Death of "Rose", a 9-week-old baby girl, in January 2015. Rose's mother pleaded guilty to manslaughter by diminished responsibility. The plea was accepted following psychiatric reports and she was sentenced to remain in a mental health facility with an unlimited restriction order. Rose's body has never been found. Mother received antenatal services from her GP and Chelsea and Westminster Hospital (C&WH) maternity services until the 29th week of her pregnancy. GP also referred mother to the perinatal psychiatry service but she returned to her home country to give birth before they could see her. Mother came back to the UK with Rose shortly before her death. Risks identified include: mother's anxiety and low mood related to her pregnancy; previous request to terminate the pregnancy; isolation from her family; low income; and separation from Rose's father. Findings include: communication across and between health services and professionals was fragmented. Professionals did not fully understand procedures for making referrals and the geographical areas covered by the C&WH midwifery service. Recommendations include: the perinatal and maternity services must audit referrals to ensure the new system is robust and vulnerable women are identified and followed up; health services should work together to develop a communication pathway locally to improve outcomes for service users.
      
 Title:  Serious case review in relation to Baby Rose: overview report. LSCB: Hammersmith and Fulham, Kensington and Chelsea, Westminster Local Safeguarding Children Board Author: Ann Duncan Date of publication: 2016  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.                                  LOCAL SAFEGUARDING CHILDREN BOARD    Serious Case Review  in relation to  Baby Rose    Overview Report July 2016          Published: 28th September 2016   Independent Author:  Ann Duncan      2  CONTENTS      The Circumstances that led to Undertaking this Review            3  Family Composition          3  Brief Summary of the Case         4  Methodology           4  A Succinct Summary of the Case        6  Key Issues and Analysis: Terms of Reference to be Addressed       8  Conclusions and Findings       13  Bibliography         14  Appendix 1:  Acronyms and Terminology    15                 3  1.1. The Circumstances that led to Undertaking this Review  1.1.1. The mother, a European National, returned home in September 2014 to have her baby; the baby (Rose) was born in November. The mother returned to the UK in late January 2015 with Rose and checked into an hotel that she had pre-booked. Three days after her arrival in the UK she informed the grandparents that Rose had been taken into care by Social Services. The grandparents travelled to the UK the following day and the mother then informed them that Rose had been abducted from her hotel room. The grandparents took the mother to the local police station to report the abduction, initially the mother was treated as a significant witness but her account of events was inconsistent and she was subsequently charged with the murder of Rose.   1.1.2. The LSCB Case Review (SCR) Sub-Group recommended to the Chair of the Safeguarding Children Board that the case had met the criteria for undertaking a Serious Case Review (SCR) under Working Together To Safeguard Children 20151, in that there was information that:  (b) (I ) the child has died.  The Independent Chair of the Board accepted and endorsed the   recommendation for a proportionate review and commissioned this SCR.  1.1.3. The mother pleaded guilty to killing Rose and entered a plea of manslaughter by diminished responsibility. The plea was accepted in light of three psychiatric reports.   1.1.4. The mother received a Section 37 Mental Health Act (MHA 1983) Hospital Order with a Section 41(MHA1983) Restriction Order attached, for appropriate treatment. The s41 Order has no time limits.   1.1.5. The mother was described as a complex person who still carries a high risk of offending which cannot be confined to just infants, be it her own or others and or future infants. She carries a high risk of violence and has difficulties with interpersonal relationships.     1.2. Family Composition                                              1 Working Together: HM Government 2015   4 1.2.1. The family members relevant to this review will be referred as follows:  Family member Anonymisation Subject Rose Mother of Rose Mother Father of Rose Father Maternal grandparents of Rose Grandparents   1.3. Brief Summary of the Case  1.3.1. The mother came to the UK seeking work in the summer of 2013. The mother met the father via an online dating service, they had six dates during which Rose was conceived, the father was unsupportive of the pregnancy and the relationship ended. Although the mother was initially ambivalent about whether to continue with the pregnancy, she went ahead and returned to her own country to give birth.  1.3.2. When Rose was approximately nine weeks old the mother returned to the UK with Rose and booked them both into an hotel. At this point the grandparents were unaware that the mother had left the country with Rose.  1.3.3. Three days later she telephoned the grandparents telling them that Rose had been taken into care by Children’s Social Services. The grandparents travelled to the UK, as they were very concerned. The mother then told the grandparents that Rose had been abducted.  1.3.4. The grandparents took her to a local police station. Following review of closed circuit television (CCTV) footage the account that the mother gave was inconsistent and the mother was arrested on suspicion of the murder of Rose and later charged.  1.3.5. The body of Rose has not been found.   2.      Methodology  2.1.1. Statutory guidance within Working Together requires Local Safeguarding Children Boards (LSCB) to have in place a framework for learning and improvement, which includes the completion of Serious Case Reviews. The guidance establishes the purpose as follows:                  Reviews are not ends in themselves. The purpose of these is to   identify improvements, which are needed, and to consolidate good practice. LSCBs and their partner organisations should translate the   5 findings from reviews into programmes of action, which lead to sustainable improvements, and the prevention of death, serious injury or harm to children. (Working Together, 2015)  2.1.2. The statutory guidance requires reviews to consider: “what happened in the case, and why, and what action will be taken”. In particular, case reviews should be conducted in a way which:  Recognises the complex circumstances in which professionals work together to safeguard children;  Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as the 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.  2.1.3. Management Reviews (IMRs). The following agencies submitted IMRs:     Metropolitan Police Service (MPS)  Chelsea and Westminster NHS Foundation Trust (C&WH)  General Practice for mother. (GP)  This was followed up with an interview with Head of Midwifery for C&WH and the Service Manager for perinatal services Central and North West London NHS Foundation Trust (CNWL)  2.1.4       The timeframe for the review is from the end of March 2014- end of January 2015.  2.1.5.     The Review directed the author to follow a number of lines of enquiry, with a view to reaching conclusions and making recommendations to the LSCB:   Information sharing/ referral pathways between health organisations, including mental health, to evaluate the effectiveness and the timeliness of the information sharing with the relevant European services.   Review the action and involvement of each agency involved with mother in the antenatal period to identify any learning to prevent this situation reoccurring.  The effectiveness of patient held maternity records in safeguarding vulnerable women.  2.1.6.  Family involvement. The involvement of key family members in the Review can provide particularly helpful insights into the experience of receiving or seeking services. The author of the review met with   6 the mother to explain the purpose of the SCR and inviting her to comment on how services could be improved. The mother felt that the GP was very kind and supportive and gave her time to talk. She also praised the midwife who undertook her ‘booking appointment’ but felt that the subsequent antenatal appointments were too short and felt that staff did not explore her feelings or why she was tearful. By the time the perinatal appointment was offered she had already decided to return home as she had recently lost her job and felt very low and isolated.    3. A Succinct Summary of the Case.  3.1. The mother attended her GP in late March 2014 as she thought that she was pregnant, this was confirmed and she was referred to the Chelsea and Westminster Hospital (C&WH) for antenatal care. At this time the mother felt happy about the pregnancy but reported that her boyfriend was not so happy about it. At the booking clinic at the hospital she disclosed that she was no longer with the father but didn’t require any additional support at this time.  3.2. On the 21/04/14 the mother emailed the GP following an appointment at the hospital the previous day ‘to discuss the interruption of her pregnancy’ and needed to see the GP urgently as she was already 14 weeks pregnant. The GP saw the mother four days later, she felt unable to continue with the pregnancy. A referral was made and an appointment made to discuss the termination of the pregnancy. The mother did not keep the appointment and continued with the pregnancy.  3.3. The mother attended seven antenatal appointments at C&WH between May and August. The mother was referred to the maternal medicine clinic as it was noted that she had protein C deficiency.2  3.4. Early in July she attended a routine antenatal appointment with her GP, she was 22 weeks pregnant. At this consultation she reported that she was anxious and low in mood about how she was going to cope. All her family lived abroad. The GP questioned the mother about any thoughts of deliberate self-harm (DSH) or suicide, which she denied. The mother was going on holiday to see her parents. The GP gave her a sick certificate and arranged to telephone the mother on her return to the UK. The GP also referred the mother to the perinatal psychiatry service (this service is provided by CNWL NHS Foundation Trust) The referral was received by the perinatal service and discussed at a team meeting on the 14/07/14; the decision was made to invite the mother for an assessment and contact the GP to complete the service specific referral form (this doesn’t appear to have happened).                                             2 Protein C deficiency is a rare genetic trait that predisposes to thrombotic disease, it was first described in 1981.   7  3.5. On the 23/07/14 the GP attempted to call the mother as arranged without success but saw the mother five days later at the surgery. The mother was noted to have anxiety and low mood related to her pregnancy and was given a sick certificate for a further four weeks. The mother had not heard from the perinatal service. A letter was sent from the perinatal service on 25/07/14 asking the mother to contact the service to arrange a date to be seen. Following receipt of the letter the mother contacted the perinatal service and requested that her assessment was postponed until after her trip home.   3.6. On the 13/08/14 the mother attended the GP for review of mood at 26 weeks pregnant. It was noted that the mother seemed stronger and had heard from the perinatal services, she was due to seen in 4-6 weeks. The mother had no thoughts of suicide or DSH. The mother was considering going back home to have her baby as she had good family support there. (This was the last visit to the GP).  3.7. The mother attended an appointment with the midwife on the 28/08/14, she was 28 weeks pregnant, and she made no further antenatal appointments.  3.8. On the 29/09/14 the GP received a phone call from the perinatal service requesting that their specific referral form was filled in and returned to the service, as the referral letter was not adequate. (This was supposed to have happened in July following the referral letter and discussion at the team meeting)  3.9. On the 24/01/15 the mother and Rose returned to the UK and travelled to a pre-booked hotel by taxi. The mother had no baby equipment with her.   3.10. A friend visited the mother the following evening and the friend reported that she spent a couple of hours in the bedroom with mother and Rose.  3.11. On the morning of the 26/01/15 the mother left the hotel alone and returned approximately an hour later having bought cleaning products and bin liners. She later left the hotel for a second time that day and returned with a pink suitcase. The mother then went to another hotel and booked a room and returned to the original hotel a few times to move her belongings.  3.12. The following day 27/01/15 the mother called the grandparents and told them that Rose had been taken into care by Social Services. On the same day she was seen to leave the second hotel with a suitcase and later returned without it.    8 3.13. The grandparents flew to the UK on 28/01/15 and the mother told them that someone had abducted Rose from the hotel room. Her parents took her immediately to the local police station to report the abduction.  3.14. The mother was arrested on suspicion of the murder of Rose and later charged, the body of Rose has not been found.  4. Key Issues and Analysis: Terms of Reference to be Addressed.  4.1. Introduction.           This section of the Review assesses the quality of multi-agency practice at those key points, which were considered to provide the most significant learning. In doing so, it takes into account both the contemporary required standards and also the information that was known, or could have been known at the time of the events. Where there is information about why practice may not have met the required standards these are explained. By understanding why things have happened in the way that they did, rather than simply what happened, the Review is seeking to achieve a greater depth of learning.  4.1.1. The body of Rose has not been found but the mother allegedly has admitted that she suffocated Rose on the 26.01.15 and disposed of the body, the mother has not confirmed where.  4.1.2. It is difficult to know whether there would have been a different outcome had the mother been seen and assessed by the perinatal service during the antenatal period. The mother didn’t tell the midwife in August, on what would turn out to be her last appointment, about her plans to return home to give birth. The mother’s view is that she did inform the midwife at this visit as she had also been made redundant from her job. As a consequence of this, the antenatal records were not copied and given to the mother to take with her and there is no copy on file of the hand held Maternity records at C&WH. The midwifery service was unaware of the referral to the perinatal service and mother was not identified as being vulnerable.  4.1.3. There is no information available to the author about the birth and the subsequent post-natal period and it would therefore be wrong to speculate.  4.1.4. The mother arrived back in the UK with Rose over a weekend. The mother had booked an appointment with the GP on the 30.01.15. Sadly events overtook this and the appointment was missed.   4.1.5. The author is of the view that the death of Rose was neither predictable nor preventable. However, the independent author agrees that there are areas of practice that could have been improved and lessons to be learnt that will further strengthen the safeguarding system.   9  4.2. Information sharing/ referral pathways between health organisations, including mental health, to evaluate the effectiveness and the timeliness of the information sharing and whether there was appropriate sharing with the relevant European services.   4.2.1. The mother was registered with a GP close to where she lived; she elected to have her baby at the C&WH.  Although the practice is only about two miles from the hospital, the practice falls outside the community boundaries for C&WH and there is therefore no allocated community midwife/team for this practice. This is likely to happen frequently in the future where pregnant women travel greater distances due to closure of local midwifery services and patient choice.  4.2.2. The GP made a referral to C&WH when the mother was eight weeks pregnant, this was her first pregnancy and was reported to feel happy about the pregnancy but her boyfriend was not so happy about it. Three weeks after her ‘booking appointment”3 she contacted the GP asking for an urgent referral, as she wanted to have the pregnancy terminated. The GP made the appropriate referral but the mother didn’t keep the appointment and continued with the pregnancy.  4.2.3. Following a consultation with the GP early in July 2014 it became evident that the mother was struggling with low mood and anxiety related to her pregnancy. The GP identified that there were other factors increasing her risk such as isolation from family; low income; no longer with the father of the baby; previous request for termination and first pregnancy. The mother was referred the same day to the perinatal service for urgent assessment. The GP made a timely and appropriate referral to secondary mental health services, however the referral was not shared with the Midwifery service and she was not considered as a vulnerable woman. There is an expectation that the referrer should follow up the referral; liaison with the midwifery team would have been beneficial.  4.2.4. Referral often involves a transfer of clinical responsibilities between professionals. A good referral should contain the following elements:  Necessity-patients are referred as and when necessary, without delay  Destination-patients are referred to the most appropriate Process-referral letters contain the necessary information, in an accessible format and patients are involved in decision making around the referral4                                              3 Booking appointment, this appointment books you in for maternity care provided by your local health trust or hospital  4 The quality of GP diagnosis and referral, The Kings Fund 2010   10 4.2.5. It would appear that the GP made good and timely referrals but feedback from the other professionals involved could have been better. However, given the fact that the GP made a referral to the perinatal service good practice would be that the GP contacted the perinatal service directly to find out what the delay was.   4.2.6. The referral was received by the perinatal service and the case discussed at the Multi-disciplinary Team (MDT) meeting on the 14.07.14. The decision of the meeting was to offer an assessment to the mother and to contact the GP to complete a referral form. According to the internal investigation by CNWL there is no record of the telephone request to the GP. The perinatal service was under pressure at the time with vacancies within the clinical team, coupled with higher than average sickness levels. A letter was sent to the mother on the 25.07.14 inviting her to contact the service; this had not been received when she was reviewed by the GP on the 28.07.14.  4.2.7. Whilst the mother was waiting for an appointment she was seen regularly by a consistent GP. After each appointment she was safety netted5 and made aware of emergency services provided by the GP practice and mental health services. There was always a follow-up appointment booked and telephone consultations were carried out. The care provided was of a good standard.  4.2.8. The GP was contacted on the 29.09.14 by the perinatal service requesting that the referral form was completed; this was the only communication as far as the practice is concerned from the perinatal service. The mother by this time had already left the country and was never seen by the service.   4.2.9. There was no referral pathway in place at the time but following an internal investigation by CNWL to learn lessons a more robust way of managing referrals is now in place. The perinatal service now sends an appointment directly to the patient and has an internal tracking system to ensure that patients are not lost within the system. There is closer working with the midwifery service; The Antenatal Care (ANC) lead now attends the perinatal referral meeting (MDT) on a weekly basis and cross references all women with their midwifery team to make sure that they are identified as vulnerable women. Further work needs to be done on how to communicate effectively with GPs by the perinatal service and other antenatal services particularly when there is no allocated community midwife because of catchment areas.   4.2.10. Normal practice would be that when mothers have elected to return to their home country to give birth, the hand held maternity records are photocopied and a copy placed on file and the mother is given a copy of the maternity records to take with her. This did not occur, as the mother had not told anyone that she was going home, she had spoken                                             5 The term ‘safety-netting’ was introduced to general practice by Roger Neighbour who considered it a core component of the general practice consultation.2   11 informally about the possibility with her GP. C&WH are used to a high number of European Nationals electing to return to their home country for the birth of the baby.  4.2.11. Unfortunately the hand held maternity records have not been available so it is difficult to know what was recorded, this will be further discussed under patient held records in safeguarding vulnerable women.  4.2.12.Both the perinatal service and maternity services have made changes to the way referrals are processed and information shared. There is still a gap between how information is shared with general practice. It might be helpful to explore further what the expectations and standards from the perinatal service are, in how to communicate effectively with GPs and other antenatal teams.   Recommendation 1: The perinatal and maternity services must audit referrals made to the service to provide assurance to the Board that the new system is robust and vulnerable women are identified and followed up.  4.3. Review the action and involvement of each agency involved with mother in the antenatal period to identify any learning to prevent this situation reoccurring.  4.3.1. The two agencies involved with the mother during the antenatal period were the GP and the C&WH Maternity Services. It would appear that the care provided within general practice was of a very high standard. I have already commented on the one area where the GP could have improved the care, which was to follow up on the referral that was made to the perinatal service.  4.3.2. The maternity services at the hospital provided antenatal care up until the 29th week of the pregnancy.  4.4. The effectiveness of patient held maternity records in safeguarding vulnerable women.  4.4.1. Pregnant women are given their own personal held maternity records at the booking appointment. They are responsible for keeping then safe and presenting them to professionals during the pregnancy. As has been previously stated the patient held maternity records for this case have not been available and it is therefore difficult to assess what information was shared on the records.  4.4.2. The maternity services were unaware of the referral that the GP made to the perinatal services and the mother was not identified as a vulnerable woman, which meant that no additional records were opened.   12  4.4.3. The maternity services keep an electronic record of all women booked to have their baby at the hospital. If there are concerns or risks identified then the normal practice would be to write a line in the patient held records such as “special consideration and management plan” which would direct professionals to review the electronic record. The pages where this information is written are half pages and therefore stand out. The electronic record is available for the professionals working within the hospital setting. Currently there is no robust platform for all healthcare practitioners to communicate via.   4.4.4. Whilst it is recognised that the hand held maternity record is a good method for transmitting information between health care professionals, the maternity service should ensure that there is a centrally held copy (backup) of all clinical contacts with pregnant woman. This is especially important for vulnerable women with chaotic lifestyles.  Recommendation 2:  The midwifery service must demonstrate to the Board that there is a plan in place to implement the centrally held electronic record system including a completion date in place.   4.5.   Was the practice sensitive to issues of racial, cultural, linguistic and religious identity and any issues of disability of the child and family? Were any such issues appropriately explored and recorded?  4.5.1. The mother came to the UK to seek employment and worked as a receptionist, there are no recorded issues regarding her ability to communicate effectively in English given that this was not her first language.  4.5.2. There were no issues of conflict raised in this case. The practice was sensitive to the patient’s needs with no religious conflicts surrounding abortion.   4.6 Evaluate the impact of any organisational change over the period covered by the review or any systems issues that you consider to be relevant.  4.6.1. General practice identified that the Information Technology (IT) system used for recording patient notes and information was changed during this period. This change however, did not affect the referrals, patient management or communication between the services.  4.6.2. The Chelsea and Westminster Hospital have amended the ‘Did Not Attend’ (DNA) policy to ensure that women who do not make a follow up appointment are followed up.     13 4.6.3. The Antenatal Clinic Lead now attends the perinatal referral meeting and cross references all women with their midwifery team to make sure that they are identified as vulnerable women and appropriate referrals are made.  4.6.4. The perinatal service identified that they did not have a pathway in place at the time of this review and that there was a higher than average sickness rate within the administration team combined with low levels of clinical staffing due to vacancies and sickness. Work has been undertaken and changes made to the referral process. There is now more robust internal tracking of referrals received by the service.  4.6.5. Whilst undertaking this review it became evident that communication across and between services and professionals was fragmented. Information about changes to service provision, how to refer to services using the correct form and the geographical areas covered by the midwifery service at C&WH were not fully understood.  Recommendation 3: Health services should work together to develop a communication pathway locally to improve outcomes for service users.  5. Conclusion and Findings  5.1.  This is a review about the death of a nine-week-old baby who was reportedly suffocated by her mother having returned to the UK without the knowledge of the grandparents who thought mother and baby were visiting friends at home. The review sought to try and understand whether there were any lessons to be learned from the case in terms of professional practice, early intervention and safeguarding.   5.2.   The mother appeared to be ambivalent about the pregnancy and asked for a referral for a termination. She then changed her mind and continued with the pregnancy despite no support either emotionally or financially from the father of the baby. The mother presented to the family GP with low mood and anxiety associated with the pregnancy and was referred to the perinatal services. Unfortunately the mother was not seen by this service and returned to her own country for the birth of her baby where she reportedly had strong family support. There is no information available to the author about the birth, the postnatal period or her mental state.  5.3. The management and care given by the GP was of a good standard.  5.4. It is difficult to say whether there would have been a different outcome to this case if the mother had been assessed by the perinatal service and her antenatal care shared with the clinicians in her home country. What is clear is that the review has identified areas of practice that can be strengthened and improved; some changes have already taken place within the services that have been involved.   14  5.5. The LSCB is invited to consider the review and findings, as a way forward to strengthen and develop the multi-agency safeguarding network across the three boroughs of Hammersmith and Fulham, Kensington and Chelsea and Westminster.    5.6. Recommendation 1:The perinatal and maternity services must audit referrals made to the service to provide assurance to the Board that the new system is robust and vulnerable women are identified and followed up.   5.7. Recommendation 2: The midwifery service must demonstrate to the Board that there is a plan in place to implement the centrally held electronic record system including a completion date in place.  5.8.  Recommendation 3: Health services should work together to develop a communication pathway locally to improve outcomes for service users.                                          Bibliography    Working Together to Safeguard Children, A guide to inter-agency working to Safeguard and promote the welfare of children, HM Government, 2015.  London Child Protection Procedure 2014(Edition 5)   The Quality of GP Diagnosis and Referral, The Kings Fund 2010.        15                 Appendix 1: ACRONYMS AND TERMINOLOGY     ANC Ante Natal Care CCTV Closed circuit television CNWL Central and North West London NHS Foundation Trust C&WH Chelsea and Westminster NHS Foundation Trust DNA Did Not Attend DSH Deliberate Self Harm GP General Practice, family doctor IMR’s Individual Management Review LSCB Local Safeguarding Children Board MPS Metropolitan Police Service MDT Multi- disciplinary Team    