Non-accidental injury to an infant boy in 2019 including eye injury, cracked ribs, and a fractured leg. Learning includes: a need to assess the impact of parental mental health on parenting capacity; a need to identify potential safeguarding concerns to a new-born baby following a family dispute; a need for information held on early help systems to be held on childrens social care systems; a need for a pre-birth assessment by childrens social care which could have informed part of the court proceedings; and a need to ensure GDPR guidelines are correctly applied by childrens social care. Recommendations include: information sharing policy, between the multi-agency safeguarding hub (MASH) and partners, should not allow GDPR to act as a barrier to sharing information when there are safeguarding concerns; the quality of recording and decision making based on effective triage in the MASH needs to continue to be improved and monitored for consistency so that information, risks and vulnerabilities can be connected; the sharing of information between early help and children social care systems needs to be strengthened so that there is a stronger interface between them; there needs to be assurance, from childrens services and midwifery, that the threshold for initiating the pre-birth protocol is being applied appropriately; and any agency that identifies that parental mental health needs are impacting on parenting capacity needs to share that with other partner agencies working with the family so that information can be triangulated and an appropriate response agreed.
      
 Title:  Child Dominik: practice learning review. LSCB: Tameside Safeguarding Children Partnership Author: Tameside Safeguarding Children Partnership Date of publication: 2022  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.                           December 2022   1 of 12          Child Dominik Practice Learning Review                             December 2022   2 of 12  The Incident  In the summer of 2019 Dominik was taken by his Mother to the GP for his immunisations and the medical practitioner noticed a haemorrhage on their eye.  The medical practitioner was concerned due to the fact that the mother could not give any suitable explanation as to how it occurred.  The mother had suggested that the baby had rolled onto his dummy but at 10 weeks old this would not be possible and a dummy would not create such an injury.  A referral was put through for a Child Protection Medical and the child was later admitted to Tameside and Glossop Hospital.  Dominik had a skeletal scan that showed 3 broken ribs and also a fracture to the top of right tibia. The Doctor performing the medical stated that these injuries were non-accidental injuries.  The likely cause of the broken ribs were either being squeezed or held too tight and the tibia fracture was likely as a result of a twist of some description. The Doctor estimated the rib breaks being caused within 1 – 3 weeks and the tibia break being within 2 weeks.  Dominik has no apparent bone deficiencies or medical issues that would go some way to explaining the cause of the breaks.  Tameside Safeguarding Children Partnership was notified of the serious incident and in accordance with statutory guidance under ‘Working Together to Safeguard Children’ 2018 convened a Rapid Review meeting.  Members of the Rapid Review Panel all agreed that the criteria for a Local Child Safeguarding Practice Review was met.  Statutory partners in Tameside along with the National Panel subsequently agreed with the recommendation.  The Review   The objective of this review is to establish the learning from the local child safeguarding practice review and consider what needs to change to improve future safeguarding practice.  Tameside used a case discussion tool piloted by Salford Safeguarding Children Partnership as their methodology for the review.  Salford’s Head of Quality Assurance and Safeguarding kindly agreed to facilitate a learning review with senior representatives of all relevant partner agencies which are listed in the table below. In preparation for the learning review a combined chronology of all relevant agency involvement had been compiled and all agencies had submitted single agency summaries of their involvement with the family.  Both of these were shared with panel members in advance of the learning review.  An overview of the single agency information and involvement is provided below.  Post Agency 1. Service Unit Manager for Child Protection and Child in Need Tameside Children’s Social Care, Children’s Services 2. Improvement Manager  CAFCASS 3. Detective Constable  Investigations and Safeguarding Review Unit, Greater Manchester Police 4. Safeguarding Specialist Nurse Tameside Pennine Care Foundation Trust 5. Lead Designated Nurse Safeguarding Tameside and Glossop Clinical Commissioning Group December 2022   3 of 12 6. Designated Doctor Tameside and Glossop Clinical Commissioning Group 7. Designated Nurse for Looked After Children (LAC) Tameside and Glossop Clinical Commissioning Group 8. Specialist Children’s Safeguarding Advisor Tameside General Hospital 9. Head of Service – Early Help Tameside Families Together, Children’s Services 10. Service Manager – Early Help Tameside Families Together, Children’s Service 11. Modern Matron/Named Midwife Safeguarding Manchester Foundation Trust 12. Performance Improvement Manager Tameside Children’s Social Care, Children’s Services 13. Senior Solicitor Childcare  Tameside Legal Services  At the time of writing this report it has not been possible to involve either of Dominik’s parents due to an ongoing criminal investigation.  A case reviewer met with the father and mother of this review and shared the final report with the family since criminal proceedings were completed. The father of the review has stated that the family wish to make no further comment and are happy for the review to be published.     Agency Involvement and Information  CAFCASS Single Agency Summary completed by Improvement Manager  Dominik’s older sibling, referred to herein as Daw, had lived with their maternal grandmother since September 2018 when they would have been 10 months old.  This was initially an informal arrangement but became a formal child arrangement order granted by the court in early 2019 and with the consent of Daw’s Mother and maternal grandparents.  CAFCASS were involved with the family from late 2018 following the application for a Child Arrangement Order.  Their intervention was limited to the service provided by Work to First Hearing (WTFH) and as part of that intervention CAFCASS are directed to conduct initial safeguarding checks with the relevant Local Authorities and the Police National Computer; and, where possible, to conduct telephone risk identification interviews with the adult parties.  Work to First Hearing (WTFH) does not require any direct contact with the child or children subject to the application.  CAFCASS completed telephone interviews with Daw’s Mother and Maternal Grandparents.  Contact details were not available for Daw’s Father but CAFCASS did advise the Court to consider a Department for Work and Pensions enquiry to locate him.  Information from Tameside Children’s Services, provided by telephone in November 2018, advised of one referral on 06/08/2018 from Daw’s maternal great grandmother regarding his weight.  Health Visitors had reviewed this, no concerns were identified and the family were referred to Home- Start.  During that sharing of information the Family Court Advisor was advised that Tameside Children’s Services were aware of the unborn child.   The Family Court Advisor spoke to the mother alone to ensure confidentiality and to allow her the opportunity to express her views without the risk of compromise.  During her interview she advised that she was five months pregnant, suffered from severe anxiety which was heightened December 2022   4 of 12 during pregnancy, high blood pressure and dizziness.  She considered that these factors impacted upon her ability to care for her Son.  He had lived with his grandparents since September 2018, her view was that Daw should continue to live with his grandparents and return to her and her partners care after she gave birth.  The mother was able to exercise Parental Responsibility, was spending significant time with her Son, was actively engaged in his care and attended medical appointments. Daw’s maternal grandparents indicated that they wanted to support Daw and his mother, but it was difficult for them to envisage him being able to return to his mother’s care immediately after she gave birth.  Further safeguarding checks with Manchester Children’s Services revealed that the family were not known to them.  Additional information from Tameside Children’s Services was provided to CAFCASS stating that in August 2018 Daw was having contact with a registered sex offender.  The outcome was to present the case to the Early Help Panel for support who agreed a referral to Home- Start.  In February 2019 Daw’s Maternal Grandparents attended the final court hearing.  Neither of Daw’s parents were present and the Mothers contact with Daw was reported to have reduced and his grandparents advised that her mental health was unstable.  The court found in favour of a Child Arrangement Order (CAO) -live with as the final outcome.  CAFCASS advised Tameside Children’s Services that the court had granted a Child Arrangement Order (CAO) -Live with in favour of Daw’s maternal grandparents due to his mother’s poor mental health.  Tameside Children’s Services indicated that they were unaware of this and had no knowledge of the unborn child.  Accordingly, a Multi- Agency referral was made to Tameside Children’s Services advising that Daw was living with his grandparents due to his mother’s poor mental health impacting upon her ability to care for him.  Concerns were shared regarding her ability to care for the unborn child.  The referral suggested that a pre-birth assessment be considered.  In March 2019 Tameside Children’s Services advised that a pre-birth assessment would be undertaken, later that day CAFCASS were informed that further enquiries had been made, the initial decision had been reversed and there would be no further action.   Children’s Social Care Single Agency Summary completed by Service Manager for Child Protection and Children in Need  Children’s Social Cares first contact with the family was in August 2018 due to the Great Grandmother of Daw contacting the Local Authority stating that he was not appropriately cared for by his Mother.  Screening checks were undertaken by the Local Authority.  The Police had visited and raised no concerns a few days prior and also the Health Visitor reported completing a health check which again raised no issues or concerns.  The matter was closed at this point.  A few days later a police referral was received and raised concerns that a known sex offender was potentially having contact with Daw.  Daw’s mother gave assurance that the individual had no sole care or unsupervised contact.  Daw was observed by the Social Worker to be well presented and raised no concerns.  The Mother agreed to support from Early Help Services.  The Early Help Panel referred the family to Home-Start in August 2018.  Between August and October they made several attempts to contact and engage the Mother without success of consistent engagement and subsequently referred the case back to the Early Help Panel in October.  December 2022   5 of 12 In September 2018 the maternal grandmother of Daw contacted Children’s Social Care regarding his welfare.  She reported she had care of Daw for the previous 9 days and had been informed by the G.P. he was underweight.  Records do not indicate what was done with this information or whether it was shared with Early Help Services.  The Early Help Panel, held in October 2018, indicates that the family had refused Home-Start but the Panel note and action the concerns relating to Mum’s mental health, the fact that she was pregnant and already has a 1 year old and appears to be moving around.  It was agreed that Health would see if Mum was accessing Midwifery and if the 1 year old had attended his 12 month check-up.    It was noted by the Early Help Panel the following week that Health had not got access to the family on 3 previous occasions that month.  The mother, maternal grandmother and child were subsequently seen and there were no immediate concerns.  According to the Early Help Panel records for the case remained open to Home-Start and they were advised to escalate if the risk escalated. However, Home-Start involvement ceased at this point and their records indicate that Tameside Families Together would pick up the case, thereby contradicting the Early Help Panel records.  No closure form was completed by Home- Start.   Children’s Social Care recorded the request for information from CAFCASS in January 2019 and indicated the information is provided at this point.  However, CAFCASS records highlight a telephone conversation with Tameside Children’s Social Care in November 2019 where this information was shared.  This telephone conversation and subsequent sharing of information is not recorded by Children’s Social Care.  Children’s Social Care recorded that in February 2019 maternal grandparents have made a private law application to the court for a Child Arrangement Order due to mother’s poor mental health and inability to care for him.  This was highlighted as a concern in respect of whether she will be able to care for the unborn baby once it arrives and CAFCASS advised that a pre-birth assessment was needed.  Support was offered from the mental health midwife and the contact was closed to universal service.  No pre-birth assessment was completed.  Manchester University NHS Foundation Trust Single Agency Summary completed by Head of Nursing & Named Midwife Safeguarding  Dominik’s mother booked for care in October 2018 at 12 weeks gestation.  She disclosed current anxiety and previous overdose aged 16 years, due to emotional abuse from her own mother, with whom she said she now had limited contact with.  A referral was made to the specialist midwives for Mental Health support with consent.  The mother attended the specialist Perinatal Mental Health Clinic in December 2018.  She disclosed that her anxiety had increased and she was having daily panic attacks.  She said she was worried about being able to look after her Son whilst it was happening and that she was currently living with her mother for support.  She also states that she is receiving daily on-line therapy for support but would prefer face to face.  A referral to Healthy Minds, Tameside for Talking Therapy was made.  In February 2019 the Safeguarding Midwives received a phone call from Tameside Children’s Social Care to inform them that CAFCASS were seeking a Special Guardianship Order on behalf of maternal grandparents due to their concerns regarding mother’s mental and health and her care of Daw.  December 2022   6 of 12 The Specialist Midwife for Mental Health was contacted in March 2019 by Children’s Social Care to inform them they believed there were no significant risks to Daw or the unborn child and that a pre-birth assessment was not required.  A few days later in April the Safeguarding Midwives telephoned Children’s Social Care as they were concerned that the plan had gone from a CAFA/pre-birth assessment to case closure and to confirm what the extent of the Multi-Agency Safeguarding Hub (MASH) enquiry had been.  They were informed that the information could not be shared due to GDPR regulations, despite there being potential concerns about the welfare of a child.  The Safeguarding Midwives said they would re-refer and escalate if there were any further concerns.  No re-referral or escalation was made by the Safeguarding Midwives.  Tameside General Hospital (Health Visiting) Single Agency Summary completed by Specialist Children’s Safeguarding Advisor  Dominik was open to the health visiting service from birth until he was removed and placed into foster care.  Contact was in line with the visiting schedule as per The Healthy Child Programme.   At the new birth visit the Mother’s mental health was discussed and she disclosed that she was on anti-depressant medication.  As a result a follow up contact was completed where she informed the Health Visitor that her intention was for her older son to return to the family home and that he was currently living with Grandparents.  Further explanation for this was not explored at this visit. Positive interaction was noted between the Mother and Dominik and the Mother is described as being affectionate.   The next scheduled visit took place at 6-8 weeks and showed Dominik was delayed in 2 of the 5 areas assessed, in the areas of communication and personal social.  During this visit it was noted that the Father was giving cuddles to Dominik. The Mother reported she was under stress due to her older child still being with Grandparents.  The Mother’s mood and mental health was assessed using the recognised tool, PHQ-4.  She scored 1 suggesting her mood and mental health was manageable and under control. The health visitor offered advice to parents on how they could address this ongoing issue and encouraged them to access specialist advice via a solicitor.   Parents did attend an appointment with Royal Manchester Children’s Hospital regarding a review of Dominik’s spine.  They responded appropriately in ensuring his needs were met.   A further visit was undertaken to review Dominik’s development due to previous identification of his delay in two areas.  His development was noted to be age appropriate and no longer a concern.  The Mother was observed to handle Dominik with affection and to be speaking to him.   The Mother’s mental health and wellbeing was discussed again and the Health Visitor checked she was still on her medication.   There were some concerns noted regarding Dominik’s weight.  This was followed up appropriately by the Health Visitor to ensure Dominik was not at risk of failing to thrive.   Pennine Care NHS Foundation Trust Single Agency Summary completed by Safeguarding Families Specialist Nurse  Healthy Minds received a referral from the Mother’s G.P. and completed an ‘Opt In’ suitability assessment over the phone in May 2018.  Following case supervision it was agreed that she would be put forward for low intensity Cognitive Behaviour Therapy (CBT) treatment as perinatal priority.  This would take the form of 1-1 treatment appointments, conducted over the phone and was December 2022   7 of 12 scheduled for June 2018.  The mother did not attend/answer the first telephone treatment appointment.  She was therefore discharged as per service policy and a letter was sent to her G.P. advising of discharge.  In December 2018 a further ‘Opt in’ suitability assessment was conducted following a referral from the Health Visitor.  The referral outlined concerns regarding the Mother’s anxiety and low mood and she was 16 weeks pregnant with her second child at this point.  The Mother shared that Daw was living with her Mum due to her poor health – she was suffering with pre-eclampsia.  No risks were identified or disclosed in relation to self, risk from and to others, neglect and safeguarding.  She noted that her partner, and father, to new born was ‘away for much of the time’.  The Mother was offered the option of the Post-Natal Well Being Group, however she declined this as she felt unable to attend due to her poor health at that point.  She expressed a wish to engage in the computer based treatment ACT (Acceptance and Commitment Therapy – a self-help programme intended to help with anxiety management techniques) as she could do this from home.  In January 2019 the mother indicated that she had found the programme OK, and that she had completed the first two modules but that she would like to access 1-1 support now instead of the computerised programme.  She was added to the list and offered a short notice appointment which she accepted.  She missed the first and second appointment and was therefore discharged from the service in line with the services policy.  A discharge letter was sent to the G.P.  Greater Manchester Police Single Agency Summary completed by a Detective Constable  Greater Manchester Police recorded a standard risk domestic incident between the Mother and her Mother in 2011.  Another incident is recorded in 2013 with the Mother saying that her Mother is constantly calling her names and putting her down, this is again mentioned in a report from Dominik’s Mother in August 2018.  In an incident in 2016 with her then partner’s family she advises the Police that she suffers with anxiety and panic attacks and states it stems from an abusive family life which is why she has moved to this address.    There are 3 family disputes recorded as incidents by Greater Manchester Police in 2018 which relate to the quality and suitability of the mother’s parenting being questioned.  2 of these incidents are reported in August 2018 in a day of each other.  One of the incidents is from Dominik’s mother indicating that she is worried that her mother is going to apply for a court order to take Daw away from her.  The other is from Daws great grandmother alleging that Daw is being allowed to have contact with a registered sex offender.     A family dispute in also recorded in April 2019 when Daws mother and partner have gone to her Mother’s house, where Daw, is residing under the child arrangement order, to try to get her Son back.  Daw’s mother was ‘thrown out of the house’ by her stepfather and she is then refused entry.  The log notes that the order was put in place to keep her son safe from her ex-partner while she was recovering from illness after pregnancy and the family have been told by CAFCASS that Mother's mental health has to be assessed first and then consideration can be given to handing the child back. The incident was closed with the appropriate Domestic Abuse closing code and a PPI (record) created, and a Domestic Abuse, Stalking and Honour Based Violence (DASH) assessment completed that was finalised as a standard risk. The PPI (record) details that Daws mother has just had a 2nd child with her current partner and the child is days old. Advice was given to both parties regarding further contact and it was advised this should be arranged through solicitors.  There was no onward referral to any partner agency at this point and the case was closed  December 2022   8 of 12   Manchester Women’s Aid Single Agency Summary completed by Senior Advocate  A referral was made to Manchester Women’s Aid in 2017 by the Midwifery Service at University Hospital South Manchester when the Mother was pregnant with her first child.  The Mother had disclosed emotional abuse perpetrated by her mother and step father, with whom she was residing.  Upon assessment the Mother disclosed that she had suffered ‘mainly emotional abuse’ perpetrated by her mother her whole life.  She agreed to 3 sessions of Living Life to the Full (LLTTF) whilst waiting for counselling.  She attended the first appointment but no others and, after further attempts to contact her, the case was closed.  She does not seem to have engaged with Manchester Women’s Aid counselling service.  Analysis Tree: Cause and Effect- factors that may have influenced the incident and individual or / and agency practice   Focal Point  The focal point in this case was the non-accidental injuries to the child.  They include an eye injury, cracked ribs, and a fractured leg.  Cause & Effect  Cause Effect The Mother was discharged from mental health service provision due to non-attendance at appointments  The mothers mental health was reported to have deteriorated at the final court hearing but this had not been assessed at the time  The impact of the mothers mental health on her parenting capacity was not assessed GMP did not identify potential safeguarding concerns to a new born baby following a family dispute  A referral was not made to Children’s Social Care and there was subsequently no assessment of needs, risks and vulnerabilities  Children’s Social Care did not record information about the Mother being pregnant at the time that it was reported to them by CAFCASS  Children’s Social Care did not connect information that was freely disclosed by Dominik’s Mother which was that she did not feel, at that time, that she could care for her 1st born child due to her anxiety to any potential risk to an unborn child  The pre-birth protocol was not triggered Information held on Early Help systems was not held on Children’s Social Care systems  Children’s Social Care were not immediately aware that the mother was pregnant with a 2nd child and that her 1st child was living with her mother due to her mental health difficulties  The pre-birth protocol was not triggered  It was deemed appropriate for the case to be managed at an Early Help level rather than it potentially being escalated to Child in Need or Child Protection   A pre-birth assessment was not undertaken by Children’s Social Care which could have informed part of the court  Health providers were not asked to share information about the family   Health providers were unaware of the application for a Child Arrangement Order  December 2022   9 of 12 proceedings (Work to 1st hearing)  Had Health Providers known an application had been made for a court order they might have sought to explore the impact of the mothers mental health on her parenting capacity  in more depth  An enhanced package of maternity support was not deemed to be necessary and was not offered GDPR guidelines were incorrectly applied by Children’s Social Care   Safeguarding Midwives did not feel able to escalate their concerns once they were alerted to the court order because they could not find out what enquiries had already been undertaken by Children’s Social Care.    The pre-birth protocol was not triggered The Safeguarding Team at St Mary’s do not have an Information Sharing Agreement with Child Health Information Department/teams’ at Tameside, Stockport and Bolton   Safeguarding Midwives at St Mary’s were told they were unable to share their safeguarding concerns with the Child Health Department   The Health Visiting Team at Tameside were unaware of the safeguarding concerns  The pre-birth protocol was not triggered  What are we worried about?    At the point that CAFCASS first made contact with Children’s Social Care the recording of information on Children’s Social Care Systems was not robust enough and meant that important connections that might have triggered the pre-birth protocol were not made. The consistency of recording in Children’s Social Care is still a risk due to pressures of the current system and workload.  Health checks are limited due to some health providers still keeping paper records.   There is no Mental Health representative in the Multi-Agency Safeguarding Hub (MASH) and although there is a virtual link, and information is accessible, the current set up is not as effective as it could be if there was co-location.    The pre-birth protocol was not applied in this case and could have been at two different points.  It wasn’t applied early on in the case because Children Social Care didn’t record and connect all of the information that CAFCASS had provided.  It wasn’t applied when it was later requested by CAFCASS because Children Social Care made enquiries with Midwifery Services and judged there to be no immediate risk because a specialist midwife was providing support in relation to the Mothers mental health needs.   Midwifery Services asked Children’s Social Care why a pre-birth assessment was not being completed but did not escalate the case any further in line with the Greater Manchester procedures due to the fact that they had no safeguarding concerns themselves.   In the absence of a pre-birth assessment professionals could still have explored the reasons why Daw was living with his Grandparents instead of his parents.  This could have resulted in an enhanced offer of support from professionals.   Information reported to, and recorded by, Greater Manchester Police in April 2019 was not shared with Children’s Social Care.  Had a referral been made to partners, including December 2022   10 of 12 Children’s Social Care and Health providers, the living arrangements for a 17 month old child, the mother’s mental health issues and the potential impact of those on her parenting capacity could have been explored.   Information sharing between 2 parts of the same system, early help and children’s social care, are not fully joined up and means that important information can be held by Early Help that Children’s Social Care don’t know about unless the case is escalated.   Early Help Services were unable to engage with the Mother and no assessment was ever completed.  Although the initial concerns still remained and they discovered that the Mother was pregnant with a second child the case was closed rather than escalated to Children’s Social Care as per the advice from the Early Help Panel.  The decision to close the case was not known or recorded by the Early Help Panel.   GDPR is still being seen, and used, as a barrier to sharing information even when there are safeguarding concerns.     The Safeguarding Team at St Mary’s do not have an Information Sharing Agreement with Child Health Information Department/teams’ at Tameside, Stockport and Bolton.   There is no free legal advice or support available to parents or carers after a court order has been granted.  In this case the Mother had the right to go back to court at any point and ask for her child back.  However, it does not appear that the Mother understood her rights or how to exercise her parental responsibility.   What has worked well?     The G.P. who picked up on the haemorrhage to the eye during a routine appointment and, following an unsatisfactory explanation from the Mother, requested a full section 47 medical assessment did a fantastic job.    The G.P. had attended a safeguarding briefing the day before and it was felt that regular safeguarding updates help practitioners to stay up to date with current issues and alert to the signs of abuse and procedures to follow.     The safeguarding procedures and practice that followed from that initial request for a medical examination are a good demonstration of the child protection system and services working well together and they did protect the child from further harm.    All reported incidents up to and including 2018 are appropriately followed up by GMP before being closed. The correct procedure was followed in relation to the child sex offender disclosure scheme and the correct referral was made to partner agencies regarding the concerns expressed for Daw, with an immediate welfare check being carried out.   When Children’s Social Care received an anonymous referral claiming that the Mother was allowing a known sex offender to have contact with her child they asked her to attend a meeting at the Children Social Care offices.  This meant that the Social Worker could properly explain the potential risks and determine whether the Mother was providing December 2022   11 of 12 adequate care and supervision for Daw.  The Mother explained that her child did not have unsupervised contact with the person in question and the Social Worker was satisfied with her response.  This showed a good degree of professional curiosity and also allowed the Social Worker an opportunity to see Daw and to observe the Mother’s interactions with her Son.   The fact that the case came into the Early Help Panel and wasn’t just NFA’d (closed – no further action) by Children’s Social Care was a good decision based on the presenting information at that time.  The case was then appropriately allocated to an Early Help Service and that service brought it back to the Early Help Panel after they couldn’t engage with the Mother.  The Early Help Panel maintained good oversight of the case, put in place appropriate checks and advised that it be escalated back up to Children’s Social Care if risks escalated.   There are some good systems already in place that just need tweaking to make them work better.  For example the addition of an Early Help Module to ICS will mean the Early Help and Children Social Care parts of the system are joined up.   The Midwifery Service were tenacious in referring to Mental Health services, they followed up on issues across border and asked questions.   Learning from this case has already been identified by individual services in the single agency summaries that have been submitted in preparation for the Learning Event.  That shows transparency, critical analysis and a willingness to learn and improve.  Recommendations  1. The Information sharing policy between the Multi-Agency Safeguarding Hub (MASH) and partners should not allow GDPR to act as a barrier to sharing information when there are safeguarding concerns.  2. The 7 minute briefing on Information Sharing should be revised and re-circulated to all partner agencies to reflect any changes to information policies and to remind them of the escalation policy when there is professional disagreement.  3. The quality of recording and decision making based on effective triage in the MASH needs to continue to be improved and monitored for consistency so that information, risks and vulnerabilities can be connected   4. The Early Help Panel should demonstrate how actions agreed at the panel are communicated to individual case managers.  They should also provide assurance that actions/decisions are re-visited by the Early Help Panel, closed with a clear rationale and signed off so that there is no opportunity for those actions to drift or for cases to be closed without their knowledge.  5. The sharing of information between Early Help and Children Social Care systems needs to be strengthened so that there is a stronger interface between them.  This will enable both services to make decisions regarding the appropriate application of thresholds based on the same information.  December 2022   12 of 12 6. Tameside Safeguarding Children Partnership should consider the development of regular forums to create routine opportunities for the sharing of professional expertise in relation to safeguarding cases.   7. There needs to be assurance, from Children’s Services and Midwifery, that the threshold for initiating the pre-birth protocol is being applied appropriately. All partners would benefit from a refresh on the triggers for a pre-birth assessment so that they can initiate their own early help assessment, make a referral to Children Social Care and/or be in a better position to professionally challenge decisions.   8. Any agency that identifies that parental mental health needs are impacting on parenting capacity needs to share that with other partner agencies working with the family so that information can be triangulated and an appropriate response agreed.  9. The DNA (Discharge) protocol for perinatal clients should be reviewed to determine whether there should be an alternative offer of engagement or support.   10. St Mary’s Hospital Manchester to review information sharing agreements with Child health.  