Death of a 4-month-old infant in May 2018 whilst in the care of a family member overnight. Police initiated an investigation but no charges were made. Child A1 lived with her parents; Mother and Father were known to Early Help and Health Services in respect of antenatal and postnatal care. At the time of her death, Child A1 was being cared for by her paternal aunt, who placed her on the sofa and then fell asleep after consuming alcohol. When she woke up she found Child A1 lifeless. An ambulance was called, and Child A1 was confirmed dead at hospital. Paternal Aunt had two children; both were made subject to Child Protection Plans in March 2018 under the category of emotional and physical abuse. There were also concerns about alcohol misuse. Ethnicity or nationality not stated. Identifies an area of learning for Children's Services as to the extent to which the Child Protection Plan in respect of Paternal Aunt's household included any risk to other children. Recommendations: ensure that Special Circumstances Forms generated by midwifery services are shared by key agencies, such as general practitioners (GPs) and health visitors; ensure that information sharing and discussion take place routinely between midwifery and GP practices where issues are identified, and concerns are raised in order to understand the holistic family circumstances; where parental alcohol and substance misuse are risk factors, practitioners are able to consider any other caring responsibilities for children including babysitting arrangements.
      
 Title:  Serious case review: Child A1. LSCB: Rochdale Borough Safeguarding Children Partnership Author: Rochdale Borough Safeguarding Children Partnership Date of publication: 2020  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1    Rochdale Borough Safeguarding Children Board  (now known as Rochdale Borough Safeguarding Children Partnership)  Serious Case Review  Child A1  Identifier Who A1 Child MA1 Mother FA1 Father PAA1 Paternal Aunt C1A1 Cousin C2A1 Cousin PGMA1 Paternal Grandmother PGFA1 Paternal Grandfather           2  1. Circumstances Leading up to the Serious Case Review  1.1 Child A1 was the first born child to MA1 and FA1.  She was born in January 2018.  Neither parent has any other children from previous relationships.   1.2 Child A1 was known to Early Help and Health Services in respect of ante and post- natal care. 1.3 Rochdale Children’s Social Care was not involved at any time throughout Child A1’s life.   1.4 Child A1 lived with her parents at the family home in Rochdale however at the time of her death she was being cared for by her paternal aunt (PAA1) overnight.  Paternal grandfather (PGFA1) was in the family home at the time but was not believed to be part of the caring arrangements for A1.  This was the first time that Child A1 had been cared for overnight by anyone other than by her parents.   1.5 PAA1 has two children, C1A1 and C2A1 who were known to Children’s Social Care in another area (LA1) due to concerns relating to Domestic Abuse between the parents, which were believed to be fuelled by alcohol.  PAA1 was also believed to misuse alcohol.  Children’s Services in LA1 became involved in February 2017 following a Domestic Abuse incident which resulted in the children becoming subject to a Child in Need Plan.  This plan ended in August 2017.  A further incident occurred in December 2017 which was reported by Greater Manchester Police (GMP) to Children’s Social Care in LA1.  Further information was collated and a Child and Family Assessment undertaken which recommended a Strategy Meeting was convened.  The meeting concluded that a S47 enquiry should be initiated and the outcome of this was to progress to an Initial Child Protection Conference.  C1A1 and C2A1 were made subject to Child Protection Plans on 14th March 2018 under the category of emotional and physical abuse.  Information shared within the Conference indicated that PAA1 had attended the nursery on 4 occasions where she had smelled of alcohol and her partner had stated that PAA1 drank a bottle of wine most nights.  PAA1 denied that she used alcohol frequently or that she had a problem with alcohol. 1.6 On 27th May 2018 MA1 and FA1 attended a concert with PGMA1 and left A1 with PAA1 and PGFA1 overnight at the Paternal Grandparent’s home.  C1A1 and C2A1 were also present.  3  1.7 A1 had been unsettled and wouldn’t take her bottle and PAA1 administered Nurofen to help her settle.  PAA1 stated she kept taking A1 in and out of the travel cot provided by the parents but later settled A1 on the side / corner of the couch. 1.8 PAA1 drank wine from approximately 17.45 hours and fell asleep around 22.30 hours.   1.9 PAA1 woke sometime after 1am and found A1 cold and blue.  She contacted the Ambulance who arrived at 02.07 hours but had tried to administer breaths to A  until the ambulance arrived.  The ambulance crew confirmed that A1 was in the arms of PAA1 and was cold, blue and stiff.   1.10 A1 was taken to hospital and time of death was confirmed at 02.56 hours.   1.11 MA1 and FA1 attended the hospital with other family members. 1.12 GMP initiated an investigation with regard to A1’s death, no charges have been authorised and no further police action will be taken.   2. Methodology and Key Lines of Enquiry   2.1 A Serious Case Review (SCR) Screening Referral Form was received from GMP on 05.06.2018 in respect of A1.   2.2 The screening panel was held in June 2018 and did not recommend to the Independent Chair of the RBSCB that a SCR should be convened.   2.3 The Independent Chair of the RBSCB agreed with the recommendation of the Panel and was of the view that the case did not meet criteria for a Serious Case Review as none of the records suggested that there were concerns regarding agencies working together.  There was no agency involvement with the family in Rochdale other than Universal Services.  It was considered that although PAA1 and her children were known to Children’s Social Care in LA1 for issues regarding alcohol abuse and domestic abuse, this was insufficient to initiate learning for Rochdale.  It was acknowledged that it was not clear whether LA1 considered that it was inappropriate for PAA1 to babysit for A1.    4  2.4 A copy of the Screening Panel Minutes was shared with the Safeguarding Children Board in LA1 at the request of the RBSCB Independent Chair for consideration and any action it was felt appropriate due to LA1’s Children’s Social Care involvement.   2.5 The National Child Safeguarding Practice Review Panel (CSPRP) were notified of the above decision and considered A1 at their meeting on in August 2018.  The CSPRP advised that in their opinion criteria for a SCR had been met as abuse or neglect was known or suspected and a child had died.   2.6 The response from CSPRP was also shared with the Safeguarding Children Board in LA1 and RBSCB Independent Chair corresponded with LA1’s Safeguarding Board Independent Chair due to the circumstances of the child’s death, i.e. in the care of PAA1.  It was felt that if there were lessons to be learned from this child’s death, it would be in respect of services supporting the family in LA1 as only Universal Services were involved in Rochdale.  RBSCB Independent Chair requested that this correspondence be treated as a referral for consideration of a SCR by LA1. 2.7 The Independent Chair of LA1’s Safeguarding Children Board responded in October 2018 to advise that a thorough review of the case had been undertaken by the Head of Quality Assurance for Safeguarding in LA1’s Children’s Social Care. The review noted that the concerns for C1A1 and C2A1 were not such that it was felt they should have been removed from their mother’s care.  Concerns related to domestic abuse incidents where both parents were believed to be victim and perpetrator and the misuse of alcohol by both parents.  Alcohol was believed to be a trigger for the domestic abuse incidents.   2.8 The review identified an area of learning for LA1’s Children’s Services as to the extent to which the Child Protection Plan in respect of PAA1’s household included any risk to other children.  The Chair of the Initial Child Protection Conference directly asked both parents whether they were involved in the care of any other children; the parents advised they were not.  It was noted that this was routine practice however this had not been recorded in the conference minutes.   2.9 It was the view of the LA1’s SCR Sub Group that any potential learning had been identified and addressed by the Service.  It was also noted that usual practice would be for the Safeguarding Children Board or Partnership of the area in which the child resided to carry out a SCR if deemed necessary and that LA1 did not intend to  5  undertake the SCR in relation to A1.  The Independent Chair did however support LA1’s participation in the SCR undertaken by Rochdale if required.   2.10 As a result of the above correspondence with both CSPRP and LA1’s Safeguarding Children’s Board it was agreed that Rochdale would undertake the SCR in respect of A1.     2.11 Requests for information were circulated to all agencies identified as being involved with A1 and the family, including LA1’s Children’s Social Care.   2.12 The timeframe for the SCR was agreed as 1st April 2017 to 4th June 2018.  This timescale covered the pregnancy and life of A1.  2.13 The first panel meeting took place in January 2019. 2.14 The Panel members were limited due to Child A1 only being known to Universal Services however LA1’s Children’s Social Care were represented to contribute to the discussion and understand the key issues for consideration.   2.15 The SCR Panel was mindful of the revised statutory guidance within Working Together to Safeguard Children 2015.  The new Working Together to Safeguard Children was published in early July 2018 which was after Child A1 had died.  The screening initially was undertaken under Working Together to Safeguard Children 2015 however there are certain elements of the new guidance which will be taken into consideration with regard to the transition from LSCB to Multi-Agency Safeguarding Arrangements.   2.16 The Panel considered their responsibility in respect of collecting and analysing information about Child A1’s death with a view to providing an analysis of what happened in the case and why; what needs to happen in order to reduce the risk of recurrence, which is easily understood and suitable for publication and identified any key learning.   2.17 The key lines of enquiry identified with regard to A1 are as follows: -  Information sharing between agencies and across Local Authority boundaries, including whether A1’s parents were aware that PAA1’s children were subject to a Child Protection Plan, whether A1’s parents had any understanding of PAA1’s suitability to care for their child   Whether agencies had any opportunity to identify potential risks to A1 in respect of family member having children subject to CPP   6   To what extent FA1 was involved ante-natally with regard to discussions about safe sleeping etc    3. Planning the Review   3.1 As stated, the first SCR Panel meeting took place in January 2019.  The chronology, key events and action plans had been completed by GMP, Early Years and Children’s Centres, Pennine Care Foundation Trust (Heywood, Middleton and Rochdale), Pennine Acute Hospital Trust, Heywood, Middleton and Rochdale Clinical Commissioning Group, Hopwood Hall College, National Probation Service and the Community Rehabilitation Company.   3.2 The Panel reviewed the timeframe set and noted that some agencies had provided information to their involvement where additional information was required. outside April 17 to June 2018.  The combined chronology was reviewed and some areas of clarification were raised, which were required for a full understanding and contribution to learning.  It was agreed that the author would liaise further with LA1’s Children’s Social Care with regard 3.3 The SCR Panel did not feel that a practitioner event was required due to the specific circumstances surrounding A1’s death.     4. Outline of how Child A1 was known to Agencies    4.1 Child A1 was first known to Early Help and Children Centres when MA1 accessed Midwifery Services and ante-natal care (Early Pregnancy Unit) at Children’s Centre 1 in June 2017 4.2 The Midwife recorded that MA1 was approximately 7 weeks gestation and discussed ante-natal screening tests, the importance of multivitamins and Group B Streptococcus Test information provided.  Records also indicate that MA1 was accompanied to this appointment but does not indicate who that was.  MA1 had a further ante-natal booking in July 2017 at 12 weeks gestation at which the dating scan was arranged.  It is recorded that there were no concerns identified and routine bloods were taken.    7  4.3 MA1 and FA1 accessed ante-natal care at Children’s Centre 1 in August 2017 at 17 weeks gestation.  MA1 reported to be well and no concerns were identified.  The Midwife discussed whooping cough vaccine, multivitamins and hypnobirthing.   4.4 Further routine ante-natal contact was made with Mother at 20 weeks gestation during which the anomaly scan was completed with no issues identified or concerns raised.   4.5 In September 2017 MA1 presented at Maternity Triage with abdominal pain at 22 weeks gestation.  4.6 MA1 was seen by her GP due to indigestion towards the end of September 2017.  She was 24 weeks gestation and had been experiencing reduced foetal movements.  She had previously had an ultrasound scan, which was normal.  MA1 was issued with a ‘fit to fly’ letter as she was going on holiday. 4.7 MA1 attended Children’s Centre 1 in October 2017 to access ante-natal appointment at 25 weeks gestation.  There were no issues identified.  It is noted that the Midwife had not made routine enquiries around domestic abuse.  MA1 was advised to have whooping cough and flu vaccines at 28 weeks.  4.8 MA1 and FA1 attended Children’s Centre 1 in November 2017 to access ante-natal appointment at 28 weeks gestation.  There were no issues identified.  The Midwife referred MA1 to Health Visiting Services to confirm pregnancy progressing and that MA1 would require Health Visitor ante-natal contact.  This is routine practice to notify Health Visiting service across the Trust in order for Health visiting teams to visit women in the antenatal period and vaccinations were booked. 4.9 MA1 and FA1 were seen again in November 2017 at Children’s Centre 1 at 31 weeks gestation; no concerns or issues were identified.  It is recorded that a possible ectopic heartbeat was heard and this was to be reviewed at Maternity Triage at hospital.  This was not confirmed at Triage and MA1 was reviewed by a doctor and discharged home with reassurance.   4.10 MA1 attended Children’s Centre 1 in December 2017 at 34 weeks gestation.  The Midwife discussed breast feeding and skin to skin.  MA1 and the Midwife planned to review again in 2 weeks and then again in 4 weeks at the hospital due to ectopic heartbeat being heard on 2 occasions.  8  4.11 A special circumstances form was generated in December 2017 following MA1 notifying the Midwife 1 week earlier, that FA1 was due to appear in court with regard to charge of assault following being involved in a fight in the City Centre whilst being out with friends at the beginning of MA1’s pregnancy.  MA1 was asked and confirmed no issues in respect of Domestic Abuse.  MA1 is said to have stated that this was FA1’s first offence or involvement with the Police.  The Court hearing was due to take place just before Christmas 2017.   4.12 MA1 attended Children’s Centre 1 between Christmas and New Year 2017 during which the growth scan was completed and no concerns identified however 2 days later MA1 attended Maternity Triage with spontaneous rupture of membranes (SRoM).  Trust Policy was followed which indicates that if labour does not start within 24 hours of SRoM, to return to triage.  MA1 was given advice and advised to contact Triage if any further signs of labour were identified.  A1 was born 2 days later at the beginning of January 2018 at 38 weeks by emergency caesarean section. 4.13 Child A1 was born with a fever and jaundice and was medicated and treatment provided.  A1 was discharged from hospital within 24 hours of delivery but returned to the hospital following a home visit for treatment for high bilirubin levels.  4.14 A1 was achieving her milestones and had received all appropriate immunisations. 4.15 The breastfeeding and safe sleeping assessments were undertaken with MA1 and recorded in the Personal Child Health Record with no issues identified and was assessed as low risk.  MA1 was breastfeeding A1 and continued to do so for 1 month when she moved onto bottle milk.   4.16 A discharge summary was sent from Pennine Acute to Pennine Care and a new birth letter was sent to MA1 by the GP, advising on the registration process for A1, immunisation schedule and 8 week check.   4.17 The midwife visited the day after A1 was discharged home and has recorded no problems reported, bloods taken with regard to the jaundice diagnosed.  The blood levels were high therefore A1 was admitted to the Children’s Unit for treatment and discharged 3 days later.   4.18 It is recorded that MA1 was described as tearful during the Midwife visit; this is not unusual however it would be expected that the Midwife ask about mother’s emotional health at each contact and this may initiate a more formal assessment if required. It  9  was noted that there was no further reference to MA1 being tearful in subsequent visits.   4.19 There is no verbal handover between midwives and health visitors. The services overlap and unless there are significant concerns around maternal mental health or safeguarding. Health visitors and GP’s are notified of births and discharges by letter automatically generated by the hospitals maternity electronic system and if any concerns are highlighted a “special circumstances” form is generated which will be sent electronically to health visiting teams within the community. 4.20 Both MA1 and A1 were seen regularly throughout January 2018 with regard to their medical needs.  The Health Visiting Service took over from the Midwifery Service and undertook a post-natal mental health check of MA1.  It is recorded that MA1 was caring for the baby confidently and appropriately.  MA1 stated she had excellent support and was assessed as requiring Universal Service.   4.21 A1 had an 8 week developmental check with MA1 at the GP practice which identified no concerns regarding her development.  She received her 1st set of immunisations on the same date. 4.22 In March 2018 MA1 and A1 attended Children’s Centre 2 for Baby Clinic and Baby Play Session.   4.23 In April 2018 A1 received the 2nd set of immunisations whilst in her mother’s care and later that same month MA1 attended Well Baby clinic.  The Health Visitor has recorded steady growth for A1 however MA1 reported that A1 is regularly sick after feeds.  Advice was provided at that time.   4.24 On 01st May 2018 Child A1 was given her third set of immunisations with consent from MA1.   4.25 MA1, FA1 and PGMA1 attended a concert on 27th May 2018 and made arrangements for A1 to be cared for by PAA1 at the Paternal Grandparents home in May 2018.  During the evening A1, PAA1, C1A1, C2A1 and PGFA1 were present in the home.  The plan was for A1 to remain with PAA1 overnight.    4.26 On that evening North West Ambulance Service (NWAS) were called to the home of Paternal Grandparents on by PAA1.  NWAS contacted GMP to advise them of a child being in cardiac arrest.  10  4.27 MA1 described A1 as being unsettled and not taking food however she did not have a temperature, rash or vomiting.  PAA1 stated that A1 would not take her bottle and kept going in and out of sleep.  PAA1 administered Nurofen to help A1 settle and moved her in and out of the travel cot in order to try and settle her.   4.28 PAA1 stated she had drank a bottle of wine plus a large glass of white wine which she started about 17.45 hours pm, and had not had anything to eat.  She eventually settled A1 on the sofa next to her and PAA1 lay next to A1 facing inwards towards her when she fell asleep at approximately 22.30 hours. She awoke sometime after 1am and found A1 cold and blue.  PAA1 contacted the NWAS and shouted her father (PGFA1).  PAA1 administered breaths until the ambulance crew took over and commenced CPR.   4.29 A Police investigation commenced due to the circumstances of A1 death. PAA1 voluntarily attended a local Police Station the following day to provide a blood sample. On the 8th June 2018 PAA1 was interviewed by Police. 4.30 MA1 sought support from her GP following the death of her daughter and FA1 was supported following presentation at A&E by Adult Mental Health Home Treatment Team until July 2018.   4.31 Information identified following the death of Child A1 indicated that FA1 had a number of convictions which is contrary to the information shared by MA1 to the Midwife.  These were identified as additional risk factors for FA1 and he was risk assessed by the Home Treatment Team on 24.06.18 as ‘Amber’ with support continuing.   4.32 The Sudden Unexpected Death of a Child (SUDC) meeting was held on 29th May 2019 and was well attended, including Consultant Paediatrician, GP Partner, the Assistant Practice Manager from Medical Centre, Deputy Manager from Early Help and Safeguarding Hub, Health Visitor, Safeguarding Specialist Nurse and Bereavement Nurse.  Relevant information was shared which included information regarding LA1’s Children’s Services involvement with PAA1 and her children.   4.33 A Home Office Post Mortem took place in June 2018 which noted no specific injuries of assault and it was concluded that the death was unascertained.    5. Analysis of Practice    11  5.1 Whilst it is referenced that MA1 was known to Mental Health Services briefly in 2013, this was not identified as part of the ante-natal support.  MA1 was a young mother however no other vulnerabilities were identified which resulted in her being in receipt of Universal Services.   5.2 In December 2017 MA1 notified the Midwife that FA1 was due to attend Court with regard to a charge following being involved in a fight whilst out with friends.  MA1 is recorded to have stated that this was the first involvement by FA1 with the Police. 5.3 The issue of domestic abuse was discussed with MA1 and she stated that this was not an issue within her relationship with FA1.   5.4 Having reviewed the information available to the Midwife at the time of the pregnancy there was no information which would have indicated safeguarding concerns for Child A1 as an unborn child.  A special circumstances form was completed with regard to the disclosure that FA1 was to attend a Court hearing and consideration was given to whether this would warrant a referral to Children’s Social Care.  The special circumstances information sharing form was sent to Pennine Care Foundation Trust safeguarding team to be shared with the appropriate health visiting team.  However there is no information as to whether this was shared with the Health Visiting Service at that time, which would have supported follow up.   5.5 It is noted that the information from MA1 to the Midwife with regard to FA1’s criminal history and forthcoming hearing was incorrect. There was no identified reason why the Midwifery Service would choose or have cause to disbelieve MA1 or explore this further in respect of FA1’s criminal history and involvement with GMP at that time.   5.6 A significant area of consideration by the SCR Panel related to whether MA1 and FA1 were aware that PAA1’s children were subject to a Child Protection Plan and the concerns identified.  As stated LA1’s Children’s Services Review noted that the concerns were not such that it was felt that the children should be removed from their mother’s care or that she was unsafe to have care of a child.  The review also raises the question as to whether the Child Protection Plan considered risks to any other children.  This question was raised by the Conference Chair at the Initial Child Protection Review which was held on 14.03.18, at which time Child A1 was 2.5 months of age.    12  5.7 The majority of children subject to a Child Protection Plan continue to be cared for by a parent or person with parental responsibility.  The arrangements in place and decision making in respect of a child subject to a Child Protection Plan would take into consideration their age and level of development.  A1’s cousins were 2 – 3 years older however they would still have required a significant amount of care and supervision.  The decision therefore for C1A1 and C2A1 to remain in their Mother’s care is relevant when considering her ability to babysit A1.   5.8 A further area of consideration was whether the paternal extended family, MA1 and FA1 were aware of the concerns underpinning the Child Protection Plan.  LA1’s Children’s Social Care have recorded that extended family members attended meetings with PAA1.  There is no reference as to whether a family tree or genogram was recorded and whether there was any discussion with PAA1 in respect of her contact with her brother and sister in law, or whether LA1’s Children’s Social Care were aware that MA1 was pregnant.  It is noted that MA1 and FA1 were not referenced at the Initial Child Protection Conference.  A family network meeting was held on 11th April 2018 at PAA1’s family home.  In attendance at that time were PGMA1, FA1, MA1 and Child A1.  The Family Network Meeting’s aim is to share concerns with family members and to assist in developing a plan to reduce the risks arising from the identified concerns.  LA1 records indicate that the family agreed to report any issues or concerns to the Police and Children’s Services and that they would keep in contact with PAA1 on a daily basis.   5.9 PAA1 stated that she had consumed a bottle of white wine plus a large glass of white wine within an approximate period of 4 ¾ hours, and had not had anything to eat.  Views may differ as to whether this is deemed an excessive amount of wine for one person within this timeframe however it is noted PAA1 would have been over the limit for driving an automobile.  The important factor for consideration is that she was caring for a 4 month old child, who as reported by her MA1 and by PAA1 was unsettled and not taking her normal feed. 6. Learning from the Review   6.1 The Review has identified that there was no evidence within the ante-natal records that MA1 was asked about domestic abuse during her pregnancy however the  13  chronology identifies that MA1 reported there was no domestic abuse in her relationship when she notified the Midwife of FA1’s forthcoming court hearing.  It is unclear whether the Midwife did make the routine enquiries and failed to record them or whether this did not occur as per policy and procedure.  This has been addressed by Pennine Acute within their Action Plan and will be addressed via mandatory training sessions for all Midwives.  Whilst there is no evidence of domestic abuse within the parent’s relationship, it is important to ensure that this issue is addressed within all ante-natal support sessions as this may support individuals who are experiencing domestic abuse to access services.   6.2 It is acknowledged that the Midwife had no cause not to believe the information provided by MA1 in respect of FA1’s criminal involvement, and would have required a clear reason to seek information from the Police in this regard.   6.3 Information sharing is identified by PAHT with regard to the timescales involved for the Special Circumstances form being completed, which was delayed.  Mental Health Services also identified the need to ensure that relevant information is shared effectively with all relevant agencies. It is also noted that MA1’s brief history and involvement with Mental Health Services in 2013 was not considered during the ante-natal period of support.   Historic information regarding MA1 would not have met the criteria for Mental Health services involvement. The Midwife would not have had access to historical mental health information as the providers are different and both have their own records and IT systems.   6.4 Information sharing and liaison with the GP is an area of learning and consideration.  Special Circumstance forms are not shared with the GP and therefore whilst the GP may have known that MA1 was pregnant they did not know that there was any cause for concern.  This is a learning point regarding communication between Midwifery service and GP practices.    6.5 Early Help and Schools highlighted that contact should have been made with the family when they failed to attend the baby massage session to ensure that they were offered another session and check whether support was required.   6.6 The issue of the quality of record keeping has been identified when undertaking this review by a number of agencies with regard to the detail and accuracy of information for example who was in attendance at the ante-natal meetings with the Midwife and  14  attending the Children’s Centres and what was discussed.  Further issues with regard to record keeping is having an understanding of the family in its widest sense and addressing support networks as well as potential safeguarding risks.  This would or could have identified issues as outlined with regard to PAA1 and her children.   6.7 A key area of focus related to the ability of PAA1 to care for A1 on the night she died.  The significant issues for consideration related to PAA1’s children being subject to a Child Protection Plan as a result of domestic abuse and alcohol abuse by PAA1 and PAPA1, and PAA1 being under the influence whilst caring for A1 on the night she died.  These matters are no longer under investigation by GMP and will be the subject of a Coroner’s Inquest therefore it is difficult to make any conclusions at this time.  6.8 It is important to note that C1A1 and C2A1 were subject to Child Protection Plans and were not removed from their mother’s care.  It was clearly the view of LA1’s Children’s Services that whilst concerns were identified which indicated the children were at risk of actual or likelihood of significant harm, it was the view that by having the Child Protection Plan in place, this was sufficient to safeguard these children at that time.   6.9 LA1 Children’s Services had considered any other children within the household at the time of the Initial Child Protection Conference but had not ensured that this conversation was recorded within the Minutes of the Conference.   6.10 PAA1 had been referred to and attended an assessment session with LA1 Integrated Drug and Alcohol Service in April 2018 who advised the score on the alcohol audit was very low and had been given alcohol awareness and advice as a brief intervention.  This was a self-reporting audit and it is noted that at the time of the Initial Child Protection Conference, PAA1 was denying misuse or frequent use of alcohol.  It is questioned whether this provided sufficient reassurance that the issue of alcohol misuse was not a risk to the children.  6.11 The information provided by LA1 Children’s Services that the parents and paternal extended family were likely to be aware of the concerns being expressed with regard to the domestic abuse incidents and alcohol misuse as they had attended meetings where this information was discussed and had been part of the safety plan in respect of C1A1 and C2A1.   6.12 Learning has been identified by LA1 Children’s Services in respect of recording the discussion regarding other children PAA1 and her partner may have come into contact  15  with or had responsibility for within the Child Protection Conference.  It is noted that Child A1 is recorded as being present with her mother MA1 at the Family Network Meeting and was therefore known to the allocated Social Worker for C1A1 and C2A1.   6.13 It is clear that LA1 Children’s Services were aware of PAA1’s alcohol misuse and had sought to put a safety plan in place to address the risks associated with this and the domestic abuse identified.  As stated the risk assessment concluded that there was a low risk however this was based on self-reporting from PAA1 and indicates that PAA1 continued to deny that alcohol was an issue for her.   6.14 Due to the circumstances surrounding A1’s death, and in taking a proportionate approach, it was not felt that a practitioner event was required with regard to contributing to the content of the review.  Agencies have identified individual areas of learning and developed single agency action plans which were actioned immediately.  Agencies will also be supported in respect of the learning across the partnership via learning events and briefings.    7. Recommendations   Where a Special Circumstances form is generated by Midwifery, this is shared with key agencies involved e.g. GP and Health Visiting Service  Information sharing and discussion to take place routinely between Midwifery and GP practices where issues are identified, concerns are raised in order to understand the holistic family circumstances.    Where parental alcohol and substance misuse are risk factors, practitioners are to consider any other caring responsibilities for children including babysitting arrangements  Acronym Meaning LA1 Local Authority 1  RBSCB  Rochdale Borough Safeguarding Children’s Board GMP Greater Manchester Police SCR Serious Case Review  16  CSPRP Child Safeguarding Practice Review Panel LSCB Local Safeguarding Children’s Board CPP Child Protection Plan GP General Practitioner SRoM Spontaneous Rupture of Membranes NWAS North West Ambulance Service CPR Cardiopulmonary resuscitation SUDC Sudden Unexpected Death in Childhood                                17  Christine Foster-Alonge Service Manager, Safeguarding  NB: Christine Foster-Alonge left the Local Authority in April 2019, amendments have been made to this report by Margaret Doe and the review panel  