Serious injuries to a 2-year-old boy in November 2020. Child A was subject to a child protection plan at the time, having previously been subjected to other injuries. Learning includes: professionals working with a family should fully understand the parental history held across agencies, including a full understanding of any learning difficulties; living with domestic abuse as a child can have an impact when a person becomes a parent; domestic abuse in the wider family may be a risk to a child; all professionals working with children need to be aware of and use the practice guidance for responding to bruises in non-mobile babies; if a child has an injury, information should be shared widely with all professionals to ensure awareness of the whole picture and any patterns of cumulative harm; when babies and children are reported to have sustained accidents, professionals should not only consider neglect through lack of supervision, but also the possibility of physical harm; professionals need to be empowered to challenge each other; and for a child's plan to be effective, a chronology of each agency's involvement is essential. Recommendations for the partnership include: review and update the practice guidance for assessment, management and referral on bruising in non-mobile babies; review and update the professional disagreement and escalation policy; partner agencies consider introducing a requirement that individual agencies produce impact chronologies for all child protection conferences; and request that agencies work together to develop systems that allow identification (possibly via a trigger or alert) when there are repeated injuries to a child or young person.
      
    Serious Case Review No: 2023/C9824  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.     1                       CHILD SAFEGUARDING PRACTICE REVIEW  CHILD A REVIEW REPORT  Independent Lead Reviewer  Chris Brannan 1                                                              1 Chris Brannan is an Associate SILP Lead Reviewer, and entirely independent of the SCP    2  Contents 1 Introduction to the case and summary of the learning Page 2 2 Process Page 2 3 Background prior to the scoped period Page 4 4 Key practice episodes  Page 4 5 Analysis by theme and learning Page 6 6 Conclusion and Recommendations Page 16   1.       Introduction to the case and summary of the learning from this review 1.1 This is a Child Protection Safeguarding Practice Review (CPSPR2) that considers practice with a 2-year-old child to be known as a Child A to identify learning.  The child suffered serious injuries in November 2020 whilst subject to Child Protection Plan, having previously been subjected to other injuries.  He was in the care of his mother and her new partner at the time of the injuries.   1.2      Learning has been identified in the following areas:   • Understanding the parent’s history • Responding to injuries in babies • Need for professional focus on physical harm as well as neglect   • Professional challenge of families and each other • Information sharing and communication • Impact of Covid-19    2.       Process 2.1 The Safeguarding Children Partnership (SCP) recognised the potential to learn lessons from this review regarding the way that agencies work together to safeguard children. It was agreed that this CSPR would be undertaken using the SILP methodology, which engages frontline staff and their managers in reviews and focuses on why those involved acted as they did at the time.   2.2 Agency reports are completed which give an opportunity to consider and analyse practice and any systemic issues and provide details of the single agency learning from the case. Then practitioners, managers and agency safeguarding leads come together for a learning event3.  All agency reports are shared in advance and the perspectives and opinions of all those involved at the time are discussed and valued at the event. The same group then attends a recall event to consider the first draft of the CSPR report.  Later drafts are also commented on by all of those involved, who make an invaluable contribution to the learning and conclusions of the review.  2.3 The views of the family are important to the review, to identify any learning from their perspective. In this case there was a delay due to the on-going police investigation. Child A’s mother was offered a face-to-face meeting but chose to be interviewed over the telephone.  She spoke very positively about the support she was offered by key agencies including Midwives, the Health Visitor and the Support Workers both prior to the birth to and following the                                                        2 Working Together to Safeguard Children 2018 Chapter 4    3  Further meetings with the Reviewer took place so that all practitioners could be involved in the process.   3 birth of Child A. She spoke about how the Health Visitor had offered practical support in her care of Child A and how during Covid lockdown the Support Worker had provided art materials and toys to engage and occupy Child A. She did not have any suggestions about how further help could have changed things in her care and management of Child A. 2.4 It was agreed that the review would identify learning by considering practice with Child A and his family from the time of his birth in December 2018 to the date he received the most serious of his injuries and was taken into the care of the Local Authority in November 2020.4  3.       The background prior to the scoped period  3.1 Agency reports identified that there had been concerns about Mother and her family from Children’s Social Care (CSC), Police and other Health professionals for a number of years.  There had been numerous referrals about Domestic Abuse involving Maternal Grandmother and her partners and allegations of sexual abuse against Mother and her siblings.  Mother was also identified by the Police at possible risk of sexual exploitation. 3.2 Prior to becoming pregnant with Child A, Mother was known to have had several Emergency Department admissions relating to concerns with mental health wellbeing, anxiety and physical health needs.  3.3 When she was expecting Child A, her midwife signposted her to mental health support services.  She had stated that the pregnancy had been unplanned, that the father was unhappy about the pregnancy and that they were no longer in a relationship.       3.4 Four referrals were made to CSC during the pregnancy to the Midwifery Services.  The first was following a domestic incident at the family home, involving her mother and mother’s partner. No Social Work assessment was completed.  Early Help was offered but the mother of unborn Child A did not engage.  3.5 No further information was sought or known about the child’s father. As he was not involved during the period being considered by this review and had no contact with Child A or his mother, he has not been further considered by the review.  3.6 Mother later met a new partner. His own children were the subject of referrals to children’s social care due to concerns when he was living with them, and he was known to the Police for a number of years for violent offences. There was an allegation of domestic abuse against his former partner, but no further action was taken. He had no involvement with adult mental health services until his arrest over Child A but recent information indicates that substance abuse may be an issue.  4.       Key practice episodes when plans in place. 4.1 The following incidents and the professional responses are largely where the learning from the review is found. Key episode 1:  4.2 On 13th January 2019 an incident occurred when Child A was aged 2 weeks old.  It was reported by Mother to the Regional Ambulance Service (RAS) that he had a head injury and had fallen from a sofa.  They relayed Child A to the local A&E hospital.  He was seen by a Junior Doctor whose findings were discussed with a Consultant.  No injuries were seen and the                                                          4 It was further agreed that any significant information and agency involvement with the family prior to this, including the pregnancy, should also be considered as required.   4 explanation was accepted, a letter was sent from the hospital to the Health Visitor to make her aware of the incident and for follow up with family.  4.3 The same day 111 5was called by the Maternal Grandmother requesting medication and later the police were called to the home concerning a Domestic Abuse situation, involving Maternal Grandmother and her partner. 4.4 Following the safeguarding referral from RAS, CSC carried out a Signs of Safety Assessment.  The recommendations from the assessment were for the case to be closed to CSC as the Social Worker had concluded that there were no concerns for mother’s parenting capacity and the explanation for the injury was considered plausible.   Key episode 2: 4.5 On 8th February 2019 RAS received a call from mother saying that Child A (aged 6 weeks) had fallen off a sofa and banged his head on the carpeted floor.  Ambulance staff visited and carried out an assessment.  No injuries were noted.  Later that same evening mother called 111 and stated that Child A had been crying non-stop.  They directed her to her GP.  Key episode 3: 4.6 On 13th August 2019 RAS received a call from mother stating that Child A (aged 8 months) had fallen and had a lump by his eye.  Mother said that Child A had fallen off on an air bed.  RAS staff recorded following their visit that the “story doesn’t quite add up”.  The Heath Visitor and Family Support Worker arrived coincidentally at the time and the Family Support Worker told RAS that a similar incident had happened two weeks ago.  Child A was taken to see General Practitioner (GP) by mother later that day.  A referral was made by RAS to CSC.  Key episode 4:  4.7 On 17th October 2019 RAS received a call from the mother stating that Child A (aged 10 months) had hit his head and was unsettled and vomiting.  The injuries noted were a contusion above the right eye, which was reportedly swollen with some redness to right cheek.  RAS made a referral to CSC.  He was conveyed to A & E at the local hospital where Child A was examined by a Consultant Paediatrician who concluded that the injuries were consistent with age-appropriate activities.  Child A was discharged home, but the matter was referred to the Emergency Duty Team (EDT) by nursing staff at A&E.  4.8 A Strategy Meeting took place the next day and this led to a joint Section 47 investigation.  Following the investigation an Initial Child Protection Conference (ICPC) took place on 15th November 2019.  The decision was that a Child in Need (CiN) plan was the most appropriate outcome for Child A.   Key Episode 5: 4.9 On 26th January 2020 Mother reported to RAS in a telephone call that Child A (aged 1 year) had fallen from his toy bike and had a bruise to his forehead.  The mother was advised to take the child to hospital.  She declined and said she would monitor him.  Key episode 6: 4.10 On 21st February 2020 a further head injury was reported to 111.  Child A (aged 1 year 2 months) was said to have his hit mouth/ head on a sink.  The injury was said to have happened the day before and no explanation was offered for the delay in reporting.  Their initial advice was that                                                       5  NHS 111    5 Child A be referred to his community dentist.  They then advised that Child A be taken to hospital as there had been a report of vomiting after the injury.    Key episode 7: 4.11 On 19th April 2020 Mother rang RAS and reported that Child A (aged 1 year and 4 months) had blood on the roof of his mouth.  Examination by staff did not find any injury but advice was given to contact the Health Visitor and GP. Key episode 8: 4.12 On 15th August 2020 there was a superficial laceration to Child A’s (aged 1 year and 8 months) left thumb.  Mother and Child A attended a local walk-in service for treatment to this injury.  This was said to have been caused on an oven whilst family were staying in a caravan with Maternal Grandmother and her partner.  A referral was sent by the Police to CSC but was saved on the wrong system and went to the Family Support Worker (FSW)   Key episode 9:  4.13 On 20th October 2020, Child A’s (aged 1 year and 10 months) Mother called RAS to report injuries to his head and ears caused when he slipped off the sink next to the bath (he had apparently been climbing out of the bath).  Ambulance staff attended and identified bruising to Child A’s forehead, right ear and a ‘boggy mass’ to the back of his head.  He was taken to A& E at the local hospital.  Child A was examined by a doctor who consulted with Consultant Paediatrician, both accepted the explanation given by mother as a plausible explanation for the injuries.  RAS made a referral to CSC.   4.14 Child A was discharged from the hospital following the examination.  His mother rang RAS later that same day and Child A was readmitted to hospital as he had been vomiting.  When Child A returned to the hospital the bruising had got worse and raised concerns about the child’s welfare.  4.15 A referral was made to EDT on 21st October 2020 from nursing staff and this resulted in a Strategy Meeting taking place on 22nd October 2020.  A Section 47 investigation then took place and a Family Assessment by CSC.  An ICPC took place on 10th November 2020 and this time Child A was made subject to Child Protection Plan under the category of neglect. Key episode 10: 4.16 On 17th November 2020 the Health Visitor noticed bruises on Child A (aged 1 year and 11 months) during a home visit.  Mother’s explanation was that they were caused when he fell on his toys.  The Health Visitor telephoned the Social Worker and expressed her concerns about the bruises.  The Social Worker visited that day and saw the bruises and accepted the explanation given by mother. Key Episode 11: 4.17 The final incident was on 22nd November 2020 when an anonymous call was made to Emergency Duty Team claiming Child A had bruising.  He was admitted to the local A& E and was examined and found to have extensive and multiple bruising to his face, genitalia, both arms, back and to the top of his right foot.  The explanation for the injuries were not consistent with the type and number of injuries.   4.18 A strategy meeting was held, and a joint Section 47 investigation was agreed.  Mother co-operated with Child A remaining in hospital, so no legal order was thought to be needed.    6 Mother later agreed to Section 20 voluntary admission into care.  Care proceedings were agreed, and an Interim Care Order was granted on 28th November 2020. 4.19 Both mother and her partner were arrested and continue to be subject to an on-going Police investigation. 5. The Learning    5.1 At the request of SCP this report will focus on what is considered to be the most important learning from the review. The learning points are identified below, following the review’s thematic analysis.  5.2 Understanding the parent’s history 5.1.1 Child A’s mother was the subject of a Child Protection Plan as a child largely due to domestic abuse. During her pregnancy with Child A, the Maternity Services shared concerns with CSC about on-going domestic abuse in maternal grandmother’s household, where mother was still living and intended to live with Child A.  They had also raised concerns about mother’s mental -health well-being and anxiety.  Children’s social care also received an anonymous referral from someone connected to the family due to their concerns about violence in the family. No social work assessment was undertaken at the time.   5.1.2 During the pathway hand over between maternity services and the Heath Visitor there was no mention of the domestic abuse in the family home, mother’s mental health was discussed however. This is because it was known that the new family would be living in their own property and not with the extended family.  Child A’s mother was supported to find her own accommodation due to the concerns about the environment for Child A at the grandparent’s home.  This was a positive outcome for Child A and his mother although it was known she was still going to spend significant amounts of time at her mother’s home, including overnight. There was a view that mother, as a young first-time single parent would require family support, but also there was the dynamic that was largely unrecognised at the time, that there was a need for support provided by mother to maternal grandmother due her own mental health issues.  5.1.3 The fact that the known domestic abuse was between adults who were not the child’s parents had an impact. Processes and practice about domestic abuse does not always extend to the wider family members, even if they are known to have contact with the child/ren. Maternity services along with other agencies had difficulty in dealing with the maternal grandmother, who was often threatening and aggressive to professionals.  It is not clear if her gender influenced how agencies viewed the potential risk to Child A and if it would have been different if the aggressive party was male.  Professionals need to think more widely about domestic abuse that a child may experience, not just between parents and to recognise that women can also be perpetrators of domestic abuse.  5.1.4 Between August 2019 and March 2020 there were seven Rapid Reviews completed in the Local SCP area. Not all of the reviews met the criteria met the criteria for a Child Safeguarding Review, however there were some common themes identified in all of the rapid reviews. A thematic review was commissioned and one of the areas of focus was Domestic Abuse. It raised the question about how professionals are able to measure the impact of domestic abuse on babies and gave examples of “presentation of the behaviour of baby, baby unsettled, cries a lot or turns their ahead away from the carer.” The police in their agency report identified that there was a lack of acknowledgement by officers of the impact of domestic abuse even if the child is not in the room and is very young.  This may be an issue across agencies.          7 5.1.5 Three assessments were completed by CSC in respect of Child A and all raised the issue of domestic abuse in the family but largely as a historic concern. They also did not give due attention to mother’s ability to parent her child safely. The need to acknowledge and understand the impact of Child A’s mother’s apparent learning needs, understanding and capacity was raised both in the agency reports and in discussions with professionals.  It has been acknowledged that the first two social work assessments were not of the standard that is now expected and that significant learning had been identified from this time generally as well as from this case. The work with Child A and the mother reflects the difficulties and need for improvement in children’s services at the time.  5.1.6 By the third social work assessment there was a view that Mother probably required a cognitive assessment to understand her level of functioning. It was known that she had experienced significant trauma in her childhood and that she had a history of her own abusive intimate relationships which were also impacting on her parenting. No formal assessment was completed in respect of Mother’s understanding and learning needs, although this was emerging as an ongoing concern. The first child protection conference made a recommendation that a PAMs6 assessment be completed as part of the child in need (CIN) plan, in order to consider the issues further.  The same issues were identified at the second ICPC and it was acknowledged that this type of assessment remained outstanding and was required. Such an assessment could have included a clearer understanding about the impact of Mother’s childhood experiences, her capacity to understand her parental role and her ability to keep Child A safe at the time and in the future. 5.1.7 The review was able to reflect with the professionals involved that if a parent reports that they attended mainstream schooling, this does not mean that they do not have learning needs, and if there are concerns in this area, further enquiries should be made. In this case although Mother reported attending a mainstream school, she in fact attended alternative provision for a period, indicating that she had significant issues at school. Mother’s first social worker did a lot of budgeting work with her and noted that she struggled to understand and to retain information, highlighting an element of learning need. However more generally she presented as if she understood things, and the social worker was largely reassured, while identifying that she would require parenting support going forward, particularly with her child’s changing needs. The health visitor, who would be working with mother, felt her needs were extensive and also noticed there were issues with retention of information. The health visitors planned to ensure that Mother received advice in small chunks that were repeated and reinforced. The family support manager confirmed they also had a plan for bite-size information given regularly. Information has since emerged, following the serious incident, that mother does have a low IQ which is likely to have an impact on her ability to parent, and this information would have been helpful to the professionals providing a service at the time.    5.1.8 There were other indicators that Child A’s mother was having difficulties. The number of calls both to RAS and 111 gave an indication about how mother potentially struggled to cope with minor ailments for Child A (and for herself in some cases). There was a total of 28 calls to these agencies. The review reflected that despite the issues, she appeared to be able to mask her trauma and learning needs and was very plausible when dealing with agencies about the cause and nature of some of the injuries to Child A.                                                            6 Assessment and support using the Parent Assessment Manual, which gives the assessor techniques to be used when they are working with parents and families with a learning difficulty or disability.   8 Learning: • The need for all professionals working with a family to fully understand the parental history held across agencies is key to providing the right support for parents and protection for young children. This includes a full understanding of any learning difficulties.  • The need to consider how living with domestic abuse as a child can have an impact when a person becomes a parent.  • Domestic abuse in the wider family may also be a risk to a child.    5.3  Following policies and procedures and information sharing when a baby or young child has  an injury  5.3.1 There were a total of eleven incidents of actual or reported injuries to Child A in the first two years of his life.  There was a mixed response from agencies about how these incidents were dealt with. In three of the incidents there were strategy meetings and section 47 investigations followed by initial child protection conferences on two of these occasions. One of which led to Child in Need Plan (CIN) and the other to a Child Protection Plan (CPP).  At the initial conference there was very little evidence presented about the work completed with mother around her parental skills. This led to the chair of the CP conference stating that there needed to be improved assessments and parenting support before a child protection plan was made.  This is considered further in section 5.4.   5.3.2 The case was passed to a new social worker who was not present at the ICPC. This has raised a systemic issue, as it had emerged that the social worker and the new manager focused on the need for a PAMS assessment in supervision and discussed the reasons for such an assessment being around Mother having a diagnosis for a learning need rather than the need for a “parenting assessment“ as such. As mother had no diagnosis the purpose of the parenting assessment was lost. This was therefore taken out of the CIN Plan. The focus of the plan focused on providing support without a more detailed assessment of mother’s parenting ability and potential learning needs. Social work supervision records show that at the time there was little reflection, but rather a list of tasks required.  Without a PAM assessment, Mother’s learning needs and capacity to provide good and safe parenting to Child A requiring a lot of support were largely unidentified.  As well as a change of social worker, a restructuring led to a change of team manager for the social worker during the time he was working with the family.  When there are changes of professionals, the initial concerns and plan for a case can be lost sight of.   5.3.3 At the time of the first incident, Child A was two weeks old and hence a non-mobile baby.  The June 2017 Safeguarding Children Partnership Practice Guidance for Assessment, Management and Referral on Bruising in Non-Mobile Babies was available to all professionals7.  In discussions with staff during the review some have confirmed being aware of and trained in using the guidance. However, it was not referred to in any documentation completed at the time of the first incident. A review of this Practice Guidance was due in 2020. It has not yet taken place and a recommendation is made in respect of this, including the need to ensure that not just ‘bruises’ are of concern. Policies need to be regularly reviewed so that they reflect current practice from learning and research.  The decision not to carry out a Strategy Meeting in line with the policy may have been influenced by the fact there was no bruising to Child A at the time. The issue of no bruising should not detract that he was not mobile and apparently suffered a head injury but no injuries were noted.                                                          7 It was due for review in June 2020. There is no information to confirm that this happened.    9 5.3.4 On reflection it has been agreed that in line with the guidance, a Strategy Meeting should have taken place and plans made for assessing that injury. The CSC assessment that was undertaken at the time concluded that the family should be stepped down to Early Help for support as the injury was not seen as concerning. The National CSPR published in September 2021 found this was a recurring issue nationally, stating that evidence that ‘policies and procedures on bruising and marks on non-mobile infants are still not always followed by practitioners.’ The review understandably questioned how these procedures are monitored for ‘adherence and impact’ in the area. This is also an issue being considered by the Safeguarding Partnership. 5.3.5 It is important to consider the wider context that professionals in local area were working in. The Local Authority children’s services had been judged by the Office for Standards in Education, Children’s Services and Skills (OFSTED) as “inadequate”.  This had an impact on the on-going issue of local staff recruitment and retention. This was significant to practice with Child A as was the  Children’s Services were functioning with large numbers of vacancies and agency social workers. In this case there were different social work staff involved at key episodes, but there was also the wider impact on staff of change and uncertainty at the time. Prior to this there had been a service redesign of health visiting provision that staff were adjusting to, as well as a new electronic system which had taken time to implement and embed.   5.3.6 The next incident (key episode 2) was not reported to other agencies by RAS. This may have been  because no injury was noted.  However the GP was notified under the Docman NHS Service. This is an electronic system to share information across the NHS. The GP practice had been aware of this incident and others reported about Child A but as confirmed in their agency report it did not prompt further communication or investigation. Incidents were at best seen in isolation, or not considered at all. In respect of RAS staff, they also tended to deal with each injury or incident in isolation. When attending they are not currently informed about previous incidents known to their own agency, which means they are working with the current case without any idea if cumulative concerns are an issue. Work is currently taking place within RAS to implement a new system which will ensure staff attending a patient are easily able to access any previous calls.  5.3.7 In the third incident (key episode 3) there was reportedly a lump near Child A’s eye.  The child was seen initially by RAS. The Health Visitor and Family Support Worker coincidentally arrived at the same time as the ambulance service, so were aware of the injury. The mother then took the child to the GP at the suggestion of RAS. The GP who saw the child does not appear to have been aware of the two previous issues, which means that they did not consider if there was a pattern of either abuse, or neglect from lack of supervision. In that incident a report was said to have been sent by RAS.   5.3.8 It has been established that a safeguarding referral was sent by RAS to CSC in respect of key episode 3. All were sent to the required email address.  Although CSC said they had not received the third email, the review has confirmed it had been received but had been recorded as a document and was not passed to any team.  The reason given was human error.  This raised several questions including whether CSC be sure it has not happened in other childcare cases. A challenge was made by the review to ask CSC what systems are in place to check that referrals are being received by the correct team and an urgent review was undertaken to ensure it was not a wider issue. Other agencies were aware of these three incidents, including GP, Hospital, HV and FSW but it did not trigger any response from them. This   10 is further discussed below where professional information-sharing and communication is considered.  5.3.9 A number of agencies were made aware of the next injury to Child A (key episode 4) when he was admitted to hospital. However, he was discharged before the matter was referred to EDT. No explanation was given at the time for this happening.  Despite this, there was a single agency Section 47 investigation by CSC and an assessment was agreed.  It was carried out by a social worker who was part of an Intervention Team set up as part of the improvement plan following the OFSTED inspection. The recommendation from the investigation and assessment led to an Initial Child Protection Conference.  The Conference was attended by Heath and Social Care staff. The police did not attend but sent a report. The Health Visitor for the family did not attend but an experienced colleague attended in her place, she knew the case well and was briefed before the conference by the allocated health visitor. The majority of agencies present recommended that Child A be made subject to a Child Protection Plan (CPP). The Independent Chair considered that not enough work had been achieved by the Family Support Worker in assisting mother as had been recommended from the first social work assessment following the first injury to Child A.  5.3.10 The chair was concerned that placing Child A on a CP plan was unfair when the mother had agreed to support but had not received it. The chair therefore overruled the recommendation from the other agencies and Child A was made subject to a Child in Need (CIN) plan rather than a CPP. This was an understandable and justifiable decision.  The Chair believed that making the child subject to a Child Protection Plan would not have added to his safety and that this could be achieved under a CIN plan, as the child’s mother was both asking for help and was clear that she needed support.  The family Health Visitor, who had not been present at the conference, but had worked with the Family Support Work maintained when interviewed that work had been achieved with mother but she had struggled to take on the advice and support given, which is why she believed that a step up to a CPP was required. Records from Early Help evidence regular contact initially but following transfer another team there was little evidence of support being provided to Mother and Child A in the months prior to the ICPC. 5.3.11 The Social Worker involved with the family were not informed of two further incidents that occurred whilst Child A was subject to the CIN plan. These incidents were known to RAS and to 111 respectively.  The review has found that these services are not able to establish easily if there is an allocated social worker, only if the child is on a child protection plan. As Child A was on a CIN plan, they were unaware that there had been concerns and an ICPC. This is a systemic issue that needs further consideration. 5.3.12 When the CIN plan came to an end, Family Support became involved again under Early           Help. Much of this involvement was during the height of the COVID-19 pandemic March –June 2020.  The issue of how the pandemic affected this case will be reflected on later in this report.  The Family Support Worker was made aware of the next two injuries to Child A, as she was told by mother.  The first incident, RAS were involved and the other involved attendance at a medical walk-in centre. Neither RAS nor the Medical Centre reported the incidents to CSC. The family support worker did not consider the injuries as a potential child protection matter so did not discuss Child A with CSC and did not share the information with the allocated health visitor. The review has also noted that the information had been shared by mother and that no notification of the child having an injury was formally shared on either occasion. This also means   11 that no one agency had a complete history of the number of injuries to Child A, meaning that the opportunity to consider cumulative harm or a pattern of concern was not possible.  5.3.13 The next three incidents show an increase in the scale of injuries.  The first incident involved Child A being taken the local A& E hospital.  He was examined and discharged prior to being referred to EDT, as had happened previously.  Child A had been readmitted by the time EDT had been informed of the first attendance.  The Doctor who did the examination was involved in the Learning Event and gave detail about he how considered the injuries consistent with the explanation offered but was not able to dispute mother’s claim that Child A bruised easily. During the Section 47 investigation that followed, professionals were made aware that mother had a new partner.  The assessment report identifies him but states he is not living in the household.  The statement from the Family Support Worker identifies mother’s new partner as being present in the house on one occasion prior to this incident.  From Police investigations it is believed their relationship started in early September 2020.  5.3.14 The outcome of the investigation was for an ICPC where Child A was made the subject of a Child Protection Plan(CPP) under the category of Neglect. There was a view shared in the assessment and ICPC that these injuries could have been accidental, with the main issue being a lack of supervision. No assessment was requested in respect of Mother’s new partner as the conference was told he did not live with the child. This was an oversight as despite not living together there were indicators that the new partner was spending a lot of time in the home and likely to be involved in the care of Child A. 5.3.15 The next two incidents happened very shortly after the CPP was made.  The first one was referred by the Health Visitor to the allocated Social Worker due to bruises seen on Child A during a visit to the family.  The Social Worker assessment was that the bruises could have been caused by the explanation offered by mother.  Discussions with staff involved with this incident now agree that a strategy meeting should have been held, followed by a timely medical examination and a Section 47 investigation. The final incident led to an immediate Section 47 investigation and subsequently Child A was made subject to an Interim Care Order. It was the rapid review of this incident, which also considered all of the other injuries that preceded it, that led to the decision to hold this CSPR. It was noted that there appeared to be significant issues about the response to each injury and information sharing about them.  5.3.16 During the discussions at the second ICPC the focus was on the risk to Child A due to neglect and agencies were very accepting of the explanations for the injuries.  It was only after the final incident where Child A received significant and concerning injuries that agencies began to review the earlier injuries.  During the recall event, it emerged that a number of the nurses in the hospital who had seen the earlier injuries had questioned the option of the doctors who considered the injuries accidental.  As will be discussed further below, staff at all levels need to have the confidence to challenge their peers and also those above them.  Clear systems need to be in place to support this. This also applies to decision making about whether a strategy meeting is required.  Learning: • All professionals working with children need to be aware of and use the Practice Guidance for responding to bruises in non-mobile babies and this review has shown the need to refer to the policy if there is any apparent or reported injury on a very young baby, not just bruising.    12 • Information must be shared widely with the professionals working with a child and family if the child has an injury, to ensure that each professional with responsibility for the child is aware of the whole picture. They can then consider patterns and cumulative harm and whether they need to challenge another professional.   • When babies and children are reported to have sustained accidents, professionals must remain open to the possibility that the child may have been subject to physical harm and not only consider neglect through lack of supervision. Physical harm must be risk assessed particularly in non-mobile children even if the explanation may initially seem plausible.  5.4 Professional challenge  5.4.1 Professional challenge should be seen as an important part of a healthy safeguarding system. Practitioners should be encouraged to give or receive professional challenge in a constructive way, that is child centred and not personal. During the period that is being considered by this review there was an agreed Professional Disagreement and Escalation Policy produced through Local Safeguarding Children Partnership. The policy sets out the process staff should take if they have a professional disagreement and if not resolved how they can escalate it.   5.4.2 The review has identified several occasions when effective professional challenge could have been used by staff to review decisions and practice made by other professionals and their agencies.  Challenge is known to be an effective way of allowing individuals to consider alternative options of intervention and practice with a family.  Munro et al8 raised the importance of practitioners working in child protection being able to admit they may be wrong and to revise their views following reconsideration and/or challenge9.  She wrote that ‘assessments are fallible, and contexts constantly changing. Therefore, professionals need to keep their judgments under constant critical review’.   The first opportunity for challenge in this case was during the pregnancy. Maternity services had made three referrals to CSC sharing concerns about domestic violence within the household and concerns about Mother’s vulnerability.  They rang CSC on a number of occasions and were told that an assessment was being undertaken.  Maternity services challenged those making the decision at the time, stressing their concerns, but did not formally escalate their concerns by discussing the case with their agency safeguarding lead and using the then LSCB policy. It was acknowledged that those making referrals to CSC did not always know what the response was to the referral, which makes challenge difficult. CSC are aware that they have work to do to ensure that referrers are informed of the outcome of the referral in a timely way. If the outcome is a social work assessment, the result of this also needs to be shared with those making the referrals in order to allow them to again consider if a challenge is required.  5.4.3 Another opportunity for a professional challenge was in respect of the first ICPC.  Those present, and the police who did not attend but submitted a report, stated their view that Child A be made the subject of a CP plan.  The independent chair decided to overrule the majority view arguing that the support that had been planned with the family had not been provided and that this should be tried through a CIN Plan before resorting to a CP plan.  The chair told the review that it was very rare for her to overrule a majority decision, and the fact that she did so reflects the strength of her feelings about the lack of work undertaken prior to the conference.  There was disagreement during the review regarding this decision. The family health visitor, who did not attend the ICPC, told the review that she believed at the time that significant work had                                                        8 Fish, S, Munro, E. and Bairstow, S. (2008) Learning together to safeguard children: developing a multi-agency systems approach for case reviews. Social Care Institute for Excellence.   9 ‘The single most important factor in minimising errors is to admit that you might be wrong.’ Munro et al 2008    13 been completed with mother by the Family Support Worker.  At that same ICPC, the Police who did not attend had sent a report with their recommendation for a child protection plan for Child A. Their learning from this review includes the fact that they have no system to check the outcomes of CP Conferences and whether their recommendation had been accepted or not, which means they are then unable to consider if they wish to challenge the decision. This matter has been brought to the attention of the Police conference team for attention and action. 5.4.4 The third potential opportunity for a professional challenge to be made between agencies was when the Heath Visitor observed bruises on Child A.  She told the review that she was not satisfied with the explanation from the mother as to their cause and that she rang the Social Worker and asked her to visit to assess the bruising.  The Social Worker rang her back and said she had seen Child A and the bruises and had accepted the explanation and was taking no further action.  On reflection, the Health Visitor said she should have voiced her disagreement and discontent and taken advice about whether the use of the Escalation Policy was required.  She did explain at the recall event that social worker is seen as the specialist and that might have been a further reason not escalate her concern. This is a common view amongst professionals, who state that they do not always feel confident to challenge those who are thought to be experts in safeguarding children. It is recognised that challenge is not easy or comfortable, however as many case reviews show, it is essential.  5.4.5 In the CSC assessment report for the second ICPC, mother’s new partner was identified, but it was stated that he was not a member of the household.  In the notes of a visit from Family Support Worker, it is recorded that he was seen in the house with Child A and that Mother had confirmed her new relationship.  At the CP Conference, the Police shared information about mother’s new partner.  Due to the nature of the information shared he was considered a potential risk to Child A and it was recommended that he undergo a risk assessment.  It was further stated that there should be no unsupervised contact between him and Child A.  Within the minutes of the CP Conference, it is recorded that mother’s partner is “not to spend time with Child A alone until the risk assessment is completed”.  There is no information confirming how this arrangement about the contact was going to managed or monitored.  The new Social Worker for Child A visited a week later, and the new partner was present in the household.  Four days following this visit Child A was seen with extensive bruising and injuries.  There was no challenge about how realistic this supervision arrangement was going to be introduced and managed.  5.4.6 Discussions during this review show that professionals are largely aware of the Professional Disagreement and Escalation Policy, which was updated in 2016 and had a review date in 2019.  It was not clear whether the policy has yet been reviewed.  As with the policy with Injuries to Non-Mobile Babies, these policies need to be regularly updated and reviewed.  Staff were very open and reflective during the review process about how difficult they find it to consider using the policy to disagree or escalate their concerns about each other’s practices or decisions. The local Thematic Review mentioned above also identified “Professional Challenge, Curiosity & Escalation” as one of its themes. It asked the following questions: What are the barriers to escalating areas of concerns? How can the system be improved to increase professional confidence? This review has provided some insight however there is a need to ensure that challenge and escalation of concerns is given the required focus within partner agencies and that these questions are given further consideration.  A recommendation has been made in respect of this.     14 Learning: • Professionals need to be empowered to challenge each other, even if they do not believe they are as qualified as the professional they are challenging.  Professional challenge needs to be child centred, respectful and constructive. • Child protection conferences need to seek and encourage professional challenge, which requires attendance and engagement in face-to-face meetings.  5      Professional information sharing and communication 5.5.1 There was good information sharing and communication in a number of areas in this case.   For example, between the health visitor and the family support service, and from the health visitor with adult mental health services for the maternal grandmother. During Covid -19 lockdown every time Child A’s mother contacted the Heath Visiting Service Hub she received a timely response. There was also good information sharing at the time of the serious injuries in November 2020.  5.5.2 The need for improvements in communication and information sharing is a common theme in serious case reviews and more recently CSPRs.  While it is acknowledged nationally that systems and processes often make it difficult for information sharing, there is also a need for improvements in professionals communicating directly with each other about children where they have concerns. The Child Safeguarding Practice Review Panel stated in their annual report 2018-19 that partner agencies need to think in terms of human factors when it comes to the need to share information and consider risk.  They state that ‘complexity of practice requires sophisticated conversation, hard wired into the DNA of our child protection practitioners’.  They ask ‘how do we help people talk to each other within a context of high-risk, high-volume and limited resource, often when practitioners are fearful of reprisals from families, employers and society at large?’  This is particularly an issue when a child is not on a child protection plan, as was the case for Child A for much of the time being considered.  5.5.3 There were a number of gaps in information sharing regarding injuries or reported injuries to Child A, and issues with agencies seeing or being able to see the cumulative picture for Child A. In total there were 14 calls to RAS and 14 calls to 111 during the period January 2019 to November 2020.  This volume of calls did not trigger any response from either agency. There is individual agency learning in respect of information sharing that needs further consideration. A recommendation has been made in respect of this.     5.5.4 Another issue identified is that GPs do not routinely receive notifications when a child is on a CIN plan. In this case the GP was aware of the RAS and hospital involvement but not that Child A was a child in need and why. CSC have confirmed that there was no direct involvement with the GP when the CIN was made apart from the lateral checks before the first ICPC. There was no sharing of information with the GP about the plan. The national CSPR published in September 2021 raised this issue and praised Northumberland for innovative practice. Their SIRS (Sharing Information Regarding Safeguarding) project developed by health partners ensures that following the booking appointment with maternity services, the parent/s are informed by letter that information will be sought from both parents’ GPs, this is repeated at future appointments.  While it was designed to improve information sharing about fathers and male partners, it shows that information sharing with and from GPs is good practice, that important information should always be shared with and by GP’s, and that GPs need to be more confident about being able to share this adult information in a child centred system.     15 5.5.5 A longer–term and on-going problem of the minutes of Children in Need and Core Group meetings not always being circulated generally was raised in agency reports and discussed at the practitioner events.  These are important documents which keep agencies informed of what is happening to children and their families, including GP’s, and ensure that any services being provided can consider what is going on for the child. This matter is well known among partners and is the subject of improvement action in the local authority.  5.5.6 While several agencies keep a chronology of their involvement with a family, this is not always shared and compiled to have a multi-agency oversight of any incidents and interventions. It is good practice to have this information, which is then shared across the professionals involved, and regularly updated when a child is subject of an assessment or a plan to support or protect a child.  This can avoid professionals providing services based on limited information, avoid incident led practice, and provide an overview of the child’s lived experience to aid decision making. Those involved in the review could see the benefit of this approach had it been undertaken when working with Child A.   5.5.7 The issue of when to arrange Strategy Meetings, decision making about Section 47 investigations and whether the investigations should be single agency or joint investigations also emerged when considering the case of Child A.  It was acknowledged that a Strategy Meeting should have been held when Child A received his first injury and when bruising was noted by the Health Visitor and then seen by the Social Worker in the family home.  On reflection the single agency investigations agreed in this case would have been more robust with a joint investigation. This was likely to have been agreed because the focus at the time was on Child A’s injuries being as a result of lack of supervision or neglect rather than potentially physical abuse that needed to be investigated.  Good practice from the NSPCC and SCIE suggest that joint investigations are a better model as “lack of Police involvement in such investigation leads to insufficient consideration by other agencies that a crime may have been committed.”  Learning points: • When a child has injuries there needs to be optimum information sharing and communication across disciplines and agencies.  • For a child’s plan to be effective, the right multi-agency information needs to be available.  A chronology of each agency’s involvement is essential to provide information for assessments and robust plans for children, and to ensure meaningful understanding of the concerns by both professionals and family members. 5.6 The Covid 19 pandemic  5.6.1 It was important that the review considered what impact the pandemic had on any of the work planned or being undertaken with the family.  All agencies confirmed that the first national lockdown in March 2020 had a significant impact on face-to-face contact with children and families in the local area.   In the context of this review, the Family Support Worker had to self-isolate and could not undertake the work required and agreed with Child A’s mother.  Mother was given the opportunity to change worker. She declined this, despite there then being a delay in what was planned.  The family was RAG rated Green in line with city council guidance which meant support should be provided virtually, rather than face to face.  Contact between mother and the worker continued using telephone and texts up until June 2020 when face to face meetings resumed.     16 5.6.2 It is also known that there was a particular impact on social workers in Britain who were often the only professionals going into family homes during the initial lockdown10. While guidance was clear that social distancing and basic PPE was required, social workers in the UK have reported that this is very difficult when visiting families in crowded housing with children who often initiated physical contact with the worker. Some professionals saw families on doorsteps and in gardens, which is not ideal when needing to consider if safeguarding was an issue.11 It is acknowledged that social workers consistently took significant personal risks to try to protect children during the pandemic. In other cases there was a concern that some families were using the threat of Covid-19 as a reason to deny professionals any access to their children.  5.5.1 The professionals involved in this review reflected on how COVID-19 had impacted on practice.  There was discussion about the impact on the second ICPC having to be held virtually, at a time where the technology was new to a number of professionals and service users.   Agencies who were present all agreed that it was difficult to gauge properly mother’s reaction to the issues being discussed. Her learning difficulties would have made this particularly difficult for her. There is progress in the local area for a return to face-to-face child protection meetings, which are being prioritised.  5.5.2 Professionals stated during the review that there was an emotional effect on all staff as they struggled to provide a service in uncertain times. The same was the case for the CSPR itself that has been undertaken virtually, without any face-to-face meetings with the professionals involved. This has been difficult for them, and the lead reviewer thanks them for their involvement and commitment to the review in difficult circumstances.   5.5.3 In the interview with mum, the summary of the learning for agencies was discussed with her. She shared that her experience of domestic abuse with in her family had had an impact on her and her siblings. She said that was why she was determined not to return to her mother’s house when Child A was born. She was not able to articulate how the experience of the domestic abuse she suffered her as a child had affected her but she knew instinctively that it had not been good for her mental health and safety. She listened to all the other learning points but made no comment. She agreed that everyone including herself and Child A were affected by COVID. She confirmed that she had not been able to attend meetings in person and it had made her feel isolated. She also said it had been difficult to manage Child A during this time. 6.      Conclusion and recommendations  6.1 The review has highlighted significant learning across all agencies which was identified in individual agency reports and during the learning events. The need for improvement actions has been acted on by these agencies and recommendations and action plans have been made.    6.2 Around the birth of Child A and just after, key agencies including the local authority experiencing and dealing with major performance issues, scrutiny and change within their organisations.  These issues had an impact on the services and work with Child A and his mother.                                                          10 Harry Ferguson, University of Birmingham. Professional Social Work magazine 6.12.21 11 The Impact of the COVID-19 Pandemic on Social Workers at the Frontline: A Survey of Canadian Social Workers  Rachelle Ashcroft, Deepy Sur, Andrea Greenblatt, Peter Donahue    17 6.3 Key components of a safe and effective safeguarding system include good communication between agencies, effective and robust challenge and good plans to make and keep a child safe.  This review has highlighted key learning in these areas for partner agencies.    6.4 The review makes the following recommendations in order to ensure that the learning from this review has a positive impact on practice and systems.  They have been devised in collaboration with the SCP case review group. There is a multi-agency improvement plan in the local area that is monitored monthly by the improvement board. This review will not repeat any of the actions included in that plan. The Local Police Force have also had an HMRC inspection that has led to the implementation of a number of improvement actions.   Recommendation 1: The Partnership must review and update the Practice Guidance for Assessment, Management and Referral on Bruising in Non-Mobile Babies (2017) in the light of the learning from this review and the local Thematic Review. Consideration should then be given to how this can have an impact on practice.  Recommendation 2: The Partnership must review and update the Professional Disagreement and Escalation Policy (2019) in the light of the learning from this review and the local Thematic Review. Consideration should then be given to how this can have an impact on practice.  Recommendation 3: The Partnership needs to request that all partner agencies consider introducing a requirement that individual agencies produce impact chronologies for all ICPCs, and request assurance that this is having a positive impact for children.   Recommendation 4: The Partnership to request that agencies work together to develop systems that allow the identification (possibly via a trigger or alert) when there are repeated injuries on a child or young person. An example of this would be for hospital to alert GP’s if a child is seen with repeated injuries and this would trigger GP’s review. Assurance should then be sought that this is having a positive impact for children.   