies; and the potential risk they can pose to young babies it is the view of the IORA that health professionals within maternity services and health visitors should gather as much information about father’s social and significant medical history as they can.  The current systems, as described by the author of the STHFT IMR, are clearly not designed to facilitate the collection of such information about fathers.  Even where it has been collected in connection with one pregnancy it will remain hidden if the man has a child with another woman, even if the same hospital trust provide Overview Report concerning Child K    Page 102 of 115 maternity services for both pregnancies.  This is because information about the father is filed within the mother’s records.  Patient choice, which results in situations where the parents of a child are not always registered with the same GP practice, adds to this problem.  There are no simple solutions to these issues and the IORA considers that they need to be addressed at a national level.    5. 9 MK moved from Sheffield to Barnsley during her pregnancy but continued to receive all her antenatal care in Sheffield and she gave birth at hospital in Sheffield.  The midwifery service in Barnsley was not told about MK and Child K until they were discharged from hospital following Child K’s birth with the result that there was no antenatal contact from Barnsley midwives.  Furthermore the social history gathered by STHFT midwives was not passed on to those from BHNFT.  These factors together meant that Barnsley midwives had less information about the family than would usually be the case, in particular they had little social history.  The IORA believes that both BHNFT and STHFT need to enter into agreements with neighbouring Trusts regarding information sharing when a woman is due to receive postnatal care from a different Trust than the one from whom she has received antenatal care and/or with whom she has given birth.    5.10 Although midwives from BHNFT visited MK and Child K an appropriate number of times after they were discharged from hospital, the visits were all carried out by different midwives.  This is not best practice and is reported to be unusual.  BHNFT have been unable to establish why this was the case.    5.11 This review has found two shortfalls in practice that were also found in another SCR completed recently in Barnsley.  Firstly neither the midwives nor the health visitors addressed the dangers of shaking a baby with MK and FK and secondly the handover from the Barnsley midwives to the Health Visiting Service was only done verbally when policy requires the midwife to complete a discharge form and give this to the health visitor.  These issues have both been addressed as a result of the previous SCR.  5.12 Professionals working with Child K and his family in Barnsley were not aware of key aspects of FK’s history including the fact that he had "another child"  who had been on the Child Protection Register, that he had a history of drug misuse and that he had been involved in a number of domestic incidents with his previous partner.  Because midwifery services in Sheffield did not have this information about FK it would not have come to the attention of midwifery services in Barnsley even if communication between the two sets of midwives had been better.  Had the health visitor in Sheffield maintained contact with FK in connection with the care he provided to "his first child" this might have been a channel by which important information could have been shared with agencies in Barnsley.  Alternatively it could be expected that relevant information from FK’s medical record could have been shared by the GP with the health visitor.  In reality the GP and health visitor did not communicate about FK’s history and, furthermore information about the domestic violence and "his first child" having been on the Child Protection Register was on "the child's" medical record but not that of FK.   Overview Report concerning Child K    Page 103 of 115  5.13 The lack of knowledge that professionals in Barnsley had about FK also suggests that they were insufficiently inquisitive about his history and did not adequately assess his parenting capacity.  This is a further example of professionals not engaging with male carers.  In the case of FK this was particularly important as from May 2011 onward he was the sole carer for Child K and "his sibling" two days each week as MK had returned to work.  As a male carer he felt uncomfortable accessing baby and toddler groups because there were no other men there and without access to a car he was isolated.  Health visiting services need to be aware of the specific needs of men who are caring for their children.    5.14 It appears that the medical care provided to Child K after his admission to hospital on 28 September 2011 was appropriate and largely of a high standard.  BHNFT did however encounter a problem with paperwork, in that the Child Protection Pack used by the paediatric consultant was an out of date pack with the result that social care were not explicitly informed of the Paediatrician’s opinion about whether injuries were suspicious.  This issue has been addressed.  5.15 The EMBRACE consultant from SCNFT encountered difficulties being required to deal with incoming requests for service whilst at BHNFT attending to Child K. This issue has been addressed by SCNFT by way of a new protocol which will reduce the likelihood of such a situation occurring in the future.  5.16 Barnsley Social Care had no knowledge of Child K until after he had sustained the injuries that led to his death.  The service then received seven phone calls and one fax from four different agencies and had some difficulty managing this.  As a result the Barnsley Social Care IMR contains recommendations to improve the service that Business Support Staff can provide within the Social Work Teams.    5.17 The main impact of the difficulty faced by Barnsley Social Care was that staff were not aware that Child K had a sibling until the evening of 28 September 2011 after Child K had died and this resulted in a delay before any action was taken to ensure "the sibling's" safety.  If Barnsley Social Care had managed the phone calls and fax regarding Child K more effectively on 28 September 2011, it is likely that they would have become aware of "the sibling" much earlier in the day.    5.18 An additional complication was that Barnsley Social Care did not believe that Child K’s injuries were being treated as suspicious during the day on 28 September 2011.  This misunderstanding stemmed from the Police believing that medical staff considered the injuries to be not serious and the cause not suspicious.  This in turn was the result of communication between the Police and the Emergency Department consultant.  The IORA has made a recommendation to minimise the likelihood of a similar situation occurring in the future.    5.19 The result of Barnsley Social Care not being aware of "Child K's sibling" and understanding that the injuries were not considered to be suspicious Overview Report concerning Child K    Page 104 of 115 was that there was a delay in taking action to ensure the safety of "the sibling".  Once the out of hours team became aware of "this child" there was a quick response which was largely appropriate although the medical assessment did not adequately explain the small bruises to his abdomen.  5.20 In addition to consideration of the services provided to the family of MK, FK, "Child K's sibling" and Child K, consideration has been given to agency involvement in Sheffield with the family of FK’s older child.   5.21 "This other child" remains alive and well, living with their mother and the majority of agencies involved in providing services were never involved in providing any services to Child K.  Therefore these agencies’ involvement in the SCR has been somewhat divorced from the events that led to it being commissioned.  Nevertheless it was important that agencies’ involvement with "this other child" was considered as it enabled the SCR Panel to consider whether information was known about FK that should have impacted on the services provided Child K and his family.   5.22 Although the majority of agencies who were involved with "this other child" were never involved in providing services to Child K, their contributions to the SCR have resulted in some important lessons being learned which will be translated into changes in practice to improve their capacity to safeguard children in the future.  5.23 The review of services provided to FK and "his previous partner and child" in Sheffield has found several examples of good practice including the decision to carry out a pre-birth assessment when "the previous partner" was pregnant and the subsequent decision to place "the child" on the Child Protection Register.  Subsequently, after "FK's previous partner and child" became homeless good support was provided by the health visitor.    5.24 The IORA considers that not all issues were fully considered when the decision was made to remove "FK's first child" from the Child Protection Register and is concerned about the lack of any involvement from Sheffield Social Care as soon as they were removed from the Register.  Consequently the IORA is pleased to learn that the policy within Sheffield Social Care has changed and any child who now ceases to be subject to a Child Protection Plan will be classed as a Child in Need for a transitional period.  This should ensure that, in the future, such cases will have a clear plan which will detail the support to be provided from services such as Children’s Social Care and the Health Visiting Service.   5.25 Shortly after "FK's first child" was removed from the Child Protection Register, FK commenced treatment for a viral infection.  It was known that this treatment was likely to make him feel unwell and to have an impact on his emotional well being and subsequently he reported, at a number of out patient’s appointments, that he felt ‘snappy’ and/or anxious.  However, there was no consideration of the impact of FK’s emotional situation on "his child".  Furthermore, although the Infectious Diseases Team communicated with the GP about FK’s treatment there was no communication between the GP and health visitor or Infectious Diseases Team and health visitor. The IORA accepts that there is no evidence that Overview Report concerning Child K    Page 105 of 115 this led to a negative outcome for "the child" but believes that more consideration should have been given to the potential for it to impact negatively on the child.  This review has found that staff at STHFT have become more aware of the need to consider the welfare of children when providing services to adults and that STHFT have introduced a new policy in relation to this since the Infectious Diseases Team were involved with FK.  5.26 There were also other times when insufficient consideration was given to FK.  The pre-birth assessment relied on self-reporting from FK about his history rather than information being checked and validated with other agencies and after FK and "his previous partner" separated, services had no further contact with FK even though he was regularly caring for his child and was living at "a family member's" home where there had been previous concerns about people who may pose a risk to children.  Many SCRs have identified that professionals have not engaged with fathers and other male carers and although agencies are becoming more aware of this and adapting policies to encourage greater engagement, this is a slow process and much still needs to be done.  5.27 The Police were called to six domestic incidents between FK and "his previous partner" and in all cases they recognised the potential impact on "their child" and took appropriate action, including making Social Care aware of the incident.  The IORA is of the opinion that Sheffield Social Care should have undertaken more thorough assessments in response to these incidents and their potential impact on "the child".  Three of these incidents took place after Social Care ceased their involvement with the family and the main professional involved was the health visitor.  However the health visitor was not informed of two of these incidents and was therefore unable to address them with FK or "his previous partner" or even to take them into account in respect of her work with the family.  The Joint Investigation Team now operating in Sheffield appears to be a positive development that should help to ensure that appropriate agencies are now made aware of incidents such as these in a timely way.   5.28 YAS identified an occasion when ambulance staff attended an incident when "the previous partner" had been the victim of an episode of domestic violence.  On this occasion there is no record of the identity of the perpetrator and therefore it is not known whether it was FK.  The ambulance staff were aware that "a child"  was present but did not identify the potential impact of domestic violence on a child and consequently did not inform Sheffield Social Care.  YAS has taken appropriate action with regard to the individual staff involved in this instance and no further recommendation is made.    5.29 "FK's first child" sustained four minor head injuries during the period covered by this review.  None of these was felt to be suspicious at the time and there is no evidence to suggest that any of them were suspicious.  Nevertheless it is emphasised that professionals need to demonstrate ‘respectful uncertainty’ when faced with an injury to a young child, particularly a non-mobile infant which they were at the time of the first injury.  It is also important that professionals consider incidents in the light Overview Report concerning Child K    Page 106 of 115 of the family history rather than treating each incident in isolation.  In order to do this it is important that the incidents and subsequent decision are thoroughly recorded for future reference.    5.30 At various times throughout the period covered by this review there are examples of some shortfalls in record keeping and communication within and between agencies.  These are outlined in this report.  6. Recommendations   6.1 39 recommendations are made within the Individual Management Reviews and the Health Overview Report and these have all been accepted and signed off by the individual agencies.  The Panel and IORA are in agreement with all the recommendations.  They are not repeated here as they are in the individual IMRs and in the Integrated Action Plan which is included as Appendix 2 of this Overview Report.  The Integrated Action Plan will be monitored by the Barnsley Safeguarding Children Board Quality Assurance Sub-Group to ensure that they are fully implemented.  Implementation of recommendations that apply to agencies within Sheffield will be monitored by SSCB who in turn will report to BSCB.    6.2 In addition to the recommendations made in the IMRs the IORA and Serious Case Review Panel make the following recommendations:  Recommendations to Barnsley Safeguarding Children Board 1. The Chair of BSCB, on behalf of the Board, should ensure that appropriate managers within South Yorkshire Police, BHNFT and Barnsley Social Care develop a protocol to guide communication between the agencies in cases where a child attends hospital and there are possible safeguarding concerns.    2. The Chair of BSCB should ensure that the Board consider what action it can take to promote the involvement of fathers in groups such as baby and toddler groups.  Recommendations to Barnsley Hospital NHS Foundation Trust (BHNFT) 3. The Strategic Health Authority will work with the Head of Midwifery for Barnsley and the surrounding area to agree a process that ensures issues arising from recommendations in the Overview report are addressed.  4. The Named Doctor for Safeguarding Children at BHNFT should ensure, following discussion with consultant colleagues, that paediatricians are provided with additional guidance regarding the need to consider the possible causes of any injuries identified during medical assessments and to clearly record their interpretation of the injury in the assessment report.  This should be completed by the end of July 2012 in preparation for the induction of new middle grade doctors in August 2012.  Recommendations to STHFT Overview Report concerning Child K    Page 107 of 115 5. The Head of Midwifery at STHFT should ensure that agreements are made with neighbouring hospital trusts regarding information sharing when a woman is due to receive postnatal care from a different Trust to the one from whom she has received ante natal care and/or with whom she has given birth.  This should include agreement regarding which trust will undertake a pre-birth home visit, when information will be shared and what information will be shared.    Overview Report concerning Child K    Page 108 of 115 Appendix 1 – Genogram                                                                                                                                                                                                                                                                                                                                                                                                                  =                                                                                                         MK   FK  MK's first child   (Child K's Sibling)   Child K  dob .10.10 dod 28.09.11   FK's Previous partner   FK's First Child     Overview Report concerning Child K    Page 109 of 115  Appendix 2 – Integrated Action Plan  1. The Executive Director for Safeguarding Children will ensure that all recommendations identified within the Health IMRs (including Sheffield Children’s NHS Foundation Trust and Sheffield Teaching Hospital’s Foundation Trust) are completed within the timescales identified  2 The Chair of BSCB, on behalf of the Board, should ensure that appropriate managers within South Yorkshire Police, BHNFT and Barnsley Social Care develop a protocol to guide communication between the agencies in cases where a child attends hospital and there are possible safeguarding concerns  3 The Chair of BSCB should ensure that the Board consider what action it can take to promote the involvement of fathers in groups such as baby and toddler groups  4 The Head of Midwifery at BHNFT should ensure that agreements are made with neighbouring hospital trusts regarding information sharing when a woman is due to receive postnatal care from a different Trust to the one from whom she has received ante natal care and/or with whom she has given birth.  This should include agreement regarding which trust will undertake a pre-birth home visit, when information will be shared and what information will be shared.  5 The Head of Radiology at BHNFT should ensure that the service always has access to radiologists with the specialist skills and experience to interpret CT scans in very young babies.  6 The Named Doctor for Safeguarding Children at BHNFT should ensure, following discussion with consultant colleagues, that paediatricians are provided with additional guidance regarding the need to consider the possible causes of any injuries identified during medical assessments and to clearly record their interpretation of the injury in the assessment report.  This should be completed by the end of July 2012 in preparation for the induction of new middle grade doctors in August 2012.  7 The Head of Midwifery at STHFT should ensure that agreements are made with neighbouring hospital trusts regarding information sharing when a woman is due to receive postnatal care from a different Trust to the one from whom she has received ante natal care and/or with whom she has given birth.  This should include agreement regarding which trust will undertake a pre-birth home visit, when information will be shared and what information will be shared.  Overview Report concerning Child K    Page 110 of 115 8 The commissioning PCT need to be assured that staff working with families collate social information on parents and carers to assess parenting experience and wider support from family and friends.   Develop an action plan and document in the records if further parenting support is required.  9 To ensure that the Health Visiting Service responds in a professionally accountable way, in line with policy and procedure and the NMC Code of Conduct an overall review of the Health Visiting Service is undertaken which includes robust consideration of the management and leadership structure within Health Visiting.  10 That Professional competency issues are considered and reviewed in relation to the practice of the  practitioners involved in the case in relation to:  1. Following procedures and guidance in relation to safeguarding children.  2. Delivering assessments and care in line with the health child programme and to the required standard.  3. Individual professional accountability in line the NMC code of conduct   11 That the aide memoire that was developed for Health Visitors to ensure that all the relevant questions are asked during birth visits and subsequent other key contacts is re-launched and embedded within practice. This should include questioning ‘Why’ babies and small children have been presented to clinic or hospital away from their area of residence.  12 Where another professional contacts the Health Visiting Service regarding concerns about a child, that this leads to the gathering of further information which would enable a fuller assessment of the situation to emerge  13 That a learning event(s) takes place for all Health Visitors in relation to Record Keeping Standards for the Trust.  14 That SystmOne is accessible in all areas where baby clinics are held. Where this cannot be arranged consideration needs to be given to the movement of clinics to address this problem  15 The midwifery service at Hospital 1 should reassure itself that midwives use the required Maternity discharge/transfer notification paperwork needed to be completed when other hospitals are requesting post natal care be taken over by Hospital 1.    16 Hospital 1 should ensure that when the EMBRACE team transfer children to Hospital 2 that all medical images from CT scans etc. are transferred with them in all cases rather than the current case to case basis.  Overview Report concerning Child K    Page 111 of 115 17  Hospital 1 should ensure that regular checks are made in the Emergency Department to check that accurate and up to date documentation is in place for child protection medical assessments.  18 Hospital 1 should engage with partner agencies to ensure that there is two way feedback about specific safeguarding children cases.  19 Improve the generic information gathering on admission to early year’s settings. Ideally this would include a sibling checklist, previous names and addresses, any previous child care setting and the name of the Health Visitor.  20 Assess the impact on services of home visits for all new parents to early years settings as standard, including the practical implications and whether the systems in place adequately support families enough for this transitional period  21Develop a system whereby services (HV, School Health and Early Years) understand and establish their role in ensuring Universal Services/Early Intervention within relevant settings maintain a focus on families including those moving into the area  22 Children’s Social Care should review the level of administrative support available to individual teams and ensure that where initial referrals are being taken from the public minimum cover is always provided  23 Business Support staff should be experienced in the specific area of work they are engaged in and should have a good understanding of the operational needs and specific aims of that aspect of the service  24 Business Support  staff should be able to focus on the specific task in hand and not have other responsibilities vying for their attention  25 The process for taking ‘contact-ins’ should be reviewed and further training offered to all Business Support staff to ensure that all areas of the ‘crib-sheet’ are covered.  26 Individual contributors to contact-ins should be clearly identified by name or initials. dates and times should be included to make it clear where additions have been made.  27 Where documents are received which are unable to be entered on ERIC a note must be made on the electronic record of their contents and receipt on the day they are received  Overview Report concerning Child K    Page 112 of 115 28 The use of the ‘R’ Drive for additional documentation which cannot be scanned into ERIC should be reviewed. If there is no alternative method it is essential that the existence of these documents is recorded as a case event  29 In procuring the  new electronic recording system the lead for Social Care must ensure that documents can be scanned into or attached via hyper-link to the record itself  30 Telephone referrals from other specialties to the acute paediatric medical team should be backed up by a written referral in the clinical notes outlining clearly the reason for the referral and any risk factors or indicators of abuse identified  31 Discussions and decisions taken during medical handover sessions should be documented in the case notes routinely especially where there are safeguarding concerns.  32 Specialist registrars should discuss as a matter of routine, referrals from other specialties to the acute team with the on call consultant or consultant on service. Action Plans have already been put in place with regards to this recommendation as part of the action plans for Child E & F case reviews.  33 Risk factors and indicators for child maltreatment to be emphasised in training sessions for both nursing and medical staff.  34 Clinical leads in Infectious Diseases ensure where a course of out patient appointments are required for completion of treatment / ongoing reviews, that  additional social information should be collected to include details of children in the household.  35 Clinical leads to ensure all Infectious Diseases staff comply with STHFT safeguarding children training plan (2011)  36 Head of Midwifery to ensure that background checks are performed on all women who refuse to give the name of the father of the unborn baby at the antenatal booking  37 Head of Midwifery to ensure that when referrals are made for specialist assessments (mental health & substance misuse) the lead professional (midwife or consultant obstetrician) receives appropriate feedback as to the outcome of those assessments.  38 Head of Midwifery to establish if recent changes to maternity records relating to fathers have been effective.  Overview Report concerning Child K    Page 113 of 115 39 When a parent/carer with a significant history is sharing the childcare once they are no longer living together in the same household, an assessment should be undertaken due to a change in circumstances  40 When an assessment identifies parenting concerns and that parent/carer moves to a different household, the current HV should inform new HV team of  the history and concerns  41 Ensure all Health Visitors are aware of the Protocol for responding to Concerns About Injury or Abuse in Infants Under 1 year old (SSCB 2009) when assessing minor injuries  42 Ensure record keeping of Health Visitors are inline with SCFT policy and NMC standards  43 Practices encourage close working relationships with Social Workers and Health Visitors, by inviting them to attend Practice meetings  44 GP computer systems are reviewed to cross reference family members and read code any safeguarding concerns identified in the family, so if one member of the family moves GP, the information will follow  45 Any self reported information that comes to light during an assessment should be checked and validated with the relevant agencies in order to ensure the assessments are robust and objective  46 Sheffield Social Care to enhance their assessment processes to ensure that fathers views are captured and represented in assessments.  This needs to include situations where children are not living with their fathers but have significant ongoing contact  47 Within the next 6 months, YAS will complete an information sharing qualitative audit with Barnsley District General Hospital Emergency Department and Paediatric Team, to test the robustness of information sharing during and following clinical handovers.       Overview Report concerning Child K    Page 114 of 115 Appendix 3 – abbreviations  BHNFT - Barnsley Hospitals NHS Foundation Trust BSCB – Barnsley Safeguarding Children Board CAF – Common Assessment Framework CT scan – Computerised Tomography scan IMR – Individual Management Review IORA – Independent Overview Report Author LSCB – Local Safeguarding Children Board MAPPA - Multi-Agency Public Protection Arrangements MAST - Multi-agency Support Team  NAI – Non accidental injury NHS – National Health Service NICE – National Institute of Clinical Excellence NSPCC - National Society for the Prevention of Cruelty to Children  PCT – Primary Care Trust PICU – Paediatric Intensive Care Unit SCNFT - Sheffield Children’s NHS Foundation Trust SCR – Serious Case Review STHFT - Sheffield Teaching Hospitals NHS Foundation Trust  SWYPFT - South West Yorkshire Partnership NHS Foundation Trust ToR – Term of Reference YAS – Yorkshire Ambulance Service    Overview Report concerning Child K    Page 115 of 115 Appendix 4 - References  Barnsley Safeguarding Children Board (2011): Serious Case Review: Child H.  Barnsley Safeguarding Children Board  Barnsley Safeguarding Children Board (2011): Serious Case Review: Child L.  Barnsley Safeguarding Children Board  Brandon, M et al (2009): Understanding Serious Case Reviews and Their Impact. A Biennial Analysis of Serious Case Reviews 2005-07. Department for Children, Hospital 2ools and Families  Fatherhood Institute (2010): The Guide for New Dads, Fatherhood Institute  Gershon P (2005): Efficiency, efficiency, efficiency; The Gershon Review: public service efficiency and the management of change. The Work Foundation  Laming (2009): The Protection of Children in England: A Progress Report. Her Majesty’s Stationery Office.  Munro, E. (2011):  The Munro Review of Child Protection – Final Report. Department for Education.  NICE (2009): When to Suspect Child Maltreatment, NICE clinical guideline 89 – Quick Reference Guide, NHS  Ofsted (2008): Learning Lessons, Taking Action: Ofsted’s evaluations of serious case reviews 1 April 2007 to 31 March 2008, Ofsted   Ofsted (2011): The voice of the child: learning lessons from serious case reviews, Ofsted   Ofsted (2011): Ages of concern: learning lessons from serious case reviews, Ofsted   Royal College of Midwives (2011): Reaching Out: Involving Fathers in Maternity Care, Department of Health  Royal College of Midwives (2011): Top Tips for Involving Fathers in Maternity Care, Department of Health  Sheffield Safeguarding Children Board (2011): Serious Case Review: Child E.  Sheffield Safeguarding Children Board 