Death of a 5-month-old child of Lithuanian parentage from a brain injury in March 2015. Father was found guilty of murder of Child D in February 2016 and also found guilty of injuries caused to siblings DD and LD. Child D was a twin who was born prematurely and spent 2 months in hospital after their birth; Child D's sibling had further health complications that required hospital appointments. Child D's parents came over from Lithuania in 2010 and started a family 3 years later. They were not known to children's social services until the death of Child D. The family were under financial pressures and away from the main support system of their extended families. There was contact with health visitors, GPs and hospitals before the birth of the twins. Findings included: considering all children in a family; fathers must be included in assessments and plans for children; highlights the importance of interpreters. Good practice was noted at the neonatal unit the twins attended and the health visitor was pro-active in seeking help for the family. Finds that improved arrangements would not have prevented the death of Child D, but there are opportunities for services to make some changes to develop their services.
      
 Title:  Serious case review: BSCB2015-16/01: born in 2014: died on 1st April 2015 aged 5 months. LSCB: Birmingham Safeguarding Children Board Author: Jim Stewart Date of publication: 2017  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.                            1                                 Independent Author:  Jim Stewart  Serious Case Review BSCB2015-16/01 Born in 2014 Died on 1st April 2015 aged 5 months  2    Contents   Page 1. Reason for the Review 3 2. Methodology 3 3. Independent Lead Reviewer 4 4. Family Composition and Background 4 5. Ethnicity, Culture and Identity 4 6. Family Background 5 7. Parental and extended Family Involvement 5 8. Criminal and Care Proceedings 6 9. The Birmingham Context 6 10. Summary of Key Events 9 11. Analysis  14 12. Service Developments since April 2015  27 13. Conclusions and Lessons Learned    29  Appendices  Terms of Reference  Bibliography  Acronyms    33 37 39       3  1. Reason for the Review  1.1 The subject of this Serious Case Review is Child D, a twin who was born prematurely on 14 November 2014 and died on 1 April 2015. An ambulance was called to the family home following an emergency call and Child D was taken to hospital where a devastating brain injury was identified which was assessed to have been a non-accidental injury. On the afternoon of 1st April life support was withdrawn and Child D died peacefully in parents’ arms.  1.2 Following a police investigation and criminal trial, Father was convicted of murder on 22 February 2016. Mother was exonerated in court from any blame in causing injuries to Child D and all charges against her were dropped. Birmingham Children’s Services have safeguarded the welfare of siblings DD and LD through care proceedings.   1.3 The twins, Child D and DD, had been born very prematurely and required significant health involvement. Child D spent almost 8 weeks in hospital before discharge and her sibling 9.5 weeks, a little longer because the child required abdominal surgery to address complications due to prematurity. Both twins were visited at home by the Health Visiting Service and seen by the family GP.  1.4 Children’s Social Care had had no involvement with the family. They became involved on 1st April 2015 following Child D’s hospital admission and death and have remained involved with Child D’s surviving twin and LD.  1.5 The Chair of Birmingham Safeguarding Children Board was notified on 29th May 2015 of the recommendation made by the Serious Case Review Sub-Group that a Serious Case Review should be undertaken and the Chair ratified the decision following a peer review discussion with another LSCB Chair on 6th July 2015.   1.6  The Chair subsequently decided that this Serious Case Review should be considered alongside a separate Serious Case Review in respect of the death of a child in a different migrant family; although the circumstances of the cases were very different it was judged that similar themes may arise which could usefully be compared and contrasted in an additional issues report.  2. Methodology  2.1 Scoping reports were requested from West Midlands Police, Birmingham Community Healthcare NHS Foundation Trust, Birmingham Children’s Hospital NHS Foundation Trust, Sandwell and West Birmingham NHS Foundation Trust, Sandwell and West Birmingham Clinical Commissioning Group, West Midlands Ambulance Service, Birmingham Children’s Social Care, Birmingham Early Years and the United Kingdom Border Force.  2.2    The Lead Reviewer has considered the information provided in a multi-agency chronology and in brief agency reports produced primarily by the Health  4  Trusts involved with the family.  He has also reviewed information gathered by West Midlands Police as part of their criminal investigation and also information subsequently gathered by Birmingham Children’s Services during assessments and care proceedings undertaken in respect of Child D’s surviving siblings.  2.2 A learning event took place on 2 December 2016 with representatives of the Health Trusts involved and some members of the SCR Sub-Group and this was facilitated by the Lead Reviewer.  2.3 The Lead Reviewer has discussed the detail of drafts of this report with the Serious Case Review Sub-Group and made final revisions in the light of the feedback and further information received from agencies and the members of the group.  3. Independent Lead Reviewer  3.1 Jim Stewart is an Independent Social Work Consultant with over 26 years’ experience of working in children’s services, child protection practice and management, including the coordination of complex case investigations and the conduct of Serious Case Reviews. He qualified as a Social Worker in 1986 and is registered with the Health and Care Professions Council.  4. Family Composition  Child D      Date of birth: 2014    Date of Death: April 2015 Sibling - DD      Date of birth: 2014   Sibling – LD Date of birth: 2013 Mother            Date of birth: 1992 Father             Date of birth: 1989  5. Ethnicity, Culture and Identity  5.1 Mother and father were both born and brought up in Lithuania, a European country which is a member of the European Union. They moved to this country as adults and had three children together whilst living in England.   5.2 Father spoke Lithuanian and a little Russian when he moved to England. His English has improved whilst living in the country and whilst an interpreter was present during the Lead Reviewer’s meeting with him, he demonstrated a good grasp of the language.  5.3 Father stated that he is not very religious. He is Roman Catholic but had not been baptised and did not practice his faith. Child D was baptised shortly before their death.  5.4 Lithuania became a member of the European Union in 2008 and both parents were able to come and work in England legally.   5  5.5 Authorities in Lithuania, the parents’ country of origin, were informed of Child D’s death and care proceedings for the two surviving children, and reported that they ‘were watching things closely’.  6. Family Background  6.1 Neither mother nor father had been known as children to Children’s Services in Lithuania. They grew up in villages close to each other. Father described a happy childhood in Lithuania. Father’s father had been an alcoholic and his mother had separated from him. Father is physically healthy; he fell from a tree and broke ribs, bones in his hand and nose in an accident before he was five years old, but made a full recovery. He stated the he and mother did not have any problems with alcohol or substance misuse and there was no domestic abuse in their relationship.  6.2 Father had worked restoring old cars in Lithuania.  6.3 Mother moved to England in 2010 when her aunt offered her work. Her aunt’s partner was also looking for someone reliable to work for him and father joined mother.   6.4 Father and mother briefly separated in England during their first year here. Father returned to Lithuania for Christmas. Mother’s brother continued to live with father and he and mother remained in contact and eventually father and mother decided to resume their relationship.   6.5 The couple both wanted children; LD was a planned pregnancy. The twins were not planned but father described the couple as being happy about the pregnancy.  6.6 The couple were reliant upon their earnings from low paid jobs and at times it is understood that they supplemented their income by taking on additional work. Mother bought and re-sold cosmetic items through Ebay and father repaired computers and cars. Father told the Lead Reviewer that mother sent money back to her family in Lithuania each month which increased the couple’s financial pressures.   6.7 Both parents had brothers living in England and there were other relatives in Birmingham. Father’s mother had been invited to live with the family in Birmingham but she missed Lithuania and returned before the birth of the twins. Father told the Lead Reviewer that he and mother both had friends in Birmingham.   7. Parental and Extended Family Involvement  7.1 Birmingham Safeguarding Children Board invited Child D’s parents to meet the Independent Lead Reviewer to contribute their views to this Review. Father agreed to meet and his views are included. Mother chose not to take part in the review.   6   8. Criminal and Care Proceedings  8.1 A police investigation took place following Child D’s death. Father was charged with murder and causing injuries to the children. Mother was charged with allowing the death of a child.  8.2 A criminal trial began on 12th January 2015 and concluded on 22nd February 2016 when Child D’s father was convicted of murder and all charges against the mother were dropped.  8.3    A Finding of Fact Hearing had taken place on 10th December 2015 as part of the care proceedings for Child D’s surviving siblings and the Judge found that the father was responsible for the death of Child D and for the injuries to DD and LD.   9. The Birmingham Context  Census Information  9.1 The 2011 census reported that:   1.073 million people lived in Birmingham. The city has a young population with 66% aged under 44 and 19% within the 20-29 years’ age group   Birmingham is the ninth most deprived of the 354 Local Authorities in England.    Birmingham is the most ethnically diverse city in the United Kingdom. In its 2015-16 annual report, Birmingham Safeguarding Children Board references academic research that found people from over 200 countries have made their home in the city. Over 60% of the population under 18 years of age is from a non-white British background (2011 census). Some 7.5% of households do not have English as their main language. Ofsted noted in their 2016 inspection report that 22.2% (238,300) of Birmingham residents were born outside the UK.   9.2 The document, An Overview of the Joint Strategic Needs Assessment for Birmingham 2012, organises information around the six Marston Review policy areas of which the first is ‘Give Every Child the best start in life’. The subsection ‘Starting well: conception and childhood’ provides the following information:   Birmingham has high rates of perinatal and infant mortality. The infant mortality rate is 7.7 per 1,000 live births, compared to the England average of 4.7. Rates are significantly higher in ethnic minority groups.    7   10% of babies born in Birmingham weigh less than 2.5kg compared to 7.5% in England. Low birth weight is as high as 29% in some areas of the city.    Breast feeding initiation in Birmingham is low at 68.1% compared to 74.6% nationally.    Immunisation rates vary across the city. Rates of Measles, Mumps and Rubella vaccination are lower in the south Birmingham area compared to the rest of the city.   9.3 The Joint Strategic Needs Assessment (JSNA) also highlights the following information about worklessness in the city:   The worklessness rate is 18.5% – higher than a year earlier (18.0%). It is higher compared to the West Midlands (13.7%) and England (11.9%).    Of the eight core cities, Birmingham’s worklessness rate is the second highest, and it is nearly two-thirds higher than the England rate. Worklessness is highest in the wards with the highest deprivation rate (IMD).   Birmingham City Hospital Neonatal Unit  9.4 This ward has 29 beds; 5 intensive care beds, 5 high dependency unit beds and 19 special care beds. The unit has a high admission rate and is regularly at capacity.   9.5 Two Paediatricians were involved in running the unit at the time covered by this Review. At least 35 Nurses,17 Doctors and 3 Advanced Neo-Natal Nurse Practitioners were involved in the care of the twins whilst they were in the unit.  9.6 There are different levels of care within the NHS which reflect the level of care provided and the needs of babies which are met:   Level 1 Special Care Baby Unit (SCBU) is for babies who need continuous monitoring of their breathing or heart rate, additional oxygen tube feeding, phototherapy recovery (to treat neonatal jaundice) and convalescence from other care.   Level 2 Local Neonatal Unit (LNU) is for babies needing short-term intensive care with apnoeic attacks who require support, including receiving continuous positive airway pressure (CPAP). Some babies receiving parenteral nutrition (tube feeding) may also need this level of care.   Level 3 Neonatal Intensive Care Unit (NICU) is for babies needing respiratory support (ventilation) weighing less than 1,000g, born at less than 28 weeks’ gestation and needing significant CPAP support  8  (continuous positive airway pressure). Babies with severe respiratory disease who also require surgery may need this level of care too.   Transitional Care: where babies who still have some needs but are almost ready to go home. Parents become the main carers with support from a Nursery Nurse or other staff on the unit.  9.7 The City Hospital Neonatal Unit is a high functioning level 2 unit which is regularly undertaking level 3 work and caring for babies born at 27 weeks onwards.  9.8 There are four family overnight stay rooms attached to the unit (two of which can accommodate siblings).   9.9 There is a Discharge Planning Nurse within the Unit staff team. Unfortunately, this member of staff was off sick during the period that the twins were in the hospital. The Unit is a member of the Southern West Midlands Maternity and Newborn Network. The vision of the Network is to oversee that the hospitals in the network provide high quality care for the right mother and right baby in the right place as close as possible to home.   9.10 Prior to discharge, staff talk to parents about safe handling and safe care. Information is also provided about basic life support (resuscitation).  9.11 A Care Quality Commission inspection published in March 2015 judged Birmingham City Hospital to be requiring improvement overall and found maternity and gynaecological services to be good.   Birmingham Children’s Hospital Neonatal Surgical Ward  9.12 The Ward comprises of 16 cots including four cots for babies requiring high dependency care and admits children between the ages of 0 and 6 months old. The main reason for admission is either emergency or elective surgery and babies can be transferred back to their original hospital or discharged home. It provides level one (special care) and two (higher dependency care required) care to babies requiring surgery. If level three care (ventilation support) is required, babies are transferred to the Paediatric Intensive Care Unit (PICU).   9.13  There are 12 surgical consultants linked to the ward which also has a Ward Manager, 28 nurses, 6 healthcare assistants and an outreach nurse.  9.14  Parents are encouraged to stay with their baby and participate in their care. Interpreters are used when necessary. The GP, Health Visitor and Community Midwife are routinely informed of admission and at time of discharge. A Family Common Assessment Framework is routinely completed after 21 days and again 60 days post admission. However, DD only spent 10 days on the ward.  9.15  The Neonatal Surgical Ward staff are required to attend Level 3 in – house Child Protection Training and have access to the Trust Safeguarding Team  9  including a CAF Lead. The Trust training compliance is at 91.9% although it is slightly lower on the ward. The ward has been involved in nearly 50 child protection cases between 2012 and December 2016.  9.16  The Care Quality Commission inspected Birmingham Children’s Hospital in 2016 and judged that the Hospital was ‘outstanding’ and that its Neonatal Services ‘requires improvement’. It highlighted the need for better recognition and review of serious incidents on the ward, improved performance information and work to ensure that nurse staffing levels meet national standards.   The Role of Children’s Centres with babies  9.17  In the period under review, children’s centre staff routinely visited parents following a birth as part of early help arrangements to make them aware of support and services available. This service is currently under review; the early information to centres about new births and the co-location with services are examples of very good practice. However, recognition of the potential duplication in centre workers making home visits given the role of Health Visitors is being considered in this review.  10. Summary of Key Events   Date  Event  2010 Mother moved to England to work and was later joined by father.  2012  5 July Mother registered with a GP and had a new patient appointment; Mother was 19 years old, her pregnancy was confirmed and an antenatal referral was made. Her low BMI indicated that she was slim, possibly underweight.  20 July Mother attended A&E at Worcestershire Royal Hospital. Father recalled that she may have fainted at work, reported lower abdominal pain and was 12 weeks pregnant.   25 July Mother was registered with a local Children’s Centre.  July  Mother began to attend antenatal services at S Children’s Centre.  2013  19 January   LD was born by emergency caesarean section at full term (39 weeks’ gestation) at City Hospital.  21 January Mother discharged herself from hospital against medical advice.  1 February Mother attended GP for a measles, mumps and rubella immunisation  10  for herself.  5 February LD was readmitted to hospital because they had not regained their birth weight.  22 February A new birth home visit to see LD took place.  13 March A male caller requested an ambulance stating that his one-month  baby could not breathe. Father has confirmed that he made this call when LD was choking and he panicked. He became frustrated at the routine questions being asked and put the phone down. When called back, he confirmed that he no longer needed an ambulance.  24 April  LD received first immunisation and first child health examination at 13 weeks. No concerns recorded.   June Father’s mother visited from Lithuania and spent 2 weeks with LD.  16 August Mother was seen by her GP; she was pregnant but she later suffered a miscarriage. As she appears not to have sought medical help it is not known how many weeks pregnant she was when the pregnancy ended.  2014  26 January West Midlands Police received a call about a drunken man smashing the house up. Officers attended. Father recalled that a drunken neighbour had joined a small party and had kicked father in the face and father asked mother to call the Police. Father stated that the Police took the neighbour home, but this is not indicated in the Police record.  11 February Mother attended GP with some vague symptoms/health concerns. Bloods taken. GP gave mother reassurances.  June Father’s mother visited again from Lithuania and stayed for 2 months. Father has explained that the plan had been for his mother to live in the small room in the house permanently but she did not settle in Birmingham and decided to return to live in Lithuania.  9 June  Mother attended GP surgery, GP noted pregnancy and referred her to Midwifery services.  14 June  Mother attended pregnancy booking appointment and marker placed on record that mother described difficulties understanding English and requiring an interpreter.  22 July Mother attended A&E due to bleeding and mother’s pregnancy with twins confirmed.  11   23 July  GP made telephone call, uncle spoken to uncle and requested that LD attend for a 13 month assessment (which was completed on 28 July.  14 November DD and Child D were born significantly premature at 28.5 weeks of gestation at City Hospital.  14 or 15 November Mother discharged herself from hospital. The children remained in hospital until January 2015.  19 November The allocated Health Visitor received reference ecards for the twins for a new birth home visit but it was noted that the babies remained in hospital.  28 November The Health Visitor made a home visit and was informed that the twins were still in hospital.  3 December Child D was moved from the special care unit to a side room due to developing a bacterial infection.  15 December The Health Visitor made a telephone call to the City Hospital Neonatal Unit for an update. She was informed that Child D was doing well but DD was poorly with an infection. She also learned about the hospital’s concerns about a lack of visiting; for example, parents had not visited since 12th December.  15 December The Health Visitor made a home visit.  2015  2 January A Sister from the Neonatal Unit at City Hospital telephoned the Health Visiting Team.  7 January  Child D was discharged home and DD remained in hospital.  11 January   DD was transferred to Birmingham Children’s Hospital Surgical Neonatal Unit because of failure to tolerate feeds and development of a distended abdomen. A colonic stricture (an abnormal narrowing of the colon – in this case in the large bowel) which required surgery was diagnosed.  January DD had a laparotomy which is a major surgical procedure that involves a cut being made in the abdominal wall to allow a surgeon access to the contents of the abdomen in order to identify and repair any emergency problems that have occurred. DD had required a bowel resection which left only 20cm of bowel.  14 January A Health Visitor undertook a new birth home visit following Child D’s  12  discharge home. Child D’s weight was on the 2nd centile (9 - 25th centile adjusted for prematurity).  21 January  DD was discharged home. The Neonatal Unit at Birmingham Children’s Hospital telephoned the Health Visitor to make her aware. The impact of DD’s surgery meant that stools would be passed every two hours and need a special milk feed. DD’s weight would require regular checks.  22 January  Parents did not bring DD to an Ophthalmology appointment. Worker(s) from a Children’s Centre visited the family at home and updated the family registration to include the birth of the twins.  23 January The Health Visitor made a new birth home visit following DD’s discharge home. The Health Visitor weighed DD and observed that mother seemed to have a good relationship with the baby and was coping with DD’s needs. The assessment took place in the bedroom the family used and mother was encouraged to register Child D with the GP as this had still not taken place. The Health Visitor accurately recorded that mother had had a traumatic birth, a long separation and parental concerns for the wellbeing of the babies. Mother was described as well and positive.  28 January Child D was taken to an Ophthalmology appointment and discharged.  30 January The Health Visitor saw Child D and DD at home with their mother and an aunt present.  Child D had gained weight but DD’s weight remained static. The Health Visitor discussed DD with surgical ward staff and was advised to ask the parents to bring DD to hospital the following Monday for review.  2 February  The twins were registered with a GP. Also, DD was taken to Birmingham Children’s Hospital (BCH) due to weight and lower respiratory tract infection.  6 February The twins were registered with the family GP and DD was taken to BCH Children’s Eye Hospital Eye Clinic Department. A Nursery Nurse made a home visit but there was no reply.    20 February  A Nursery Nurse weighed the twins at home and advised to contact the GP re a lump in DD’s groin.  24 February  The Twins attended for respiratory problems. DD again attended BCH Emergency Department because due to an enlarged testicle, the child was not passing urine and a hernia was diagnosed.  11 March The Health Visitor records attending a Team Around the Family (TAF) Panel and discussed the family’s housing issues. Early  13  support confirmed that they could potentially provide support to the family. Police representative also suggested that the Health Visitor should contact NASDOM which is a multi-lingual advice centre aimed for communities who do not speak or have very poor English language skills to offer help and advice as needed. Children’s Social Care/Early Help have reported back that the family were not on the agenda and there was no formal discussion of the family at the TAF meeting on this date.  23 March The Health Visitor spoke to father during a home visit as mother was reported to be out shopping. Child D had gained weight steadily and DD had also gained weight.  The Health Visitor discussed the potential benefits of a Family Common Assessment Form (fCAF) and father stated that he would discuss this proposal with his wife.  30 March Mother began a new job working nightshifts which she had found through a friend. Father had the care of the children.  1 April An ambulance was called to the family home at 00.45. On arrival Child D was unresponsive and suffered a cardiac arrest. Child D had bleeding in the lungs due to severe blood clotting problems. A CT scan showed a devastating injury, brain swelling and bleeding within the brain. Child D showed no signs of life; Child D was removed from the ventilator in the afternoon and died peacefully in parents’ arms.  DD had a child protection medical on the same day and there were no obvious signs of any inflicted injury.   2 April LD had a child protection medical by a Community Paediatrician which like DD showed no outward signs of concerns.   7 April  DD had a planned admission for completion of the child protection medical assessment. The CT head scan results were normal. Skeletal survey results showed multiple fractures: Bilateral rib fractures, bilateral fractures of the distal femoral (thighbone) metaphysis and proximal tibial (shinbone) metaphysis and distal tibial metaphysis. The radiologist reported that the appearances of rib fractures suggested that they were of different ages.   Note:  The metaphysis is the wide portion of a long bone which contains the growth plate, the part of the bone that grows during childhood.  The epiphysis is the rounded end of a long bone, at its joint with adjacent bone(s).   The diaphysis is the shaft or central part of a long bone.   1. Distal means situated away from the centre of the body or from the point of attachment and Proximal means situated nearer to the  14  centre of the body or the point of attachment.  9 April Police informed Children’s Social Care that they had discovered photographs showing facial injuries to LD when reviewing the contents of parents’ mobile phones. Children’s Social Care successfully applied for Interim Care Orders to safeguard both surviving siblings. Father and mother insisted that LD had fallen whilst out shopping with mother and this was the cause of the injuries observed in pictures on a mobile telephone.   11. Analysis   Good Practice  11.1 This review has identified a number of examples of good practice:   The Midwife asked screening questions about domestic abuse at ante-natal appointments.   The general quality of health visiting recording; this included a comprehensive GP liaison form written by the Health Visitor to share with the GP the issues she had identified with the family and the action she had taken to meet their needs at the beginning of March 2015   The Health Visitor checked and fed back to the family regarding hospital appointments, medical advice and prescriptions for the specialist milk and sought support for their housing situation.   There was written and verbal transfer and discharge information communicated by hospital staff in writing and verbally to the Health Visitor when the discharges from the Neonatal Unit took place.   The Health Visitor explained the Family Common Assessment Framework (fCAF) process to mother and father and encouraged them to agree to completion of an fCAF.    The Eye Clinician recognised the risk of non-attendance at screenings for Retinopathy of Prematurity (an eye disorder affecting premature babies – see below for further information) and was proactive in completing the first review before DD’s discharge.    There was a thorough medical examination of DD at the Children’s Hospital Emergency Department on 2 February 2015.   Key Issues   15  11.2 The review has also highlighted a number of areas of practice which would benefit from further consideration and learning and action to make arrangements and professional practice more robust.  The vulnerability of babies, the particular challenges of parenting premature children and twins and the significance of neonatal care  11.3 During the first post discharge home visit to Child D on 14th January 2015, the Health Visitor recorded that mother had experienced a traumatic birth experience, a long separation and parental concerns for the babies’ welfare and recognises that this can impact on maternal emotional wellbeing.   11.4 DD was transferred from City Hospital to Birmingham Children’s Hospital on 11 January 2015. DD was discharged from hospital on 21st January at 10 weeks old. In addition to prematurity and being a twin, DD the sibling twin had significant bowel surgery prior to discharge and then needed a strict regime of two hourly feeds and weekly weight reviews. DD’s skin was vulnerable due to frequent stools and required additional attention to skin care routine and weekly assessment. DD also had a hernia which caused pain. DD was slow to gain weight.  11.5 DD attended the Accident and Emergency Department with respiratory problems on 2nd February 2015 and again on 24th February due to concerns about the ability to pass urine. At the second attendance, a consultant identified that DD had an inguinal hernia (a lump or swelling in the groin) as well as an umbilical hernia (a painless lump in or near the belly button).   11.6 Both Child D and DD required assessment for Retinopathy of Prematurity (ROP) which is an eye disorder affecting premature babies. It affects the immature blood vessels of the retina and occurs weeks after birth. Complications can lead to vision problems or blindness if left untreated and therefore babies need to be reviewed regularly so that problems can be identified and treated early if necessary. DD was confirmed to have stage 2 ROP on 21 January 2015. (Stage 1 is mild and Stage 5 is severe).  11.7 A number of the national reviews of Serious Case Reviews have highlighted the vulnerability of babies aged under one-year-old and that the potential risk to children is increased by prematurity and multiple births. The authors of the Triennial Review of Serious Case Reviews 2011-2014 published in 2016 note that ‘We know from our past biennial reviews that the very young are particularly vulnerable, and that premature babies, babies with a low birth weight and/or requiring initial (or in some cases lengthy) special care baby unit nursing, and babies born with neonatal abstinence syndrome potentially pose challenges to their parent(s) over and above the considerable demands of any new-born infant.’   11.8 The Biennial Review of Serious Case Reviews 2005 - 07 published in 2009 included seven sets of twins (4%), double the small number (2%) in the 2003-05 study. This was higher than the national average of 1.5% of all deliveries (NHS maternity statistics England 2005-6). The 2005-07 review noted that:  16   ‘The extra demands made by multiple births are known to place increasing pressure on parents - particularly when the babies are premature or more difficult to feed or care for.’  ‘Babies born prematurely with low birth weight are harder to look after, more difficult to feed and may cry more. This may in turn prompt angry reactions from a parent,’  ‘A baby’s stay in the hospital special care baby unit can inhibit the bonding process’.  ‘These early disadvantages can have lasting consequences and prematurity and low birth weight can be markers for difficulties throughout the life course’.  11.9 In the 2011 report Ages of Concern: Learning from Serious Case Reviews, Ofsted also highlighted the ‘fragility of babies’ and the potential for practitioners to underestimate this fragility and also the risks resulting from parents’ own needs given this vulnerability. 35% of the 602 children subject of the 471 Serious Case Reviews between 2007 – 11 evaluated by Ofsted were babies under the age of one-year-old. In the Triennial Review of Serious Case Reviews, 73% of the 48 children who died from fatal physical abuse were aged under 2 years old.  11.10 Working Together guidance (2013, 2015 and the 2017 update) includes an expectation that Local Safeguarding Children Boards should ensure that training should cover how to identify and respond early to the needs of all vulnerable children, including unborn children and babies. It is important that these risk factors are clearly highlighted in both Early Help and Child Protection training, procedures and guidance within hospitals and in the wider multi-agency documents.  11.11 Birmingham Safeguarding Children Board supported a ‘Never Shake a Baby’ campaign in April 2012 which involved the distribution of an information leaflet in community healthcare settings across the city. In 2016 the Board launched the ‘Keep me safe while I sleep’ Safer Sleeping Campaign designed to promote safe sleep arrangements and the steps parents and carers can take to reduce the risks. Health Visitors issue resource packs at the 28-week antenatal visit and discuss the information at the first post-natal home birth visit.   11.12 There were significant issues in respect of both the Child D and DD around feeding, frequency of parental contact, and parent-child attachment.   Breastfeeding.  11.13 The reviewer for the Sandwell and West Birmingham Hospitals NHS Trust has raised questions about the level of advice given to mother at Birmingham City Hospital about breastfeeding. The discharge summary for LD and mother  17  indicated that mother was not observed to breastfeed well. This may have been the reason for LD’s poor weight gain.   11.14 When there was a discussion about the use of the breast pump and sterilising equipment on 16 November 2014, it is not clear whether this included advice about attending a breastfeeding support group and where and how to store expressed milk.   11.15 On 29th November a Neonatal Nurse made mother aware that there was not enough expressed milk for the twins and an alternative may have to be given. There is no record of any discussion about how she was expressing milk or her dietary intake which would affect her production of milk.   11.16 Mother visited the babies twice on the evening of 29th November 2014. She stated that she was struggling to express milk for both twins and received advice. A plan to refer to the Infant Feeding Team was recorded but the referral was not made. Mother was given an expression log with a plan to review on 3 December 2014. The log was never reviewed and no further support was recorded.   11.17 During a hospital visit on 19th December, mother informed staff that her breast milk had finished and that she planned to return the borrowed breast pump to the unit.  Attachment  11.18 When mother visited on 3rd December 2014, this was the first recorded visit for four days. Mother stated that she did not wish to hold the baby because she felt like she had a cold. During a short visit (10 minutes) on 20 December, mother again stated that she did not want to touch the babies stating that she had a sore throat. There was no record of any discussion about her reluctance to hold her babies on either occasion.  11.19 Nurses recorded positive interaction between mother and Child D on the ward on a number of occasions. These notes needed to be considered in the context of limited and irregular visiting.  Parental visiting in hospital and communication with hospital staff  11.20 There is an early entry in the hospital records that the parents ‘would appear not to want to be in hospital’.   11.21 The family are recorded as not having a car and relying on public transport. The twins were born during winter and spent nearly two months in hospital. The family home was approximately 6 miles from the City Hospital Unit.  11.22 During a home visit on 16 November, mother informed a Midwife that she was visiting the babies daily. This information was inaccurate. This was the only home visit by the Midwifery Service because the babies spent so much time in hospital.   18   11.23 The records indicate that mother and father did not visit the twins on at least 21 days between mid-November and 2 January 2015: 21/11/14, 25/11/14, 27/11/14, 30/11/14 (Sunday) – 02/12/14, 04/12/14, 05/12/14, 07/12/14 (Sunday), 09/12/14, 11/12/14, 13/12/14 (Saturday), 14/12/14 (Sunday), 17/12/14, 18/12/14, 21/12/14, 22/12/14 (Sunday), 25/12/14, 26/12/14, and 02/01/15.  11.24 Mother visited on 30 November and interacted well with the babies and took photographs. Father has told the Lead Reviewer that he kept in touch with the babies’ progress through photographs.  11.25 When mother visited on 3rd December 2014, there is no record of staff enquiring as to why father was not visiting or why mother was visiting so infrequently.   11.26 On 8th December mother visited the twins with LD; this is a rare reference to their older sibling whose presence was accepted as a reason for keeping the visit brief.  11.27 When the Health Visitor learned through a telephone call to the Neonatal Unit on 18th December that parents had not visited for 3 days and previous visiting was limited, she visited the family home to discuss the hospital’s concerns. Mother told the Health Visitor that she could not visit because LD had been unwell.   11.28 A Nurse expressed concern to mother about her level of visiting on 27th December and mother stated that she was unable to visit due to LD. Mother planned to leave the ward but was encouraged to provide care and feeds and eventually stayed over an hour. This demonstrates that when there was challenge and encouragement, a positive outcome for the twins was achieved and perhaps could have been achieved on other occasions.  11.29 On 29 December 2014, a Neonatal Nurse attempted to contact the Health Visitor regarding the lack of visits and a statement by mother that she did not have the funds available to travel.   11.30 A Nurse gave a Unit booklet to mother with its telephone number on 27 December and mother called the Unit on 30 December 2014 when a Nurse advised her that the babies were stable and also enquired about when she would next visit.   11.31 Both parents visited the babies on 31 December and it was noted that father fed Child D.  11.32 On 2 January 2015 a Sister from the Neonatal Unit telephoned the Health Visiting Team who returned the call. The Sister shared her understanding that mother was struggling to see the twins on the Unit because she was caring for her older child.   19  11.33 An Advanced Neonatal Nurse Practitioner recorded on 15th December that ‘on discussion with the Health Visitor I have not referred the babies to Social Services today but will give the mother another couple of days to demonstrate appropriate visiting’. Then on 16th December a Doctor states that mother is to be referred to Social Services if no visits or infrequent visits observed or continues. Any referral would be for the twins and the Sandwell and West Birmingham Hospital Trust reviewer has appropriately noted that there should have been further conversation with mother, the Health Visitor and consultation with Midwifery Services about any previous concerns.  11.34 The planning process and recording in the City Hospital Neonatal unit in 2015 did not ensure that actions which were not completed were rolled on to the next care or action plan. The concern about the level of visiting to the twins should have been referred to the Safeguarding Lead in the hospital and could usefully have been discussed in more detail with both parents. If this had not led to improved contact, a referral to Children’s Services could have been considered.  11.35 This situation raises important questions about the support offered to parents whose children have to spend time in the Neonatal Unit and the threshold where concerns about poor levels of parental visiting should lead to action, potentially including a referral to Children’s Services.   11.36 DD transferred from City Hospital Neonatal Unit to Birmingham Children’s Hospital Neonatal Surgical Ward on 11th January 2015 and during this admission mother visited on seven of the eleven days DD spent on the Surgical Ward but very briefly. One visit lasted for 10 minutes. Father did not visit and neither parent telephoned the unit during DD’s admission. On 12th January mother had stated that she had to look after Child D and LD.    11.37 Birmingham Children’s Hospital summary of involvement for this Review noted that staff in the Neonatal Surgical Ward did not explore the fact that father did not visit or raise the lack of visits with the GP or Health Visitor. If this issue had been recognised, staff could have discussed it with parents and contacted the Trust CAF lead for support and advice. The Lead Reviewer acknowledges that DD had a relatively short stay on the Unit.   11.38 The Biennial Review of Serious Case Reviews 2005 – 07 included an example of one case ‘where a baby was in the neo-natal unit for some weeks, family members were only able to visit infrequently and most days “staff noted that there were no enquiries or visits from the family” and expressed their concerns’. Distance from the hospital, lack of finance and lack of child care arrangements contributed to this situation and a difficult early environment for the baby.’ There appear to be some similarities with the circumstances of the family but it is important that staff explore these practical issues for each individual family. They may be common issues for families but cause and effect should not be assumed.  11.39 In interview after Child D’s death, mother told the Police that she sometimes borrowed money from her aunt and from her brother’s partner for bus fares to  20  visit. Staff from the City Hospital Unit informed the Lead Reviewer at a learning event that there are strict criteria for parents to qualify for financial assistance from the hospital.    Quality and depth of assessment in providing universal and early intervention services  11.40 It appears that no professional involved with Child D or DD clearly understood the family’s circumstances. This case highlights the importance of careful consideration of the level of support to new parents within the wider family and environment in all assessments (early help, child in need family support or child protection). This can usefully include a genogram.  11.41 Mother attended antenatal services at S Children’s Centre where she registered with father. Father recalled that they attended antenatal classes together. Mother attended S Children’s Centre again when pregnant with the twins.  11.42 The family made alterations to their rented property to allow multiple occupancy. A couple with a two-year old child lived in the property for a period when LD was born but before the birth of the twins. The sub-tenant provided some support in caring for LD. Records do not indicate that this was understood by Health professionals involved with the family.   11.43 There is a section in the form for the Neonatal Unit weekly review to record parental communication and safeguarding issues. The Lead Reviewer agrees with the reviewer for Sandwell and West Birmingham Hospital Trust correctly that the fact that these were left blank (on 22nd December 2014) demonstrates a focus on medical issues rather than holistic assessment.   Communication between hospital and community health professionals and Discharge planning  11.44 Ofsted advised LSCBs to ‘scrutinise local systems for transfer of cases between the Midwifery Service, the Health Visiting Service and GPs in its 2011 Ages of Concern report.  11.45 On 19th November 2014 the twins were allocated to a Health Visitor for a new birth visit. The record noted that the babies were still in hospital. The Health Visitor made an introductory home visit on 28th November and met mother.   11.46 The Health Visitor and the Neonatal Unit discussed the lack of parental visits in telephone conversations on 15th December 2014 and 2nd January 2015. On 15th December the Health Visitor telephoned the Unit for an update and visited mother at home to discuss the hospital’s concerns about the frequency of visiting.  11.47 There is no single child electronic patient health record in Birmingham accessible by all health professionals in the city. Staff in the Neonatal Unit can access Maternity records for mothers and children.  21   11.48 A Neonatal Nurse attempted to contact a Health Visitor on 29th December about the lack of parental visiting and parents’ statements about limited finances and left a message. A Neonatal Nurse contacted a Health Visitor on 2 January to request a home visit (in advance of discharge) and was advised that a Health Visitor would be allocated the following week. There was a telephone handover between the Neonatal Nurse and the Health Visitor on 7th January 2016 prior to Child D’s discharge from hospital.   11.49 When DD was transferred from City Hospital to Birmingham Children’s Hospital on 11th January 2015, the neonatal discharge summary letter received in the transfer did not mention any safeguarding concerns.   11.50 A key question is whether the discharge of a premature baby with associated additional health needs should have been discussed at a meeting prior to discharge.  11.51 At a medical review on 2nd January, a Doctor confirmed the plan to continue with the current care arrangements and to prepare the twins for discharge. On the same day, the Ward Sister at City Hospital Neonatal Unit telephoned the Health Visitor and expressed concerns about parents not visiting. The Ward Sister also informed the Health Visitor that discharge planning had started.   11.52 There was communication between the Unit and a duty Health Visitor and the mother’s GP by telephone on 7th January about discharge. The GP refused to give Nutri-prem 2 formula milk (food for the dietary management of the additional nutritional needs of preterm and low birthweight infants post discharge) for at least a week as they could not register the baby until then. A Midwife confirmed Child D’s discharge in telephone calls to the GP and Health Visitor via her administrative staff the following day.   11.53 There is no hospital record outlining what time on 7th January 2015 Child D went home and who with, or what information parents were given regarding Child D’s care.  11.54 A discharge planning meeting involving hospital and community health professionals could have usefully clarified the knowledge of the family’s circumstances at that time and also ensured that planning was proactive and not reactive. A timetable of outpatient appointments and home visits could have been agreed with the family and avoided any clashes.   11.55 On 21st January 2015 a Nurse from the Children’s Hospital Neonatal Surgical Ward telephoned the Health Visitor to make them aware that DD had been discharged and to request that they monitor DD’s weight weekly. It is not clear what discussion took place, if any, about the impact of DD’s return to the family would be and parents’ capacity to cope.  11.56 When DD was discharged on 21st January, the Consultant had asked for a follow up in clinic in 4-6 weeks and also at the Neonatal Unit at City Hospital.  22  There was no appointment made for a review at the Children’s Hospital and the Trust has not identified the reason for this oversight.    11.57 The Orthoptist made telephone calls to the GP and Health Visitor on 2nd April 2015 to follow up DD’s non-attendance at orthoptist appointments. It had been identified in discussion at the TAF Panel that Children’s Centre could support attendance at orthoptist appointments and it would have been more useful to have addressed this issue and also the prescription of specialist milk for Child D at a planning meeting prior to discharge.    Consideration of all the children in a family  11.58 LD, the couple’s first child, had been readmitted to hospital briefly on 5th February 2013 due to failing to regain birth weight. LD had not been observed to breast feed well which may have been a reason for poor weight gain. Parents had been anxious to leave hospital and LD was discharged with an appointment to re-attend in two days for a weight check. There is no record that LD was taken to this planned appointment.  11.59 There were delays in LD receiving routine assessments and immunisations. LD received the 13 month immunisations five months late.  11.60 LD was one year and ten months old when the twins were born. There is no record of the care arrangements for LD whilst the mother was in hospital and father was visiting. Father told the Lead Reviewer that he and mother felt that the unit was not an appropriate place to take LD due to the lighting, number of wires and sensitive equipment.   11.61 In relation to LD, the Birmingham Community Healthcare Trust summary noted ‘minimal indication or voice of the 22 month old in the records and no additional record or reassessment was made of the child’s needs in view of the issues identified in care and assessment plans’.  11.62 LD’s own needs and the potential impact on the child’s care of the arrival of twins with additional needs required consideration by health professionals. Sidebotham et al (2016) state that ‘Hearing the voice of the child’ requires safe and trusting environments for children to be seen individually, speak freely, and be listened to. This is particularly important when children display early signs of neglect or emotional abuse, but are unable to express their concerns. In a case involving a six month old, premature baby……. engaging with the older sibling may have led to a better understanding of the family context’. The difficulty in feeding LD, the parents’ pattern of not visiting or wishing to avoid hospital and also not bringing LD to appointments were early indicators of issues which arose again with the twins.  Non- attendance at health appointments  11.63 Staff responded to poor attendance by parents at appointments. It is positive that the Hospital’s policy and practice highlight that the child ‘was not brought’, an approach which the recent Triennial Review noted ‘can help maintain a  23  focus on the child’s ongoing vulnerability and dependence, and the carers’ responsibilities to prioritise the child’s needs’.  11.64 Child D was not taken to an ophthalmology appointment on 22nd January, the day after DD was discharged, and DD then missed an ophthalmology appointment on 30th January. By 31st March 2015, DD had missed four orthoptist appointments. The Orthoptist made telephone calls to the GP and Health Visitor on 2nd April 2015 to follow this up. Letters were sent to the family home about appointments but the ability of the parents to read English appears not to have been assessed.   11.65 Child D was not taken to a hospital baby clinic appointment on 3rd March 2015. LD was not brought to a GP appointment on 23rd February but it is not recorded what the appointment was for.   11.65 The Health Visitor has recorded that during the discussion about the family at the TAF Panel on 11th March that Early Support could assist with retinopathy of prematurity; presumably this meant help with attendance at appointments. As highlighted earlier, it is unfortunate that this discussion had not taken place at a discharge planning meeting in January.  Threshold for escalation of cases including Referral to Children’s Social Care  11.66 Hospital staff recorded consideration of a referral to Children’s Services on two occasions. The Lead Reviewer agrees with the opinion of the reviewer for the Sandwell and West Birmingham Hospital Trust that it is not clear that the threshold for referral to Children’s Social Care had been met. However, there should have been consultation with the Trust’s Safeguarding Lead to highlight and consider how to respond to the concerns about a lack of parental visiting to the twins. There should have been closer pro-active planning between hospital and community staff and this would have been assisted by discharge planning meetings prior to the discharge of each twin back to the care of their parents in the community.   Working with Diversity  11.67 Birmingham is a ‘super diverse’ city in which services are having to adapt to meet the needs of families from a considerable number of countries who speak a wide range of languages. The number of people/adults who have moved to Birmingham from those countries which joined the European Union in 2008 including the number of adults from Lithuania have increased yearly up to 2013.   Providing information to parents and interpreting and translation services  11.68 In the 2011 Ages of Concern report, Ofsted recommended that LSCBs ‘check on the quality, availability and relevance of materials and educational programmes which support the development of parenting skills, especially for teenage and young parents’. This Review has highlighted the importance of  24  interpreting and translation services for parents whose first language is not English to ensure good communication and informed consent.  11.69 Father describes learning to speak English whilst he was living in Birmingham. When father called an ambulance in March 2013 because he was concerned about LD’s breathing, there was a language barrier and the call handler had to ask questions multiple times. The father was frustrated and it is recorded that he was aggressive.   11.70 When father called emergency services on 1st April 2015 he requested the use of Language Line (a professional interpreting service which can provide translation services twenty-four hours a day; an operator requests the language required by the caller and facilitate a three-way conference call with the caller providing information through the interpreter). However, the call handler was unable to obtain an interpreter who spoke Lithuanian.   11.71 There was an inconsistent approach across Health Services to providing interpreters and establishing the parents’ level of verbal comprehension before and after the children’s births:   The initial ante-natal information mentions the need for interpreters but there is no record that they were used in hospital.   There is no reference to mother’s understanding of English or her communication needs when she attended a new patient appointment at the GP practice in July 2012 which confirmed her pregnancy.   On 14th June 2014 mother told the Midwife at her pregnancy appointment that she had difficulty understanding English and required an interpreter and a marker to that effect was added to her maternity record.   When the twins were born at City Hospital on 14th November 2014, the Doctor noted that parents’ English was reasonable but an interpreter should have been used to explain complex information about Child D’s health condition and treatment.    Nurses also gave mother information in English about breastfeeding and the need to obtain a steriliser.     On 19th November 2014, hospital staff talked to parents about consent to participate in SIFT, a controlled trial of two speeds of daily increment of milk feeding in very preterm or very low weight infants. They had been given a leaflet in English and stated that they were uncertain about whether to go ahead.    On 24th November a Doctor spoke to mother without an interpreter about Patent Ductus Arteriosus (PDA) and its treatment with medication. PDA is an extra blood vessel between a lung artery and body artery. It may  25  eventually heal by itself in the first few days of life but can remain in           pre-term babies but is moderate and can be treated.    On 28th November 2014 the Health Visitor noted during a home visit that mother may need interpreter services to understand technical information.   A Neonatal Nurse telephoned the parents on 8th December 2014 to inform them that Child D required a blood transfusion but there is no indication that Language Line was used. On a positive note, Hospital records note that before DD’s discharge, staff met mother with an interpreter to explain discharge information.    When mother visited on 17th December, she was given a Basic Life Support (resuscitation) leaflet by a nurse and an explanation of its contents although there was no interpreter. Mother stated that she would take the leaflet home as she ‘cannot read very good English’.    During a hospital visit on 27th December a Neonatal Nurse checked whether mother had the telephone number of the unit and provided mother with a Unit booklet with the number highlighted. Mother was encouraged to call for an update on the babies’ progress if she could not visit. The twins had been on the ward for over a month at this point.    On 14th January 2015 the Health Visitor recorded that she felt that mother’s understanding of basic English was good. She had not arranged an interpreter but noted that she would do so for future visits to ensure mother’s understanding and to give her more opportunity to ask questions.   Letters were sent to the family home in 2015 about appointments but the ability of the parents to read English appears not to have been assessed.  11.72 It is usual practice at Birmingham Children’s Hospital Neonatal Unit to book an interpreter in advance to explain the care plan and treatment of a patient and Language Line can be used at other times. It is recorded that an interpreter was present to assist in obtaining consent to treatment on 12th January and prior to DD’s discharge on 21st January.  11.73 Written information in Lithuanian was not provided to the parents in any of the health settings they had contact with. Father shared with the Lead Reviewer his view that providing information in the red book is a very old fashioned way of communicating with parents and he would have preferred a DVD or online video to learn about parenting and the stresses which can occur. He also suggested that it would be useful to have had more information about what parents should not do with young children and about the frustrations and agitations parents can experience.     26  Working with Fathers  11.74 Father has been found guilty of causing the fatal injuries to Child D.  Professionals had limited contact with him. Father recalled two occasions when he had contact with professionals in the community. On 15th December 2014, the Health Visitor met with father during a home visit to follow up poor parental visiting and suggested that father looked after LD to allow mother to see the twins in hospital. The Health Visitor later met father during a home visit on 23rd February 2015 and on 23rd March 2015 when he agreed to discuss the offer of an fCAF assessment further with mother. Mother told Police that father had safely cared for LD on many occasions and she did not have concerns about him caring for the children when she went to work.  11.75 Hospital records indicate that father visited the twins in hospital 6 times between November and December 2014; five times in November and then one more time on 31st December. These were always joint visits with mother.   11.76 The Health Visitor saw father during a home visit on 23rd March who informed her that mother was out shopping. Father described symptoms of colic for Child D and the Health Visitor gave him advice on winding. He agreed to discuss the potential completion of an fCAF with mother.  11.77 Mother told the Police that father had called Child D a demon because the baby cried a lot. Also, father took time off work in 2015 citing the twins as the reason. Mother had worked some of his shifts but this arrangement did not work out.  11.78 The 2011 Ofsted Ages of Concern report noted that Serious Case Reviews concerning babies ‘concluded that too often there had been insufficient focus on the father of the baby, the father’s own needs and his role in the family’ and prompted LSCBs to ‘take a strategic overview of the involvement of fathers in assessments of risk and safeguarding concerns, with a particular focus on unborn children and babies, in line with locally determined procedures’. The Triennial Review of Serious Case Reviews 2011-14 found that biological fathers were the perpetrator in 29% of the 48 fatal physical abuse cases; the actual figure is likely to be higher given that in 40% of the final reports it was not clear who the perpetrator was.  11.79 There had been limited opportunities to assess father. This Review highlights the importance of involving fathers.  Consideration of the Wider Family and Environment  11.80 The Health Visitor identified a housing pressure for this family and was proactive in trying to assist the parents in addressing this. The Ofsted Ages of Concern report highlights the special importance of suitable housing for parents of new babies. Child D died before the actions proposed at the TAF Panel in March were taken forward.    27  Recording  11.81 In 2014, a Health Visitor could not create or add to a child’s record until the child was born. This is why information about ante-natal involvement had to be added to records following the birth of the twins.  11.82 There were a number of hospital recordings only entered on one of the twin’s records when they should have been entered on both.  11.83 There was limited recording about the interaction between parents and the twins on visits and recording did not include the length of visits to the Neonatal Units. The Ages of Concern report highlights a learning point that practitioners should ‘confidently use and share the evidence from their direct observation and knowledge of parents and their babies to inform assessments of risks’. This author would also emphasise that this equally applies to the assessment of children’s needs. The Hospital Trust have highlighted one example of a detailed record by a student Midwife in December. It included observation of the interaction between mother and the twins and also included details of the care provided by mother during the visit.    Early Help  11.84 On 22nd January 2015, a worker from a Local Children’s Centre made a home visit and updated the family’s registration following the birth of the twins and completed a pre-assessment.   11.85 This Review has noted the recent development in November 2016 of the Early Help model and processes in Birmingham. This case raises questions about the level of communication and joint working between Children’s Centre workers and Health Visitors and the quality of recording at TAF Panels in 2015.   12.  Service Developments in Birmingham since April 2015  City Hospital Neonatal Unit / Sandwell and West Birmingham Hospital NHS Foundation Trust   12.1  At a Learning Event facilitated on 2nd December 2016 by the Lead Reviewer, staff and managers at the City Hospital Neonatal Unit outlined a considerable number of changes/improvements which have taken place since early 2014.  12.2  Since 2016 two Consultants provide separate/dedicated cover to the Neonatal Unit 8.30am to 5pm on weekdays and 8.30am to 2pm at weekends. They are on call and provide long-arm cover at other times.   12.3  The Neonatal Unit has recently introduced a family integrated care approach to partnership working with parents. This involves parents more closely in the care of their babies and encourages them to complete a parents’ log/journal. The model of care is underpinned by parent education and includes the  28  completion of a contract of care with parents at the outset. Training of all staff in the Unit will be completed in the coming year.  12.4 In November 2016, the Neonatal Unit introduced a new care planning document which encourages Doctors and Nursing staff to highlight and continue to include in daily plans actions which have not been achieved. This provides an opportunity to monitor progress and includes nurse led formal review dates.   12.5 In 2016, the Trust have enabled the Unit to offer free car parking and meals vouchers to mothers which addressed two considerable pressures on families with a child in a Neonatal Unit.    12.6  The Unit have recently changed documentation and practice around breastfeeding if a mother is not providing 350 millilitres by day 7.  Birmingham Children’s Hospital Eye Department  12.7  The BCH report notes that the Eye Department have improved their recording practice to include the time of any calls made and also the reason given for any failed appointments.   Birmingham Children’s Hospital Neonatal Surgical Ward  12.8  Staff complete individual care plans including discharge plans in conjunction with the parents. The nursing care plan for the neonate and the care discharge plan forms were updated in April 2016 and will be reviewed again in April 2017. The multidisciplinary discharge action list form was devised and introduced in 2015.  12.9  The roll out of the ‘Right Service, Right Time’ practice guidance across BCH continued in 2015 to increase staff awareness of the importance of early assessment of needs and risk and offer of early support including communication with community professionals and use of the Family Common Assessment Framework (fCAF) process.  Birmingham City Council and Birmingham Safeguarding Children Board  12.10  In November 2016, Birmingham have introduced new Early Help procedures and a Signs of Safety and Wellbeing model with revised documentation. As part of the new developments, Early Help Panels have replaced the Team around the Family Panels.  12.11 Ofsted re-inspected Children’s Services in Birmingham in 2016 and their report, published in November 2016, made a number of recommendations including two particularly relevant to the matters under review:   Ensure that Local Authority staff and partners, through the Local Safeguarding Children Board, understand the early help offer and are able to undertake assessments of need and offer appropriate  29  interventions at an early enough stage to prevent escalation to statutory intervention.   Strengthen assessments and plans to ensure that they fully reflect and respond to all children’s and young people’s diverse needs.   13.  Conclusions and Lessons Learned  13.1  Child D was murdered by his father. Her death could not have been predicted. Mother and father were a couple who came to England, worked hard to achieve a better life, and started a family. They were young parents living in another country where some relatives lived but they lived away from parents and other members of their extended family. They were clearly facing a challenge in parenting a one-year-old child and two premature twins, one of whom had further additional needs due to having required bowel surgery. The family lived in a privately rented multiple-occupancy house and had limited extended family support.  13.2  The National Institute for Health and Care Excellence (NICE) published guidance in 2010 setting out a model for service provision for pregnant women with complex social factors. These factors include poverty, homelessness, substance misuse, recent arrival as a migrant; asylum seeker or refugee status, difficulty in speaking or understanding English; becoming a parent aged under 20 and domestic abuse. Child D’s family had lived in Birmingham for more than two years at the time of the twins’ birth, the young parents experienced financial and housing pressures, English was not their first language.  13.3  The father has been found guilty of causing the fatal injuries to Child D and he alone is responsible for Child D’s death. He suggested to the Lead Reviewer that the pressures babies can place upon parents and carers should be emphasised further to parents in the advice and information given to them. Many Serious Case Reviews and reports have noted the particular vulnerabilities and needs of pre-term babies and babies under the age of one-year-old and the pressures they can place on parents.  13.4  Child D and DD were provided with complex specialist care and a number of lessons have been identified to strengthen assessments and planning of early help to families in these circumstances, discharge planning and communication between hospital and community services.   13.5  The Review has recognised some examples of good practice. This case highlights the expert specialist health care available on busy hospital wards which helps premature babies to survive and the complex needs such children have. It is important to recognise the pressures and high demands on staff in providing this complex care in the Neonatal Units. The Health Visitor was      pro-active in seeking help for the parents to find better accommodation. She discussed the family at the local Team around the Family Panel in March 2015 although not apparently as a formal agenda item.    30  13.6  This Review has not found that improved arrangements or practice would have prevented the death of Child D but rather there are opportunities for services to make some changes as part of their commitment to continuously developing and improving services.  13.7  Some staffing issues affected the service provided to the family but did not contribute to Child D’s death. The level of staffing in the Neonatal Unit did not meet national best practice but is reported to be improving. There was some confusion around the allocation of a Health Visitor to the twins. BCHC records indicate that a Health Visitor was allocated at an early stage whilst the twins were in hospital and she sought to arrange appropriate cover during a period of leave. However, hospital records state that a Neonatal Nurse was informed on 2 January 2015 that the case would be discussed for Health Visitor allocation the following week. It appears that this was a reference to finding alternative cover whilst the allocated Health Visitor was not available and the covering Health Visitor was off work due to illness but this was not clearly conveyed to the hospital Nurse making enquiries.  13.8  The needs of Child D, the family and their home circumstances were not clearly understood by any professionals involved with the family. The absence of discharge planning meetings for Child D and DD meant that a significant opportunity was missed to explore the complex needs of the twins, their parents’ capacity to meet their needs, the significance of poor parental visiting in hospital, cramped home conditions, and for joint planning between hospital and community health professionals. A number of learning points have been identified to make assessment, planning of early help (including discharge planning) and recording practice within the hospital units more robust. There are also lessons about communication and joint working between hospital and Community Health Services.   13.9  The Review has considered questions about the depth of assessment by professionals in universal services necessary to understand the needs of children with complex and additional need and the support required by their parents. A number of the learning points from this Review around assessment have been common findings in other Serious Case Reviews in Birmingham and nationally which suggests that they need to be continuously highlighted and addressed in staff supervision, workforce development and practice guidance.  Learning Points   1. The vulnerability of all children under one-year-old and the potential additional risks associated with prematurity, multiple births and inadequate housing cannot be underestimated; it should be emphasised in Early Help and Safeguarding procedures and guidance. It may be useful for Birmingham Safeguarding Children Board to revisit again the actions recommended in the Ofsted 2011 Ages of Concern document.    31  2. All children in a family should be considered in assessments. The voiced or interpreted experiences of an older child, their parenting and progress can provide insight into the care needs of new babies.  3. It is essential for professionals to engage and work with fathers or male partners and to include them in assessments and plans for their children.   4. There should be careful consideration of the wider family and environment in any assessment.  5. Care Plans should be regularly reviewed, any obstacles to addressing risks or needs highlighted and concerns escalated to ensure that they are addressed.   6. Multi-disciplinary discharge planning meetings should be held to coordinate services and address the needs of babies in particularly complex cases.  13.10 The City Hospital Neonatal Unit does not operate a key worker system for babies in hospital and Managers have not indicated that this is necessary to improve services.    13.11 This Review has highlighted the importance of appropriate interpreting and translation services to ensure good communication and working with parents. This is a considerable challenge given the number of languages spoken by parents in Birmingham, a very diverse city. However, efforts must continue to be made to ensure that interpreters are available either in person or by telephone.   13.12 The planned development of parent led care in the neonatal unit is welcomed; it provides another opportunity to explore and understand parents’ circumstances more fully and to promote partnership working. Also, the introduction of a visiting log provides an opportunity to make patterns of visiting, the length of visits and the quality of interaction very clear.   13.13 Father has suggested that information in the Red/Child Wellbeing Book could be made available electronically. This merits further consideration as it could provide opportunities to share information in a wide range of languages. Any development would have resource implications and may be usefully taken forward on a regional or national basis.   13.14 There is an intention in the development of the new Early Help Panel to address issues around the quality of recording of discussions at Panel. The developments in the City Hospital and in Early Help Services in Birmingham, which were not made as a consequence of this case, provide opportunities to improve practice, multi-agency working, service delivery and outcomes for children, particularly those who are born prematurely.      32  Further Learning Points from this Review are:  7. Parents will always benefit from interviews undertaken in, and information provided in, their first language and the common first languages of parents in Birmingham will continue to change due to the city’s super diversity.  8. Some parents will benefit from information in easy access formats and through a variety of media. There may be opportunities using the internet and smart media to further develop the range of information available for families.  For example, it would be useful if the Welcome Guide for parents used in Sandwell and West Birmingham Hospital NHS Trust could be available in a range of languages or translated by an interpreter or in an easy access version using symbols available for parents where literacy or level of understanding are an issue.   9. It is important that the availability and delivery of interpreting services and translated information and any challenges experienced are regularly reviewed and addressed with providers by all agencies.  10. A sufficient number of telephones are required to ensure access for staff and parents to telephone interpreting services on the neonatal ward at Birmingham City Hospital.   11. Staff at Birmingham City Hospital Neonatal Unit will benefit from their new assessment recording and planning tool which clearly indicates where risk factors such as poor visiting are not being adequately addressed and supports implementation of the escalation procedure whereby staff raise concerns with senior colleagues, including the Safeguarding Lead, as necessary.  12. The completion of a visiting log in the Neonatal Unit – completed by parents and staff and overseen and reviewed by hospital staff – will improve understanding of the pattern and quality of contact between parents/carers and their children where a child’s circumstances are particularly complex.   Birmingham Safeguarding Children Board will consider the learning points and any further action required to ensure the necessary developments in arrangements and practice are achieved.    Jim Stewart Lead Reviewer 28 February 2017   33  Appendices  A) Terms of Reference BIRMINGHAM SAFEGUARDING CHILDREN BOARD TERMS OF REFERENCE  SERIOUS CASE REVIEW – BSCB 2015-16/1 Date of birth - 2014   Date of death 01.04.2015  1. Background  On the 31st March 2015 an ambulance was called to the home address for Child A in respiratory distress, Child A was transported to Birmingham Children’s Hospital where CPR commenced.  CT scans showed a devastating brain injury which is felt to be non-accidental.  Child A was admitted to PICU however life support was withdrawn.  Both parents were arrested on suspicion of murder.    2. Information Known About the Family  Initial discussion around the table indicated that this family were unknown to a number of agencies; no safeguarding concerns were noted by Health Visiting or Primary Care teams.  3. Process of Decision Making  The case was discussed at Serious Cases Review Sub Group on 8th May 2015.  It was established that the case met the criteria for a Serious Case Review, as abuse/neglect was suspected to be a factor in the child’s death.    Working Together to Safeguard Children March 2015  “Regulation 5 (1) (e) and (2) set out an LSCB’s function in relation to Serious Case Reviews, namely: 5 (1) (e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned. (2) For the purposes of paragraph (1) (e) a serious case is one where: (a) abuse or neglect of a child is known or suspected; and (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.”   The Independent Chair of the BSCB was formally notified on 29th May 2015. Following consideration of the SCR Sub-Group recommendation, scoping document and Terms of Reference, and after a peer review discussion with a colleague chair the Independent Chair ratified her decision to commission a SCR.  The target date for completion and submission of the SCR Report is 5th April 2016.  The commissioning of chronologies has commenced with a target date for completion of 7th November 2015.   This case is subject to criminal proceedings, the SCR will not be published until the conclusion of these and relevant information from there considered.  However, the learning will be agreed and action taken to use the learning as soon as possible during the conduct of the review. The Board will ensure that any emerging findings are acted upon by agencies to ensure that any early lessons are fully implemented.        34  3. Terms of Reference  4.1 Aim  To review the circumstances leading to the incident that caused the death of the child and to the subsequently identified previous injuries to siblings, and establish what lessons are to be learned from the case about the way in which local professionals and organisations work individually and together to safeguard and promote the welfare of children.  To identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on and what is expected to change as a result.  To improve intra and inter-agency working and to better safeguard and promote the welfare of children.  4.2 Process  A Lead Reviewer will be appointed to work with the SCR Sub-Group to manage the process.    A representative to be seconded from Housing to consider any related issues.  A representative to be seconded from Save the Children (or other independent organisation offering specialist cultural advice) to advise upon any cultural or language issues identified.  4.3 Time Period to be considered by this Review  The SCR should focus on the period from 14th November 2014 up to the date of death 1st April 2015.  The Review should also consider scoping chronologies from each agency containing relevant information relating to agencies’ contact with the mother, her father and the eldest sibling outside that time frame as far as it impacts on the experience of the children in their care, their lifestyle and relationships, their ability to meet the children’s needs and the environment in which the parents and children were living.  5. Scoping the Review – Key Issues  5.1 The review will fully consider each agency’s contact with Child D, mother, father, and any relevant contact with siblings and agency knowledge of other adults in the household over the time period of the review.   5.2 The SCR Report will consider relevant research and any relevant nationally published reviews to inform this review.  5.3 The Lead Reviewer will consider how and when the most appropriate method of securing family members’ involvement with the SCR process whilst adhering to BSCB’s guidance on the involvement of family members and being mindful of the criminal investigation.    5.4 Consideration needs to be given to the racial, cultural, linguistic and religious background to this case and to the issues for migrant families in the city.     35   5.5 BSCB will obtain legal advice as necessary.  Current BSCB legal advice relating to SCRs and other publication will be adhered to.   5.6 Relevant information to emerge from criminal proceedings planned for some point in the future will be taken into account by Lead Reviewer, in liaison with the SCR Sub-Group.    5.7 The social care representative will be responsible for provision of information from family proceedings.  5.8 Agencies will implement the learning from this case prior to publication.   5.9 At the conclusion of the Serious Case Review agencies will debrief those staff involved in the case. BSCB will agree a method of disseminating key learning and monitoring through the Learning and Development Sub-Group with SCR Sub-Group.  6. Issues to be addressed within the Review   Fully consider the circumstances of this family and their needs collectively and individually.  Identify the degree to which these needs were recognised and responded to by those professionals in contact with this family.  Consider and explore the significance and implications of the family members’ migrant status and the impact of this on the way professionals responded to them and they responded to professionals.  Explore agency knowledge of individual family members and whether any relevant information was shared between agencies about the household.  Review what advice and support is given to frontline staff in all agencies about meeting the needs of migrant families.  Examine whether the early help offer available in the city and information provided for the parents is adequate and appropriately designed for migrant families.  Consider the opportunities and barriers afforded by the implementation of national legislation and policy with regards to migrant families and whether this results in avoidance of statutory agencies and a reduction in engagement and opportunities to meet needs and safeguard children.  If necessary, examine the themes arising in this case in the light of other similar situations.  7. Additional guidance is also available to Chronology Authors   Chronolator Guidance  Chronolator Template  8. Methodology and Timetable  The Lead Reviewer will offer advice to Individual Agency contributions Authors as required to ensure a focus on analysis of involvement and the specific issues and broader safeguarding factors. Chronologies, genograms and summary reports will be completed by 6 November 2015.  The Lead Reviewer will seek specialist advice as necessary in October/November 2015 from the Housing and Save the Children representatives and also request information about  36  migrant families in the City and identified general service needs from Birmingham Council and the Director of Public Health   The Lead Reviewer will liaise regularly with the LSCB Manager or Chair of the SCR Sub-Group about progress of the Review.  The Lead Reviewer will meet with the Serious Case Review Sub-Group on 18th December 2015 to discuss initial key findings identified, actions required and a draft Serious Case Review report.   The Lead Reviewer may arrange a review with the SCR Sub-Group Chair a learning event with practitioners, their managers and agency review authors in January 2016 to test hypotheses and develop learning.  A revised and updated Serious Case Review report will be agreed with SCR Sub-Group by the end of January 2016 and shared with LSCB members. Agreed actions will be developed into an implementation plan. Also a decision will be made in the light of progress of criminal proceedings and any Coronial involvement about the potential for involvement of family members in expanding learning and the potential to achieve the target submission date of April 2016.                                     37  Bibliography  Birmingham City Council/BDP - International Migration in Birmingham 2012-13   Service Development Team, Planning and Regeneration (2015/01) Birmingham Health and Wellbeing Board – An overview of the Joint Strategic Needs Assessment for Birmingham 2012  Birmingham Safeguarding Children Board - Right Service, Right Time Delivering effective support for children and families in Birmingham: Guidance for Practitioners March 2015 (Version 2)  British Association of Perinatal Medicine Service - Standards for Hospitals Providing Neonatal Care (BAPM 2010)  Department for Children, Schools and Families - Improving safeguarding practice: study of serious case reviews 2001-2003 - Rose W and Barnes J (2008)  Department for Children, Schools and Families - Analysing child deaths and serious injury through abuse and neglect: what can we learn? 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Acronyms   BCH: Birmingham Children’s Hospital  BCHC Birmingham Community Healthcare NHS Foundation Trust BSCB: Birmingham Safeguarding Children Board  CPAP: Continuous positive airway pressure fCAF: Family Common Assessment Form JSNA: Joint Strategic Needs Assessment  LNU: Local Neonatal Unit LSCB: Local Safeguarding Children Board  NICE: National Institute for Health and Care Excellence NICU: Neonatal Intensive Care Unit PDA: Patent Ductus Arteriosus  PICU: Paediatric Intensive Care Unit ROP: Retinopathy of Prematurity  SCBU: Special Care Baby Unit TAF: Team Around the Family   