Death of a 6-year-old boy and his mother and the attempted suicide of his father in April 2013. Father pleaded guilty to manslaughter on the grounds of diminished responsibility. He was diagnosed with a psychotic mental illness and detained under the Mental Health Act 1983. Child L and parents were not known to any specialist services. Previous contacts with health services for injuries to Child L and Adult L were judged to be accidental. The day before the incident, father consulted his GP about feeling in low mood and hearing voices; there had been no previous mental health issues. GP requested an assessment by a mental health practitioner and a meeting was scheduled for the next day. Identifies good practice including the GP's referral to mental health services and school support to pupils and families after the deaths. Issues identified include: missed opportunities for sceptical and curious enquiry by health professionals; no enquiry about Child L by GP; 'shortcoming of human inference' leading mental health specialists to think a GP would rate a case high risk to get a quick assessment; and use of a telephone triage system for mental health assessment. Uses a systems methodology based on the Social Care Institute for Excellence (SCIE) framework to present the key learning. Questions for consideration cover: overcoming cognitive influence and human bias in information sharing; ensuring sufficient enquiry and recording of any presentations for medical treatment; and use and availability of tools and frameworks for assessing risk.
      
 Title:  A serious case review: ‘Child L’: a domestic homicide review: ‘Adult L’: the overview report. LSCB: Lancashire Local Safeguarding Children Board Author: Peter Maddocks Date of publication: 2015  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.                                   Lancashire Safeguarding Children Board  Lancaster District Community Safety Partnership        A Serious Case Review ‘Child L’  A Domestic Homicide Review ‘Adult L’   The Overview Report    April 2015       Index  1 Introduction and context of the review ..................................................... 4 1.1 Rationale for conducting a serious case review and a domestic homicide review 5 1.2 The methodology of the combined serious case review and domestic homicide review ....................................................................................... 6 1.3 Reasons for the review and terms of reference for the review ................ 8 1.4 The scope of the review ................................................................... 8 1.5 Particular issues identified by the panel for further investigation by the individual management reviews: ............................................................... 11 1.6 Membership of the case review panel and access to expert advice ........ 11 1.7 Independence and experience of the lead reviewers ........................... 12 1.8 Parental and family contribution to the review................................... 13 1.9 Timescale for completing the review ................................................ 16 1.10 Status and ownership of the overview report ..................................... 16 1.11 Previous serious case reviews and domestic homicide reviews in Lancashire 17 1.12 Summary conclusion of the review .................................................. 17 1.13 The family and other significant people ............................................ 23 1.14 Cultural, ethnic, linguistic and religious identity of the family ................ 24 2 Synopsis of agency involvement ............................................................. 26 3 The critical reflection and analysis obtained from the individual management reviews. ................................................................................................... 29 3.1 Summary .................................................................................... 29 3.2 Significant themes for learning that emerge from examining the individual management reviews .............................................................................. 29 TOR 1 What knowledge or information did agencies have that indicated the adult victim might be a victim of domestic abuse, or that child L might be at risk of significant harm? .................................................................................... 30 TOR2 What services were offered to the adult victim, the perpetrator and child L and were they accessible and sympathetic?................................................. 34 TOR 3 What information did family and friends have that might have indicated the adult victim and/or child L were at risk of abuse? ......................................... 39 TOR 4 What knowledge did agencies have that the perpetrator might be a perpetrator of abuse and pose a risk of significant harm to Child L or the adult victim? ................................................................................................. 40 TOR 5 Were there any risks in relation to resources or capacity that had an impact on how services were provided to the victims or to the alleged perpetrator or that impacted on agencies’ ability to work effectively with other services? .............. 41 4 Analysis of key themes for learning from the case and recommendations ...... 44 4.1 Learning from previous serious case reviews ..................................... 45 4.2 Cognitive influence and human bias and its influence in judgments and decision making ..................................................................................... 45 4.3 Responses to incidents or information .............................................. 48 4.4 Tools to support professional judgment and decision making ............... 50     4.5 Issues for national policy ................................................................ 50 5 APPENDICES ....................................................................................... 52 Appendix 3: Single Agency Recommendations.............................................. 53      1 Introduction and context of the review  1. This combined domestic homicide and serious case review examines the death of a 40 year old mother (the victim) and her six year old child (Child L) and the attempted suicide of the 34 year old father (the perpetrator) who had killed them both and then had attempted to take his own life in April 2013. It is a tragic and highly unusual incident that has caused great distress and confusion for the family, friends and other people who knew the family. It has also caused ongoing emotional and mental trauma for the perpetrator.   2. The taking of life is the most serious of crimes. This tragic incident occurred shortly after the perpetrator had first experienced symptoms of psychosis and he was due to participate in a mental health assessment just a few hours after he took the lives of his family and attempted to take his own. The perpetrator had no prior thoughts or motivation to harm himself or to cause injury to anybody else. He had no prior history of mental illness and no history of substance misuse  3. The deaths are highly distressing for the family and friends and for the professional services such as school and primary health services who knew the family. The review has been assisted by the participation of those people in providing information to help understand what occurred and to support professional learning in regard to a very rare and unusual set of circumstances.   4. The consistent information and evidence provided for the review is that the killings were entirely out of character and are difficult to comprehend for the family and friends as well as for the perpetrator himself. Such deaths which are variously referred to in research and other literature as family annihilation or familicide are very rare within the UK as well as in other countries.  5. It was a late morning in early April 2013 when the police were summoned to a domestic property in the county. On arrival they found the adult victim and Child L already deceased and the perpetrator suffering from self-inflicted multiple and life threatening stab wounds in several locations on his body. He was arrested on suspicion of murder and was taken to hospital where he survived his self-inflicted injuries. His general physical fitness combined with the speed and quality of the medical treatment including paramedical care at the scene was a significant factor in saving his life. He subsequently appeared in court charged with two counts of murder and was remanded in custody although was transferred to a secure hospital to receive ongoing assessment and treatment.  6. The perpetrator subsequently pleaded guilty to manslaughter on grounds of diminished responsibility. He has a psychotic mental illness, a delusional disorder to which both the prosecution and the defence agreed on the     diagnosis. The perpetrator is to remain in hospital indefinitely under S37 of the Mental Health Act 19831. He will also be subject to a restriction order under section 41 of the same legislation.  7. Child L and the adult victim were not known to any of the specialist services in the county. They were both registered with the GP as was the perpetrator. Child L attended a local primary school.   8. Less than 24 hours before the deaths, the perpetrator had consulted his GP about feeling low in mood and had reported hearing voices in his head. He had been accompanied by the adult victim to the surgery who was concerned about her partner’s behaviour. There had been no previous mental health difficulties.   9. The GP who had recent experience of working in psychiatric services took a detailed history and contacted the single point of access to mental health services requesting a prompt assessment of the perpetrator’s symptoms. An initial assessment was conducted by telephone the same day and a follow up face-to-face meeting was arranged for the following day with an experienced mental health practitioner (MHP1)2. The mental health practitioner is a health practitioner who has undertaken specialist training.   10. This appointment was not kept due to the events already described in the first paragraph.   1.1 Rationale for conducting a serious case review and a domestic homicide review  11. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires a Local Safeguarding Children Board to undertake a review of a serious case in accordance with procedures set out in chapter 4 of Working Together to Safeguard Children (2013).   12. The local safeguarding children board should always undertake a serious case review when a child dies and abuse or neglect is either known or is suspected to be a factor.   13. The circumstances under which a domestic homicide review must be carried out are described in legislation and national guidance. The relevant legal requirement is the Domestic Violence, Crime & Victims Act (2004) Section 9 1 This is a court order imposed instead of a prison sentence, if the offender is sufficiently mentally unwell at the time of sentencing to require hospitalisation. The psychotic illness was diagnosed several weeks after the killings. 2 The single point of access is through telephone, fax or post. The referral was triaged by a mental health practitioner (MHP1) who made contact with the service user the same day the referral was received.                                               that came into force on the 13th April 2011. The national guidance is described in Multi-agency statutory guidance for the conduct of domestic homicide reviews.  14. A domestic homicide review must review the circumstances in which the death of person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a person to whom they were related or with whom they were or had been in an intimate personal relationship, or a member of the same household as themselves.  15. The Lancashire Safeguarding Children Board and the Lancaster District Community Safety Partnership took advice respectively from the Department of Education and from the Home Office and made a strategic decision to combine the reviews to ensure that information was coordinated and that analysis would identify learning for the two boards responsible for the statutory reviews. The decision to combine the reviews also ensured there was no duplication and made best use of the combined resources of the organisations involved in the review.   16. The two boards agreed to commission the independent lead reviewers to coordinate the work of the joint review. Neither of the lead reviewers has worked for any of the services contributing to this review. Further information about their relevant experience and knowledge is provided in section 1.8.  17. One of the lead reviewers, Annie Dodd, took principle responsibility for chairing panel meetings and facilitating case groups and managing the review process including liaison with the family, the different services and with the police major inquiry team through the senior investigating officer (SIO) and the panel police representative.   18. The second lead reviewer, Peter Maddocks, took principle responsibility for writing the combined overview report.  19. The reviewers shared responsibility for collation and analysis of information and presenting the findings of the review to the joint boards and to practitioners and other stakeholders in the county.   1.2 The methodology of the combined serious case review and domestic homicide review  20. This review was completed using the methodology and requirements set out in the relevant government national guidance in respect of serious case reviews and domestic homicide reviews.       21. A case review panel was convened of senior and specialist agency representatives to oversee the conduct and outcomes of the combined review.   22. Work began on compiling a chronology in June 2013, which coincided with the appointment of the lead reviewers.   23. The panel established terms of reference, identified key lines of enquiry for the review and set a timetable for submission of reports and other evidence and information. This included seeking appropriate contributions from family and friends.   24. The panel established the identity of services in contact with the family during the time frame agreed for the review. For services that had significant involvement they were required to provide an independent management review in accordance with Home Office requirements3 (and are listed in section 1.4). These reports were completed by senior people who had no direct involvement or responsibility for the services provided to the child or adults.   25. The local safeguarding children board in Lancashire was already working on how future serious case reviews in the county could be developed in order to provide a more productive window into the local systems for safeguarding and protecting children4 and have participated in regional and national pilot work on using system learning within serious case reviews developed by SCIE (Social Care Institute for Excellence).  26. The review panel decided to build on the learning that had been developed from two previous SCRs in the county; one of those had been wholly conducted using the SCIE framework and another SCR had used the framework to present the findings from the review.  27. The analysis in the final chapter of this report uses some of the framework developed by SCIE to present the key learning within the context of the local systems. This also takes account of recent work that suggests that an approach of developing over prescriptive and SMART recommendations have 3 The revised Working Together published in 2013 removed this as a prescribed requirement for SCRs.  4 CA Vincent, (2004) Analysis of clinical incidents; providing a window on the system not a search for root causes. Quality and Safety in Health Care.  The article argues that incident reports by themselves tell comparatively little about causes and prevention, a fact which has long been understood in aviation for example and is the basis of developing a systems learning approach to serious case reviews in England.                                               limited impact and value in complex work such as safeguarding children5. The final chapter of the review for example explores the influence of professional self-confidence and calibration of risk and the tools that are used by professionals to help inform their judgments and decisions.   1.3 Reasons for the review and terms of reference for the review  28. The reason for undertaking a serious case review is that Child L died as a result of non-accidental injuries. The reason for undertaking a domestic homicide review is that the adult victim was killed by her partner with whom she was living when she was killed along with her son.  29. The deaths were reported to the Lancashire Safeguarding Children Board on the 10th April 2013 and the case was considered by the serious case review (SCR) group on the 7th May 2013 who recommended to the independent chair of the local safeguarding children board that the circumstances of Child L’s death met the criteria for a mandatory serious case review. The Chair of the community safety partnership was notified on the 11th April 2013 and community safety partnership was notified on the 13th April 2013.  30. The serious case review was commissioned by Nigel Burke, the independent chair of the Lancashire Local Safeguarding Children Board on the 7th May 2013. The domestic homicide review was commissioned by City Councillor David Smith, the Chair of the community safety partnership on the 7th May 2013.  31. The first meeting of the panel for the combined review on the 24th June 2013 confirmed the scope and terms of reference for the review. The scope and terms of reference of the review was routinely discussed and updated at subsequent panel meetings to take account of any new or emerging information and reflection.   32. The purpose of the review is to establish what lessons are learned from the case through a detailed examination of events, decision-making and action. In identifying what those lessons are, to improve inter-agency working and better safeguard and promote the welfare of children and adults who are vulnerable to or victims of domestic abuse in Lancashire.  1.4 The scope of the review  5 Department for Education (2011), A study of recommendations arising from serious case reviews 2009-2010, Brandon, M et al,  The study calls for a curbing of ‘self-perpetuating and proliferation’ of recommendations. Current debate about how the learning from serious case reviews can be most effectively achieved is encouraging a lighter touch on making recommendations for implementation through over complex action plans                                              33. The review covers the time from when the adult victim and the perpetrator had first met, and includes the lifetime of Child L. The period under review is therefore from January 2002 until the day of the deaths in April 2013.  34. Organisations were asked to review any earlier information about both parents and check if it had any bearing on understanding their capacity as parents, including any evidence of violent or sexual behaviour, mental ill health or substance misuse.   35. All information known to a service providing an individual management review was reviewed. Any information regarding involvement prior to the period of the detailed chronology and analysis was summarised in the individual management review.   36. All agency chronologies included detailed information about when the child was seen or observations were made about them.   37. Agencies that identified significant background histories on family members pre-dating the scope of the review provided a brief summary account of that significant history.   38. Reviews of all records and materials were considered including;  • Electronic records  • Paper records and files • Patient or family held records.  39. Individual management reviews were completed using the template provided by the Lancashire Local Safeguarding Children Board, and were quality assured and approved by the most senior officer of the reviewing agency.  40. The review was completed in compliance with relevant local and national guidance. For serious case reviews the national guidance is set out in Working Together to Safeguard Children (2013), Chapter 4. There is local associated local safeguarding children board guidance and relevant procedures. Individual management reviews were completed in accordance with Multi-agency statutory guidance for the conduct of domestic homicide reviews. The following agencies have provided information for the review.  a) Blackpool Teaching Hospital NHS Foundation Trust (provided health visiting and school nursing services) b) NHS England (GP services for the whole family)  c) Lancashire Care NHS Foundation Trust (provided the single point of access to mental health services) d) Lancashire Constabulary (historical information and investigated the circumstances of the killings and the subsequent attempted suicide)     e) Southport and Ormskirk Hospitals NHS Trust (services provided in July 2010 by the accident and emergency department at Southport and Formby District General Hospital to the adult victim and Child L and the services provided by the paediatric accident and emergency department at Ormskirk District General Hospital to Child L in regard to scald injuries that occurred during a camping holiday)6. f) The independent kindergarten service where Child L attended a nursery until he began school g) Two primary schools attended by Child L (second primary school because of the house purchase and move) h) University Hospital Morecambe Bay (provided midwifery and accident and emergency services)   41. Information that was sought from other services at the outset of the review is described in the appendix to this report. Written information was received from a Walk In Centre that provided treatment for Child L when had a scald injury.   42. Information was also sought from members of the families and is described in section 1.9.  43. The revised national guidance for serious case reviews allows the local safeguarding children board to use any learning model which is appropriate to the case. The guidance requires the review to   a) recognises the complex circumstances in which professionals work together to safeguard children;  b) seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  c) seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  d) is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings.  44. The national guidance in regard to domestic homicide reviews provides advice on issues that the review should consider. This also includes a requirement for the panel to establish terms of reference for the review and the provision of reports from agencies with significant contact or involvement.   6 The adult victim’s foot was dressed for a scald injury and she and father were advised to attend the paediatric accident and emergency department with Child L who had a blister on the abdomen as there are no paediatric emergency facilities at Southport Hospital; the paediatric accident and emergency department is based at Ormskirk Hospital.                                              1.5 Particular issues identified by the panel for further investigation by the individual management reviews7: 45. In addition to analysing individual and organisational practice, the individual management reviews should focus on:  a) What knowledge or information did agencies have that indicated the adult victim might be a victim of domestic abuse, or that Child L might be at risk of significant harm? b) What services were offered to the adult victim, the perpetrator and Child L and were they accessible and sympathetic?  c) What information did family and friends have that might have indicated the adult victim and/or Child L were at risk of abuse?  d) What knowledge did agencies have that the perpetrator might be a perpetrator of abuse and pose a risk of significant harm to Child L or the adult victim?  e) Were there any risks in relation to resources or capacity that had an impact on how services were provided to the victims or to the alleged perpetrator, or that impacted on agencies’ ability to work effectively with other services?   1.6 Membership of the case review panel and access to expert advice  46. The case review panel that oversaw this review comprised the following people and organisations;   Position Organisation Annie Dodd Independent  reviewer and chair Early Years Lead Quality and Continuous Improvement Service (LCC) Named Nurse Safeguarding Children University Hospital Morecombe Bay Assistant Director of Nursing – Safeguarding Adults Lancashire Care Foundation Trust Review Officer Lancashire Constabulary Quality and Review Manager Safeguarding Unit Schools Safeguarding and Children's Social Care (CSC), LCC Safeguarding Manager Fylde and Wyre and Lancashire North Clinical Commissioning Groups Acting Principal Social Worker Children’s social care services (LCC) Designated Doctor Safeguarding and NHS North and East Lancashire 7 These are the detailed issues that are analysed by the individual management reviews and in the detailed analysis.                                              Children Looked After  County Head of Active Intervention and Safeguarding Adult Social Care, LCC Named Nurse Safeguarding Children Blackpool Teaching Hospital NHS Foundation Trust (health visiting and school nursing) Safeguarding Practitioner Blackpool Teaching Hospital NHS Foundation Trust (Acute) Named Nurse Safeguarding Children Southport and Ormskirk Hospital Peter Maddocks Independent reviewer and author of the overview report Panel Observers/Support Business Manager Lancashire Safeguarding Children Board  Community Safety Officer Lancaster City Council Community Safety & Justice Coordinator  Lancashire Community Safety Partnership   47. The independent author of the overview report attended every meeting of the panel.  48. The panel had access to legal advice from a solicitor in the council’s legal service.  49. Written minutes of the panel meeting discussions and decisions were recorded by a member of the local safeguarding children board staff team in Lancashire.  1.7 Independence and experience of the lead reviewers8  50. Annie Dodd chaired the review and was previously employed as an assistant director with a local authority children’s social care service and has over 30 years’ experience as a qualified social worker and is registered with the Health and Care Professions Council (HCPC). Ms Dodd is now self employed as a consultant. She has previously chaired a serious case review for Lancashire SCB but has no other connection with Lancashire Safeguarding Children Board and has not been involved in any aspect of the management of the case.  51. Peter Maddocks is the author of this report and has over thirty-five years’ experience of social care services the majority of which has been concerned with services for children and families. He has experience of working as a practitioner and senior manager in local and national government services and the voluntary sector. He has a professional social work qualification and 8 National guidance set out in Working Together to Safeguard Children 2013 refers to lead reviewers whereas Home Office guidance for the conduct of domestic homicide reviews refers to the distinct and separate roles of chair of the panel and the author of the overview report; both sets of guidance require independence.                                               MA and is registered with the Health and Care Professions Council (HCPC). He undertakes work as an independent consultant and trainer and has led or contributed to several service reviews and inspections in relation to safeguarding children. He has undertaken agency reviews and provided overview reports to several local safeguarding children boards in England and Wales as well as work on domestic homicide reviews as a chair and author. He has undertaken work as an overview author on previous serious case reviews in Lancashire. Apart from this, he has not worked for any of the services contributing to this review. He has participated in training and professional development as a reviewer; this has included specific training in the use of systems learning applied to serious case reviews.   1.8 Parental and family contribution to the review  52. The perpetrator and other members of the extended families were made aware of this review when it was commissioned. A letter was initially sent by the lead reviewer who chaired the review panel, who in consultation with the police ensured that the relevant national guidance was complied with9.   53. The perpetrator’s mental health deteriorated following the killings. He was initially judged to be unfit to enter a plea for the purpose of the criminal proceedings. In view of his mental health it was considered inappropriate to seek any direct contact with him. This decision was taken in consultation with the medical team providing care and treatment. Information was sought from people who know the perpetrator and the family.   54. After the completion of the criminal proceedings further contact was made with the perpetrator through the consultant supervising his ongoing treatment and care and the perpetrator confirmed that he was willing to participate in a discussion with one of the lead reviewers.  55. That discussion took place in late 2013 and included one other professional member of the review panel along with a member of the professional team working with the perpetrator.   56. During that meeting the perpetrator talked about his relationship with the adult victim and Child L and his recollection of events and circumstances leading up to the deaths. He was not asked about the reasons or for details about the killing of the adult victim and Child L.   57. The perpetrator recalled feeling very down and depressed; paranoia and anxiety were also symptoms that the perpetrator had felt. The perpetrator 9 A Guide for the Police and the Crown Prosecution Service and Local Safeguarding Children Boards to assist with liaison and the exchange of information when there are simultaneous chapter 8 serious case reviews and criminal proceedings; (April 2011).                                              was very distressed by events and still could not believe what had happened. The perpetrator said that the house move had been very stressful. It had coincided with him being unable to work in his landscape gardening business because of the severe weather at the time. The perpetrator acknowledged that he had always been a bit of a worrier and could get anxious about ‘nothing’; for example dealing with the routine tax returns, ensuring that they had enough money (which they did).   58. The perpetrator did not know why he began to feel paranoid and thought that people were after him. He felt generally closed in, lost and scared and when he began to hear voices he had sought advice from the GP. The perpetrator had felt fine about talking with the GP and about the referral to psychiatric services. He had become anxious when the meeting did not happen the same day as seeing the GP and because the hospital was located close to a prison the perpetrator had begun to have feelings of being sent away and possibly locked up.    59. The perpetrator described having a happy childhood with a supportive family. He had a happy childhood. He had a small group of friends at school. He had not been very confident. He had two girlfriends before meeting the adult victim in 2003. His first relationship had lasted about 30 months and the second for about 12 months.   60. The perpetrator met the adult victim after he moved to eastern England after being made redundant from a factory. He described getting on very well from the start and that he had loved her and both had been devoted to Child L.   61. The perpetrator and victim were both quiet individuals who enjoyed each other’s company. They occasionally went out to a pub for example. The victim had friends at work with whom she socialised sometimes.   62. Almost all relatives and friends who were contacted for the review indicated their willingness to contribute information. All were consistent in describing the family as being apparently happy and were all deeply shocked by the incident.   63. A maternal aunt to the adult victim explained that the adult victim was a very quiet girl, as were her parents. They had kept themselves to themselves. She is very sad about what happened and described Child L as a beautiful little boy. She said that she cannot understand how the perpetrator could have done what he did to him. This aunt had never met the perpetrator, but did meet his parents at a memorial service the family had for the adult victim’s mother for those that couldn't attend the funeral. She confirmed that the perpetrator's parents were very upset about what had happened and told her they didn't understand why it had happened.       64. A paternal aunt to the adult victim had known her since her birth. This aunt explained that the adult victim had been very quiet and didn't speak until she was five years old and had started school, but since then she was a ‘very sunny person’. She was chatty when she came to visit (last visit from the adult victim, the perpetrator and Child L was during the autumn school half term 2012). There were no issues that the aunt knew about, nothing at all to suggest what happened would happen. The aunt described the perpetrator’s parents as lovely people, and described how they attended the memorial service in the east of England following the death of the maternal grandmother. The aunt mentioned a pastor who managed a shop in the adult victim’s original home town outside Lancashire where the adult victim had worked for 15 years.   65. A paternal aunt to the adult victim who lives outside Lancashire and therefore had less contact with the family recently commented that they had always seemed to be a lovely family; the adult victim and Child L appeared very happy and described the perpetrator as a bit quiet.  66. The parents of the perpetrator and the perpetrator’s sister have had extensive contact with the family since the start of the perpetrator’s relationship with the adult victim and the subsequent birth of Child L. They also confirmed the description provided by other relatives and friends that the relationship between the perpetrator and the adult victim had been good and described a loving family who were well supported and in contact with the extended family. They share the shock experienced by others.  67. The paternal family had thought that the perpetrator had a medical problem when it was noticed that he was showing unusual symptoms such as drinking an excessive amount of water a few days before the killings. They thought that he possibly had developed a physical ailment such as diabetes for example. They had also become aware that other aspects of his behaviour had become unusual. For example, he thought people were being ‘funny’ with him. Initially this was not severe but increased over a period of several days. The perpetrator knew he had some sort of problem but could not identify what it was. The appointment with the GP was made on the expectation that the perpetrator had developed a physical condition such as diabetes and this was having an impact on him along with the usual stress of going through a house purchase and the house move that had been completed three weeks previously.  68. Some of the family felt that the visit to the GP had inadvertently exacerbated the perpetrator’s feelings of anxiety (and this was subsequently confirmed when the perpetrator spoke with the reviewers). The GP had asked lots of questions and completed a physical assessment which had not identified any physical problems. The perpetrator was advised that a referral had been made to a local psychiatric hospital service. It is the family’s perception that this appeared to have shocked the perpetrator and the adult victim with the     suggestion that the perpetrator was mentally ill and a possible expectation that he was to be admitted to a psychiatric hospital.  69. After the GP consultation it seemed to the family that the phone ‘never seemed to stop ringing’ and this apparently added to the sense of heightened stress. The first phone call from the mental health practitioner included the question about whether the perpetrator felt suicidal. The paternal family feel this should not have been asked over the phone.   70. A further call to rearrange the scheduled face-to-face assessment with a male also inadvertently troubled the perpetrator who had been having thoughts that other people thought he was gay and therefore the suggested arrangement implied additional meaning for the perpetrator.   71. The family felt that the perpetrator had developed a fixation that there was a plan to keep him in the psychiatric hospital. He could not understand why he should be going there otherwise. He had talked a lot about the scheduled appointment.   1.9 Timescale for completing the review  72. The case review panel met on six occasions between June 2013 and October 2013. The initial chronology of services involvement was completed by July 2013.  The first draft agency reviews were completed in August 2013. The first draft of the overview report was completed in September 2013. The overview report was presented to an extraordinary meeting of the local safeguarding children board and community safety partnership in January 2014.  73. The report could not be finally published until the completion of all parallel processes in April 2015.   1.10 Status and ownership of the overview report 74. The overview report is the property of the Lancashire Safeguarding Children Board and the Lancaster District Community Safety Partnership as the commissioning boards.  75. Since June 2010, all overview reports provided to local safeguarding children boards in England have to be published in full. The same expectation is also made in national guidance for overview reports for domestic homicide reviews. This overview report provides the detailed account of the key events and the analysis of professional involvement and decision making in relation to Child L and the adult victim.       76. The report has to balance maintaining the confidentiality of the family and other parties who are involved whilst providing sufficient information to support the best possible level of learning.   77. An executive summary was provided at the conclusion of the review. This provides a brief summary of events and the most significant points of learning identified as a result of the review. The local safeguarding children board and community safety partnership will determine how and what further information is provided to the family at the conclusion of the review and following the submission of the overview report and executive summary to the Department of Education and the Home Office.    1.11 Previous serious case reviews and domestic homicide reviews in Lancashire  78. The local safeguarding children board in Lancashire had undertaken nine previous serious case reviews between 2008 and 2013.   79. This is the fifth domestic homicide review in Lancashire since the statutory implementation in April 2011 although this is the first review that involves a familicide and it does not involve any history of abuse or substance misuse.  As there are 14 community safety partnerships within Lancashire, a consistent approach to domestic homicide reviews has been developed with all relevant agencies based on the serious case review process.  80. Reference is made by several individual management review authors to relevant findings in serious case reviews completed locally or in other parts of the country and is also referenced where relevant in this overview report. The purpose of this is to highlight where similar issues or themes have been identified in previous reviews. This ensures that any improvement or learning action already recommended is not unnecessarily repeated.   81. Subsequent chapters of this review describe in greater detail the specific lessons to emerge from a detailed analysis of this review and include comments on how learning from previous reviews has been used.  1.12 Summary conclusion of the review   82. Cases where people kill their families and then commit suicide are thankfully rare in the UK and in other similar countries.   83. Familicide is defined as “a multiple-victim homicide incident in which the killer's spouse or ex-spouse and one or more children are slain10”. It remains 10 Wilson, M., Daly, M., & Daniele, A. (1995). Familicide: The Killing of Spouse and Children. Aggressive Behavior,                                              a relatively understudied phenomenon and there is very limited information or research in regard to family annihilation or familicide.  84. In domestic abuse there is more usually some prior indication of potential harm and a pattern of escalating behaviour. In regard to domestic and child abuse there is a considerable range of information and research evidence to inform the analysis and development of learning. Because familicide is a rare event there is relatively little data and limited research that can help professionals identify factors that might indicate a heightened risk of it occurring and therefore preventing it.   85. The research indicates there are numerous motivations for the crime of familicide. Harper and Voigt’s (2007) study found that familicide is typically carried out by the head of the household whose motivation is the belief that they no longer can care for their families11. This appears to have been a significant factor in this case when the perpetrator feared that he might not have the capacity to care for his family; it is not certain whether this related to the onset of his psychosis or reflected concerns for example about his business.   86. Research concerning familicide has also identified several other characteristics with respect to perpetrators; familicide is a particularly male dominated crime; men were responsible for 95 per cent of all familicidal killings (Wilson et al, 1995).  87. Researchers have also found that intimate crimes rarely take place in public locations, and that most familicides take place in residential settings such as in this case at the family home. Harper and Voigt (2007) found most familicide victims are victimized in their own bedrooms and “the majority of incidents take place in residences located in middle-class suburban communities”.   88. There is a high prevalence of suicide among the offenders of familicide12. A larger proportion of genetic parents commit suicide following filicide, parents who kill multiple victims are more likely to commit suicide than those who kill a single victim, and parents are more likely to commit suicide after killing an older child than parents who kill a younger child. There is no significant difference in suicide rates between filicidal killings. Wilson et al’s (1995) study observed that half of the male perpetrators of familicide committed suicide.  11 Harper, D. W, & L. Voigt. (2007). Homicide followed by suicide an integrated theoretical perspective. Homicide studies, 11, 295- 318. cited by Bartholl and Sheldon 12 Shackelford, T. K., Weekes-Shackelford, V. A., & Beasley, S. L. (2005). An Explanatory Analysis of the Contexts and Circumstances of Filicide-Suicide in Chicago, 1965-1994. Aggressive Behavior,                                              89. The research that is available in the UK draws a distinction between groups of killings. These are described by Yardley, Wilson and Lynes13 as revenge killings and a second group that is ‘altruistic’ where the killing serves ‘a necessary even if distasteful means towards a desired outcome’ or from ‘a warped sense of love and loyalty’. Within the group the same researchers go on to describe four categories that are anomic, disappointed, paranoid or self-righteous. This case appears to have the characteristics of an anomic killing described in more detail in paragraph 88.   90. The limited study of UK deaths identifies some common traits. These include that many of the men who kill in these circumstances are from lower socio economic backgrounds, are underemployed and have histories of disruption and offending in childhood that might continue into adulthood. The mean age of the adults who killed was 38 and the children killed were a mean age of 6 years old. Almost a third (32.2 per cent) were stabbed, the child was killed by their biological parent and the killings occurred in a private place (home or secluded location) rather than in any confrontation with services such as the police.   91. The research evidence that is available identifies some risk factors that may predict more severe domestic violence. Amongst these is over enmeshment which might possibly be a factor in this particular case.  92. Over enmeshment is a condition identified by academics such as Professor Gelles of the School of Social Policy & Practice at the University of Pennsylvania, USA in which perpetrators either view “their family members as possessions that they control or [they] don’t see any boundaries between their identity, their wife and their children. And so these are suicides of the entire family, where the anomic, overly enmeshed individual can’t bear to leave the pain behind and so takes his wife and children with him”14.  93. Anomic suicide which is also described in the UK study published in the Howard Journal and by other academics including Professor Gelles reflects an individual's moral confusion and lack of social direction, which is related to dramatic social and economic upheaval. Social norms become unclear during times of change. Individual behaviour is less susceptible to social norms and can induce feelings of threatened masculinity. In this case for example the perpetrator had developed concerns that other people might think he was gay (the perpetrator explained that he did not have a girlfriend until relatively late adolescence that had been the source of some joking by family members but had surfaced in his memory when he became unwell).   13 Elizabeth Yardley, David Wilson and Adam Lynes. A Taxonomy of Male British Family Annihilators, 1980–2012;; The Howard Journal 2013. 14 Bernie Auchter, Men Who Murder Their Families: What the Research Tells Us; NIJ Journal / Issue No. 266                                               94. People (and men in particular) do not know where they fit in within their communities or societies. This can occur when an individual goes through extreme changes in wealth; while this includes economic ruin, and it can also include windfall gains. In both cases, previous expectations from life are pushed aside and new expectations are needed before an individual can judge their new situation in relation to the new frameworks.   95. In this case the family had moved into a new area having purchased their home with a bequest from the death of the maternal grandmother a month before the killings. The perpetrator had set up a gardening business. The police investigation following the killings has not identified any significant financial difficulties although a colleague of the adult victim’s has mentioned feeling that the family did have financial worries perhaps associated with the seasonal nature of the perpetrator’s business and the adult victim working only part time. The perpetrator confirmed that he had worried at times about business and the house move had been very stressful for him.   96. The perpetrator reported feeling that one of his regular customers was ‘being funny with him’. He began to feel that other people were talking about him. On the day that the perpetrator went to the GP to discuss his symptoms that would lead to his urgent referral for a mental health assessment, a relative had been sentenced to six years imprisonment; the offence had no direct connection with the family. The relative had bullied the perpetrator although this was not the reason the relative went to prison.   97. In the evening of the same day of the GP consultation the perpetrator had expressed his concerns that Child L would be bullied and that other people would think he was a paedophile (which has no substantiation but reflected the perpetrator’s mental and psychological distress at the time). In a statement to the police after the killings the perpetrator also described his concern about the possibility of becoming a hospital in-patient as result of the mental health assessment and that he would be unable to care for his family.   98. Very little if any of this information was known to any of the services that have participated in this review. Even if they had known all of the information, there was little to indicate from the perpetrator’s behaviour or conversation or from his partner to indicate a risk of significant or immediate harm.   99. Although the review has examined the onset of mental health symptoms for the perpetrator just before the killings and with the benefit of hindsight is able to identify important learning especially in regard to early response to the emergence of those symptoms, there was no opportunity for either family and friends or the professional services that were in contact with the family to have predicted and therefore prevented what happened to Child L and the adult victim.       100. Until the untimely and tragic deaths this was a family who were living quietly and without any exceptional or unusual incidents or the involvement of any specialist services or from the police. The perpetrator and his family had become aware that he was not feeling well and had sought advice and help and he was co-operating with the assistance and support being offered.  101. The information for the review describes how the adult victim moved to Lancashire after she and the perpetrator had developed a relationship and had quickly planned to have a child. The information provided to the review and analysed in later sections includes reflection about how the potential social and economic isolation of women is not part of routine health screening for example when registering as a new patient.   102. The review reinforces the importance of routine checking for potential indication of domestic abuse especially when any injuries are observed in or outside clinical settings. For example, both the adult victim and Child L had treatment for different injuries that were described as accidents although there were shortcomings in the level of detail that was checked at the time. There were also gaps in how some of this information was then passed to services such as the GP.   103. This is not to suggest that abuse or violence was confirmed or missed as a feature in this family but it does reinforce the importance of professionals maintaining an appropriate level of sceptical curiosity.  104. The review has examined the referral to mental health services on the day before the killings. Although there was a prompt response and practitioners complied with the relevant protocol for the initial and immediate response and contact with the patient there is learning and improvement identified, for example in regard to risk assessment and management in new cases with active and untreated psychosis.    105. The review panel agrees with the individual management review provided on behalf of the mental health service that a face-to-face mental health assessment should have been given even higher priority with the perpetrator if it had been correctly understood that he was experiencing a first and untreated episode of psychosis; there was a difference of professional opinion between the GP and the mental health practitioner (MHP1).   106. The risks associated with the first episode of untreated psychosis had been a factor identified in a regional domestic homicide review that had led to implementation of clinical guidance in the health service in the county. The protocol was not implemented in this case because although the GP thought that the perpetrator might have been showing symptoms of psychosis the subsequent assessment by the specialist mental health practitioner did not identify symptoms to confirm such a diagnosis.       107. This is not a criticism of either professional who both had relevant training and experience and can both be expected to make a professional judgment of their own. The review explores some of the factors and influences that contributed to how judgments were made for the purpose of identifying learning.   108. The perpetrator had been the subject of a face-to-face assessment by the GP who made the referral to the mental health service and there was a telephone consultation between the GP and MHP1 and a telephone triage assessment by the mental health practitioner on the same day that he had first disclosed his symptoms.   109. There was a differential diagnosis as to what specific mental health symptoms the perpetrator was experiencing which is described and analysed in later sections of this report.  Not unreasonably some of the relatives have queried whether the killings could have been prevented if the perpetrator had been seen by a psychiatrist. Regrettably, even if the face-to-face assessment had occurred the same day, this would not have necessarily prevented the killings and the perpetrator’s attempted suicide. This would have only been prevented if there had been a decision that the perpetrator required in patient treatment either as a voluntary patient or if the legal thresholds had been met for detention under the mental health legislation, or the perpetrator had felt less anxious about no longer being able to care for his family.   110. This would have required evidence that the perpetrator posed a risk of harm to himself or to others. No evidence has been found to indicate that any professional had grounds for such a concern and there was never an indication from the adult victim or from Child L that they had ever felt threatened by the perpetrator at any time.   111. It is impossible and unwise to second guess what symptoms would have been diagnosed in a face-to-face assessment for example with a consultant psychiatrist or what treatment plan might have been identified. There was agreement in the panel and with the benefit of expert advice and opinion that in the presentation of symptoms to the GP and the MHP1 there was no basis to think that in-patient treatment would have been a likely outcome.  112. The purpose of conducting a statutory review is to undertake a detailed examination of the events within the context of understanding how the judgements, decisions and actions were taken by the various professionals involved with the family for the purpose of drawing out learning to inform future policy, service development and individual practice. The rest of this report describes in detail the interaction and information that different services had with the family and identifies the key learning.        1.13 The family and other significant people  113. The adult victim was aged 40 years old when she and Child L died.  the perpetrator was 34 years old. Child L was an only child. Both of the adult victim’s parents had died, her mother relatively recently. The perpetrator has siblings and his family live locally and there had been regular contact.   114. There had been no evidence of any relationship difficulties. This was confirmed in the contact and conversation with family friends and relatives who contributed to this review and is consistent with the recollections from various professionals who came into contact with them. The hospital sister at Ormskirk remembered the family’s attendance because of the fact the family was on holiday camping and remembered having a conversation about their holiday. The interaction between all family members was good and they were ‘chatty’ with each other.    115. The adult victim and the perpetrator had first met when the perpetrator was working in the east of England where the adult victim was living at the time.  He had been working in a factory in Lancashire until he was made redundant and had moved to the east of England following a break up with a previous girlfriend. The perpetrator’s father had known people in the east of England.  The perpetrator met the adult victim in 2003 aged 24 years old. The perpetrator described the relationship as really good and how he had loved the adult victim getting on really well from the moment that they had met. They moved to Lancashire. They decided they wanted to have a child. The perpetrator described Child L as the ‘best son (he) could ever have had’.   116. On moving to Lancashire the perpetrator had found work as a gardener and the adult victim worked part time as a sales assistant. In 2012 the perpetrator had set up his own business as a self-employed gardener.   117. The perpetrator and the adult victim were quiet individuals; they did not go to pubs often and preferred doing activities together.   118. The paternal family describe the perpetrator as having always been quiet since childhood with a few friends. The family said that he was not bullied at school and the perpetrator confirmed this.   119. The perpetrator had two previous relationships. The second relationship had ended by the end of 2002 and coincided with the perpetrator being made redundant. This previous girlfriend had made a complaint to the local police when she reported being ‘pestered’ by the perpetrator when she had told him that she wanted to end their relationship. This had involved the perpetrator making unwanted phone calls to her. There was no physical violence ever reported although she did say that her mobile phone had been     damaged by the perpetrator. The police had not introduced the DASH protocols15 at the time and the information was not screened as a domestic abuse incident. The information came to light as a result of the major inquiry by the police investigating the killing of the adult victim and Child L. Once the perpetrator had been advised by the police he had desisted from any further contact.   120. Child L had required eight days care in a neo natal ward following his birth. He was slow to put on weight and had been assessed for hearing difficulty after he started statutory education; the hearing assessment concluded that Child L did not have a hearing difficulty. Before starting school he was enrolled with a local children’s centre between March 2008 and April 200916.   121. There was one occasion when a health visitor observed a bruise to the adult victim’s face in June 2009. She denied that it was anything other than an injury caused when gardening17. Less than a week after this visit the adult victim took Child L for one of his regular nursery sessions by which time the bruise was not visible. The paternal family mentioned that the adult victim had been injured on one occasion when she had an epileptic fit in the bathroom.   122. There were no other injuries or concerns identified until the presentation at the GP surgery the day before the killings to discuss the mental health symptoms. At that consultation, the adult victim did say that she was becoming worried about the perpetrator’s behaviour although did not give any indication that she was worried about any immediate or significant risk of harm.  123. The perpetrator enjoyed his work as a gardener and had regular customers. The winter was less busy although the family managed their finances and the ability to purchase their house outright shortly before the killings had represented a reduction in their monthly outgoings.   1.14 Cultural, ethnic, linguistic and religious identity of the family  124. The maternal and paternal families are both white British. Their first and only language is English and there is no record of any physical or learning 15 The DASH (domestic abuse, stalking and honour based violence) risk assessment is a tool used by police services throughout the UK to assess the risk that a victim is exposed to and can help in identifying the action required to manage risk.  16 These are centres that are open to all parents, carers and children under five years of age and many of the services are free.  17 After the killings and the review was commissioned members of the family have mentioned that they thought the bruise had occurred during an epileptic fit in the bathroom.                                              disability18. In late 2012 the family purchased outright the home where the killings took place. The house move resulted in Child L changing to a different primary school in the county.   125.  Both adults were in employment. The perpetrator was self-employed in his gardening business. The adult victim worked part-time as a retail sales assistant.  126. Lancashire has a population of 1.16 million, which is projected to grow by almost eight per cent to 1.23 million by 2028. The county comprises a mixture of urban, rural and coastal communities and covers twelve district councils four of which (Burnley, Hyndburn, Pendle and Preston) rank in the top 30 most deprived districts in the country (Index of Multiple Deprivation 2007).   127. Five per cent of the population are from minority ethnic backgrounds, predominantly Pakistani and Indian, clustered mainly in parts of the east of the county and in Preston. More recently, small but growing numbers of people from Eastern Europe have begun to settle across the county, with concentrations in Lancaster and Preston.  128. A total of 20 per cent of children across the county are income deprived according to the Index of Multiple Deprivation 2007. Six areas (three in Burnley, two in Preston and one in West Lancashire) are ranked in the two per cent of the most deprived in England for child poverty and 9.5 per cent of children in Lancashire live in super output areas ranked among the 10 per cent worst nationally for income deprivation.   129. In contrast, the area that the family had moved to in late 2012 has low levels of crime and is above the median in terms of deprivation and health.   18 There is a reference later in the report to the GP records having some information that the adult victim had received remedial education support as a child although the records provide no other detail.                                               2 Synopsis of agency involvement   130. This narrative summary of professional contact with Child L and the adult victim provides an account of the most significant events and decisions from the different services involved with them during the timeframe established for the review.   131. This summary, and indeed the whole overview report, has to strike a balance between protecting the confidentiality of the child, their family and the various people who were in contact with them whilst providing a sufficiently detailed account of events in order to draw out the points for learning and development in the later chapters. Therefore, the summary does not contain every contact with the family.   132. In late 2002 a previous girl friend of the perpetrator had made a complaint to the police that he had taken her mobile phone. He had been making unwanted calls to her. The phone was returned to the partner and no further action was taken. The police have taken a statement as part of their investigation in which the ex-partner confirmed that she had never been subject of domestic abuse by the perpetrator and that he had stopped trying to contact her after she had contacted the police.   133. the perpetrator had left Lancashire less than a week later and moved to the east of England. Less than a month later, in late January 2003 the paternal grandparent (PGP) reported that the perpetrator had caused damage to the front door of the PGP’s home. He did not want to make a formal complaint and no further action was taken.   134. In June 2003 the perpetrator’s sister contacted the police to say that the perpetrator had returned home just before midnight and had ‘gone berserk’. Five minutes later the paternal grandmother called to say the police were not required and that her daughter had got too excited about her brother. The police attended. No complaint was made and no offence was recorded and the perpetrator was transported to the great grandmother’s home.   135. There was routine contact with GP services and in October 2005 the adult victim was diagnosed with epilepsy following two episodes of losing consciousness in June and October 2005 respectively. It was around this time that the adult victim mentioned that she had plans to start a family the following year. The diagnosis of epilepsy had implications for this plan in regard to the medication that she was prescribed to manage the condition. There are associated issues in relation to an enhanced risk of depression that are discussed in the individual management review from the GP practice.  136. In July 2006 the adult victim’s pregnancy was confirmed. Child L was born in February 2007. He was born in a poor condition requiring resuscitation and admission to the neo natal ward where he remained for eight days. The adult     victim was discharged from hospital on the day of the birth. Child L made progress. In November his weight was below the ninth centile19. the adult victim had continuing physical health problems following the birth associated with the pregnancy.  137. Between March 2008 and April 2009 Child L was enrolled with the local children’s centre where he attended sessions with the adult victim.   138. In June 2009, the health visitor made a routine home visit during which the adult victim was noted to have faint bruising below her left eye although she was wearing makeup. The health visitor was unable to ask directly about the bruise as the perpetrator was present. Opportunity was given to contact the health visitor if the adult victim wanted to talk about diet or “anything else”20.   139. Three weeks later, the adult victim contacted the health visitor by phone to change the venue of a planned appointment to take place at the paternal grandmother’s home as Child L had stayed overnight the previous evening. During the phone conversation, the health visitor enquired about the bruising she had seen at the last visit. The adult victim explained that this had occurred when she had been sweeping up leaves. She made clear that it was not the result of any domestic violence. Child L’s dietary intake had improved and the health visitor was happy that Child L’s weight was now above the 2nd centile. The adult victim reported that Child L’s diet had improved because he was eating a greater variety of foods. Child L had also started going to a nursery. He had been initially shy and had gravitated towards adults. The adult victim felt that Child L was enjoying nursery.  140. In March 2010, three year old Child L was taken to the local hospital emergency department by a grandparent with a ‘head injury’ having fallen from a buggy. This attendance at the hospital was not notified to the GP. Child L was seen and documented as ‘walking, talking and playing normally’. Further analysis is provided in later sections in regard to the level of detail that was recorded in regard to the circumstances of this injury.   141. In July 2010 the adult victim and Child L both had treatment at a hospital emergency department in Southport for scald injuries. The adult victim had an injury to her foot and Child L had a small blister to the abdomen. The 19 A centile chart is a size for age chart that is used to decide whether the size of a child falls within the normal (average) range or whether the child is larger or smaller than normal. Centile charts show the position of a measured parameter within a statistical distribution. They do not show if that parameter is normal or abnormal. They merely show how it compares with that measurement in other individuals. They are called centiles and not per centiles. If a parameter such as weight is on the 3rd centile, this means that for every 100 children of that age, three per cent would be expected to be lighter and 97 heavier. On the 9th centile, 9 would be lighter and 91 heavier.  20 The nursery staff never saw any injury or bruising to the adult victim.                                                perpetrator had accompanied them and they are remembered by the hospital sister who was on duty as having been chatty. The injuries were reported to be the result of an accident while they were on a camping holiday. Both the adult victim and Child L had treatment at the hospital and on the advice of the sister Child L was taken by the parents to another hospital in Ormskirk that had a paediatric service.  142. In September 2011 Child L started school. A month after enrolment his teacher suggested that his hearing should be checked. An assessment in January 2013 did not identify any hearing loss.  143. In April 2012 Child L was treated at a hospital emergency department for an injury to his head. It is documented that Child L was ‘hit on forehead by handle of walking frame’ causing a lump on the left side of the forehead. Child L was described as being ‘happy, alert and playful’. The safeguarding children section of the patient documentation was not completed and no discussion with the school nursing service was apparently considered. Further analysis is provided in later sections of the report.  144. In January 2013 Child L was transferred to a new school because the family had bought a house and moved to another area in the county.   145. In early April 2013 Child L’s parents went to the GP to discuss the perpetrator’s mental health symptoms. The GP took a detailed history and promptly referred the perpetrator to the single point of access service and a duty mental health practitioner (MHP1) quickly contacted the perpetrator by phone within an hour of receiving the referral and completed an initial assessment by phone. An appointment was made to see him the following day. The referral and initial assessment confirmed that there was no history of self-harm and no suicidal ideation currently. Further information and analysis is provided in later sections.   146. The adult victim and Child L were killed overnight and the appointment was therefore not kept.      3 The critical reflection and analysis obtained from the individual management reviews.  3.1 Summary  147. The individual management reviews were completed using national guidance set out in Working Together to Safeguard Children (2013) and Multi-agency statutory guidance for the conduct of domestic homicide reviews which was also supported with additional local guidance provided on behalf of the local safeguarding children board. The individual management reviews included action plans for implementing recommendations. All the individual management reviews are countersigned by the senior manager for the individual commissioning agency.   148. Many of the services have already taken action or initiated action in response to improvements or areas of development identified through their individual review.   149. For some of the authors, they were simultaneously working on other individual management reviews for other serious case reviews. All of the authors were also undertaking their usual range of professional roles and responsibilities.   150. The national guidance has removed a requirement to provide a health overview report (HOR). No HOR was provided in this review.   3.2 Significant themes for learning that emerge from examining the individual management reviews  151. The agency reviews identify themes that have implications for policy development and staff training. In the summary of the review’s finding provided in chapter one there is acknowledgement that some of the issues to come out of this review are reflected in the findings from national evaluation and research.   152. The good practice identified by the review included:  a) The extended consultation with the GP which had lasted 20 minutes was followed immediately by the GP personally making a telephone referral to mental health services;  b) Prompt and sensitive arrangements were made by the school following the death of Child L to provide support to the school community and information provided to families; this included the provision of additional pastoral support at school and work with the local church to have playground support; involvement by the critical incident team to     support the school staff and anticipating the possibility of the traumatic incident prompting disclosures or requests for specific help from other families.     c) The hospital sister in Southport referred Child L to another hospital for a paediatric assessment and treatment after the scald injury.  153. The remainder of this chapter summarises key evidence relating to the terms of reference established for the individual management reviews.  TOR 1 What knowledge or information did agencies have that indicated the adult victim might be a victim of domestic abuse, or that child L might be at risk of significant harm?  154. The killing of a domestic partner and a child is a distressing and shocking experience for the family as well as for other people including professionals who were in contact before the deaths. Relatives and friends who have contributed information to the review have consistently described a family that was content and committed to each other. None of them had concerns in regard to the safety or wellbeing of any family member. They were a family who sought help and advice appropriately in regard to their health and wellbeing and of Child L.   155. The individual management review from the schools provided information about the extent of support that was provided to pupils and other members of the school community after the death of Child L. The two schools have been rated as good or outstanding by Ofsted that includes their work in regard to safeguarding children.   156. The same report describes the attention and awareness given to identifying children who may be exhibiting signs or symptoms of distress or abuse. Child L was a quiet child but showed no indication of being unhappy or being a child at risk of harm. The other services, primarily health that came into contact with Child L and the adult victim had similar views.   157. It is not uncommon in reviews that are required to collate and analyse a great deal of information following a tragic incident to identify with the benefit of hindsight, the occasions when there may have been opportunities to identify signs or symptoms of concern or abuse. The level of detailed enquiry and analysis required by a SCR and domestic homicide review can often reveal information that was either not identified at the time of events taking place or had a different interpretation.   158. In this case there was one occasion when a health visitor had noticed during a home visit in June 2009 that the adult victim had a bruise which was still visible through make up. The perpetrator had been present and therefore the health visitor had not asked any direct questions about the     bruise although when she left the house she had made a point of encouraging the adult victim to speak with her if there was anything she needed to talk about.   159. The health visitor had followed up the bruise although this did not happen for three weeks when the adult victim had called to change the venue for the health visitor’s scheduled home visit; the adult victim then stated that the bruise had been caused accidentally by a garden rake when she had been gardening. The individual management review acknowledges that this was too long a delay given the information that is known about following up evidence of injuries quickly to encourage disclosure and to secure evidence for further enquiries.   160. The only other occasion when the adult victim was seen with a physical injury was when she presented with a scald burn at another hospital emergency department in July 2010 when the family were on holiday locally. Although the adult victim and Child L initially went to the same emergency service, Child L was treated separately at another hospital’s paediatric emergency service in regard to the same accident. The injuries were reported to have occurred whilst the family were camping although there was no detailed history recorded in regard to the particular circumstances under which the injury had been acquired.   161. The individual management review author from the Southport and Ormskirk Hospital NHS Trust observes that if the hospital sister had not still been employed in the Trust and had such a clear recollection of the presentation at the hospital there would have been little other information to know about the incident. The fact that the family presented in such a positive fashion was the reasons that little inquiry was made about circumstances or the recording of information. The hospital sister did ensure that treatment was prompt and liaised with the other hospital paediatric service to ensure that Child L attended.  162. There were two other occasions when Child L was taken for hospital treatment. In March 2010, three year old Child L was taken to the local hospital emergency department by a grandparent with a ‘head injury’ having fallen from a buggy. This attendance at the hospital was not notified to the GP. Child L was seen and was documented as ‘walking, talking and playing normally’. Child L was attending a nursery at this time where there is no record of an injury to Child L and the nursery was not aware of any hospital treatment. Further analysis is provided in later sections of the report in regard to the level of detail that was recorded about the circumstances under which injuries occurred.   163. In April 2012 Child L was treated at a hospital emergency department for an injury to his head. It is documented that Child L was ‘hit on forehead by handle of walking frame’ causing a lump on the left side of the head. Child L     was happy, alert and playful. There is limited documentation as to how Child L had sustained the injury. The safeguarding children section of the patient documentation was not completed and liaison with the school nursing service was not apparently considered. Further analysis is provided in later sections of the report.  164. Care needs to be taken in not applying a hindsight bias that because of what happened to Child L and the adult victim begins to ascribe these presentations as missed opportunities that could have prevented their deaths. It remains probable, based on what is known from the information collated and analysed for the review and during the police inquiry, that these were accidents.  However, it would be expected practice to have seen a higher level of professional curiosity and recording than was achieved and would also have given greater confidence that abuse was not missed.   165. The individual management review on behalf of the GP service discusses other learning to emerge from a detailed examination of the patient records. For example, the individual management review highlights that the adult victim moved to Lancashire after meeting the perpetrator when he was temporarily working in another part of the UK. When she registered as a new patient, there was no consideration as to whether she was socially isolated or where her support was located over and above her relationship with the perpetrator. The same individual management review also highlights that epilepsy carries a heightened chance of depression which was not apparently considered when the adult victim sought advice about pregnancy. The individual management review draws attention to the prevalence of social isolation and depression in child injury and domestic abuse.   166. None of the services were able to provide information as to whether a learning or cognitive difficulty was an issue for the adult victim although the GP report highlights that the adult victim had remedial education support when she had been at school although her medical records for that period are missing and therefore no more detailed information is available.   167. The GP consultation on the 8th April 2013 had resulted in a referral being made to the county mental health services through the Single Point of Access. Although there was nothing in the demeanour of either parent to cause immediate concern about the perpetrator being at risk of self-harm, it is apparent that the perpetrator was experiencing what the GP thought could be a psychotic episode and was the reason the GP made an urgent referral by telephone in spite of having other patients already waiting for their consultation. The individual management review describes how the GP had recent experience of working in psychiatric services for six months.   168. Neither the GP nor MHP1 who initially dealt with the referral had inquired about Child L. Although the GP had spent 20 minutes talking with and assessing the perpetrator’s mental and physical health, neither the GP nor     the MHP1 during their telephone discussion with the perpetrator later the same day used a depression assessment tool such as the PHQ-9 to collate information about the perpetrator’s mood and general mental health21. The individual management review on behalf of the mental health service confirms that the PHQ-9 is rarely completed until a face-to-face assessment is completed by the MHP1.   169. The referral from the GP was recorded by the duty mental health practitioner (MHP1). There is inevitably a degree of risk in information being misunderstood or being given differential inference between the person providing information and the individual recording it. Some of this reflects a fundamental attribution for example in regard to recording evidence of risk; on the form there is a section asking for information about risk screening where the tendency is to look at the safety of practitioners which is valid but also requires a conscious consideration of risk on a broader front. Experienced practitioners will assert that this is integral to their practice although their recording may not explicitly reflect this.   170. There is also what is described in research literature as the ‘shortcomings of human inference’. This can help describe how judgments can be influenced by inference where for example the mental health service know that GPs will almost certainly allocate a judgment of high risk to their referral and that this is understood as trying to give their patient a higher priority for attention rather than reflecting a more objective assessment of concern22.   171. The service may therefore be less bound by a third party judgment and especially if that third party is seen to be ambivalent. The judgment in regard to risk is decoupled from the data and intelligence about the subject of the risk. None of this should be read as a criticism of the GP or the mental health practitioners but rather is intended to develop an insight into how important aspects of roles and functions are carried out.   172. The mental health service responded promptly to the telephone referral. Having taken the call from the GP and tried to contact the perpetrator through the telephone landline MHP1 successfully made contact through the adult victim’s mobile phone.  The parents were in a local public park at the time. The mental health practitioner completed a telephone triage and having concluded that the perpetrator was not requiring an immediate face-21 The individual management review on behalf of the GP practice discusses the various tools that are available to general practitioners that included the PHQ-9 assessment tool that has been validated for use in primary health care settings. The tool is designed to assess the patient’s mood over the previous two weeks rather than relying just on immediate observation and self-reporting of current mood.  22 Nisbett & Ross, (1980). Human inference: Strategies and shortcomings of social judgment; Prentice-Hall                                              to-face assessment then made arrangements for this to be completed the following day.   173. During the referral discussion and the triage conversation, no information was disclosed that indicated there were any historical or current concerns about domestic abuse.   TOR2 What services were offered to the adult victim, the perpetrator and child L and were they accessible and sympathetic?  174. Until the perpetrator began to experience his first disclosed episode of mental health symptoms to the GP and the subsequent referral to the mental health services by the GP, the family had not come to the notice of any other services other than those providing health care for the family and the early years care and education provided for Child L. Child L was a regular attendee at nursery and at primary school and was meeting the recognised developmental milestones.   175. The provision of services to the family was largely routine and unremarkable. This included appropriate contact with the family GP services, midwifery and health visiting services as well as presentations at hospital emergency services following accidents. Contact with the school was also routine in as far as Child L was a regular attendee at school and his parents participated in parent evenings and attended school events.  176. The purpose of the review is to allow reflection and analysis about whether any aspect of services could be improved. This does not imply people were not doing their jobs correctly but rather looks at how the service can be improved or can be provided with enhanced levels of awareness or sensitivity.  177. The GP individual management review comments about the gap in historical patient records for the adult victim that cannot be explained; the time period is from when she was living in another part of the country although it would be expected practice for records to be transferred to a new practice when a patient has registered with a new GP.   178. The individual management review comments that although a routine patient check was completed when the adult victim transferred to the GP practice, the framework of the patient check still does not prompt inquiry about wider social and emotional issues and which may or may not have been significant factors for the adult victim. The individual management review makes reference to community and social isolation as factors that can be associated with domestic abuse (and forms of child abuse).   179. The GP individual management review also discusses the fact that the reviews of the adult victim’s epilepsy did not include questions about     depression although there is an associated life time prevalence of between six and thirty per cent for patients diagnosed with epilepsy. The same individual management review also points to depression as being a factor identified in incidents of domestic abuse (and is also a factor in child maltreatment and abuse).   180. The same individual management review also comments that there were not routine screening questions about domestic abuse; this is not a local or national requirement in GP contracts and there is research still being undertaken in the UK to establish whether there should be changes to the policy.   181. The presentations at the hospital emergency services by the adult victim and Child L were opportunities for a more sceptical and curious enquiry about the circumstances under which the injuries had occurred. Child L was twice presented with an injury; on one of those occasions it was because he had fallen from a buggy and on another he had a bump to his head. The GP was only told of one of those presentations and also had incomplete information in regard to the adult victim receiving hospital treatment. The GP also received incorrect information about a presentation for Child L at hospital that referred to a scald when in fact Child L had an injury to his head.   182. The individual management review on behalf of UHMB describes the historical systems for notifying the GP services about any hospital attendance by a patient relying on practitioners generating a letter; this appeared to be the case in regard to Child L but this was overlooked. The current electronic patient information system generates a notification when a patient is presented for hospital treatment. In many parts of England hospital trusts have well established paediatric liaison services that have responsibility for overseeing information about hospital admissions or treatment of children and young people and have a critical role in coordinating information. UHMB will have established a paediatric liaison service from September 2013. This service will have oversight of gathering of hospital and treatment information in respect of all children aged 18 and under who have been presented and admitted for treatment. They will also be responsible for communicating the collated information to the relevant primary and community care professionals such as GPs and health visiting and school nursing services.   183.  One of the hospitals has been subject of critical inspection reports and changes have already been instituted in regard to how history is taken and communication with primary health services such as the GP.   184. In regard to the perpetrator, when he consulted his GP regarding the onset of his low mood and other symptoms, the GP took a thorough history with regards to the voices that the perpetrator was hearing.  the perpetrator was clear that the voices were not talking to him, but were rather talking about him.  The GP asked specifically whether the voices were asking him to do     anything and the perpetrator’s reply was that they were not.  The GP asked specifically whether he had any thoughts of self-harm or suicide and the perpetrator had said he did not.    185. The GP did not think that there was an immediate risk to the perpetrator or to the adult victim who was present throughout the consultation. The GP had not appreciated at the time that the couple had a child although even with the benefit of hindsight, there was nothing in the initial assessment to indicate risk of significant harm and injury to any of the family.  186. The GP contacted the Single Point of Access, which is the correct referral mechanism for urgent mental health problems.  The GP explained the situation to them and asked for ‘a quick assessment’, given the perpetrator’s recent onset of mental health symptoms.  There was an initial assessment over the telephone that same day by a mental health practitioner and a face-to-face appointment was given for the following day. This was the day on which the killings took place; they had not attended the hospital appointment.   187. The perpetrator had been called by telephone immediately after the referral was made by GP by the same mental health practitioner who had received the referral from the GP; the individual management review described this as timely and provided consistency. The practitioner followed the referral pathway in Lancaster and Morecambe for urgent assessments. Two attempts were made to call the perpetrator on his landline before a successful attempt via the adult victim’s mobile phone.  The perpetrator was in a local park when he took the phone call.  The practitioner discussed with him the concerns the GP had relayed and explored the nature of his voices.  The perpetrator agreed to a face-to face assessment with the practitioner the following day which continued to offer consistency.   188. Telephone triage is the standard practice across the Trust for all referrals marked urgent made to the Single Point of Access as a way of clarifying the referral and “gate keeping” the allocation of assessments.  The Single Point of Access in Lancaster and Morecambe receives approximately 25 referrals a day and these are processed by the duty worker.   189. The individual management review on behalf of the LCFT discusses the shortcomings of a telephone based triage service drawing attention to research and other evidence. The individual management review is concerned that a telephone triage for symptoms of mental disorder has limitations as it relies only on sound. No other senses can be used such as body language or demeanour and eye contact observations are not available to a telephone triage. Likewise, the full range of interpersonal communication is not available to establish rapport and establish patient confidence and trust to disclose their symptoms. When he responded to the telephone triage, the perpetrator was in a public place and may not have had     sufficient privacy for a confidential discussion of his symptoms. In this case the GP had had opportunity of face-to-face contact in the privacy of a consulting room which concluded in the immediate and urgent referral for a mental health assessment.   190. The duty mental health practitioner recorded that the GP had stated that the perpetrator was “? Hearing voices” and “paranoid people are talking about him”.  Following the telephone conversation with the perpetrator the mental health practitioner concluded that the voices were ‘an internal dialogue’ rather than instructions or incitement to act in particular ways23. The mental health practitioner was therefore not working on a premise that the perpetrator was presenting with symptoms of untreated psychosis.   191. With the benefit of hindsight and the detailed analysis provided in the individual management review, this working hypothesis may have represented a degree of over confidence. This is not a criticism of any individual specialist practitioner. The judgement they arrived at was consistent with what they ‘heard’ during the telephone referral and the triage telephone assessment.   192. The individual management review on behalf of the mental health service offers an analytical commentary about the shortcomings of the referral process, the reliance on a telephone based triage service and the other influences such as cognitive and human inference. This is explored further in the later chapter that presents key findings from the review.    193. The decision to arrange the face-to-face assessment meant that using tools such as the PHQ-9 and completing a more detailed history were postponed, albeit for less than 24 hours. The delay had been an additional source of anxiety for the perpetrator. Even if the face-to-face assessment had been completed that same day it would be false to conclude that the awful events overnight could have been prevented. The perpetrator would have been free to remain at home unless there had been any evidence to support either voluntary or compulsory in patient treatment. The pace and scale of crisis and deterioration in his emotional and mental condition was not indicated in the information presented.   194. The individual management review from the LCFT draws attention to Blue Lights and an internal briefing that had been published following a domestic homicide review in a neighbouring authority. Blue Lights are applicable to all mental health clinical staff and are a method of sharing learning from incidents across Lancashire Care NHS Foundation Trust.  23 The individual management review explains that internal dialogue refers to the general experience of most people thinking in their own words their internal thought processes rather than being auditory or hallucinatory and therefore more distressing for the patient and indicative of for example a psychotic episode.                                               195. Blue Light 71 was issued in October 2011, and concerns the treatment of first episode psychosis. This was produced following a post incident review (PIR)24 of a domestic homicide where it was found that a person experiencing first episode psychosis who was not assessed by the appropriate service for her needs in a timely manner.  It recommended that where an individual is actively psychotic and untreated, and therefore is at risk to themselves or to others, they will require an emergency assessment on the day of presentation involving a senior member of medical staff. Therefore all such presentations must be referred through the Crisis Resolution and Home Treatment Team for comprehensive assessment and formulation of a treatment plan.  196. There is further analysis in the individual management review and in later sections of this report. The mental health practitioner did not feel that the perpetrator’s symptoms were indicative of active psychosis or represented a source of risk. The mental health practitioner felt that the adult victim could have alerted the mental health practitioner to a risk of harm because the contact was made through her mobile phone although it is acknowledged that in compliance with maintaining patient confidentiality the mental health practitioner did not identify them self to the adult victim when they made contact with the perpetrator on her mobile phone. There are also issues to be considered in regard to the relationship and working arrangements between the single point of access team and the Crisis Resolution and Home Treatment Team.   197. The conclusion therefore for the panel is that although the response by all services to the different members of the family can be described as sympathetic and prompt, particularly in regard to the onset of the perpetrator’s symptoms, there are aspects of learning that will be looked at in later sections of the report.   198. When the police interviewed the perpetrator after the killings and he had made some physical recovery from his own self-inflicted injuries, he described how worried he had been about the prospect of being hospitalised and feeling his family would be unable to cope. This anxiety was not known and therefore was unrecognised to the GP and to the Single Point of Access practitioner at the time. The paternal family have also provided information to the review about how the GP consultation and referral to the mental health service inadvertently exacerbated the symptoms.   24 A post-incident review (PIR) is an evaluation of incident response used to identify and correct weaknesses, as well as to determine strengths and promulgate them through organisations and is used in health trusts across the UK. PIRs are normally used to support revision to services or clinical practice.                                              TOR 3 What information did family and friends have that might have indicated the adult victim and/or child L were at risk of abuse?  199. Several of the individual management reviews acknowledge that analysis of the case provides an opportunity to reflect on whether their staff had enough or sufficiently recent training to develop their awareness about domestic abuse. For example about making more rigorous checks into the circumstances of accidents and the barriers that face women living in coercive and abusive relationships. There is no evidence that the adult victim ever indicated that she was the victim of abuse or coercion.   200. Research as well as the findings of reviews into child abuse and domestic homicide highlights the heightened risk of domestic abuse for example during pregnancy. This is not to suggest that every pregnant woman is at risk of domestic abuse or that even the adult victim was a victim of domestic abuse.   201. The point is to create awareness on the part of professionals to screen and look for indicators of domestic abuse rather than rely on explicit disclosure or other evidence.  The GP individual management review makes the point that a killing is often not a first attack and is often preceded by psychological or emotional abuse that is not identified by primary health services in contact with the victim or abuser.   202. The GP individual management review acknowledges that there were gaps in information provided to the practice from the hospitals that provided treatment to Child L when for example Child L had fallen from a buggy. The GP practice was told about the scald injuries although these were recorded in the barest detail and did not record any further enquiries that would be expected in accordance with clinical guidelines such as those published by NICE25.   203. The individual management review on behalf of UHMB comments that there had been delays in implementing national guidance on screening women during pregnancy for evidence of domestic abuse26. The same individual management review also acknowledges that the more limited local procedures that had been in place for considering potential safeguarding issues were not fully complied with; a significant factor was judged to be 25 The individual management review has commented that nowhere in the GP records is it documented that there were any further inquiries made into the circumstances surrounding these injuries.  NICE Clinical Guideline 89 When to suspect child maltreatment (2009) recommends that practitioners should seek an explanation for injuries.  This should be done in an open and non-judgmental manner.  There is no evidence to suggest this was done in this case.  26 The UHMB author points out that NICE guidance published in 2006 was not introduced to the Trust and it was in 2012 when the current guidelines and staff development was implemented.                                               workload associated with the closure of a hospital emergency department in Cumbria and staff shortages.   204. The bruise to the adult victim in June 2009 was the only record of an injury being observed outside of a hospital emergency service. Although this was followed up and the adult victim confirmed that it was nothing more than a gardening accident, the follow up occurred almost three weeks later. Research shows that women in particular are reluctant to disclose domestic abuse and that on average up to 35 incidents will have occurred before such a disclosure is made.   205. The reasons for not disclosing abuse include social isolation and economic dependency including housing; the adult victim had moved to Lancashire and with the exception of her elderly mother, had no family although she did make friends with a colleague at work and appeared to have a good relationship with family relatives.   TOR 4 What knowledge did agencies have that the perpetrator might be a perpetrator of abuse and pose a risk of significant harm to Child L or the adult victim?  206. The police had historical information about a previous partner of the perpetrator following his harassment of her when she ended their relationship at the end of 2003. This was stopped when she reported it to the police and he had been advised about his conduct. His father (paternal grandfather) had ensured that a mobile phone was returned to the ex-partner.   207. the perpetrator met the adult victim very soon after this relationship ended and there were never any reports of concerns about their relationship to the police or to any other service.  208. When the perpetrator experienced the onset of psychosis, the adult victim arranged for him to be seen by the family GP. During the consultation the adult victim did not disclose any concerns about her own safety or to Child L. The GP individual management review comments that the history taken by the GP included exploration about the perpetrator’s threat of harm although this was focussed primarily on whether he had any thoughts of self-harm (which he did not). He was not asked about any thoughts of harming other people. Although he appeared unkempt, he kept good eye contact with the GP who made a referral immediately to the local mental health service.   209. With hindsight, aspects of decision making in response to the GP referral was not based on complete information or sufficient consideration of other relevant factors. This is not to blame or place responsibility for what happened on any individual. Even if the perpetrator had been invited to a face-to-face assessment on the day of the referral from the GP it does not     then infer that he would have been diagnosed as requiring inpatient treatment.   210. The local protocol for treatment of first episode psychosis recognises that analysis of serious untoward incidents has identified an emerging theme in regard to people who are actively psychotic and have not been treated are always at risk in the first episode.  211. The protocol stresses the importance of a same day assessment to also consider urgent treatment and other intervention if necessary and for the assessment to involve a consultant psychiatrist or their deputy.   212. This reinforces the view that a primary threat will be from the person with the symptoms being a risk to their own safety. In terms of what is understood about the circumstances of the killings and attempted suicide, it appears that this is a case of familicide triggered by the psychiatric and psychological crisis rather than being the product of an escalation of abuse.    TOR 5 Were there any risks in relation to resources or capacity that had an impact on how services were provided to the victims or to the alleged perpetrator or that impacted on agencies’ ability to work effectively with other services?   213. With the exception of the individual management reviews from the UHMB and the LCFT mental health service, resources are not identified as a significant factor in how the case was dealt with at the time.   214. The individual management review from UHMB describes significant historical problems that may have been contributory factors to how for example some aspects of inquiry and recording of information about the accidents described in earlier sections. These included low levels of safeguarding training (but rapidly improved and at the time of submission of the individual management review for this review was at required CQC levels27), the absence of paediatric liaison arrangements and children’s nurses (addressed following Ofsted and CQC visits), and reorganisation of services.   215. The individual management review also describes the extent to which significant turnover of staff has had an impact that has included the degree to which organisational memory is limited. The individual management review describes very considerable improvement work and acknowledges the need to complete the required improvement actions in safeguarding arrangements in regard to for example establishing safeguarding champions.  27 Care Quality Commission that is responsible for checking that national standards are met in health services.                                              216. The LCFT individual management review explores the various factors that had an influence on the practitioner’s decision not to offer a same day assessment, some of which reflect local working arrangements. The practitioner made the decision not to apply the Blue Light protocol based on their assessment that he was calm, there were no indications of thoughts of harm to himself or others, and it was their opinion that the possible voices described in the GP referral were the perpetrator’s own internal dialogue.  217. Had the practitioner followed the Blue Light they would have needed to contact the Crisis Resolution Home Treatment Team who have the resource and responsibility to provide same day assessments.  The author of the individual management review interviewed the Single Point of Access practitioners and the review established that there are interface issues between Crisis Resolution and Home Treatment Team and Single Point of Access and that the Single Point of Access practitioners report inconsistent responses and thresholds when referring to the Crisis Resolution and Home Treatment Team.  This may have impacted on the practitioner’s decision making in respect of the timing of the assessment.    218. The mental health practitioner stated that they were confident in their clinical judgement, that had the perpetrator needed it the mental health practitioner would have contacted Crisis Resolution and Home Treatment Team but that they felt the perpetrator did not require the protocol / referral to Crisis Resolution and Home Treatment Team as they had assessed that the perpetrator was not a risk to himself or to others.    219. As stated in previous paragraphs, the process of telephone triaging urgent referrals is a standard practice in the Single Point of Access.  The use of such telephone triage in mental health has been subject to a research study in Australia and the individual management review author is able to draw some parallels with its use and access to resources in this case.  The individual management review includes a reference to a particular study28 from 2007 (although not in Lancashire):  “One of the central themes to emerge from the interview data was that the gate keeping of resources is intrinsic to the mental health triage role, and that decision making in triage is typically influenced by the availability of resources such as inpatient beds and access to crisis teams. The interview data established that nurses commonly experience ethical tension between the interests of economics underpinning the mental health triage model, and the provision of equitable, ethical, quality mental health care”.  28 Sands N (2007); Mental health triage: towards a model for nursing practice,  Journal of Psychiatric and Mental Health Nursing, 14, p243–249                                                220. The individual management review author is concerned that the decision not to follow the Blue Light protocol was affected by the Crisis Resolution and Home Treatment Team relationship. Had the perpetrator been assessed that day by a psychiatrist, the GP’s referral information would have been clarified on a broader range of evidence and directly observable cues. In this case the GP’s referral information suggesting that he might have been hearing voices and was therefore a “high risk” was replaced by the self-report of the perpetrator in the telephone triage assessment.    221. The individual management review author considers whether urgent referrals should receive a telephone triage as part of the process and the need to ensure that it remains clinically-led. The system of telephone triage is a nationally recognised and implemented system.  The individual management review author confirmed that the mental health practitioner completed a thorough telephone triage, but does draw the attention to the managers in LCFT as well as to the review panel of the limitations of the telephone triage for example in a practitioner not being able to observe non-verbal information about the patient’s demeanour or presentation.   222. The individual management review explains that the LCFT has adopted a stepped care model of service29. This ensures that the expertise and resources of the Trust are offered to match the needs of patients; the patients with the most complex needs receive a service commensurate to their needs. Alongside addressing the needs of patients, the model addresses the reality that the resources that can be made available are finite. Therefore patients are only referred to be stepped-up when their needs have been clearly assessed and considered, and when sufficient efforts have been made to manage at the lower step of provision.   223. The individual management review considers that the experience of MHP1 and their colleagues combined with interface issues may have contributed to misplaced confidence in the telephone triage process and the development of a culture of self-sufficiency to manage within the single point of access.  Additionally, the team is made up of mental health nurses with limited input from a psychiatrist; the single discipline may reduce the availability of sufficiently rigorous challenge that can be present within teams where there are more than one discipline with different perspectives and expertise available and a culture of sceptical inquisitiveness.      29 Step care mental health services are a system of delivering and monitoring treatment designed with the intention to deliver the most effective but least resource intensive services that are provided promptly and that patients only ‘step up’ to more intensive or specialist services when clinically required.                                               4 Analysis of key themes for learning from the case and recommendations  224. Any meaningful analysis of the complex human interactions and decision making processes that are involved in multiagency work with vulnerable individuals or families has to understand why things happen and the extent to which the local systems (people, processes, organisations) help or hinder effective work locally within ‘the tunnel’30.   225. In this chapter the panel set out key findings that are designed to offer challenge and reflection for the local safeguarding children board and community safety partnership and their partners. The emphasis is not on the more traditional formulation of SMART recommendations. The key findings are framed using a systems based typology developed by SCIE. Although this review has not used systems learning to collate evidence, there is value in using the following framework to identify some of the underlying patterns that appear to be significant for local practice in Lancashire;  a) Cognitive influence and human bias b) Responses to incidents and information c) Tools to support professional judgment and decision making.  226. The remainder of this report aims to use this particular case, and to reflect on what this reveals about gaps or areas for further development in the local child protection system and use it as a limited window into the local systems.   227. In providing the reflections and challenges to the local safeguarding children board and/or the community safety partnership there is an expectation that there will be a response to each of the key findings as well as to the 31 recommendations and the associated action plans that are described in the agency individual management reviews. As far as the key findings described in the remainder of this chapter it is anticipated that the local safeguarding children board or the community safety partnership will take the following action.  a) An indication as to whether the board(s) accepts the findings; b) Information as to how the board(s) will take the findings forward; c) Information about which board and who is best placed to lead on any particular activity to promote improvement and learning; d) An indication of the timescales for responding to the findings; e) Information about how and when it will be reported. 30 View in the Tunnel is explained by Dekker (2002) as reconstructing how different professionals saw the case as it unfolded; understanding other people’s assessments and actions, the review team try to attain the perspective of the people who were there at the time, their decisions were based on what they saw on the inside of the tunnel; not on what happens to be known today through the benefit of hindsight.                                               228. The local safeguarding children board and community safety partnership will determine how this information is managed and communicated to relevant stakeholders. This report recommends that a formal response is also published.   4.1 Learning from previous serious case reviews  229. The local safeguarding children board in Lancashire had undertaken nine previous serious case reviews between 2008 and 2012. This is the third domestic homicide review in Lancashire. Reference has been made to the domestic homicide review completed in a neighbouring area that led to the development of the Blue Light guidance mentioned in the previous chapter.  4.2 Cognitive influence and human bias and its influence in judgments and decision making Self-confident practitioners working within imperfect systems; the influence and shortcomings of human inference in risk assessment; the calibration of risk.  230. In this case there was relatively little involvement or contact with services and only a brief period of less than 24 hours between the perpetrator first disclosing his symptoms with the GP and the tragic deaths occurring.   231. The individual management reviews from the GP and from the LCFT in regard to the Single Point of Access Service provide information and analysis in regard to how the process of referral was handled from the GP to the mental health practitioner on duty. Both individual management reviews confirm that both services and the individual professionals involved have complied with the relevant professional standards and local protocols. Further, even if there had been any different decisions or action taken, it would not have resulted in the perpetrator being anywhere other than at home with his family on the night that the killings and attempted suicide took place.   232. A review such as this is required to analyse how decisions and action are taken for the purpose of learning. For that reason, the panel with the help of the agencies individual management reviews has looked at why there was an apparent discrepancy between the GP concluding that the perpetrator was exhibiting symptoms of psychosis and the mental health practitioner who did not. If the mental health practitioner had agreed with the GP that the perpetrator was exhibiting the onset of a psychotic condition his referral would have been managed in compliance with the Blue Light protocol described in an earlier section of the report for all first and untreated episodes of psychosis.       233. Although this would have meant that the perpetrator would have been seen by a consultant psychiatrist the same day that the referral had been received, this would not necessarily have been able to prevent the tragic events without in-patient assessment and treatment. The perpetrator’s presentation during the contact with the GP and the mental health practitioner suggests that this would have been an unlikely outcome.    234. The influence of human bias in how information is processed and analysed in complex processes such as a mental health referral is an area that a learning based review attempts to explore in order to understand how people make their judgments and decisions.   235. In this case the GP’s referral information suggesting that the perpetrator might be hearing voices and was a “high risk” was replaced by the self-report of the perpetrator in the telephone triage assessment.  The individual management review author draws attention to the tensions of managing finite resources (such as consultant psychiatric expertise) and making clinically led judgments.  236. The individual management review highlights that GP referrals to the service are invariably marked as high priority and it is widely assumed within the service that this is an effort to give the patient priority in what is known to be a busy referral service (over 25 a day). In this case the referral was a telephone call made by the GP with MHP1 recording the information. There is an assumption that the GP will have a more generalist knowledge of mental health (in this case the GP had recent experience of working in a psychiatric setting although this would not give the depth and level of training and experience of mental health professionals working longer term in specialist services) and conditions such as psychosis and the referral is the opportunity to subject the information to a more expert mental health service.   237. There are also interface issues between the Single Point of Access Service and the Crisis Resolution and Home Treatment Team in regard to differing interpretation on thresholds for urgent referrals and inconsistencies in response which was encouraging the mental health practitioner duty team to not make referrals until they had completed an assessment.    238. Within this context the individual management review analyses whether the mental health practitioner was over-confident in their judgement that the perpetrator was not displaying psychotic symptoms based on the telephone triage discussion. This is not a criticism of the mental health practitioner by either the individual management review or by the author of this report but is more an analysis of how working practices and cultures have developed.        239. There has been a lot of research on the overconfidence effect in decision making and judgements31 reviewed for example by Lichtenstein, Fischhoff, & Phillips. People are generally unaware of the "shortcomings of human inference" thus they rely on biased or selected samples of data, over-rely on their personal traits or ‘pet’ theories and use subjective calibration strategies32. As people are generally unaware of these inferential errors they tend not to adjust their subjective confidence and thus are overconfident in their judgment.   240. In this case, there was a tendency to give greater weight to the telephone call than the information and professional judgment being offered by the GP. This is not a statement that says one professional got the judgement right and another got it wrong. Instead, it is to understand how specialist practitioners working in a busy and pressurised setting are processing information that is opaque and nuanced.   241. The most consistent finding in relation to the overconfidence effect has been that people generally are not well calibrated, they tend to have too strong a belief in the correctness of their judgements and they are too confident.   242. This can be especially the case when one person feels they are more expert than another person. When people are overconfident they believe that they know more than they in fact do know, or believe their accuracy to be higher than it in fact is. Over-confidence was referred to as a “cognitive conceit”33. This can be particular phenomena in single discipline teams or services that regard themselves as the expert.  243. The LCFT report considers whether the initial information in the referral urgent referrals should receive a telephone triage as part of the process and whether this is a resource-led process rather than clinically-led.  The author is not suggesting the worker did not carry out a thorough telephone triage, but is drawing attention to the limitations of telephone triage.    Issue for consideration by the local safeguarding children board and community safety partnership  1. Are there any specific issues to be addressed by local organisations in the development of referral, risk assessment and information sharing 31 Lichtenstein, S., Fischhoff, B., & Phillips, L. D. (1982). Calibration of probabilities: The state of the art to 1980. In D. Kahneman, P. Slovic, & A. Tversky (Eds.), Judgement under uncertainty: Heuristics and biases, (pp. 306-334). Cambridge, England: Cambridge University Press. 32 Nisbett, R., & Ross, L. (1980). Human inference: Strategies and shortcomings of social judgment. Englewood Cliffs, NJ: Prentice-Hall. 33 Block, R. A., & Harper, D. R. (1991). Overconfidence in estimation: Testing the anchoring-and-adjustment hypothesis. Organizational Behavior and Human Decision Processes,                                               between the specialist mental health services and other professionals in the county?  4.3 Responses to incidents or information Injuries may be accidental but abuse must be considered and also take account of the potential barriers for victims to disclose information; ensuring that there is sufficient enquiry and recording of information about the circumstances of any presentations for medical or health treatment.   244. The panel found no substantiated evidence that either the adult victim or Child L were ever subjected to abuse by the perpetrator and have noted the extent of remorse, confusion and distress he has experienced since the killings. In terms of that incident none of the services had any indication that this was a possibility and the information shared from the police investigation confirmed that there was no apparent premeditation.   245. The previous section of these findings discussed the influence of cognitive factors such as overconfidence and the shortcomings of human inference when assessing evidence as in this case from another professional. In this part of the report the focus shifts to looking at whether medical practitioners showed enough rigour in how they managed presentations by the adult victim and Child L for treatment following injury. It is clear that they were all regarded as accidents but there was an over-reliance on the information presented to the clinicians and not enough evidence that more sceptical and research informed history taking and assessment was taking place.  246. The individual management review from the Southport and Ormskirk Hospitals NHS Trust describes how the cognitive influence of how the family presented was an influence in not taking a more sceptical approach to the taking of a history. This was not confined to that service or that one occasion. Even though this is not a case that has involved coercion or abusive behaviour, the review is an opportunity to improve the opportunity for identifying potential indicators and symptoms.   247. For example, the adult victim was observed with a bruise to her eye. It was understandable that the health practitioner did not want to be more assertive in her enquiries during the home visit; if it had been an injury caused by her partner there was a strong likelihood that the adult victim would not disclose information or that the possibility of disclosure would increase risk. Although the practitioner tried to show empathy and encouragement to contact her, she did not make any follow up enquiries until three weeks later.   248. Research and the evidence from reviews such as this reinforce the importance of grabbing moments of possible disclosures of abuse. Children and adult victims of abuse face many and diverse barriers to disclosing abuse and therefore sensitive but prompt follow up is required. Delay in follow up     will compromise other processes such as securing forensic and medical evidence as appropriate for effective investigation and intervention.   249. The adult victim stated that the injury had been the result of a gardening accident and apart from the scalding injury, there were no other occasions when either physical injury of or other indicators seen to suggest that the adult victim was subject to domestic abuse or coercion.   250. The adult victim and Child L were treated for scald injuries. There is little information recorded about how the scalding occurred. They were also treated at separate clinical locations which represent potential vulnerability in clinicians being able to identify patterns. There were two other occasions when Child L was seen at hospital following accidents and again there was little information recorded in regard to circumstances. There were also gaps in making sure the GP practice were informed about all presentations and having accurate details about circumstances.   251. Recognising and identifying evidence of abuse relies on respectful and sceptical inquiry and taking of history until the deaths of Child L and the adult victim, this was a family who were never a concern for any service in the county. Although there is no evidence that either the adult victim or Child L had suffered abuse there had been occasions when they had been seen by health professionals who could and should have been more curious when for example the adult victim was seen with a bruise and both had suffered scald injuries.   252. Although there is nothing to indicate that the injuries were not caused by the accidents that were reported at the time, there was a naïve approach to taking histories and sharing information with the GP practice for example.   253. There have been previous serious case reviews that highlighted similar shortcoming in emergency care settings.   254. The follow up to the bruise was done three weeks after it had been first observed. A central theme of the serious case review is the extent to which the opportunities for making sufficient enquiries and sharing of information were not sufficiently exploited. The considerable history of the perpetrator in particular remained undiscovered for many of the services.  Issue for consideration by the local safeguarding children board and community safety partnership  2) Are the local safeguarding children board and community safety partnership sufficiently confident that current arrangements for recognition and responding to indicators of child or domestic abuse in emergency health settings?      4.4 Tools to support professional judgment and decision making The use of tools or frameworks to make referrals and conduct triage and allocate priority is susceptible to human biases and organisational pressures  255. The review with the help of the agency individual management reviews has looked in detail at the mechanisms for making and managing referrals. Under current arrangements there is a high reliance on the quality of information passed over to the Single Point of Access and the use of the telephone based triage.   256. The GP individual management review discusses the absence of any recommended tools or frameworks for GPs to use when being consulted by a patient and assessing risk. For example, there is a patient health questionnaire (PHQ-9) that gathers information about mood and thoughts of harm over a preceding two week period rather than just being focussed on symptoms during the consultation. This assessment is not used uniformly or indeed any other framework.   257. Mention has already been made of the cognitive influence arising from the mental health practitioner seeing a variety of referrals and inconsistent information. In this case, the perpetrator’s GP had recently completed working in a psychiatric setting.  258. The report has also discussed the analysis provided in the individual management review from the LCFT in regard to the shortcomings of a telephone based triage system. Allied to this is overall rate of referrals and managing the pathways through the stepped care model of accessing assessment and treatment services.   Issue for consideration by the local safeguarding children board and community safety partnership  3. Are the local safeguarding children board and/or the community safety partnership satisfied with current arrangements described in this review for the identification, assessment and management of risk associated with the onset of psychotic or mental health crisis?   4. How can the learning from the review be transferred into professional risk assessment and practice?    4.5 Issues for national policy  259. There are no nationally recommended risk assessment frameworks for health professionals to use when assessing and managing risk of harm from patients experiencing emotional or mental health crises.      Peter Maddocks, CQSW, MA. Independent author December 2013   CONFIDENTIAL    5 APPENDICES   Appendix 1: list of agencies contacted for the review  University Hospital Morecambe Bay General Practitioners Blackpool Teaching Hospital Trust (health visiting and school nursing) Lancashire Care Foundation Trust Constabulary Primary schools Morecambe Kindergarten Early years Probation Trust Women's Aid Southport and Ormskirk Hospital Adult social care Lancaster City Council Lincolnshire agencies (all agencies contacted to request any known historical information)  Appendix 2: family and friends contacted for the review  Maternal Aunts to mother Paternal Aunts to mother Cousin of mother Work Friend of mother School Friend of mother Paternal Uncle to child Paternal Aunt to child Paternal Grandparents to child   2015LancashireChildLOverview Page 52 of 57 CONFIDENTIAL    Appendix 3: Single Agency Recommendations  a) Education: No recommendations  b) General Practitioners:  1. Screening for domestic violence Currently the practice does not screen for domestic violence. The guidance for conducting Domestic Homicide Reviews states that "murder is often not the first attack and is likely to have been preceded by psychological and emotional abuse" and it is recognised that most of those experiencing abuse are not identified by their GP (Richardson et al. BMJ 2002). One study conducted in primary care in the USA put the figure of those identified at fewer than 10%. Questions on domestic violence are now incorporated into antenatal care but as yet there is no consensus on the benefits of routine screening for all. The National Screening Committee found that it did not meet the criteria for a national screening programme, one reason being that there is a lack of evidence on effective interventions for those who do identify themselves. Nevertheless routine reviews such as new patient and post-natal checks may represent the only chances a victim of abuse has to attend the surgery without arousing the partner's suspicion and safeguarding concerns should be borne in mind.   There are a number of screening tools for domestic violence. These include some general, well phrased questions which could be incorporated into routine checks.  I would recommend that the practice considers incorporating these into its computer templates. This should be preceded by general training on identification and management of disclosures of domestic violence so that the questions would only be asked in the appropriate setting and manner. Mother's possible social isolation following her move from Lincolnshire may have increased her vulnerability. Such risk factors may be picked up if enquiries are made about wider social circumstances at routine checks and again I would recommend that consideration is given to the incorporation of this.   2.  Depression screening for all chronic diseases Currently screening for depression is only performed for patients with Coronary Heart Disease and Diabetes as part of the Quality and Outcomes Framework. As shown in the critical analysis other chronic diseases (including epilepsy and asthma as suffered by mother and father respectively) are linked to varying degrees with depression and I would recommend that consideration is given to incorporating the two screening questions into all chronic disease reviews.  3.  GP Practice/Health Visitor communication When Child L was discharged from hospital a copy of the discharge letter was sent to his health visitor recommending that his weight gain be monitored. There is no further record of his weight until 2011. It may be that this information is contained in Child L's Red Book but I do not have a copy of this. There is no record of any communication about Child L's weight gain between the surgery and Health Visitors. Currently the practice has neither a formal nor informal arrangement for regular  2015LancashireChildLOverview Page 53 of 57 CONFIDENTIAL    information sharing with the attached Health Visitors. Consideration should be given to implementing regular two way communication  4.  Further exploration of psychological symptoms Father presented on 29/3/10 with chest pain. During the consultation he disclosed that he was under some stress due to the poor weather as he worked as a self-employed gardener. This is the only mention in the medical records of any psychological symptom prior to 8/4/13. The focus was, as is appropriate, on father's symptom of chest pain but there does not appear to have been any further exploration of his stress. This may have been due to time constraints or it may have been done but simply not documented. It may have been appropriate to explore this further, perhaps at a separate appointment and I would recommend that consideration is given as to whether disclosures such as this should prompt any further enquiries. I am well aware that I have the considerable benefit of hindsight when making this recommendation and I would again stress that in my opinion this would in no way have prevented the tragic events that took place three years hence.  5.  Emergency Department attendances I feel that the circumstances surrounding the scald to mother and Child L should have been explored in greater detail. It is unclear whether this was not performed due to time constraints, a training issue or requires a change in practice policy. It may be that it had been done but not documented. This case shows us the importance of recording such discussions. Emergency attendances for certain types of injury or frequent attendances may indicate abuse and NICE guideline 89 (2009) recommends we seek an explanation for any injury in an open and non-judgemental manner.  Currently the urgent care dashboard will flag up frequent attendees but presumably this would only cover a single hospital trust and an abused child may be taken to a number of different locations for treatment in an effort to allay suspicion. I discussed this with the practice's nurse team leader who felt that the urgent care dashboard could be configured to flag up multiple attendances at different locations. I would recommend that practitioners when they receive an Emergency Department discharge for a child or adult ask themselves whether there may be safeguarding concerns.  In the case of injury to an adult which arouses suspicion of domestic violence the "child behind the adult" should be considered and an appropriate risk assessment made.   6.  Assessment of risk to others and recording thereof in Mental Health consultations There is no mention in the records as to whether the GP made an assessment of the risk father posed to others. GP 1 felt it was not necessary to specifically question father on his intent to harm others as his mental state examination and observation of father did not give any indication that this was at all likely. As discussed below there is evidence to support this approach. However he did not document it.   As GPs we are trained to always ask about thoughts of self harm when a patient presents with a Mental Health issue but under normal circumstances we would not usually ask about intent to harm others. No assessment tool was used in the consultation as this was an episode of psychosis for which no general practice  2015LancashireChildLOverview Page 54 of 57 CONFIDENTIAL    assessment tool exists. In consultations for depression without psychosis there are a number of possible assessment tools - the Patient Health Questionnaire (PHQ 9), Hospital Anxiety and Depression scale (HAD) and the Beck Depression Inventory being the most commonly used. None of these includes a question on intent to harm others. GP 1 did not ask mother about her feelings in relation to the risk of self harm or harm to others posed by father. He had already ascertained whether father had any intent to self harm and it would not have been appropriate to put these questions to mother in his presence. Vinestock (1996) states that when assessing risk to others "the patient's own statements tend to be less reliable and the emphasis is more on behaviour and collateral information".    I reviewed a number of mental state examination templates. Some asked questions about thoughts or intent of harming others and some did not. Although not qualified to comment on whether specific questions should be asked to assess risk to others, I would recommend that risk to others is not only considered but specifically documented in Mental Health consultations as we already do for risk of self-harm. It is important to remember that risk cannot be completely eliminated and accurate prediction is never possible for individual patients (RCPsych 2008). Information regarding more advanced risk assessment tools can be found in the documents listed in the reference section.  7.  Consider whether there is a child safeguarding issue when a parent presents with a Mental Health problem Quite correctly the focus of the consultation was on father who was presenting with a serious mental health problem. However, parental mental health problems are well known to be a significant factor in child abuse, being one-third of the "toxic trio" of major risk factors. We need to be aware when dealing with an adult patient that there may be a "child behind the adult" and ensure that the needs of the child are not overshadowed by the needs of the parents (Keep Me Safe RCGP, 2005). The RCGP Curriculum recommends that physical, psychological, social, cultural and spiritual issues should be considered in the assessment and management of mental health problems.  In the case of Child L the GP was not aware that a child lived with father and mother. In my opinion it would be good practice to make inquiries as to who lives in the household as this may raise safeguarding issues. I must stress that in my opinion GP 1's management of the case remains appropriate despite not being in possession of this information and having this knowledge would have made no difference to the tragic outcome.  All practice staff should have the relevant safeguarding training as recommended by the Intercollegiate Guidance for Safeguarding Competencies (2010).  Staff should have training commensurate with their responsibilities - level 1 for all practice staff, level 2 for practice nurses and although GPs only require level 2 training for revalidation it is recommended that they undergo level 3 training as this includes multi-agency working relevant to their everyday practice.   2015LancashireChildLOverview Page 55 of 57 CONFIDENTIAL     8.  Communication between Primary Care and Mental Health practitioners GP 1 made an urgent referral to the Mental Health team via the single point of access. This was done immediately after father and mother left the consulting room. He was told that father would be assessed that same day but as we know father was actually given an appointment for assessment the following day. In my opinion where there is a change in the original care plan such as this, then that information should be communicated back to the referrer to ascertain whether this is acceptable as the referrer is the person who has actually seen the patient. I do not believe this is the responsibility of the GP and therefore this recommendation would apply more to the Mental Health service. I do feel that communication in general between the practice and Mental Health team should be looked at to enable any other potential problems to be identified.   9. Support for GPs and practice staff  During my interviews at the surgery it became clear that although GP 1 had had significant support from his colleagues in the practice, there was no formal support structure in place at a higher level to help surgeries when affected by such a tragedy.  This could perhaps involve a debriefing exercise or counselling support. I would recommend that the responsible CCG considers implementing this as a matter of urgency.  c) Blackpool Teaching Hospital NHS Foundation Trust  1. If bruising is noted that indicated a suspicion or potential domestic abuse, questioning of the victim should happen as soon as possible.  2. Domestic abuse training that will address the importance of providing contact details of Women's Aid when domestic abuse is suspected but denied.  3. Ensure all health visitors and school nurses aware of the most recent guidance from DOH 2013 health visiting and school nursing programmes, no.5 Domestic Violence and Abuse Professional Guidance  4. Record keeping training - looking at basic entry details such as time of visits/contacts and also completion of the record regarding information about fathers/significant males living in a household.  d) Southport and Ormskirk Hospitals NHS Trust 1. Continue to raise awareness of signs of domestic abuse via safeguarding training  2. Ensure information is available regarding domestic abuse for patients in the accident and emergency departments. 3. Staff are aware of the importance of documentation and the need for a full history and details of attendance. 4. To develop the Domestic Violence Link Nurse at Southport Accident and Emergency Department  2015LancashireChildLOverview Page 56 of 57 CONFIDENTIAL    5. Review the Accident and Emergency Domestic Violence protocol to include routine questioning  e) Lancashire Care NHS Foundation Trust 1. The referral form is in need of review to ensure areas of identified risk are focussed and of an assured standard. This will include recording and training aspects.   2. That triage information is recorded on the clinical record system (rather than added to referral form). Citing who has provided the information. 3. That consideration should be given to the use of multi-disciplinary working, increased access to clinical discussion.  4. To review the potential for isolation in the current environment of the Single Point of Access team in Lancaster and Morecambe – small office, lone working 5. To review the interface with CRHT re referrals for urgent assessments.  6. To understand the capacity of urgent referrals and the use of telephone triage  7. Consider whether the Blue Light 71 needs to be revised to ensure risks and vulnerabilities are understood.   8. To review stepped care model and the concept of resources influencing pathways.    f) Kindergarten 1. Awareness raising session for staff on Domestic Abuse and the effects on children especially early years children and babies and the effects on women. (How to spot potential signs and gain support access for parents and children.)   2. E learning CP training for all staff annually rather than the 3 yearly updates at present this would go above and the current recommendations within the EYFS guidance  g) Constabulary  Third party reporting of Domestic Abuse to be written into the new DASH Policy and Supporting Procedures currently under review.  h) University Hospitals of Morecambe Bay NHS Foundation Trust  1. To set up archive evidence index for safeguarding. 2. Specific training from Woman’s Aid on domestic abuse to continue to support A+E staff and Midwives and develop skills in the issue of Domestic Violence. 3. UHMBFT A+E to work with Lancaster Women’s Aid to raise the awareness of the support available to victims of Domestic abuse.   4. UHMBFT clinical service team to work with the local MAPPA coordinator to strengthen information sharing of individuals who pose a risk to the others who may access care from UHMBFT.  2015LancashireChildLOverview Page 57 of 57 