Death of a baby girl in 2017. The cause of Molly's death was unascertained, however there were factors present similar to those found in cases of Sudden Infant Death Syndrome. Learning: identifies opportunities where communication and information sharing could have been better; a lack of professional curiosity and an over-optimism of all agencies in relation to the assessment of the future risk of domestic abuse; lack of professional challenge as well as a lack of awareness of disguised compliance from parents; and an increased risk of neglect to the children due to the interlinking of several parental risk factors including poverty, domestic abuse, substance misuse, nonengagement with services and poor and overcrowded housing conditions. Recommendations include: ensure that thresholds in respect of neglect are clearly understood; ensuring there is an agreed process which ensures that multi agency decision making when challenged has an appropriate escalation process; the need for an antenatal missed appointment policy; review the effectiveness of and compliance with the was not brought policy.
      
 Title:  Serious case review – Baby Molly. LSCB: Durham Local Safeguarding Children Board Author: Sharon Hawkins Date of publication: 2020  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.                                SERIOUS CASE REVIEW – BABY MOLLY       Independent Reviewer Sharon Hawkins February 2019        1   Chapter  Page Number Introduction 2 Publication 3 Reason for the Review 3 Specific Terms of Reference 4 Timescale 6 Family Involvement 6 Parallel Processes 7 Independent Reviewer and Panel 7 Process and Methodology 8 Family Composition, Ethnicity, Diversity and Cultural Issues     9 Background Narrative as Known to Agencies          9 Chronology of Significant Events Identified in the Timeline  11 Appraisal of Practice and Analysis of the Key lines of Enquiry.  17 Conclusion and Recommendations 24     2  1 INTRODUCTION-The Child’s Journey 1.1 This Serious Case Review is about the services provided to Baby Molly and her family prior to her death in the autumn of 2017.  In her second interim report titled ‘The Child’s Journey’1, Professor Munro identified the importance of understanding the ‘child’s journey’ through services and for families to receive effective help at the earliest point for problems arising from family and social circumstances.  1.2 On the morning of her death, it is reported Molly woke for her feed at approximately 4am, Molly took four ounces of formula milk from a bottle and was settled back in her Moses basket, which was located at the bottom of the parent’s bed.   1.3 Molly was discovered lying on her back in her Moses basket by her parents and there were no signs of life. The mother called for an ambulance and Molly was transported to hospital and despite resuscitation throughout this was unsuccessful and she was pronounced deceased.  1.4 In the bedroom where Molly slept there were two cots on either side of the Moses basket where Sibling 2 and 3 normally slept. On the evening before Molly died Sibling 3 slept in Sibling 1’s bedroom as Sibling 1 had spent the night with her grandparents and Sibling 2 had co-slept with her parents. 1.5 Molly was the youngest of four siblings. Sibling 3 was her half sibling from the father’s previous relationship and she had come to live with the family shortly before Molly was born.  1.6 Initially there were no suspicious circumstances and it was considered that Baby Molly had suffered an unexpected sudden infant death and the post mortem was undertaken by a Forensic Paediatric Pathologist. Preliminary results indicated that cause of death was unascertained pending further investigation.  1           The Child’s Journey- 2nd Interim report https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/206993/DFE-00010-2011.pdf .   3  1.7 Toxicological analysis of samples from Molly’s parents showed use by both of them of cocaine, and similar analysis of samples from Molly showed the presence of cocaine metabolites at what was described as an extremely low level probably attributable to environmental contamination. The unlikely possibility of the exposure to parental use of illicit drugs having played some part in Molly’s death means the cause of death remains unascertained, albeit there were factors present similar to those found in cases of Sudden Infant Death Syndrome (SIDS).  1.8 Coronial proceedings were completed after the Serious Case Review Report was completed where a narrative conclusion was given. 2.     PUBLICATION   2.1 This report has been anonymised to protect the identity of the child and family involved; the subject child shall be known as Baby Molly.  3.     REASON FOR THE SERIOUS CASE REVIEW 3.1 In England, Regulation 5 of the Local Safeguarding Children’s Boards (LSCB) Regulation 2006 sets out the functions for LSCB’s. This includes the requirement for LSCB’s to undertake reviews of serious cases in specified circumstances. How LSCB’s undertake the review is not set out in statutory guidance however “Working Together to Safeguard Children 2015”2 identifies that  “Reviews are not the  ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children.” 3.2     Working Together 2015 requires SCRs to be conducted in such a way that:   2 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf  4   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 3.3 The Durham LSCB Serious Case Review Sub-Committee met in May 2018 to consider the case and made a unanimous recommendation to the chair of the Board that the case did meet the criteria for a Serious Case Review as Baby Molly had suffered serious harm and abuse/neglect was suspected to be a factor in the case.  The Serious Case Review was to consider all four children. 4.       SPECIFIC TERMS OF REFERENCE 4.1  The Review will:  Determine whether decisions and actions in the case comply with the policy and procedures of the named service and Durham LSCB.  Examine inter-agency working and service provision for the child and family.  Determine the extent to which decisions and actions were child focused.  Was previous relevant information or history about the child and/or family members known and considered in professionals' assessment, planning and decision-making in respect of the child the family and their circumstances? How did that knowledge contribute to the outcome for the child?  Establish what lessons can be learned about the quality and effectiveness of agency and multiagency working,  5   The impact of equality and diversity factors on practice.  Were there obstacles or difficulties in this case that prevented agencies from fulfilling their duties? This should include consideration of both organisational issues and other contextual issues?  Seek contributions to the review from appropriate family members and keep them informed of key aspects of progress.  Take account of any parallel investigations or proceedings related to the case.   How much information was self-reported and was there evidence of professional curiosity and challenge.  Was information regarding parental risk factors such as domestic abuse and parental substance misuse considered as part of assessment and decision making. Key Practice Episodes  The decision making and timeliness of the response to the referral on 5 September 2017 in terms of whether the escalation process and challenge process was followed appropriately.  The delay in the commencement of the single-assessment following the referral on 5 September 2017.  The discussion and decision making regarding the allocation of the case to the One Point Service when the initial referral in September 2017 was graded as a Level 4.  The co-working arrangements between the Social Worker for the Sibling 3 and the Social Worker for the Molly and whether Sibling 3 had been included in the single-assessment.  The response and actions by the Health Visitor regarding the issue of the tongue tie.  6   The significant delay by CDDFT in submitting a retrospective referral to Children’s Services following Sibling 2’s attendance at hospital on 15 October 2017 where parents left the department before Sibling 2 was treated.    The discussion and actions from the GP Safeguarding Meeting.    5.     TIMESCALE 5.1 The timescale for the active period of the review is from the period prior to Molly’s birth until after her death and covered a 12 month timeframe.   6.     FAMILY INVOLVEMENT  6. 1 The LSCB Business Manager met with the parents of Baby Molly following the decision for a serious case review to be held.  The purpose of the meeting was to explain the Serious Case Review process and to obtain the views from family members about the services they had received.  6. 2 Both parents advised that they did not feel that anyone could have done anything differently.  The mother expressed concern that the Social Worker had explained that she would not be told of Baby Molly’s cause of death until the Serious Case Review had been completed. Clearly this information was not accurate and has raised an expectation in the parent which will not be addressed by the review when only coronial process will potentially give mother the answers she requires. The coroner has asked to be updated regarding the progress of the Serious Case Review.  6. 3 Positively the parents identified strengths in the services they had received. The mother identified the consistent relationship with the Health Visitor over a six-year period. She felt if she had any problems then the health visitor would respond and come out to see her. The father concurred with this view stating that they had confidence in the health visitor and that the mother would not speak to any other professionals other than the health visitor.  6. 4 Support was also offered by other health professionals to the family at different times particularly the GP and Midwifery Service. An example of support from the GP was identified when Sibling 3 came to live with the family. Both the GP and Health Visitor  7  supported the couple to register Sibling 3 with their GP Practice and the Social Worker supported them to get the father’s name added to his daughter’s birth certificate.     7.     PARALLEL PROCESSES  7. 1 Coronial proceedings were completed after the Serious Case Review Report was completed where a narrative conclusion was given.         8.      INDEPENDENT REVIEWER AND PANEL  8.1 Independent Reviewer, Sharon Hawkins was commissioned to undertake this Serious Case Review. Sharon qualified as a Social Worker in 1994 and after 18 years of being employed in Local Authorities in the North West of England she became an Independent Safeguarding Consultant in 2012. Sharon has 24 years of experience of both social work and management at various levels including Head of Service and Assistant Director in frontline children’s services. She is experienced in completing Serious Case Reviews, Managed Reviews and reflective learning reviews and completed the national training programme for Independent Reviewers in 2013. Chronologies were requested from the following agencies:   County Durham and Darlington NHS Foundation Trust - CDDFT  North East Ambulance Service NHS Foundation Trust  Primary School 1  Primary School 2  CYPS  Durham Police   General Practitioner   Harrogate and District NHS Foundation Trust  8  8.2 The members of the Serious Case Review Panel for Molly comprise of senior managers from the key statutory agencies who have had no direct involvement with the case. The panel members identified authors within their own agencies to complete the chronologies. The role of the panel was to actively manage the review and to provide oversight and scrutiny through all aspects of the process. The Independent Reviewer and Business Manager chaired this panel. 8.3 The following agencies were represented on the Panel.   Children and Young Peoples Service- CYPS   Durham Constabulary  Education Development Service  North Durham and DDES CCG’s  County Durham and Darlington NHS Foundation Trust  North East Ambulance Service NHS Foundation Trust  Harrogate and District NHS Foundation Trust     9.     PROCESS AND METHODOLOGY 9.1 The Serious Case Review Panel met to consider the timeframe and Terms of Reference for the review. This review was undertaken using a systems approach and is compliant with Working Together 20153 and 20184. Each agency with knowledge of the family has completed a Timeline of their involvement and this was utilised alongside a Learning Event with practitioners. The Learning Event was an integral part  3 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf  4 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/729914/Working_Together_to_Safeguard_Children-2018.pdf  9  of the review, ensuring that the voice of practitioners was heard and that they had the opportunity to actively contribute to the process. Using a systems approach, the emphasis of the Learning Event was on understanding what happened, why some decisions were made and what learning could be captured. The Learning Event was based on the Welsh Child Practice Review Model5.   10. Family Composition, Ethnicity, diversity and cultural issues Name / Acronym Relationship Age Molly Subject Child 33 days Mother     Mother of Molly and Sibling 1 and 2 27 years Father 2 Father to Siblings 2,3,4 27 years Father 1 Father of Sibling 1 N/K Sibling 1 Oldest Sister 5  years Sibling 2 Middle Sister 16 months Sibling 3 Half -sister 14 months 10.1 Baby Molly and her Siblings and the parents are of White British heritage. The family lived in a small two bedroomed rented property which was overcrowded for their needs. There was up to five people sleeping in the bedroom occupied by Molly.  11.    Background Narrative as Known to Agencies          11.1 Baby Molly and her family had been known to universal services for many years. The father was known to the police and the family where considered to be at the edge of criminality due to their links to people known to the Police.  There was a history of domestic abuse involving father and his previous partners.  Within this family network, both parents self-reported to professionals that there was no domestic abuse within their relationship.  However, some agencies were aware of at least two incidents drying this scoping period which are reflected below.   5      Protecting Children in Wales, Guidance for Arrangements for Multi-Agency Child Practice Reviews, Welsh Government, 2012    10  11.2 In 2014 the police were called to a disturbance regarding a male who had two knives. They discovered the father at the end of the road with a knife to his throat he was making threats to the police officers. Father was arrested, and a welfare visit was undertaken to the home address and there were no concerns. 11.3 In February 2015 the father attended the address of his ex-partner under the influence of alcohol; he kicked the front door in. The father wanted to know who his ex-partner had at the home. He was subsequently arrested and charged with using violence to enter premises and was found guilty in court. 11.4 In January 2016 there was a domestic incident between the father and the mother. Mother, at this time was pregnant with Sibling 3. It was alleged that the mother was abusive towards the father and that he had retaliated, grabbing her arm, pushing her and punching a cupboard door.  The father was arrested for assault, but no further action was taken. 11.5 In June 2016 HV1 undertook a home visit to carry out a family needs assessment, the father advised the health visitor that he binge drank occasionally and drank alcohol regularly. The mother admitted to smoking cannabis in her teenage years. She also admitted to smoking cannabis in the period before Sibling 1 was born. She did not disclose current drug misuse. 11.6 In July 2016 HV1 undertook the new birth 4-6 week visit to Sibling 2. Sibling 2 was observed to be sleeping on her stomach. The risks around allowing the baby to sleep in this position were explained to the mother by HV1. HV1 also observed that the kitchen window was broken, the parents informed HV1 that a neighbour had thrown wood through the window and that this had resulted in them having to ring the police. There was no explanation offered as to why the neighbour had carried out this action and HV1 did not explore this further with either the parents or the police. 11.7 In September 2016 Sibling 1 started at Primary School 1, she was aged four at this time. Her attendance was very poor at 68.4%. Due to her age the school were unable to take any action however her attendance was monitored by the Educational Welfare Officer. Reasons for non-attendance included illness. She was noted to have a bad  11  cough, frequently arrived at school late, was unkempt and smelt strongly of cigarette smoke. 11.8 In November 2016 a further incident of domestic abuse was reported to the police. The referrer reported that the incident was ongoing. Police attended at the property and the parents and Sibling 3 were present. The parents admitted to having had a verbal disagreement, no concerns were noted in respect of the children. 11.9 There was a history of non-engagement with health appointments including immunisations and antenatal care during mother’s pregnancies. During mother’s pregnancy with Molly there were concerns regarding mother’s physical health, but she failed to attend consultant appointments.      12.    Chronology of significant events identified in the timeline  12.1  In January 2017 Sibling 1 left Primary School1 unexpectedly. The school had very little interaction with Sibling 1’s parents and she was brought into school by her aunt on most days that she had attended. Her aunt was also the primary person who collected her. 12.2  The mother booked in for ante-natal care at the GP surgery in February 2017. She was 13 weeks pregnant. The pregnancy was perceived as high risk and the mother needed care following the birth.  The mother also was a heavy smoker and would not engage in any cessation treatments and had an elevated BMI of 306.  12.3 An ante-natal risk assessment was completed at 13 weeks gestation, both parents were unemployed at time of booking. They did not report any mental health issues or substance misuse, they denied a history of domestic abuse or police involvement. Mother stated she did not drink alcohol.  6 A BMI of 25 to 29.9 is considered overweight. A BMI of 30 and above is considered obese. Individuals who fall into the BMI range of 25 to 34.9, and have a waist size of over 40 inches for men and 35 inches for women, are considered to be at especially high risk for health problems  12  12.4 Also, in February 2017 Sibling 1 and Sibling 3 attended health appointments due to illness. Sibling 3 was admitted to hospital with breathing problems. 12.5 The following week HV2 undertook the nine-month review of Sibling 2 at the home address. Smoking cessation was discussed with the mother and safe sleeping was revisited. 12.6 In March 2017 the mother failed to attend three appointments with the midwife. She also walked out of the clinic on another occasion when she was due to see the midwife. Follow up letters were sent to the mother including one which was hand delivered. Also, during the same month Sibling 2 attended the GP on two occasions with gastroenteritis and an upper respiratory tract infection. 12.7 At the beginning of April 2017, the mother again failed to attend her ante-natal appointment with the midwife, Sibling 3 also was not taken to her appointment for her immunisations. Mother further DNA ante-natal appointments rearranged for later in April. 12.8 By April 2017 Sibling 3 was now living with her father and the mother following an incident between Sibling 3’s mother and her current partner. The father was not in agreement to Sibling 3 returning to her mother’s care.  12.9 Also, in April 2017 the police were contacted by an anonymous person to advise that the father was wanted by the police and that he had taken his daughter (sibling 3) from her mother’s care. 12.10 The same month CYPS received a referral alleging that the father was substance misuser and domestic abuse perpetrator. The referrer stated that there were often other adults in the property and there was anti-social behaviour. 12.11 The matter was progressed with a recommendation for a Single Assessment to be completed. Sibling 1 was spoken to in school and expressed no concerns about her home life. Observations of the other children’s engagement with their parents was positive. The assessment did not include the views of either the midwife nor the GP and given the history of DNA ante-natal appointments this information was important  13  and should have been considered. The assessment did not conclude until June 2017 and it was identified that there was no ongoing role for CYPS. 12.12 Due to the incident between Sibling 3’s mother and her partner a Single Assessment was commenced in that household. A different social worker had been allocated to this. Despite Sibling 3 having moved to her father’s house both social workers completed their assessments in isolation. Sibling 3 was not considered in the assessment that was undertaken regarding the allegations that her father was using and dealing drugs and a domestic abuse perpetrator. The assessment undertaken in respect of Siblings 1 and 2 did not consider the impact of Sibling 3 joining the household which was already overcrowded and the parenting capacity of the mother and father to meet the needs of all the children. 12.13 At the end of April 2017, the mother attended her scan appointment with the midwife. During this appointment the history of DNA appointments was not discussed with the mother and there was no challenge around the risks to the pregnancy due to this history. Mother had been classed as having a high-risk pregnancy due to her own health problems and this should have warranted some discussion. Mother’s heavy smoking was again discussed with her, but she refused smoking cessation support. 12.14 In May 2017 Sibling 3 attended the GP with wheezing and breathing difficulties. At the end of May 2017, the mother also attended for a growth scan with the community midwife. The pregnancy was noted to be progressing well and a further growth scan was scheduled for 28 weeks gestation. Mother was again advised of her options regarding smoking cessation support but declined this. 12.15 Some weeks later the mother failed to attend her 28-week appointment with the consultant. The mother was contacted by the midwife initially by telephone and stated that she would be late. When she failed to attend she was again contacted and advised the midwife that she was still at home and would not be attending. This was discussed with the Consultant and the scan was rearranged for the following month. 12.16 The following month the GP Surgery identified that the family were a cause for concern.  This was due to numerous DNAs for immunisations, midwifery checks and GP appointments.  A discussion was held at a practice safeguarding meeting.  There  14  was multi-disciplinary attendance at this meeting, but this was not a multi-agency meeting as this is not routine practice. 12.17 The rest of the summer period was largely uneventful until September 2017 when the mother contacted the police regarding Sibling 1 being missing. The mother advised the police that Sibling 1 had not been see for over half an hour. Sibling 1 was subsequently found under blankets in a corner of a room”. 12.18 Following this incident, the police made a referral to CYPS, and following screening by the First Contact Service it was agreed that the case needed statutory intervention and the referral was escalated to Families First Team to complete a Single Assessment of the child and family’s needs. This threshold decision to progress was made in early September however 17 days later the Team Manager of One Point7 discussed the decision with the Families First Manager and given there had been a positive single assessment completed in June 2017, which had concluded that social work intervention was not needed the case was agreed as a Level 3 case and deemed as not in need of a social work assessment. 12.19  In late September 2017 Baby Molly was born. The Newborn & Infant Physical Examination (NIPE) was undertaken and Baby Molly was noted to be doing well and no concerns were noted apart from tongue tie8. A feeding assessment for tongue tie was completed by the acute midwife and it was noted that Molly could lift her tongue past her mid mouth and no feeding issues were identified.  12.20 Mother was persistent that she and Molly be discharged from hospital the same day.  Molly had been born at lunchtime and the mother and baby were discharged some eight hours later.  The reason for wanting to be at home was not explored with mother, although it was known that she had three children at home. Tongue tie had been recorded in the discharge summary and that a referral for this had been completed.  The outcome of the referral is not known.  7          http://www.durham.gov.uk/onepoint 8 https://www.nhs.uk/conditions/tongue-tie/  15  12.21  In October 2017 a family worker from One Point undertook a joint visit with the HV1 to introduce herself to the family. The family worker discussed the information regarding Sibling 1 hiding under blankets. The parents advised the family worker that they had panicked and called the police when they realised she was missing.  12.22 The home was very crowded during the visit as the grandparents and a neighbour was in the home. Mother was provided with the initial One Point paperwork and a further visit was organised for two weeks later. On this visit it was proposed that a Home Environment Assessment Tool would be completed9. 12.23 In mid-October the mother contacted 111 as she was concerned as Sibling 2 was unwell. The call was transferred by the Health Advisor to 999 as an emergency. The mother informed the operator that Sibling 2’s lips kept turning blue, she was vomiting and had a rash on her abdomen which had been there for the past three days; Sibling 2 was also drowsy.  12.24  A rapid response vehicle was dispatched to the address and Sibling 2 was taken to the Emergency Department (ED) with her mother and father. The parents detailed a history of vomiting for two days and said that she had been off her food.  Sibling 2 was given treatment and her parents were informed that she would need a further blood test prior to being discharged home to ensure her blood sugars were back to normal. However, the parents left the hospital before Sibling 2 had the blood test. Following this the hospital had to contact the Police, who along with the ambulance service responded, and Sibling 2 was found at her grandparents’ home and brought back to hospital with her mother and father in the early hours of the following day. Sibling 2 received treatment and was discharged home with her parents.  There was no evidence within CDDFT’s records that a referral was made to Children’s Services following this incident. 12.25 Four days later, HV1 undertook a home visit and discussed Sibling 2’s attendance at ED with the parents. The issue of the parents removing Sibling 2 from the hospital  9 http://www.durham-lscb.org.uk/wp-content/uploads/sites/29/2016/06/Home-Environment-Assessment- Tool-37918-CYPS-Nov-16.docx  16  before receiving treatment was addressed with the parents by HV1. The HV1 records indicate that a referral was made by the hospital to Children’s Services, there was no evidence in the hospital notes to indicate a referral had been made and had the HV followed this up she would have ascertained that one had not been received. There is no indication that HV1 followed this up to ascertain to outcome of the referral. 12.26 Also, in October HV1 undertook a home visit, present was the mother and Molly. The mother advised the HV that she felt that the tongue tie had resolved itself and that Molly was moving her tongue more freely. HV1 observed a small amount of blood in Molly’s mouth; it is not clear if HV1 checked the mouth to ascertain if the blood was from the tongue tie or another cause. It was evident that a four-week-old baby with blood in her mouth should have generated curiosity from the HV as to the mechanism and source. 12.27 During this visit HV1 also did not carry out the home environment assessment however HDFT10 policy states that it should be completed before the child is eight weeks of age. 12.28 Four days following HV1 visit a 999 call was received regarding a baby in cardiac arrest, paramedics attended the household and Molly was transported to hospital and despite resuscitation throughout this was unsuccessful and she was pronounced deceased.    12.29 Following Baby Molly’s death witness statements were taken from both parents by the police. Father was interviewed, and he admitted to using cocaine whilst at a stag party the weekend before Baby Molly’s death.  Mother when interviewed as a witness, stated, that she did not normally take cocaine, however, had done so as a one-off and smoked cannabis on the previous Saturday night also. It was agreed that a Strategy meeting would be convened.   10 https://www.hdft.nhs.uk/services/childrens-services/  17  12.30 A skeletal survey was undertaken and nothing untoward was found. The post mortem did not establish a cause of death which was determined to be unascertained pending further investigations.  13.   APPRAISAL OF PRACTICE AND ANALYSIS OF THE KEY LINES OF ENQUIRY.         Introduction 13.1 This section will provide the overview, appraisal of practice, analysis of the key lines of enquiry and the findings of this serious case review, with recommendations for Durham Local Safeguarding Children Board and its partners. The findings relate to what has been learnt about the strengths and developmental areas in the multi-agency system. 13.2 The findings of this serious case review do not indicate that inter-agency practice nor the practice of any individual or organisation could have altered the outcome of this case. There are multiple factors of poverty, poor housing, mental health, domestic abuse and drug misuse all of which have a negative impact on children’s life chances. However, inevitably, in any review where a child has died there will be lessons to be learnt. In this case there are a number of areas where practice could have been better, but this is unlikely to have altered the outcome for Baby Molly. The scrutiny undertaken across the partnership following Baby Molly’s death has meant that some areas of practice have already improved considerably. 13.3 A Learning Event took place and was attended by practitioners and managers from the main agencies. Some key information was shared during the Learning Event which clarified information already provided by agencies. Attendance at the practitioner event was good and those attending participated actively in assisting with analysis of events and identifying learning from the case. Practitioners at the Learning Event identified several missed opportunities and areas where practice could be improved.      18  Analysis of Events during the period under review. Theme: Communication and Information Sharing 13.4 In the analysis of serious case reviews evaluated by Ofsted between 2009 and 2010 it was identified that in most of the serious case reviews analysed there were sources of information that could have contributed to a better understanding of the children and their families. They also highlighted concerns about the effectiveness of assessments and shortcomings in multi-agency working. That analysis has resonance with aspects of this serious case review. 13.5 There are many opportunities where communication and information sharing could have been better. The handover of information between School 1 and School 2 when Sibling 1 transferred was an area whereby the family vulnerabilities could have been highlighted. Sibling 1 left her first primary school abruptly and with no notice. The poor handover of information meant that School 2 did not have the knowledge or understanding of the concerns in respect of Sibling 1. Had this information been known then a TAF11 may have been considered at an earlier point.  13.6 There was also poor information sharing between the Midwifery Service and the Health Visiting Service post birth. Baby Molly is reported to have had a tongue tie which was identified to the Health Visitor by the mother. There was no handover between the Midwife and Health Visitor which should have taken place. The HV did not have any scepticism or curiosity about the tongue tie and did not check back with midwifery as to whether this had been picked up in the post birth examination. At the Learning Event practitioners identified that tongue-tie needs a process for accurate recording and observation and it should not rely on the parent or carer.  13.7 They also identified that practice has moved on in this area since the death of Baby Molly and there are now top-to-toe observations of new-born babies by the Health  11 https://www.durham.gov.uk/strongerfamilies    19  Visitor at all primary visits and any concerns are clearly recorded and information triangulated. 13.8 At the Learning Event it was also identified that the scrutiny following the death of Baby Molly had resulted in vastly improved communication between the two services due to the implementation of new procedures. This includes midwifes now sending information regarding feeding to Health Visitors. They advised that there was still some way to go and that the process needed to be continually developed. Theme: Lack of adherence to Safeguarding Procedures 13.9 CYPS have a duty to undertake Child Protection enquiries when they suspect that a child is either at risk of significant harm or has been harmed. The point of these enquiries is to establish what action needs to be taken and by whom. During the period under review there was a couple of incidents whereby enquiries under S47 should have been considered and may have been appropriate. 13.10 When the health visitor attended and observed blood in Baby Molly’s mouth she did not record if there was any consideration as to whether the there was an injury or consideration of a non-accidental injury given the presenting symptoms. She did not arrange for Molly to be examined by a doctor to see if there were any other medical reasons for the blood in Molly’s mouth. Not alerting a doctor or health professional to the observation of blood in a non-mobile baby’s mouth did not allow for medical tests, further inquiries or response to this unexplained incident.  13.11 When Sibling 2 was removed from the hospital by the parents in the October before she received treatment was a missed opportunity to share information and concerns regarding the family and their presentation. The hospital failed to refer the matter to Children’s Services despite the police and ambulance service having to be dispatched to collect Sibling 2 from the grandparent’s home. This incident should have triggered a Strategy Discussion to share information about the children and the family. 13.12 Prior to the death of Molly, the parents had attended the hospital on other occasions with the children and were observed at times to appear under the influence. This information was not shared with other agencies who were involved with the children  20  at the time and was first mentioned at the Learning Event. Drug misuse was not challenged or explored with the parents. Working within statutory timeframes 13.13 Working together 2015 identifies that within one working day of a referral being received by the local authority a social worker should decide about the type of response required. This will include determining whether:   Child requires immediate protection and urgent action is required.  Child is in need and should be assessed under section 17 of the Children 1989.  Any services are required by the child and family and what type of service; and  Further specialist assessments are required in order to help the local authority to decide what further action to take. 13.14 Following the police referral following Sibling 1 being missing; the case was allocated to a support worker to make contact with the family. A referral decision was not made until 13 days later when the threshold decision was made that the case should be progressed to Level 3. This was significantly outside of the statutory timeframe. This decision was discussed four days later by the manager of the Families First Team with the Team Manager at One Point and agreed it was Level 3 work and One Point would work with the family. The case then transferred from Families First Duty Tray to One Point Duty Tray. This is 17 days following the referral being received.   13.15 At the learning event there was concern raised about the multi-agency threshold decisions made in September 2017. Many practitioners believed that the case had initially been identified as a Level 4 case needing a social work assessment and that this decision had been overturned following a discussion between the two team managers in Families First and One Point and ‘de-escalated’ to a Level 3 case.  A screenshot of the decision making was provided by CSC which identified a discussion between the both managers which clearly shows a Level 3 decision. However, there was clearly miscommunication and confusion across the partnership about what  21  decision was made in this case initially in the MASH and what actions would subsequently be undertaken. 13.16 Practitioners were also concerned to know what mechanism would be in place if there is a disagreement between a MASH decision and the receiving Team Manager. MASH practitioners at the learning event acknowledged that timescales are generally tight, and discussions do not always take place when more information comes to light. If an operational manager decides to either step down or step up a case, then MASH are not consulted or informed. The professional network in attendance identified that there needed to be a procedure around this. A new electronic child recording database has been introduced and is starting to show impact in this area. 13.17 The Joint Targeted Area Inspection12 undertaken in July 2018 identified that there was often an over-optimism of all agencies in relation to the assessment of the future risk of domestic abuse, and this included a lack of professional challenge as well as a lack of awareness of disguised compliance from parents. Since that time a cumulative risk assessment tool has been introduced which enables a better analysis of these cases to take place at the point of contact and this is making a difference to practice and outcomes. 13.18 Delays were also identified in respect of the statutory timeframe for the completion of Single Assessments to conclude and for a decision on next steps being reached. This should be no longer than 45 working days from the point of referral13. In this case the assessment started in April 2017 did not conclude until June 2017 placing it outside of the statutory timeframe. However, the school nurse was contacted in the May to advise that the case was closing. The outcome of the assessment in June was for no further action from CYPS and the family were signposted to other services.  12 https://files.ofsted.gov.uk/v1/file/50015171 13 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/592101/Working_Together_to_Safeguard_Children_20170213.pdf   22  13.19 The assessment did not include the views of the full multi-agency network involved with the family and this therefore brings into question the robustness of this assessment. The Health Visitor and school nurse had been spoken to however if the information held by the GP and Midwife had been considered it would potentially have changed the outcome of the assessment and subsequent work may have taken place with the family. 13.20 Although the decision reached following the assessment was for no further action by CYPS following the April referral, the record for Sibling 1 was never closed. It also appeared that there was a delay in closing the case on the electronic case management system and the other Siblings case records were not closed until July 2017.    Working Effectively with Neglect. 13.21 Long term neglect has a profound impact on children’s lives and developmental outcomes. Research evidences that a robust assessment which has a clear focus around parenting concerns, causal factors and how those impact upon children is crucial. The assessments should to be followed with a plan which has identified actions, outcomes to be achieved, and timeframes for change. 13.22 There was an increased risk of neglect to the children due to the interlinking of several parental risk factors which included poverty, domestic abuse, substance misuse, non-engagement with services and poor and overcrowded housing conditions. Home conditions were often described as cluttered and with six people living in a small two bedroomed property it is easy to see why this may have been so, but it was not clear in the recordings what was meant by ‘cluttered’. At the learning event practitioners were able to identify that the home was not dirty, but conditions were poor and there was a lack of storage, but the mother managed the best she could in such cramped conditions.  13.23 The impact on the children on living in such poor conditions was never fully assessed. Sibling 1 was described in her first primary school as unkempt and smelling strongly of cigarette smoke; which it appears all the children were exposed too, despite the mother informing the family health visitor that both she and the father smoked outside  23  of the home. The impact on Sibling 1 and 2 was not considered in the assessment undertaken in April 2017 when Sibling 3 Sibling 3 joined the household which was already overcrowded . Mother was also pregnant with Baby Molly. 13.24 Mother’s non-engagement with antenatal services was not viewed through the lens of neglect in respect of the unborn child and on many occasions the other Siblings’ missed health appointments and were late for immunisations.   Theme: Lack of Professional Curiosity and Professional Challenge. 13.25 The 2005-07 Biennial Review notes the importance of trust in family and worker relationships but ‘respectful uncertainty’,14 should accompany this as it can take time to recognise and respond to disguised compliance.  13.26 On a number of occasions the parents concealed the full extent of their drug misuse from professionals and it was only following the death of Baby Molly that the full knowledge of this became known and although there is no suggestion that this was a factor in the death of Baby Molly had it have been known and triangulated with the other information known about the parental risk factors including domestic abuse and missed health appointments then it may have resulted in earlier intervention and support to the children. 13.27 There were occasions where professional curiosity was required.  For example, the incident when Sibling 1 was reported missing and despite this incident, professionals did not consider why she had disappeared and remained hidden under blankets. For a small child to be missing and stay still and hidden for over 30 minutes this was of concern...  The father had a history of domestic abuse and there had been allegations in respect of domestic abuse in his relationship with the mother.  When HV1 visited the family,  14 Lord Laming – Victoria Climbie Enquiry  24  following this incident, domestic abuse was not considered as a possible pre-curser to this incident.  Conclusion and Recommendations  13.28 Statutory guidance requires that Serious Case Reviews provide a sound analysis of what happened in the case and what needs to happen to reduce the risk of recurrence in future cases. In 1989 the United Nations Convention on the Rights of the Child (UNCRC) set out in detail what every child needs to have for a safe, happy and fulfilled childhood15.  13.29 In this Serious Case Review there were multiple factors which impacted upon the children’s life chances and are circumstances in which many other children live in the UK. The multiple factors of domestic abuse, drug and alcohol misuse, smoking, poor housing, missed health appointments and lack of aspiration in respect of education all have an impact on the outcomes for children and they are not something that LSCB’s and SCR processes will solve alone. In England and Wales in 2016 there were 219 unexplained infant deaths, a rate of 0.31 deaths per 1,000 live births16.  13.30 Research undertaken by Melissa Bartick and Cecilia Tomori in 201817 identified that populations with the world's lowest rates of SUID/SIDS have low income‐inequality or high relative wealth. One of the key messages to come out of the report was that comprehensive approaches to infant mortality are needed that address poverty, inequality, and racial discrimination and include structural interventions for smoking cessation and breastfeeding. 13.31 However, recognition of how these factors impact is needed by professionals working with vulnerable families so that they can ensure that children receive the right support  15 https://www.unicef.org/french/adolescence/files/Every_Childs_Right_to_be_Heard.pdf 16 https://www.lullabytrust.org.uk/professionals/statistics-on-sids/ 17 Sudden infant death and social justice: A syndemics approach-   https://onlinelibrary.wiley.com/doi/full/10.1111/mcn.12652  25  to limit the impact of these circumstances and to help the family to fulfil their children’s needs. The vulnerability of children under one years of age is well evidenced in research and 45% of serious case reviews in England are in respect of children of this age. Timely responses to referrals and assessments in respect of the families in which these children live is crucial. The delay in threshold decision making and completion of the Single Assessments in this case had an impact on the quality of support and services this family received but would not have prevented the death of Baby Molly. 13.32  This review has identified that there is confusion in respect of threshold decisions. There is not a clear and agreed process in place when there is disagreement in respect of the threshold decision made within the MASH.  Recommendation:  The DSCP should assure itself that there is an agreed process which ensures that multi agency decision making in the MASH when challenged has an appropriate escalation process to mediate on such decision. 13.33 A key learning point from this review was also in respect of the mother’s non-engagement in ante-natal care and in respect of the missed health appointments for the children. There was not a recognition that non-engagement in the antenatal period was potentially harmful to the unborn child. It was the mother’s choice to miss her screening, consultant and scan appointments and by doing so this did evidence neglect towards Unborn Baby Molly.  13.34 In respect of the missed appointments for the siblings this was also evidence of neglect, but this was not recognised as such and so was not responded to.  Recommendation 2:  An Antenatal Missed Appointment policy is in place. This policy to be to be reviewed, updated and compliance to be reviewed.  Recommendation 3:  There needs to be a meaningful discussion by the midwifery service with women who DNA about lack of engagement. Recommendation 4:  The DSCP should review the effectiveness of the ‘Was Not Brought’ policy and agencies who have implemented the policy to be requested to provide assurance that it is being complied with.  26  Recommendation 5:  The DSCP should assure itself that thresholds in respect of neglect are clearly understood across the partnership. Recommendation 6:  The Home Environment Assessment to be completed at the antenatal or primary care visit.  It is good practice that the Home Environment Assessment Tool is completed at every visit, but this should be done in liaison with the One Point Service to reduce the impact on families. 13.35 It was identified at the learning event that there was not a handover visit between the midwife and the health visitor. At the point of transition between the two services the information regarding whether Baby Molly had tongue tie or not was not clear. The health visiting service identifies that they were not informed that Baby Molly had tongue tie and that this was self-reported by the mother during the primary visit with the health visitor. As the Midwifery and Health Visiting Service is managed by two different Trusts, this was considered to be a barrier to joined up working.  Recommendation 7:  Consideration should be given to ensuring that there is a handover visit/discussion between the midwifery service and health visiting service at the point of transition. Single Agency Recommendations - CDDFT 13.36 Ensure maternity records and child health hand held record are fully completed to include all relevant information on discharge from hospital. 13.37 A referral to children’s services to be made automatically when a child leaves ED/ UCC against medical advice or without completing necessary treatment. 