Death of a premature 9-week-old baby girl in June 2017 from unascertained causes. Mother had fallen asleep with Child Y and when she was awoken by her 7-year-old daughter, Child Y was not breathing. Child Y was of African-Caribbean ethnicity. Mother had history of mental health difficulties, and reported being sexually abused as a child in the West Indies, and learning difficulties due to a childhood accident. Mother and Child Y's four siblings were known to Children's Social Care Services and Police; NSPCC referral in 2016. History of violence within relationships with Fathers 1 and 2, and private law dispute about residence arrangements with Father 1. A Family Assistance Order was made in 2015. Allegations of physical abuse and online sexual exploitation involving Siblings 1 and 2 and Father 1 lead to a Children's Social Care assessment. Social workers concerned about Mother's parenting; risks of co-sleeping with Child Y were discussed on several occasions. Five children (including Child Y) and Mother were living in the two-bedroom flat, which health visitors noted were poorly decorated and sparsely furnished. Police observations at the time of Child Y's death showed that the home environment was dirty and smelly, with no suitable sleeping place for Child Y. Learning includes: the need for raised and constant professional curiosity; learning about invisible men; a greater willingness to escalate issues if agency responses appear insufficient; effective record keeping. Recommendations include: policies and guidance should be amended to require midwives and health visitors to enquire about, observe and record, where and in what a baby is/is to be sleeping.
      
 Title:  Serious case review: Child Y. LSCB: Lewisham Safeguarding Children Partnership Author: Fergus Smith Date of publication: 2019  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.                                      Lewisham Safeguarding Children Partnership  Serious Case Review  Child Y                                                                                                                                                                           Author: Fergus Smith 1st  June 2018     Contents 1 INTRODUCTION 1 1.1 ‘Trigger incident’ & reason for serious case review 1 2 MOTHER’S BACKGROUND 5 2.1 Childhood & previous relationships 5 3 PERIOD OF REVIEW: 2016 – CHILD Y’S DEATH 6 3.1 Introduction 6 3.2 Concerns about the well-being of child Y’s siblings 6 3.3 Awareness of & initial response to child Y pregnancy 13 4 RESPONSE TO TERMS OF REFERENCE, CONCLUSIONS & LEARNING 23 4.1 Response to terms of reference 23 4.2 Conclusions 27 4.3 Learning 28 5 RECOMMENDATIONS 29 5.1 Introduction 29 5.2 Lewisham Safeguarding Children Board 29 5.3 Lewisham Clinical Commissioning Group 29 5.4 Lewisham Children’s Social Care 29 5.5 Lewisham & Greenwich NHS Trust 29                                                                            CAE                                                                   1                             1 INTRODUCTION  1.1 ‘TRIGGER INCIDENT’ & REASON FOR SERIOUS CASE REVIEW 1.1.1 Mother’s account of the trigger incident is that she had lain down on a double bed with her 9 week old baby (referred to in this report as ‘child Y’) and fallen asleep. She was awoken by her 7 year old daughter who noticed blood coming from the baby’s nose. An ambulance was summoned and transported child Y to hospital. Resuscitation attempts which had begun at the home and continued en-route to hospital were unsuccessful and child Y was declared deceased at 14.11 on 10.06.17. 1.1.2 Child Y (a female of African-Caribbean ethnicity) had been born at 32 weeks gestation, spent 22 day in the Neonatal Unit at Lewisham Hospital, primarily to establish feeding, and had then been discharged to the care of her single mother who was by then living with 4 other children in a 2 bedroom flat. During child Y’s stay in hospital, mother had been seen to share a bed and had been advised on more than one occasion that this could be risky because such an immature baby cannot maintain its airways. 1.1.3 Post mortem examinations revealed no specific cause, natural or unnatural to account for the death, which appears to be ‘Sudden Infant Death Syndrome (SIDS)’1. 1.1.4 A ‘rapid response meeting’ of the ‘Child Death Overview Panel (CDOP)’2 was convened on 15.06.17 and details about mother’s complex social history discussed. A recommendation was made that a serious case review (SCR) should be undertaken. That recommendation was ratified on 12.10.17 by the independent chairperson of Lewisham’s Safeguarding Children Board on the basis that the required criteria for completing a SCR (reproduced in paragraph 1.2.1) were satisfied. 1.1.5 The Department for Education (DfE), regulatory body Ofsted and the ‘National Panel of Independent Experts’ (NPIE)3 were informed of the above decision and this review was undertaken between November 2017 and March 2018 in accordance with the terms of reference reproduced in section 4.  Following approval by Lewisham’s Safeguarding Children Board (LSCB) a copy of this report is being sent to the NPIE and DfE.                                                    1 SIDS is defined as the death of an infant older than 7 days and less than 1 year of age that remains unexplained after review of the clinical history, circumstances of death and negative post-mortem examination; it is a sub-set accounting for about 80% of the larger total of ‘sudden unexpected death in infancy’ (SUDI) – 20% have a clear cause such as an infection or criminal conduct. 2 Each Local Safeguarding Children Board (LSCB) is responsible for ensuring that a review of the death of any child ordinarily resident in its area is completed by a CDOP which may (as in this case) alert the LSCB chairperson to its view that a serious case review may be required. 3 The NPIE was established by central government in 2013 in order to advise Local Safeguarding Children Boards on the initiation and publication of serious case reviews.                                                                               CAE                                                       2                                       1.2 PURPOSE, SCOPE & PROCESS OF THE REVIEW 1.2.1 Regulation 5 Local Safeguarding Children Boards Regulations 2006 requires Safeguarding Children Boards (LSCBs) to undertake reviews of ‘serious cases’ in accordance with procedures in Working Together to Safeguard Children HM Government 2015. A ‘serious case’ is one in which abuse or neglect is known or suspected and the child has died or has been seriously harmed and there is cause for concern as to the way in which the local authority, LSCB partners or other relevant persons have worked together to safeguard the child.  1.2.2 Its purpose is to identify required improvements in service design, policy or practice amongst local or if relevant, national services. A SCR is not concerned with attribution of culpability (a matter for a criminal court), nor the cause of death (the role of a Coroner).   1.2.3 The period of review was from 01.01.16 to child Y’s death on 10.06.17 though issues and events of particular relevance prior to 2016 have also been considered. An independent report was commissioned from Children Act Enterprises (CAE) Ltd (www.caeuk.org). On the basis of material supplied (a merged chronology of agencies’ contacts and self-critical individual management reviews), lead reviewer Fergus Smith would:    Collate and evaluate it   Conduct consultation / learning events with relevant professionals and  Develop for consideration by the serious case review team a narrative of agencies’ involvement and an evaluation of its quality, conclusions and recommendations for action by the LSCB, member agencies and (if relevant) other local or national agencies  FAMILY & PROFESSIONAL INVOLVEMENT 1.2.4 Attempts were made at face to face contacts, to involve mother in this review. She declined to participate and made it clear that she was opposed to its completion. An early briefing event for involved professionals was convened when the purpose and process of the SCR was explained and queries resolved.  1.2.5 The aims of involving staff at the above initial and at a planned second event were to ensure the accuracy of information within the report, to amend or clarify provisional conclusions and to encourage acceptance and application of the learning that was emerging. In the event, there was insufficient response amongst involved practitioners for a second event and the learning from this review is being incorporated into the Safeguarding Children Board’s ongoing training and development programmes.                                                                                 CAE                                                       3                                       PANEL MEMBERSHIP  Lead reviewer (chairperson)   Lay representative from the Lewisham Safeguarding Children Board (LSCB)  Consultant Community Paediatrician & Designated Doctor Lewisham Clinical Commissioning Group (CCG)  Designated Nurse Safeguarding & Looked After Children for Lewisham CCG   Options & Advice Manager Strategic Housing Borough of Lewisham    Safeguarding Children’s Adviser Lewisham & Greenwich NHS Trust  Named Midwife Lewisham & Greenwich NHS Trust  Named Nurse Lewisham & Greenwich NHS Trust   Quality Assurance Manager Lewisham Children’s Social Care  Service Manager Access, Inclusion & Participation Lewisham  Service Manager for Safeguarding & Reviewing Hackney  Representative of Metropolitan Police Service    Representative of London Ambulance Service +  Interim Safeguarding Children Board Business Manager SOURCES OF INFORMATION  Lewisham Clinical Commissioning Group (GP Services)  Lewisham and Greenwich NHS Trust Queen Elizabeth Hospital (midwifery, neonatal and health visiting services)  Lewisham Children’s Social Care (responding to referrals and liaison with Hackney Children’s Social Care)  Hackney Children’s Social Care (responding to referral, supporting a Family Assistance Order and liaison with Lewisham)  School attended by sib.3 and sib.4  Metropolitan Police Service (responding to earlier reported offences and the SCR trigger event)  London Ambulance Service (LAS) (emergency response to trigger event)  Children & Family Court Advisory and Support Service (Cafcass) (a letter summarising its involvement)                                                                                             CAE                                                       4                                       IMMEDIATE FAMILY (APPROXIMATE AGES AS AT DATE OF Y’S DEATH)                    Father of   Sib.1 & 2  35 Mother  34    Age 34   Sib.3  10 Child Y  9 weeks Father of   Sib.3 & 4   38  Sib. 4  7  Sib. 1  15   Sib. 2  13 Father of   Child Y  ? dob ?                                                                               CAE                                                       5                                       2 MOTHER’S BACKGROUND  2.1 CHILDHOOD & PREVIOUS RELATIONSHIPS 2.1.1 Child Y’s mother has reported being sexually abused by a family member as a 6 year old child back in the West Indies. She has also reported (though no medical / psychological confirmation has been traced) that as a result of an accident in childhood, she has some learning difficulties, in particular with reading and writing. 2.1.2 It is understood that mother arrived in the UK in 1999 when she was 16 years of age. In 2002 she became pregnant with sib.1 and went on to have a second daughter sib.2, both by ‘father 1’. 2.1.3 Mother’s relationships with father 1 (and to a lesser extent with the father of her next 2 children) were volatile. Mother initiated numerous allegations of violence by father 1 toward her, or one of their daughters. Mother and father were though, consistent in declining to provide witness statements to support any potential prosecutions. 2.1.4 Observations of officers attending the various reported incidents suggest that mother was at times the instigator of violence and often exaggerated or invented allegations. Mother’s mental health was observed by attending police officers to be fragile. 2.1.5 Mother and father 1 split up and re-united on an unknown number of occasions and finally parted in about 2015 (by which time mother had borne 2 more children by ‘father 2’). Mother’s allegations against her ex-partner continued throughout a prolonged private law dispute about residence arrangements and into the period of review described in section 3 below. Information supplied by the Children and Family Court Support and Advisory Service (Cafcass) confirms that a ‘Family Assistance Order (FAO)4 had been made on 06.11.15. 2.1.6 In late 2015, the court had determined that the girls should be resident with their father with alternate weekend and half of school holidays with mother. The court’s direction for sib.1 was that she was to have contact with her mother ‘at father’s discretion’. Sib.2 appeared to be ambivalent and on occasions (sometimes it seems at her mother’s request) made false allegations against her father or exaggerated typically adolescent grievances. This pattern of behaviour continued and is analysed in more detail in the period under review.  2.1.7 The numerous contacts with mother and father 1 and father 2 in the decade preceding the review period is that Police responses were prompt, proportionate and complied with Metropolitan Police Service (MPS) guidance.                                                  4 A FAO is issued under s.16 Children Act 1989 as amended by Sch.3 para. 56 Adoption and Children Act 2002 and s.6 Children and Adoption Act 2006; it is a means of providing for up to 12 months, social work support to families experiencing difficulties after separation or divorce; the court conveys a duty on a CAFCASS or a local authority social worker to befriend, advise and assist anyone named in the order (often in relation to facilitating and monitoring contact with a child/ren).                                                                               CAE                                                       6                                       3 PERIOD OF REVIEW: 2016 – CHILD Y’S DEATH  3.1 INTRODUCTION 3.1.1 This section contains an account with some italicised commentary about professional standards of the services provided during the review period. Section 4 offers a response to each element of the review’s terms of reference and summarises overall conclusions and learning. 3.2 CONCERNS ABOUT THE WELL-BEING OF CHILD Y’S SIBLINGS 3.2.1 Information provided by school refers to an incident in mid-January 2016 when mother was thought to be homeless and sib.3 (then aged 8.5) was described by staff as ‘struggling with anger issues’ and ‘not always attending school’ (the attendance rate of sib.3 and sib.4 was approximately 90% - a level considered unacceptable by the local authority). MOTHER’S REFERRAL TO CHILDREN’S SOCIAL CARE 3.2.2 Mother attended Lewisham Children’s Social Care on 15.02.16.She reported concerns about father’s care of her two elder daughters who lived with him (following private legal proceedings the previous year) in Hackney. The response given by the ‘advice & information worker’ was that mother should seek legal advice and no further action was taken. Mother’s confusion about her legal status (she wrote that she did not hold parental responsibility, though she did) and a difficulty in reading and writing was noted. Information emerging from this review indicates that mother’s concerns included her claim that sib.1 (age 13) had previously lived through domestic violence and of sib.2 (age 11) was being ‘molested’ by her ‘violent and aggressive’ father.  Comment: on the basis of what was alleged, a referral to Hackney Children’s Social Care should have been initiated; in spite of a subsequent re-design and reported increase in capacity of the service (heavily overloaded at the time) a precautionary recommendations had been made in section 5. NSPCC REFERRAL TO CHILDREN’S SOCIAL CARE 3.2.3 2 days after mother’s expression of concern and prompted by mother providing similar allegations to the NSPCC a formal referral from that agency was sent to Hackney and (for information) to Lewisham Children’s Social Care. This referral suggested mother’s reference to father ‘sexually molesting’ his elder daughter, might refer to him talking about menstruation. Mother had also claimed that the girls were not resident with her only because she had been made homeless in 2015. On receipt of this referral, the Lewisham MASH team manager TM1, determined that no further action (NFA) was required of her agency.   Comment: insofar as the allegations related to the children living in Hackney and that its Children’s Social Care Service was known to have been alerted, the management decision was proportionate to the available information.                                                                                 CAE                                                       7                                       3.2.4 Hackney’s response, having gained the consent of their father, was to meet both elder girls alone and separately at school. Sib 1 (aged 13) refuted all aspects of the referral and said that she had chosen not to see her mother. She claimed that her sister sib.2 (aged 11) who saw their mother every weekend was ‘brainwashed’ by her. Sib.1 reported that when living with her mother she had been obliged to complete household chores and look after her younger siblings. She also indicated that her mother ‘made things up’.  3.2.5 Sib. 2’s responses were significantly different. She reported father to be violent and wanted to live with their mother. She acknowledged though, that mother had asked her to say that father hit and molested her sister.  Comment: Hackney’s response was thorough; the complexities of the family situation were already becoming apparent. ON-LINE SEXUAL EXPLOITATION  3.2.6 Whilst mother’s allegations were being investigated, sib.2 revealed to Police that her elder sister had been sending explicit images and videos of herself to older men. With father’s co-operation, officers arranged a forensic examination of the child’s laptop and confirmed contacts as described, with 2 adult males in America. Interpol was alerted and no further action was taken by the Metropolitan Police. ALLEGATION OF ASSAULT BY SIB. 2  3.2.7 On 29.02.16 sib.2 accompanied by her mother, attended Lewisham Police station and alleged an assault by her father (a slap on the upper arm). Sib. 2 said that she wanted to live with her mother. Father had meanwhile reported his daughter as ‘missing’ and later characterised the event as a further example of his ex-partner seeking to get the court order determining residence with him, to be altered. Strategy discussion 3.2.8 A strategy discussion was held between the Child Abuse Investigation Team (CAIT) DS1 and SW1 in Hackney Children’s Social Care and a decision made that father’s admitted slap of his daughter did not reach the threshold for a prosecution and that a single agency investigation would suffice.  3.2.9 On the basis of there being no evidence to support mother’s allegations, a decision would be made on the 01.03.16 that no further action was required of the Police CAIT and that a Children’s Social Care assessment would begin.                                                                                 CAE                                                       8                                       Sib.2 ‘Emergency Department’ presentation 3.2.10 The precise timing of events is uncertain, but on 01.03.16 sib. 2 (presented by whom was unrecorded) attended the Emergency Department (ED) at University Hospital London (UHL). She complained of symptoms (soreness of a small contusion to one of her shoulders) which she suggested were linked to the reported assault by father. Her living arrangements as noted by staff, were that she lived with her father during the week and her mother at weekends.   3.2.11 The incident was intended to be referred to the internal safeguarding meeting, by means of a completed CAF and the GP informed. Comment: records do not confirm that the attendance was debated at the safeguarding meeting on 03.03.16, nor is there evidence that Children’s Social Care was directly notified either via the completed CAF or by phone; this represented a missed opportunity for better multi-agency recognition of the family dynamics and a more accurate risk assessment. A recommendation is included in section 5. Assessment of need 3.2.12 At a visit made by Hackney’s assessing social worker SW2 on 01.03.16 sib. 1 expressed a wish to remain with her father and cited difficulties if she were to be resident with her mother, e.g:  Being less required to attend school  Having to complete excessive chores  Being hit with a belt ‘weekly’  Excessive and embarrassing religious rituals (drinking and ‘anointing’ with oil) 3.2.13 Sib. 2 who was spoken to alone, acknowledged some positive aspects of living with her father but felt less favourably treated than her sister. She expressed a determination to move to her mother. The social worker’s record indicated his view that school attendance and behaviour were likely to deteriorate if sib.2 moved back to her mother. Though neither child reported violence between their parents, they both spoke of an incident in which their mother threatened their step-father with a knife and recalled that the Police had been involved. The description of maternal care raised implications for the younger siblings which were recognised and triggered actions described below. Comment: the social worker’s concerns and responses were, on the basis of known information, justified.                                                                                   CAE                                                       9                                       3.2.14 On 02.03.16 both parents were seen separately. Father complained of the difficulty of maintaining contact because his ex-partner moved around so much. Mother expressed her belief that it was inappropriate for teenage girls to be cared for by a male. Later on 10.03.16, Lewisham Children’s Social Care was alerted by Hackney’s SW2 to the need to assess mother’s parenting of her younger children, citing:  Mother taking money from the children when she had seen them for contact  Trying to influence the children to make false allegations against their father (including sexual misconduct toward sib.1) and seeking an intrusive and un-needed medical examination    An allegation by sib. 1 that her mother had last year smashed her mobile phone and poured oil on her to rid her of (presumably bad) ‘spirits’   3.2.15 Lewisham’s TM2 required further enquiries to be made and on 22.03.16 spoke by phone with Hackney’s SW2 who had met the Lewisham-based children as part of his work. He indicated that:    The August 2015 s.47 enquiries had concluded that father had not acted unlawfully  Hackney had no ongoing concerns about father’s parenting  Hackney’s concern was focused on mother’s mental health and its impact on her care of the children living with her  Sib.2 spoke warmly / positively about her mother whilst sib. 1 had declined any contact for some 5 months 3.2.16 After a final home visit, SW2 indicated the case in Hackney would be stepped down to the ‘Family Support Team’. Lewisham’s TM2 later determined the reports from Hackney did not meet the local threshold for an assessment. She discussed this with SW2 who was completing a S.7 welfare report5 for private legal proceedings. He agreed to re-refer if his contact raised new, or reinforced current concerns. Comment: SW2’s current involvement offered a level of reassurance; however, (and allowing that no confirmation has been found that they were actually included in what was shared with Lewisham) some of the earlier issues identified by the older girls coupled with existing knowledge about mother would have justified an attempt by Lewisham to engage her, obtain consent for further checks and to explore the younger children’s lived experiences; the response suggests a higher threshold for a response may have been applied in Lewisham. 3.2.17 Mother registered sib.3 (aged 9) and sib.4 (aged 6) with ‘GP Practice 1’ in Lewisham on 14.03.16. A further visit to the older girls’ father reinforced SW2’s view that he was capable of meeting their needs.                                                    5 Under s.7 Children Act 1989 a court may ask the local authority to complete and submit a report on any aspect of a child’s welfare; this typically arises as in this case, in the context of parental disputes about residence or contact.                                                                               CAE                                                       10                                     2ND SET OF ALLEGATIONS BY MOTHER 3.2.18 On 29.03.16 in a phone call with mother, an unnamed Lewisham duty social worker tried but was unable to get mother to consider whether she was encouraging, or actually asking her daughters, to initiate false rumours about her ex-partner.  Comment: a justified attempt; the value of records is diminished if it is not possible to define which professional made them. 3.2.19 During the same conversation mother reported that she had called Police in August 2015 in the belief that sib. 2 whilst on the phone to her half-brother had been assaulted by her father. Mother claimed this daughter had reported being beaten until she vomited blood and had been refused access to a hospital. Mother claimed to have had no feedback following Police involvement. Comment: this had been investigated by Police and Hackney Children’s Social Care; sib.1 had refuted the account offered by sib.2 and mother – an example of mother’s tendency to imagine, exaggerate or invent (with the additional risk that the example she was setting would be followed by sib.2).  3.2.20 Mother refuted the allegation about anointment for religious reasons and went on to link alleged domestic abuse by her elder daughters’ father with her depression and referred to being ‘in and out of hospital’. She alleged her elder daughters had not been registered with a GP and spoke of sib.2’s episodic breathing problems. She referred also to the criminal record of her ex-partner for violence in 2003. The record of this phone conversation refers to mother ‘being irrational though not abusive’ throughout and constantly yelling. Mother acknowledged lifelong involvement with child protection and care services. The conversation was ended by the duty social worker who judged that it was not going to be possible to derive further useful information. Comment: a discussion of this significance should not be conducted by phone; the call nonetheless highlighted a range of reasons to be concerned about mothers care of dependent children which should have been followed up. 3.2.21 The report submitted by Lewisham Children’s Social Care identified scope for improving co-ordination on its IT system, of emails, records of phone conversations and ensuring duplication of relevant information across the case records (when relevant) of siblings. The agency has reported the initiation of corrective action, though a cautionary recommendation has nonetheless been included in section 5.  3RD SET OF ALLEGATIONS BY MOTHER 3.2.22 On 06.04.16 mother alerted Police to an image on Instagram of sib.2 (then 13) holding a large knife.  She again emphasised her fear of her ex-partner and did not want officers to attend his address for fear of repercussions. Mother declined an appointment offered and was advised to contact Children’s Social Care (whether Hackney or Lewisham is unclear) because it was understood that the agency was already involved.                                                                                 CAE                                                       11                                     3.2.23 Lewisham TM2 completed on 08.04.16, a record of her decision (and its rationale) of ‘no further action’ by Lewisham with respect to mother’s latest allegations. Hackney would contact again if a planned visit to the younger children in Lewisham revealed any further or new concerns. Comment: the decision and (helpfully) its associated rationale were justified. 3.2.24 A week later (on 13.04.16) sib.3 (aged 8) and sib.4 (aged 7) were each seen alone during a home visit by Hackney’s SW2. The former described being religious, singing songs, reading the bible and praying. In addition he described doing chores around the house which ‘he enjoyed’. His sister reported that he also ‘did cooking and cleaning’. Sib.4 identified her mother’s favourite pastime as praying and reported being smacked on the hand with her mother’s open hand if naughty. Comment: given the reported level of age-inappropriate exploitation, it is unsurprising that sib.3 had also reportedly accidentally burned his sister’s leg whilst boiling water for noodles; a scar on his hand said to have been caused by a mop was also noted though how that old injury had (or was said to have) occurred was not captured in records. 3.2.25 At the same home visit, a lack of bedding on the bunk beds was noted. Mother’s assertion that it was being washed was accepted and her account that the children preferred to sleep with her left unexplored. 3.2.26 Mother identified a large family network in Enfield, though no detail was sought or provided (more curiosity and follow-up might have generated useful support). She also reported having been ‘bright’ before a childhood accident (an account later repeated to a health visitor). Mother proposed consulting her GP for her acknowledged illiteracy. RENEWED CONCERNS FROM HACKNEY  3.2.27 On 29.04.16 Hackney’s SW2 emailed Lewisham’s Emergency Duty Team (EDT). Based upon his direct work with sib.1 and sib.2, he was concerned about mother’s parenting. Hackney was, he reported, seeking a medical examination to clarify whether there was evidence of physical abuse of sib.1 whilst with mother (‘weekly belting’). Sib.1 had reported similar mis-treatment of sib.3 and sib.4. SW2 also reported that mother was at times, using an unidentified person whom she had known for only 2 months to care for her children. Comments: these allegations (with the exception of the unknown caregiver where the nature of his concerns are not stated) and references to historic domestic abuse were essentially repeats of those previously reported in March. 3.2.28 SW2 sought a ‘needs assessment’ of sib.3 and sib.4.  The initial response of TM4 was focused on the reference to mother’s use of an unfamiliar caregiver and concluded that more information e.g. results of the checks completed for the s.7 welfare report being completed for private law proceedings, would be required of the referrer before Lewisham’s threshold for an assessment was met.                                                                                 CAE                                                       12                                     3.2.29 The proposed response was ratified by TM2 who noted that mother had previously indicated an unwillingness to have Children’s Social Care involvement (she had reported having been in care herself and having an antipathy toward social workers). It has been reported that the ‘no further action’ response would have been relayed back to Hackney by ‘Business Support Staff’ and that no further request for agency involvement was received. Comment: setting aside the uncertainty about what was actually fed back to Hackney (Lewisham has been unable to locate a record of it), TM2 had on 08.04.16 suggested that SW2 get back in touch if concerns remained; from the perspective of the involved children, there remained unresolved allegations of use of a belt etc.  3.2.30 At about this time GP Practice 1 received a request for information to support a ‘S.17 assessment’ of the siblings in the care of mother. Comment: Hackney was undertaking a S.7 report, not a S.17 assessment, responsibility for which (if one was being completed) would fall to the borough in which children lived; it may be that the Practice was unfamiliar with s.7 and mis-recorded the request. 3.2.31 School 1 has described a minor incident at school on 13.05.16 when sib.3 (rising 9) rolled up some paper like a cigarette and said he was smoking ‘weed’. This was apparently discussed with his mother. COMPLETION OF HACKNEY’S ASSESSMENT & FINAL COURT HEARING TO DETERMINE RESIDENCE OF SIB.1 & 2 3.2.32 The conclusion of Hackney’s assessment was that the allegations against the older girls’ father were unsubstantiated and his care was good. The case was stepped down to the Family Support Team. Mother’s inability to focus on anything except her determination that her elder girls be returned to her care was made clear. A final court hearing was, following mother’s representations, put back until 27.07.16. 3.2.33 There was a further incident on 22.06.16 when sib. 2 was reported to the Police by her father not to have returned home from school and was later found at her mother’s home. She described being shouted at but not hit, by her father the day before and was very resistant to returning to him. Police did return her to her father and completed a Merlin notification to Children’s Social Care. 3.2.34 At the final court hearing on 27.07.16 an application by mother for a change of residence for sib.2 was dismissed. The existing Family Assistance Order (FAO) made in November 2015 was extended until 26.01.17 so that Hackney could try to assist the parents with contact arrangements. On 01.08.16 Hackney’s SW3, some days ahead of a deadline to report to the court on progress, sought from Lewisham information about any parenting course in the borough that mother might attend.                                                                                  CAE                                                       13                                     3.2.35 The above communication seems to have been mistaken for a request to confirm whether mother had been on such a course. An email reply was sent to Hackney 4 days later from Lewisham’s MASH confirming the dates of earlier referrals to Lewisham (March and April). Comment: the response to the question from Hackney (which was itself not entirely clear), indicates that it was misunderstood; the report submitted to the serious case review also identifies a systemic weakness in how such contacts are captured in Lewisham and a recommendation is made in section 5. MOTHER’S REQUEST FOR LEARNING DISABILITY ASSESSMENT 3.2.36 On 15.09.16 mother consulted GP1 and sought an assessment of her cognitive capacity. She referred in particular to her difficulties in reading / writing and was referred to a ‘Mental Health Learning Disability Team’. The referral was turned down later that month with a suggestion that the GP re-direct the referral to IAPT6 (though this source is not known to offer the form of assessment required and requested). Comment: the rejection of the referral was unfortunate. Some insight into mother’s learning needs could have helpfully informed professional expectations of her ability to cope with parental challenges; the need for certainty about where such assessments may be undertaken is believed to be of national significance and justifies a recommendation in section 5 that the LSCB alert NHS England. 3.3 AWARENESS OF & INITIAL RESPONSE TO CHILD Y PREGNANCY  3.3.1 On 04.10.16 mother presented at A&E complaining of abdominal pains and revealed a positive pregnancy test some 3 weeks earlier. 3.3.2 During October 2016 father was increasingly concerned about events at the girls’ school and community, and associated bullying. His previously good level of engagement has been described as diminishing from this point. In late October mother called Police twice to report what appeared to be a neighbourhood dispute about noise levels. This was reported to have been resolved without any formal action.  3.3.3 GP3 was consulted by mother on 25.10.16 and initiated an ante-natal referral which referred to her history of sexual abuse, domestic violence, a daughter who had been subject to a child protection plan in 2004 and mother’s depression during 2005. The GP did not take the opportunity to initiate a safeguarding referral and the concerns mother alluded to were not coded in a manner that would facilitate immediate identification from the summary page of the primary care record.                                                    6 The IAPT programme began in 2008 and is focused on treatment of adult anxiety disorders and depression in England.                                                                               CAE                                                       14                                     3.3.4 Whilst a ‘vulnerable child in the family’ code was later added to mother’s medical records, it was not added to those of sib.3 and sib.4, rendering recognition of need / risk less easy at subsequent GP presentations. 3.3.5 On 01.11.16 school 1 report that sib.3 was clearly upset though unable to clarify why. The special educational needs co-ordinator (SENCO) liaised with SW2 from Hackney Children’s Social Care who reported his 2 unsuccessful attempts to prompt acceptance of a referral by Lewisham Children’s Social Care.  Comment: it is unfortunate Hackney did not escalate its justifiable concerns. 3.3.6 At a further GP consultation on 03.11.16 this time with GP3, mother was issued with a form to excuse her from seeking work. It cited awaiting an assessment by the learning disability team, ‘severe learning disability’, ‘dyslexia’ and pregnancy. Comment: the referral for an assessment by the learning disability team had already been rejected, though mother may not at this stage have been informed of that. Aside from pregnancy, the descriptions (severe learning disability and dyslexia) went beyond the knowledge base / competence of a GP. 3.3.7 A midwife MW1 saw mother at GP Practice 1 on 07.11.16 and recorded risk factors as ‘previous social services involvement, past domestic abuse, learning disability, and 2 older children living (for unknown and unexplored reasons) with their father’. Mother refused to provide details of a man to whom she claimed to be married, who lived ‘far away…and who was awaiting ‘immigration status’. Mother also referred to her own mother (child Y’s grandmother) having a ‘learning difficulty’. With her consent, a referral was made that day (presumably on the basis of mother’s self-reports – the CAF was completed later) to the Midwifery Safeguarding Meeting and Lewisham’s Children’s Social Care MASH. Comment: in the light of mother’s responses (some of which were untrue, lacking credibility or misleading e,g. ‘no social worker involvement since 2006’) a good deal of relevant information had been obtained by the midwife whose response to what she was told, was sensitive and prompt. 3.3.8 At the routine ‘maternity safeguarding meeting’ on 11.11.16 (it is uncertain whether a social worker was present) it was noted that mother’s childhood experiences had not been explored at the booking appointment and that she had not referred to the (anyway incorrect) ‘fact’ provided by the GP that her eldest child had been subject of a child protection plan in 2004. The outcome of the discussion was that the ‘safeguarding midwife’ MW2 would, in consultation with MW1 complete a CAF. This was done by 16.11.17                                                                                 CAE                                                       15                                     3.3.9 There is no evidence that the Health Visiting Service was (as intended) sent the completed CAF by Midwifery. The later ‘targeted’ ante-natal visit suggests though, an awareness of additional needs prompted by her awareness that a CAF was going to be completed. Neither health visitor nor midwife followed up with either involved borough. The ‘Maternity Safeguarding Pathway’ now requires a copy of each maternity safeguarding notification to be sent to health visitors and GPs via secure email, so no recommendation has been made. 3.3.10 At a further consultation with GP5 on the same day, mother reported that her visa allowing her presence in the UK, was due to expire in January 2017. She was advised that she could seek a supportive letter from the Practice and she did so in December. On 16.11.16 MW1 completed and submitted a CAF to Children’s Social Care. Comment: the implications of mother’s immigration status had been largely un-explored though Lewisham’s Children’s Social Care had noted that mother had been and was no longer of ‘no recourse’ status, claimed at that time to ‘have recourse to public funds’ and was hence in receipt of Benefits. 3.3.11 Lewisham Children’s Social Care TM1 authorised on 18.11.16, a formal response to the Midwifery referral and receipt of the completed CAF. ‘Information and advice’ about children’s centres including one for adults with learning difficulties was provided. MW1 has no memory of receiving confirmation of Children’s Social Care’s response and no record of such feedback has been traced. The view held in Lewisham was that the involvement of the court in ongoing residence-related private law proceedings and Hackney’s work was sufficient. No further information or escalation of its concerns was initiated by Midwifery where MW1 had assumed that the named midwife routinely followed up any CAF referrals). The absence of such ‘follow-up’ unintentionally reinforced a view in Social Care that it needed to take no additional action. Comment: mother was known to be functionally illiterate and to have significant learning and mental health difficulties; some allegations against her were serious and SW2 who had met all the children had explicitly recommended an assessment; Lewisham’s response took insufficient account of known history; its response again raises questions about the threshold being applied. ANTE-NATAL CARE & OTHER SIGNIFICANT EVENTS 3.3.12 At a ‘Targeted’ Ante-natal Health Visiting’ meeting on 13.12.16 the case was allocated to HV1 with a view to offering ante-natal contact. An appointment letter was sent for a visit on 20.02.17. Comment: mother’s illiteracy, though known to agencies did not prompt the use of alternative / supplementary methods of communication; the formal ‘vulnerable ante-natal pathway’ required a visit within 4 weeks of a referral.                                                                                 CAE                                                       16                                     3.3.13 Sib.1 and sib.2 were by early 2017, displaying some intimidatory behaviours toward other pupils and school was having difficulty in getting their father to attend and discuss the issue. On 10.01.17 bullying by sib.1 was sufficiently serious to prompt by Police a ‘First Instance Harassment Warning’ and for the school to require her to sign an ‘Acceptable Behaviour Contract’. Father failed to attend a ‘Team Around the Child’ meeting on 25.01.17 and concerns about sib.1’s use of social media continued. 3.3.14 At the planned home visit on 20.02.17 HV1 explored mother’s background and was told of previous abusive relationships and that Children’s Social Care involvement had been a function of her having ‘no recourse to public funds’. Mother reported that the Home Office had now granted her ‘leave to remain’. She attributed the fact that her elder daughters lived with their father to her previous homelessness. 3.3.15 HV1 noted the flat to be sparsely furnished though tidy. She identified no hazards. Required equipment for the baby was discussed (though it is unclear whether suitable sleeping arrangements were actually confirmed) and a genogram completed (an expectation in targeted health visiting cases). Mother’s self-reported learning difficulties remained un-explored.   3.3.16 There were also unexplored discrepancies between mother’s accounts of her relationship with child Y’s father in the maternity safeguarding record and that noted by HV1, with the former referring to a supportive man and the latter to her having asked him to leave because of verbal and emotional abuse. Comment: neither Health or Social Care records in either borough refer to the father of child Y (father 3) ever having been resident; ‘father 2’ and father 3’ are essentially invisible – a recurring challenge for professionals working with anxious and avoidant families.  3.3.17 Mother again attributed involvement of Children’s Social Care during her relationship with father 1 as being about her lack of recourse to public funds and referred (inaccurately) to one of her 2 elder daughters having been subject of a child protection plan. The extent and impact of mother’s apparent learning difficulty / disability remained unexplored and represented a missed opportunity to better appreciate the extent to which they might impact on parenting. 3.3.18 HV1 agreed to review the situation at 36 weeks gestation and asked whether mother might wish to join the ‘Maternal Early Childhood Sustained Home (MECSH) visiting programme7. Completion of a maternal mood assessment revealed no concerns.  Comment: the accuracy of mother’s account remains uncertain; HV1’s records have been described as concise and accurate, though mother’s response to the appropriate offer made, remains unknown.                                                       7 MECSH is a structured programme of sustained home visits for families at risk of poorer maternal and child health and development outcomes.                                                                               CAE                                                       17                                     3.3.19  At a midwifery appointment on 23.02.17 mother reported having ‘separated’ from her husband and linked this to verbal abuse.  JOINT INVESTIGATION OF FURTHER ALLEGATIONS  3.3.20 On 05.03.17 mother presented her elder daughters to Hackney Police station where they described an alleged assault by their father on Christmas Eve. They also referred to a number of other incidents when their father had been drunk and acted in an aggressive manner.  STRATEGY DISCUSSION 3.3.21 Following a strategy discussion on 06.03.17 between DS2 and TM3, it was agreed that the allegations would be jointly investigated and that the girls could meanwhile remain with their mother. Father appeared to be accepting of the girls’ stay with his ex-partner, though did later that month query how this could be reconciled with the court-ordered arrangements for residence. 3.3.22 When mother was seen by MW1 at GP Practice 1 on 13.03.17 she reported the fact that her daughters were now with her and went on to register her 2 younger children with the Practice. Mother was not asked when her daughters had joined her, though it seems likely that it had occurred since her last contact with MW1 in February. 3.3.23 A social worker met with both girls together on 15.03.17 and Achieving Best Evidence (ABE) interviews were completed on 17.03.17 when the girls offered comparable accounts. Sib.2 reported to the Hackney social worker that her mother claimed that their father was a gang member (something not identified in the report supplied by Police). Father reluctantly agreed to ‘child protection medicals’ which were finally completed on 27.03.17. Comment: sib 1 in a further ABE interview on 16.07.17 would admit that she had been coerced by mother and sister into making her allegations; sib.2 would also admit over the summer that their mother had persuaded them to   exaggerate some occasional smacks inflicted by their father. By that time though, over 6 months had elapsed which (as a matter of law) precluded the possibility of any potential prosecution for common assault. 3.3.24 HV1 was informed on 27.03.17 by the midwife that sib.1 and sib.2 had returned to their mothers’ care as a result of allegations against father of physical abuse. Police were said to be involved. Neither the midwife (who was new to community-based work and unaware of any such expectation) nor health visitor shared this information with either local authority Children’s Social Care. This was an example of insufficient professional curiosity and represented a missed opportunity. 3.3.25 Following an interview under caution on 05.04.17 the criminal investigation of allegations against father were passed to the Crown Prosecution Service (CPS).                                                                                 CAE                                                       18                                     BIRTH OF CHILD Y & POST- NATAL SUPPORT 3.3.26 In response to a 999 call on 08.04.17 mother was transported to Lewisham Maternity Unit where child Y was born prematurely (by caesarean section) later that day and subsequently transferred to the neonatal unit (NNU). Though its origin and recorder remains unclear, some biographical information was captured in the hospital’s paper records and some intention (which remained unfulfilled) was expressed to seek further information about mother’s social situation.     Comment: it is important that the origin of information (which may or may not be accurate) as well as the involved professional are clearly recorded. 3.3.27 Mother returned home after 3 days at which point it is unclear what proportion, if any of the previous concerns about mother and family were recognised by ward staff. A post-natal phone appointment was arranged for 21.04.17 and child Y remained in the NNU. Mother’s post-natal discharge summary was uploaded to the electronic record and a copy sent to the GP on 11.04.17. The summary contained no reference to the concerns identified by Midwifery or NNU staff or the referral to Children’s Social Care. Comment: this was a missed opportunity to recognise and respond across agencies to a significant level of established social need. 3.3.28 Research during the course of this review has confirmed that MW1 completed a visit to mother on 12.04.17 (child Y was then 4 days old) and on 18.04.17 (day 10). She subsequently asked Community midwives to visit on 02.05.17. 3.3.29 In response to what or whom is unrecorded, but on 19.04.17 the neonatal consultant provided a letter advocating the need for a warm, clean and dry environment for a pre-term baby with an increased risk of respiratory diseases. During the course of the SCR, it has been deduced that this may have been prompted by a ‘notice of intention to evict’ received by mother on 21.04.17.  3.3.30 HV3 applied (by phone) a standard test8 for possible depression on 21.04.17 and found no cause for concern. A home visit was to be made once child Y was home. Comment: though good practice to check on emotional well-being, a new birth visit should be completed (in hospital if not at home) within 7-14 days post-delivery. There appears to have been no curiosity with respect to the result of the referral to Children’s Social Care, about which the health visitor should have been aware.                                                    8 The ‘Whooley’ questions for depression are 1. During the last month, have you often been bothered by feeling down, depressed or hopeless? (YES/NO); 2. During the last month, have you often been bothered by little interest or pleasure in doing thing? (YES/NO)…….YES to one or both questions is take as a positive screen for depression (Whooley et al, 1997).                                                                               CAE                                                       19                                     3.3.31 Following a GP consultation the day before, on 22.04.17 sib.2 was seen at A&E complaining of chronic ankle pain. Whilst there, she reported physical abuse of her sister. This (appropriately) prompted the examining doctor to contact Hackney Children’s Social Care where confirmation of the residence arrangements and reassurance about the girls’ safety was provided. A&E records capture mother’s claim to be homeless and to have experienced past domestic abuse. 3.3.32 At a neonatology meeting on 24.04.17 it was reported that no safeguarding concerns had been identified whilst child Y was an in-patient and that staff were aware of mother’s background. 3.3.33 The day after the above meeting at a ward round by the consultant, the need to clarify the outcome of the Midwifery Service CAF supplied to Children’s Social Care and to explore mother ‘rooming in’ (i.e. staying with her baby) was identified. NNU staff consequently made contact with Lewisham’s MASH. On the paper records used, names, roles are unclear (a recurring problem in hospital records seen).  3.3.34 Whilst acknowledging the liaison with Lewisham’s MASH as good practice, the report supplied to this serious case review evaluated the NNU’s level of understanding of recorded safeguarding concerns / social history as insufficient e.g. it is uncertain whether staff were aware of the return to mother of her elder daughters. 3.3.35 On 27.04.17 an unidentified doctor (once again the signature is illegible) was told that the response to the CAF had been that a referral to a Children’s Centre was to be made. This was accepted without challenge.  On 28.04.17 mother was offered advice and shown a DVD about basic life support (BLS) but said she was too tired to complete the practical aspect thus leaving it uncertain what she had actually understood. She was advised about the risks of co-sleeping and appropriate ways to maintain the optimum temperature for child Y. 3.3.36 Mother disclosed to the NNU nurse Children’s Social Care involvement with sib.1 but was apparently too upset to elaborate. She confirmed her separation from the father of child Y and referred to a ‘church sister’ who was looking after her other children whilst she ‘roomed in’. Comment: curiosity about the ‘church sister’ and the reasons for Children’s Social Care involvement would have been helpful (together with the earlier example of not following up mother’s reference to having extended family in Enfield, this offers an example of insufficient professional curiosity).                                                                                  CAE                                                       20                                     CHILD Y’S DISCHARGE HOME 3.3.37 After 6 ‘high dependency’ and 7 ‘special care’ days, child Y was discharged on Sunday 30.04.17 (a Bank Holiday weekend). A discharge summary was sent to the GP Practice (and by 03.05.17 was uploaded to ‘child records’ and thus available to the Health Visiting Service). In addition to plans for ongoing medical support, safeguarding issues were included and some (inaccurate) information brought forward from obstetric notes. On 02.05.17 a phone call was anyway made to the Health Visiting Service to confirm the discharge and request regular weighing of child Y. Comment: that otherwise useful liaison and request for weighing could usefully have been completed prior to the discharge of child Y; such notifications are now completed by email thus rendering it unnecessary to formulate any recommendation. 3.3.38 A community midwifery visit was completed on 02.05.17 (by a midwife other than MW1 – no signature was provided). Mother was breast-feeding and apparently managing well in ‘temporary housing’. On 03.05.17 sib.1 and sib.2 (newly registered patients) were mistakenly coded by the GP Practice as being ‘subject to child protection plans’. Comment: all professional records should be attributable to the individual who generated them; the mislabelling at the Practice suggests that either GP5 and/or administrative staff may need to be briefed on the precise meaning of a child protection plan.  3.3.39 HV2 visited on 08.05.17 but mother was not at home and was seen instead on 11.05.17. On 09.05.17 child Y was brought by her mother to a paediatric ophthalmology clinic (the results of which became available only after the death of child Y).  3.3.40 At her visit on 11.05.17 HV2 had concerns, but not about mother’s parenting. Mother reported that her elder daughters were present (not at school) because, following abuse by their father, they were living with her. She refused to name child Y’s father. The impact of mother’s self-declared learning difficulties were discussed. A report to this serious case review by school 1 referred to a listless and unwell sib.4 (then aged 10) saying at school the day before ‘mum says I will be in trouble if I don’t stay in school’ and ‘mum has a new baby.’ 3.3.41 Mother denied using drugs, alcohol or tobacco. The risks of co-sleeping were discussed (as they had been whilst child Y in hospital) and mother advised to consult her GP as soon as possible to obtain a further formula prescription. HV2 left mother a list of tasks to be completed and she intimated that the children could help her read them.                                                                                  CAE                                                       21                                     3.3.42 Amongst her comprehensive observations of the accommodation, HV2 noted that the flat was poorly decorated, sparsely furnished and that during the visit, mother had killed what may have been a cockroach. ‘Baby equipment’ was noted in the living room, though it is uncertain whether this included somewhere suitable for child Y to sleep (in view of the co-sleeping at the time of death, a relevant issue). Comment: 5 children including a vulnerable baby were living in this 2 bedroom flat; whilst self-evidently less than ideal, it is understood such a situation is not unusual and would not constitute ‘overcrowding’9; the need for health visitors and midwives to be inquiring about sleeping arrangements is recognised by the inclusion of a recommendation is section 5. 3.3.43 Though raised in the ante-natal period, the option of joining the MECSH programme was not re-visited. Nor does it seem that the CAF completed by the Midwifery Service and passed to Children’s Social Care had been supplied to or anyway informed responses of the Health Visiting Service. In the knowledge that her older children helped their mother to read, a list of baby-related issues that needed to be raised with the GP was formulated and left. Mother reported that her elder girls had a social worker and that due to his abuse of them, their father was in Police custody. Comment: if the health visitor had made contact with Children’s Social Care, she would have learned that mother’s account was inaccurate and a further example of well-established behaviour patterns; depending upon children to interpret for a semi-literate parent is not good practice. 3.3.44 At what may have been a chance encounter on 12.05.17 at the GP practice (mother was there in her own right), HV2 undertook to source a pram, though did not explore further how mother was coping without one. She observed that child Y was being cared for by sib.1 (aged 14). 3.3.45 Later that week an enquiry made of mother by Hackney Children’s Social Care about the elder girls’ non-school attendance elicited the information that she was unhappy with the school, resentful of local services and of the behaviour of the girls’ father. Next day father attended the office in Hackney to express his concern about a deteriorating level of school attendance. Father later (25.05.17) reported to Hackney that sib.1 was unhappy about her mother’s plan to change her school but was scared of saying so. 3.3.46 Mother failed to bring child Y for a cranial ultra-sound scan on 02.06.17. The apparently standard response was a note (directed toward whom is not stated) stating …’please review the clinical situation and advise if this is still required’.  Comment: the consequences of such an unclear and rigid policy will be experienced by the child patient rather than the parent, and requires re-thinking.                                                    9 See House of Commons Library BRIEFING PAPER Number 1013, 14 November 2016 ‘Overcrowded Housing (England)’ see http://researchbriefings.files.parliament.uk/documents/SN01013/SN01013.pdf                                                                                CAE                                                       22                                     3.3.47 At an appointment on 09.06.17 with GP6 name mother mentioned housing and visa problems (she had previously claimed to have been given a right to remain in the UK). Child Y received her initial immunisations on the same day.  TRIGGER INCIDENT & OBSERVED ENVIRONMENT AT TIME OF DEATH 3.3.48 At 13.22 on 10.06.17 a 999 call was received to report a 2 month old female not breathing and with blood coming out of her mouth and nose. Child Y was transported to hospital where after further unsuccessful attempts to resuscitate her, life was pronounced extinct. A post-mortem examination suggested natural causes and in consequence the Coroner’s Office discontinued its investigation. 3.3.49 Police observations of the environment in which the family were living were markedly different to those captured about a month before by the health visitor. The most significant issues recorded on the day that child Y died were of an excessively high temperature, cockroach infestation, a very dirty and smelly environment, no available food and no indication of a suitable sleeping place for child Y (a ‘Moses’ basket was being used to store clothes). 3.3.50 It may be that, in consequence of the pressure of all 5 children, the environment had deteriorated rapidly from the ‘acceptable’ condition observed a month earlier. Equally, it may be that the police officer was more critical in his assessment.                                                                                 CAE                                                       23                                     4 RESPONSE TO TERMS OF REFERENCE, CONCLUSIONS & LEARNING   4.1 RESPONSE TO TERMS OF REFERENCE WAS PROFESSIONAL AWARENESS SUFFICIENT TO RESPOND EFFECTIVELY TO:  Needs and lived experience of the children  Needs of mother?  Cultural, identity and other diversity issues within the family  Potential indicators of abuse (e.g. mental health, drugs, alcohol, domestic abuse) 4.1.1 Hackney’s SW2 had very appropriately sought and distinguished between the views of both sib.1 and sib.2 during the thorough enquiries prompted by the NSPCC referral of February 2016.  4.1.2 In spite of the efforts expended by Hackney, it is not entirely certain that the (historical?) allegations made by sib.1 of mother’s use of a belt were entirely resolved. Had Lewisham responded differently to mother’s initial allegations or to the liaison initiated by SW2 in March and April 2016, the ‘lived experience’ of sib.1, 2, 3 and 4 might have become clearer.  4.1.3 Setting aside issues of sib.3’s school attendance and associated comments the child made to school staff, some observations of family circumstances also raise questions about the children’s ‘lived experience’ e.g:  The extent to which mother was depending upon her then 8 year old son to clean and cook and look after his younger sister (as well as the credibility of his enjoyment of praying)  The lack of bedding accepted in April 2016 (the record made by Police on the day of child Y’s death, suggests that the children and in particular child Y, may latterly have had nowhere suitable and safe to sleep   The impact of what was recognised in both boroughs as (at best) exaggerated allegations about father’s conduct  (immediate anxiety / confusion for the children and setting an example (which sib.1 and sib.2 later followed) 4.1.4 The needs of mother (in particular potential mental health needs) were recognised by Hackney as of significance in terms of her capacity to look after her children. There remains doubt about the precise detail shared by SW2 with TM2 in Lewisham.  It does though seem that by default, rather than design, Lewisham assumed that unless or until an explicit allegation emerged from the private law proceedings (which were themselves essentially limited to the narrower issues of residence and contact), or SW2 presented more compelling evidence, the borough’s threshold for assessment was not reached.                                                                                 CAE                                                       24                                     4.1.5 The unsuccessful attempt in late March 2016 by the Lewisham duty social worker to encourage mother to recognise the direct and indirect impacts on her children that exaggerated allegations were having, provides evidence that staff were mindful of the problem. Mother’s histrionic responses proved sufficient on that occasion, to close down this justified line of enquiry. 4.1.6 Perhaps of central importance (without a formal assessment it was not possible for involved professionals, nor the serious case review panel to form a conclusive view) was mother’s level of cognitive ability and associated capacity to parent a large and growing family. 4.1.7 No agency identified any concerns about drugs or alcohol and no evidence has been located to suggest that they should have done. All were told of mother experiencing domestic abuse though the comprehensive record supplied by the Police (much of it pre-dating the review period) as well as accounts offered by her children suggest that she may have as often been a perpetrator.  WERE HISTORICAL FACTS KNOWN OR TAKEN SUFFICIENTLY INTO ACCOUNT:  Parents’ history  Any previous involvement of either parent with Adult or Children’s Services 4.1.8 Whilst Hackney Children’s Social Care worked directly with the father of sib.1 and sib.2 and clearly recognised his historical and current capacity to be a ‘good enough’ parent, other agencies captured very little about fathers 1, 2 or 3. This was in part a result of mother’s refusal to divulge information, in particular the name of child Y’s father (whom she described as her ‘husband’ and whose identity she disclosed to Police only after child Y’s death). It was also a function of an insufficiency of professional curiosity and recognition of the relevance of such men either as a source of support or because of a need to evaluate the risk they might pose. 4.1.9 Mother’s reference in April 2016 to a large family network in Enfield remain unexplored though could (if accurate) have been the source of much needed support. Her reference to a lifelong and unwelcome involvement of social workers (as well as her histrionic behaviours during the aborted phone conversation in March 2016) might usefully have prompted more reflection on mother’s personal history.                                                                                 CAE                                                       25                                     4.1.10 Whilst there was a level of consistency in mother’s reports of her childhood and associated accidents and abuse, there existed no easy or obvious way (she having apparently entered the UK aged 16) of confirming or challenging what was reported. Some of her assertions having been recorded in good faith, were shared with other agencies and became accepted as ‘fact’:  A childhood accident that had left her with lifelong learning difficulties (encapsulated by some agencies as ‘illiteracy’ and by others as ‘dyslexia’)  Sib.1 having been subject of a child protection plan in 2004  A series of relationships in which she had been the ‘victim’ 4.1.11 With respect to issues that may be described as diversity-related, Lewisham records offer evidence of some exploration of mother’s erstwhile precarious existence as someone with ‘no recourse to public funds’ (NRPF). The extent to which the man described as mother’s husband (child Y’s father) was relevant to her or his wish to remain in the UK remains uncertain. WERE POLICIES & PROCEDURES EFFECTIVE?  Did practice accord with ‘Working Together to Safeguard Children 2015’  Local multi-agency policies and procedures  Did actions accord with assessments and decisions made  Were appropriate services offered or provided or relevant enquiries made in the light of assessments  Were records systematically reviewed to evaluate and assess risk 4.1.12 Hackney’s response to the NSPCC referral of mid-February 2016 was thorough. It and the response to sib.2’s allegation of an assault by her father were proportionate and justified. The Police response to the on-line exploitation of sib.1 confirmed between those 2 sets of allegation was also the right one. 4.1.13 The alleged physical abuse by mother referred to first in March 2016 seems to have been marginalised in the subsequent exchanges between boroughs. 4.1.14 In October 2015 Hackney would have been justified (based upon London-wide agreed procedures) in escalating its view that Lewisham Children’s Social Care should complete an assessment of mother’s parenting of the younger children. Uncertainty about the Lewisham’s threshold criteria then and now justifies a precautionary recommendation for consideration by what is understood to be a current strategic ‘MASH Steering Group’ charged with ensuring lawful and effectives responses to contacts by other agencies and individuals.                                                                                 CAE                                                       26                                     4.1.15 The joint investigation of the further allegations raised by mother in March 2017 was somewhat delayed because of the birth of child Y and by default rather than intention, ended (contrary to the views of the court in private law proceedings) with the elder girls becoming and remaining resident with their mother.  4.1.16 There were latterly examples of actions not following agreed policies / protocols e.g. compliance with ‘vulnerable ant-natal pathway’ or timing of the new birth visit. 4.1.17 All actions taken by operational staff appear to have been supported by relevant managers and although there were inadequacies such as a lack of signature in several health records or a failure to obtain further necessary information necessary (each specified at relevant places) none resulted in any adverse result to child Y or her siblings. WAS QUALITY OF WORK GOOD ENOUGH?  Voice of the children  Information sharing  Thresholds for intervention  Record keeping  Managerial oversight (first-line & senior)  Were there deficiencies due to organisational capacity (resources, staffing, other underlying systemic issues)  Professional disagreements 4.1.18 As noted elsewhere, the voices of child Y’s siblings (and at minimum, sleeping arrangements for child Y) could have been explored more. SW2 was careful to recognise and seek the views of each child he met, but the account by the 8 year old sib.3 of his positive enjoyment of chores and praying (and his sister’s account of his culinary responsibilities) are surprising and were worthy of further enquiry.  4.1.19 As stated above, the allegation of sib.1 of her mother’s use of a belt as well as the professional concerns about mother’s mental health shared by Hackney, ought to have been explored and were unintentionally overlooked in the several exchanges between involved boroughs. 4.1.20 No indications emerge of any reluctance to share information between agencies though several examples where this was not achieved in a timely or effective manner have been identified. An inability to identify the author of several (mostly health) records diminishes their value.  4.1.21 Lewisham Children’s Social Care has acknowledged that some of its response were constrained by the then structure and level of demand. It is clear that Lewisham’s threshold for intervention was higher than Hackney’s. The SCR panel was concerned to ensure that the current threshold criteria are appropriate and consistently applied and has in consequence developed a recommendations within section 5.                                                                                  CAE                                                       27                                     4.2 CONCLUSIONS 4.2.1 This serious case review highlights the challenges for all involved professionals of distinguishing between the majority of victims of domestic abuse whose experiences go under-reported or insufficiently recognised and a proportion whose allegations about adult on adult or parent on child assaults, are fabricated or exaggerated. 4.2.2 Police and Hackney Children’s Social Care (as well as the court in the private law s.8 Child Arrangements Order proceedings) succeeded in drawing that distinction. 4.2.3 Whilst it was to a degree shaped by its responsibility of discharging the extended Family Assistance Order, the threshold for intervention by Hackney Children’s Social Care was lower than that applied by its equivalent in Lewisham.  4.2.4 The need for greater certainty about mother’s cognitive ability and any associated deficit in parenting ability was, helpfully, recognised and the attempt by the GP to respond to mother’s request for an assessment a welcome one. The failure of the attempt illustrates what is believed to be a more widespread gap in the portfolio of services required to safeguard and promote the welfare of children. 4.2.5 Health Services had expended significant efforts in advising mother on how to minimise the risks of SIDS. A less ready acceptance of mother’s reassurances about sleeping arrangements would have been desirable. The fatal event itself (setting aside an increased level of risk associated with bottle-feeding and excess room temperature) was unpredictable and unpreventable by any actions that might reasonably have been taken by involved professionals.                                                                                 CAE                                                       28                                     4.3 LEARNING 4.3.1 Transcending responses provided to the individual elements of the terms of reference and the broad conclusions of the review, the more general learning points (the first 5 emerge often in serious case reviews) are that:   The case offers several examples of the need for raised and constant professional curiosity (and respectful uncertainty about parental assertions) – it remains a matter of debate to what extent insufficiency of such curiosity is a function of overload / lack of time to reflect on observations, or about the individual professional  Recorded personal history is a critical source of evidence in evaluating presenting circumstances   There are significant benefits in identifying and learning more about ‘invisible men’ (potentially sources of support as well as risk)  There should be a greater willingness to challenge / escalate issues if agency responses appear insufficient or are not confirmed   The need to maintain effective record keeping (ensuring identification of author and when relevant, legibility of writing) is vital in complex multi-agency work  There remains a need to further promote amongst parents an understanding of what research has revealed about sudden infant death and how to reduce risk                                                                               CAE                                                       29                                     5  RECOMMENDATIONS 5.1 INTRODUCTION 5.1.1 The following recommendations are those considered to be of most strategic significance and may require further multi-agency negotiation. 5.2 LEWISHAM SAFEGUARDING CHILDREN BOARD 5.2.1 The LSCB should alert NHS England to the widespread absence of any commissioned arrangements which enable GPs to refer-on for a diagnosis of a learning disability and the extent to which it is impacting or may impact, on future capacity to provide safe and good enough care to dependent children. 5.3 LEWISHAM CLINICAL COMMISSIONING GROUP 5.3.1 The involved GP practice should be reminded of the relevant ‘Read Codes’ for capturing and distinguishing ‘vulnerable’ children and those ‘subject of a child protection plan’. 5.3.2 A briefing based upon the findings of this serious case review should be circulated to Practice managers and the GP safeguarding leads. 5.4 LEWISHAM CHILDREN’S SOCIAL CARE 5.4.1 The ‘MASH Steering Group’ should take all necessary steps to ensure the current threshold for incoming contacts is lawful, consistently applied and known to and accepted by all relevant local and London agencies. 5.4.2 A review should be completed of how / where records of phone calls, emails and ‘walk-ins’ are stored so as to standardise expectations. 5.5 LEWISHAM & GREENWICH NHS TRUST 5.5.1 The Trust should take all necessary steps to ensure that referrals to the internal safeguarding meeting:  Result in the required debate  Are recorded on the relevant IT system and   (In cases where a referral is made to Children’s Social Care) that an acknowledgment of that referral and the agency’s proposed response is kept 5.5.2 If a midwife initiates a MASH referral, s/he should inform the relevant GP and Health Visiting Service.                                                                                 CAE                                                       30                                     5.5.3 All midwifery staff should upload letters and document safeguarding concerns to ‘ICare’ (its database). 5.5.4 An audit should be completed of all Emergency Department attendances ‘rag-rated’ red (urgent) to ensure that they are being discussed in a timely manner at the ‘ED safeguarding meeting’. 5.5.5 Policies and guidelines should be amended to require midwives and health visitors to enquire about, observe and record as a matter of routine, where and in what a baby is / is to be sleeping.  5.5.6 All community midwives should have the opportunity to meet with their team leaders for a ‘one to one’ every 3 months so as to ensure that, in addition to advice and guidance from the Maternity Safeguarding Team, there is management oversight of complex cases. 5.5.7 All midwives rotating out to community work should complete a ‘one to one’ session with a member of the Maternity Safeguarding Team so as to ensure that the midwife understands the ‘safeguarding pathway, how to escalate concerns and is confident about utilising the consultancy function of that team. Overview child Y draft 3 01.06.18  GLOSSARY / ABBREVIATIONS  ABBREVIATION  MEANING BLS Basic life support LSCB Lewisham Safeguarding Children Board CAF Common assessment framework CAIT Child Abuse Investigation Team CAMHS Child & Adolescent Mental Health Service CDOP Child Death Overview Panel EMIS A patient database accessible to many primary care practitioners IMR Individual management review LSCB Local Safeguarding Children Board MECSH Maternal Early Childhood Sustained Home   visiting programme NICU Neonatal Intensive Care Unit NSPCC National Society for Prevention of Cruelty to Children NPIE National Panel of Independent Experts SCR Serious Case Review SIDS Sudden Infant Death Syndrome SUDI Sudden Unexpected Death in Infancy UHL University College Hospital London           