Death of Child C, a 3-month-old Black British/Caribbean girl, in September 2016 from cardiac arrest, while in the care of her mother. After her death, Child C was found to have multiple fractures consistent with non accidental injuries. Parents received custodial sentences. Child C was born prematurely at 28 weeks and admitted to neonatal unit. Hospital staff made referral to children's services regarding mother's limited visits during her baby's stay and engagement with staff. A child protection plan was made for Child C and her sibling. Mother and children moved in with maternal grandmother, to avoid children being taken into care. Previously, mother of Child C lived between family and friends and turned down offers of housing. Mother of Child C denied a relationship with the father of children but said he was supportive. Child C was travelling in a sling on the bus with her mother. Mother asked passengers for help, saying her baby had stopped breathing. Child C presented at hospital with cardiac arrest and bruising and swelling to her head and eyes. Maternal history of: domestic abuse; abuse as a child; homelessness; and reluctance to engage with services. Findings include: impact of poverty and homelessness on the child (including pre-birth) should always be considered; and investigations of fathers must be pursued even when resistance from mothers. Recommendations include: training for staff working with avoidant and hard to engage families should include identifying disguised compliance; and the relevant LSCB's must get assurance that agencies demonstrate how fathers or absent parents are included in any assessments.
      
 Title:  Serious case review: Child C: final report. LSCB: Barking and Dagenham Safeguarding Children Board Author: Barking and Dagenham Safeguarding Children Board Date of publication: 2018  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.                                       Serious Case Review: Child C  Final Report        Published: January 2018.     Contents        Page  The Circumstances that Led to this Review  3 - 4 Family Composition  4 Summary of the Background  5 - 9 Details of Practice and Analysis  10 - 67 Conclusion and Recommendations  67 - 70 Appendices:   Appendix 1 – Methodology  71 - 74 Appendix 2 - Timeline  75 - 94 Appendix 3 - Actions already taken by individual agencies   94 - 100 Appendix 4 - Acronyms and Terminology  101 Appendix 5 -  References  102  1.1.  The Circumstances supporting the decision to undertake this SCR   1.1.1.  Child C was born prematurely at 28 weeks and 5 days gestation at home; following transfer to Newham University Hospital (NUH) she was admitted to the Neonatal Unit. Child C remained in the Neonatal Unit for a period of 65 days; the mother visited the unit on only 18 occasions before Child C’s discharge on 5th August 2016. Staff on the Neonatal Unit at Newham University Hospital (NUH) made a referral to London Borough of Barking and Dagenham Children’s Services regarding the limited visiting of mother and engagement with the staff.  1.1.2.  Ten days after Child C’s discharge from the Newham Hospital Neonatal Unit she was made subject to a Child Protection Plan (CPP) in the London Borough of Barking and Dagenham under the category of ‘neglect’ along with her older sibling.   1.1.3.  On 28th September the mother of Child C was travelling on a bus with Child C in a baby sling; the baby’s head was covered with a white cloth. The sibling of Child C was also with her and was in a pushchair. The mother asked for help from the passengers saying that her baby had stopped breathing, one passenger carried out Cardiopulmonary Resuscitation (CPR) on Child C prior to the arrival of the emergency services. The ambulance crew that attended the scene were concerned that Child C’s jaw was locked and called the police. Child C was taken to NUH where she was pronounced dead.  1.1.4. Child C presented at NUH in cardiac arrest, she was not breathing, was very cold to touch, and had stiffness in her neck and limbs. She also had bruising and swelling to her head and eyes.  1.1.5.  The parents of Child C were arrested on suspicion of the murder of Child C and later charged with a) Murder; b) Assault/ Neglect; c) Causing/ Allowing the Death of a Child.  1.1.6.  A skeletal survey conducted post death indicated that Child C had suffered multiple fractures that were old and new fractures which were considered to be consistent with non accidental injuries (NAI)  1.1.7.  The case was considered by Barking & Dagenham Safeguarding Children Board (BDSCB) Serious Case Review (SCR) Panel on the 10th November 2016 to consider if the criteria had been met, under Regulation 51 namely:  (a) abuse or neglect of a child is known or suspected; and                                             1 Local Safeguarding Children Boards Regulations 2006  (b) (i) the child has died.  1.1.8.  The then Chair of the Board accepted the recommendation to conduct a Serious Case Review, in line with Chapter 4, Working Together2  1.1.9.  In May 2017, the parents of Child C were found guilty of causing or allowing the death of Child C. They both received custodial sentences.   1.2.  Family Composition   1.2.1. The family members relevant to this review will be referred to as follows:  Family member  Description used in this report Age at time of Child C’s death Ethnicity Subject Child C 3months Black British / Caribbean Mother of Child C Mother 25  Black British/ Caribbean Father of Child C Father 52 Black British Sibling Of Child C Sibling Older than Child C by a couple of years Black British / Caribbean Maternal Aunt of Child C Maternal Aunt 29 Black British/Caribbean Maternal Grandmother of Child C Maternal Grandmother 50 Black British /Caribbean   1.2.2. Family involvement. The involvement of key family members in a Review can provide particularly helpful insights into the experience of receiving or seeking services. Letters were sent to the mother via her solicitor and directly to the father. To date there has been no response.                                                 2 Working Together. HM Govt 2015  1.3.  Summary of the background  1.3.1.  The mother of Child C was the sixth of eight children. Following a disclosure by Child C’s maternal grandmother in 2007 of domestic abuse, the family moved to a women’s refuge and then to accommodation in Essex. Child C’s mother returned to live in London in 2010 when her relationship with her mother (the maternal grandmother) had broken down. She had no fixed abode and was reported to live between family and friends.  1.3.2. The mother, now a resident of Newham, continued with her transient lifestyle during her first pregnancy and gave birth prematurely at 34 weeks gestation to Child C’s sibling (April 2014). She avoided professionals and only engaged with services on her own terms, evidenced by sharing different information depending on which agency she was talking to. The mother denied that she was in a relationship with the father of her children but stated that he was supportive.    1.3.3. The mother approached Newham Housing Needs Service on the 7th April 2014 with a letter from the maternal aunt stating that she could no longer allow the mother to stay on a temporary basis in her flat in Tower Hamlets. The mother was offered temporary accommodation in both Forest Gate and Edmonton. She turned down both of these offers, citing proximity to her father and brother whom she had alleged assaulted her for the former, and the latter because it was too far away.  Chronology of Housing Offers/Events  Date Location Outcome 25 April 2014 Forest Gate Rejected: too close to father and brother 11 December 2014 Chadwell Heath Accepted 11 March 2015 Chadwell Health Cancelled: not living there 17 March 2015 Edmonton Rejected:  too far away 7 April 2015 Dagenham Accepted:  Signed for on 9 June. Moved in 6th July April 2016 Dagenham Cancelled: not living there   1.3.4. The mother experienced a late spontaneous miscarriage (at 21 weeks gestation) on 16th June 2015, at the father’s home. The mother and the baby were conveyed by ambulance to hospital. The baby was reported by ambulance staff to have shown signs of life but subsequently died.   1.3.5. The mother also self reported a number of early miscarriages (five to seven) and had presented for fertility treatment aged 19. Three births had all been premature and home deliveries with no professional present.    1.3.6.  Following nearly 16 months of tenancy arrangements, in March 2016, the London Borough of Newham cancelled the mother’s tenancy for a flat in the London Borough of Barking and Dagenham (LBBD) as it transpired that she had never been resident at this address and they concluded the homelessness duty had been discharged in April 2016. The mother was pregnant with Child C, her third pregnancy in less than three years, and on 2nd June 2016 again delivered prematurely at 28 weeks and 5 days gestation at the address of Child C’s siblings father. Child C was admitted to the Neonatal Unit at Newham University Hospital where she remained for a period of 65 days.   1.3.7. During Child C’s time in the unit her mother visited her on only 18 occasions.  Prior to Child C’s discharge a strategy discussion was held and an Initial Child Protection Case Conference (ICPCC) was planned to take place in the LBBD on the 15.08.16. On 5th August Child C was discharged from the Neonatal Unit into the care of her mother who planned to stay with her sister (the maternal aunt) in Tower Hamlets (the third London borough).   Date Event Outcome 25 July 2016 Strategy meeting with Police Recommends case progressed to ICPC 29 July 2016 Professionals Meeting held at the hospital Mother to register with GP in Tower Hamlets  Tuesday 2 August 2016 Discharge Planning Meeting held at the hospital Child C to stay with mother and sibling at maternal aunts flat in Tower Hamlets Friday 5 August  Child C discharged from the Newham Hospital Neonatal Unit At 6pm 15 August Initial Child Protection Case Conference held by LBBD Child C and older sibling made subjects of Child Protection Plans under the category of neglect 17 August Threshold of Care and Legal Planning Care proceedings should be initiated.  If Meeting held by LBBD children not seen by 19 August Emergency Protection Order to be considered 19 August Maternal grandmother and maternal aunt offer support to directly avoid children being taken into care Family Support Plan signed and agreed that the family will move to Essex to live with maternal grandmother   1.3.8.  At the ICPCC on 15 August convened by the London Borough of Barking and Dagenham (LBBD), Child C and her sibling were made subject to a Child Protection Plan (CPP) under the category of neglect. During the conference the mother was antagonistic and stated that she would not comply; she refused to say who the father of Child C was or where he lived. In view of this further action from the ICPC meeting was for further consideration of a legal planning meeting if the mother’s non-compliance continued.  1.3.9. Concern escalated as Child C had not been seen by a health professional since discharge from the Neonatal Unit at Newham University Hospital and it was unclear where the family was living.  A Threshold of Care and Legal Planning Meeting (TCLPM) was convened two days after the ICPCC (17 August); the TCLPM provided a framework for how the case should be progressed and managed. This meeting was attended by LBBD Group Manager CSC, Senior Solicitor, Court Progression Officer, Social Worker and Minute Taker and concluded that care proceedings should be initiated.   1.3.10. On 19 August the maternal grandmother and maternal aunt of the children visited LBBD Children’s Services with the mother and stated that the mother wished to take Child C and the older sibling to live with the maternal grandmother in Essex, who offered to monitor and support the mother as she did not want her grandchildren to “go in to care”.  1.3.11.  Following initial investigations, the family moved to Essex on 22 August. Essex Children’s Services were advised of the children’s move into their area and asked to add the names to the list of children on a CPP.  1.3.12. On 23 August the social worker contacted the maternal grandmother to check how things were going and no concerns were raised, and the mother had planned to register with the local GP practice.  1.3.13. On 24 August the safeguarding plans for both children were sent to the TCLPM to report and review the change of circumstances.  The TCLPM decided not to proceed with care proceedings for the children at that time. This was to allow for a period of support with the wider family in the care of the children. The TCLPM directed that a safeguarding agreement should be put in place, specifically that if the mother moved out from the grandmother’s address with the children, then the social worker and police must be informed. The Child Protection Plan (CPP) was to continue and more core groups to be held. The maternal grandmother was informed and that she must make contact with SW3 /police if the mother leaves Essex with the children.  1.3.14. On 26 August (this was the Friday of the August Bank holiday weekend) the mother rang the social worker to inform her that the maternal grandmother had “kicked her out”.  The maternal grandmother spoke with the social worker and stated that she could not look after her daughter and grandchildren indefinitely and that the LA needed to find accommodation for them. The mother had also forgotten to bring her bank card with her and the maternal grandmother could not continue to support her financially. The maternal grandmother gave a positive report of the mother interacting well with the children. The family had registered with a GP and had made contact with the Essex Housing Department.  1.3.15. The social worker spoke with the mother on 1 September and she confirmed that she and the children were still living with the maternal grandmother and was due to see the Housing Department the same day.  1.3.16. A joint home visit by the social worker and health visitor was carried out on 6 September.  This was also convened as a Core Group Meeting.  1.3.17. On 8 September the social worker was unable to contact either the mother or maternal grandmother to get an update on the housing situation.    1.3.18.  On 14 September the social worker was again unable to contact the mother but did speak to the maternal grandmother who told the social worker that the mother had taken the children back to London for three days (12-15th September). The maternal grandmother had failed to tell the social worker about the departure despite this being part of the safeguarding agreement. SW3 informed the Team Manager who instructed SW3 to tell the maternal grandmother that she must notify the police of this. SW3 was unable to speak with the maternal grandmother and left a message instructing her to tell the police.    1.3.19. Following an unannounced home visit by the social worker on the 19th September it appeared that the family were co-operating and that progress was being made in relation to: an application to housing, health appointments, outstanding development checks and immunisations for the children.   1.3.20. Shortly after the completion of the visit on 19 September, the mother and the two children again left the address in Essex returning to London; again, the maternal grandmother failed to inform the social worker. The mother sent text messages to the health visitor asking to rearrange a planned home visit scheduled for the 26.09.16.  1.3.21. It is now understood that the mother remained in London with the children. On the morning of the 28 September the mother boarded a bus with Child C in a baby sling; the baby’s head was covered with a white cloth. The sibling of Child C was also with her and was in a pushchair. The mother asked for help from the passengers saying that her baby had stopped breathing, one passenger carried out Cardiopulmonary Resuscitation (CPR) on Child C prior to the arrival of the emergency services.  1.3.22. The emergency services attended and called the police, as there were suspicious circumstances. Child C was pronounced dead at the hospital.   2.  Methodology   2.1. For details about the review process and methodology; see Appendix 1.   3.  Details of Practice and Analysis  3.1.  Introduction   3.1.1. The detail of this SCR has been divided into five time periods. A timeline of key events for each of these time periods can be found in Appendix 2. What happened, and the underlying practice, is considered alongside multi-agency decision-making, assessments and interventions. The appraisal is set out to assess the quality of the multi-agency practice at key points, and identify which are considered to provide the most significant learning. In doing so, it takes into account both the contemporary required standards and also the information that was known, or could have been known, at the time of the events. Where there is information about why practice may not have met required standards, this is explained.   3.1.2. It aims to provide an outline of what happened and how the various professionals responded or took action. This extends to give a clearer view and takes what happened into a discussion about why things may have happened in the way they did. By doing this the Review is seeking to achieve a greater depth of learning about safeguarding practice and the systems that underpin this with all the agencies that were directly engaged. This learning extends beyond the individual circumstances of this situation and will be the basis of each agency’s development activity after the publication of this report  3.1.3. Some important development and learning has already commenced through the process of the SCR panel, the development of each individual Independent Management Report (IMR) and organisations have already considered developments and learning that has direct future impact.  This is set out in Appendix 3.    3.1.4. The family had six different addresses in four different local authorities. When the family moved, it resulted in changes to children social care and health service provision particularly the health visiting service.   3.1.5. In order to understand where responsibility for the case rested during the timeframe for the SCR, the local authority with ongoing responsibility has been identified.   3.1.6. What is clear throughout all these circumstances are the ongoing challenges that professionals face working with transient families who have multiple or complex difficulties. This becomes even more difficult with avoidant, hard to engage and resistant families when the need to safeguard vulnerable children is a primary concern, not least the sharing of information in a timely manner when different IT systems are used and they do not align.   3.2.   Period 1: October 2013 – July 2014     (Please see summary time line at Appendix 2 pages 76 – 80)  Agencies involved: • London Borough of Newham – Adult Services and Children’s Services • Newham Housing Needs Service  • Home to Home • GP1 • GP2 • Newham University Hospital  • Midwifery Acorn Team • Newham Intensive Hospital Intervention Team • East London NHS Foundation Trust (ELFT) – Health Visiting Team  Mother is homeless and pregnant and gives birth prematurely to Child C’s older sibling, the London Borough of Newham (LBN) undertakes a single assessment.   During this period the mother presented with housing issues which did not meet the threshold for statutory intervention from children’s social care however the professionals are focused on the issue of housing and pay insufficient attention to:   • The mother’s transient lifestyle,  • The impact that this has on her ability to parent and  • Her resistance to working co-operatively with professionals.   3.2.1.   In October 2013 GP1 raised an Adult Safeguarding alert concerning the mother who was pregnant, of no fixed abode and had allegedly been physically abused by her brother and her father.   3.2.2. The London Borough of Newham Access to Adult Services (ASC) team received the alert, being the first point of contact for all adult services. ASC were unable to make contact with the mother, as she did not respond to the telephone calls. A letter was sent to the mother advising her to make contact and to attend the domestic violence service for support. ASC made a referral to children’s services (CSC) regarding the unborn child.   3.2.3. The mother contacted the service in November and gave her consent for a referral to be made for domestic violence support. At this point she stated that she was living with an uncle and she was assessed as not meeting the threshold for assessment and on-going support from ASC.   3.2.4. The mother gave the name, address and date of birth of the father of the unborn baby (Child C’s older sibling); this information was available to Children’s Social Care (CSC) via the Care First IT record system. The contact made by ASC with the mother was by telephone; she was never seen face to face by the service.  3.2.5. The mother attended Newham University Hospital (NUH) for her antenatal booking appointment with her sister (maternal aunt) in October 2013. The mother was correctly identified for priority antenatal care and was referred to the Acorn Team3 due to her homelessness and ‘complex social history”. The mother was reported to be very underweight.   3.2.6. Unfortunately, the Midwifery Acorn team records that are separate from the Maternal Hand Held Records, have not been found and there is therefore a gap in recording how the Acorn Team Midwives worked with the mother during this pregnancy, and what if any additional concerns or risks were identified. Barts Health raised a clinical incident report at the time. They now undertake regular audits to ensure that the Midwifery Acorn records, hand held records and main hospital held records all marry up post delivery.    3.2.7. The father of the baby was identified at this appointment on 29 October 2013 including his address and that he was currently unemployed. No further details were recorded or what level of involvement he would have with the baby. This could have been an opportunity to discuss the relationship and to consider whether the father provided support and stability or posed a risk.   3.2.8. The triennial review of SCRs in March 20164 makes the following recommendation: ‘Efforts must be made to increase the visibility of fathers in practice, policy and research around neglect. Too often mothers are the focus, this can mean that the risks and protective factors that fathers bring to a child’s life may be missed. Local service leaders can enable this through policy review and practice audits’. This is a key lesson for all the agencies who worked with this family.  3.2.9. At the end of October 2013 the father attended his GP2 stating that he felt anxious and depressed and had been buying diazepam5 off the street. A Patient Health Questionnaire (PHQ-9)6 was appropriately completed and he scored 25/27 indicating severe depression and was restarted on an anti-depressive drug and a referral was made for counseling; it is unclear as to whether this was taken up.                                               3 Vulnerable Woman’s Maternity Team 4 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 -2014 (DfE 2016 5 Benzodiazepine – used for their sedative, anxiety- relieving and muscle relaxing effect 6 A multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression; it is widely used in General Practice. 3.2.10. The GP practice made significant effort to follow up the review of the father’s mental health. The father failed to respond to telephone calls from GP2 practice to come into the surgery for a review of his mental health; this was good practice and demonstrated that GP2 wanted to review the father’s mental health. He eventually attended the GP surgery four months later.   3.2.11. When questioned by GP2 the father stated that he lived alone and this was reinforced by his records indicating that he was a ‘single man’ and there were no linked family members on the GP system. While it is not clear whether GP2 asked the father specifically if he was in contact with any children the information available at the time presented no contra indications Furthermore, at this point neither Child C nor their older sibling had been born. It is now known that he had children from a number of different relationships.  3.2.12. It is clear that GP2 worked on the basis of the information available at that time.   3.2.13. The case was allocated to SW1 who worked in the Newham Intensive Hospital Intervention Team at the beginning of January 2014. This was following the opening and closing of the case until the mother was 22 weeks pregnant. The allocation included supervisory direction for a single assessment to be undertaken.   3.2.14. SW1 demonstrated tenacity at attempting to contact the mother undertaking an unannounced visit and multiple telephone calls but was successful in meeting with the mother on only one occasion when she was advised to present at the Homeless Persons Unit to apply for housing in her own right.   3.2.15. Following this meeting SW1 reported, “It had been impossible to meet with mother as she disengaged from this assessment. The mother’s presenting need is to find a suitable accommodation where she will live with her baby. When she realised that Social Care are not in a position to provide her need at present as she has no live child, she has not thought it necessary to continue to engage with the assessment.”   3.2.16. The assessment recognised that the mother had been a victim of violence perpetrated by her own father and brother but saw the risk as being reduced by the fact that the last incident was in March 2013 and concluded  ‘It has been difficult to comment on all areas needed to complete this assessment to make any meaningful recommendations, however, the baby when born does not appear to be at imminent risk except the risk of homelessness and this could be assessed again when the mother presents at the hospital to have the baby’.  3.2.17. Based on the information available to Newham CSC at that time the threshold for further statutory intervention was not met, mother reported that the risk of domestic abuse was reduced as she had moved away from the perpetrators and although she did not have her own tenancy she had found herself a temporary place to stay and was advised to present to the Homeless Persons Unit.  3.2.18. The mother failed to attend two routine ante natal appointments in a row but did attend the next one. She blamed the fact that she had no permanent address and was experiencing problems with her phone; this was a constant feature throughout the review period, when the mother would have a number of different mobile numbers and would say that she had been given the wrong time for appointments.    3.2.19. The Midwifery Service has a ‘Did Not Attend’ pathway in place and staff followed this in managing missed appointments. Staff need to be reminded and remain curious as to why appointments are missed and should always consider the potential for ‘disguised compliance’7 or ‘non-compliance’8 this will be will be discussed under Section 3.7.  3.2.20. In April 2014 Child C’s sibling was born prematurely at 34 weeks gestation and the midwives informed the social work team as instructed; the mother had agreed to work with the social worker regarding housing.   3.2.21. Mother and baby were fit for discharge four days after the birth, but the mother refused to leave and remained in hospital for a total of 12 days post delivery. During this time the father of the baby stayed on the ward for an afternoon whilst the mother went to the housing department, however, the Housing Needs Service does not corroborate this account; it is unclear where the mother went. This was another opportunity for professionals to find out more about the father and the role he played within the family.  3.2.22. The mother had presented to the Housing Needs Service on the 07.04.14 with a letter from her sister (maternal aunt) stating that she could not stay with her any longer, as there was insufficient room at her flat in Tower Hamlets.   3.2.23. The mother also disclosed at this appointment that she had been staying with her uncle in a one bedroom flat but said her uncle did not want any visits from the ‘council’. A subsequent home visit confirmed that the mother had been staying ‘off and on’ with the uncle, but that he had mental health problems and did not want the baby to stay in his flat because he was a smoker.   3.2.24. The mother was referred by Newham Housing Needs Service to ‘Home to Home’ which was a mother and baby unit for young                                             7 Parents giving the appearance of co-operating with professionals to avoid raising suspicion and allay concern. 8 Parents’ lack of co-operation and /or hostile attitude of parents. mothers. She turned this down due to the property being in the area (Forest Gate) where her father and brother lived (she had alleged they had assaulted her).   3.2.25. Following the birth of Child C’s sibling a new birth notification was received by East London NHS Foundation Trust who are commissioned to provide a range of services including health visiting in the LBN.   3.2.26. The new birth visit9 was completed on the post-natal ward as the mother and baby were still in the hospital due to the mother’s homelessness and her refusal to leave the hospital. HV1 assessed the family as meeting the Universal Partnership Plus10 and a follow up visit was planned for the 16.05.14.11 This was conducted in line with the requirement that the Health Visitor Service is the lead agency on the delivery of the Government’s Healthy Child Programme; pregnancy and the first five years, (DOH, 2009). This states that additional support may be needed by some parents and will depend on their individual risks, needs and choices. The aim is to identify any health or development related concerns as early as possible so that the required level of support and intervention can be agreed and if appropriate refer or signpost to another service.  3.2.27. The mother and baby were discharged to the uncle’s home on 24 April 2014, 12 days after the birth, and the midwife visited the same day. The midwife was concerned about the sleeping arrangements for the baby as it was a one bed roomed flat, there was no cot in evidence, the mother was sleeping on the sofa and the flat ‘stank of smoke’.   3.2.28. A duty social worker visited the property the following day. The social worker raised concerns regarding the cigarette smoke in the home, lack of space and co-sleeping arrangements for mother and baby, which the social worker advised to stop with immediate effect. The duty social worker liaised with housing and advocated on the mother’s behalf and following this, housing agreed to provide mother and baby with accommodation.   3.2.29. The case was closed by Newham Children’s Services on 19.05.2014 on the basis that the presenting issue was housing, which was being addressed by the housing department.    3.2.30. This decision fell below the required standard as it did not gather sufficient information about the lifestyle of the mother, the role of significant others, such as the biological father, reasons for her poor                                             9 New birth visit is completed 10-14 days after the birth 10 Four levels of health visiting intervention, Community, Universal, Universal Partnership and Universal Partnership Plus: Health Visitor Implementation Plan: A Call to Action (DH 2011). 11ELFT Health Visitor Operational Framework states follow up visit should take place two weeks after the new birth visit. attendance and engagement with professionals and its impact on the baby.    3.2.31. Supervision was provided throughout this period and whilst it gave direction it did not encourage professional curiosity or ensure the assessment was completed in full. It is well documented that in working with families to safeguard children, the sense that professionals make of information they receive will inevitably be vulnerable to common errors of human reasoning (Munro; 1999).   3.2.32. The importance of regular supervision and management oversight for all professionals will be discussed under additional learning, see Section 3.17  3.2.33. The mother cancelled the planned follow up visit made by HV1 for the 16.5.14 by text as she stated that she was not at her uncle’s address and the appointment was rescheduled for four days later (20 May). The mother and sibling were not at the uncle’s address when HV1 attempted the rearranged visit. The mother then requested to see HV1 at the Child Health Clinic (CHC) on the 22.05.14; she arrived nearly three hours late.   3.2.34. This pattern by the mother of cancelling appointments but then wanting to rearrange may have encouraged HV1 to think that she wanted to engage with the service.   3.2.35. On 22 May 2014 The mother told HV1 that she had been ‘kicked out’ by her uncle and she had been staying with the father of the baby. This was the first time that the mother had shared with a professional that she was staying with the father of the baby.   3.2.36. HV1 did not record his address and did not enquire about the role and relationship; this was a further missed opportunity to gain more information and insight in to how much time the mother and sibling spent with him, and what his role and influence was.   3.2.37. The mother failed to attend a further two appointments with the health visiting service, this was despite contacting the mother directly by phone to remind her about the appointments.    3.2.38. HV1 did not share the non-engagement by the mother with GP1, the case had already been closed by Newham Children’s Service (NCS) on the 19.5.14. This was an opportunity for HV1 to consider concerns about disguised compliance.12 While HV1 made a referral back to CSC (see para 3.2.43) on the basis of neglect if the potential of disguised compliance been considered this could have added weight to the referral.                                               12 This can lead to a focus on adults and their engagement with the service rather than achieving safer outcomes for children. 3.2.39. ELFT have a clear policy for how to manage missed appointments, the ‘Did not Attend’13policy states when two appointments are missed ‘The staff member has an individual professional responsibility to respond to failure to attend an appointment in a manner based on an assessment of the service user’s risk and their identified needs’.  3.2.40. When children do not attend or there are repeated cancellations and rescheduling of appointments by parents, professionals should be curious about why and move away from the response ‘did not attend’ to ‘was not brought’. Recent research into health agency ‘Did not attend’ policies has shown inconsistency and that they can, at times, be a systemic defensive response by agencies to help manage large workloads.14 Non-compliance with appointments may be a parent’s choice but it may not be in the child’s best interest. Repeated cancellations and re-scheduling of appointments for children should be treated with curiosity. A shift away from using the term did not attend (DNA) to was not brought (WNB) would help ‘maintain a focus on the child’s ongoing vulnerability and dependence, and the carer’s responsibilities to prioritise the child’s needs. In some cases it may be considered a sign of neglect.    3.2.41. HV1 followed up with Housing Needs Service on the 24.5.14 enquiring about the progress of the case.  3.2.42. The mother approached the Housing Needs Service on the 12.6.14 stating that she was back living with her uncle. The homelessness caseworker sent a letter the same day asking the mother to submit the requested documents: proof of identity for herself and the child, proof of residence for the past five years and proof of income. The mother is advised in the letter that this information must be sent within seven days to avoid the closure of her case. The Housing Needs Service received no response within the timeframe.   3.2.43. At the end of July 2014, HV1 referred the case to Newham Children’s Care Services citing concerns for the safety and wellbeing of Child C’s sibling as neglectful. The mother had failed to bring Child C’s sibling for developmental checks, outstanding primary immunisations and there was no clarity about where the family was living.   3.2.44. It should be noted that HV1 was a newly qualified health visitor, and it appeared that at this time the onus was for HV1 to seek                                             13 ELFT Did Not Attend policy guidance 14 Munro, Eileen (2012) Review: Children and young people's missed health care appointments: reconceptualising 'Did Not Attend' to 'Was Not Brought' - a review of the evidence for practice. Journal of Research in Nursing, 17 (2). pp. 193-194. ISSN 1744-9871 and Lisa Arai, Terence Stephenson & Helen Roberts; The unseen child and safeguarding: ‘Did not attend’ guidelines in the NHS; Archives of Disease in Childhood, March 2015;  http://adc.bmj.com/content/early/2015/03/16/archdischild-2014-307294   supervision; the danger being that if health visitors do not recognise risk, or the significance of these, then they may not seek out supervision.   3.2.45. ELFT have since implemented a mentoring programme15 for all newly qualified health visitors and regular safeguarding supervision. See Section 3.17.   Learning Points:   • GPs should be reminded to “Always ask patients with mental health difficulties, learning difficulties or drug and alcohol misuse whether they have significant care responsibilities. Consider their capacity to care for children safely. Record this information in medical records and emphasise it in referrals and correspondence about patients” • Impact of poverty and homelessness on the child (including pre-birth) should always be considered in cases where these issues are present  • Parents who are homeless are often the most vulnerable in society.  • Clear standards for assessment should be developed, or if they already exists re-affirmed with professionals  • All relevant family information should be recorded and appropriate follow-up questions asked. The importance/impact of the father’s role should be acknowledged   • Barts Health should consider reviewing the Did Not Attend pathway to ensure that poor engagement and disguised and non-compliance are considered.  • Professionals should share experiences of non-compliance   • ELFT staff should be reminded of the ‘Did not Attend’ policy and consider reviewing and implementing a ‘Was not Brought’ policy  • Mentoring programme for all newly qualified health visitors and regular safeguarding supervision – Actioned                                             16 ELFT Mentoring Programme for newly qualified health visitors including monthly reflective safeguarding supervision.  3.3.  Period 2: August 2014 – June 2015   (Please see summary time line at Appendix 2 pages 80 – 85)  Agencies involved: • London Borough of Newham – Children’s Services • Newham Housing Needs Service • Newham Intensive Hospital Intervention SW Team • Police  • London Ambulance Service • Midwifery Service Newham University Hospital • Emergency Department at Newham University Hospital • East London Foundation Trust (ELFT) Health Visiting Service • North East London Foundation Trust (NELFT) Health Visiting Service   In December 2014, Newham Housing Needs Service placed the mother in Bed & Breakfast accommodation in Chadwell Health in the London Borough of Barking and Dagenham. The Intensive Hospital Intervention Team between 4 August 2014 and 10 February 2015 completes a second single assessment and the case closed in May 2015. The mother has a spontaneous miscarriage at 21 weeks gestation on 16 June 2015.    This period of time highlights the challenges encountered by multi-agencies when working with a mother who chooses when and where she wishes to engage with the services, and shares different information with different professionals. This means that information sharing by all the professionals becomes key to protect and safeguard children.  3.3.1. Following the referral from HV1 LBN triage identified issues of neglect and the case was reopened under the Intensive Hospital Intervention Team. It was less than three months since the case had been closed by SW1 working in the Intensive Hospital Intervention Team; SW2 was allocated to work with the family.  3.3.2. The mother’s non-engagement with the ELFT health visiting service continued, she had failed to attend a total of five appointments between July – September (2014).   3.3.3. The failure of the mother to attend the appointments was again not shared with SW2 nor were enquires made with GP1.   3.3.4. HV1 did not follow ELFT policy. Consequently, SW2 thought that the mother did keep appointments with the health visiting service. The mother did attend on the 02.10.14 at the CHC for a follow up health review.   3.3.5. During the time (August 2014 to June 2015) that ELFT health visiting service was in contact with the mother and Child C’s sibling none of the contacts took place in the home setting; there had been no assessment of the home environment. The family was initially assessed as meeting the need for Universal Plus16 but this was then changed to Universal following attendance at Child Health Clinic in the local Children’s Centre where the family was seen by HV2. The explanation provided for this was there was no access to the RIO17 IT system in the clinic setting and HV2 did not check the records on her return to the health visiting base; had she done so then the family concerns would have been noted.  3.3.6. In September 2014 the mother provided Newham Housing Needs Service with the required documentation namely: the full birth certificate of Child C’s sibling, the Child Benefit book and letters confirming Income Support (this was three months after the request to provide the documents within seven days).   3.3.7. On the 11.12.14 Newham Housing Needs Service provided the mother with B&B accommodation in Chadwell Heath18. However, this was cancelled in March 2015 after it was discovered that the mother had never stayed in the Chadwell Health B&B accommodation and told the HNS that she had been advised by SW2 to vacate the room because of a bed bug infestation.   3.3.8. Following the placement of the family into Chadwell Heath B&B accommodation, HV1 contacted the health visiting service19 covering the new address and did a verbal handover. Unfortunately, the full health visiting records were not forwarded and the mother’s records remained active on the RIO system for ELFT health visiting service, this resulted in the full history and contact pattern not being available to the new health visiting team in North East London Foundation Trust (NELFT).  The remaining records pertaining to Child C’s sibling were sent in error to Redbridge and it was almost three months before this was rectified and the records received by the health visiting team covering the Chadwell Heath area. There then followed a number of attempted visits to the family in their new accommodation by the health visiting team. At this time NELFT were experiencing a high number of vacancies and health visitors were moved to different areas at short notice to cover Child Health Clinics and New Birth Visits resulting in a fragmented management of                                             16 Provides on-going support from the health visiting team plus a range of local services including Social Care, Children Centres, GPs and third sector organisations.  For example: complex issues including domestic violence, health and social issues and safeguarding issues etc. Families allocated to this package of care will be offered up to maximum of 1 contact per month/minimum of 6 contacts annually dependent on planned interventions requirement.    17 Electronic Care Record System  18 The property was in the LBBD. 19 NELFT; Barking and Dagenham mother and Child C’s sibling.  3.3.9. The single assessment by SW2 took 120 days to complete which falls well below the required standard of 45 days. During this time the assessment was impeded by the persistent failure of the mother to engage.   3.3.10. SW2, like SW1, was tenacious in providing support to address the issue of homelessness and persistently attempted to contact the mother, undertaking unannounced home visits, attempting to contact via telephone and chasing her whereabouts via the uncle and the maternal aunt.   3.3.11. Despite these attempts SW2 met with the mother and baby on only one occasion.   3.3.12.  SW2 met with the mother and Child C’s sibling on the 12.11.14 at her uncle’s address and the SW noted, ‘how the mother actively stimulates her child, his attachment and strong relationship with the mother and the uncle’. SW2 also noted that when the sibling was lifted from the car seat, the child was wet through, enough to wet her own clothes when the child sat on her lap.  SW2 requested information from the health visiting team and received a response on the 5.2.15 (three months later) HV3 confirmed that Child C’s sibling was up to date with developmental checks and immunisations but had presented with marks on his face and his weight had dropped by 1 centile. HV3 advised the mother to go to her GP1. There was no follow up with the GP by SW2 and these issues were not progressed as SW2 considered that they were health related issues and had been addressed by GP1.  3.3.13. The mother had provided no details of the child’s father and he remained unknown, despite the opportunities to glean information outlined in (para 3.2.7) The absence of information about a family should always be considered in context and must include, both the reasons for the lack of information, and the significance of that information for the child.   3.3.14. The single assessment by SW2 concluded on 6 February 2015 that the mother presented as caring towards Child C’s sibling and capable to meet a range of the child’s needs.  ‘From the information gathered it is my view that the neglect of Child C’s sibling’s health needs are no longer a safeguarding concern at this stage’.   3.3.15. The mother had reported that she did not see a need for ongoing support as she loved her baby and would never expose the child to any harm. Her main concern continued to be housing and although she was in Bed & Breakfast (B&B) accommodation SW2 never visited her at this address.  3.3.16. On 5 February 2015, the day before the single assessment was completed, NCS requested police intelligence relating to the mother, the request stated that the information was required for an assessment regarding the mother and Child C’s sibling This information was provided by the police and was known at the time that the case was closed by NCS see para 3.3.25.  3.3.17. On the 06.02.15 an ambulance was called to the address of the father of Child C’s sibling where it was reported that a nine-month old child had a high temperature, rash on forehead, shivery and crying. Following an assessment at the house20 the sibling was taken to NUH where the Co-op GP assessed the sibling;21 Child C’s sibling was discharged home.   3.3.18. SW2 contacted the NELFT health visiting team on the same day asking them to carry out a home visit, a home visit was attempted on the 12.02.15 which was unsuccessful, but a card was left inviting the mother to attend the clinic. The mother attended the Child Health Clinic with Child C’s sibling the following day (13.02.15). This was the only face-to-face contact the health visiting service (NELFT) had with the mother and Child C’s sibling, this included: three attempted telephone calls to book appointments, five effective telephone calls, two pre-arranged home visits (not kept) and two unannounced home visits that were unsuccessful. In all there was input from eight different health visitors.   3.3.19. At the end of March 2015 an offer of temporary accommodation through the private leasing scheme was made. The mother accepted the offer of a flat in the LBBD  3.3.20. In early March (2015) the mother self referred to the midwifery service as she was six weeks pregnant and was seen by the same midwife in the Acorn Team that had booked her for her previous pregnancy. Although mother presented for antenatal care at an early stage she did not attend for all appointments or turned up at the wrong time.  3.3.21. The father’s name was recorded under two different surnames, this was not challenged or explored further, and it was identified that he was age 40 plus (in fact he was 51) and she was 24 years of age. Professionals should always carry out further checks when different names or aliases are given.   3.3.22. It was also recorded that the father had children with another partner and was unemployed. Risk factors were identified: mother’s low weight, previous pre-term delivery before 34 weeks gestation, she did not smoke or drink (although at her first booking she stated that                                             20 The father’s address 21 Primary care located within the Accident and Emergency Department to review patients that are deemed suitable tor GP management. she did smoke) and she had a social worker due to her housing issues.   3.3.23. At this appointment the mother gave more information about the father including that he had other children; however, this information was not shared with the other agencies and another opportunity to assess the father of the children was lost This may have been because the midwife knew the mother from her last pregnancy and that SW2 had not flagged any concerns with the midwifery team.  3.3.24. On the 10.05.15 the mother took Child C’s sibling to the Urgent Care Centre (UCC) with a head injury. The sibling was aged 13 months at the time. The explanation given was that the sibling had been jumping on the bed and fell and hit their head on a windowsill. At the time there was confusion about whether Child C’s sibling was subject to a CPP as this was flagged on the IT system, they were in fact a Child In Need (CIN). Staff in the unit followed the correct procedure for dealing with a child on a CPP and informed SW2 by fax about the injury.   3.3.25. At this point the case was still open to Newham Children’s Service but no further enquiries were made in respect of the incident by NCS.   3.3.26. While it is impossible to state categorically, it would be unusual for a child of 13 months of age to have the ability to jump up and down on a bed without any support and further exploration of the history should have been undertaken to ascertain his/her gross motor skills and the context of the injury in order to exclude non-accidental injury.   3.3.27. On the 13.05.15 the manager in the Intensive Hospital Intervention Team made the decision to close the case on the basis that the original concern was about the mother not seeking health input for the child and the housing issues and it was recorded that both had been resolved. It is unclear whether the fax sent from Urgent Care was seen by SW2 or the manager as there was no reference to it within the IMR for NSC. It is impossible to determine what happened to this fax though it is clear that SW2 was not aware of the head injury.  This meant that an opportunity to follow this up was lost.   3.3.28. At the time of concluding the assessment work SW2 was asked by the authorising manager to establish the mother’s address and send a referral to the relevant Local Authority. This action did not happen meaning that information/assessment was not made available to LBBD.  3.3.29. On the 02.06.15 an ambulance was called, again to the father of Child C’s siblings address in the London Borough of Newham, where it was reported that the mother had given birth to a premature baby. It was reported that on arrival a hostile man holding a child approximately one year of age met the ambulance crew.   3.3.30. The London Ambulance Service (LAS) has in place a safeguarding adults and children policy and practice guidance which are reproduced on its intranet and website22. LAS report that staff come across hostile situations and people regularly, this is sometimes due to the delay in an ambulance attending and sometimes due to the nature of the call and that the people on the scene are upset and distressed. On this occasion following their assessments and attendance it was deemed that a safeguarding referral was not needed.   3.3.31. The baby/fetus was taken to the Emergency Department (ED at NUH); the baby died and a death certificate was issued23. A midwife on the assessment unit spoke to the father on the phone to keep him informed but it is unclear if they had been given his contact details or spoke to him using the mother’s mobile phone.   3.3.32. The father was clearly more involved than the mother was disclosing to professionals.   3.3.33. This was the second time that the ambulance had attended the father’s address in the London Borough of Newham yet the mother continued to deny that she knew where he lived or that they were in a relationship.   3.3.34. There were many different discussions about whether the infant who went to the ED was a neonatal death or a late miscarriage before the viable 24 weeks of pregnancy.  Irrespective of whether it was classified as a death or miscarriage the process for allowing mother to spend time with the baby and having mementoes was the same. The mother was referred to the bereavement midwife and was seen for a follow up appointment on 03.08.15. The Acorn team was notified. The care received by the mother at this time was of a good standard.  3.3.35. The mother wanted to arrange for the baby to be buried, however, the Registrar Office at NUH had difficulty making contact with the mother. When contact was made the mother had failed to register the birth and said that she was not in a financial position to pay for the burial. On the 14.10.15 the mother was offered a hospital funeral, the mother turned this down stating she would be unable to attend but still wanted to arrange her own funeral for the baby.   3.3.36. Over the next few months numerous attempts were made by the Deputy Superintendent Registrar to contact the mother including phone calls, leaving messages on the voicemail and by letter. It is unclear as to whether the mother did make contact however the baby                                             22 http://www.londonambulance.nhs.uk/health_professionals/safeguarding-child_protection.aspx. 23 Death certificate of a live-born child dying within the first 28 days of life, death was due to extreme prematurity. was buried at the end of March 2016 in the City of London Cemetery.   Learning Points:  • The absence of information should always be considered in context and must include, both the reasons for the lack of information, and the significance of that information for the child.   • If there is concern about an injury of a child attending UCC/ A&E Departments the referral must be followed up to ensure that it has been received.  • Professionals do not always identify chaotic lifestyle and frequent changes of address as potential child protection issues. Any neglect strategy or guidance should reference these features   • Mobility and lack of parental cooperation are common factors and need to be recognised as a risk factor that should heighten concern.  • Professionals to be reminded that when different names or aliases appear to be used then further checks with agencies working with the family should be undertaken.  • The admitting address is not routinely recorded only the discharge address    3.4. Period 3: July 2015 – July 2016.   (Please see summary time line at Appendix 2 pages 85 – 91)  Agencies involved:  • London Borough of Newham Children’s Services   • Newham Housing Needs Service • London Borough of Barking and Dagenham Children’s Services • London Ambulance Service • Midwifery Services • Neonatal Unit, Newham Hospital  • North East London Foundation Trust (NELFT) Health Visiting Service    Mother is pregnant with Child C, she moves into a tenancy provided by Newham Housing Needs Service in July 2015 in the London Borough of Barking and Dagenham. She abandoned this accommodation and the homelessness duty was discharged in April 2016. Child C is born prematurely at home and admitted to Newham University Hospital Neonatal Unit where she resides for 65 days.  This period highlights escalating concerns about the mother’s engagement and her attendance on the Neonatal Unit to visit and care for Child C. Despite the concerns, Child C is discharged into the care of her mother without a period of ‘rooming in’ on the unit. It would appear that ‘professional optimism’ wins out despite the family having no fixed abode and the mother’s poor history of parenting and engagement with relevant agencies to date.  3.4.1.  The mother was pregnant and again self referred to the midwife on the Acorn Team in February 2016. The information the mother gave at the booking clinic with regard to the number of miscarriages differed and that she had never smoked. The mother was screened using the Whooley Questions24 and did not disclose that she had been suffering, or had suffered with mental health concerns. The mother was now living in temporary accommodation (in LBBD) with Child C’s sibling.   3.4.2. The father’s name was recorded by the Acorn Team and matched the first name given at their last booking appointment in March 2015; no further enquiry was made.  On this occasion, the mother did not meet the criteria for the Acorn Team as she no longer had a social worker and she was living in temporary accommodation; the plan was for shared consultant care. The mother’s attendance for routine ultrasound scans and antenatal appointments was varied; she attended three scans and then failed to attend two. This pattern was repeated with the midwives clinic where she failed to attend three but not consecutively. It would appear that she was doing ‘just enough’ to keep the professionals at bay. The midwives managed her attendance using the Did Not Attend Pathway.  3.4.3. Evidence suggests that women who have had a premature birth are more likely to have a premature birth in subsequent pregnancies. Other risk factors include: being under weight (which may indicate poor nutrition), low income and poor housing. At the booking appointment for pregnancy, women are routinely asked about drug use; the staff did not feel that there was any evidence to suggest that the mother did use drugs, and she consistently denied using substances when asked as part of the booking process.  3.4.4. The Housing Needs Service liaised with the managing agent reference the temporary accommodation as they have a duty to visit                                             24 NICE guidelines (CG192), 2014 clients once every quarter; it is now clear that they had never found the mother in on any of the visits carried out. The managing agent visited the property on 17.03.16 and a neighbour informed the managing agent that no one stayed at the property. The managing agent entered the property and noticed that there were no signs that anyone lived there; no proper furniture or food was in evidence. The managing agent notified Housing Needs Service the tenancy was cancelled and the mother was reported to have abandoned the property. Following the cancellation, the homelessness duty was considered discharged25 in April 2016.  3.4.5. It was not known where the mother and Child C’s sibling were living at this time. The information was not shared with LBN Children’s Social Care, at this time the case was closed to NSC and the Housing Needs Service were unaware of any concerns regarding the family. Newham Housing appears to have worked on the assumption that the person has gone back to family, or found alternative accommodation.26  3.4.6. Although LB Newham had determined that the family did not meet the threshold for statutory intervention it could be argued that the mother and Child C’s sibling were vulnerable given that housing had been and was now an ongoing risk. Key learning from this is that consideration should be given to implementing an information sharing agreement between Housing and CSC when tenancies are cancelled and there are young children in the household.    3.4.7. Child C was born prematurely at 28 weeks and 5 days27 in early June at the address of the father of Child C’s sibling (in the LB of Newham); this was the third time the mother had delivered at this address  3.4.8. This was the fifth time an ambulance had attended this address however they were spread over a period of more than one year. The London Ambulance Service does not flag addresses for ‘Frequent Callers’ this would only be done   if there has been abuse/assault against attending members of ambulance staff and if LAS have been notified by CSC that an unborn child is at risk. At this time there was no flag against this address.                                             25 The council had accepted the mother’s homelessness application and had provided suitable accommodation. 26 The Homelessness Code of Guidance states: -  FAMILIES WITH CHILDREN UNDER 18 11.29. It is important that social services are alerted as quickly as possible to cases where the applicant has children under 18 and the housing authority considers the applicant may be homeless, or threatened with homelessness, intentionally. Section 213A(2) therefore requires housing authorities to have arrangements in place to ensure that all such applicants are invited to agree to the housing authority notifying the social services authority of the essential facts of their case. The arrangements must also provide that, where consent is given, the social services authority are made aware of the essential facts and, in due course, of the subsequent decision on the homelessness case. 27 The earlier a baby is born the higher the risk is of health problems.  3.4.9. The mother and baby were taken to NUH and the baby was admitted on to the Newham Hospital Neonatal Unit; initially the baby required ventilation to assist with her breathing.   3.4.10. The mother refused to stay in hospital and took her own discharge the same day; this was against medical advice. The plan was for her to go and stay with the father of the children for a few days. The address was recorded at discharge was in fact a different flat number, she gave the number as 12 rather than 16. It is not known whether this was a transcribing error or a deliberate act by the mother to give false information.  As a consequence of this error, the midwives had difficulty finding anyone at the property when they subsequently attempted a postnatal home visit.   3.4.11 The midwives also reported that it was difficult to make contact with the mother via the mobile phone number that she had provided them with. The midwives managed to make contact by phone on the third attempt and an appointment was made for the postnatal clinic,28 which the mother kept, and the subsequent follow-on appointment. There then followed a period of non-engagement by the mother with the midwifery service.  3.4.12 The baby resided on the Newham Hospital Unit for a total of 65 days; the mother visited her on 18 occasions.  The safeguarding advisor instructed the staff on the Neonatal Unit to keep a visiting record as the mother had not visited Child C from the 2-6th June and had made no telephone contact. The staff on the Neonatal Unit on the 21.6.16 made a referral to NCS as the staff were concerned about limited visiting by the mother, requesting food when on the unit and difficulty in making contact by phone.   3.4.13 The staff were advised that the referral needed to be sent to the LBBD, as this was where it was reported that the mother lived. A Multi-Agency Referral Form (MARF) was completed and sent on 27.06.16; the referral stated poor visiting, difficulty in contacting the mother by phone, unable to engage with her to offer support, and that the mother requested food when she came on to the unit, she appeared to have financial difficulties and general lack of preparation for the baby; a copy was also shared with the health visiting team in NELFT.   3.4.14 The referral was received at LDBD Multi Agency Safeguarding Hub (MASH) on the 29.06.16 and the case was considered the next day; it was recommended to be progressed to assessment, the reasoning for this was: concern about the neglect of baby, mother’s lack of concern for her child, Child C’s sibling’s missed health and developmental appointments, the need to consider her parenting capacity and a query about mother’s mental health. MASH spoke with the mother who                                             28 Postnatal clinics have been in operation since 2011, all women receive an initial home visit post discharge from hospital and then future postnatal care is arranged in collaboration with the women. informed them that she was staying with her sister (the maternal aunt) in Bow and would move back to her address in LBBD when Child C was discharged (it is now known that she no longer had this property, but professionals were unaware at the time).  The mother also said that Child C’s father was not involved, although she had discharged herself from hospital to the father’s address; she was described as being very defensive. In fact the mother was lying to professionals about her personal circumstances.  3.4.15. Background reports, referrals and the single assessments from Newham Children’s Services were downloaded from the case record system in Newham on 22 July 2016. There is no record to indicate that these records had been shared before or at the point of the case closure by NCS in May 2015 see para 3.3.28.   3.4.16. Staff on the Neonatal Unit facilitated a telephone conversation with HV3 and the mother, who agreed to attend the CHC the next day but she failed to keep this appointment.   3.4.17 Prematurity and giving birth at home with no medical assistance have been discussed in the SCR biennial reviews29 the impact that the needs of extra demanding pre-term baby places on parents, often compounded by the time spent apart from the new baby who is in the Neonatal Unit.   Learning Points:  • The importance of triangulating information with other professionals and not only accepting the information given by parents must be considered where there are other parenting engagement concerns.  • The importance of checking addresses at point of discharge particularly when leaving against medical advice.    THE LONDON BOROUGH OF BARKING AND DAGENHAM COMMENCE WORK WITH THE FAMILY  3.4.18. The case was allocated to SW3 (working for the LBBD) by the Team Manager in the Assessment Service and sets out an interim safety plan with clear tasks and a timeframe. This included seeing the children, establishing the role and whereabouts of the father, setting up a discharge planning meeting as appropriate and completing the single assessment by the 04.08.16.                                               29 Brandon et al, 2009:55 3.4.19. SW3 visited Child C the Newham Hospital Neonatal Unit and spoke with staff to find out more about the mother’s visiting pattern and to ascertain from the staff on the unit what would be the normal pattern of visiting by parents. The exact number of times that the mother had visited Child C on the Neonatal Unit was not provided at the time. SW3 also asked staff at what point would the possible abandonment of Child C be reached.30 The staff were unable to give any clarification at this point.   3.4.20. It is worth noting that following the allocation of the case all the work undertaken by SW3 took place out of the LBBD area, in Tower Hamlets, Newham and Essex.  3.4.21. On the 12.07.16 the mother failed to attend the Newham Hospital Neonatal Unit for a specific appointment; the mother needed to give consent for a blood transfusion for Child C and supply a blood sample.31 SW3 and the Children’s Safeguarding Advisor were present on the ward so that they could talk with the mother; she failed to arrive at the appointed time and eventually turned up nearly three hours late by which time they were no longer present on the unit.  3.4.22. SW3 contacted the mother by phone and arranged to meet with the mother the following day. SW3 heard a child crying in the background, the mother told her it was Child C’s sibling and asked her not to interfere. She challenged the mother about how difficult it was to contact her and that this was not helped with frequent changes of her mobile number (this was now her third number) the mother told SW3 that she should appreciate that she had answered the phone. SW3 asked the mother where she was currently living, she responded that she was living in Manor Park but refused to give an address but said that she also stayed with her uncle. SW3 told the mother that she was concerned about the following issues: infrequent visits to Child C, living at different addresses in different boroughs, providing two different surnames for Child C’s father, and that professionals had not seen Child C’s sibling; the mother was reported to be defensive and agreed to meet the next day. This was a good conversation that SW3 had with the mother and identified the concerns that she had about the mother’s lifestyle and her sharing different information with professionals.  3.4.23. SW3 (LBBD) did meet with the mother the next day and stated that the information gathered would be recorded as part of the single assessment that she was undertaking.  The mother had brought Child C’s sibling with her and it was agreed that SW3 would carry out a home visit at the mother’s address in LBBD. The mother agreed to                                             30 Child abandonment occurs when a parent, guardian, or person in charge of a child either deserts a child without any regard for the child's physical health, safety or welfare and with the intention of wholly abandoning the child, or in some instances, fails to provide necessary care for a child living under their roof. 31 Babies born prematurely may have a low level of red blood cells causing anaemia. this, even though she was no longer in this property, and failed to inform the social worker; this resulted in a wasted visit by SW3 to the property although SW3 was then able to confirm that the mother had vacated the property some 11 weeks ago because it was being cleaned and cleared of rubbish. This was a clear example of the mother giving false information and continuing to insist that this was the address that she was living at. SW3 attempted to phone the mother but there was no reply.  3.4.24. At this point SW3 had clarified that the mother did not reside at this Barking and Dagenham address however it was still not known where the mother and Child C’s sibling were living. During supervision of the case with the Team Manager (TM) it was agreed that the LBBD should continue to work with the family, as there was still no clear understanding of exactly where the mother and her children were living.  3.4.25. The LCPP32 state that in order to provide mobile families with responsive, consistent, high quality services, London local authorities and agencies must develop and support a culture of joint responsibility and provision for all London children (rather than a culture of ‘borough services for borough children’)   3.4.26. The Named Nurse for Safeguarding at NUH requested a Strategy meeting outlining the ongoing concerns re the mother’s minimal visits to see Child C; the visits were short, lack of provision of clothes and nappies, and multiple addresses and contact details. This is quickly followed by a request for a professional meeting; SW3 responded that she would update the staff following her assessment.  3.4.27 Child C was fit for discharge on the 19.07.16 and the Named Nurse for Safeguarding (NUH) contacted SW3 by email in order to plan a discharge meeting. The mother and Child C’s sibling visited Child C; the mother had again forgotten to bring in any clothes for Child C. It was noted that Child C’s sibling looked well and exhibited no apparent stranger danger awareness,33 and would go off with any member of staff (Child C’s sibling was just over two years old at this time). SW3 raised this concern with mother and that Child C’s sibling was walking on ‘tip-toes’ and there was possible language delay; the mother dismissed the concerns and threatened SW3 that she would ‘never take my children away’.  3.4.28. Supervision took place between the TM and SW3, the safety plan was reviewed; it was agreed that Child C should not be discharged from hospital until the situation about accommodation was clear and deemed safe. The mother had also failed to disclose details about the father of the children and no further information was known. It                                             32 Chapter 6.1.2. 33Stranger danger is the danger presented to children and adults by strangers. The phrase stranger danger is intended to sum up the danger associated with adults whom adults or children do not know.   was also agreed that if the mother’s pattern of behaviour continued then the case would be escalated through Child Protection Procedures. This was good practice with a clear instruction to escalate and recognition that the risks for the children were increasing.  3.4.29. The Team Manager had a telephone discussion with the police and it was agreed that the case did meet the threshold and a Section 4734 enquiry was commenced. The London Child Protection Procedures were not complied with. Specifically:  “The strategy meeting / discussion must involve LA children's social care, the police and relevant health professionals.”   3.4.30. The Strategy meeting / discussion should have taken place on the Newham Hospital Neonatal Unit given that Child C was still on the unit and it would allow the maximum number of hospital clinical staff to attend and make valid contributions. Given that staff on the Neonatal Unit made the referral it is difficult to justify why this did not happen and was a serious omission.  3.4.31. Discussion at the SCR panel meeting on the 28 June 2017 highlighted that East London Boroughs have adopted an approach of using an initial telephone call between CSC and police only as an initial response to Section 47 enquiries. Following this there may be a decision to call a S47 Strategy meeting/ discussion. However, there is a risk in this approach in that it can lead to an absence of multi-agency involvement in the investigation and assessment of the family.35The need for this is explicit in the pan London Child Protection Procedures. LBBD now use a telephone conferencing process (implemented in September 2016) so that all agencies are now routinely invited to and able to engage in strategy meetings / discussions.    3.4.32. The mother was still refusing to tell the hospital staff where she was living and accused them of lying about how frequently she had been visiting Child C. SW3 informed the mother verbally about the Initial Child Protection Case Conference (ICPCC) and also sent an invitation to the address in Tower Hamlets (maternal aunt’s home) where she was supposed to be staying after the baby was discharged from hospital. SW3 also arranged to see the mother at the maternal aunts flat the next day.   3.4.33. SW3 visited the property and met with the maternal aunt, the mother failed to attend, as she could not ‘drag Child C’s sibling out of bed so                                             34 A Section 47 enquiry means that CSC must carry out an investigation when they have ‘reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or is likely to suffer, significant harm’1. The enquiry will involve an assessment of the child’s needs and the ability of those caring for the child to meet them. The aim is to decide whether any action should be taken to safeguard the child. 35 London Child Protection Procedures (2016) Chapter.3.4.11. early in the morning’, the mother refused to say where she was staying. SW3 advised maternal aunt about the concerns, she stated that she did not know where the mother was currently staying but would accompany her to the ICPCC and give her support. SW3 then phoned the mother and arranged for her to attend CSC offices the next day. The meeting was scheduled for 1.30pm, the mother eventually turned up at 4.30, three hours late and was dismissive about the concerns that SW3 had, namely: how difficult it was to contact the mother, that she refused to say where she was living and would not give any details about the father of the children.  The maternal aunt accompanied the mother for this appointment.  3.4.34. A discharge-planning meeting was held on 2 August 2016 at NUH, Child C was medically fit to go home. This followed an intense period of communication between the Named Nurse for Safeguarding, staff on the Neonatal Unit and SW3. The mother attended the meeting, but the maternal aunt was unable to attend.  The discharge planning meeting should have been chaired by the team manager in line with procedures. This was the first planning meeting and was crucial in setting up the Child in Need plan ahead of the ICPCC.  3.4.35. A discharge plan was put in place and the mother was told that she had to stay with the maternal aunt (in Tower Hamlets) at this address and register with a local GP. SW3 and the new health visitor covering the address in Bow were to visit weekly. The mother had been given plenty of time to register with a GP but failed to do so. Prior to discharge the baby’s milk was changed from prescription milk to regular formula milk, this was because the mother still had not registered with a GP and therefore there was no ability for a prescription to be written and the milk dispensed. The Consultant Paediatrician was of the opinion that Child C’s milk could safely be changed to regular formula milk.  3.4.36. The actions of the discharge planning meeting were recorded in the CSC case records however, there is no evidence that these were distributed to the professionals that attended the meeting or sent apologies. This was a significant omission. The actions of this meeting could have been framed and given the status of the safety plan due to the level of concern that had unfolded during Child C’s hospital stay. This is made even more critical given that the mother was going to be living at an address in yet another authority  3.4.37. The use of a template for CIN plan: plans for children in need upon discharge from hospital should be recorded using the Child in Need plan template, distributed to the relevant professionals, and parent/s and recorded accordingly whilst also being chaired by a Team Manager is an action already taken by the LBBD.     Learning Points:  • Strategy / discussion meetings must follow the LCPP requirements and be based on multiagency engagement.  • Minutes of discharge planning meetings are critical and must be shared in a timely manner with all professionals involved in the care of the baby/ child being discharged from a hospital setting.    3.5.  Period 4: 5th August – 22nd August 2016    (Please see summary time line at Appendix 2 pages 91 – 92)  Agencies involved: • London Borough Of Barking and Dagenham Children’s Social Care • London Borough of Barking and Dagenham Legal Team • Neonatal Staff NUH • Metropolitan Police • North East London Foundation Trust (NELFT) Health Visiting Service  Child C is discharged from Newham University Hospital Neonatal Unit to an address in the London Borough of Tower Hamlets, the third London borough. This was the address of the maternal aunt. An Initial Child Protection Case Conference is held and Child C and her sibling are made subject to a Child Protection Plan under the category of neglect. A Threshold of Care and Legal Planning Meeting is held two days later due to mother’s expression of non-compliance.   This period of time highlights the challenges encountered by multi-agencies when working with mobile and avoidant families when trying to protect vulnerable children.    3.5.1. Child C was discharged into the care of the mother on Friday 5th August at about 6pm. Child C received  the first dose of the primary immunisations  after consent was obtained from the mother. The staff had initially suggested that Child C stay on the Neonatal Unit for 24 hours post immunisation but the mother was frustrated by the this and had made arrangements for a taxi to collect them.  The Consultant Paediatrician was happy for Child C to leave the unit. Primary immunisations are given in the community to premature babies and are not observed for a period of 24 hours. Routine advice was given to watch for signs of a fever and to give paracetamol if required.  3.5.2. There is a discrepancy about the actual date of Child C’s discharge from the Neonatal Unit; LBBD had the date of discharge as the 06.08.16 but Barts Health had it recorded as 05.08.16. This discrepancy about the discharge date is of some concern and that the discharge was over a weekend. It was planned that SW3 would visit at the maternal aunts flat on the Monday 08.08.16 where the family had agreed to stay post discharge.  3.5.3. Prior to Child C being discharged from the Neonatal Unit, it would have been beneficial for the mother to have been invited to stay on the unit overnight, ‘Rooming In’, thereby allowing staff to observe how the mother cared for Child C in a supported environment, i.e., whether there were signs that the mother was developing an attachment with the baby and so would be able to meet the needs of a premature baby with whom she had spent very little time. This was an omission and fell below expected practice.  3.5.4. At the point of discharge Child C was reported to be thriving and growing well but there was very little written documentation about Child C’s daily routine, including whether she was an easy or difficult baby to feed, if she was difficult to settle or whether she was happy and contented or cried excessively, and how frequently she was feeding over a 24 hour period. Child C’s weight was recorded as being just under the 25th centile36 Child C’s head circumference is recorded as 33.6cms but there was no record of her length. These growth measurements are an important baseline for professionals so that subsequent measurements can be recorded and plotted on the centile chart. The relationship of all these measurements will identify the need for further monitoring or investigations by professionals involved in her care.  3.5.5. On the 8.08.16 (the first working day following discharge) SW3 made a planned home visit to the Tower Hamlet address where the mother and her two children should have been living, they were not at home but the maternal aunt was and SW3 was invited into the flat. SW3 contacted the mother by phone, she stated that she was out buying milk and would be back in five minutes. SW3 observed that there was no change to the flat from SW3’s previous visit. There was no evidence that the family were living at this address. SW3 waited for 45 minutes; the mother turned up as she was leaving and had a deep cut above her right eye. When questioned by SW3 the mother attributed the injury to a blackout stating that she had a history of suffering from blackouts but refused to allow SW3 to contact her GP1 for further information.  The mother had reportedly been referred to the Neurology Team by GP1 to investigate the cause of her reported blackouts. However, it is unclear whether a referral was made, or the mother chose to give this information to deflect further questioning                                             36  UK WHO growth charts 2016 from the professionals.  The mother’s GP medical records have not been available for this SCR despite numerous attempts to locate them. GP1 retired and the patients registered with the practice were allocated to other local practices.  3.5.6. The arrangements in the discharge plan quickly became problematic; the mother and children were not at the maternal aunt’s address or with the uncle.  The uncle reported to SW3 when she attempted a home visit that he had not seen the mother for 18-24 months (this was new information and possibly not accurate) and was also reported to say that the mother had undefined mental health issues.  3.5.7. Shortly after this visit the mother contacted SW3 by phone; the mother was aggressive and difficult and swore at SW3; the mother stated that SW3 had no right to go to see her uncle without her permission. It is now known that the uncle contacted the maternal aunt who contacted the mother immediately after SW3 left, to tell her that she had visited; this indicates that there was some level of communication between members of the wider family about professionals’ visits.   3.5.8. SW3 pursued the line of enquiry as directed by the team leader to establish the whereabouts and role of the father. SW3 contacted the community midwifery team and obtained the discharge address that the mother had given the hospital on 2 June 2016 when she took her own discharge, reportedly to the father’s address in Newham. SW3 made a home visit to this address but there was no response (we now know that this was the wrong flat number) The mother continued to state that she was staying at the address in Tower Hamlets with the maternal aunt to SW3. The invitation to the ICPCC was sent to this address, as this was where the mother was supposed to be staying.  3.5.9. The ICPCC was held on the 15.08.16 the mother, Child C and maternal aunt were in attendance. It was clear that the discharge plan was not working; neither Child C nor her sibling had been seen in the past ten days, by any professional, since discharge from the hospital.  The Police were present at the ICPC, information was requested regarding the mother and maternal aunt. The mother who attended the conference refused to give any information about the father except his name.  This made it difficult for the Police, or other agencies, to undertake checks. Further work was remitted to the social worker as part of the interim safety plan (see para 3.4.18).   3.5.10. Child C attended with her mother; a friend was reportedly looking after Child C’s sibling. (The conference had to be stopped as Child C was hungry and the mother did not have any milk with her, a ready-made feed was obtained).  3.5.11. Child C and her sibling were made the subjects of a Child Protection Plan (CPP) under the category of neglect. During the conference the mother made her unwillingness to comply with the plans very clear; she presented as resistant and antagonistic and stated that she would not comply. This was very concerning and the Chair of the conference recommended that in light of this, that SW3 and the TM review the situation within 24 hours and escalate as appropriate.   3.5.12. The London Borough of Barking and Dagenham should have shared that the children were made subject to a CPP under the category of neglect, with the two London Boroughs where it was known the mother had connections and possibly lived; namely Newham and Tower Hamlet. This was an oversight but the responsibility for the CPP remained with LBBD irrespective of where they were living at this point.  3.5.13. The Team Manager decided to convene the Threshold of Care and Legal Planning Meeting (TCLPM) following the recommendation made by the Chair of the ICPCC. This was a direct response to the escalating risks and the increased concern about how to safeguard the children.   3.5.14. The TCLPM remit is to decide based on a robust analysis of the level of assessed risk whether:  ➢ it is in the best interests of the child to provide a further period of support for the family with the aim of avoiding proceedings;   or  ➢ Whether proceedings should be initiated immediately.  Child C and her sibling were referred for discussion at the Threshold of Care and Legal Planning Meeting (TCLPM) on 17th August; two days after the ICPCC, this was timely and resulted in approval for care proceedings to be issued.  3.5.15. A proposed Public Law Outline (PLO) plan identified a number of further assessments to be undertaken; including a psychological assessment and a drug test, this is the first time that drug use has been considered as a possibility, apart from the routine enquiry during her pregnancies, which she answered no to. The safeguarding plan also made it clear that the mother, Child C and her sibling must live at the maternal aunt’s address in Tower Hamlets until all proposed assessments are complete, that the social worker and health visitor will visit on a fortnightly basis to assess the development and progress of the children and that the mother signs the safeguarding agreement.  3.5.16. The father of the children was named in the minutes (although the first name is different) and the mother reported that he had Parental Responsibility37 although SW3 stated that the mother had refused to give the father’s details to professionals. SW3 had asked the mother to provide a copy of the children’s birth certificates in order to see if the father is named, the mother did not provide them at this point in time.  3.5.17. The following day (18.08.16) the maternal grandmother contacted SW3 to say that she would be able to care and support the family. The involvement of the family came at a critical point when a decision had been made to instigate care proceedings and was accepted by the Team Manager and agreed by the Group Manager (a recording is made in the case files by the TM) as providing an appropriate alternative arrangement and was seen as being a positive source of support, which should be tried out.  3.5.18. As a result of this development the maternal grandmother and maternal aunt met with SW3 and the TM on the 19.08.16. At this point the mother was not with them. They left the offices and returned with mother. The maternal grandmother had put herself forward to offer accommodation and practical and emotional support, as she stated that she did not want to see her grandchildren go into care. The maternal grandmother proposed that the mother and her two children move to Essex and stay with her in her two bed roomed flat. It was made clear at this meeting that the maternal grandmother must contact SW3 and the Police if the mother left Essex at any time.  3.5.19. The TM made a case recording as management oversight about the maternal grandmother putting herself forward to offer accommodation, practical and emotional support plus monitoring. Following the initiation of safeguarding checks, the Group Manager agreed the plan for the family to move to Essex.  The Group Manger reiterated in an email to SW3 that there must be a strong commitment by the mother to adhere to the CPPs and that they must remain in Essex.  3.5.20. However, given the fact that the maternal grandmother had herself been a victim of domestic abuse and that the mother had grown up in this household further questioning about whether the maternal grandmother was capable of supporting and managing the situation and working with SW3 could have been considered in more depth. It was reported by SW3 during an interview that the maternal grandmother presented as a plausible individual who understood the context of the situation and said she would be able to manage the mother and offer support to the family. It was also noted that the maternal grandmother had removed herself and her children from the perpetrator and was currently living in Essex with her youngest child (see para 3.11.5). It could not have been known at the time that this                                             37 Jointly registering the birth of the child with the mother, getting a parental responsibility agreement with the mother or getting a responsibility order from a court, in the case of unmarried parents. decision was made that the maternal grandmother would fail to inform SW3 when the mother left Essex with her two children.  3.5.21. A risk assessment of the maternal grandmother and maternal aunt was completed, and the view taken that the maternal grandmother was able to emotionally support the mother and her two children. This was a temporary arrangement and further assessments would be undertaken at a later stage.  An assessment should include both the capacity and ability of the person who has put themselves forward as well as considering the potential interaction and sustainability of the relationship they already have with the birth parent (the mother); in this case daughter and sister (the maternal aunt).    Learning Points:  • Careful consideration should be given for parents with poor visiting patterns to complete a Rooming-In to allow an assessment of the ability of the parents to care for a premature baby and observe the development of bonding.  • Staff need to be reminded about the importance of recording vital measurements and developmental milestones, feeding regimes and management of babies leaving the neonatal unit in order to have a baseline to assess growth and development  • When children are subject to a CPP in one borough but known to be mobile this information must be shared with other boroughs or local authorities where they have previously lived/ or should currently be living.  • An ICPCC is an invaluable forum for the sharing of information especially regarding other relatives, associations or absent fathers.    3.6.  Period 5: 22nd August – time of incident resulting in the death of Child C.    (Please see summary time line at Appendix 2 pages 92– 94)  Agencies involved: • LBBD Children’s Services • LBBD Legal Department • Metropolitan Police • Essex Children’s Services • Essex Housing Department • An Essex Clinical Commissioning Group • A local Provider Health Service in Essex • London Ambulance Service  Following the approach by the maternal aunt and grandmother to the London Borough of Barking and Dagenham Children’s Social Care, the mother and her two children move to Essex to live with the grandmother.   This period highlights the challenges to safeguarding systems when family members are not transparent with the agencies involved and fail to adhere to the safeguarding plan in place; resulting in an escalation of risks to vulnerable children.  3.6.1. SW3 instigated safeguarding checks with the Police regarding the maternal grandmother and the accommodation in Essex was then checked for suitability. The maternal grandmother lived in a two bed roomed flat with her youngest 16 year old son, he was happy about his sister and her two children coming to stay.  Child C’s sibling was going to sleep in his room, as there were bunk beds. It was reported that the maternal grandmother worked nights but would be around during the day to offer practical and emotional support and monitor the mother with her children.   3.6.2. The family moved to Essex by taxi on 22.08.16, they were collected from a street in the Manor Park area; it was reported that the taxi driver had to wait for almost two hours, as the mother was not ready when he arrived. We now know that in fact the address that was shared with the taxi firm was the wrong address and that the mother was possibly collected from the street.  3.6.3. SW3 notified Essex Children’s Services on 23 August 2016 that the children were the subject of Child Protection Plans and were now resident in their area.38   3.6.4. The case was reviewed by the TCLPM (24.08.16), the decision was not to continue with care proceedings and directed that the CPP continue and that a safeguarding plan be put in place in which the mother, Child C and her sibling lived at the maternal grandmother’s address and that the social worker must be informed if she moved out with the children. They also considered whether this plan could be held safely as it would be at least 4-6 weeks before Essex Children’s Social Care would be able to review the case, as the accommodation was temporary. It is unclear how this was communicated to the family apart from an email by the Group Manager to the TM and SW3 reiterating the fact that the mother and                                             38 Chapter 6:London Child Protection children must remain living in Essex at all times.   3.6.5. The mother registered herself, Child C and Child C’s sibling with a local GP3; mother gave her last address as the flat in LBBD, despite the fact that she had never lived at the address; the mother continued to lie about her personal circumstances. The registration form specifically asked whether any other services were involved with the family or young person e.g. Social Care or Child and Adolescent Mental Health Services (CAHMS). The mother circled Yes on Child C’s form for Social Care but no further details were provided or requested by the practice staff. The mother did not note any social care involvement with Child C’s sibling.   3.6.6. The current patient registration form used by this practice did not specifically contain a tick box to ascertain if the children are subject to CPPs, or if they were Looked After Children (LAC).  Currently there are no standard forms widely used in Primary Care when new patients register that asks specifically whether there is active social care involvement, including if children are subject to a CPP. At the point of patient registration the practice is relying on the parents sharing the information, as there may be some delay in previous records and notes being available. When families have a history of mobility and avoidance the potential for selective information to be given is increased.  3.6.7. On the 1 September 2016 a letter was sent by SW3 to the GP3 surgery that stated that the children were subject to a plan under the category of neglect at LBBD and requested that the GP surgery provide detailed information about all contacts made with the mother and children and to provide this within the next 72 hours due to significant concerns that the LBBD had regarding the children. A response was sent back to SW3, on the 5 September stating that the family were registered with the practice and had contacted the mother regarding outstanding immunisations for the children. At this point neither children had been seen by the GP in Essex nor had they attended the local Accident and Emergency Department.    3.6.8. However, the original letter was not embedded within the health records of the children or mother. The IMR author for the GP3 Practice was unable to ascertain why this was the case and surmised that the failure to scan the letter in to the notes was as a result of human error. This particular practice has different sites, all letters/ faxes and correspondence go to the main site to be scanned and then tasked to individual GP’s to read and action.   3.6.9. Action has already been taken by the GP practice to mitigate against this happening and amended the Standard Operating Procedure (SOP). However, the consequence of this omission was that there was no safeguarding alert placed on the EMIS IT system alerting all professionals, within the GP practice, with access to the system that the children were subject to a CPP under the category of neglect. Whilst practice staff were unaware of the child protection plan, the staff working within the surgery did not have any concerns regarding the care or presentation of the children; presentations were positive and the children received their outstanding immunisations.  3.6.10. The mother had been previously registered with this practice (in Essex) until 2010 when she returned to London. It would also appear that Child C’s sibling was registered here in 2014 prior to the alleged move into the temporary accommodation in LBBD.   3.6.11. Previous GP records for the family were unavailable39 from GP1 in Newham see para 3.5.5. This would suggest that Child C was never registered with a GP whilst living in Tower Hamlets at the maternal aunt’s address. Despite numerous efforts to locate the records for both the mother and Child C’s sibling, they have not been located; this has resulted in a gap of information that the mother may have shared with her GP1 in Newham. As a consequence of this potential key information/ learning has been lost.  3.6.12. On the 24.08.16 a transfer in telephone call was made by the health visitor (HV3) in NELFT to the duty health visitor in a local provider health service in Essex. This duty health visitor allocated the case the same day and the assigned health visitor (HV4) made contact with the mother and booked a planned home visit on the 01.09.16. The movement-in visit was required to be completed within 10 working days.40   3.6.13. Although health records were sent to the local community provider a copy of the CPP was not included. The minutes of the ICPCC were circulated to all professionals on the 19 September 2016, 22 workings days later. The standard is 20 working days but the period did cover a bank holiday.  However, information about the family and that the children were subject to Child Protection Plan in LBBD under the category of neglect was passed on verbally to the safeguarding network in Essex. In order for health visitors to undertake a robust assessment and understand the context of the family and the rationale for the children being subject to a CPP under the category of neglect, all available information and past records should be read. If all of this information was not available to HV4 then there is an expectation that contact would be made with SW3 in LBBD to discuss the case and ask for a copy of the CPP to be sent immediately via a secure email address.41 This did not occur.   3.6.14. The home visit on 1 September by HV4 focused on the sleeping                                             39 Transfer of previous GP records should not exceed a maximum delay of 8 weeks, however NHS England was aware of a significant backlog within the contracted notes transferral service that affected a significant volume of patient records. 40 A Local Provider Health Service Essex 41 Each health professional has a NHS secure email address. arrangements of Child C, there was no cot and it was reported that she either slept in the car seat or with the mother; HV4 advised the mother to line a drawer and put Child C in this to sleep until a cot could be obtained. Child C was weighed by HV4 and the weight was recorded in the Parent Held Record (Red book) as stated in the IMR for the local community provider. However the weight was not recorded in the HV records and it is therefore not known what the weight at this time was. HV4 did inform SW3 in a telephone call that the children had been weighed and there were no concerns. The importance of recording and plotting weights and measurements on the centile charts should be reinforced with all staff that come in to contact with children and young people. This was the first time that Child C had been weighed since discharge from the Newham Hospital Neonatal Unit on 5th August and was an opportunity to assess whether she was continuing to grow and thrive. This was also highlighted as a learning point for Barts Health at the point of Child C’s discharge from the Neonatal unit see para 3.5.4.  3.6.15. The mother reported that Child C cried more than their older sibling; though this information was not explored any further. This was an opportunity to explore with the mother what Child C’s routine was and assess whether the mother had realistic expectations of looking after a premature baby. HV4 commented on the cramped conditions within the flat and that it appeared that the maternal grandmother was not very happy that the mother and her two children were staying with her, this was useful information given that it was the family that had suggested that the mother move to Essex with her two children and stay with the maternal grandmother who was recorded as supportive of the plan.   3.6.16. HV4 contacted SW3 later that day; the only information that was shared concerned the lack of a cot and that the children had been weighed and there were no concerns as recorded in SW3 case records. HV4 requested the CPP to be sent, SW3 informed her that she would bring a copy to the Child Protection core professional group scheduled for the 06.09.16 at the maternal grandmother’s flat.  Although the core meeting was scheduled for five days later, it would have been best practice for the CPP to be sent that day.  3.6.17. The Core Group took place on 6th September 2016.42 The mother, maternal grandmother, Child C and their sibling, SW3 and HV4 were present. This was the first time that SW3 saw the mother, Child C and her sibling, and the maternal grandmother in their ‘home’ environment in Essex. There were no minutes of the Core Group meeting. This was a significant omission. This meeting was a key opportunity for professionals to review the CPP and the safeguarding agreement whereby the mother and her two children must stay in Essex, and if she did leave then the maternal grandmother must                                             42 The core group was held late due to children’s change of address and family living out of borough. notify the social worker and police immediately. It is reported that the mother and maternal grandmother were aware of this expectation. What is not clear is how this was communicated to the family - either in writing or verbally. The Core Group provided an opportunity to remind all present about the expectations and conditions set out in the safeguarding plan and CCP. This would have provided clarity to all parties involved about the rules and the escalation if the plan is not being adhered to. Because of the lack of minutes of the Core Group it has not been possible to ascertain whether the conditions of the safeguarding plan were reiterated verbally at this time. HV4 stated that she was unaware of this stipulation when interviewed by the IMR author. The importance of recording and documenting key meetings has been identified and is a key learning point for all agencies involved. The LBBD has also identified the need to strengthen the safeguarding plan/agreement by using a model template which sets out the expectations of the parent/s and any other family members involved; the services to be provided; arrangements for review; and the contingency plan if the agreement is seen not to be working.   3.6.18. During the time that the family were supposed to be living in Essex SW3 made two home visits, the 6th and the 19th September. The 6th was also when a Core meeting took place. SW3 also made contact by phone on four occasions.  3.6.19. It was noted that Child C’s sibling interacted positively with the mother and grandmother, whilst Child C was asleep in a car seat. The mother confirmed that the children were due to be seen by GP3 the next day and that Child C’s sibling was up to date with the immunisation schedule. The mother showed SW3 Child C’s birth certificate; the father’s name was not on the certificate.  At this meeting it was established that the mother still had not presented herself to the housing department in Essex and it was agreed that the maternal grandmother would accompany her to the housing department in the next few days. At the end of the meeting HV4 took a signed form by mother, which allowed GP3 to share information with social care.  3.6.20. Child C was examined by GP3 on the 07.09.16, it was reported that Child C was well and had put on weight according to her mother. At this time GP3 was unaware that both children were subject to a CPP, as the records were not flagged on the IT system as outlined in para 3.6.9. It was recorded that GP3 did not have any concerns about the children. The mother did bring Child C for her routine 2nd dose of primary immunisations and an appointment was given for the 3rd dose which was due to be given in four weeks time.  3.6.21. On 8th September, two days after the core meeting (on 6.09.16) the LBBD SW3 attempted to speak to the mother by phone to get an update about the contact with the Housing Department; a voice mail message was left for the mother to respond. Six days later on 14th September 2016, SW3 again attempted to talk to the mother on the phone; again there was no response. At this point SW3 contacted the maternal grandmother, who informed her the children had left with their mother on 12.09.16 to go to London and were due to return on Thursday 15th September 2016.   3.6.22. On Monday 12.09.16 the mother sent a text to HV4 that she needed to go out and could she come to the flat before 3pm. It is reported that the mother was relaxed and chatty during this visit. We now know that this was the day that she left for London accompanied by her two children.  3.6.23. This development was in breach of the safeguarding agreement made to safeguard the children; and after SW3 discussed the situation with her Team Manger she attempted to phone the maternal grandmother to request that she report to the Police that the mother and children were missing.  As there was no one answering a message was left on her answer phone (see para 1.3.18). As a consequence, SW3 next visited on 19 September (the third working day after the breach) to make a Child Protection home visit to the family in Essex. The fact the mother had taken the children back to London and that the maternal grandmother had failed to inform SW3 called in to question whether the basis of the CPP was fully secure and safe. It might have been considered appropriate to alert the TLPCM of this development or take other action.  3.6.24. SW3 followed up this breach when she made the unplanned home visit on Monday 19.09.16. When SW3 arrived the mother was about to leave for an appointment with the Practice Nurse for Child C’s Rotarix.43 SW3 asked the mother if she could accompany her to the GP surgery but she refused so SW3 took the opportunity to meet with the maternal grandmother, with whom she felt that she had a reasonable relationship.   3.6.25. SW3 was reassured during the visit when she was shown a card with the details of the housing officer on it, by the maternal grandmother When the mother returned from the GP surgery she appeared to be much calmer, maintained eye contact, accepted that there needed to be changes made and appeared to be very positive about the situation, this was in stark contrast to any of the previous meetings that she had with the mother.  Child C’s sibling was observed playing with toys and was particularly fond of tractors, played ‘peek- a- boo’ from behind the sofa and was seen laughing and interacting well. SW3 felt that the sibling did have a relationship with the mother but was always looking for affection and would climb onto adults’ laps. Child C was often asleep or sleepy on the visits that the SW3 made to Essex.                                             43 Oral vaccine against rotovirus, a common cause of diarrhoea and sickness, administered at 8 and 12 weeks.  3.6.26. This was the last time SW3 saw the family. It is now known that immediately after SW3 left the maternal grandmother’s home the mother left with her two children and took the train back to London (see para 3.10.6.)   3.6.27. HV4 received a text from the mother on the 26.09.16, ‘I can’t remember if we have an appointment but if we do can we please reschedule it. Thank-you.”  HV4 responded by text, offering an appointment for the next day; there was no response from the mother. On the 27.09.16 HV4 received another text from the mother ‘it is OK for you to come tomorrow anytime will be fine” HV4 responded by text offering a 4pm appointment for the following day, the mother sent a text back at 12:19 ‘Yes that’s fine’.   3.6.28. It is now known that the family were in London from the 19th and again the maternal grandmother had failed to inform SW3 as stipulated in the safeguarding agreement. HV4 was unaware that the family had left for London immediately after the previous re-arranged visit on 12.09.16. HV4 was also unaware of the safeguarding agreement that was in place (see 3.6.17), specifically that the mother and her two children must remain in Essex, and if they left or attempted to leave then SW3, or the police, must be informed immediately. This arrangement was not included within the CPP at the time of transfer in to Essex.  3.6.29. On 28th September 2016 the mother Child C and their sibling boarded a London bus. During the journey, the mother asked for help as Child C had stopped breathing.  Emergency services attended the scene and Child C was taken to NUH where she was pronounced dead, non-accidental injury was suspected; the parents were subsequently arrested on suspicion of murder.   Learning Point:  • Minutes of core meetings must be shared with all professionals involved in the care of the children in a timely manner.  • Written safeguarding plans should be discussed with professionals at point of movement in to new local authority  • Staff should be reminded about the importance of sharing information/plans   • Staff should remain curious at all times particularly when the attitude or behaviour of an individual changes dramatically and may appear to become more compliant.  • The importance of uploading CPP onto GP records and putting a safeguarding alert on all the records so that all professionals with access to the records working in the practice have this information (SOP in place). This has already been actioned   3.6.30. The next part of the report provides the analysis of items set out in the Terms of Reference (TOR) agreed by the Serious Case Review Panel on 28.04.17. Due to the number of different agencies and professionals involved in the provision of care to the family, the named agency / organisation is set out for a clearer and a better understanding.   3.6.31. There is also a section where learning that has emerged from the SCR that is not covered by the TOR will be discussed and analysed. The recommendations made in this section are for all the Safeguarding Children’s Boards involved with this case, unless specifically directed to an individual Board. The individual recommendations made within the Independent Management Reviews are included in Appendix 3.  3.6.32. The areas set out for analysis by the original TOR are:  1. The level and extent of agency engagement and intervention and whether his was appropriate to the assessment of parent’s ability to provide adequate care and supervision of Child C and her sibling.  2. The recognition of safeguarding factors by all agencies and how these were addressed.  3. Were practitioners aware of the needs of the children in their work, and knowledgeable about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare.  4. The quality of assessments on which decisions and actions were taken.  5. Whether there were any factors in the history of any adults that indicated they posed a risk to children.  6. Whether race, religion, culture was a factor in this case and had been fully considered.  7. The extent and quality of partnership working among key agencies and across local authority borders.  8. The effectiveness of working arrangements and information sharing and communication between all professionals and whether this could have been improved.  9. The existence of any factors relating to the ‘capacity and climate’ within agencies which may have impacted upon practice in this case (i.e. vacant posts or staff on sick leave etc  10. In addition to the above the review should consider learning for both the individual agency and how agencies work together through the BDSCB.  3.7. The level and extent of agency engagement and intervention and whether this was appropriate to the assessment of parent’s ability to provide adequate care and supervision of Child C and her sibling.  3.7.1. Throughout the period under review, there was a pattern of poor engagement by the mother with all agencies; the mother engaged almost entirely on her own terms or when professionals informed her that the concern had increased to such a level that further intervention was deemed necessary e.g. the concerns raised by the staff on the Newham Hospital Neonatal Unit that resulted in the Initial Child Protection Case Conference and the intervention of the extended family to prevent care proceedings for the children. At the very least this demonstrated that the mother did not lack an understanding of what was required but showed a very significant will not to work with professionals in the best interests of her children.  3.7.3. In this case the mother’s behaviour included: avoidance,44ambivalence,45 confrontation46 and deceit. To employ appropriate support, and challenge parents when non-engagement or disguised compliance occurs, professionals need to be supported through: adequate supervision, training and management oversight. The way in which the mother sought to “manage” professionals in this situation included:  ➢ Cancelling and re-booking appointments  ➢ Early self-referral to Midwifery Services and then not attending appointments  ➢ Attending appointments at the incorrect time  ➢ Doing just enough to keep professionals at bay  ➢ Moving from one address to another and refusing to give details                                             44 When a parent fails to turn up, is unavailable for planned visits or cutting visits short. 45 When a parent is late for appointments and repeatedly make excuses for missing them 46 When a parent disputes the facts and argues with the professional.  ➢ Lying about living in LBBD even when the tenancy had been cancelled  ➢ Frequent changes of mobile phone numbers  ➢ Agreeing to live with maternal aunt following Child C’s discharge from the Newham Hospital Neonatal Unit and then failing to do so.  ➢ Failure to disclose father’s details  ➢ Giving a variety of reasons why it has been difficult to keep appointments, Child C’s sibling sleeping, unwell or couldn’t find anyone to look after them  ➢ Aggressive / defensive responses to professionals and calling them liars  ➢ Becomes more compliant when threatened with more invasive action  3.7.4. Although professionals challenged the information that they were being given, the meetings and telephone conversations quickly became hostile and aggressive and the mother was verbally abusive on more than one occasion. The danger of this is that the focus moves to trying to maintain a relationship with the mother and in doing so the ‘lived experience’ of the child(ren) becomes lost or diluted.   3.7.5. Brandon et al (2008)47 note that disguised compliance, by its very nature, makes it difficult for professionals who are involved with a family to maintain an objective view of progress in safeguarding the welfare of a child. Disguised compliance ‘wrong foots’ professionals and can prevent or delay understanding of the severity of harm being experienced by children in the family.  3.7.6. At the most basic level, disguised compliance harms children as it prevents professionals being able to properly assess the risks to children in the household. Professionals are unable to progress work due to a lack of access or where the level or quality of contact with the family is so limited it makes ongoing work impossible. All disguised compliance involves resistance to change and an inability or unwillingness on the part of parents and carers to address risks to their child. Assessments of the parent’s capacity and willingness to change should therefore be carried out alongside assessments of the child’s life.                                             47 .(http://webarchive.nationalarchives.gov.uk/20130401151715/ https:/www.education.gov.uk/publications/eorderingdownload/dcsf-rr023.pdf)  3.7.7. The mother appeared to try and control different relationships with the professionals involved with her and her family. A range of factors including: experience of seeking help in the past which will influence the present, trust and attachment, experience of authority, any cultural racism/ discrimination or something to hide will all have an influence on how a family or individual will engage. The influence of other adults who are ‘behind the scenes’ including ‘shadowy males’ must also be considered. With the benefit of hindsight what might have been perceived by professionals as disguised compliance or non-engagement at the beginning; it is now evident that the mother and her extended family were giving false information and on occasions lying directly or failing to pass on information in the best interests of the child(ren).  3.7.8. There is a significant need to consider the appropriate levels of support, guidance and challenge for front line professionals (in all disciplines) to ensure that they are protected and supported to recognise and work with the often overwhelming feelings that working with families such as this may evoke.  3.7.9. Professionals need to be able to distinguish between disguised compliance and typical behaviour in families with complex/chaotic needs. Within the context of family intervention work, multiple and complex needs is sometimes used to refer to families who have often reached the stage where they are presenting with externalised behaviours which have negative and very disruptive consequences for themselves and those around them such as persistent offending behaviour or persistent anti-social behaviour. Other terms such as troubled families and families with multiple problems are also used to describe families with multiple and complex needs.48 Front line workers need particular support and to be advised of strategies and practical approaches to cut through any deliberate obfuscation.  Policy needs to be clear and followed to both safeguard children and workers in these situations.  3.7.10. The quality of the assessments undertaken by both Newham and LBBD were significantly hampered by the lack of engagement by the mother. Her resistance to work co-operatively with professionals made it difficult to fully grasp the lived experiences of the children.  3.7.11. When LBN were undertaking the assessments the level of concern for the mother, the unborn child and subsequent sibling of Child C was at a lower level and it was determined that it did not meet the threshold for statutory intervention.  Though the pre-emptive closure of the case on 15th May 2015 was regrettable  3.7.12. Following the birth of Child C and the referral by staff on the neonatal                                             48 Providing intense support for families with multiple and complex needs unit at Newham Hospital to the LBBD the concerns escalated about the mother’s behaviour and in particular the refusal by the mother to come to the hospital to give blood, the poor visiting pattern and short duration of these visits and most importantly the perceived lack of interest/ urgency in taking Child C home.  3.7.13. The mother denied any on-going relationship with the father and refused to say where he lived. She shared the name of the children’s father with the midwifery service, albeit two names were given, and she also stated that they were no longer in a relationship but that he was supportive. Further exploration of the relationship and of the expected role of the father did not occur. The father’s shadowy presence continued throughout the review period, though he visited the post-natal ward to care for Child C’s sibling and came to see Child C on one occasion whilst she was on the Neonatal Unit. It is assumed by the ambulance crew that it was the father that was seen when they attended his home address in response to a 999 call; this may suggest that this was where the family lived for most of the time. This information was recorded by the single agencies working with the family, but was not shared, analysed or properly pursued. The two names provided by the mother for the father had the same first name and one of the second (family) names corresponded to that of Child C’s sibling. The potential risks the father posed (and possible strengths he offered) remained unassessed for the duration of the professionals involvement. This was a significant omission.  3.7.14. Engagement by the mother in the antenatal period was poor for all three of her pregnancies. During Child C’s pregnancy the mother attended three out of a possible 14 appointments; though she knew that the risk of having a premature birth was higher, yet she still failed to attend. As previously discussed the mother was not being cared for by the Acorn Team at NUH for vulnerable women during this pregnancy because it was thought that she had been given temporary accommodation and there was no longer involvement from Newham CSC. Poor antenatal attendance is of concern and should have been flagged, the mother appeared to do just enough to convince the professionals that she was complying with her care and that she had mitigating circumstances to explain why she failed to attend her scheduled appointments.   3.7.15. This pattern of poor engagement continued with the health visiting service, firstly in ELFT and continued in NEFLT. Contact was mainly by phone or attendance at CHC, pre-planned visits were either cancelled or there was no reply. As a consequence of this, there was no assessment within the home environment. The initial assessment made by the HV1 (ELFT) was for the highest level of support; this was quickly changed to the Universal Service following attendance at the child health clinic (where she was seen by HV2). When the family moved to the LBBD this resulted in the health visiting service being provided by NELFT. The poor engagement continued and any contact that was made was either by phone or at the clinic (a total of eight health visitors were involved) because of staff shortages, the use of bank staff and that there was no named health visitor for the family. Consequently, there was no assessment of the home environment or consideration of the lived experience of the child.   3.7.16. Following the premature birth of Child C and her subsequent admission to the Neonatal Unit at NUH, staff became increasingly concerned about the lack of visiting by the mother and difficulty in contacting her. The staff correctly identified that the mother’s ability to provide adequate care to her children needed to be further assessed. A referral to LBBD Children’s Social Care was made by staff on the Neonatal Unit and was appropriately responded to. SW3 was allocated to the case and agreement via a strategy discussion with Police, to take the case to an Initial Child Protection Case Conference within the 15 days time frame. There was an opportunity to make some assessment of the mother’s parenting ability, in particular caring for a premature baby, by inviting her to ‘room-in’ on the Neonatal Unit and care for Child C for a period of time prior to discharge, this did not happen and was an omission. It is unclear as to whether the mother was asked to ‘room-in’ and declined or the mother was not asked. The ability to carry out a robust and meaningful assessment was sabotaged by the mother by avoiding planned visits by SW3 following discharge from the hospital and prior to the ICPCC but was not assiduously pursued by the concerned professionals at the time. Both children were made subject to a CPP under the category of neglect; and due to the mother’s behavior and expressed view that she would not comply with the plan an urgent review was carried out 24 hours later to ensure that the children were safeguarded.  3.7.17. The Team Manager decided to convene the Threshold of Care and Legal Planning Meeting (TCLPM) held on 17 August 2016 due to the escalating risks and the increased concern about how to safeguard the children. The meeting resulted in approval for care proceedings to be issued.  This was timely and met practice standards.  3.7.18. When the mother and the children moved to Essex there appeared to be some initial better engagement by the mother with the health services. The health professionals worked with the mother to ensure that the children received their outstanding immunisations, and in the case of Child C’s sibling a developmental assessment. A family health needs assessment was not completed whilst the family resided in Essex; they were there for just under five weeks.  3.7.19. What is clear over the course of the time period of this review is that the mother was prepared to lie to the professionals working with her. This included denial of knowing where the father lived, pretending that she was still living in the flat In LBBD 11 weeks after the tenancy had been cancelled. It would also appear that the maternal aunt and grandmother did not inform the professionals engaged in safeguarding the children when the mother was not living at the agreed address.    3.7.20. Mobile or transient families are often able to avoid contact with professionals and as a result individual agency’s systems do not always enable sufficient focus to be maintained on the needs of vulnerable children. When parents are also rude and verbally aggressive to practitioners the management of the case becomes even more challenging. The use of a chronology identifying missed appointments and untruths should have formed part of the historical information available to professionals working with the family so they could triangulate such information and at least catalogue the extent and nature of the “non-compliance”. While this historical information should not determine current thinking it should have significant impact on decision making.   Learning Point:  • The use of chronologies to identify missed appointments and untruths should be used in cases to support the management and decision making to better safeguard children.  • The inability to complete a meaningful assessment when parents do not engage means that the risks to the children cannot be properly assessed  • The focus of the professionals must remain on understanding the lived experience of the children, what was their everyday life like?    3.8. The recognition of safeguarding factors by all agencies, with the exception of police and how these were addressed.  3.8.1. There were a number of safeguarding factors evident in the mother’s history and her lifestyle choices that she made. These included:  • The mother presented as a young homeless women living between extended family and friends in East London.   • The mother had moved with her own mother (maternal grandmother) and two younger siblings to a Women’s Refuge in Essex due to domestic abuse and she had also alleged that her father and brother had assaulted her when she returned to live in London.  • The mother also made an allegation against ‘her boyfriend’ (the father of the children) in 2013.  • At the time of her first pregnancy she reported that: she was no longer in a relationship with the father of the unborn child, unemployed and in receipt of benefits.   • She already had a poor attendance at health appointments and chose what information she was prepared to share with professionals involved with her care.   • She had three premature births at home in the space of three years. It is unclear as to whether the professionals considered whether there was any link between these and an environment of domestic abuse.  3.8.2. It is acknowledged that this list is drawn up with some elements of hindsight, though many of those issues were known about, sometimes in individual settings, at the critical decision making opportunities.  3.8.3. During two of the mother’s pregnancies she was under the care of the ‘vulnerable women’ midwifery team at NUH. Her attendance was poor and she seemed to ignore advice given by the midwives. It is difficult to comment further about whether safeguarding factors were considered by the team, due to the unavailability of the records. However, there were a number of factors including:  •  the mother’s history including self reported early miscarriages  • chaotic and mobile lifestyle  • poor attendance at antenatal appointments  • history of domestic abuse  that were significant enough that professionals should have made plans as to how the case would be managed and escalated as appropriate. There was no referral made to NCS by the midwifery team, but this may have been due in part to the premature birth of Child C.  3.8.4. The staff on Neonatal Unit at NUH were very proactive in identifying safeguarding factors and communicated well with the Named Nurse for Safeguarding within the hospital and the subsequent referral to MASH in LBBD. The staff also identified concerns around the discharge plan for Child C and in particular the fact that the family were moving into another London Borough (this was the third) and that the mother had failed to register with a GP in the area prior to the discharge of Child C. There had also been difficulty in identifying the health visiting team that would take on the case in Tower Hamlets. We know that when mobile families move, the current case transfers between health visitors does not guarantee that contact will be maintained with the family which can potentially lead to vulnerable children’s needs being overlooked. The Named Nurse rightly challenged LBBD CSC about health not being included in the Strategy Discussion/ meeting and followed up her concerns by email, The Named Nurse from NUH also attended the ICPCC; this was good practice.  3.8.5. The LBBD identified the concerns following the referral to MASH and allocated a social worker to complete a single assessment by the 4.08.16. The instructions and timeframes were clear and there is good evidence of communication and supervision with the TM. Following the children being made subject to a plan for neglect the CPP were of a good standard with clear timelines and expected outcomes for the children. The Chair of the ICPCC was sufficiently concerned about whether the safeguarding plan would work due to the behaviour of the mother when she attended that she directed the SW to review and escalate the case as required. This showed a firm and clear grasp of the issues of safeguarding at this early stage.  3.8.6. When the family moved to Essex, there was a clear safeguarding plan in place, the focus being that the mother and her children had to remain living with the maternal grandmother, and if she left the house with the children then the maternal grandmother must notify the social worker immediately. The lack of Core Group minutes has already been identified as a significant issue see para 3.6.17. The safeguarding plan needed the full cooperation of the maternal grandmother and when she failed to inform SW3 the first time that the family returned to London it was reasonable to think that this may happen again and should have merited a review of whether the safeguarding plan was robust enough.   3.9. Were practitioners aware of the needs of the children in their work, and knowledgeable about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare?  ‘Neglect can be difficult to define because most definitions are based on personal perceptions of neglect. These include what constitutes ‘good enough’ care and what a child’s needs are. Lack of clarity around this has serious implications for professionals in making clear and consistent decisions about children at risk of neglect’ (NSPCC.2012)  3.9.1. It is well known that neglectful parenting is almost inevitably a sign of complex and longstanding problems such as mental ill health, domestic abuse, a poor physical environment or entrenched behaviour by a parent or parents. The understanding of neglect is a partnership requirement and must not just be the responsibility of Children’s Social Care. In this SCR the initial assessment carried out by NCS had focused on the issue of housing and did not fully explore the chaotic and poor engagement in a wider context and assess the parenting capacity of the mother in a meaningful way. The absence of information about the father was a feature throughout.  Different information was held by the agencies attempting to work and support the mother and was not pulled together until the third assessment undertaken by LBBD.  3.9.2. The Intensive Hospital Intervention Team in NCSC initially identified potential safeguarding concerns under neglect, in relation to the mother failing to safeguard the health of her unborn child.  There was an absence of evidence within the case files of a robust assessment of risk for neglect. The focus continued to be supporting the mother to secure housing with little exploration of the impact on the transient, chaotic lifestyle on the mother’s ability to meet the needs of her unborn child. The sibling remained as a Child in Need (CIN) in Newham until the case was closed in May 2015. During this time there was no Team Around the Child (TAC) Meeting or multi-agency consultation and planning around the decision to close the case, and a missed opportunity to consider the need to update the assessment following the report that Child C’s sibling had suffered a head injury allegedly caused by jumping on a bed. When the social worker requested information from the health visiting team in NELFT it took over three months for the response. There was a lack of urgency and case drift, in part due to the high volume of referrals, high caseloads held by social workers and an over reliance on agency staff see section 3.15.  3.9.3. Staff on the Neonatal Unit at NUH clearly identified risk factors and neglectful parenting and appropriately referred the case to the LBBD.  3.9.4. The work undertaken by the LBBD social worker kept a clear focus on the needs of the children and identified that the mother’s parenting capacity showed indicators of neglectful parenting. The mother’s behaviour had implications for the welfare of the children and the social worker escalated the case, which, resulted in the children being made subject to a CPP under the category of neglect and then consideration of safeguarding action through the court. However, professionals in Essex did not know about the safeguarding plan and specifically the requirement that the mother and the two children must not leave the maternal grandmother’s address. The GP practice in Essex did receive the information about the children being subject to a CPP under the category of neglect in the LBBD. However, this was not uploaded onto the Information Technology system and as a consequence of this the records did not have a safeguarding alert applied see para 3.6.8.   3.9.5. At the time of this review there was no overarching tool to support professionals in assessing and gathering evidence about possible indicators of abuse or neglect. Since then both Newham and Essex have worked on the positive benefits of having a Neglect Strategy and both have one in place. LBBD Care Profile tool49 is in place for social care staff who have received briefings on its use.   3.9.6. Ofsted commented that ‘those local authorities providing the strongest evidence of the most comprehensive action to tackle neglect were more likely to have a neglect strategy and /or systematic improvement programme across policy and practice, involving the development of specific approaches to neglect50   3.10. The quality of assessments on which decisions and actions were taken.  3.10.1. A good assessment, including family history and identification of risk factors, is fundamental to ensuring that a strong and appropriate plan for the level of required intervention is put in place. Professionals need to maintain a healthy curiosity and continually assess at each professional intervention in order to detect any changes in the family dynamics. Risk factors are cumulative, the presence of more than one increases the likelihood that the problems experienced and the impact on the (unborn) child and parent will be more serious. Research evidence from SCRs 51 suggests that history is an important part of assessing current and future parenting capacity. A safe child protection system needs to deal proficiently with risk, probability and impact; it is not enough to respond reactively after an incident of significant harm has been caused to a child.  3.10.2. Risk should be assessed from the perspective of the children and should not be unduly influenced by sympathy for the adults’ experience. In this case the number of opportunities that the professionals, who were attempting to work with the family, had to undertake an assessment was limited. However, the assessments that were completed were not child centered, and crucially did not explore the attachment between the mother and child(ren) or indeed question how she was meeting the basic needs of her children given the chaotic lifestyle she was leading. Perhaps as a consequence of this, the potential and actual risks to the children were not clearly understood. For example, the safeguarding network of professionals did not acknowledge the possible additional impact of poverty and homelessness on the lived experience of the children.  3.10.3. The quality of the assessments undertaken by professionals in this SCR were seriously impeded by the lack of engagement and avoidance and duplicitousness by the mother. The assessments completed by Newham CSC were impeded by mother’s sabotaging                                             49 Graded Care Profile is an assessment tool used to assist in the identification of neglect. 50 In the Child’s time: professional response to neglect. 51 Brandon et al, 2008 of visits resulting in only two successful face to face contacts and this compromised the extent to which holistic assessments of parental, environmental and social factors could be undertaken.  The assessments were not sufficiently child centered therefore the focus remained in supporting the mother to secure accommodation and did not explore complex safeguarding issues.   3.10.4. The importance of and need to support social workers to determine how long to spend on individual cases, and to balance ‘thoroughness and depth’ and ‘timeliness and proportionality’ is a crucial part of management oversight and supervision. Assessments must be outcome focused, the plan reviewed regularly and evidence collected to determine that progress is being made. The analysis of each assessment should be strengthened by critical reflection in supervision and reduce case drift.   3.10.5. As already highlighted in the appraisal of practice the health visitor in ELFT initially assessed the family as meeting the needs of a Universal Partnership Plus and arranged a follow up visit with the mother at home two weeks later (the new birth visit was undertaken on the postnatal ward). This appointment was not kept and there then followed a period of time when the mother either re-arranged a scheduled appointment or turned up late, the result being that there was drift in the case and the mother and sibling were not being assessed. HV1 referred to NCSC when Child C’s sibling was seven months old as she had been unable to assess the mother and child and had missed various health checks and immunisations.   3.10.6. When the case was referred to the LBBD SW3 there were clear concerns about the mother and her avoidant and manipulative behaviour. As previously stated in para 3.3.28. SW2 did not pass on the information to LBBD when the case was closed and the family had moved into accommodation in LBBD. Information held by Newham was provided to LBBD on 16 July 2016. SW3 worked tirelessly to engage with the mother in order to carry out a meaningful assessment.  SW3 visited the numerous addresses that were on file for the family in order to see the children and complete an assessment. SW3 showed persistence, flexibility and commitment in her role and was not afraid to challenge the mother’s account despite being verbally abused by the mother. Although the assessment did begin to surface some issues there could have been a firmer focus on the mother’s ability to parent and her bond/attachment to Child C, particularly as the key reason for the referral was attachment and parenting. Nonetheless, the assessment did lead to the escalation of the case and a plan to safeguard the children.   3.10.7. Professionals are dependent on what individuals choose to disclose and this is shaped by the awareness, perception of the workers, and the candour of the individual. There were a number of issues that the mother was not candid about, or actively tried to conceal. These included:  • The mother not disclosing the information to all professionals about the father of the children; this may have been because she was unwilling or felt too scared, was unaware of her partner’s background or denied its significance.   •  The self-reported number of miscarriages experienced by the mother; the ‘blackouts’ and the cut over the right eye may have been as a result of domestic abuse. With the family history of domestic abuse, the maternal grandmother, her own father and brother assaulting her. Professionals had considered the risk of domestic abuse but thought that it had diminished as there had been no reported incidents since 2013 and the mother denied having a partner or being in a relationship.  • The mother’s reluctance to allow her GP medical records to be accessed during the assessments undertaken may suggest that there was information that she did not want other professionals to know.   3.10.8. The role of the professional is to remain curious and intrusive about what information is not being shared, and the possible reasons behind this.   Learning Point:  • Robust systems of management oversight and supervision to allow reflective analysis and development of outcome focused plans to evidence real change for the children  • Remind staff about the importance of history, the past may be a significant pointer of the future.    3.11. Whether there were any factors in the history of any adults that indicated they posed a risk to children.  3.11.1. The absence of any checks as to whether the father of the children posed any risk to the family or whether he was supportive and provided stability has already been discussed under the appraisal of practice. The lack of knowledge about him or the drawing together of the various strands or fragments of information left a significant and ultimately defining gap in professionals’ knowledge. Work has commenced in ELFT to ensure that the father’s details are recorded and what role it is understood that he has within the family unit.  3.11.2. It is imperative that fathers do not remain invisible and that investigations are pursued despite reluctance, resistance or any self-reporting that there is no ongoing relationship with a father.   3.11.3. In this case information about where he lived, his possible names and that he had visited both his children following their births in the hospital was known by some of the professionals working with this family but it was not shared or acted on in a meaningful way.  3.11.4. As set out in para 3.2.11, GPs need to do all that they can to establish the circumstances of any adults who present with anxiety, depression and/or substance misuse whether they care for children and in what capacity. In the absence of a national framework setting out GP responsibility to consider the dependents of patients it is useful to reflect on learning gained by the National Society for the Prevention of Cruelty to Children  (NSPPC) from a number of serious case reviews in which they state GP’s must:  ‘Always ask patients with mental health difficulties, learning difficulties or drug and alcohol misuse whether they have significant care responsibilities. Consider their capacity to care for children safely. Record this information in medical records and emphasise it in referrals and correspondence about patients’52   This is repeated here to reinforce good practice  3.11.5. Safeguarding checks were undertaken to assess the suitability of the maternal aunt and grandmother in providing accommodation and general support to the mother and her children. However as discussed in (para 3.5.20.) there was no individual assessment of the maternal grandmother or maternal aunt in relation to their own capacity and ability to act in the best interests of the children and not to be unduly influenced by their relationship (or lack of it) with the mother. Given that both the maternal aunt and the maternal grandmother had not co-operated with the safeguarding plan that was put in place, and had in fact chosen to be complicit with the mother when she returned to London on 12th September 2016, there should have been more exploration of why the maternal grandmother failed to inform the social worker and whether she could be relied on if it happened again. The decision to allow the mother and children to go to Essex was not wrong. In any event it would have been difficult for the local authority to pursue another course in the face of the maternal grandmother’s determined statement to provide care and avoid the children entering the care system.  It was however an on-balance decision that the extended family, and in particular the maternal grandmother, would offer support and stability and allow more time for the LBBD to complete further assessments.   3.11.6. There was also little known about whether the mother posed any                                             52 https://www.nspcc.org.uk/preventive-abuse/child-protection-system/casereviews/learning/gps-primary-healthcare-teams/. risks or any exploration about whether she would be able to protect her children from harm. This is of particular significance given some of the family background of intergenerational domestic abuse. The mother reportedly lived with different friends and family but the exact whereabouts or who the other adults were in the house was unknown. Her mobile and chaotic lifestyle was a feature throughout the whole time period of this review and despite securing accommodation chose not to live in it. It is well recognised that when families are homeless they experience difficulty in accessing benefits; the mother often made reference to financial difficulties. The mother’s financial situation was not explored in any real depth, nor why she was always hungry on the occasions that she did visit Child C on the Neonatal Unit.   3.11.6. The extended family were viewed as supportive when they came forward at a point of crisis to assist the mother in caring for her two children. When the maternal grandmother ‘stepped in’ to provide accommodation for the family at the time it was seen as a positive and allowed a further period of time to support the mother in demonstrating that she was capable of meeting the needs of her children. SW3 was reported to feel that she had a good working relationship with the maternal grandmother and that she had demonstrated good insight. In light of this it would have been very difficult for the local authority to purse legal proceedings to remove the children from the mother.  It could not have been foreseen that the grandmother’s expressed concern and apparent agreement with the arrangements would have been so shallow. There was little to suggest that the maternal grandmother would fail to inform SW3 if the mother left Essex with her two children but having failed to do so on the first occasion it is unclear what reassurances were obtained from the maternal grandmother by SW3 that she would fulfil the agreement to do so if the family left Essex and returned to London. In point of fact on the day that this meeting took place (19.09.16) the mother left for London and was away until the events of the 28th September.   Learning Point:  • It is imperative that father’s do not remain invisible and investigations pursued even when there is denial or resistance from the mother.  • The importance of requesting police information on father’s when undertaking assessments.     3.12. Whether race, religion, culture was a factor in this case and had been fully considered.  3.12.1. There is very little reference made to the self-identity of the family or what pivotal role it might play in the day-to-day life of the family and extended family. It was recognised that a detailed assessment of the family was needed, though not possible in the immediate need to secure mother and children in what appeared to be an available and more stable setting. By understanding the cultural background of the family, professionals can get beneath the surface of assessments of risk by gaining an understanding of risk and resilience, strengths and vulnerabilities. Using this as a starting point, how best to provide services to meet their needs may be better facilitated.  There is nothing to suggest that culture or ethnicity was considered in any of the assessments undertaken.    3.13. The extent and quality of partnership working among key agencies and across local authority borders.  3.13.1. The quality of partnership working demonstrated in this case is variable and to a significant extent reflects the difficulties that key agencies experience with mobile and avoidant families. This is further complicated when service provision changes due to the family residing in another London Borough or moving to another local authority. When another layer of different health providers is added it becomes increasingly difficult for professionals within the key agencies to maintain strong working relationships. This becomes even more challenging and difficult when there is no shared IT system even within the health services.  3.13.2. When the initial assessment was instigated by NCS there was some evidence of partnership working between health, housing and social care. However, when the family moved into temporary accommodation in the LBBD this necessitated a change of health visiting provision and NCS found it increasingly difficult to speak to the family health visitor (NELFT) allocated to the family. It is now known that eight health visitors were involved (NELFT site a combination of agency, bank and different clinic attendances as a contributing factor).  In these circumstances co-ordinated and close partnership working was almost impossible.     3.13.3. There was good partnership working between the staff on Neonatal Unit at Nehwam Hospital, who liaised with LBBD CSC and the health visiting service in NELFT. There continued to be difficulty in establishing the health visiting team that would provide services whilst the family were living in Tower Hamlets, as a consequence of this Child C was not seen by a health professional until the move to Essex.  3.13.4. There was some good partnership work when the family moved to Essex but it is evident that partners in Essex were not all aware of the full facts of the case, as outlined in the appraisal of practice. This mitigated against professionals in Essex being able to fully conduct their roles.    3.14. The effectiveness of working arrangements and information sharing and communication between all professionals and whether this could have been improved.  3.14.1. Throughout the time period of this review there was a great deal of information that was shared, however because there was no key worker for long periods, an overall plan with clear measurable outcomes was missing. Recent published SCRs 53 highlight the difficulties professionals face with mobile and avoidant families in sharing timely and critical information. Professionals need help to ‘analyse and assess the risks that arise when a vulnerable family moves across boundaries and all professionals change.54  3.14.2. As previously discussed in the appraisal of practice and the specific TOR, professionals working with the mother were not always clear about why NCS had been involved and what the status of Child C’s sibling was. When Child C’s sibling presented with a head injury there was confusion about whether the child was the subject of a CPP or was a Child In Need. The attendance was shared with SW2; GP1 and NELFT health visiting team but no follow up of the family was carried out. This omission was discussed in the appraisal of practice.   3.14.3. There are no prescribed systems in England for case transfer across local authority boundaries for Children in Need (CIN) but there is an expectation that professionals share information. There are however no standards for professionals working within the new local authority to contact or see the child(ren) and once the case is passed on there is no obligation on either LA to keep the case open.  3.14.4. Health visiting services shared information at the point of transfer with a telephone call prior to the transfer of records. The midwifery service completed a communication form and forwarded to the health visitors. However, there was still no clear plan and little evidence that professionals had comprehensive and necessary information about the known or potential risks.  3.14.5. The staff in the Newham Hospital Neonatal Unit and the Named Nurse were clear about the concerns and made an appropriate referral to MASH that resulted in the case being allocated to a senior social worker and an ICPP.                                              53 Oxford, Tri-borough and Luton LSCBs 54 http://www.oscb.org.uk/wp-content/uploads/Child-Q-SCR-Summary-sheet.pdf  3.14.6. When the children became subject to a Child Protection Plan on the 15 August 2106 the information was not shared with Newham or Tower Hamlets despite the fact that the children were supposed to be living in Tower Hamlets and it was known that they also had been living in Newham, this should have happened. This has been highlighted as a learning point under section 3.5 of this report.  3.14.7. Information was shared with the health agencies in Essex and CSC were also informed that the family had moved in temporarily and the children were subject to a CPP. We now know that this information was not uploaded on to the GP IT system, which meant that professionals working within the practice did not have this information when they family attended for appointments. The previous GP records were not available to the Essex GP practice as previously discussed.  3.14.8. The Core meeting held at the maternal grandmother’s home was an opportunity for professionals to meet and review the Plan, and understand the conditions that the family had agreed to. The minutes or any recording of this Core Meeting, the areas covered including the safeguarding plan, and the actions that each agency agreed were not circulated.  Nor have they been made available in this SCR process. This falls below expected practice. Health understood that their focus was to ensure that the children completed any outstanding immunisations and developmental assessments.   3.14.9. Communication and information sharing is vital in ensuring that the professionals working with families understand the full picture and are clear about the issues and concerns that need to be addressed. This becomes even more important with a mobile family where there is evidence of intentional deceit about where they are living and with whom. It is far easier for mobile families to avoid contact with professionals particularly when they move across local authority boundaries, which means that the case is transferred on and other partner agencies such as health visiting are provided by different organisations.   3.14.10 Although the London Child Protection Procedures (LCPP) were generally followed in this case, it is clear that there were gaps in information shared and the identification of the concerns surrounding the family (these have been previously identified in the report see 3.3.1). In the triennial review of SCRs published in 2016, it states: ‘Our reviews of serious case reviews spanning more than ten years suggest that, despite national guidance and legislation, there are deep cultural barriers to effective information sharing among professionals.’ The additional learning is that all staff have a duty to read the records prior to a contact, so that they are clear about what the purpose of their intervention is, and what information is missing in order for them to identify what may be required to ensure a robust assessment is completed.    3.15. The existence of any factors relating to the ‘capacity and climate’ within agencies which may have impacted upon practice in this case (i.e. vacant posts or staff on sick leave etc)  3.15.1. Caseloads in the Intensive Hospital Intervention Team were high, at 30, with additional pressures on the team to support the referral and assessment team. At the time it was reported that the numbers of referrals was high and the through- put was slow. This had a direct impact on the length of time that cases were open and in this case clear case drift. This was recognised in the Single Inspection by Ofsted in 2014, as was the fact that the LBN were also aware of the issues and had a comprehensive plan in place. The implementation of the improvement plan commenced in 2015; resulting in a move to work in locality teams, and the work of the Intensive Hospital Team was subsumed into locality teams. A hospital liaison manager was appointed to ensure that the close working relationship with Newham University Hospital continued. There was also increased management capacity, improvements to the MASH and a new comprehensive quality assurance and performance programme.  3.15.2. NELFT identified the high numbers of health visitors involved with the family whilst living in Dagenham. There were considerable staff shortages and there was a reliance on bank and agency staff that were moved at short notice to cover Child Health Clinics and caseloads in other area of the borough. This had a direct impact on how this family was visited and assessed. There were eight health visitors involved in delivering the service.  The health visitors reacted to either information being shared or enquiries being made and an attempt to determine where the family was living. There was no overview of the possible risks and concerns within the family due to the high number of health visitors working on the case.   3.16. In addition to the above the review should consider learning for both the individual agency and how agencies work together through the Safeguarding Children’s Board.  3.16.1. This case highlights the difficulty of ‘keeping track’ of a mobile and avoidant family. All LSCBs should give consideration as to how information sharing across boroughs particularly with housing and health service provision can be strengthened.   3.16.2. The case was accepted by the LBBD as at the time there was an understanding that the family were residents of the borough. At the point that is was clarified that the family were in fact not residents of the borough, the decision was made to keep the case, as it was unclear as to the exact whereabouts of the family. This was a sound decision made in the best interests of achieving continuity.  3.16.3. The lack of focus on the children’s lived experience is stark in this report. In part due to the non-engagement of the mother and therefore the opportunity to assess the children was limited. When professionals did meet the family the focus was very much on dealing with the problems presenting and trying to keep the mother engaged. The ‘voice of the child’ was lost.  3.17. Additional learning identified during the course of the Serious Case Review, the importance of supervision and management oversight.  3.17.1. Brandon and colleagues (2008) stress the importance of effective and accessible supervision. This helps staff put into practice the critical thinking required to understand cases holistically, complete analytical assessments, and weigh up interacting risk and protective factors.  3.17.2. Supervision was provided throughout the period of time that the case was open to the LBN. However, due to the difficulties in parental engagement the case drifted and there was insufficient consideration and analysis of the implications of the mother failing to engage with the process and a lack of a child focus. There was no professional curiosity about where and with whom the mother and her child was living, what risks they may present of if there were protective factors. The decision to close the case, which was supported by the supervisor, was based on a partial assessment. The LBN have identified the need to strengthen supervision within their IMR. A follow up on this action should be a local SCB priority.   3.17.3. The supervision and management oversight provided to SW3 in the LBBD was of the expected standard, with good clear instruction and timeframe from initial allocation of the case. There was regular supervision by the TM to SW3 and also met with the mother and SW3 to agree a plan when the concerns were escalating. When they discovered that the family was not residing in the borough they decided that there was a danger that the family ‘might get lost’ within the system if they transferred the case, and they were still unclear about where the family were actually living. The Team Manager should have chaired the Discharge Planning meeting in line with procedures as this was the first planning meeting and should have been seen as setting up a CIN plan ahead of the ICPCC. There is evidence in the records and through an interview with SW3 that she felt well supported by her manager.  3.17.4. Comments have been set out in para 3.2.44 on the situation for HV1 with regard to accessing supervision in the appraisal of practice. ELFT provide regular safeguarding supervision and use ‘Signs of Safety’55 to support the practitioner to reflect on the strengths and risks present in the case  3.17.5. Primary Care and in particular GP’s have a unique role in working with families. The mother’s GP medical records from GP1 have not been located despite attempts by Newham CCG to trace the records for the mother and sibling. As a result there is a gap in the information and understanding of how and when the mother attended her family doctor and what information she gave to GP1.  3.17.6. As previously discussed, professionals working within Primary Care should be supported to ensure that they consider the possible impact on the adults ability to care for children or dependents when they themselves may be vulnerable due to drugs or alcohol misuse, or suffer from mental health issues.   3.17.7. One other issue that has emerged in this review is that despite very extensive professional contact over the whole period, there was no understanding of the mother’s ability or capacity to read and understand documents, letters or reports.  It seems to have been assumed that in light of her somewhat streetwise demeanor/use of texts etc that she was able to read and understand. Though the use of texts and apparent level of articulation may cover considerable difficulties in really understanding official documents.   4.  Conclusion and Recommendations.  4.1. Among many lessons this case highlights the difficulties that professionals experience when working with non-compliant, chaotic, mobile and duplicitous families. This family lived at six different addresses (these were the addresses that the professionals knew about), and in four local authority areas, three of which were in London.  The mother engaged with the different agencies and professionals on her terms. She often managed to do ‘just enough’ in terms of attending health appointments to suggest she was complying and trying to keep her appointments. She shared different information with different professionals and was verbally aggressive and abusive, she accused professionals of lying or giving her the wrong appointment times.   4.2. The mother made it difficult for social workers to complete meaningful assessments and as a consequence the voice of the child was not always captured. To some extent the professionals got caught up in managing the more immediate impact of her behaviour and responding to her transient lifestyle and very difficult attitude, and an enormous amount of time was taken up by trying to pin the mother down to where and with whom she and her children were living.                                              55 Framework for the Assessment of Children in Need and their Families, DH, 2000.  4.3. At the point when the LBBD had made the decision to commence care proceedings for the children, her extended family stepped in to support the mother. The maternal grandmother was seen as supportive and suggested to the social worker that she had insight in to the issues that needed to be addressed by the mother. The realistic child protection plans and safeguarding agreement with the additional caveat that the maternal grandmother must report immediately to the social worker if the mother left the address in Essex with the children, was reasonable but undermined by the mother’s actions and the failure of the maternal grandmother to alert the authorities.  4.4. The father of the two children remained a ‘shadowy, invisible’ presence throughout the review period. The mother denied that they were still in a relationship and refused to give details to all the professionals involved with the family. There was information about the father in the single agencies but it was never shared. The consequence of this was the father and his considerable role and influence remained unknown throughout the period under review. Consequently, there was no assessment completed of whether he posed a risk to the children or was a protective factor.  4.5. The mother had grown up experiencing domestic abuse and had moved with her mother (maternal grandmother) to Essex before returning to London at the age of 17. The mother reported that she had been assaulted by her own father and brother and received support for this. There is also a reference to an incident of domestic abuse by her boyfriend in 2013. The SCR panel discussed the possibility of the self-reported miscarriages, the premature births, history of blackouts and an injury to her face as possible signs of domestic abuse; there was no evidence to support this.  4.6. There was concern about the care of Child C and her sibling by the mother, and in particular her transient lifestyle, avoidance of engaging with services and failing to put the needs of her children first. But there was no specific evidence that Child C would experience serious physical harm. In these circumstances, it is reasonable to say neither Child C’s death nor her injuries could have been predicted. However, there was a constellation of factors both in the history of Child C and the older sibling that presented a cumulative picture of risk, neglect and poor understanding of the mother’s wish or capacity to care for Child C. The issue of the father was a singularly significant factor in the risks to both children.   4.7. The recommendations arising out of the learning from Child C’s experience are:   Recommendation 1:   That LB of Newham consider the most appropriate way of ensuring an information exchange between housing and CSC when a tenancy is cancelled, and when there is a reason to believe that there is a neglect or risk to a child to ensure that wider issues of safeguarding and possible neglect and risk to children are evaluated  Recommendation 2:   Barts NHS Trust must ensure that staff are made aware about the importance of recording vital measurements including weight, height and head circumference. When babies and young children have been in hospital for extended periods and there are any concerns about parental engagement with child(ren), developmental milestones as well as a summary of feeding and sleeping patterns must be recorded and where considered necessary should be shared at the point of discharge with all community staff and social care.  Recommendation 3:   The Safeguarding Children’s Boards involved in this case must assure themselves that single and multi-agency training for staff working with avoidant and hard to engage families include the identification of disguised compliance, collusion and deception as part of any existing training programmes, or devise new modules as necessary.  Recommendation 4:   All agencies need to consider whether the arrangements they have in place, including strategies/policies, procedures, training and supervision for staff and managers, are adequate, specifically to identify neglect and assess its likely impact and risk to children.  This must include support and guidance to staff on practical approaches that can be used.   Recommendation 5:   The relevant LSCBs must seek assurance that all agencies can demonstrate how fathers or absent parents are included in any assessments that are undertaken. This is to ensure that consideration of risks or protective factors are evaluated in order to ensure that practical steps are put in place to safeguard any children.  Recommendation 6:    The relevant LSCBs need to be assured that a full and robust assessment is undertaken on family members (or anyone that puts themselves forward) to provide support or care for children who have met the threshold for care proceedings. The assessment must include the capacity and ability of the individual and consider the interaction and sustainability of the relationship they have with the birth parent. This must include realistic and frank assessments of any background factors that may have an impact on current behaviour and attitudes.   Recommendation 7:   The LSCBs need to be assured that systems are in place so that minutes of any Core Group Meetings are shared with all the relevant agencies involved in the protection of the named children concerned.    Recommendation 8:  Relevant LSCBs must assure themselves that procedures and arrangements are in place to ensure that Child Protection Plans (CPPs) are shared with all key agencies who have a role with either parent(s) or children in relation to the CPP.   This must include ensuring the timely distribution of the CPP in the most appropriate way (electronic, fax, uploading to shared systems, or paper copies etc) to ensure that all key managers and staff concerned are sighted on agreed CPPs.    Recommendation 9:   The relevant LSCBs concerned need to be assured that at their own local level procedures are in place, and are followed, to ensure that health agencies are fully involved in strategy meetings and fully informed of the outcomes.  This is already a requirement from the London wide Child Protection Procedures.  Appendix 1:  Methodology  1.1. Statutory guidance within Working Together requires Local Safeguarding Children Boards (LSCB) to have in place a framework for learning and improvement, which includes the completion of Serious Case Reviews. The guidance establishes the purpose as follows:  Reviews are not ends in themselves. The purpose of these is to identify improvements, which are needed, and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action, which lead to sustainable improvements, and the prevention of death, serious injury or harm to children 1  The statutory guidance requires reviews to consider: “what happened in the case, and why, and what action will be taken”. In particular, case reviews should be conducted in a way which:  ➢  Recognises the complex circumstances in which professionals work together to safeguard children;  ➢ Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  ➢ Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  ➢ Is transparent about the way data is collected and analysed; and  ➢ Makes use of relevant research and case evidence to inform the findings.   1.2. The SCR used the traditional methodology of obtaining chronologies and Individual Management Reviews (IMRs) from 12 key agencies involved in providing services to Child C and her family over the time frame from October 2013- September 2016. The period under review covers the pregnancy of Child C’s older sibling, a miscarriage and the pregnancy and first three months of Child C’s life.   The process was led by an Independent Reviewer working with the Serious Case Review Panel (SCRP) and included:  • 4 meetings of the SCR Panel   • Membership of the SCRP was:                                               1 Working Together 2015  2 Agency Designation of member Chair Group Manager Safeguarding Quality Assurance LBBD Ann Duncan Independent Reviewer BDSCB Business Manager LBBD Operational Director Children’s Care & Support LBBD Group Manager, Children’s Care &Support LBBD Legal Services Principal Solicitor CCG B&D Designated Nurse CCG B&D Named GP  Integrated Care Director Metropolitan Police Review Officer Specialist Crime Group Newham CCG Designated Doctor Newham Housing Needs Services Team Leader Newham CSC Head of Service Newham Adult Social Care Senior Advisor Safeguarding Barts Health NHS Trust Named Nurse Safeguarding Children ELFT Health Visiting NELFT Named Nurse for Safeguarding NELFT Associate Director Essex  Local Health Provider In Essex Lead for Safeguarding Children CCG Essex Associate Designated Nurse Safeguarding Children   Terms of Reference are:  1.3.  The SCR seeks to learn lessons for future practice by examining and critically analysing the following key issues relevant to this case:  1. The level and extent of agency engagement and intervention and whether his was appropriate to the assessment of parent’s ability to provide adequate care and supervision of Child C and her sibling.  2. The recognition of safeguarding factors by all agencies and how these were addressed.  3. Were practitioners aware of the needs of the children in their work, and knowledgeable about potential indicators of abuse or neglect and about what to do if they had concerns about a child’s welfare.  3  4. The quality of assessments on which decisions and actions were taken.  5. Whether there were any factors in the history of any adults that indicated they posed a risk to children.  6. Whether race, religion, culture was a factor in this case and had been fully considered.  7. The extent and quality of partnership working among key agencies and across local authority borders.  8. The effectiveness of working arrangements and information sharing and communication between all professionals and whether this could have been improved.  9. The existence of any factors relating to the ‘capacity and climate’ within agencies which may have impacted upon practice in this case (i.e. vacant posts or staff on sick leave etc  10.  In addition to the above the review should consider learning for both the individual agency and how agencies work together through the BDSCB.  1.4. The following agencies submitted IMRs:  • Children’s Care and Support Service, Safeguarding and Review Service and Legal Services, LBBD • Barts Health NHS Trust (NUH) • Children’s Social Care, LBN • Housing Needs Service, LBN • Health Visiting Service, North East London NHS Foundation Trust • Health Visiting Service, East London NHS Foundation Trust • General Practice Newham CCG (father’s records) • Adult Social Care LBN • An Essex Clinical Commissioning Group on behalf of a GP practice. • London Ambulance Service • Metropolitan Police Force, Specialist Crime Review Group • A Local Provider Health Service in Essex(Health Visiting)  1.5 The author was present at an interview conducted by the Operational Director Children’s Care and Support for the London Borough of Barking and Dagenham with SW3. This interview took place, as the IMR author for the LBBD had been unable to interview her as she was out of the country. This interview provided very useful information and some valuable insight in to how difficult and  4 challenging the mother was to both work and engage with.  1.6 The author of the SCR, Ann Duncan, was commissioned by BDCSB to write the overview report; she was independent of the case and all agencies involved.  She has a background in health and worked at executive level for 10 years prior to leaving the NHS. Ann’s final post in the NHS was as Director of Integrated Governance for a Central London PCT. Her responsibilities included: commissioning and quality for services across health care providers, leading for safeguarding and, she was the Trust’s representative on the Safeguarding Children Board. She is an accredited Social Care Institute of Excellence (SCIE) Reviewer and is familiar with both Root Cause Analysis and Domestic Homicide Reviews. To date, the author has completed eight SCRs covering: neglect, neglect and rape, infanticide, unexplained death of a toddler whilst in the care of the father and physical injury to a six-month-old baby. Other work includes: undertaking RCAs for deaths in custody (mainly at Wormwood Scrubs Prison) and an IMR for a school where an honour killing was suspected.   5 Appendix 2 – Summarised timeline of events  The table below sets out a summary of the background and main events covered by the SCR report.  The sections reflect the time periods addressed in the report  Date  Event Historical background: 20 June 1964 Father of Child C born (Father) 6 February 1991 Father’s former partner reports that their child aged 12 months had been abducted by the Father.  She alleges that she had suffered 2 years of physical and sexual abuse and that her 4 year old child, had been physically abused.  The Father denied the allegations and no action was taken NB in 1991 there was not an auditable pathway to notify Children’s Services that these children had come to police notice and there were safeguarding concerns so it is unknown if CSC were notified 28 July 1991 Mother of Child C born (Mother)  2nd November 2004 Father’s home searched for drugs.  He advised he was a methadone user to combat ecstasy addiction.  No drugs found.  He was using alias of LH January 2005 Father linked to violent gang July/August 2007 Mother goes to Essex refuge with her mother (maternal grandmother) and siblings due to domestic violence by father. Referral record 15 Aug in Newham. Referral made to Essex Children’s Services 13 November 2007 GP records start for Father at Newham GP December 2007 Medical records note Father is a cannabis user December 2008 Intelligence suggests Father is selling drugs from his flat 2009 No date given Father comes to police attention 4 times re possible drugs misuse and using his premises for dealing in drugs 30 November 2009 Father first mentions depression to his GP (related to sickness benefits not being paid) 2010 Mother returns to London – relationship with the maternal grandmother had broken down 6 April 2011 Mother attends fertility clinic (aged 19).  In a relationship for 2 years Address is at Homeless Young People’s Project, E7  14 April 2011 Letter to Mother’s GP from specialist registrar re clinic visit 20 July 2011 Mother did not attend appointment at infertility clinic 26 July 2011 Letter from consultant to Mother’s GP.  Mother discharged from clinic 11 March 2013 Mother attends ED with PV bleeding.  Negative pregnancy test July 2013 Mother says assaulted by father in the street 20 September 2013 Mother attends ED having blackouts for years, sometimes failing down.  Cannot get GP appointment for referral to neurologist.  Asking where to get free pregnancy test.  Details taken to make GP appointment  6  Time Period 1: October 2013 to July 2014.  Relates to paragraphs at 3.2 onwards   28 October 2013 Safeguarding Adults Referral received from GP – Mother was victim of violence from her father and brother, is homeless and pregnant. She has lost contact with her key worker.   Information forwarded to Children’s Service due to pregnancy. No further action – insufficient grounds for concern.  Mother to be advised to contact Access Team 29 October 2013 Mother attends maternity booking-in/first ante natal care with her sister (maternal aunt).  Referral to Acorn Team due to family history.  She is living at her uncle’s address Partner recorded as LH (unemployed) living at an address in the London Borough of Newham 14 November 2013 Mother’s referral from Newham Adults is received by Newham CS.  Said to be homeless and living between sister (maternal aunt) and her uncle: father of unborn child will give support. Outcome: case to open to the Hospital Team 16 November 2013 Mother attends Newham Hospital Urgent Care – pregnant (14/40), vomiting and lack of foetal movement.  UTI diagnosed and antibiotics given 19 November 2013 Newham CS referral review.   As pregnancy only in its 15th week case to be closed and re-opened in the 20th week (23 December 2013).  Case can continue to receive support from Adult Social Care 17 December 2013 Mother has maternity appointment – no notes 2014  2 January 2014 Maternity notes of appointment - Mother feeling well etc . 6 January 2014 Newham CS allocates case to complete pre-birth assessment.  Action to include genogram, establish current situation and support network and make sure the baby’s father is included in the assessment, liaise with midwifery, NAADV and Adults Services. Single assessment started by Social Worker in the Hospital SW Team 13 January 2014 NCS ring Mother twice – no response.  Letter sent to inform of home visit on 23rd Jan at 12noon 23 January 2014 Home visit. No-one answered the door.  No response to phone calls 27 January 2014 NCS make contact with Safeguarding Midwife.  Midwife also finding it hard to contact Mother.  Her next appointment due 26 Feb 31 January 2014 NCS phone Mother. She doesn’t understand need for home visit – advised of duty to assess regarding domestic violence and homelessness.  Appointment made for 4 Feb 2 February 2014 Mother attends maternity appointment – has abdominal pains for 3 weeks.  Reviewed by midwife and registrar.  Nothing abnormal detected 4 February 2014 NCS meet Mother at the hospital.  Says she is homeless and has her belongings with her.  Mother advised to speak with sister (maternal aunt)/friends/her uncle about spending the night with them and then presenting to the Homeless Persons Unit in the morning.  Says was assaulted by her father in July  7 2013, that she is no longer with the baby’s father (after relationship of 3 years) but that he has promised to look after the baby and has had 4 miscarriages 5 February 2014 Mother fainted on a train.  Scan normal, foetal movement found.  Offered blood test – refused as GP had taken one recently and said it was normal.  Told to return if further issues 24 February 2014 NCS get housing update – Mother has not yet presented herself.  She was last seen by housing in December 2012 but case closed as she was not a priority. Phone call to Mother but no response 5 March 2014 Assessment completed 10 March 2014 Review: Assessment (allocated 6 Jan) completed on 5th March:  Social Worker met Mother once and advised her to present at the Homeless Persons Unity to apply for housing.  Social worker found it impossible to engage with Mother after this meeting as she disengaged from the assessment. Actions: Maternity Alert to be sent to all hospitals for professionals to refer back to Newham if Mother is still living in Newham for an in-depth assessment to carried out Referral to Early Childhood Midwifery Service for support and parenting advise after the birth Case to be closed to the Hospital Assessment Team as efforts to contact Mother failed Decision by Manager: case to close by 14th March 2014 11 March 2014 Case closed.  Mother advised to contact Children’s Centre for help with securing private property to live in 20 March 2014 Phone call from Mother apologising for lack of contact – says been unwell and gives a new phone number.  Says she has applied for income support and needs MAT1 form.   Mother directed to the midwife and social worker agrees to assist her with this and to book an ante natal appointment for her. Call made to midwife and new phone number passed on 21 March 2014 Mother attends antenatal appointment (32 +1 weeks). Appears well, bloods taken and scan booked.  Social worker due to see Mother same day. Noted that Mother had missed 2 antenatal appointments that had been due at 25 weeks and 28 weeks. (3 missed appointments would have triggered home visit) 25 March 2014 Phone call from Mother at the Job Centre asking for housing update.  She is advised to go to the Homeless Unit. 3 April 2014 Mother attends antenatal appointment – all Ok. Social worker joins for the appointment.  Labour plans discussed Social worker notes – Mother not attended housing and needs letter from her uncle regarding her homelessness and a supporting letter from midwife and social worker.  Mother advised to collect both the latter letters the next day.  8 7 April 2014 Mother approached Housing Needs Service East Ham.  Case allocated to homelessness case worker.  Interview carried out and home visit requested.  Letter from maternal aunt asking her to move out presented. 12 April 2014 Mother brought to hospital by ambulance with contractions at 20.30.  Taken to Labour ward.   13 April 2014 Baby (Sibling) delivered in good condition at 34 weeks. Mother admitted to ward post delivery.  Documents show Social worker aware of delivery 14 April 2014 New birth notification received via fax from Newham University Hospital.  Notification allocated to administrator for processing. Social Worker spoken to and will visit the next day regarding housing. Entry by Social Worker says spoken to Mother re housing and that the social worker would go to talk to the housing again now the baby (sibling) had been born 15 April 2014 BCG appointment letter sent to Mother – but as BCG was given on the postnatal ward the mother phones to cancel the appointment. Child Health Admin Team phone Mother to confirm her address (at her uncle’s address) to identify appropriate health visiting team. Midwives noted to be awaiting social worker input. Mother advised to present herself at housing.  Mother says maternal aunt or Father will look after baby(sibling) while she goes to housing. Email sent to housing confirming the baby’s birth (sibling) and requires housing. 16 April 2014 Midwives say baby is fit for discharge.  Waiting for results of housing issues Home visit to uncle’s address.  He confirms the mother cannot stay with him any longer 17 April 2014 Electronic health notes say baby discharged with mum to home.  No mention of housing issue.  Paper notes record Sibling’s weight (2125g). EDT Report:  contact with midwife – no concerns regarding bonding and care of baby – enquires about the housing situation.   EDT worker told that Mother had a home (uncle’s address) to go to but choosing not to, she had been encouraged to seek own accommodation.  Mother says she is registered for housing and that her uncle is refusing her return but had refused to give his phone number for mediation.  LA could provide temp accommodation but Mother declines.  Social Care refer the matter to housing 18 April 2014 Baby (sibling) well. Mother adamant that she does not want to go home until Tuesday (22nd April) 22 April 2014 Phone call from health visitor to arrange new birth visit with Mother.  Mother still on post-natal ward.  Visit arranged for next day. Baby (sibling) well. Father is on the ward giving support while Mother goes to housing 23 April 2014 Health Visitor sees Mother on post-natal ward.  Confirms address as her uncle’s but says is homeless.  Advice given on health, registration with a GP and Children’s Centre.  Mother says she has a social worker. Health visitor leaves voice message for social worker asking to make contact  9 Site manager has discussion with Mother and her uncle about returning home. Hospital Visit – Mother described past experience of domestic violence by father and brother, states the baby’s father is “L” and although not in relationship they get on well and he plans to be involved with the baby, says she has been living between maternal aunt in Tower Hamlets and her uncles in Newham.  Mother advised to go to her uncles as he had agreed for her to stay a few weeks. Discussion with Service Manager: Mother to stay on ward until the next day (24th), to speak to uncle re housing pending Housing Service action. Failing this the hospital will call the police to remove Mother and CYPS will consider care arrangements for the baby (sibling) Referral made to Home to Home agency.  Homelessness case worker refers Mother to Mother and Baby Unit 24 April 2014 Mother and baby (sibling) discharged to uncles address in Newham. Email sent by Paediatric Liaison to health visitors Post-natal home visit by community midwife – Mother staying in living room on sofa.  No Moses basket, house smells of smoke 25 April 2014 Housing update – referral made to Home to Home accommodation for mothers and babies.  Accommodation is available at Forest Gate and contact to be made with Mother on 28 April to view.  CYPS informed. 29 April 2014 Mother refused the accommodation offered.  Social Worker notes explain reason for refusal (fear of violence) 30 April 2014 Homelessness worker speaks to Mother. Mother explains reasons for refusal (fear of violence).  Mother asked to bring in ID and documents of proof of address 1May 2014 Phone call from health visitor to Mother.  Mother says she refused accommodation.  Home visit planned for one week later.  Family places on Health Visiting Universal Plus Care Package 14 May 2014 Phone call from social worker to health visitor to say case closed as family only have housing needs 16 May 2014 Home visit due. Text from Mother to Health Visitor to reschedule home visit for 20 May 19 May 2014 Case closed.  Needs are housing related and these are being addressed in the housing department. No further role for CYPS Case records closed at Hospital Social Work Team in Newham 20 May 2014 Home visit not achieved – Mother and baby (sibling) not at home.  Phone call in late afternoon agreeing to take sibling to the Children Centre at 11.30am on 22 May 22 May 2014 Mother failed to attend children centre for scheduled time but did attend at 14.00.  Says she has been kicked out by uncle and is staying with sibling’s father. Child’s health visiting package stepped down to Universal 23 May 2014 Phone call from Health visitor to family housing requesting update. Health visitor called Homelessness Duty Line to advise Mother was homeless and moving place to place.  10 12 June 2014 Mother visits Housing Needs Service at East Ham. Email sent to Homelessness case worker to say the mother and 3 month old baby were homeless. Phone call and letter to the mother requesting ID and proof of residence again. Gives 7 days’ notice to produce the info or the case would be closed 22 June 2014 Case assigned to another homelessness case worker July 2014 Date unknow.  Father attends GP asking for re-referral to mental health services – which he attends 14 July 2014 Mother and baby (sibling) discussed at Family Support Network 15 July 2014 Mother fails to bring sibling for their 12 – 16 week health review and her own Maternal Mood Assessment 18 July 2014 Non-attendance followed up by phone call to the mother by Health Visitor.  Care package escalated to Universal Plus.  New appointment scheduled for 31 July at the children’s centre 30 July 2014 Phone call and text reminder to Mother from Health Visitor about appointment on 31st 31 July 2014 The mother failed to attend for the sibling’s 12 – 16 week health review for 2nd time.  Referral made to Newham Children’s.  Triage completed for Mother and baby (sibling) requesting social care assessment and support for the family No record of liaison with the GP.  Health Trust’s “Did Not Attend” (DNA) policy guidance not followed.  Social worker allocated to the family  Time Period 2: August 2014 to June 2015.  Relates to paragraphs at 3.3 onwards   August 2014 Date unknown.   Father states that he lives alone when asked by GP Psychiatrist record notes he is a cannabis users 1 August 2014 Referral from health visitor received.  Says that Mother is not responding to attempts at contact, gives summary of housing situation – main concern is health and safety of the child – that it appears that since the case closure the family’s situation had deteriorated.  Housing to visit on Tuesday (5th). Outcome:  Case opened to the Hospital Social Work Team  4 August 2014 Single assessment started by Social Worker 5 August 2014 Sibling seen late for their 12- 16 week health review and Mother for her maternal mood assessment. Mother declares a miscarriage but not when this was Care Package stepped down to Universal 11 August 2014 Health visitor phones Children’s Social care for update.  Invites contact from newly allocated social worker (ML) 15 August 2014 Phone call and text from health visitor to Mother re update on social care referral.  Family care package reviewed and changed to Universal Plus  11 Referral from Family Support Worker – concerns re unstable housing and its impact.  Mother waiting for diagnosis re her blackouts and has had counselling for domestic violence.  Passed to allocated social worker 19 August 2014 Previous homelessness case worker explains to current homelessness case worker that Mother’s ID etc had never been received.  Mother is chased for the documents 3 September 2014 Mother provides required documents and has interview with housing.  Homelessness Case Worker determines that Mother is not intentionally homeless 4 September 2014 Letter sent to Mother to confirm homelessness application has been accepted 9 September 2014 Phone call to Mother from Health Visitor to confirm social worker visit. Mother says she has a new key worker.  Mother invited to attend child health clinic on 17th Sept 17 September 2014 Mother did not attend review appointment for sibling. Rescheduled for 26th Sept Mother attends ED with possible miscarriage, just found out pregnant (approx. 7/40), faint positive test, booked for scan on 18th 18 September 2014 Mother attended scan.  Uterus empty.  26 September 2014 Appointment rescheduled to the 29th 29 September 2014 Mother fails to attend health review appointment for sibling.  New appointment offered for 2 October October 2014 Date unknown.  Father has by now settled into his new medication and attending every few months for Medical Certificates. Date unknown.   Mother attends a scan (a follow up to one in September at ED) 2 October 2014 Sibling seen for health review.  Family remains on Universal Plus care package – for health review in 6 weeks 29 October 2014 Action: Social worker to contact Mother again re need to escalate concerns as she has not engaged with the assessment.  Mother is reported to be living with a friend in East Ham but CYPS do not have an address 12 November 2014 Handwritten notes say numerous attempts to contact Mother but phone is permanently engaged NCS phone call to Mother – says she is at her uncles.  Request made to visit in next 10 minutes but Mother says she is on the way to appointment at Job Centre to present her ID.  Mother reminded of a text message re the case being escalated to Child Protection if she continues to disengage.  Home visit (at uncles) carried out at 2pm – very smoky not conducive for a baby Sibling seen by Newham Children’s Services. (1st and only time seen by Newham social worker). Sibling is noted to have attachment and strong bond with Mother and mother’s uncle.  Sibling noted as being wet through but not showing any signs of distress about this 14 November 2014 Mother and baby (sibling) seen for child health check. Rash noted on sibling – advised to see GP.  Health visitor to contact housing for update 27 November 2014 Email sent by social worker to housing for update – concern expressed that sibling was now 7 months old and the situation still not resolved. Asked for matter to be addressed with sense of urgency  12 8 December 2014 NCS phone call to housing case worker.  The case had been accepted long ago and transferred to Housing Supply.  The case is with letting/private sector.  Social worker says not acceptable and agrees to email setting out concerns re unmet housing needs of sibling. Email sent same day 11 December 2014 Mother attends interview and is booked into temporary accommodation at Chadwell Heath. Mother also completes her medical assessment form and cites medical problems. Homelessness case officer refers her to “Now Medical” an independent medical advisory service Ongoing concerns about missed appointments for sibling and non-engagement with professionals 22 December 2014 Now Medical assessment is returned to Newham Council.  States that although Mother has had episodes of blackouts requiring brief hospital admissions she did not appear to have any substantive medical condition or diagnosis nor that she was currently being treated for any medical condition.  They stated there were no other relevant medical issues and no essential housing needs were identified.  The report recommended that the floor level, location and type of accommodation offered were not relevant and that there was no medical need to reside within the Borough 2015  27 January 2015 Phone call to Mother from health visitor seeking housing update.  New address is given and case handed over to local health visiting team 29 January 2015 Phone call between Health visitor and Barking Health Visiting Team for verbal hand over of case 30 January 2015 Records received from Newham and sent to Seven Kings Team (this is in Redbridge and was an error) 3 February 2015 Electronic records transferred from ELFT to B&D Child Health Team 4 February 2015 Phone call to Health visitor requesting update Phone call to her uncle.  Uncle also says unable to contact Mother.  He does not know her address Email to housing for update.  Response - Mother placed in emergency accommodation. Her booking was cancelled last night as she was about to be made an offer of PRS and officer not able to contact her.  Was expected to come to office tomorrow (5th) due to cancellation 5 February 2015 Mother attended ELFT walk in clinic with sibling for weight check.  Three red spots noticed on forehead.  Notes family address changed to Chadwell Heath. NCS request address update from housing NCS request update from health visitor – response gives address as Chadwell Heath and that the mother had been seen that day – sibling weight had dropped (now 7.89kg) Newham CS phone call to Chadwell Heath Health Centre to request urgent visit.  No response Newham CS request for police intelligence to the Child Abuse Investigation Team regarding sibling.  No details of father given. Police Merlin shared with Newham CS 6 February 2015 Mother calls ambulance for sibling at 21.28 from the father’s address in London Borough of Newham. Mother attends ED with sibling - possible insect bites.  Electronic notes say (incorrectly) that there is a CP Plan from 3 Feb 2014 Sibling seen by co-op GP at 22.54 re red blotches. Discharged back to GP  13 NCS phone call to Chadwell Heath Health Centre.  Case received on 3 Feb and waiting allocation. Agreed to do health visitor home visit on 9 Feb and feedback. Single assessment completed (started in August) concludes main concern is about housing and not a safeguarding concern. Mother only seen once in the 6 month period Managing Agent of accommodation emails to say Mother not living at the property – 2 more emails sent on 27 Feb and 6 March Records from Newham received and sent to Health Visitors at Chadwell Heath. There is a phone call between health visitor and social worker.  Noted Health visitor only for the next week.  Social Worker conveyed family history 10 February 2015 Health visitor update to NCS – visited the property but no one present.  Social worker to complete urgent home visit that day. Unannounced visit made to Chadwell Health.  No-one home.  Mother’s uncle called – he has no contact either but will keep trying Single Assessment signed off 11 February 2015 Sibling’s attendance at ED on 6th Feb is put on RIO NCS email Housing for update.  Concern sibling not seen since December 2014. Response is that the address is correct by they are trying to contact her and if she does not make contact they will have to cancel the booking.  Housing asked for Managing Agents details to gain access to property 12 February 2015 Email re psychosocial meeting re Sibling’s ED attendance.  Health visitor advise to send ED notification to the B&D Child Health Team Opportunistic home visit by Health visitor – no answer.  Social Worker informed 13 February 2015 Sibling and Mother seen at drop-in Child Weight Clinic – 8.04kg.  Mother says she is going to Stratford Housing Dept. Plan made to visit Mother the next week.  Social worker updated 17 February 2015 Phone call from health visitor to Mother to arrange transfer-in home visit.  Mother said not at home that day. Plan to visit on 19 Feb 19 February 2015 No one at home for visit.  No answer to phone calls to Mother – message left asking for her to make contact 20 February 2015 Health visitor phones Mother – no answer message left Health visitors change at this point – now with Chadwell Heath 27 February 2015 Housing Needs Service receive another email/phone call from temporary accommodation agent to say Mother was not living in Chadwell Heath March 2015 Date unknown.  Father sees GP with chronic back pain which is resistant to pain relief. Script for morphine given. 3 March 2015 Phone call from Health Visitor to Mother – home visit agreed for 10.30am.  No one home.  No response to phone call message left requesting contact  14 6 March 2015 Housing Needs Service receive another email/phone call from temporary accommodation agent to say Mother was not living in Chadwell Heath 10 March 2015 Mother attends maternity booking in. Partner “LH”.  Risk factors identified and states there is a social worker due to housing issues.  Case to be under Acorn Team.  Partner identified as 40yrs + but Sibling not documented.  Currently living in B&D in temporary accommodation waiting housing in Newham.  No longer with father of sibling but he supports her with care of 1st child.  Case not been closed because father not engaged with Social Worker and Housing.  Social worker to attempt contact with father and get update on housing Case to subsequently close by 26 March 2015 Paper records show partner is “LW”, unemployed with other children, address in London Borough of Newham Newham Social Worker supervision notes include statement that the sibling is meeting their development needs 11 March 2015 Temporary Accommodation at Chadwell Heath cancelled 16 March 2015 Phone call from Mother to say no where to stay.  Appointment arranged for 17 March Attends scan – about 6 weeks pregnant  Scan showed Mother was 6 weeks pregnant and later scanned booked in.  Mother rescheduled this appointment because she was no longer living in Chadwell Heath because of the bed bugs and was back at her uncles.   Mother said the social worker was aware of the situation 17 March 2015 Mother attended viewing in Edmonton but refused property due to distance 20 March 2015 Maternal aunt phones to say Mother has been locked out of Chadwell Heath property Health visitor leaves message for Mother to contact her 23 March 2015 Mother requests change of scan from Barking Birth Centre to Newham as she no longer lives in Chadwell Heath. Now staying with uncle in Newham and a friend.  Says social worker aware and helping with housing 24 March 2015 Social worker from Hospital Assessment Team requests alternative temporary accommodation for Mother.  Viewing arranged from 7 April 25 March 2015 Mother tells Health Visitor she was evicted and is moving from place to place Health visitor updates social worker 26 March 2015 Scan date changed from 27th to 28th at Newham. Text sent to Mother 8 -12 months check letter sent for appointment on 9th April.  Social worker confirms to health visitor that the mother was evicted 27 March 2015 Offer of temporary accommodation made in Dagenham– viewing on 7 April 30 March 2015 Phone call to Mother by Housing for response to letter – no answer.  Call made to maternal aunt who offers to contact Mother  15 NCS raises questions with housing that if accommodation offered refused would she be evicted from the current property and also that that property was unfurnished  1 April 2015 Housing response – Mother could return to old address to collect her things Text received from Mother and call returned – encourage to attend viewing  7 April 2015 Entry by Redbridge Health Visiting Team – noticed the address is in B&D and records sent by Newham in error 9 April 2015 Mother did not attend 8-12 months health review for sibling 13 April 2015 Redbridge send records to B&D 22 April 2015 Health Visitor phone call to Social Worker requesting update 27 April 2015 Mother calls to confirm scan details for the next day. Advised to come in 10 minutes early 28 April 2015 Mother failed to attend time of appointment – phone goes to voice mail. She shows up at 16.00 – not scanned because she walked off  30 April 2015 Angry phone call from Mother to midwife. Midwife to set up new scan 10 May 2015 Mother takes Sibling to ED for head injury – discharged.  Sibling showing as on CPP (incorrectly) so Children’s Services notified by fax.  Address recorded on A&E Sheet as the mother’s uncle’s address but with handwritten note saying Chadwell 12 May 2015 Attends scan. Delivery date estimated to be 4 November 2015.  Still living at uncles with the sibling.  Allocated flat in Dagenham but waiting for renovations. Is supported by maternal aunt, friend and partner.  Letter to GP for iron deficiency.  Antenatal scan booked for 16 June 13 May 2015 Notification of sibling attendance at ED received and sent to Child Health Team Management Direction to progress case to closure as real concern was about Mother not seeking health input for sibling and housing issues.  Sibling’s father not engaged but sibling does not reside with him.  No further role for CYPS 15 May 2015 Mother’s case is closed by social care  Time Period 3: July 2015 to July 2016.  Relates to paragraphs at 3.4 onwards  9 June 2015 Mother signs tenancy for accommodation in Dagenham 22 June 2015 Mother did not attend appointment. Phone goes to voice mail. Mother text to re-arrange 26 June 2015 Mother attends ED in ambulance.  Baby delivered by at the Father’s address in Newham by LAS – dead.  Lives with uncle. Referred for bereavement midwife support. Midwife says the mother thinks she has had up to 6 miscarriages. Unclear if miscarriage or neonatal death. Decision to issue neonatal death certificate. Post mortem declined 6 July 2015 Mother moves into accommodation in Dagenham Managing agent remembers Mother being upset and referred to having had a still birth  16 August 2015 Date unknown:  funeral papers issued to Mother 3 August 2015 Bereavement midwife follow up with Mother and the death certificate is collected.  Numerous (no dates) attempts to contact Mother beforehand. 10 August 2015 ELFT notified of still birth by NUH.  Bereavement visit offered and confirmed with Mother where it transpired that she no longer lived at the given Newham address.  Maternity ward contacted to confirm the gestational age 17 August 2015 Health visitor phones Mother to confirm home address and arrange bereavement visit 18 August 2015 Bereavement visit not achieved. Health visitors informed by uncle that family had moved to Dagenham. October 2015  Date unknown.  Father tells GP he is buying diazepam off the street 12 October 2015 Deputy Superintendent Registrar emails to say they are still waiting for Mother to register the birth of her (dead) child. Mother due to attend Registrar’s office – but does not 14 October 2015 Email states Mother offered a hospital funeral, but she would not be able to attend.  This was declined, and Mother said that she wanted to organise her own funeral 30 December 2015 Letter sent to Mother asking her to confirm that she wanted to carry out her own funeral.  She was advised that they could not keep the body post 4 weeks and if there was no response the bereavement office would make arrangements  31 December 2015 Letter from Deputy Superintendent Registrar to Mother informing her that if she did not make contact within 10 days they would issue a duplicate death certificate, so the hospital could organise a funeral 2016  February 2016  Date unknown:  Mother contacts Acorn midwife direct and informs her that she is pregnant again.  Acorn midwife refers her for a scan and pre-term clinic. Date unknown:  Mother did not attend the pre-term clinic nor her maternity appointment.  Appointment was rescheduled but then rescheduled by the hospital. When she booked LH was identified as the partner.  Said she had never smoked, did not drink, was living alone in temporary accommodation and that she had had 5 miscarriages. There was resolved domestic abuse history and Children’s Services had closed her case in 2015. As no new issues identified no referral was made to Children’s Services and Acorn Team declined her. Mother was referred to the Foetal Medical Unit due to her previous obstetric history 15 February 2016 Email sent by the Bereavement Officer to the Deputy Superintendent Registrar saying Mother wanted a funeral of her choosing but had not been in touch.  Bereavement officer requested duplicate death certificate, so they could organise a funeral 9 March 2016 Letter from Bereavement Officer to Mother saying that due to no contact they would organise a funeral for 31st March at City of London Cemetery.  She was asked to let the funeral directors know if she would be attending  17 17 March 2016 Last time managing agent of accommodation in Dagenham visited the property.  A neighbour said Mother never stayed there. On entering the agent found no proper furniture, food or sign of residency.  Previous to this there had been quarterly visits by the agent but Mother had never been there and had not responded to letters or phone calls April 2016 Date not known, managing agent notifies Newham Council and cancels tenancy. There was no forwarding address. Notes that homelessness duty had been discharged. 25 May 2016 Mother did not attend appointment with midwife 2 June 2016 Child C born (28 weeks gestation) Midwife called to Mother’s partner’s address early in morning – baby is born.   Ambulances take Mother and baby to hospital from the Father’s address in Newham Mother discharges herself against medical advice later that day. Visits neonatal unit at 5pm.  Says she will return the next day Birth notification address is Dagenham 3 June 2016 Post-natal home visit – no access to property, no answer on phone 4 June 2016 Post-natal home visit – no access to property, no answer on phone 5 June 2016 Midwife sees Mother at home – no problems - follow up at post-natal clinic 6 June 2016 Staff note that Mother not visited since 3rd June – no answer to phone calls.  Safeguarding adviser requests strict visiting record is kept Mother visits SCBU at 18.00 (visit 1) 8 June 2016 Mother visits neonatal unit (visit 2) 9 June 2016 Mother attended post-natal appointment 10 June 2016 Mother visits neonatal unit (Visit 3) 11 June 2016 Mother had to be called to because Child C needed a blood transfusion and she needed to supply a blood sample so this could go ahead immediately. Mother agreed to come the next day and said she would bring in clothes and nappies for Child C.  12 June 2016 When Mother did not arrive, she was called and said that she was having trouble getting someone to look after Sibling and he was ill (flu) so she requested to come in the next day instead of the 16:00 deadline (as bloods need to get to the pathology laboratory for processing), she was advised no.  The Social Worker and safeguarding children team were on the unit waiting for Mother to arrive so they could talk with her. Mother arrived at 16:40 and said the traffic had been bad, Sibling did not look like he had flu and mum had the blood test. Prior to Mother arriving on the unit that day it was discussed with the consultant that if the baby (child C) had not been transfused by the next day it would be unsafe for the baby and would need immediate action.  18 June 2016 Date unknown: A strategy meeting was requested by the safeguarding children team to the Social Worker due to issues that included multiple DNAs in ‘community health’ for Mother and Sibling; minimal visits, short durational visits; lack of provisions for Child C; multiple addresses and contact details; Sibling’s lack of contact with health professionals.  It was also noted that if the hospital were unable to obtain a vital blood sample from mother then they would request the police to collect mother.  13 June 2016 Mother visits the neonatal unit (visit 4) Mother tells the Social Worker she will visit more. She also reports that she is not living in the current address due to electricity and gas issues that were down to the previous tenants.  Safeguarding children team request a professionals meeting and the Social Worker says that she will update all staff following her assessment.  16 June 2016 Mother attended post-natal appointment At 19.00 Mother visits the neonatal unit (visit 5) 17 June 2016 Health visitor attempts new birth home visit. Unable to get Mother on phone or on flat’s intercom 21 June 2016 Referral sent to NCSC – main issue is lack of visits by Mother but she is also asking for food when there Health visitor attempts new birth visit at home.  Neighbours says they have not seen Mother for some time 22 June 2016 Hospital Safeguarding Adviser advises neonatal unit staff to contact Mother to ask her to visit 23 June 2016 Mother does not attend post-natal appointment 24 June 2016 Midwife report says Mother forgot about appointment on 23rd June – was offered (but refused) home visit for the 25th June - said would come to post-natal clinic next week. Health visitor unable to contact Mother and wants staff to ask her to call.  Staff say referral has been made to SCS but waiting for response.  Referral refaxed to Newham CSC.  CSC referral to Newham made and shared with Child Health. Child Health ask for referral to go to B&D as well 27 June 2016 2nd CSC sent to B&D at 16.00 28 June 2016 Hospital Safeguarding Adviser visits the neonatal unit and advises staff to contact Mother – no answer, message left 29 June 2016 Mother visits neonatal unit (visit 6).  Speaks to health visitor on the phone and arranges visit for the next day Hospital Safeguarding call LBBD CSC Triage.  Told case being looked at.  LBBD CSC ring back at 17.00 to say case referred to Family Support Worker Police received referral by CAIT for ICIP.  Health visitor attempts home visit – no answer 30 June 2016 Mother visits neonatal unit (visit 7) – sibling being looked after by his father.  She attends the post-natal clinic, but the clinic is running late, so she leaves – has to pick sibling up from nursery  19 2 July 2016 Mother and a friend visit the neonatal unit (visit 8) 5 July 2016 Mother phones to say she’s been ill but will visit neonatal unit on 6th. Staff seek and get details of social worker There is a planned post-natal appointment but no answer at the house  (the father’s address in Newham) and unable to get hold of the mother by phone Emails between Newham Hospital Safeguarding Adviser and SW about keeping up to date to aid discharge planning 6 July 2016 SW visits neonatal unit and leaves details for Mother. Community midwife wants to discharge Mother so speaks to SW and agrees to visit Mother to assess situation 7 July 2016 SW phone both Mother and the Father – no answer.  Leaves message for both Mother visits neonatal unit in the evening (visit 9) 11 July 2016 Mother is phoned to say a blood sample is needed from her for Child C’s transfusion. Mother says she will be in on the 12th 12 July 2016 SW visits neonatal unit hoping to see Mother.  Mother phones saying trying to get someone to look after Sibling.  SW and Safeguarding Nurse wait on the ward.  Safeguarding Nurse has discussed with the consultant at what point the issue needs to be escalated – decide if Mother not in by 13th Mother visits (visit 10) at 18.20 to give blood sample so Child C can have blood transfusion 13 July 2016 Mother and sibling visit neonatal unit (visit 11).  SW sees both of them and arranges a visit for the 15th 15 July 2016 Mother and sibling visit neonatal unit (visit 12)  Team Manager supervision – Child C cannot be discharged until housing issue is sorted out – checks with Newham Housing to be carried out.  Case to be escalated if Mother’s behaviour continues SW attempts home visit – Flat has been vacant since 29 April 16 July 2016 Mother visits the neonatal unit (visit 13) 18 July 2016 Child C fit for discharge 19 July 2016 Mother visits neonatal unit with Sibling (visit 14) SW asks for planned discharge date The named nurse wanted to understand why mother was unable to visit and also know if the HV had any concerns about Sibling. She clearly states that whilst she does not want to keep a well baby on neonatal unit she cannot safely discharge whilst she has concerns regarding parental engagement The Named Nurse requested a Discharge Planning meeting (DPM). It is noted that the SW wanted to discuss the case with her team manager. There was an escalation of concerns regarding no accommodation as well as the other concerns previously stated. 20 July 2016 Named Nurse says cannot discharge Child C until there is a safe place to go to 21 July 2016 Mother tries to visit neonatal unit with maternal aunt–  issue about visiting hours  20 22 July 2016 Notes say Child C is fit for discharge.  SW emails Named nurse to say case escalated and a 87a completed for strategy meeting with the police 23 July 2016 Mother visits neonatal unit (visit 15) – leaves phone number to be told when DPM is 25 July 2016 SW says won’t hold a DPM until the strategy meeting held with the police Strategy meeting held – recommends the case progresses to ICPC 26 July 2016 Mother visits neonatal unit (visit 16). Says she is living in Bow with maternal aunt and sibling is at her uncles. 27 July 2016 Mother visits the neonatal unit (visit 17) ICPC arranged for 15 August. SW tells Named Nurse that mother will live with maternal aunt and a home visit is arranged for 28th July. Professional meeting proposed for 29th and DPM on 1 Aug. Mother tells health visitor her address is her sister’s (the maternal aunt) address in Tower Hamlets. 27 or 28 July 2016 Mother visits neonatal unit with the baby’s father (visit 17 or 18) -  entry not dated, just says between 27th and 28th  28 July 2016 SW visit to maternal aunt’s house - Mother did not attend. Maternal aunt says she will support Mother at the ICPC meeting 29 July 2016 (Friday) Professional Meeting takes place.  Attendees: neonatal unit Nurse, Named Nurse for Safeguarding. SW met with Mother (with maternal aunt).  Mother arrived at 16.30 for a 13.30 meeting.  Agreed plan for Mother and children to live with maternal aunt.  SW to assess suitability of home 31 July 2016 Mother calls neonatal unit and requests update 1 August 2016 (Monday) SW requests DPM for 2nd August 2 August 2016 (Tuesday) DPM at Newham Hospital.   Attendees:  Mother, SW, Named Nurse for Safeguarding, Neo Natal Ward Doctor, Neo Natal Ward staff nurse. Apols from Tower Hamlets Health visitor.  Date for discharge not set.  Not registered with GP Designations of people in attendance written down.  Health visitor does not attend but there is a request for an update after the meeting.  Maternal aunt’s address is recorded as is Mother’s phone number but it says that she is unavailable.  Dr had written notes saying Child C was fit for discharge but needed routine blood tests and eye review next Thursday (4 August?).  Someone says that Mother will be at her maternal aunt’s address for about 3 months.  Social worker says the home environment is fine and that maternal aunt is sensible.  Noted that Mother needed to register with a GP in Tower Hamlets and speak to the cab firm about a car seat. Noted that social worker spoke to Mother about time management and the need to stay at maternal aunt’s address, that the children’s whereabouts needed to be known and that the case would not be transferred to Tower Hamlets at that time. 3 August 2016 (Wednesday) Mother visits neonatal unit. (visit 18 or 19) Also advised to register with GP  21 4 August 2016 (Thursday) Mother asked to come in and sign consent forms for immunisations  Time Period 4: 5th August 2016 to 22nd August 2016.  Relates to paragraphs at 3.5 onwards  5 August 2016 (Friday) Consent forms not signed Social worker happy for discharge.  Doctor advised Mother that babies usually kept in for 24 hrs after immunisations.  Mother says will be back at 18.00 and wants to take Child C home.  Child C discharged at 6pm Paperwork sent to GP1–  Mother not yet registered with GP in Tower Hamlets Discharge says mother’s address is the maternal aunt’s address in Tower Hamlets and that this is the discharge address. Father is “LH” living at an address in Newham. Notes that mother is moving to stay with maternal aunt 8 August 2016 (Monday) B&D Multi Agency CP Conference date set for 15th August SW visits maternal aunt’s address to see Mother and Child C – no answer.   Maternal aunt says Mother has said she’d cancelled the visit because Child C was unwell. Mother angry that maternal aunt was contacted.  Agreed priority to take Child C to hospital  Conference date set for 15 August 9 August 2016 (Tuesday) SW emails Named Nurse to say Mother said she took Child C to hospital on 8th. Named Nurse confirmed Mother did not attend hospital but had called and was advised to go to A&E 11 August 2016 (Thursday) Health visitor tells SW of failed meeting with Mother at Globe Town Health Centre and attempted unannounced home visit but no-one home Tower Hamlets health visitor not attending ICPC as Mother not living in Tower Hamlets and there will be no further support.  Responsibility with GP Surgery SW does unannounced visit to try and see Mother and children at her uncle’s address, Uncle presents as vulnerable adult.  Says not seen Mother for 18 – 24 months Team Manager approved social worker’s report for the ICPC 12 August 2016 (Friday) Agreed case can go to TCLPM if Mother does not attend or allows the SW to see the children 15 August 2016 (Monday) ICPC held at Barking Town Hall Both children put onto CP Plan Neglect. Child C not seen by a professional since her discharge Named Nurse attended.  Her notes say Mother arrived late and left early.  No notes from Conference 16 August 2016 (Tuesday) Agreed to escalate case to attention of Group Manager and agreed to be taken to Thresholds of Care and Legal Planning Meeting with Public Law Outline plan Single Assessment recorded as completed on ICS 17 August 2016 (Wednesday) TCLPM held – meets criteria for applying for interim care order.  Decide not to remove children now but keep under review.  If children not seen by 19th August application for Emergency Protection Order to be considered  22 Unannounced home visit by SW at maternal aunt’s home – no one in. Home visit arranged for 18th Re maternal aunt’s checks – no concerns 18 August 2016 (Thursday) Home visit by SW.  Not in, SW phoned Mother who said she would be back in 5 minutes.  SW waited for 45 minutes then left. Maternal aunt gave permission to SW to look round – no evidence of Mother and the children living there. SW bumped into Mother in the street and challenged her about where she was living – insisted she lived at that flat 19 August 2016 (Friday) SW sees Mother and children at the office.  Plan to relocate to Essex SW requests Police checks on Maternal Grandmother. Mother, Maternal Grand Mother and maternal aunt sign Family Plan. Plan is for Mother to move with the children on 21st August to live with maternal grandmother but live with maternal aunt in the interim.  Social Worker to visit on 21st August  Time Period 5: 22nd August 2016 to Child C’s death.  Relates to paragraphs at 3.6 onwards  22 August 2016 (Monday)  SW visits maternal grandmother’s home to check suitability. SW recorded that Mother and children had moved to live with maternal grandmother Core Group originally planned for this date SW told to alert Essex of children on CP Plan moving into their areas and to alert the CP Chair Family relocate to Essex 23 August 2016 (Tuesday) SW contacts CP Chair, Health Visitor in Tower Hamlets and Essex CSC Health Visitor notified by SSW that Mother had moved to Essex on 22nd and that SW would be asking Essex to place the children on a temporary register 24 August 2016 (Wednesday) SW tells health visitor of Mother’s new address in Essex B&D health visitor gives hand over to new health visitor over the phone CP Summary completed by health visitor.  Details of next CP Conference records and date of Core Group confirmed Mother registers at GP practice in Essex TCLPM updated.  Legal advice is not to issue PLO. Safeguarding agreement to be put in place, work with CP plans. Core group meetings to be arranged. SGO advise to be sought for maternal grandmother if needed  Community Health records show a move of children on CPP.  Icon is added to record 25 August 2016 (Thursday) GP practice asks Mother to come in with the children’s Red Books.  Sibling is booked in for  12 month immunisations that afternoon.  Maternal grandmother attends for appointment with sibling 26 August 2016 (Friday)  SW receives phone call from Mother saying the maternal grandmother has kicked her out and she needs accommodation in B&D  23 SW speaks to maternal grandmother who says she cannot accommodate Mother and the children indefinitely 30 August 2016 (Tuesday) GP practice rings Mother and advises her to bring Child C in on 7th Sept for immunisations and to see the GP 1 September 2016 (Thursday) Health visitor does home visit to maternal grandmother’s address – sees both children.  Another visit/Core Group arranged for 6th Sept  SW letter to GP – both children on a CPP at LBBD under category of neglect 5 September 2016 (Monday) GP confirmed with B&D that Mother had registered with their surgery.  GP requested Social Care to liaise with Essex Social Care to organise Health Visitor  6 September 2016 (Tuesday) Core Group Meeting held at maternal grandmother’s address.   Mother, maternal grandmother, SW, Health Visitor 4 present.  7 September 2016 (Wednesday) GP sees Child C with Mother, Sibling and maternal grandmother.   8 September 2016 (Thursday) GP practice rings Mother to remind her to bring in child C’s Red Book – she does SW phones Mother and also maternal grandmother.  Neither answer. Messages left asking them to make contact 12 September 2016 (Monday) Home visit by Health Visitor 14 September 2016 (Wednesday) SW phones Mother – no answer.  SW phones maternal grandmother who says that Mother and the children left on 12th September after the visit by the health visitor. Mother is due back on 15th (Thursday) 16 September 2016 (Friday) GP practice phone Mother and make appointment for Child C on 19th 19 Sept (Monday) Child Protection Home Visit by SW.  Mother, Sibling and Child C seen at maternal grandmother’s address.  Mother on way to GP appointment. ICPC minutes received and sent to professionals and parent GP sees Child C and appointment for Child C’s 3rd round of immunisations is booked 23 September 2016 (Friday) Housing Options Essex ring SW – Mother does not have appointment – case still being checked 26 September 2016 (Monday) Mother cancels Monday’s (26th) visit and re-arranged for Tuesday (27th) by text Family discussed at Children’s Centre Meeting.  Family allocated to worker 27 September 2016 (Tuesday) Text from Mother - not available for the afternoon visit from health visitor.  Could it be re-arranged to Wednesday afternoon (28th).  Visit booked for 16.00 on 28th  24 Case supervision – SW view is that Mother responding better and showing more insight. Decision needed whether LBBD continues to work with the case or to discuss transfer to Essex. Plan to visit every 2 weeks 28 September 2016 (Wednesday) 09.30 Mother boards bus in with Child C in a baby sling and the 2 year old Sibling in a pushchair.  After around 20 minutes she arises alarm that Child C is not breathing. Passenger on bus performs CPR   LAS and police called to incident and Child C is taken to Newham General Hospital with the mother. 11.30 Child C is pronounced dead. A rapid response meeting was convened and police investigation by the Child Abuse Investigation Team started Mother and Father arrested on suspicion of murder Phone call from maternal grandmother to social worker to say Child C had died Newham Hospital inform team manager of death and likely NAI – 16 weeks and 6 days old Strategy Meeting held at LBBD with GM, TM, Police and health 30 September 2016 (Friday) Specialist post mortem.  Cause of death “head injury”. Skeletal survey post death indicated multiple fractures that had occurred on different dates and were consistent with NAI. 1 October 2016 (Saturday) Both parents charged with murder.     25 Appendix 3: Recommendations from IMRs:  The recommendations from the Independent Management Reviews demonstrate that ‘learning’ from this case has already happened and changes have been made to practice. Examples include:  • ELFT have introduced a mentoring programme for newly qualified health visitors that includes monthly supervision using ‘Signs of Safety’  • LBN and Essex have introduced a Neglect Strategy to support practitioners in the identification and management of neglect  • LBBD the use of CIN templates at the point of discharge from hospital  • Barts Health to emphasise  ‘Think Family” in training programmes and reinforced in supervision  • NELFT Health Visitors to consistently use the assessment framework to document needs assessments in children’s records  • Essex Clinical Commissioning Group will ensure that their current standard operating procedure reflect that where the patient discloses safeguarding information that this is reviewed by the practice safeguarding leads and appropriate alerts are uploaded to the patient record  • Local Health Provider has tightened the process around attachments to record, to ensure it is documented in the electronic record that these have been read by the named clinician.  All of the recommendations made in the IMRs should be reviewed by the respective LSCBs.  London Borough of Barking and Dagenham:  1. Quality of practice in single assessment and plans  Continuing attention and support has to be given to the guidance and training for social workers and case supervisors about:  a) Voice of the child: the voice of the child must be strong and ‘jump off the page’ in assessments, plans and case records, including records about health and development needs. There should be further input about practice guidance and ‘what does good look like’ and with particular attention to situations in which there are difficulties with parent/s engaging and in which children are non-verbal.  26  b) Use of research: the principle of drawing on research findings and in this case use of the Research in Practice briefing with the Dartington research about attachment should be evident in assessment and case records to inform and underpin decisions and a plan for support and intervention  c) Working with neglect: the Children’s Social Care service should also now put into practice a tool which would be used when carrying out assessments and also ongoing work when neglect is an issue. This would also be with a view to developing the tool for multi-agency working.  d) Invisible father: the child/ren’s father remained invisible due to mother (and her family) misleading professionals on a regular basis. Despite this, as happened in this case, investigations should continually remain vigilant as to the possibility that father might be hidden or emerge and then a risk assessment should follow. Self-reporting by a mother should be respected but has to be checked further.  e) Working with uncooperative and hard to engage families: a strong theme in this case and a significant challenge for the staff who were trying to fulfil their responsibilities to the children. There is procedural guidance in place on the London Child Protection Procedures but further support through training is also merited. There are no easy answers but input, including training, would give social workers and managers the opportunity to think and reflect further about the issues involved  2. Safeguarding process and procedural points  a) Use of template for CIN plan: plans for children in need upon discharge from hospital should be recorded using the Child in Need plan template, distributed to the relevant professionals, and parent/s and recorded accordingly whilst also being chaired by a Team Manager.  b) Agreement with parents and families: Child in Need plans or Child Protection plans should be used as the starting point for the formal agreement between parent/s and the local authority. These should be signed by the parent/s as an indication of agreement.  Further guidance would be helpful about the use of ‘safeguarding agreements’ if a written agreement is needed further to the plan – referred to as a written contract in the London Child Protection  27 procedures. If used then there should be a model template which sets out the expectations of the parent/s and any other family members involved; the services to be provided; arrangements for review; and the contingency plan if the agreement is seen not to be working.  As with the use of CIN or CP plans if the parent does not sign in agreement or the agreement is breached then the contingency plan must be considered including discussion at the Threshold of Care and Legal Planning meeting or more immediate emergency action.  3. Children and families moving across local authority boundaries  a) Children on child protection plans moving across local authorities: if a child who is the subject of a child protection plan moves to another local authority then that local authority must be notified.  The child protection plan should also be shared at the earliest possible point with any other members of the core group in the local authority area concerned.  4. Disseminate findings and lessons learned  The findings and lessons learned will be disseminated through meetings with staff and forums for further discussion such as supervision, team meetings, service meetings and the Practice Improvement + Outcomes Group for Team Managers.  Lessons learned will be assimilated in to training provided for social workers, managers and independent reviewing officers   London Borough Of Newham:  Newham were already sighted on and have begun to address issues flagged in the IMR. Notably:  1. A partnership wide implementation of an evidence based systemic tool for neglect.  2. Driving forward a systemic approach to assuring consistency in practice, quality of assessments and robust reflective supervision  3. Improved and proactive information sharing across agencies.  A comprehensive plan was in place to address issues and was  28 operationalised in 2015.16.  London Borough Of Newham Adult Social Care:  No recommendations  London Borough of Newham Housing Needs Service:  No recommendations.  Newham CCG – General Practice:  No recommendations   Barts Health NHS Trust:  1. Acorn Teams notes should marry up with the hand-held maternity notes.  2. Notes audit to be conducted on the Neonatal Unit.  3. Neonatal unit Community Nurse to be in place in Neonatal Unit.  4. Audit of the use of the purple sticker within postnatal notes.  5. Meeting proforma to be launched within Neonatal Unit and paediatric ward to cover all multiagency meetings such as strategy and discharge planning meetings.   6. Training and supervision to emphasise more regarding the use of genograms and Think Family approach.  7. Letter to be developed and sent to regularly used CSC that any strategy meetings should take place on Newham hospital site if the child is an in-patient  8. Standard Operating Procedure to be developed in cases of later miscarriages attending ED.  9. Bereavement registrars to escalate to clinical staff if delays in parent(s) attending to receive death certificates and organise funerals.  10. Learning flyer regarding this case to be shared when SCR finalised and share at all sites safeguarding meetings.  11. Teaching around complex discharges from Neonatal Unit  12. Rooming in to be offered to all parents once their baby is close  29 to fit for discharge.  13. Staff to be made aware of escalation processes both internally and with external partners   East London Foundation Trust:  1. Review of health visitor’s operational protocol.  2. Monitor staff access to safeguarding supervision and case discussion  3. Review of administrative process for transferring records out of the Trust  4. Improving communication blocks across organisational boundaries.  North East London Foundation Trust:  1. Key learning from SCR to be cascaded through managerial frameworks from ISG to frontline practitioners.  2. Key learning from SCR to be shared with Safeguarding Children Supervisors.  3. Health Visitors to be professionally curious and to escalate safeguarding concerns where indicated.   4. Health Visitors to consistently use the assessment framework to document needs assessments in children’s records   5. Areas of emerging learning from SCR are formally discussed in managerial supervision with all universal services practitioners.   6. Practitioners involved in child C’s and her siblings care to be aware of emerging learning from SCR to include notable practice and areas to be strengthened.  7. Health visitors to be clear about Corporate Health Visiting and their accountability.     An Essex Clinical Commissioning Group on behalf of a GP practice:   1. Essex Clinical Commissioning Group, ensured the GP practice involved amended their current standard operating procedure to reflect that where the patient discloses safeguarding information that this is reviewed by the practice safeguarding  30 leads and appropriate alerts are uploaded to the patient record” 2.  Essex Clinical Commissioning Group ensured the GP practice involved amended their GP patient registration form for children up to the age of 18, to include a tick box that would indicate if children are subject to a child protection plan and/or are a current Looked After Child 3. Cascades (internally) revised contact details for the health visiting service once received following the change to a new provider from the 1st April 2017  The Local Provider Health Service in Essex:  1. Initial Health Needs Assessment Standard Operating Process  2. Transfer in of children on CPP or CIN to be notified to Safeguarding team for review of case.  3. Skills workshop on disguised compliance for 0-19 service clinicians. To include information around late cancellations of appointments and when these should be escalated.  4. Tighten process around attachments to record, to ensure it is documented in the electronic record that these have been read by the named clinician.  London Ambulance Service NHS Trust:  No recommendations.  Metropolitan Police Specialist Crime Review Group:  No recommendations.            31 Appendix 4: Acronyms and Terminology   ASC Adult Social Care BARTS Barts NHS Foundation Trust CPR Cardio Pulmonary Resuscitation CAMHS Child and Adolescent Mental Health CHC Child Health Clinic CIN Child in Need CPP  Child Protection Plan CSC Children Social Care DfE Department for Education ED Emergency Department ELFT East London Foundation NHS Trust GP General Practice / Family Doctor HV Health Visitor HNS Housing Needs Service ICPCC Initial Child Protection Case Conference IMR Individual Management Review IT Information Technology LAS London Ambulance Service LBDD London Borough Barking and Dagenham LBH London Borough of Newham LCPP London Child Protection Procedures MARF Multi agency Referral Form MASH Multi agency Safeguarding Hub MP Metropolitan Police NN Named Nurse NAI Non Accidental Injury NCSC Newham Children’s Social Care NIHIT Newham Intensive Hospital Intervention Team NUH Newham University Hospital NHS Trust NSPCC National Society for Prevention of Cruelty to Children SCR Serious Case Review SCRP  Serious Case Review Panel SW Social Worker TAC Team Around the Child TCLMP Threshold of Care Legal Planning Meeting TM Team Manager UCC Urgent Clinical Care       32 Appendix 5:  References  Working Together to Safeguard Children, A guide to inter-agency working to Safeguard and promote the Welfare of Children (HM Government, 2015)  London Wide Child Protection Procedures 2016  Assessing Children in Need and their Families: Practice Guidance (DOH 2000)  Research Briefing: Neglect (NSPCC 2012)  Developing an effective response to neglect and emotional harm to children. Ruth Gardner University of East Anglia and The National Society for the Prevention of Cruelty to Children (January 2008)  Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 -2014 (DfE 2016)  Brandon M, Belderson P, Warren C et al (2008) The preoccupation with thresholds in cases of child death or serious injury through abuse and neglect, Child Abuse Review, 17 (5), 313-330  Sofia Serious Case Review Tri-borough (Dec 2015)  Child J Serious Case Review, Luton Safeguarding Children’s Board (02.06.2107)  UK – World Health Organisation Growth Charts (2016)   