Serious head injury of a 4-month-old boy in June 2013. Baby T had attended hospital 6-weeks prior to the incident with bruising, strongly suspected to be non-accidental. Mother and father did not live together and mother claimed to be the sole carer for Baby T leading up to this incident. A subsequent Working Agreement named father as the parent with supervisory responsibility for all contact with Baby T and his three siblings. All four children were the subjects of a child protection plan at the time of the incident. Mother and father were arrested and later admitted causing or allowing physical harm; they received a Community Order and suspended sentence respectively. Family were known only to universal services prior to the first incident. Father had a long history of mental health problems including chronic and severe anxiety and depression. The depth of father's mental health problems, as told to his GP, were not known by mother or children's social care. Identifies systemic learning and uses the Significant Incident Learning Process (SILP) model to pose questions relating to thematic learning, covering: low GP attendance at child protection conferences and the implications of a series of strategy discussions or conversations replacing formal, face-to-face strategy meetings. Makes various interagency and single agency recommendations.
      
 Title:  Serious case review: re: Baby T: born: February 2013: overview report. LSCB: Gateshead Local Safeguarding Children Board Author: Paul Tudor Date of publication: 2014  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.                            GATESHEAD LOCAL SAFEGUARDING CHILDREN BOARD  SERIOUS CASE REVIEW RE: Baby T Born: February 2013  OVERVIEW REPORT        Lead Reviewer P Tudor        August 2014 Baby T SCR - Final anonymised version   CONTENTS 1. INTRODUCTION 1.1. Introduction to Serious Case Reviews 1.2. Introduction to SILP 1.3. Introduction to the circumstances 1.4. Introduction to the family 2. PROCESS 3. BACKGROUND AND CONTEXTUAL INFORMATION RELATING TO MOTHER AND CHILDREN 4. KEY PRACTICE EPISODES 5. INITIAL CHILD PROTECTION CONFERENCE (3 May 2013) 6. PROFESSIONAL INTERVENTIONS WITH FATHER 7. SYSTEMIC LEARNING 8. THEMATIC LEARNING 9. FINDINGS FOR THE BOARD 10. SINGLE AGENCY RECOMMENDATIONS  Appendices  i. Terms of Reference and Project Plan ii. Agency Authors Template  Baby T SCR - Final anonymised version  1  1. INTRODUCTION 1.1. Introduction to Serious Case Reviews Serious Case Reviews have operated for many years, until recently under 2010 guidance “Working Together to Safeguard Children”. This guidance contained mandatory and discretionary thresholds and prescriptive advice on processes with IMR and Overview Report templates. In April 2013 new guidance was issued and Chapter 4 emphasises the importance of a Learning and Improvement Framework, of which reviews on cases is one element. Regulation 5 (2)(a) of the LSCB Regulations 2006 still requires Serious Case Reviews to be undertaken in defined circumstances; but the new guidance stipulates that reviews should be completed in a way which: - recognises the complex circumstances in which professionals work - seeks to understand the reasons that led individuals and organisations to act as they did - seeks to understand practice from the viewpoint of individuals and organisations at the time - is transparent about the way in which data is collected and analysed. (Chapter 4, para. 10) The guidance also advises that any learning model may be used, consistent with the principles contained in the guidance. 1.2. Introduction to SILP In 2010 Paul Tudor and Leicestershire & Rutland Safeguarding Children Board devised a methodology entitled Significant Incident Learning Process (SILP). The key principles of SILP are: - proportionality Baby T SCR - Final anonymised version  2  - learning from good practice - the active engagement of practitioners - systems methodology. These principles and the SILP methodology are entirely consistent with the 2013 Working Together to Safeguard Children guidance. 1.3. Introduction to the family       It is understood that for a long time parents had lived separately whilst remaining in a relationship. 1.4. Introduction to the circumstances Aged seven weeks, Baby T was presented at hospital with bruising below his shoulder blades and around the armpits and also to the buttocks. Non-accidental injury was strongly suspected and this led to Children’s Social Care and Police investigations.  An Initial Child Protection Conference placed his name and those of his three siblings on Child Protection Plans.  The Working Agreement and Child Protection Plan was that his Father would be the parent with supervisory responsibility for all contact with Baby T’s mother because she claimed to be the sole carer for Ty leading up to the injuries. Just over six weeks after the Initial Child Protection Conference and resulting Child Protection Plan Baby T was again presented at hospital; and on this occasion with symptoms of being floppy and unresponsive and then having seizures.  X-rays and a CT scan revealed a fractured skull. “Mother” 36 “Father” 39 “Baby T” 4 months  “Baby E” 16 months  “Brother K” 11  “Brother C” 14  Baby T SCR - Final anonymised version  3  Both parents were arrested and charged. Care Proceedings were issued and the children were placed with relatives. Subsequently Father admitted the charge of “Causing or allowing physical harm” and received a suspended sentence. The mother admitted the same charge and received a Community Order. The two older children have returned home to their Mother under Supervision Orders. The two younger children have been made the subjects of Special Guardianship Orders and placed with relatives. 2. PROCESS At a meeting of the Gateshead Local Safeguarding Children Board (LSCB) Case Review Sub Group on 3 October 2013, the decision was taken to recommend to the Independent Chair of the Board that the criteria for a Serious Case Review were met.  Following peer consultation with another LSCB Independent Chair, the Gateshead LSCB Chair endorsed the decision to initiate a Serious Case Review on 21 October 2013. A further decision was taken shortly thereafter to use an alternative methodology rather than the “traditional” SCR process; and the company operating SILP (Review Consulting Ltd) were approached. Paul Tudor attended another meeting of the Case Review Sub Group on 13 November 2013 and explained the SILP process and methodology, from which the sub group were willing to proceed.  Thereafter Terms of Reference, a Project Plan and an Agency Authors’ Template were approved (see Appendices [i] and [ii]) and the agency reports were commissioned. A Learning Event was held on 4 February 2014 and was very well attended (30+) including several Consultant Paediatricians, Designated Doctors, representatives of Community Health, GPs, Nursing, Police, Children’s Social Care, Education, Barnardo’s, Mental Health. The agency reports had been circulated a few days in advance so that the participants had comprehensive Baby T SCR - Final anonymised version  4  material in order to generate productive and challenging discussion, analysis and debate. A first draft of this report was then circulated a few days ahead of a Recall Event (3 March 2014) and again a large number of participants (25+) debated the issues. This process helped to formulate the final version which was presented to the Gateshead LSCB on 26 March 2014. Whilst the final version was accepted and endorsed by the Gateshead LSCB (after a few minor amendments), it was decided to postpone submission and publication until after the criminal trial (in case new information emerged); and to invite parents to contribute (which could not take place until after the trial).  Invitations were sent out, to which Father did not respond; but Mother expressed an interest in speaking to the Lead Reviewer and LSCB Business Manager. An interview was set up and held on 1 August 2014, at which Mother was supported by an Advocate. Her views have been woven into the text at the appropriate places. Advice was taken in respect of involving Brother C and Brother K in the review and it was felt by a number of professionals that they would find the process very distressing and would be upset by any approach as they were upset by everything that had happened and did not wish to talk to anyone about it, therefore they were not contacted. Baby T himself is too young to have been consulted as part of the SCR process.  The process has been very efficiently administered by Linda Conroy, to whom my sincere thanks. 3. BACKGROUND AND CONTEXTUAL INFORMATION RELATING TO MOTHER AND CHILDREN As an introduction to this section it is noteworthy that the family had very little contact with agencies prior to the scoping period.  Baby T SCR - Final anonymised version  5  General Practitioner Mother has been registered with the same GP all her life; no concerns for her welfare or parenting skills have been identified. For the children, no significant events or safeguarding issues emerged prior to the scoped period.  Routine consultations and appointments were conducted (i.e. immunisations, common health concerns).  Community Midwife Mother had attended all her antenatal appointments for her pregnancy with Baby E (born February 2012) and she had continued work (a Production Administrator) throughout both pregnancies. She was breast-feeding Baby E throughout her pregnancy with Baby T. Child Health All the children received universal health visiting and school nursing.  They attended A&E for minor illnesses and injuries; no safeguarding concerns were ever raised. Education For Brother C, attendance has been something of an issue throughout his school career, dropping to 62% in his first year at secondary school.  In Year 7 it was always his father who rang the school to inform them of absences and the school had little contact with his mother. After two failed appointments (when parents had been invited to discuss attendance), a Letter of Concern was sent by the Education Welfare Service and his attendance improved the following year.  The Education Welfare Service has established a staged response to managing attendance problems which is more proactive. The Education Welfare Service has established weekly allocation meetings and monthly Baby T SCR - Final anonymised version  6  supervision sessions allowing for a robust approach to individual case management. There have been some low level behaviour issues with Brother C which the school have dealt with by verbal reprimands and loss of privileges only.  Academically he is achieving within his abilities. Brother K presents very well and is making good progress.  He is popular and no significant behaviour issues are reported. Police and Children’s Social Care Neither parent nor the children were previously known. 4. KEY PRACTICE EPISODES This section acknowledges a style promoted by Learning Together (SCIE). 4.1. Antenatal Visit At the 13 August 2012 booking appointment by the Community Midwife, no presenting problems or concerns were identified (i.e. Mother and Father were both non-smokers, Mother stated that she did not use alcohol or substances,  did not disclose any domestic violence and no mental health issues were disclosed), however she did suffer gestational diabetes with her last pregnancy. Antenatal clinic appointments were completed on 5 September 2012, 9 December 2012, 3 October 2012, 12 December 2012, 19 December 2012, 4 January 2013, 30 January 2013, 6 February 2013 and 21 February 2013, i.e. all her appointments.  Throughout, no safeguarding concerns were identified though Mother became very tired (she was still working and breast-feeding Baby E).   Baby T SCR - Final anonymised version  7  4.2. Baby T’s birth in February 2013 A planned induction took place at 37 weeks due to a large baby, increased amniotic fluid and gestational diabetes. No resuscitation was required immediately, but after 15 minutes some breathing difficulties were noted and therefore Baby T had a short admission to Special Care Baby Unit (SCBU) at HOSPITAL 2.  Father was present at the birth. Mother’s Comment She feels the midwives were not as observant as they could have been and that it was she who drew their attention to the baby’s breathing difficulties. Baby T returned from SCBU after a day; Mother commenced breast-feeding and it went well; they were discharged the following day. 4.3. Postnatal Three routine home visits were conducted by a midwife in late February/early March 2013. Mother required injections daily for 6 weeks as she was at increased risk of thrombosis. A record states “technique shown to partner” (2 March 2013), thus confirming that Father was present at the home on that occasion – see Section 6 of this report. Mother’s Comment In fact Father felt unable to administer the injections (as did Mother herself) and so it was her sister who administered them. A primary visit was made by the Health Visitor on 8 March 2013. The issue of co-sleeping was discussed and Mother was aware of the risks and knew that it was not advisable.  Application of the Early Warning Assessment showed the lowest level score, i.e. universal intervention.  Baby T SCR - Final anonymised version  8  Father was not living with the family but staying over to help; Mother was tired; still breast-feeding Baby E (who is only 12 months older) but denied she was feeling down. The Health Visitor continued this visit on 8 March 2013 with Baby E’s 9-12 month assessment and there were no concerns about her development. Further home visits were made by the Health Visitor on 15 March 2013 and 22 March 2013.  Baby T had a steady weight gain and the reviews were due to him being jaundiced.  On advice to the Health Visitor from a Paediatric Senior House Officer, Baby T was taken by his mother to HOSPITAL 1 on 22 March 2013 where he was assessed by the medical team regarding his jaundice. On 28 March 2013, Baby T was taken by his mother to the hospital with a history of poor feeding and vomiting.  He was admitted for a few hours; blood tests were taken and he was discharged within the day because the tests were normal and he fed well whilst on the ward.  The diagnosis was of an early viral upper respiratory tract infection. Baby T’s GP received notification of the 28 March 2013 hospital presentation; and he was seen again on 11 April 2013 by his GP for a routine 6-8 week examination. Baby T’s head circumference was taken, testicular and hip examinations were conducted, there was no cardiac murmur; and there was good parental eye contact. No concerns were noted and there was no evidence of a viral infection.  Mother’s postnatal examination was conducted at the same time and again no concerns were noted. 4.4. Bruises 14 April 2013 Mother presented Baby T at the Walk-in Centre, concerned that a rash on his nose might be an abrasion or possible meningitis.  The Walk-in Centre referred him to the HOSPITAL 1 Paediatric Team.  Baby T SCR - Final anonymised version  9  On examination, there was bruising on his buttock (no explanation), a small area on his lip looked infected and was crusting; a lesion on his nose; bruising on left and right sides of his back under the shoulder blades within the armpit. Mother could offer no explanation and reported that there were no other carers other than “dad at home” (meaning that Father was at home at the current time, but it was established that he did not live there on a permanent basis).  She was not aware of the other children causing any injury to him other than his 14 month old sister having nipped him and left a bruise previously on his leg. The first examining doctor was a Paediatric Trainee and she appropriately considered non-accidental injury as part of her differential diagnosis. Therefore she drew it to the attention of the Consultant Paediatrician on call that evening, who also reviewed Baby T and initiated some blood tests.  These blood tests were normal.  Again Mother was unable to provide any explanation for the bruising.  Mother was told by the Consultant Paediatrician that Baby T would need to stay in hospital overnight for further tests and that the Duty Social Worker, the Health Visitor and the GP would be spoken to.  The following day, CT scans and X-rays showed no subdural haemorrhage or fractures. 4.5. Investigation The Consultant Paediatrician duly phoned Children’s Social Care Emergency Duty Team (EDT) at 21.00 hours and the EDT Social Worker informed the Police at 22.30 hours.  Between them they confirmed that there was no previous knowledge or information in either Police or Children’s Social Care records.  A Strategy Discussion took place confirming that Baby T needed to remain in hospital overnight.  As Mother was breast-feeding both Baby T and Baby E, it was arranged by Children’s Social Care, with the agreement of the Police, that Baby E would be brought to the hospital and a childminder was organised to chaperone Mother’s care and breast-feeding of both children; leaving Father to look after the two older boys overnight. Baby T SCR - Final anonymised version  10  Comment This represents good early information sharing between Hospital/Police/Children’s Social Care; and very good, imaginative and sensitive practice by Children’s Social Care and ward staff in keeping a mother and young children together. However, Mother’s view is that this arrangement was more about checking Baby E than supporting her and the two children staying together. As that Consultant Paediatrician was on leave the following day, a colleague Consultant Paediatrician agreed to take over the management of the case; and did so by reviewing Baby T on the morning of 15 April 2013 and meeting Mother.  The only explanation she could offer for the bruising below his shoulder blades and around the armpits was lifting him when she was breast-feeding and carrying him. A CT head scan, skeletal survey, and ophthalmology review were all conducted and later in the afternoon reported as normal.  Baby T remained well on the ward (see Section 8).  Mother confirmed in her interview that it was explained to her that the baby’s eyes had to be checked and she understood that possible shaking might be suspected. The Consultant Paediatrician consulted the GP, who reported no concerns or abnormalities at the 6-8 week check on 11 April 2013 (Key Practice Episode 4.3). The Consultant Paediatrician also reviewed Baby E and confirmed normal development and no signs of injury. 4.6. The Plan In addition to a joint visit to the hospital by Police and Children’s Social Care to see Baby T and Mother, and also to meet the Consultant Paediatrician, there were a number of telephone conversations between the Consultant Paediatrician, the allocated Social Worker, who was at the hospital, the Baby T SCR - Final anonymised version  11  Assistant Team Manager who was at an office and the Police during the afternoon of 15 April 2013.  These comprised Strategy Discussions confirming that the bruising to a non-mobile infant was concerning and unexplained; that Mother had been the sole and consistent carer for Baby T; and she reported that Father had never cared for Baby T alone, although he visited the family home daily. Checks made with the Police and with the Local Authority (in relation to the two older boys at school) were all unremarkable.  Therefore a written agreement was devised whereby Mother would move out of the family home and reside with her grandmother, and Father would move in.  He would take over the care and responsibility of all four children, but Mother would visit a lot to breast-feed Baby T and Baby E and to share the care of the children, but under his supervision. She was indeed at the family home most of the time, as she described that there were no time constraints. Analysis of systems in relation to strategy discussions/strategy meetings, and of the practice relating to the plan are discussed at Sections 7 and 8. 4.7. Section 47 enquiries by the Social Worker The following activities took place: • Liaison with the schools for the two older children • Liaison with Health Visitor and School Nurse • Liaison with Police and Consultant Paediatrician • Legal consultation • Liaison with the children’s and Mother’s GP • Two announced and two unannounced visits • The two older boys seen and spoken to away from the family home • Childminding support was offered to Father but he declined Baby T SCR - Final anonymised version  12  • A referral to Barnardo’s Family Support service • The family did not want any other extended family members involved Comment This represents very comprehensive and efficient practice of a high standard.   However, the obvious gap is that no contact was made with Father’s GP – see Section 8. 4.8. Other interventions At a Health Visitor home visit on 16 April 2013 – Baby T appeared well and his jaundice had resolved.  Mother was feeling down and low (tearful) and attributed this to Children’s Social Care involvement. On 19 April 2013 Mother contacted the Health Visitor regarding new marks on Baby T’s face.  They both considered them to be milk spots and the Health Visitor advised Mother to seek medical attention if they got worse. Comment The Health Visitor should have consulted her Safeguarding Nurse Advisor and it would have been appropriate to inform both the GP and the Social Worker. At a review by the Consultant Paediatrician on 1 May 2013, Baby T was well; there was no further bruising; and repeat X-rays were taken and proved normal. 4.9. Initial Child Protection Conference See section 5. 4.10. Challenge and Escalation The Consultant Paediatrician sought supervision with the Designated Doctor on 7 May 2013 and they agreed that from the history this was likely to be non-Baby T SCR - Final anonymised version  13  accidental injury.  The supervision arrangements were discussed and there was concern that the plan may not ensure safety within the family home. On 8 May 2013 the case was also discussed at a Regional Consultant Paediatric Peer Review meeting at HOSPITAL 2 and this was attended by the Consultant Paediatrician. The conclusion was that non-accidental injury was likely and that the vulnerable infant may be at risk in the home with this current supervision plan.  The following day (9 May 2013) the Consultant Paediatrician relayed this view to the original Referral and Assessment social worker who agreed to pass it on to the newly allocated Safeguarding and Care Planning social worker (see 4.11 below).  The Consultant Paediatrician has recorded the views of the Peer Review and his contact with the social worker in the hospital records. Another Consultant Paediatrician who chairs the Peer Group at HOSPITAL 2 contacted the Designated Doctor on 9 May 2013 by email (which was read on 10 May) expressing concerns about the care arrangements and raising whether breast-feeding had been given a greater priority than safety.  The Designated Doctor was unable to speak to that Consultant Paediatrician on 10 May. She then spoke to the previously allocated Social Worker who confirmed that the concerns of the Peer Review had been passed on. The newly allocated Social Worker was not available and therefore the Designated Doctor spoke with their Team Manager later that same day (10 May 2013).  The Team Manager satisfied the Designated Doctor that the plan had been agreed at the Child Protection Conference; it would be monitored by the Core Group; and during the preceding three weeks there had been no indication that the parents were not cooperating.  Therefore there was no real reason to remove Baby T from the household.  Additionally, Police checks were being undertaken on the maternal aunt so that she could offer additional support.  The Designated Doctor confirmed in the Learning Event that she was satisfied with this explanation. Baby T SCR - Final anonymised version  14  In the Learning Event and the Recall Event the Team Manager again reinforced that breastfeeding had not been given undue prominence; and certainly had not overridden the need for a safe plan for the children.  Indeed the original plan had been that Mother would express milk and it was only when she was unable to do so that she came to the house for all the feeds. A third discussion on this case took place at a local Peer Review (at HOSPITAL 1) on 21 May 2013 with four other Consultant Paediatricians present, including the Designated Doctor. The previous concerns about the safety of supervision were reiterated but no further action was recorded. Comment The Regional Group is a forum for paediatricians across the region to access peer support and advice on the management of Safeguarding cases.  Challenge is healthy.  It has been reported for this Serious Case Review that for the Chair of the Peer Group to make contact with the Designated Doctor is unusual and emphasises that they thought the situation was a risky one. 4.11. Ongoing investigations Meanwhile, immediately after the Initial Child Protection Conference the case had transferred from a Referral and Assessment Social Worker to a Safeguarding and Care Planning Team Social Worker.  They made a joint home visit to introduce the new worker to the family on 8 May 2013 and then she made a further home visit on 14 May 2013. The case was allocated within Barnardo’s to a named Project Worker on 9 May 2013. 4.12. Core Group 15 May 2013 The allocated Social Worker was unavailable at short notice to chair the Core Group meeting; and the chairing was therefore undertaken by a Duty Social Worker who had very limited knowledge of the case. Baby T SCR - Final anonymised version  15  Parents were present, and during the meeting the other professionals (School Nurse, School and Health Visitor) expressed concern that the two older children did not need to be on Child Protection Plans; and having their mother residing out of the family home may be having a detrimental emotional effect. There was a recorded view that the safety plan should be reviewed regarding Mother not having unsupervised contact with the two older children. Comment There is a systemic flaw in that no Social Worker or Team Manager with any knowledge of the case was present.  Whereas the Core Group was considering a relaxation of the Child Protection Plan, no input is recorded describing the escalation and challenge from Paediatricians (see Section 4.10).  No changes were actually made by this meeting as the Chairing Social Worker said she could not agree to them. The Children’s Social Care Team Manager did know of the challenge; and the issues of safe supervision were so important that ideally the Core Group should either have been rearranged, or another meeting called urgently when the Social Worker and/or Team Manager could be present. However, there is a very real dilemma about Core Groups going outside of prescribed timescales (10 days from the Initial Child Protection Conference) as these are set out in Working Together to Safeguard Children (2013). Therefore there is a very real pressure to keep within timescales. 4.13. Ongoing interventions • Health Assessments on Brother K and Brother C by the School Nurse on 15 May 2013 revealed no concerns. Baby T SCR - Final anonymised version  16  • A 3-4 month check by the Health Visitor during a home visit on 21 May 2013 confirmed that Baby T’s development and height and weight were fine and there were no concerns. • A second immunisation by the GP on 28 May 2013. • An initial home visit by Barnardo’s Project Worker on 29 May 2013 and then a subsequent visit on 30 May 2013, to complete paperwork. • Mother presented to the GP on 3 June 2013 with low mood (crying, not sleeping, poor concentration) but she declined counselling. • A Child Protection visit was undertaken by the Social Worker on 4 June 2013 and all the children were seen.  Although Mother was tearful, both parents were still agreeing to follow the plan. • Parenting Assessment visits by the Barnardo’s Project Worker on 5 June 2013, 6 June 2013, 13 June 2013 and 17 June 2013. 4.14 Second Core Group Meeting 10 June 2013 Again the parents attended and the Social Worker, but only one school was represented; and the Health Visitor and the Barnardo’s Project Worker both tendered apologies.  This time the concerns expressed by the HOSPITAL 2 Peer Group were discussed; but the conclusion of the Core Group was that there did not need to be a change of plan, as parents were cooperating.  Indeed, as there had never been any safeguarding concerns regarding the two older boys, there was in fact a change in the plan, i.e. that they no longer needed to be supervised in their day to day contact with their mother.  Also the Police checks on the aunt had come back clear so she could act as a supervisor of Mother’s contact, to relieve some of the pressure on Father. Comment On reflection, agencies are saying that there should have been more challenge to the sustainability of the supervision arrangements and the Baby T SCR - Final anonymised version  17  stress they were causing.  Children’s Social Care hold the view that the plan was an integral part of the assessment and was never envisaged as a long-term arrangement.  It would be constantly re-evaluated up to the Review Child Protection Conference and members of the extended family were being brought in to offer additional support. Mother suggested that she did not receive Core Group minutes from either the first or second Core Groups. 4.15. Second presentation to hospital 14 June 2013 Baby T was brought to HOSPITAL 1 by his mother and aunt early morning (5.22am).  He was seen by a Trainee Doctor and then by a Consultant Paediatrician. Mother reported to the doctors that Baby T had woken up screaming and very distressed, breathing fast and snuffly; then he had a floppy episode and then brought up some blood-stained phlegm.  Mother was very open with the Consultant Paediatrician about previous child protection issues and that Baby T was subject of a Child Protection Plan. On examination there was no sign of bruising and there seemed to be appropriate mother/child interaction; but “he does not look happy” (Doctor’s notes) and three non-blanching red spots to the right leg were recorded. Blood tests revealed a raised platelet count and a white cell count; and Baby T was diagnosed with a probable viral infection.  He was discharged later that afternoon with a plan to repeat the blood tests in two weeks.  Children’s Services EDT and the GP were notified (in the form of a discharge summary). Comment A systemic issue – the notes from the Designated Doctor’s discussion with the Children’s Social Care Team Manager were not in Baby T’s hospital records at this point as the Designated Doctor is based on another site.  Therefore the examining Consultant Paediatrician did not have access to this dimension. Baby T SCR - Final anonymised version  18  4.16 Second Injuries Baby T was brought back into HOSPITAL 1 at 15.23 hours on 18 June 2013 by his parents, who reported a history of short episodes which looked like seizures while they were travelling in the car.  At A&E staff noted further seizures and treatment to stop the seizures was commenced.  He was transferred to a ward where further seizures were observed.  Therefore he was later transferred to HOSPITAL 2 for ongoing care and further investigations.  Meanwhile, a CT scan had revealed a skull fracture.  Children’s Social Care and the Police were informed; and an EDT social worker attended at 20.10 hours.  The Police also attended and therefore there were conversations between Police/EDT and medical staff.  It was quickly arranged that one maternal aunt would stay with Mother, and another maternal aunt would look after the three remaining children at home. A Strategy Meeting was held on 19 June 2013 and it was confirmed that the three children would remain in the care of the maternal aunt after a Regulation 24 Connected Person’s Assessment was completed and approved.  The other aunt was also assessed in order to assume responsibility for caring for Baby T upon his discharge from hospital.  All contact by parents would be supervised by Children’s Social Care.  Section 47 enquiries by the Police and Children’s Social Care were commenced and subsequently both parents were arrested and interviewed under caution. Baby T was discharged from hospital to the maternal aunt on 26 June 2013 following a Discharge Planning Meeting earlier that day.  Discharge communication was sent to the GP and follow-up arrangements with the Consultant Paediatrician at Gateshead were clearly documented.  Baby T SCR - Final anonymised version  19  4.17. The Services Offered The involvement of General Practitioner, Hospital, Police, Children’s Social Care, Health Visiting, Schools, etc. have all been described in some considerable detail in the text of Sections 3 and 4 above.  The other service to the family was a commissioned one, i.e. Barnardo’s. Based on a telephone referral on 2 May 2013, the request for work from Barnardo’s Sungate service was specifically to undertake an observational role and to report on family functioning and attachments to inform the social worker’s assessment. On 22 May 2013 the Project Worker met with the Social Worker to gain background information; and the outcome was a request for 2 x 2 hourly visits per week within an 8-week timeframe for the Social Work Assessment to be completed.  Within these visits, in addition to observation, the Project Worker would report on parenting ability and offer both parents emotional support. During the appointed six visits (see Section 4.13) the worker made detailed observations of child care, family functioning, child development and identified no issues to cause concern, other than parents’ anxiety about the circumstances.  The case was discussed thoroughly in supervision. 5. THE INITIAL CHILD PROTECTION CONFERENCE (3 May 2013) As per Gateshead LSCB Inter-Agency Child Protection procedures, the Social Worker used Form CF62 to request to arrange an Initial Child Protection Conference and emailed it to the Safeguarding Unit on 18 April 2013.  At that time invitations were mainly sent by hardcopy letter through Royal Mail postage.  The Social Worker had not identified Father’s GP and therefore they were not invited, the significance of which is discussed at Section 8. The invitations were not sent until 29 April 2013 (11 calendar days after receipt of the request) and only 4 working days prior to the conference (i.e. Monday to Friday 3 May 2013), but this time scale was within the 15 days Baby T SCR - Final anonymised version  20  from the Strategy Discussions on 15 April 2013.  Nevertheless, there was a more than adequate attendance (representing Children’s Social Care, Police, Hospital Doctor, Health Visitors, School Nurse, Schools) though the Chair should have highlighted the absence of GPs.  There was also a wide range of reports tabled (Children’s Social Care, Paediatric Assessments, Health Visitor, School Nurse, Schools, Police).  Comment This number of reports from all participants represents very good practice. Both parents had received invitations and both attended, but on their own and without support.  The Health Visitor and School Nurse reports had been shared with them prior to conference; they were unable to fulfil the appointment which the Social Worker offered to go through the conference report the day before but the conference report was posted through their letterbox.  Moreover, they arrived early in order to go through the report with the Social Worker beforehand.  They also had a half hour meeting with the Chair prior to conference.  The Chair made attempts to facilitate their involvement in the conference but reportedly they did not make much contribution or challenge in the conference. Although Referral and Assessment Team Social Workers always prepare a chronology when opening a case, on this occasion the conference did not receive a stand-alone chronology as the interventions and timescale were very limited; but a chronological sequence was contained in the text of the Social Work report. There is no recorded evidence of any discussion about inviting the two older siblings or asking an advocate to represent their views or to participate in some other form.  Neither they nor an advocate attended or participated in any way.  However, the Social Worker informed the Recall Event that Brother C had been asked if he wanted to attend or participate in some other way and Baby T SCR - Final anonymised version  21  he declined.  Nevertheless, their views did assist in formulating the plans, i.e. they wanted their Mother to return but they supported their Father’s role in caring for all four children. The content and process of the conference (as represented by the minutes and as analysed by an independent author preparing a report for this Serious Case Review) gives no information or insight into Father’s background, his current circumstances, his relationships with Mother and the children, or his parenting capacity.  There should have been.  In the absence of this dimension, a requirement to satisfy this should have been clearly spelled out in the Child Protection Plan; “parenting assessment” is too vague. (Gateshead does have a specified format for a parenting assessment and most professional conference attendees would be aware of the prescribed format).  Similarly, the Outline Child Protection Plans have vague timescales “as soon as possible”, “ongoing”. There was a further missed opportunity to explore Father’s role when the Child Protection Plans were being formulated and Father talked of “the house is up all night and it is very distressing for everyone”.  This could – and should have – opened up discussion about the family functioning and his role in it.  There are two process issues reflected in the minutes of the Initial Child Protection Conference.  It was very good practice for the Consultant Paediatrician to present published journal evidence to support his views; but this is not recorded in the minutes.  Neither is there a record of the break in the conference at which point parents were asked to leave for a few minutes while the conference received confidential information. The standard for the distribution of the decision for conference and the Child Protection Plans is 24 hours.  In this instance the distribution took place on 14 May 2013 (11 calendar days and 7 working days later).   The explanation was a technical issue with CareFirst (the electronic recording system) which was reported to the CareFirst Helpdesk. Baby T SCR - Final anonymised version  22  The standard for the distribution of the Chair’s report is 20 working days which would have fallen on 3 June 2013.  In fact they were distributed on 2 September 2013, i.e. 3 months out of timescale and 4 months from the conference.  The delay was caused by operational issues.  These issues are now being addressed and 96.4% of Child Protection Plans are now distributed in timescales.  Work continues to take place to ensure that Child Protection Chair’s Reports are distributed on time, which is monitored on a weekly basis.  Comment Not only is the record of the conference a crucial working document for the professionals and the family, but it also makes it very difficult for a Chair to confirm the accuracy of the minutes from memory three months previously. 6. PROFESSIONAL INTERVENTIONS WITH FATHER NB: His first name is sometimes spelt differently. This discrete section is necessary, partly because there is a lot of missing information in the management of the case because no checks were made with Father’s GP; and partly because there is such a contrasting and discrepant history. Father has known his current GP since 2000 and by 2003/04 this GP was the only doctor that he would see.  Father has been known to the practice since 1993 for anxiety symptoms.  Over the course of the next few years he was considered to have chronic anxiety with social and agoraphobic symptoms and obsessional thoughts. He was referred to a psychiatrist in 1993 for anxiety and depression from which he was referred to an anxiety management group. There were hospital presentations in 1994 (panic attack; persistent nausea; depression and feelings of self-harm); and he called an ambulance after taking an overdose.  He was then seen by a number of professionals within Baby T SCR - Final anonymised version  23  mental health (Psychiatry, Psychology, CPN, OT) and all reported non-compliance with medication and missing appointments; he lacked motivation to engage in therapeutic work. Low mood led to referrals in 1998/99 but he continued to fail appointments. Again in 2006 with the same outcome. The Psychology service was involved 2007-09 and Father made reference to his two boys whom he saw at weekends. They were assessed as a protective factor in relation to his mental health. At a multi-disciplinary team meeting in July 2009 it was considered that Father did not have a serious mental health problem, but he lacked motivation to change and was unwilling to accept support and the psychological work ended in November 2009. With his GP, Father remained on antidepressant medication.  In a report for Benefit purposes the GP noted: “He is a man whose life is severely affected and restricted by his mental health problems but he rejects help and is difficult to engage. His strategy is avoidance of life to reduce anxiety.  His problems are chronic and stuck”. (August 2010) Within the scoped period (July 2012-June 2013), Father saw his GP monthly and this is corroborated in the chronology for this Serious Case Review.  He was being treated for depression by regular antidepressant medication and his condition appeared stable and he declined offers of intervention such as counselling. I now quote some of the General Practitioner entries and have left them in note form as they appear in the records:   Baby T SCR - Final anonymised version  24  Appointment date Entry in records 2 August 2012  6 September 2012 Continues in his very small, safe world with no real motivation to change. 8 October 2012  8 November 2012 A range of mental health options declined; a young recluse really, a terribly small life, in some ways content with it, not a risk to himself, no thoughts of self-harm, no harmful behaviours, but not normal or good for his two sons to visit, i.e. not stimulated or engaged by him, but no safeguarding concerns. He saw the boys at his father’s house. 6 December 2012  8 January 2013  5 February 2013 Went to his ex-wife’s house for Christmas and enjoyed seeing the children 4 March 2013 Sees kids occasionally at his dad’s house, spends time between his dad’s and his brother’s. (NB: In the light of this 4 March 2013 entry, the midwife reported showing him an injection technique for Mother at a home visit on 2 March 2013.) 11 April 2013 Zero motivation; content in a very restricted lifestyle 16 May 2013 Reported that his father was in hospital and he was staying with his brother. (NB: Section 4.6 of this report. From 16 April 2013 he has been the supervising parent under a Working Agreement and responsible for all four children.)  In summary, the GP knew nothing of the two younger children, nor of Father having contact with the boys’ schools (Section 3), nor of the information shared in the conference that Father visited the family home 3 or 4 times per week including staying overnight. The observations of the Barnardo’s Project Worker (and reinforced by Health Visitor) was that when Father was in the supervisory/caring role for the children; he was very passive; he needed prompting from Mother to play with and distract Baby E when Mother was breast-feeding Baby T.  Also, that Baby T SCR - Final anonymised version  25  Father felt he had been forced into this role, rather than taking it on by choice; and he needed to learn a lot about day to day care, of which Mother was still undertaking the majority. Father showed an interest in the process by asking many questions and generally he presented quite well.  However, he remained in the background, eg. sitting in the kitchen leaving Mother to undertake the main care (Health Visitor record of a home visit on 16 April 2013). In the interview with the Lead Reviewer and LSCB Business Manager, Mother was able to provide some background context to her relationship with the children’s father. He had lived at the home of his grandparents; Mother and Father met on a night out in Newcastle and she became pregnant with the eldest boy within four months. However, Father chose not to move in with her, though he visited regularly. He never wanted to commit to sharing a mortgage; though he did offer her some financial support. With the two boys they spent time together as a family at Christmas, birthdays and went away on holidays together. On occasion, they attended Parents’ Evening at school together.  He had several jobs and was always in work, often at Call Centres. Mother attributes his depression to suffering two close bereavements in quick succession; but she had no knowledge of the depth of his mental health problems as described in his GP’s statement in the criminal proceedings.  She stated that she was shocked when she read the report from his GP; and she reflects that if she had been given any such knowledge or insight, she would not have agreed to the supervision arrangements discussed earlier in this report.  Author’s Comment It has already been fully discussed in previous sections of this report that Children’s Social Care also did not have or obtain this insight. The analysis for this Serious Case Review has constantly been struck Baby T SCR - Final anonymised version  26  by the great disparity between the GP’s description of Father’s mental health history, and Mother having no inkling of this history, despite them being together for 15 years. Maybe he was deceptive towards his partner; maybe he exaggerated his symptoms to his GP; but he has declined an invitation to meet the Lead Reviewer, and so this disparity cannot be explored any further for this Serious Case Review. Finally, Mother describes Father as quiet and he always liked to be in quiet areas (e.g. in restaurants) and she confirmed that he used to wear headphones quite a lot, for peace and quiet. Nevertheless, after Baby E was born, Father came through every day to help and they were talking seriously about him moving in on a permanent basis (prior to the events under review). 7. SYSTEMIC LEARNING a. This Serious Case Review has identified some good practices and systems: - The roles and responsibilities were clearly identified and communicated between clinicians at HOSPITAL 1 and HOSPITAL 2. - For the investigation of the second injuries, while the Police were interviewing the parents, the Consultant Paediatrician made herself available by phone so that they could discuss the explanations that were being given.  This allowed the Consultant Paediatrician to consider and discount them which, in turn, enabled the Police to effectively challenge the parents during the interviews.  This process included taking items mentioned by the parents to show the Consultant Paediatrician for her consideration. - The GP was consulted by the Consultant Paediatrician during the investigation of Baby T’s first injuries on 15 April 2013. - The GP received discharge summaries and handovers from A&E, Walk-in Centre, Cause for Concern, Special Care Baby Unit (5 March, Baby T SCR - Final anonymised version  27  22 March and 28 March 2013, 14 April and 18 April 2013, 14 June and 17 June 2013). - Hospitals are now sending copies of Immediate Response forms to GPs rather than them waiting for delayed Discharge Forms. - The use of the Information-sharing form from Health Visitors to GPs. - A provisional proforma describing injuries and examination given to the Social Worker and Police Officer whilst at the hospital and then a copy emailed later. - Strategy Meetings and Pre-discharge meetings held in hospital to provide the opportunity for clinicians and professionals to attend with least interruption. - Health Visitor and Safeguarding Nurse attended 19 June 2013 Strategy Meeting and the Health Visitor attended the Discharge Planning Meeting on 26 June 2013. b. This Serious Case Review has also identified some issues which have been put in place recently, some of which have arisen directly from this process: - Distribution of Child Protection Plans within 1 working day of the conference is currently 100%. - Child Protection Conference invitations and minutes are now distributed electronically by secure email with “read/receive” facility. - Within Children’s Social Care for Section 47 enquiries an additional mandatory section has been included in the documents detailing checks have been undertaken with the parents’ GP and that they may be two different GPs.  Social Workers have been briefed. - A Health Visitor contact antenatally is now a standard expectation (but it was not so at the time). Baby T SCR - Final anonymised version  28  - Children’s Social Care Team Managers have been advised of the importance of the first Core Group and of ensuring that it is chaired by the allocated Social Worker or Team Manager. c. Nevertheless, there remain some outstanding issues: - GP attendance at Child Protection Conferences remains very low (approximately 2%) and the incidences of GP reports to conference is still only approximately 20%. These figures are being monitored regularly by the Safeguarding Unit and the CCG and are being raised in GP Newsletters and in training sessions for GPs. - The issue of regular meetings between Health Visitors and GPs was a recommendation from a previous Serious Case Review. There is a Link Health Visitor allocated to each GP practice and they should meet at least quarterly; but not wait for scheduled meetings when there are urgent case issues to be discussed and information to be shared. In this case meetings took place with the Practice Manager which is not acceptable, as the Practice Manager does not have clinical authority. - Notes of any discussion with a Designated Doctor must be placed on the child’s hospital records at the earliest opportunity. - There is another practice issue which Mother raised in her interview. She considered that there were several examples in which the Police and hospital staff lacked discretion, eg. the Police were in uniform accompanying her between wards; the curtains were not drawn when photos were being taken, so that other parents could see what was happening. 8. THEMATIC LEARNING Contained in the agency reports and debated at the Learning and Recall events, a number of key areas have emerged; and they are best posed as questions. Baby T SCR - Final anonymised version  29  8.a. Did Paediatricians convey and explain their thinking on how significant the first injuries were? Implicit in the fact that an Ophthalmology Review and CT head scans were ordered during the investigation of the first injuries on 14 April 2013, was that “shaken baby” was being considered; particularly in the light of the siting of the bruises.  The Police confirm that the first Paediatrician they dealt with did explain that she was considering “shaken baby”, but in the absence of other features discounted it.  None of the Children’s Social Care staff involved in this investigation ever heard the phrase being used or the condition being considered.  The Consultant Paediatrician who took the lead on the investigation and the Designated Doctor have explained to this Serious Case Review that in the light of the positioning of the bruises they had to consider “shaken baby” even at a low level, in order to try to prevent such behaviour escalating to a serious “shaken baby syndrome”.  In order to gain Baby T’s mother’s consent for the tests, the Consultant Paediatrician and/or nursing staff must have explained their thinking to a greater or lesser extent to her.  However, such explanation and clarification was not made to the investigating Social Worker or Police Officer; and the issue of Strategy Discussions rather than Strategy meetings comes into play at this point (see Section 8b below).  Whilst the phrase “shaken baby” does not appear in the Initial Child Protection Conference minutes, and the Chair of the conference who attended the Learning Event has no recollection of the term being used, there is no doubt that the conference members did understand the significance of the injuries to such a young baby.  This is evidenced by the Consultant Paediatrician bringing to the conference journal literature; and also by the outcome of all four children being placed on Child Protection Plans.  In particular, the investigating Social Worker and Police Officer, both of whom attended the Learning Event, confirmed that they Baby T SCR - Final anonymised version  30  understood and accepted the seriousness and significance of the injuries to a non-mobile baby. 8.b. Did the process of a number of conversations and strategy discussions on 15 April 2013 compensate for the lack of a formal Strategy Meeting? There is clear evidence that the investigating Social Worker and Police Officer were at the hospital during the afternoon of 15 April 2013; and they were speaking to both parents and the Consultant Paediatrician; and they were also consulting with the Team Manager back at the Children’s Social Care office.  As a result, a Working Agreement Plan was put in place (see 8.3 below).  However at the Learning Event, the Consultant Paediatrician described the process in hindsight as “a series of conversations in motion” and he doesn’t consider that he contributed to the plan or was party to the decision; the plan was presented to him and he accepts that he did not make a challenge to it. The dynamics of a series of conversations are very different to those of sitting down for a face to face meeting where ideas can be thoroughly explored. Rather than a series of bi-lateral communications, “the whole is greater than the sum of the parts”.  A recommendation has emerged from this dimension. 8.c. Was the decision to allow Father to take over the care of the children and to supervise Mother’s contact a wise and defensible one? The Children’s Social Care stance is that this was a proportionate decision and plan, on the grounds that Mother was stating that only she had had sole care of Baby T and therefore she appeared to be taking responsibility.  There were no identifiable concerns regarding Father (to whom the Social Worker had spoken at some length); and it gave all four children the stability of remaining at home. Moreover, birth fathers would not normally be routinely assessed in order to care for their own children; and both Mother and Father signed a Working Agreement. Baby T SCR - Final anonymised version  31  As a pragmatic and short-term solution, it can be concluded that the decision was a reasonable one. 8.d. Were there opportunities to review that decision and the plan; and were those opportunities utilised? The position of Mother taking responsibility at the time of Baby T’s first injuries and therefore Father not being considered as a perpetrator was accepted by everyone and never revisited or reconsidered.  He was consistently seen as the safety factor. There were significant members of the respective extended families, notably Father’s father and Mother’s mother and sisters.  Mother and Father made it known that they did not want their extended families to be informed or involved. However, once Children’s Social Care were into Section 47 enquiries, there is a strong argument that it would have been justifiable to pursue contact and enquiries with the extended family as, inevitably, members of the extended family often hold vital information. Structurally there were two major opportunities to gain very valuable information.  Whilst the Section 47 enquiries were generally very comprehensive (see Section 4.7), the significant omission was not to identify and subsequently contact Father’s GP.    Secondly, (and similarly), not to identify this GP to the Safeguarding Unit so that they would receive an invitation to the Initial Child Protection Conference.  Equally, this should have been picked up by the conference.  Also, there is an important reference in the minutes of the Initial Child Protection Conference “Mother said this means Father is literally up 24 hours.  Father advised the whole house is up every night and it is very distressing for everyone”.  This throws light on the future sustainability of the plan.  Thereafter, of the three Peer Review and Supervision discussions, the first was relayed by the Consultant Paediatrician to the Social Worker, the first and Baby T SCR - Final anonymised version  32  second were relayed by the Designated Doctor firstly to the Social Worker and then to the Team Manager, and the third was not relayed.  However, by then the Working Agreement which was endorsed by the Child Protection Plan had been in operation for over three weeks, with no indication that it was being breached, i.e. the parents appeared to be cooperative. 8.e. If Children’s Social Care and the professionals at the Initial Child Protection Conference had been given the information from Father’s GP and from Mental Health Services which appears at Section 6 of this report, would it have made a difference to the plan? Father’s GP and representatives from Mental Health Services attended both the Learning Event and the Recall Event and made it clear that if they had been approached by Children’s Social Care and/or invited to and attended the Initial Child Protection Conference, they would have shared all the information contained in Section 6; even if this meant overriding Father’s consent, as he was being put in charge of the children. The Children’s Social Care position is that Father’s mental health problems emanate from a period a long time ago, and the only current medication is antidepressants.  This in itself would not necessarily preclude him from assuming care of the children; and the plan and working agreement could still have gone ahead, albeit with more discussions with him, perhaps more support and analysis, and perhaps more intervention based on his apparent limited experience for caring for the two young babies. The GP’s position is that Father was barely able to look after himself or meet his own needs; he would have no ability to look after the children.  Moreover, he was “leading a double life” and/or being significantly dishonest with his GP. This “double life” and dishonesty certainly needed to be rigorously exposed and explored before putting him in a supervisory and responsible role, eg. the GP states that he could not stand noise and was constantly wearing headphones, whereas this was never seen at the family home. Baby T SCR - Final anonymised version  33  The Children’s Social Care agency report states: “Further checks into Father’s health history would have revealed the extent of his psychiatric history, now fully evident and it is likely that if this information had been known at the time that the children would not have been placed in his care.” This aspect also impacts on Father not being given the opportunity to make an informed choice or decision. Collectively, the conclusion from this Review is that it is very unlikely that the plan would have been agreed in its current form if this information had been known and shared with a professional group (Strategy Meeting, Initial Child Protection Conference, Core Group, etc.). 8.f. Does Baby T’s presentation on 14 June 2013 represent a missed opportunity to protect him? Mother and her sister (Baby T’s aunt) presented him to hospital with a history of him having woken up screaming, breathing fast and then having a floppy episode and bringing up some blood-stained phlegm.  The Consultant Paediatrician attended the Learning Event and explained that whilst the possibility of non-accidental injury was considered, given the non-blanching spots on his legs, vomiting and evolving diarrhoea, likelihood of infection was a priority that had to be ruled out. Hence the baby had blood tests and was observed on the ward; with no suggestion of any witnessed bleeding from any site and improving observations, he was diagnosed to have a viral illness and subsequently discharged. As a part of safety netting, the family were offered 48 hours open access return to the ward, and repeat blood tests appointment given for two weeks. NICE Guidelines suggest that the presentation as described would be highly suspicious of non-accidental injury; the more so as it was known that Baby T was already on a Child Protection Plan based on non-accidental injuries four Baby T SCR - Final anonymised version  34  weeks earlier. With the benefit of hindsight it is easier to reflect and consider NAI as the closest differential. However, at the time, given the information available, risk of life threatening infections remained the priority. 8.g. Were there other missed opportunities? There should have been more “respectful curiosity” (Laming), eg. at the hospital during the first investigation when Mother stated that Father had no independent contact with the children.  Although the investigating Social Worker did speak to both parents individually and did explore the family circumstances, there should have been more challenge about the practicalities of the 24 hour supervisory care and responsibility. Nursery Nurse intervention could have been considered/provided to assist regarding Baby E’s jealousy and disruptive behaviour; and/or should a nursery placement have been considered for her? A physical assessment of the baby should have been undertaken at the Health Visitor’s primary visit. The Health Visitor should have explored Mother’s emotional health, eg. tearful at Primary visit having undergone a traumatic birth; and later tearful regarding Children’s Social Care intervention. 8.h. What were some of the uncertainties, dilemmas and ambiguities identified in this Serious Case Review? It is a very real dilemma for Social Workers on the one hand to respect the family’s right to confidentiality by not contacting members of the extended family; yet on the other hand balancing the need to gather information for enquiries and also to establish support networks for the children, which might mean that parental consent is overridden. Whilst injuries to a non-mobile child may be highly suspicious of non-accidental injury,that suspicion can rarely be translated into a definitive confirmation or certainty, without an explicit admission, eg. the absence of any Baby T SCR - Final anonymised version  35  findings from X-rays and CT scans doesn’t rule out a diagnosis of non-accidental injury. In this case the uncertainty was compounded by Mother presenting so openly and honestly. One record states “Mother’s openness is perplexing”; indeed she was perhaps almost over-compliant, e.g. during the investigation of Baby T’s first injuries she consistently stated that she was the only person who had sole care of him. With hindsight, this might be regarded as a form of disguised compliance. 9. FINDINGS FOR THE BOARD a. The Board will want to oversee the following specific recommendations which are of a multi-agency/joint agency nature. 9.1. For significant injuries to children there must always be a Strategy Meeting rather than Strategy Discussions.  As such Strategy Meetings may need to be called at very short notice and sometimes out of office hours, invitations to Health Visitors, GPs, Named Nurse, etc. may not be possible; and/or their attendance may not be possible. The core attendance should remain as Children’s Social Care/Police/Doctors. 9.2. For Strategy Meetings where the decision to progress to a section 47 enquiry has been agreed, copies of the Strategy Meeting record must be circulated to the respective GPs and Health Visitors/School Nurses, whether or not they have attended, in order that they are kept informed of the circumstances. 9.3. After the Child Protection Conference there will be circumstances in which professionals will take a keen interest in the case and may want to make further contributions even though they have not been named as members of the Core Group (eg. Police, Paediatricians, etc.). The keyworker should consider making specific wider invitations to Core Group meetings; equally, those professionals should Baby T SCR - Final anonymised version  36  proactively make it known to the keyworker that they wish to contribute/attend. 9.4. Challenge/escalation of the Child Protection Plan should be directed to the Safeguarding Unit in general and the Conference Chair in particular, as the Child Protection Plan is a multi-agency process and responsibility.  9.5. At the time of any professional enquiries or investigations or bookings, seek the identity of parents’ GP, and try to ascertain whether each parent and the children are registered at the same or different GP practices. b. There is much systemic and practice learning contained in this Serious Case Review and the LSCB will want to ensure that the learning is disseminated through briefing sessions, newsletter, etc. 10. SINGLE AGENCY RECOMMENDATIONS These recommendations have been identified by the agency authors in their own reports and have been signed off at a senior level within the respective agency. The Board accepts responsibility for overseeing and ensuring their implementation. 10.1. Hospitals a. The Peer Review process needs to be robust and with clear outcomes from discussions, recorded by the doctor bringing the case to supervision in the child’s hospital records at the earliest opportunity. b. The current Safeguarding Children Supervision Policy (OP75b) should be followed with use of the discussion sheets and minuted records and action points. It will be amended to state that in addition to other supervision, consultants should seek specific supervision prior to attendance at ICPC. c. It is recommended that Consultant Paediatricians attend a minimum of 6 Peer Review sessions per year. Baby T SCR - Final anonymised version  37  d. Paediatric medical staff to ensure that they have access to the child’s full set of medical records when a child about whom there is a safeguarding concern presents. e. There needs to be sufficient capacity to offer in-house Peer Review on a fortnightly basis. f. Paediatric medical staff to document that they have read and understood the nature of safeguarding concerns when dealing with a child who is the subject of such concerns. g. All staff to be trained in the use of the colposcope in the Bluebird suite to take photographs of injuries with parental consent. h. When reports are disseminated for conference and a body-map has been used to document injuries then copies of the body-map should be included with the report. 10.2. General Practitioners a. When a patient is known to suffer from a diagnosis of depression their family circumstances should be explored and documented in the medical record to ensure any risk to children in their care is fully appreciated. 10.3. General Practitioners/Health Visitors a. General Practice needs to have robust arrangements to review children and their families. When a child/children become subject to a Child Protection Plan a discussion of these cases should take place with the Safeguarding Lead GP and the Health Visitor and GP Practice team members at an agreed date and time. This must be seen as a priority. A record of these discussions must always take place, and scanned onto the patient record.  Baby T SCR - Final anonymised version  38  10.4. Consultant Paediatricians/Designated Doctor a. Consideration should be given to formally recording discussions which take place during a medical supervision meeting where concerns are identified and how these concerns are taken forward and where they are documented. 10.5. Health Visiting a. When advice is requested by a practitioner from the Safeguarding Team and actions agreed, the practitioner is required to adhere to the plan unless they become aware of new information which makes the plan invalid. 10.6. Safeguarding Children Unit a. Chairs of Initial Child Protection Conferences must immediately write to the designated professional lead (or, for health provider organisations, named professionals) for safeguarding of the agencies who do not attend or present a report to an Initial Child Protection Conference and request a report is completed within five days and sent to the Chair of the Initial Child Protection Conference and the Lead Social worker to enable the information to be shared within the first core group.  b. Chairs must ensure when fathers are registered with a different GP and reside at a different address their GP practice is notified in writing by the Safeguarding Children Unit, within 24 hours of the Initial Child Protection Conference, his children are the subject of child protection plans. The GP practice must also be invited to attend all future Review Child Protection Conferences so that this can be logged in the patient’s records and flagged for the GP to action to ensure they can contribute to the future risk assessment of the child/children involved.   Baby T SCR - Final anonymised version  39  10.7. Children’s Social Care  a. For Section 47 enquiries add a mandatory section in the documentation confirming that checks with parents’ GP have been undertaken and that they may be two different GPs. NB: This has been actioned and social workers have been briefed. b. Team Managers must emphasise the importance of first Core Groups and ensure that they are chaired by the allocated Social Worker or a Team Manager. NB: This has been actioned.  Appendix (i) Terms of Reference and Project Plan      GATESHEAD LOCAL SAFEGUARDING CHILDREN BOARD  TERMS OF REFERENCE & PROJECT PLAN SUBJECT :  BABY T D.O.B. xx.2.13   Appendix (i)             Terms of Reference & Project Plan   1. Introduction Baby T presented to a Walk-in Centre on 14 April 2013 with bruising which was considered to be non-accidental. (He was then aged 2 months.) A resultant Child Protection Conference placed Baby T and his three siblings on Child Protection Plans, and all contact with his mother had to be supervised. On 18 June 2013 (then aged 4 months) Baby T presented at hospital after he had been brought in “floppy and unresponsive”. He was found to have a fracture to his skull. Police investigations are proceeding and Care Proceedings have been instigated. The Independent Chair of Gateshead Safeguarding Local Children Board, in consultation with members of the Case Review Sub Group, has decided to invoke a Serious Case Review (21 October 2013). The Department of Education and Ofsted have been advised accordingly. It has also been decided to use SILP methodology. 2. Purpose The purpose of a SILP remains the same as that for a Serious Case Review, namely: • 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 • To 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, March 2010) Appendix (i)             Terms of Reference & Project Plan   3. Framework Serious Case Reviews and other case reviews should be conducted in a way which: • Recognises the complex circumstances in which professionals work together to safeguard children; • Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did; • Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; • Is transparent about the way data is collected and analysed; and • Makes use of relevant research and case evidence to inform the findings (Working Together, para. 10, March 2013) 4. Specific Scope The subjects: • “Baby T” (subject child) • both parents – “Mother”, “Father” • the three siblings – “Baby E”, “Brother K”, “Brother C” The time period – from 10 July 2012 (the antenatal booking) to 26 June 2013 (Baby T’s discharge from hospital after the serious injury). Appendix (i)             Terms of Reference & Project Plan   5. In addition Agencies are asked to review and report on significant events and safeguarding issues on both parents and children prior to July 2012. This material will be used primarily to provide a background context and therefore should be concise and summarised, highlighting any particular learning points. 6. Agency Reports (see template document) Agency reports within the scoping period will be commissioned from: • Gateshead Council Children’s Social Care • Gateshead Safeguarding Children Unit • Five heath agencies • Two NHS Foundation Trusts in relation to acute services – Gateshead Health NHS Foundation Trust and Newcastle Hospitals NHS Foundation Trust • South Tyneside NHS Foundation Trust in relation to community based health services • Two GP practices – the practice that Leona and the four siblings were registered with in Gateshead and the practice that Lee/Leigh were registered with in Northumberland • Northumbria Police • Education (including two named schools) In addition: • Northumberland Tyne and Wear NHS Foundation Trust (mental health); a free-form narrative as background information and involvement re: Father • A brief note from Gateshead Council Legal and Corporate Services • A summary of the school careers of the two older siblings in free-form narrative Appendix (i)             Terms of Reference & Project Plan   All of these to be used as background context. 7. Analysis 1. Critically analyse and evaluate the events that occurred, the decisions made and the actions taken or not. Were there missed opportunities or episodes when there was sufficient information to have taken a different course? Were assessments conducted effectively and appropriate conclusions drawn? 2. Where judgements were made or actions taken which indicate that practice or management could be improved, try to get an understanding not only of what happened, but why. 3. Demonstrate whether your agency/service heard and responded to the child’s voice. 4. Identify and explain if your agency/service believes that other agencies/services should have been sought and/or provided. 5. Identify good practice. 6. Were professionals proactive in escalating concerns and effecting challenge where appropriate? 7. From an inter-agency perspective, were processes and communication effective? Did services operate in silos rather than being “joined up” with each other? 8. Engagement with the family A letter will be sent from the Chair of the LSCB informing parents of this Review and its purpose. A little while later Independent Author will write to them again as a follow-up and invite them to participate in the form of a home visit/ interview/correspondence/telephone conversation. Their contribution will be woven into the text of the Overview Report; and they will be given feedback at the end of the process. Consideration will be given to the two older siblings. Appendix (i)             Terms of Reference & Project Plan   Hopefully any interviews will take place prior to the Learning Event so that their voice will be heard at the Learning Event. 9. Documentation The “bundle” for the Learning Event will comprise: • Integrated Chronology • Agency reports • Child Protection and Core Group minutes (copy for PT; participants invited to bring their own copies) 10. Timetable Commissioning letters to agencies for Authors 25 November 2013 Agency reports back by 21 January 2014 Quality assurance of the reports by PT 23 January 2014 Distribution of agency reports 27 January 2014 Learning Event 4 February 2014 Recall Day 3 March 2014 Presentation to LSCB 26 March 2014  Appendix (ii)                Agency Report      GATESHEAD LOCAL SAFEGUARDING CHILDREN BOARD  AGENCY REPORT TEMPLATE (Name of the agency)  SIGNIFICANT INCIDENT LEARNING PROCESS SUBJECT : BABY T D.O.B. xx.2.13    Appendix (iii)          Single Agency Recommendations   1. Please see Terms of Reference and Project Plan document for: • Introduction • Purpose • Framework 2. Specific Scope The subjects: • “Baby T” (subject child) • both parents – “Mother”, “Father” • the three siblings – “Baby E”, “Brother K”, “Brother C” The time period – from 10.7.12 (the antenatal booking) to 26.6.13 (Baby T’s discharge from hospital). 3. In addition Agencies are asked to review and report on significant events and safeguarding issues on both parents and children prior to July 2012. This material will be used primarily to provide a background context and therefore should be concise and summarised, highlighting any particular learning points. 4. Within the Scoping period (10.7.12-26.6.13) a. Summarise in narrative form the key information on the child and parents from your agency/service. b. Summarise the services offered and/or provided to the child and parents; and the decisions reached. Appendix (iii)          Single Agency Recommendations   5. Analysis 5.1. Critically analyse and evaluate the events that occurred, the decisions made and the actions taken or not. Were there missed opportunities or episodes when there was sufficient information to have taken a different course? Were assessments conducted effectively and appropriate conclusions drawn? 5.2. Where judgements were made or actions taken which indicate that practice or management could be improved, try to get an understanding not only of what happened, but why. 5.3. Demonstrate whether your agency/service heard and responded to the child’s voice. 5.4. Identify and explain if your agency/service believes that other agencies/services should have been sought and/or provided. 5.5. Identify good practice. 5.6. Were professionals proactive in escalating concerns and effecting challenge where appropriate? 5.7. From an inter-agency perspective, were processes and communication effective? Did services operate in silos rather than being “joined up” with each other? 6. Key Learning Points 6.1. What did we do well which we need to keep doing? 6.2. What didn’t we do so well that needs to stop? 6.3. What things need to be done differently to lead to improvements and how should this be done? 6.4. What is to be learnt about improving multi-agency working? Appendix (iii)          Single Agency Recommendations   7. Recommendations You may make in-house/single agency recommendations (but are not obliged to do so). If you are making recommendations please make them SMART, i.e.  Specific Measurable Achievable Realistic Timely 8. Sign-Off (Neither the reviewer nor senior sign-off person has had any direct involvement with this case prior to the death of the child.) Agency Reviewer: Date: The reports of all reviews must be signed by the relevant senior officer, indicating that the review has been: • carried out to the required standard and • the learning points are accepted by the organisation • the recommendations/action plan will be implemented The Senior Officer accepts that: • The review has been carried out to the required standard. • The learning points reached in the review are accurate. • The recommendations/action plan will be implemented. Appendix (iii)          Single Agency Recommendations    Senior Officer:  Job Title:  Date:  On completion, please send or deliver the completed report by 21 January 2014 at the latest. 