Severe non-accidental injuries to a 3-month-old infant in August 2019. Learning includes: fathers need to be as visible in all agencies' antenatal and postnatal care and support as mothers; pro-active and tenacious attempts need to be made to involve fathers in assessment and the planning and delivery of support for children, this may require a specific approach to engage them; and when vulnerable young women stay with friends or partners in houses of multiple occupation, professionals should show curiosity about the other residents, especially males, and consider whether they pose any risk. Recommendations include: seeks assurance from all agencies that offer services to children and families that they have individually and collectively considered how best to improve arrangements to engage vulnerable young parents, especially fathers; ensure that all agencies keep fathers, as well as mothers, in mind especially during pregnancy and early babyhood; as well as assurance from Children's Social Care that pre-birth assessments are being done for all babies that need them, and that child and family assessments are shared more frequently and consistently with other agencies including GPs.
      
 Title:  Child safeguarding practice review: Child J. LSCB: South Tyneside Safeguarding Children Partnership Author: Karen Perry Date of publication: 2021  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.                                                              CHILD SAFEGUARDING PRACTICE REVIEW  Child J     October 2020 Lead Reviewer: Karen Perry    Publication Date: 25th November 2021                     2  CONTENTS 1. Introduction                                                                               page 3 2. Details of the family and case context                     page 4 3. Key Episodes        page 4 4. Thematic analysis       page 7 5. Good Practice       page 22 6. Conclusions and summary of lessons learned   page 22 7. Recommendations       page 24 3  1. INTRODUCTION  1.1. This Child Safeguarding Practice Review (CSPR) is in respect of Child J, who was seriously harmed, aged 3 months, due to non-accidental injury. The injuries, which were caused by more than one assault, included head trauma with brain and retinal haemorrhages, small bruises to the face, chest and right arm. During the course of the care proceedings the court “Finding of Fact”1 concluded that: the injuries had been caused when Child J was in his father’s sole care by him forcefully throwing the baby onto a soft yielding surface and other rough handling around the same time; and that both parents should have sought medical attention sooner.   1.2. All learning points are listed in section 4, at the end of each theme. What follows is a summary of the most significant learning from this review. Overall, practitioners tended to underestimate the impact of the parents youth, their childhood and family circumstances due to the mature way they presented. Fathers need to be as visible in all agencies’ antenatal and postnatal care and support as Mothers; this may require a specific approach to engage them.  Pre-birth assessments for unborn children provide added value to those completed on expectant mothers who are themselves children in terms of: a focus on fathers; the parenting capacity and family and environmental factors for both parents; and balancing strengths with risks. All practitioners’ assessments and plans should be informed by historical information and practitioners should explore and consider in detail what parents mean by “good support” being anticipated or received from extended family members. It is important to share (with consent) Child and Family assessments with other agencies, especially when there are significant vulnerabilities and/or further support has been declined. It is not uncommon for birth marks to develop in the first few weeks of life. However when exercising professional judgment about whether a new mark on a young baby is a birthmark it is important to be fully informed about all parental vulnerabilities and risk factors.   1.3. The South Tyneside Safeguarding Children Partnership (STSCP) will ensure that learning is widely disseminated locally and publish this report on their website. To avoid unnecessary disclosure of sensitive information, details in this report regarding what happened focus only on the facts required to identify the learning. The CSPR takes into account multi-agency involvement from January 2017, when Child J’s mother moved back to South Tyneside (Local Authority 2) from Local Authority 1,  until Child J was taken to the Emergency Department in August 2019.    1.4. The STSCP agreed to undertake this review using the Significant Incident Learning Process (SILP), a learning model which engages frontline staff and their managers in reviewing cases, focussing on why those involved acted as they did at the time.2 Family members were also offered the opportunity to speak to the lead reviewer. Mother did not want to participate and Father’s whereabouts were unknown at the time of writing this report.     1This is a court hearing which draws conclusions from the evidence presented about what happened. The standard of proof is “on the balance of probability”  2 Due to Covid 19, meetings with practitioners and quality assurance and approval panel meetings were achieved by video conference rather than face to face  4  2. DETAILS OF THE FAMILY AND CASE CONTEXT 2.1. Child J has no siblings. Child J’s parents are referred to as Mother and Father. Other family members will be referred to by their family relationship e.g. Maternal Grandmother.  Child J has been described as a placid and contented baby. Mother and Father were aged 17 years and 18 years old respectively at the time of Child J’s birth.  2.2. Some information prior to 2017 is relevant. Mother returned to live Maternal Grandfather in Local Authority 2 in January 2017 (age 14 years) for a fresh start. She had been living with Maternal Grandmother in Local Authority 1 over 200 miles away. When Mother lived in Local Authority 1 there was involvement from a School Nurse (considerable) and Children and Family Services (some).   2.3. Father has a history of anti-social behaviour which started in primary school. He disengaged from secondary education and was described by school staff who knew him as not being afraid of confrontation and using this to resolve issues; there was more than one incident of physical aggression to other pupils.  He/his siblings were the subject of a number of referrals to Children and Family Services,  which resulted in no further action.  3. KEY EPISODES  Key Episode 1: from January 2017 until September 2018 (support offered to Mother after her arrival in Local Authority 2 until she became pregnant)  3.1. During the 18 months after her arrival in Local Authority 2, Mother was referred to the Integrated Safeguarding and Intervention Team (ISIT)3 in January 2017, June 2017 and March 2018 regarding historical or current allegations about Maternal Grandfather misusing alcohol and/or being violent to Mother. The first and last of these referrals resulted in social work assessments; further social work involvement was declined. The second referral did not result in an assessment as neither Maternal Grandfather nor Mother thought one was necessary.   3.2. For a few weeks in 2017 Mother received a service from the Young People’s Violence Advisory service (YPVA) regarding abuse by an ex-boyfriend. During May 2017 Mother disclosed being raped in 2016 by her ex-boyfriend; the YPVA worker supported her to report this to the Police.  In early July 2017 the YPVA Service supported Mother to make a self-referral to CYPS by telephone as she was reporting flashbacks from previous violent relationship with the 17 year old boyfriend.  Support from the Lifecycle service was offered; Mother did not take this up.    3.3. In June 2018 Mother contacted the Social Worker who had completed the second assessment; she asked for a referral to Places for People for housing support as she was returning to Local Authority 2 from visiting Maternal Grandmother. As no suitable accommodation was available Mother returned to live with Maternal Grandfather.     3 The ISIT (Integrated Safeguarding and Interventions Team) is a multi-agency team which receives contacts and referrals from professionals and members of the public who are concerned about a child. The team includes representatives from Education, Early Help, Police, STFT and Probation services, who are co-located to enable swift and effective information sharing and decision making. "Virtual" team members from NTW, Housing and Adult Social Care extend the reach of the ISIT. 5  3.4. During the period under review records show that Father had very limited contact with any agency. There are three instances of potential relevance to this review; a domestic incident with Paternal Grandfather when father arrived home drunk, and an attendance at the Emergency Department with a punch injury involving fractured fingers. These were both in the spring of 2017 when Father was 16 years old. The third was in mid-February 2018 when Father was arrested for an attempt to possess cocaine. He subsequently admitted the offence and received a caution and was referred to the Youth Justice Service for voluntary intervention; he did not take up the two sessions that were offered on substances and the law.  Key Episode 2: from September 2018 until May 2019 (Mother’s pregnancy)  3.5. In mid–September 2018, aged 16 years, Mother attended the GP. She suspected she might be pregnant.  At the beginning of October 2018 Mother attended an initial appointment with a Midwife and a referral was made to the Pregnancy Options Service.4   3.6. In mid-September 2018 mother contacted the Integrated Safeguarding and Intervention Team (ISIT) for advice about obtaining a tenancy for herself and Father. Mother was signposted to the council’s housing service and a local young people’s housing service. In late September 2018 Mother moved into a shared female only flat in supported accommodation for single people aged 16 years-25 years,5 with a view to being considered for the young parents’ accommodation.  Mother left the supported accommodation almost four months later, having only stayed there three nights. Apart from short stays with Maternal Grandmother, in October 2018 and over Christmas, she was effectively living with Father in a house he shared with other males.  Twice in the first half of October 2018 and again in mid–December 2018 supported accommodation staff reported Mother missing to the Police as she had not indicated her whereabouts. Each time she was located with Father at his address.    3.7. During October 2018 and at the beginning of November 2018 supported accommodation and the Pregnancy Options Service (PAS) staff respectively made separate referrals to Children and Family Services. They were concerned about the vulnerability of Mother due to her staying with Father (and older males) and what she had told them about Maternal Grandfather’s alcohol misuse and aggression.  Social Worker 3 was allocated to conduct a single assessment of Mother’s circumstances.   3.8. In mid-November 2018 Mother left the supported accommodation. She told the Social Worker she would be returning to Local Authority 1 to live with Maternal Grandmother until the birth of the baby. The move back lasted a week after which she was permitted to return to the supported accommodation on the basis she stay at least four nights per week and actively engage with support. The Social Worker, who had made a referral to Local Authority 1, restarted  Mother’s assessment.  This was in progress when, just before Christmas 2018, due to Mother’s vulnerabilities (including minimal family support) the Midwife also made a referral to the Integrated  4 This is part of the sexual health service which offers opportunities for discussions about continuation or otherwise of pregnancy and future contraceptive planning  5 1 full time member of staff visits Mon-Fri 9am-5pm weekly-fortnightly. Compulsory keyworker system (13 residents per key worker), keyworker meetings weekly or fortnightly. Support plans with agreed outcomes, reviewed every 3-6 months. Staff provide support with budgeting, domestic skills, benefits, access to other agencies and support, health matters, access to education 6  Safeguarding and Intervention Team (ISIT) requesting a pre-birth assessment for Child J.  3.9. In early January 2019 supported accommodation staff liaised with the Social Worker, indicating that it would be approximately 2 months before Mother could access the young parents’ scheme. During January 2019 Mother failed to engage with the supported accommodation three month review and handed in her keys saying she and Father had secured a council tenancy together.  Accordingly, before ceasing involvement Social Worker 3 made a visit to the new tenancy and made a welfare funding application on the couple’s behalf for some essential furniture.   3.10. In mid -February 2019 Mother was admitted to an antenatal ward due to abdominal pains at 25 weeks pregnant. The ambulance crew which brought her in were so concerned about the home conditions (sleeping on a mattress on the floor with no carpets and no heating) that they informed the Midwife and made a referral to Children and Family Services.   In response to a query by phone Mother advised that the couple had only just moved in and beds and flooring were being delivered the following week. Mother was subsequently seen at antenatal clinic and a Midwife made a home visit in the second week of March 2019, when home conditions were described as “immaculate”, with everything ready for the baby.   3.11. In mid-March 2019, by virtue of requesting a routine prescription for Mother the Midwife discovered that she didn’t have local GP. Mother registered with South Tyneside GP Practice 2 about a fortnight later.  In Mid-April Father registered with a GP for first time since his family had been struck off in December 2015 due to Paternal Grandparents’ aggression in the surgery.   3.12. Towards the end of March 2019 the Health Visitor identified the level of support to be offered as “Universal Plus”,6 but subsequently amended this to “Universal” after her visit as there were no obvious risks or concerns and the parents seemed prepared for the birth.   3.13. Key Episode 3: from May 2019 until August 2019 (postnatal period up until Child J was taken to the Emergency Department)   3.14. Child J was born towards the end of May 2019.  The Midwife made a number of postnatal home visits. On the first visit completed the day after Child J was born the Midwife examined the baby and completed a body map showing nothing abnormal detected. In early June 2019 the Health Visitor made her first postnatal visit; both parents were present and observed to handle Child J appropriately.   3.15. In early July 2019 the Health Visitor made second postnatal home visit to complete the standard 6-8 week check. Father was not there. Mother drew the Health Visitors’ attention to a 1.5cm red mark to the baby’s left inner arm. The Health Visitor recorded the mark on a body map. She considered the mark was a newly visible birth mark, because it is not uncommon for birth marks to develop in the first few weeks of life.    However a few days later Mother and Father took Child J to local GP Practice 2 for a  6 This level of need provides ongoing support from the health visiting team over and above standard contacts and other local services to deal with more complex issues  as appropriate 7  routine 6-8 week check.  The GP completed a physical examination; nothing abnormal was detected;  no birthmark has subsequently ever been seen.  3.16. On the 31/08/19 Child J was taken to the Emergency Department with the injuries which triggered this CSPR. Father had called for an ambulance suggesting that Child J was lethargic and vomiting. Father told the paramedic who attended that he had fallen down the stairs with Child J in his arms the previous day, when Mother was out.    3.17. Agencies have taken appropriate action to treat the injuries, investigate their cause and protect Child J.   4. THEMATIC ANALYSIS   4.1. The learning from this review was identified from information and opinions provided in the agency reports and at the practitioners learning events.  The themes are:   • Care of young babies and injuries  • How practitioners and agencies worked together to support young people/to support young parents    • Insufficient focus on fathers/males   Theme:   Care of young babies and injuries   4.2. It is not known what triggered Father to injure Child J, or why Mother was not able to protect the baby and delayed in seeking medical attention.  Father may have lacked the skills to cope with difficulties without resorting to aggression, although none of the practitioners involved were aware of any evidence of concerning behaviour during the pregnancy or after Child J was born.  The couple separated within a few months after the baby was injured. Records show that since the incident Father has displayed controlling, intimidating and aggressive behaviour towards Mother. It is not known whether this behaviour occurred previously during pregnancy and whilst the baby was in their care, but no practitioner had seen any previous evidence about domestic abuse, and Mother had consistently indicated, when asked as part of routine practice, that this was not an issue.   4.3. Babies are fragile; during antenatal and postnatal care Mother and Father were given verbal information and a leaflet about this, including the dangers of shaking babies and advice about strategies e.g. placing babies in a safe place and taking time out/seeking help if they feel stressed. The Health Visitor told this review that when discussing the challenges of being a new parent she always normalises feelings of being overwhelmed and/or stressed whilst caring for a new baby; that babies do cry and go through periods of being unsettled.  In this case Mother told her she could call her own mother and that Father was supportive.  Father did not make any particular comment but the Health Visitor told this review that he was present for the discussion and appeared attentive.   4.4. We do not know whether Child J had a bruise in June 2019. We do know that whatever the mark observed was, it was not a birthmark. If it was a bruise, research suggests that bruising is found in less than 1% of infants who are not independently mobile,7 and  7 https://www.rcpch.ac.uk/resources/child-protection-evidence-bruising 8  that a significant number of infants with a serious non-accidental injury have had a previous “sentinel” injury.8 Consequently like Local Authority 2 the majority of Safeguarding Partnerships have policies on bruising in immobile babies9, and this is the relevant policy and procedure for any mark noticed on a non-mobile baby.   4.5. Mother was presenting as a competent young mother throughout. At the point that she drew the Health Visitor’s attention to the mark on Child J’s arm Health staff had seen Father on a number of occasions when he had presented appropriately, including handling the baby, and Mother had not raised any concerns about him, (and she had had been given ample opportunities to do so).  The relevant local NHS guidance for bruises in non-mobile babies  includes the exercise of  professional judgement, without the need for any consultation with others, where the practitioner is confident that the mark is a medical condition like a birth mark. This was the Health Visitor’s view in this case. However no birth mark was seen during a subsequent physical examination by the GP, or since.  Perhaps if that Health Visitor had been better informed about risk factors and vulnerabilities this might have led to a more cautious approach identifying the mark as a birthmark.    4.6. The Health Visitor documented the mark on a body map in the parent held Personal Child Health Record, 10 otherwise known as the “Red Book” and saved a copy on the electronic record. The GP who completed the physical examination at 6-8 weeks would not have recognised the potential significance of the absence of the mark; he had not seen the body map because GPs do not have access to Health Visitor records. In any case GPs would not consult a previous body map unless they saw a mark. Whilst some Health practitioners told this review they felt the “Red Book” was a valuable communication tool between Health professionals and should be used consistently, in practice there are some barriers to their effective use.  For example, parents do not always bring them to consultations and this review was told that GPs do not tend to routinely view Red Books as information is difficult to find, the content being often illegible and not searchable.  Since the period of this review conversations have started about allowing read only access for GPs to both health visiting and midwifery records.  However GPs would still need a reason to look at records; they are unlikely to  look routinely.   4.7. As a result of previous Serious Case Reviews some years ago in Local Authority 2 involving bruising in non-mobile babies Health agencies implemented training for staff and provide periodic audit reports to the safeguarding partnership regarding the effectiveness of their arrangements. The most recent audit was completed in May 2020. The survey findings demonstrate that Health Visitors are aware of the pathway, know where to find it and are confident using it. The review of cases confirmed that Health Visitors are using the pathway appropriately and using post-natal information to support their decision making.  Social Care Managers told this review that Health practitioners and staff in early years educational settings make referrals to the  8 Ibid and http://healthland.time.com/2013/03/12/how-small-bruises-lead-to-big-ones-in-child-abuse-cases/  9 Bilson (2018) http://bilson.org.uk/child-protection/bruised-babies/  10 Personal Child Health Record is a health and development record given to parents/carers at a child's birth. It was nationally developed and its format and content is kept under review by a multi-disciplinary panel. Health professionals record health and development  information eg weight, height and vaccinations, parents can also add any accidents, illnesses etc    9  Integrated Safeguarding and Intervention Team (ISIT) for suspected bruising to non-mobile babies. In this case the ambulance staff made a referral to the Integrated Safeguarding and Intervention Team (ISIT) when observing bruising at the time of the incident which led to this review. Bruising in immobile babies is included in annual training for ambulance crew and paramedics.   4.8. During the investigation into the injuries which prompted this CSPR,  information from both parents suggested that Child J did not always sleep in his Moses basket; including on the evening before Child J was taken to the Emergency Department, when Mother  arrived home from a night out to find the baby asleep in a baby bouncer in the living room, and left him there overnight. Whilst not related to the injuries which precipitated this review, the failure to adhere to safe sleeping guidance11 can contribute to Sudden Death in Infancy (SUDI). Child J’s parents were advised a number of times about safe sleeping, and the Health Visitor told this review that both appeared attentive when she discussed this with them. They received a leaflet from the Lullaby Trust and a Moses basket was known to be available; practitioners had no knowledge of the baby sleeping anywhere else.  South Tyneside agencies intend to improve the known inconsistency with which local parents follow safe sleeping advice by considering the findings of a recent report12 by the national Child Safeguarding Practice Review Panel involving a sample of 40 cases of SUDI.   Summary of learning: Care of young babies and injuries  • It is not uncommon for birth marks to develop in the first few weeks of life, however when exercising professional judgment about whether a new mark on a young baby is a birthmark it is important to be fully informed about all parental vulnerabilities and risk factors.    Theme: How practitioners and agencies worked together to support young people/young parents   4.9. There were a number of occasions where the parents vulnerability due to their youth was not recognised by a range of agencies. Father was only 18 years old at the time of Child J’s birth.  Throughout all the period under review Mother was still a child;  her legal status as a child was not recognised by a range of different agencies.  There were two occasions when Mother sought support due to potential homelessness but was not offered a formal assessment of her needs by a Social Worker, as she should have been.  At the end of June 2018 Mother told her previous Social Worker she was imminently returning from visiting Maternal Grandmother in Local Authority 1 because she was not safe from her ex-boyfriend, and that there were no other relatives she could stay with, including her father who had asked her to leave his home. Mother was signposted to the Young People’s (housing) Advisor who told her there was no suitable accommodation available. Mother was aged 16 years; national guidance in place since 201013 specifies that all 16 and 17 year olds who present as potentially in  11 https://www.lullabytrust.org.uk/research/evidence-base/ 12Sidebotham P et al July 2020  Out of routine: A review of sudden unexpected death in infancy (SUDI) in families where the children are considered at risk of significant harm Child Safeguarding Review Panel 13https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/8260/Provision_20of_20accommodation.pdf 10  need of accommodation as a result of family breakdown should be offered an assessment of their needs under the Children Act 1989. The assessment should include consideration about whether the child should be accommodated under section 20 arrangements if their welfare would be seriously threatened if accommodation is not provided. This needed to be completed in South Tyneside as Mother stated she was not safe from the ex-boyfriend and there was previous evidence of risk to her from him.    4.10. Whilst there was a social work assessment undertaken after Mother moved into supported accommodation in September 2018, this assessment was triggered by subsequent referrals from other agencies, rather than housing need.  The Integrated Safeguarding and Intervention Team (ISIT) management decision for no further action in September 2018 was that Mother was seeking advice about housing; she was not homeless as she was living with Maternal Grandfather and pregnancy was not yet confirmed. The pregnancy was not relevant (necessary) in terms of the Local Authority duties and the decision did not take into account, as it should have done, information available from historical records about the fragility of the relationship between Mother and Maternal Grandfather.  A senior manager from Children’s Social Care  told this review that arrangements have been changed so that all homeless 16-17 year olds are now assessed and discussion takes place to enable the young person to make an informed decision about their legal status. This has resulted in more assessments being done, with a number resulting in young people becoming accommodated under section 20 arrangements.   4.11. Supported accommodation policy permits residents to come and go as they please, however if they are under 18 and want to stay out overnight, they are required to give the address of the place they are staying and daily contact is maintained via text or telephone.  If security staff are unable to contact the young person they will  report them missing. In the autumn of 2018 Mother was 16 years old when she went missing, so still a child according to the definition in the relevant national guidance.14 She was also known to be pregnant although there is only reference in Police records to this as a possibility and not until the December 2018 incident.  The National guidance gives the Local Authority a duty to offer children a Return Home Interview15 within 72 hours of any child who goes missing being found or returning. None were completed because Mother’s whereabouts were so promptly confirmed by Police Officers that they did not submit either  Missing Person report or a Child Concern Notification (CCN) to Children and Family Services, as they should have done for any of the three occasions when the supported accommodation staff had contacted Police.  On the first and third occasions16 Mother was seen by Police Officers to establish she was fit and well. It is not recorded whether she was spoken to alone as she should have been. According to Police records supported accommodation staff were “happy” for her to stay at Father’s address; they had no concerns for her safety, and had reported her missing as she had not confirmed her whereabouts for a few days. Supported accommodation staff told this review that  whilst they would not have used that  14 https://www.gov.uk/government/publications/children-who-run-away-or-go-missing-from-home-or-care   2014 15 This is different from the police ‘safe and well check’. Return interviews should be undertaken by a trained independent worker who is able to take forward actions that emerge. Interviews are an opportunity for the child’s voice to be heard and to find out what prompted going missing. 16 On the 2nd occasion supported accommodation staff informed the police she had been in touch before they gained access  11  terminology, as Mother being at Father’s  accommodation was not ideal, they did not believe there was a significant risk.   4.12. The home visit by the Community Midwife in February 2019 was a constructive response to the concerns raised by the ambulance service, especially as antenatal home visits by midwives were not standard practice at this time.  However whilst it is understandable that the Community Midwife arranged the home visit at the next antenatal clinic appointment as there was no immediate danger to the (unborn) baby, this delay did not take into account that Mother was age 16 years, i.e. still a child herself. There is also no evidence of any enquiry with Mother or Social Worker 3 by the person who had taken the referral from the ambulance staff about the source of the problem with the heating or whether this had been resolved.   4.13. There was also an occasion when Father’s vulnerability by virtue of his age and status as a child was not recognised. Father was under 18 years in February 2018 when he was cautioned for possession of cocaine. No Child Concern Notification (CCN) was raised with Children and Family Services, as there should have been, possibly because there was no other specific evidence of vulnerability. In future the Police intend to ensure that all drug arrests for children will be notified which will mean both that consideration can be given to whether the child might need support and also that there will be a record if future relevant referrals are made, for example should the person become a parent.   4.14. From September/October 2018 Mother and Father were consistently presenting as a couple who were expecting a baby, and this was known to a number of practitioners and agencies; for example Children and Family Services, GP surgery, Midwifery service and supported accommodation. Yet their needs as a young couple, in particular for accommodation, were not proactively considered. Paragraph 2.6 of the national guidance regarding youth homelessness mentioned above says the needs of the child should be considered in the context of any relationship with a partner, which includes providing accommodation with a partner. Father was himself only just 18 years old at this point.  The young parents’ accommodation is open to couples as well as Mothers or Fathers. Records show that Mother had been made aware of this in September 2018 but both the supported accommodation worker and Social Worker 3 told this review they believed that Mother’s preference was always for a tenancy rather than the young parents’ accommodation.    4.15. NSPCC research17 identified 10 common pitfalls in assessment practice. Three of these are particularly helpful in analysing practice in this case. The first relevant pitfall is “An initial hypothesis is formulated on the basis of incomplete information, and is assessed and accepted too quickly. Practitioners become committed to this hypothesis and do not seek out information that may disconfirm or refute it”. This is a phenomena sometimes otherwise referred to as confirmation bias; that a first view of a situation strongly influences future seeking or analysis of (contradicting) information.18 A number of practitioners described Mother as mature for her age, she generally presented as confident, candid and articulate. Whilst the pregnancy was not planned, Mother was happy to be pregnant There is no evidence that anyone asked  17 Broadhurst et al (2010) 10 common pitfalls in assessment practice and how to avoid them www.nspcc.org.uk/inform 18 Munro (1999) Common Errors of reasoning in child protection practice  LSE  research articles online http://eprints.lse.ac.uk/358/1/Common_errors_of_reasoning_1999.pdf 12  Father how he felt about the pregnancy.  Mother had taken up antenatal and postnatal health care service appropriately, although contact with other agencies during the whole period under review was more ambivalent, characterised by initial or limited engagement and then withdrawal.  No practitioner had any concerns about Father’s presentation or behaviour towards Mother or the baby during the period covered by this review. Some key information was self-reported. Whilst sometimes this was checked e.g. when Mother was contacted by Integrated Safeguarding and Intervention Team (ISIT) after the referral from the ambulance services her explanation that she was awaiting delivery of furniture was checked with Social Worker 3.   However there are other examples of limited evidence of any reflection, analysis or checks to see if what practitioners were being told was accurate. This included: telling Social Worker 3 that she was taking up independent skills training and support from supported accommodation; placing reliance on Mother’s good engagement with her own assessment in the decision not to conduct a pre-birth  assessment despite evidence of previous withdrawal; and parents telling a number of practitioners they had good support from their respective families.  Although the Midwife promptly alerted the GP when she discovered that Mother was not registered with a local GP, she accepted Mother’s (false) self-report at the next clinic as it is not usual practice to check.   4.16. A second relevant pitfall is “attention is focused on the most visible or pressing problems; case history and less “obvious” details are insufficiently explored.” Information about history and risks were not always visible in records or consistently available, sought or shared within or between agencies. When Local Authority 1 referred Mother to the Integrated Safeguarding and Intervention Team (ISIT) in early 2017 there was a verbal exchange of information but no previous assessments or chronology were provided or requested, for reasons which are not known. Whilst Police checks were done regarding Maternal Grandfather and his partner there is no evidence that historical information was sought during assessments by Social Workers from agencies in Local Authority 1 about Mother’s health or education, nor about the Police investigation that was on-going regarding the rape by the ex-boyfriend. At the time of the first assessment Mother was 14 years old, living with a parent with whom she had not lived for many years and attending a new school at a critical point in her education. Social Worker 3 told this review that by the time of her involvement she felt there was sufficient information in the contacts and two previous assessments to make direct contact with Local Authority 1 unnecessary.    4.17. Mother’s GP record contains multiple scanned documents which include extensive involvement from a school nurse in Local Authority 1.  However the contents of these had not been summarised which meant that any GP seeing her would not be aware of her history without extensive reading of the records, which is not possible for routine appointments. Whilst this was complicated by Mother’s movements between areas/practices, she was registered with the first practice in Local Authority 2 for 18 months which would suggest arrangements for compiling summaries are not robust. A local GP told this review that making a summary of a patient record is usually an administrative task. This would have been very challenging by the time of Mother’s arrival in Local Authority 2 given the volume and complexity of the information contained in separate documents.  He felt that standards might be improved by training and auditing to agreed area-wide criteria.  In addition it is not known why the school nursing records from Local Authority 1, which would have been valuable to the 13  school nurse locally, were not available at the time to her, nor why there was no liaison between the two school nurses to share information.   4.18. Limited Information about any of the social work assessments appears to have been shared with other agencies, other than the outcome; there is no evidence that any social work assessment was shared with other agencies, nor of seeking Mother’s consent, which would have been necessary before sharing an assessment. Social Workers told this review that, unless assessments resulted in either a Child in Need or Child Protection Plan (neither of which were applicable in this case) it was not usual to have any multi-agency meetings or share assessments with other agencies, unless they were requested or it was identified as important for a specific  reason.  It would have been good practice to share the third assessment with the Midwife in full, particularly in view of the Social Worker’s conclusion that an Early Help Plan would have been helpful, had the parents been willing to accept one.  It is not known why the Midwife did not ask for a copy, although practitioners told this review it would be unusual to do so unless the Midwife wished to challenge the outcome, (which she didn’t in this case). It was also pointed out that it would be harder to challenge the outcome without seeing the details in the assessment. Not having a copy of the assessment meant that both the Midwife and then subsequently the Health Visitor had very limited knowledge of details in the assessment, including not knowing all the relevant history.  In addition, the handover from the midwifery service to the Health Visitor was incomplete in terms of full information about all referrals made and their outcomes. Therefore, the Health Visitor was not aware of all risk factors or that the preferred outcome of the latest social work assessment was for support via an Early Help Plan.  Being better informed might have led to a more cautious approach both to reducing the level of health visiting support to Universal and/or identifying the mark as a birthmark.  Practitioners also expressed the view that it would be helpful to more routinely seek consent for copies of assessments to be shared with GPs given the whole-life continuity of service they provide.    4.19. Lack of continuity of service due to Mother changing address sometimes made information sharing more difficult. During the period covered by the review she was registered with 4 different GP practices. When midwives were aware she had moved between South Tyneside and Local Authority 1 they took steps to ensure she continued to received antenatal care. However they were not always aware she was not registered with a GP; in particular as the specialist young women’s Midwife was not GP attached she would be unaware of the fact that mother had not re-registered with a local practice until a need arose to contact the GP practice.   4.20. Sometimes information sharing was made more challenging  by more specialist services within agencies not having access to records available to their colleagues providing universal services. The Pregnancy Options Advisor did not have access to any other Health system records or vice versa. The Midwife working with young people did not have direct access to GP records. To overcome this verbal handover or printed handout is given to the specialist Midwife from the booking Midwife, which includes any relevant safeguarding information, GPs do not have access to midwifery records, midwives in a specialist clinic (eg the young women’s clinic)  engage with the GP or the GP practice safeguarding Multi-Disciplinary Team (MDT) indirectly via the Midwife attached to the GP Practice  for cases  where they have identified social risk. If the antenatal care had been provided by the Community Midwife at the GP Practice, as it would be now due to recent service changes, the MDT would have 14  been informed of the antenatal Integrated Safeguarding and Intervention Team (ISIT) referral. There would have been discussion at each MDT until all practitioners present (Midwife, Health Visitor and GP) agreed that there was no ongoing risk, with better hand-over and documentation in GP records of the child of the antenatal concern, and therefore a more robust handover of care to GP and Health Visitor.    4.21. It is unclear whether Mother and/or baby was discussed at any MDT meeting during the period under review; if they were discussed at the first Local Authority 2 GP there was no entry made on the patient record. Consistently ensuring the outcome of MDT meetings is transferred to GP patient records is not a problem unique to Local Authority 2, so discussions could have been held, although the GP from local practice 2 confirmed that there were none during the period Mother was pregnant or after Child J’s birth, as the practice has a robust system for adding notes to the patient record contemporaneously. At the time the criteria for discussion at MDT meetings did not include Mother’s circumstances as she had none of the adult vulnerabilities listed and neither these nor the child criteria include pregnancy/parenthood at a young age. (This will be amended as a result of this review).    4.22. Mother was the sole subject of the social work assessment started at the end of 2018; no pre-birth assessment was conducted with regard to Child J. Initially this was because at the point of the first referral the pregnancy was in its earliest stages. The decision was reviewed by the Practice Manager when Mother returned to Local Authority 2 in November 2018 and again when the Midwife made a referral in December 2018. Decisions about whether or not to do assessments on unborn children are made on a case by case basis. The Team Manager told this review that the deciding factors were that there appeared to be no safeguarding concerns or new vulnerabilities not previously known about and that Mother was engaging with her assessment and so the plan was to continue the existing assessment only, ensuring that it covered accommodation, relationships and support.  This meant that there was only limited consideration of Mother’s parenting capacity and no profile on Father: his parenting capacity; and the family and environmental factors, particularly his history and  the functioning of his wider family, as there would have been had a pre-birth assessment been completed.    4.23. A third relevant pitfall from the NSPPC research previously cited is “There is insufficient full engagement with parents (mothers/fathers/other family carers) to assess risk.” Analysis of this regarding engaging Father is contained in the theme insufficient attention given to males below. Insufficient consideration was given to the level of family support the young couple might receive. Specific details about the nature of the support were either not sought, or the potential implications of information available was not recognised. All agencies knew that Maternal Grandmother lived over 200 miles away; therefore day to day practical support was unlikely to be forthcoming, despite Mother reporting daily phone contact. Two agencies that had had contact with Maternal Grandmother described behaviour which might cause difficulties for Mother. Supported accommodation records show Maternal Grandmother telephoning staff about safety in the supported accommodation; whilst this could be seen as advocating on behalf of Mother, there was no evidence of the actual concerns that Maternal Grandmother raised. Records show that staff  interpreted her behaviour as “hostile” , and her stance may have encouraged Mother to pursue these unsubstantiated concerns too.   The Community Midwife told this review that in the last four weeks of Mother’s pregnancy Maternal Grandmother 15  attended antenatal appointments with mother. Due to the way Maternal Grandmother had behaved at these, the Midwife had some concerns about the relationship dynamics between Maternal Grandmother and Mother. As she was only staying in Local Authority 2 for a short time Maternal Grandmother was keen for the baby to be delivered and the Midwife felt that at times she tried to tell her her job. The Midwife did not feel that Maternal Grandmother posed a threat as she was returning to Local Authority 1, however there is no evidence of consideration of the impact of the consequent limited practical support she might provide, or how her attitude to services might influence Mother’s response to professional advice.   4.24. A number of agencies knew that Mother’s relationship with Maternal Grandfather, and his influence on her engagement with services was also not always positive. On her arrival in Local Authority 2 Maternal Grandfather ensured she was enrolled in a school, registered with a GP, and was sympathetic regarding previous abusive experiences once he became aware of these. However records show he was reluctant for ongoing involvement of any non-universal service, including ones with which Mother seemed to be positively engaging and benefitting. For example YPVA staff believed that Mother disengaged with their service after the referral they made in June 2017 to the Integrated Safeguarding and Intervention Team (ISIT) due to his influence; as well as refusing consent for assessment by or support from social workers, he had made it clear to the YPVA service that he disapproved of the referral. Children’s Social Care records (contacts and assessments prior to the pregnancy) also show a variable relationship between Mother and Maternal Grandfather; times where they seemed to get along and other periods where the relationship broke down, also alcohol misuse by Maternal Grandfather and his partner and alleged domestic abuse in that relationship.   4.25. Records show that both parents told practitioners that Father’s family would or did provide “good support”, however no practitioner seems to have explored what that meant in detail in terms of day to day practical and/or emotional support.  Social Worker 3 told this review that she had briefly met Paternal Grandmother and Paternal Aunt when visiting the new tenancy.  Perhaps the lack of some furniture she found at her visit to the new tenancy should have made her more sceptical of the parents’ statement that they would help with furniture and baby equipment. Mother also told her she could maintain a positive relationship with Paternal Grandmother after some initial unspecified difficulties.   However in particular did hold information that might question the paternal extended family’s ability to provide effective support, for example: there had been a number of referrals about conflict and aggression between family members and antisocial behaviour in the community: Father had left home at a young age due to overcrowding; and Father’s family had been removed from a GP list due to aggression from his parents.   4.26. Part of the reason for the referral to the Integrated Safeguarding and Intervention Team (ISIT) from the Pregnancy Options Advisor was recognition of Mother’s social isolation. Social Worker 3 told this review she had tried to encourage Mother to move into the parents’ accommodation as this would give her the opportunity to make some friends of a similar age.  Mother had been encouraged by the Health Visitor to attend baby clinics and parent and baby groups at the children’s centre for the same reasons. However, she did not do so, despite indicating that she would. She was also 16  told about Bright Futures19 a charity which run a peer support group specifically for young mothers held in a Children’s Centre.    4.27. There was no evidence of consideration of an Early Help assessment by either the Midwife or the Health Visitor.  When the safeguarding referral was closed the Midwife did not challenge the decision as she was satisfied with the outcome of the referral and the Health Visitor felt that universal services were sufficient to support this family.     4.28. Services for young vulnerable parents were fragmented during the time period covered by the review.  The Family Nurse Partnership (FNP) service, which was designed to provide intensive support to first-time parents under 20 years old,20 was decommissioned in July 2018.  Since then the 0-19 child health service has developed a Young Parent Pathway with Public Health which is offered to all vulnerable parents under the age of 21 years of age. This involves increased visits by the named Health Visitor; two visits antenatally, followed by monthly visits for the first 6 months after the baby is born. However this pathway was not in place for during the ante-natal and post-natal period for Child J. In March 2019, before Child J was born, the Health Visitor changed the level of proposed support to universal after her visit as she felt there were no obvious risks or concerns and the parents seemed prepared for the birth. The decision to step down the level of Health Visitor involvement from “Universal Plus” to “Universal” was not overseen by a manager, who might have proposed an alternative approach of maintaining the status quo at least until it was clear how the parents were coping after the baby was born. As a result of this case the Health Trust intends to ensure management oversight of such decisions in future and to better promote the Young Parent Pathway, which has been followed by Health Visitors since September 2019, although it remains in draft at the time of writing.   4.29. The third social work assessment, which concluded towards the end of January 2019 obtained information from all the relevant agencies.  It identified that parents would benefit from an Early Help plan to provide support to Mother and Father and hoped this could be co-ordinated by an Outreach Worker from a Children’s Centre. The parents did not want the involvement of an Outreach Worker and so social worker involvement ceased as there were no safeguarding concerns that would justify over-riding their (lack of) consent. In any case the advice from the Children’s Centre Manager was that parents could not be allocated an Outreach Worker during Mother’s pregnancy. Nor could a service be offered after birth unless a Social Worker remained involved.  This would indicate a gap in Early Help service provision which could otherwise provide families like Child J’s with additional information and support pre and post birth.    4.30. Practitioners believe nonetheless that, Covid-19 restrictions notwithstanding, Children’s Centres have a range of useful services for young parents, including additional groups looking at specialist areas like benefits as well as more traditional  19 https://brightfuturesne.co.uk/  Parents can self-refer or be referred by a professional. works with  young women aged 11-25 ; raising their self-esteem and confidence around a range of issues which affect them including alcohol and substance misuse, sexual health and relationships, homelessness, family relationships, friendships, school, education, training, crime and anti-social behaviour.     20 The Family Nurse Partnership is an intensive, structured, home visiting programme, which is offered until the child is 2 years old.  There are conflicting perspectives in evaluation and research on how effective this programme is in a UK setting, but the point being made here is not about the effectiveness or otherwise of FNP, it is about decommissioning a service which practitioners were familiar with without being clear about what was going to replace it  17  parent and baby groups.  The local Children’s Centre was only a few streets away from where the parents lived; it is not known why Mother did not attend. It is recognised that young parents can feel vulnerable and intimidated but are offered support to attend if they require it.  This is important because service users in general are more likely to engage if services are accessible and responsive. It may require courage to request help, or agree to receive it, and the moment where they are most willing to engage may pass quite quickly. This effect can be multiplied for young people as adolescence in general is a time of rapid physical development, which may be out of kilter with maturation of the brain with the “executive” function, (which is responsible for planning, reasoning and impulse control) being the last to fully develop. Young people also tend to want to fit in with their peers.21 In terms of successful service delivery for young people, this means that the offer needs to be accessible, normalised/non stigmatising and offered in a timely and persistent way.   4.31. A number of agencies did recognise this through,  for example,  the use of text messages as one method of engaging Mother (supported accommodation staff, social workers, midwives,) and offering flexible appointments;  supported accommodation staff were willing to change appointments and both they and the Pregnancy Options Advisor offered evening appointments at Mother’s request. Some agencies were tenacious and/or proactive in attempts to offer support. For example in 2017 the YPVA staff attempted planned and unplanned appointments and contacted school to better understand the barriers to re-engagement and to promote re-referral, if appropriate.  Mother and Maternal Grandfather confirmed by text that they felt adequately supported by Police and education.  Staff at the supported accommodation were persistent verbally and in writing in attempting to persuade Mother to access support and benefits so that her rent would be paid, and agreed to have her back after her stay in Local Authority 1 towards the end of 2017.  Both agencies specifically recognise that it takes time to build trusting relationships with young people.  To build rapport and promote contraceptive planning the Pregnancy Options Advisor attends the hospital antenatal clinic for young women at hospital and offers home visits (which Mother took up) so that young people do not have to attend the sexual health clinic.   4.32. This case was not discussed in formal supervision received by the Pregnancy Options Advisor, Midwife or Health Visitor. However the Midwife did discuss the case with the named Midwife for safeguarding after receiving the notification from the ambulance about home conditions. Supervisees are expected to identify those cases that require discussion in formal supervision although supervisors may also choose cases or themes to discuss. The most recent national triennial report of all Serious Case Reviews conducted between 2014-1722 suggests that it is those cases already within child protection procedures which are most likely to be identified for safeguarding supervision.  Health practitioners told this review that the cases chosen by supervisees tend to be those which are particularly complex or already identified as involving safeguarding issues or where there is a difference of view with another agency;  for example about the outcome of a referral.  These factors were not considered to apply in this case, apart from the example given. Reflective supervision would have  21 Blakemore SJ (2018)Inventing Ourselves: The Secret Life of the Teenage Brain Transworlddigital 22Brandon M et al 2020 Complexity and challenge;  a triennial analysis of Serious Case Reviews 2014-17 Department for Education  18  challenged assumptions and more systematically identified risks and protective factors and gaps in information which might have resulted in better recognition of the level of vulnerability of these young parents. However it is understandable why this case was not raised in ongoing supervision by supervisees; especially in the context of practitioners’ whole workloads (Health Visitors have caseloads of 320 children each).    Summary of learning: How practitioners and agencies worked together to support young people/young parents  • Where expectant and new parents are under 18 years old practitioners should be mindful of their potential vulnerability and legal status as children however mature they may seem for their age • Where a 16 or 17-year-old presents as potentially homeless they should be offered an assessment under the Children Act 1989. If they have a partner assessment of their accommodation needs should take this into account, especially if either person is an expectant parent • Drug related arrests of children and young people should be notified to Children’s Services for consideration of risk and support  • Self-reported information may not be accurate and significant statements should be triangulated with evidence from other sources  • The importance of seeking understanding and using historical information to inform assessments and plans • Pre-birth assessments for unborn children provide added value to those completed on expectant mothers who are themselves children in terms of: a focus on fathers; the parenting capacity and family and environmental factors for both parents; and balancing strengths with risks  • There is value in seeking consent from service users to share Child and Family assessments, especially when there are significant vulnerabilities and/or further support has been declined.  • Assessments should be shared with GP’s as well as practitioners who are actively involved at the time; unlike many other services, their involvement continues throughout a child’s life  • The importance of practitioners exploring and considering in detail what parents mean by “good support” being anticipated or received from extended family members, including any potential impact on parents’ engagement with services  See recommendations 1 and 2   Theme: Insufficient focus on fathers/males   4.33. During pregnancy and the postnatal period, whilst the primary focus of services is understandably on mothers and babies, consideration should also be given to the couple relationship and the characteristics, circumstances and needs of fathers’   including the extent to which fathers are either a protective factor or a risk.  This was not effectively achieved in this case.    4.34. Enquiries about Father by Health practitioners were mostly limited to the standard antenatal and postnatal enquiries about Domestic Abuse. No practitioner working with the family knew he was not registered with a GP through most of the period. Although there is no evidence that this had an impact in this case, in general 19  encouraging fathers to register with the same GP as Mother (and baby) increases the potential for cross reference of relevant information.23   4.35. Although Father was seen by practitioners this was usually alongside Mother rather than in his own right, and the effect overall was that he was not as visible as a parent as Mother was. There are few references to Father in the midwifery and health visiting records, including no comment on his limited attendance at antenatal appointments; the Midwife told this review that Father did attend some appointments towards the end of the pregnancy but that at most appointments Mother stated he was at work. While this is likely to be accurate there is no evidence of attempts to consider the level of his likely involvement and abilities with the baby, the support he could give to Mother or any need he might himself have for information or support.  Whilst Father was asked by Social Worker 3 about whether a pre-birth assessment and Early Help support was necessary, this was towards the end of the assessment on Mother. His view that neither Mother nor he needed additional support because he had previous experience of babies in respect of his younger siblings and support from his family, including Paternal Grandparents seems to have been taken at face value.   4.36. Because there was no pre-birth assessment completed Father, did not feature significantly in the social work assessments.  This meant that Health practitioners working with parents in the antenatal and postnatal period had no awareness of his previous aggression towards peers, or the family history which included indicators of less than optimal parental care. Nor were they aware of some evidence that that the wider family style was to resolve problems through aggression, for example being removed from a GP’s practice list due to Paternal Grandparents’ aggression in the surgery.    Whilst both parents were seen to handle the baby there is no evidence of any specific detailed discussion pre or postnatally about their respective roles in Child J’s care.  Father was known to be working.  Whilst this provides him with some respite it also means he was likely to be tired and have much more limited hands-on experience.  Like mother he was also a young parent (he was still a teenager at the time of Child J’s birth) and there is no evidence that this was seen as a potential vulnerability, even notwithstanding the lack of knowledge by healthcare practitioners of his history of volatility.   4.37. The Triennial Review of Serious Case Reviews 2014-2017 previously cited found that there continues to be a “dearth of information” evident in practice about men, even in established relationships where the father is involved in caring for the child, as in this case. In the last 5-10 years there has been increasing focus on tackling the (lack of) attention to fathers in assessment, care planning and service delivery and provision. Whilst there is an American study that focuses on home visiting programs (sic) by professionally trained staff with the aim of promoting the health and development of young children, the majority of the (UK) academic research focuses on Children’s Social Care. However the issues described and the tactics and strategies suggested to improve engagement are largely consistent across the studies24 and have wider application to any agency working with parents and children.    23 There are plans to implement the Sharing Information Regarding Safeguarding (SIRS) which would entail the Community midwife contacting the fathers GP to request any safeguarding information that would be a potential risk to his ability to parent. 24 Swann G (2015) Developing an approach to improving support in Children’s Social Care Tavistock & Portman NHS Trust with the University of East London; Sandstrom et al (2015) Approaches to Father 20   4.38. Personal and contact details of fathers are less likely to be recorded than those of mothers,  who are also more likely to be included in meetings. It is not unusual for fathers to be involved late during interventions, and at crisis point. Where fathers are absent from children’s lives little attempt is made to find our whether they might be a protective factor or a resource and able to offer support. Where fathers are considered to pose a potential risk to children these risks are more likely to be assessed than any strengths. This is important because the literature reviews in the research cite a range of studies which demonstrate the benefits of (healthy) paternal involvement in children’s lives in terms of a variety of improved social, emotional and educational outcomes. Key determinants of a father’s successful involvement in the care of his children are: his willingness to be involved; his ability to adapt to changing family circumstances and his relationship with the child’s mother.  Mothers were found to be the primary gateway or barrier to a father’s involvement; at a basic level they could withhold information about his identity and might have very sound (e.g. safety) motivations to do so.    4.39. New fathers were found to need social support to manage the emotional transition to parenthood and integrate employment within parenting, support which may or may not be available from extended families and friends.  Despite recent trends in fathers spending more time with their children, in British society women tend to be seen as the primary care takers, unless this is very obviously not the case. Services for children, especially young children, are usually provided by women, which may make some men reluctant to engage, especially as generally speaking British men are not socialised to show vulnerability or discuss problems.    4.40. Whilst not underestimating the challenges, especially of working with men perceived to be dangerous,  the studies identified the following prerequisites for effective approaches: for practitioners to spend time building relationships with fathers; for services and approaches to be designed to appeal to men, and delivered  at times they found convenient e.g.  outside working hours.  The American study found that first time fathers in particular were keen to participate in programs(sic) that explicitly paid more attention to their needs and role. Fathers were appreciative of the efforts to engage them, and many (but not all) enjoyed the peer group support which many practitioners considered to be an essential component  of the offer.   4.41. Health practitioners told this review that the Young Parents Pathway included a monthly visit in the first 6 months, with additional support.  In terms of young fathers, pre-Covid-19 the Children’s Centres in Local Authority 2 had groups which have received good feedback from fathers that have attended.  However here is no monitoring of whether a father has engaged with the Young Parents Pathway as the majority of contact is with mother and baby. Whilst Health Visitors will try to actively engage with fathers when they are present at contacts there is no specific consideration within the pathway about how best to promote father’s engagement, nor whether they might benefit from any separate contact with a specific focus on fathering.  An additional barrier to practitioner contact with fathers since the period covered by the review has been necessitated by precautions during the Covid-19  Engagement and Fathers’ Experiences in Home Visiting Programs Urban Institute Scourfield J et al (2013) Improving the engagement of fathers in child protection Cardiff University 21  pandemic which mean that fathers are not allowed at scans or clinics. This may also have an impact on antenatal attachment for fathers.   4.42. The research previously cited concluded that effective inclusion of fathers in assessment and care planning/provision of support requires whole system change which requires: leadership from senior managers; understanding and tackling the gaps in practice and service provision; collecting data, setting goals and targets and monitoring progress, training for staff at all levels, and support and challenge through supervision for frontline practitioners.   The good practice guide for practitioners and managers produced by Gavin Swann which covers the practice issues for staff and their managers in a practical and accessible way is particularly useful.  4.43. When Mother went missing from the supported accommodation, it was anticipated by staff that she would likely be at Father’s accommodation and this is where the Police found her. Police Officers told this review that it would be standard practice to look round the property and consider the other persons there. In this case this does not appear to have extended to consideration of the other males in the property which was a House of Multiple Occupation, despite the CSE flag previously attached to Mothers record by the Police. Whilst some agencies were aware of the  potential vulnerability of Mother staying in this accommodation (e.g. supported accommodation staff told the Integrated Safeguarding and Intervention Team (ISIT) that the males were “older”)  there is no evidence that any practitioner visited the property or met any of the other males living there, or made any enquiries about them including asking Mother or Father what they knew. Social worker 3 told this review that whilst she knew that Mother stayed overnight sometimes with Father she thought this was mostly at Paternal Grandmother’s house. Prior to the couple moving into the joint tenancy, her meetings with Mother were at the supported accommodation and until this review she had not realised how very few nights Mother had stayed there.     Summary of learning: Insufficient focus on fathers/males   • Fathers need to be as visible in all agencies’ antenatal and postnatal care and support as Mothers  • Pro-active and tenacious attempts need to be made to involve fathers in assessment and the planning and delivery of support for children; this may require a specific approach to engage them   • When vulnerable young women stay with friends or partners in Houses of Multiple Occupation, professionals should show curiosity about the other residents, especially males, and consider whether they pose any risk   See recommendation 1   22   5. WHAT PRACTICE WORKED WELL?   5.1. When undertaking a review, it is important to also consider what worked well, especially if this might have broader applicability to protecting or supporting other children and families.  Examples of what worked well include;   • Mother’s first GP practice showed good practice with routine enquiry for domestic violence when attending for contraception consultation in 2017   • The YPVA worker supported Mother to report the historical rape  • When Mother reported the historical rape Police in Local Authority 2 informed Police in Local Authority 1 in case the ex-boyfriend continued to associate with young girls   • The ability of SW2 and SW3 to develop strong relationships with Mother  in short time periods; Mother was comfortable in contacting them both to request further advice and support when she felt this was required  • Referral to Local Authority 1 in 2018 included a brief chronology of involvement  • Pregnancy Options Adviser completed a comprehensive initial assessment which included historical information.  The referral to the Integrated Safeguarding and Intervention Team (ISIT) was also comprehensive and included mother’s views  • In early June 2019 the Pregnancy Options advisor visited Mother at home at her request to discuss contraception; future plans had also been discussed towards the end of the pregnancy    • A range of practitioners completed a routine enquiry that Mother was not victim of domestic abuse during her pregnancy/after the baby’s birth  • When Mother was accompanied to GP appointments the name of any accompanying person was recorded    • The supported accommodation staff kept her place open, despite her not staying often  and kept trying to engage her    • The ambulance crew attending Child J made a referral  to the Integrated Safeguarding and Intervention Team (ISIT) due to the bruising witnessed by the crew in an immobile baby.   6. CONCLUSIONS AND LESSONS LEARNED   6.1 The Triennial report on Serious Case Reviews (SCRs) between 2011 and 2014  identified that children of teenage mothers with one child are disproportionately likely to come to significant harm and be the subject of a SCR compared to those of older mothers. Cases involving teenage mothers comprised 54% of the cases, whilst the average age 23  of all first time mothers was 28 years old in 2013 and 2014.25 In 2011 Ofsted published a thematic analysis of Serious Case Reviews conducted between 2007 and 2011 with a particular focus on babies under 12 months old and older children.26  The key findings for the babies were: shortcomings in the timeliness and quality of pre-birth assessments  including no pre-birth assessment where one was justified; the risks resulting from the parents’ own needs being underestimated, particularly given the vulnerability of babies; that there had been insufficient support for young parents;  the role of the fathers had been marginalised including insufficient understanding of his role in the family; a need for improved assessment of, and support for, the parenting capacity of both parents; particular lessons for both commissioning and provider health agencies, whose practitioners are often the main, or the only, agencies involved with the family in the early months; practitioners underestimating the fragility of the individual baby. A number of these findings resonate with this case. 27  6.2 Mother almost always presented as mature, confident and articulate to the extent that her youth was overlooked and her vulnerability due to her history tended to be underestimated before, during and after her pregnancy.  Practitioners had more incidental contact with Father, but had no concerns about the way he presented during the period covered by the review, and although his previous aggressive responses to conflict were concerning, practitioners  may not have seen him as a significant risk even if they had found out more about his background. Both parents had managed independent living and obtained a tenancy together. Mother had sought help on a number of occasions and taken up antenatal and postnatal care appropriately. However there was very limited curiosity about Father’s background and circumstances to assess whether he was a risk or protective factor and no detailed exploration of the couple’s  parenting capacity, either separately or jointly, nor any detailed consideration of the extent and nature of any support they might receive from their extended families.  These issues would have been more visible had a pre-birth assessment been undertaken. Because the parents did not seem vulnerable compared to other service users of a similar age, practitioners did not take sufficient account of the likely challenges faced by young parents with relatively limited social support and a level of adverse childhood experiences. Families like these are unlikely to take up support unless it is easily accessible, provided promptly at the time required  and perceived as non-stigmatising.  6.3 It is not known what the mark was on Child J’s arm, so it is unclear what any further response might have involved.  However at no (other) point was there any justification for imposing involvement that parents did not wish to consent to, and, even had they taken up services offered, no guarantee that Child J would have not received the injuries that precipitated this review.       25 Sidebottam P et al (2016) Pathways to harm pathways to protection; a triennial analysis of Serious Case Reviews 2011-14 Department for Education 26 Ofsted (2011) Ages of concern: learning lessons from serious case reviews 27 In January 2020 the Child Safeguarding Practice Review Panel announced that they are undertaking a new national thematic review into non-accidental injury in children under one. One of the strands being explored is understood to be the importance of considering and working with fathers; the findings are likely to help with service improvements resulting from this review 24   7. RECOMMENDATIONS  7.1 The individual agency reports have made single agency recommendations.  South Tyneside Safeguarding Children Partnership(STSCP) has accepted these and will ensure their implementation is monitored.   7.2 To address the multi-agency learning, this Child Safeguarding Practice Review identified the following recommendations for STSCP: 1) That STCSP seeks assurance from all agencies that offer services to children and families that they have individually and collectively considered how best to: a. improve arrangements to engage vulnerable young parents, especially fathers and  b. ensure that all agencies keep fathers, as well as mothers,  in mind especially during pregnancy and early babyhood 2) That STCSP seeks assurance from Children’s Social Care that pre-birth assessments are being done for all babies that need them, and that Child and Family Assessments are shared more frequently and consistently with other agencies including GPs  3) That STSCP seeks assurance from each agency involved in this review that learning points have been identified and action has been/or is being taken to address and disseminate them     