Death of a baby boy in December 2014 aged six-weeks. Cause of death was given as sudden death in infancy; the birth of a second child led to reinvestigation of the case. The pathologist felt the two fractures to the baby's knee were more likely to be non-accidental injuries and not linked to vitamin D deficiency. Both parents were known to statutory services during their childhoods in response to concerns about parental care. The mother was a vulnerable adult and was diagnosed with a mild learning disability. Shared Lives carers described her as needing constant prompting with basic daily living tasks. Mother left the scheme before her pregnancy. Parents received enhanced health visiting services and were in regular contact with a children's centre. Children's social care were not involved with the family at the time. Key findings include: the importance of professional curiosity to ensure roles and remits are well understood; when a learning disabled woman becomes pregnant, the impact on her ability to care for her children should be considered; adult services practitioners require a deeper understanding of their safeguarding responsibilities and should work collaboratively with other agencies; importance of professionals communicating with each other to verify information given to them by family members; the need to communicate key information to the couple should have been informed by a formal assessment. Recommendations to the LSCB: to develop a local partnership-wide "think family" strategy; to secure a better shared understanding of roles and responsibilities to enhance effective joint working; to cascade key learning from this SCR to front-line staff by means of bespoke briefings.
      
 Title:  Serious case review: Baby D. LSCB: Hull Safeguarding Children Board Author: Linda Richardson 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.                             Hull SCR/ Baby D/LR Final Report/ February 2018            Serious Case Review  Baby D       February 2018                   2  Contents   1. Circumstances which led to a Serious Case Review   2. The approach used (including details of review team and practitioners group)    3. Scope and terms of reference (including review period and rationale)    4. Overview of what was known to agencies    5. Appraisal and analysis of practice    The ways in which professionals in adult services understood parent’s vulnerabilities and the impact these could have on parenting abilities   The effectiveness of multi-agency working   The effectiveness of communication with the family   6. Concluding comments   7.  Summary of Learning Points and Recommendations    Appendix 1: Serious Case Reviews     3 1. Circumstances which led to this SCR  1.1. Baby D died in December 2014, aged 6 weeks.  1.2. Baby D had not been identified by health practitioners as being unwell prior to his death. There had been four contacts with the GP when Baby D was being treated for constipation and thrush to the throat but otherwise he appeared healthy and there were no recorded safeguarding concerns. The parents were in receipt of enhanced health visiting services and were in regular contact with a children’s centre and a care co-ordinator (CC1) from the Community Team, Learning Disability (CTLD). A community nurse (CN1) from CTLD also visited occasionally. There was no involvement at the time from children’s social care (CSC).  1.3. After his death, and in line with procedures, a paediatrician examined Baby D. Medical records indicate that he was appropriately dressed and seemingly well cared for. There were no indications of concern, no nappy rash, concerning marks or bruising. However, a skeletal X-ray revealed a recent fracture, and an old fracture, around the right knee.  1.4. The post-mortem showed that Baby D had a vitamin D deficiency and professionals accepted this at the time as an explanation for the fractures to the baby’s knee. The coroner determined the cause of Baby D’s death was sudden death in infancy in association to areas of non-compaction of the left ventricle.1   1.5. The Independent Chair of Hull Safeguarding Children Board (HSCB), supported by a sub-committee of the board, made the decision that, as there were no concerns or evidence of abuse or neglect, the criteria for a Serious Case Review (see Appendix 1) were not met. Although practitioners had previously expressed some concerns around dirty home conditions and had queried how MD, specifically, would cope as a parent, there was no evidence to suggest these factors contributed to the death of Baby D. There were, however, other factors present which are known to be associated with sudden death in infancy: the baby’s age, gender, the winter weather conditions and the baby’s sleeping position at the time of death. Following a discussion at the Child Death Overview Panel, it was agreed that a local “Lessons Learned Review” should be held in order to identify any areas of learning, which could be of benefit to future parents.  1.6. MD gave birth to a second child in 2015. Concerns about the care of that child resulted in family court proceedings. During this process, a pathologist revisited the previous report on Baby D’s injuries and cast doubt on the accepted explanation of how these occurred. The pathologist reported that the two fractures were more likely to be as a result of non-accidental injuries and were not related to any vitamin D deficiency, as had previously been stated. Although these injuries were not linked to Child D’s death they did indicate the possibility that Baby D had been physically hurt at some time during his short life, an unusual occurrence in such a young baby.                                                                 1 This is a condition which affects the development of the heart muscle whilst in the womb      4 1.7. On Tuesday 20th September 2016 the Independent Chair, following consideration of the available information and in response to a recommendation from the sub-committee, made the decision that the criteria for a serious case review were now met and that the HSCB would proceed with an SCR in line with statutory guidance.   2. The approach used  2.1. The Board appointed an independent lead reviewer experienced in undertaking serious case reviews, and who had no prior connections to any of the agencies involved in this review, to work alongside an officer of the LSCB and the Designated Nurse for Safeguarding Children (NHS Hull CCG) as joint reviewers. This combination of reviewers, with local knowledge and one without, served the review well and enabled a sensitive and efficient engagement with local agencies.  2.2. A review team was established and chaired by the independent lead reviewer. The review team gathered and analysed data, appraised practice and agreed the content of this report. Agencies represented on the review team were:    Linda Richardson  Independent Lead Reviewer   Lorna Morris   Reviewer, NHS Hull Clinical Commissioning Group Lee Smawfield    Reviewer, HSCB Professional Practice Officer Neil Colthup     Manager, HSCB Laura Bell     Business Support Coordinator, HSCB  Named Nurse for Safeguarding City Health Care Partnership Professional Practice Officer Adults Social Care, Hull City Council Group Manager   Children’s Social Care, Hull City Council Community Housing Manager  Neighbourhoods and Housing, Hull City Council Assistant City Manager,   Early Help & Commissioning, Hull City Council Named Nurse for Safeguarding Humber NHS Foundation Trust Named Nurse for Safeguarding  Hull and East Yorkshire Hospitals NHS Trust Named GP for Safeguarding  NHS Hull CCG  Written contributions were also received from Humberside Police and Yorkshire Ambulance Service.  2.3. A practitioner’s group was established which brought together frontline professionals who worked directly with the family. Individual conversations were held with seven key professionals in order to better understand their role in working with the parents as vulnerable adults. Individual conversations were also held with the Shared Lives scheme manager and Shared Lives carers.  The openness and willingness of practitioners to reflect on their work with this family contributed to much of the learning, which has emerged from this review.        5 2.4.  The practitioner’s group consisted of:   Health visitor Midwife Children’s Centre practitioner Children’s Centre manager Community Team, Learning Disability social worker Community Team, Learning Disability care coordinator Group Manager, Children’s Social Care Community Nurse, Humber NHS Foundation Trust Children’s Social Care social worker based at the local hospital General Practitioner  2.5. The reviewers also met with the parents and maternal grandfather of Baby D and their views and helpful contributions are represented in this report.  2.6. At the start of the review, a time line of agency interventions was collated to illustrate multi-agency activity, who knew what and when. Agency leads were then asked to complete a first draft of an agency learning report, which described and analysed practice within their own agencies. These learning reports were presented to the review team for comment and challenge. Further data was provided through scrutiny of various assessments and agency records.   3. Scope and Terms of Reference   3.1. The review team agreed that the period under review would be from January 2014 when MD met FD just prior to moving out of the ‘Shared Lives Scheme’2, up until the death of Baby D in December 2014.  3.2. The review team chose not to set specific terms of reference from the outset but allowed key issues to emerge as the review unfolded. This approach allowed a wider exploration of events rather than a pre-determined focus on specific issues without understanding what happened, when and why. After the third panel meeting and with the benefit of agency learning reports and individual conversations with key practitioners, initial lines of enquiry were identified and this helped the review team build a framework with which to review practice and safeguarding systems. These were:  The ways in which professionals in adult services understood MD’s vulnerabilities and the impact these could have on their parenting abilities   The effectiveness of multi-agency working   The effectiveness of communication with the family.                                                                2 Shared Lives Scheme provides family-based accommodation or support for vulnerable people. The emphasis is on providing an ordinary family life, so that people can live or stay within the community.    6 4. Overview of what was known to agencies  Background Information 4.1. Both MD and FD were known to statutory agencies at various times throughout their childhoods in response to concerns about parental care, and each had times in their lives when they were estranged from their families.  4.2. As a young adult, FD sought and accessed support from a number of professionals over the years, in respect of his depression and need to better manage his emotions. At times, FD was homeless but then acquired a tenancy in his own right a few weeks before his relationship with MD began.  4.3. As MD grew into her teens, there were professional concerns about her vulnerabilities. A Child and Adolescent Mental Health Service (CAMHS) assessment highlighted that she had significant developmental needs, which could possibly be helped through family work. However, both the family and MD declined offers of support and MD continued to live at home with her father, stepmother and siblings. As MD grew older, she frequently ran away from home and was often picked up by police when they found her sleeping rough, seemingly unaware of the dangers to which she could be exposed. There were continued concerns about her vulnerability and the possibility that she was being sexually exploited. Interventions by the Local Authority Safeguarding Adult (LASA) team when MD was 19 led to a referral in March 2012 to the Community Team, Learning Disability (CTLD)3 for support and assessment of a learning disability.4  4.4. MD continued to go missing at various times and relationships with her family broke down. Concerns about MD continued and a safeguarding strategy meeting was held in October 2012. At the meeting, recommendations were made which required the completion of MD’s assessment to determine the extent of her learning disability and also that MD should be allocated a social worker to provide professional support.   As social worker 1 (SW1) was already involved with another family member and had met MD previously, she became the allocated social worker and led on the assessment of MD’s needs.   4.5. Later that month, SW1 began to consider options for an emergency placement for MD when her father and stepmother said she could no longer live with the family.  MD very briefly moved in with her birth mother but this arrangement did not last and MD moved back to live with her father and stepmother.  4.6. A cognitive assessment of MD was completed by a clinical psychologist and a community nurse (CN1) from the CTLD team between November 2012 and March 2013 and this diagnosed MD with a ‘mild learning disability’ A recommendation for a referral to family therapy to address ‘systemic issues which were thought to be contributing to MD’s behaviours’ was not accepted by the family and consequently no family work was undertaken.                                                               3 The community learning disability team (CTLD) is the first point of contact to both inpatient and community services. Individuals accessing the service have a learning disability diagnosis, are over 18 years of age or in transition from children’s services. 4 In this document a learning disability refers to the difficulties a person may have understanding new or complex information, learning new skills or coping independently.     7 4.7. The LASA team had previously assessed MD, as having ‘substantial’5 support needs making her eligible to receive services from local authority adults services. After needing an emergency placement following another family breakdown, MD was introduced to a Shared Lives placement 6 in March 2013 and moved in with carers in May of that year.  By this time, SW1 was on long-term leave of absence and CC1 took over the case and was responsible for overseeing the support and placement package offered to MD. An occupational therapy assessment around daily living skills was completed whilst MD was living in this placement and concluded that, from observations, MD would continue to need support and assistance to live independently in the community.  4.8. MD stayed in the Shared Lives placement from May 2013 until January 2014. During this period a number of reviews took place each attended by MD, Shared Lives carers, the Shared Lives placement worker, and CC1. During these reviews MD indicated that she was happy and settled in the placement. She was noted to have a wide circle of friends with whom she had regular contact and often talked about wanting a ‘normal life’ and having a boyfriend and a baby. Support was offered to MD about sexual health and contraception. There were no concerns raised regarding her safety but Shared Lives carers did describe MD as requiring ‘constant prompting’ with basic daily living tasks such as preparing food and maintaining personal care.  Period under review 4.9. In January 2014, MD left the Shared Lives scheme to move in with FD, who she had met several days earlier, effectively bringing to an end her involvement with local authority adults services. At the time very little was known about FD but it was understood that he had a tenancy of his own. The Shared Lives carers visited MD a few days later and were extremely concerned about the conditions of the home in which she and FD were living. There is no formal record of an end of placement review but the practitioners from adult services recorded that, in their view, MD was capable of making her own decisions and they therefore respected her wish to remain living with FD. The Shared Lives placement was kept open for approximately 4 weeks after she left but then her case was formally closed to adults social care. There was no review of this decision.   4.10. In early Spring 2014, MD became pregnant and there followed numerous calls made to the NHS 111 number, A&E and midwifery services by FD, both in connection with MD’s general health and in relation to her pregnancy. The nature of the calls indicated both parents knew very little about the physical aspects of pregnancy.  In the early stages of MD’s pregnancy and following a discussion with the hospital social worker, a midwife made a referral to CSC requesting parental support for the couple. After 4 weeks, when there had been no response from CSC, the midwife rang the duty officer in CSC and was advised to refer the couple onto the children’s centre for support and practical help and that the children’s centre would make a referral to CSC should they consider it necessary.                                                                 5 This refers to the Fair Access to Care Services (FACS) eligibility criteria banding of substantial need. FACS contained four bands – low, moderate, substantial, and critical. 6 Shared Lives scheme offers an alternative to residential care for vulnerable adults. Care and Support is provided by trained and approved carers in various locations but usually in the carer’s own home.       8 4.11. Records indicate that MD was seen by 32 midwives at 24 antenatal appointments during her pregnancy even though she was noted to have a healthy and uncomplicated pregnancy. It became clear to midwifery services both before and after the birth, that this was a very vulnerable couple, both of whom were thought to have some learning difficulties and who were observed to have significantly high dependency needs. Contact with CC1 by midwives provided some information about MD’s background and as the pregnancy progressed, the concerns of the midwives as to how the parents would cope once the baby was born continued.  4.12. Although the case was formally closed to adults services, CN1 and CC1 from CTLD initiated some informal contact with the couple throughout the pregnancy and after the birth. Both MD and FD described CC1 to other professionals as their social worker, although this was not the case.  4.13. MD and FD were noted to engage well with the children’s centre sometimes making contact up to 5 times a week. The children’s centre practitioner (CCP1) offered practical advice about budgeting, parenting and house cleaning and the couple willingly accepted any support or advice offered. An enhanced health visiting service was introduced by the health visitor who was concerned about the state of the home and the number of animals living in the house. Professional concerns centred on the extent to which the couple fully understood the advice given to them, but the couple were thought to have prepared well for the birth of the baby.  4.14. Baby D was born in November 2014. Midwifery records refer to some concerns about how the couple would manage but there were no further referrals made by midwifery or any other professionals to children’s social care before or after the birth and Baby D and MD were discharged from hospital following confirmation from both parents they had support from family and from CC1.  4.15. CP1 visited the family to work with the parents on understanding first year of baby’s life and to assist them with securing grants. In early December 2014, Baby D, aged 26 days was seen with MD and FD at the children’s centre post-natal clinic by a community midwife. He appeared well and no concerns were identified so the baby was discharged from midwifery care. Records indicate that both midwives and the health visitor gave appropriate safer sleeping advice and both professionals could recall specific conversations they had with the parents about sleeping arrangements. The health visitor and the children’s centre practitioner last saw Baby D during separate planned appointments on 17th December 2014. There were no concerns identified about the care of Baby D and MD disclosed to both practitioners that she thought she might be pregnant again.  4.16. MD and FD took Baby D to 4 GP appointments following his birth where the parents sought advice about wheezing, crying, constipation and thrush. The GP provided medical treatment and gave advice to MD and FD about not smoking near Baby D and to keep the animals away. The last GP appointment was on 22nd December 2014 but no concerns about Baby D were noted.        9 4.17. Baby D died at the end of December 2014 aged 6 weeks. MD had contacted Yorkshire Ambulance Service via a 999 call and CPR instructions were given over the telephone to FD until the ambulance crew arrived. Baby D’s death was attributed to sudden death in infancy in association with non-compaction of the left ventricle. The pathologist identified Baby D’s risk factors for sudden death in infancy as including: male sex, winter months, age and prone sleeping.    5. Analysis of Practice  5.1. It important to recognise how much hindsight can distort judgment about the predictability of an adverse outcome. Once a tragic outcome becomes known, there can be a tendency to look back over the history of the case and pinpoint certain actions or moments which are believed to be critical in leading to that outcome. Hindsight-bias can also lead to a false reassurance that what happened was predictable and therefore could have been prevented. The review team was particularly mindful of the dangers of hindsight- bias especially given what became known about the parent’s more recent history. Every attempt was made to keep an open mind to understand why certain actions and decisions in relation to this family would have made sense to professionals at the time.  5.2. Whilst the view from the second pathologist was that Baby D’s fractures were more likely to have been caused from non–accidental injuries than as a result of any vitamin D deficiency, they were not deemed to be a contributory cause of his death. However, the possibility that Baby D may have been subject to physical harm during his short life required the review team to consider whether any learning could be drawn from the actions and decision-making of professionals involved with the family at the time.  5.3. The review team identified three areas of significant practice (ASPs), which provided a useful framework to review how well agencies worked together before and after the birth of Baby D.  ASP 1: The ways in which professionals in adults services understood MD’s vulnerabilities and the impact these could have on their parenting abilities  ASP 2:  The effectiveness of multi-agency working  ASP 3:     The effectiveness of communication with the family  5.4. ASP 1: The ways in which professionals in adults services understood MD’s vulnerabilities and the impact these could have on their parenting abilities.  Since 2010, statutory guidance7 has placed much greater emphasis on the responsibilities of adults services to ‘think family’. Whilst the importance of supporting vulnerable adults in their parenting roles is acknowledged, the welfare of the child remains paramount and must precede any consideration of parental rights. This in itself can create challenges for those working in adults services.                                                               7 Working Together to Safeguard Children 2010, 2015     10 The review team wanted to understand how professionals working in adults services understood their safeguarding responsibilities as they relate to the children8 of their service users.  The extent to which MD’s vulnerabilities were known 5.4.1 MD's vulnerabilities were well known to practitioners in adults services following three specific assessments which were undertaken when she was a young adult, one of which described her needs as ‘substantial’. The two reviews and one ‘outcome focussed’ review which took place whilst she was living in the Shared Lives placement indicated that, although she was settled in her placement and responded well to support, she continued to need daily prompting about basic living tasks and self-care. Practitioners from adults services were aware of MD’s background and although they had not seen the assessment reports, they told the review team that, even without a diagnosis of a ‘mild learning disability’, they believed that, very possibly because of her early childhood experiences, MD would always have needed support to live independently.  5.4.2 When MD decided to leave the Shared Lives placement in January 2014, concerns were expressed by professionals working with her as to how she would manage, even with the support of a new partner. The Mental Capacity Act 2005 (MCA) has formalised existing case law and added new requirements in respect of decision-making by people aged 16 years and over and states that a person must be presumed to be competent to make their own decisions unless it can be demonstrated otherwise. Professionals from adult services told the review team that, whilst there were some concerns both voiced and recorded about her decision to leave the placement, they did carefully consider her mental capacity and were left with no option but to respect her decision to move out of the Shared Lives placement. The Shared Lives carers stated that in their view, MS’s ‘substantial needs’ had not diminished in any way and she remained highly vulnerable. 5.4.3 The agency learning report for adults social care refers to two reviews, which took place after MD announced her decision to leave. One took place in January, where a decision was taken to keep the placement open until the end of the month, and a second review occurred in early February.  This review led to the closure of the case by adults social care, although the case did remain open to the CTLD community nurse in the multi-agency CTLD team. None of the practitioners spoken to as part of this review, including the Shared Lives carers, can recall attending any meeting after MD had left the placement. The review team were not provided with any minutes or records of these reviews, and concluded that these were internal reviews rather than multi-agency ‘end of placement‘ meetings.  5.4.4 It is ‘expected’ practice that ‘end of placement’ reviews take place especially when placements end unexpectedly and MD’s placement agreement identified that such a review would happen when the placement ended. Such a meeting with MD and key practitioners would have needed to acknowledge the circumstances under which MD had left her placement and assessed her future support needs given what was known about her ‘substantial’ vulnerabilities. Good practice would also have ensured some consideration about the possibility that, given her new relationship, MD could well become pregnant at some future date.                                                               8 This includes unborn children    11 The placement agreement had stipulated that while in Shared Lives, MD was to be encouraged to practice safer sex and to continue her contraceptive regime. MD had talked openly to the Shared Lives carers and other professionals about wanting a boyfriend and a baby. The Shared Lives carers told the review team that, had their views been sought, they would have expressed significant concerns about how MD would look after a baby without additional support given that she needed so much daily prompting to care for herself.  5.4.5 The review team were informed that at the time it was not common practice for professionals in adult services to ‘think family’ and practitioners reminded the review team that MD was not pregnant when she left the Shared Lives placement nor when the case was closed to adults social care several weeks later. They also queried the ethical aspect of sharing information without consent if they were no longer formally involved with the family.  Learning Point 1: At key transition points in the lives of vulnerable adults, their future needs should be considered alongside a review of the existing service provision  5.4.6 The practitioners from CTLD learnt from Midwife 1 that MD was pregnant, about one month after the case had been closed to adults services. MD had told the midwife that CC1 was her social worker and Midwife 1 appropriately made contact to establish what sort of support was being offered. She was advised however that MD’s case was no longer open to them as she had left her placement earlier that year. It is unclear from midwifery records what information was shared at this stage about MD’s vulnerabilities and her experiences when living in the Shared Lives placement. What does become clear at this point is that MD thought of and described CC1 as her social worker. It appears that Midwife 1 understood that the case was no longer open and assumed this was in response to there being no identified concerns.  5.4.7 This was a missed opportunity to share some important information. However, it emerged from the review process that different professional groups may not share the right information because they work to different criteria for information-sharing, use a different language and lack sufficient understanding of each other’s roles. This means they may not understand what information is important for other agencies to have and so do not ask the right questions or pass the information on. Both CC1 and midwifery acknowledged they knew very little about each other’s roles and this seems to have impacted on their understanding about what they needed to know and what they were able to share.  5.4.8 Both CC1 and CN1 had available to them considerable information about MD in terms of her childhood, her past experiences and her background; CN1 in particular, was in receipt of the specialist assessments relating to MD which described in detail her vulnerabilities and the difficulties she encountered in undertaking daily tasks and retaining even simple information. Sharing information at this stage would have assisted the midwife’s understanding of the extent of MD’s vulnerabilities and could well have supplemented the referral to CSC, which she had made the previous day. However neither professional suggested a meeting to discuss concerns, CC1 because she did not see this as her role and was no longer involved with the family and Midwife 1 because she had been informed by CC1 that the case had been closed and there were ‘no issues’.     12 5.4.9 Following the conversation with Midwife 1, both CN1 and CC1 began to visit MD on an informal basis, describing how they would ‘pop in’ to see how she was doing. Both practitioners acknowledged they had no formal remit for these visits but describe being concerned about MD because of her vulnerabilities and all that had happened in her life. Due to the nature of these ‘pop ins’, the visits and contacts were not recorded by either practitioner so the review team was unable to analyse or assess what they were doing and with what frequency. MD and FD continued to view CC1 as their social worker because she ‘visited and helped us out’. CC1 told the review team she was unaware that she was regarded as a social worker not only by the family but also by other professionals with whom she had contact.  Learning Point 2: The importance of ‘professional curiosity’ does not only sit in relation to work with families it also applies to conversations between professionals to ensure that roles and remits are well understood.  5.4.10 The review team was concerned to note that a lack of managerial oversight allowed two professionals to visit a family seemingly without any remit or accountability. The review team was not provided with any records of these visits and yet CC1 liaised with other professionals and offered a view as to how well the couple were managing - feedback which other professionals accepted as being from a professional they assumed had been allocated to work with the family. The commitment of these professionals to ensure MD’s well-being is commended but without a clear purpose or plan for the visits and without any multi-agency collaboration, it is difficult to know or measure what they achieved other than a reassurance for the professionals themselves that MD was ‘OK’.  5.4.11 In discussions with professionals and managers in the review team, it became evident that the practitioners in adults services saw their primary function as supporting MD’s independence as a vulnerable adult and believed any responsibility for considering or protecting the needs of an unborn child lay with childcare workers and health professionals and not themselves as practitioners working in adults services. Comments such as ‘we do not do parenting assessments’ and are ‘only there for the adult’ highlight the need for improved levels of understanding about roles and responsibilities in adults services in relation to the safeguarding of children and unborn babies.  5.4.12 The responsibility for safeguarding children does not only lie with children’s services, it is a requirement of safeguarding children policy that adult services know whether their service users have children or become pregnant. Section 11 of the Children Act 2004 clearly places duties on a range of organisations and individuals including those who work in adult services, to ensure their functions, and any services that they contract out to others, are discharged having regard to the need to safeguard and promote the welfare of children. Where a vulnerable woman in receipt of services from adults social care is known to be pregnant, adult service’s assessment should include assessing the potential impact of those vulnerabilities on any children in the family or any child about to be born.  5.4.13 The difficulty in this situation is that the two workers from CTLD were visiting MD on an ‘informal’ basis and described their involvement only as ‘keeping an eye on things’. As the case had been formally closed to adult services, there were no means or mechanisms to update any assessment when MD became pregnant.     13 Neither CN1 nor CC1 considered themselves as ‘working’ with MD or saw the need to share what they knew about MD’s vulnerabilities with any of the professionals working with MD and FD during the pregnancy and after the birth. The review team understood that this was because sharing or offering information about MD and her background was not considered part of their professional remit but also the review team was told that information about MD was ‘never asked for’ and had it been needed, it was presumed that social workers would have asked for it.  Learning Point 3:  Where a learning disabled woman becomes pregnant (or has other children) it is essential that professionals who are in contact with her consider to what extent her disabilities or vulnerabilities could impact on her ability to care for her children and they should liaise with children’s services accordingly. 5.4.14 According to the agency learning report, both CN1 and CC1 did have some concerns about MD’s ability to parent a child and these were discussed with their respective managers. The report refers to these concerns being also discussed with ‘the local child protection team’ who advised ‘there was no role for [CSC] in work with this family’. The review team could find no record of this conversation in any agency records so it remains unclear what information, if any, was shared, when, by whom and with whom.  5.4.15 When SW1 returned to work and learnt that MD was pregnant, she shared her concerns with her senior, with CC1 and with CC1’s senior. She expressed a high level of concern about how MD would be able to care for a baby, based on what she knew about the difficulty MD had in taking care of herself. Her concerns did not however lead to a referral to CSC and SW1 did not pursue the matter. The agency learning report states that the practitioners believed that if a referral had been necessary, their seniors would have acted accordingly. With the benefit of hindsight, SW1 stated that in future, under similar circumstances, she would refer her concerns directly to CSC.  5.4.16 From conversations and information contained in the agency learning report, it was suggested that concerns not being referred to CSC was possibly linked to a lack of understanding by those in adult services about children’s social care systems. The report also suggests that there may exist within CTLD and wider adult services a belief that parents with learning disability are treated unfairly by children’s social care and that their children are less likely to remain in their care than the children of non-disabled parents. This led the review team to explore with practitioners and managers whether a ‘professional bias’ may have influenced their thinking about ‘reporting ’ their concerns’ about MD’s parenting capacity to CSC or indeed expressing these to other professionals.   5.4.17 CN1 had considerable knowledge about MD and the input from this practitioner would have significantly strengthened any referral to CSC. CN1 was however very clear that it was not within his remit to comment on or assess parental capacity and believed professional judgements about parental abilities and risk to children were best left to those professionals who worked directly with children and families. The review team was equally clear that decisions about parenting abilities must be made by those skilled and experienced in parenting assessments but was also of the view that professionals working in adult services are well equipped to contribute to those assessments and advise on how a person’s learning disability or mental health could impact on their ability and capacity to care for, nurture and protect a child.     14 5.4.18 There were references in panel and practitioner discussions to the view, held by some, that there was never any evidence that Baby D was at risk of anything other than ‘poor parenting’. Such views highlight the importance of practitioners in all services understanding what ‘poor or inadequate’ parenting looks like so they are better able to recognise when a lack of ‘good enough’ care is, or could be, impacting on the safety or well-being of a child. Learning Point 4:  This review has highlighted that some practitioners in adult services require a deeper understanding about the roles and responsibilities of colleagues in other agencies but also need to better understand their own safeguarding responsibilities to work collaboratively with other agencies to safeguard and protect children and vulnerable adults. The comments of practitioners suggest that some practitioners in adult services may be reluctant to communicate and share information with other professionals because they view the well-being of the adult as being their primary concern.  5.4.19 CN1 and CC1 described that, although they were ‘aware’ of each other’s involvement with MD and FD, they did not collaborate and knew very little about the contact each had with MD and they did not receive ‘supervision’ as such in relation to their contacts with MD. The review team was informed that, during the period under review, there was little management oversight or supervision of practitioners in CTLD due to a vacant post and long- term sickness. The team was co-located with local authority adults social care staff, however at the time there was a fragmented approach in managing cases within the team, with little discussion or information sharing. This was compounded by inconsistent management and supervisory arrangements. Practitioners acknowledged that parenting and safeguarding children was at the time rarely considered in team meetings or supervision sessions unless there was a high profile case involving several agencies. They acknowledged there were gaps in their knowledge about how children’s services functioned but the review team agreed that this was also evident in health agencies and children’s services in terms of their understanding about the roles and responsibilities of colleagues in adult services.  5.4.20 Safeguarding children training and improved supervisory arrangements will go some way to supporting decision-making and practitioners being better equipped to navigate the safeguarding children system. However, the views expressed by professionals in adult services in relation to the assessments of parents with learning disabilities is concerning and especially so if they influence their decisions about whether or not to liaise with colleagues in children’s services.  Learning Point 5: There would be benefit in HSCB seeking clarification from partners in adult services whether these views are held by a minority of practitioners and managers or are representative of a service-wide issue, which requires immediate attention.  Learning Point 6: It would be helpful if HSCB sought assurance from senior managers that there are effective systems in place which encourage practitioners in adult services to ‘Think Family’ and which also support managers to monitor those cases which involve dependent children. Where both LA adults' and children's social care are providing services to a family, practitioners need to be better supported to share information in a timely way, undertake joint assessments and agree interventions.     15 5.4.21 Situation now: All practitioners within CTLD are now employed and managed by Humber NHS Foundation Trust and have been since 2016. Safeguarding children supervision is available on a 1:1 basis every three months as a minimum for all staff, facilitated by a supervisor who has completed safeguarding children supervision training. All relevant cases are reviewed at this time. Professionals from the same professional group or from different professional groups may also meet to discuss child protection cases. This provides clinicians the opportunity to bring their own cases for discussion and allows safeguarding practitioners to disseminate learning and facilitate case discussions. Any member of staff, irrespective of their role can access safeguarding children supervision should the need arise, by contacting the Safeguarding Team. 5.4.22 During the board’s section 11 audit and challenge process in 2016, adults social care services completed a self-assessment to review their policy, practice, and procedures in relation to safeguarding children. The audit identified an urgent need for staff training and this was accompanied by a commitment from senior managers to ensure and support the attendance of their workforce to training programmes delivered by HSCB. The review team was told that due to staff shortages, competing priorities and other changes taking place across adults social care, managers faced challenges in releasing staff, and, as a result, only a small number had attended. 5.4.23 HSCB should require partners from adults social care to advise the board on what safeguarding children training has been accessed and by whom and what proposals senior managers have in place for meeting future training needs.  Learning Point 7: It seems clear that professionals should work together for the benefit of the child and there are policy imperatives to ensure that agencies work together to provide better services. However, doing so raises a number of challenges. One challenge lies in finding effective ways to manage different professional perspectives and cultures and to promote better ‘joined up’ working between adult and children’s services. If practitioners in adult services have access to high quality training, good supervision, which fosters a culture of respect for staff in different disciplines, and access to multi- disciplinary discussions, they are more likely to consider the safety and development needs of children/unborn babies in their work with vulnerable parents.  5.5. ASP 2: The effectiveness of multi-agency working  Safeguarding children is everyone’s business and therefore every agency and person who comes into contact with a child or a prospective parent has a responsibility and a role to play to safeguard children in that family. The need for effective multi-agency working and information sharing in order to secure improved safeguarding outcomes for children is clearly stated in a number of reviews, policies, and statutory guidance. As well as focusing on the actions of the individuals who were directly involved with the family, the review team tried to understand and distinguish the influence of a range of organisational factors in the decisions and actions taken. Whilst the focus on organisational systems does not diminish the responsibility of individuals to act professionally and to work effectively, it does help to explain the organisational factors that sometimes make it harder for them to do so.      16 5.5.1 There was no single or multi-agency assessment informing any of the support services offered and yet the support offered to the family went far beyond that of any universal offer with practitioners describing that they were ‘going above and beyond’ their remits to provide the level of support that they felt the family needed. Although there were good examples of communication between professionals, there were a lot of assumptions made, based on misunderstandings of each other’s roles, remits and what information each agency might have access to, with little evidence of professionals actively seeking out information or sharing information which would have contributed to multi-agency assessment and planning for the family.  Referral Pathway 5.5.2 Following MD and FD’s first antenatal appointment in April 2014, Midwife 1 consulted with the children’s social care hospital social worker when the couple told her that MD’s social worker was CC1. Midwives told the review team that it was standard practice to consult with the hospital social worker when they were considering making referrals to children’s social care; the hospital social worker had access to the Care First9 system and, in response to queries about referrals, was quickly able to check the system to determine if there was any ongoing social work involvement with a family.   5.5.3 Midwife 1 was advised that MD was known to CTLD but she should submit a referral to the CSC Access and Assessment Team, stating that MD was pregnant and needed ‘parenting support’. Midwifery records indicate the referral was submitted as advised and although it did not clearly state specific concerns, it did identify that MD was pregnant and she and FD would need support during the coming months and after the birth of their baby. The process for midwives making referrals at that time required a hard copy to be posted to the Access and Assessment Team, a copy sent to the safeguarding midwifery team and a copy sent to the hospital social worker ‘for information only’.  5.5.4 There is however no record that this referral was ever received by CSC and consequently information about Baby D was never ‘opened’ on CSC‘s system either as an open case or as an ‘information share’. Midwifery did not immediately follow up their referral when, not unusually, they did not receive an acknowledgement by CSC. Having submitted the referral, the midwifery team assumed it had been received and actioned, they were reassured as they had spoken with the hospital social worker and believed they had in effect ‘reported that the couple clearly needed support’. The review team was told there was an assumption that the hospital social worker liaised regularly with the Access and Assessment Team.  5.5.5 There was, however, no system in place which required the hospital social worker to follow up the referral she had discussed with Midwife 1 and, as consultations with the hospital social worker were not recorded on Care First, the information shared and included in the submitted referral was lost. Whilst the hospital social worker provided reassurance and guidance to midwives, previous SCRs have identified that this role did lead to some confusion and too easily compromised the referral pathways for midwives.                                                               9 Care First is an integrated computerised business system which supports social work practitioners and managers in undertaking the key tasks of assessment, planning, intervention and review    17 Since February 2017, system changes have meant that the hospital social worker expertise has been taken back into children’s social care and the post is no longer based within the hospital. Mandatory training has been completed within midwifery in order to increase the confidence of midwives in identifying and articulating concerns about unborn children and improvements have been made in midwives contacting CSC directly with any concerns.  5.5.6 Four weeks after the submission of the referral, Midwife 1 again contacted CSC to ask about ongoing support for MD. The advice given by the duty officer was that the family no longer had support from CTLD and a referral should be made to the children’s centre for practical support. It is important to note that this information would have been accessed from records pertaining to MD as no record had been opened in relation to unborn Baby D.  5.5.7 Without a clear understanding of how information is recorded and accessed on the ICT system, the information from the duty officer was interpreted by the midwife as ‘the case had been open but was now closed because there were no concerns.’ The midwife queried why there had been no response to the referral made in April and the duty officer agreed to look into this and get back in touch. Midwife 1 later contacted CSC and the hospital social worker to ask for an update but received no reply and the matter was never escalated.   Professional assumptions 5.5.8 It appears that having been given this information by the duty officer, there was an assumption in midwifery that CSC had undertaken some sort of assessment and concluded that no further action was necessary. There were no further referrals into CSC by midwifery staff. MD accessed maternity care from an early point in her pregnancy, receiving an early pregnancy scan at 8 weeks. She had 24 antenatal contacts including the nine antenatal appointments scheduled for uncomplicated pregnancies (NICE 2008). Thirty-two different midwives were involved at various times in MD’s care throughout her pregnancy and during the first four weeks of Baby D’s life. The contacts were in considerable excess of what might be deemed ‘usual’ contact with maternity services and clearly indicated a high level of parental anxiety, which warranted further exploration. At the time there was however no system in place to flag up this unusual pattern of contact by a family.   5.5.9  The midwives contributing to this review explained that they had a high level of concern in relation to the ability of the parents to cope with a new baby and were ‘telling anyone and everyone’ about their concerns but ‘no one was listening’. Despite these frustrations there were no further referrals to CSC and no contact was made with the Safeguarding Midwife for support and guidance. Midwives were reassured that support was being provided to the family by CC1, who was repeatedly described by MD & FD as their social worker. This information was not however verified and led to an assumption that information was being passed back to CSC to help with the task of putting the ‘safeguarding jigsaw together’. Learning Point 8: Assumptions can sabotage effective communication and have the potential to lead people down unintended paths. The finding from this review highlights the importance of professionals communicating with each other to verify information given to them by family members rather than making assumptions about the role and remit of other colleagues in contact with the family.     18 5.5.10 During their involvement with MD and FD, it became evident that both parents, but especially MD, had some form of learning difficulty and this led to heightened concerns from midwives about how the couple would cope with their baby and what support services would be available. There was no explanation as to why the advice of the Learning Disability Liaison Nurse was not sought. This is a post which has been established in the trust since 2011, but the review team was told that, at the time, the service was rarely accessed by midwives and there was very little guidance available to them about working with learning disabled parents. In March 2016, the maternity services launched a vulnerability toolkit for midwives, which includes guidance on how best to support pregnant women with learning disabilities.  5.5.11 Midwifery records refer to a ‘slip’ being forwarded to the children’s centre sometime in May 2014 and the community tracker10 was updated to advise that consent should be sought when the couple attended their next antenatal appointment. However, the children’s centre records show it was not until late September 2014 that they received a referral from midwife 11, making a request for support for the family to improve housing conditions ready for the birth of the child, including obtaining cooking and refrigeration equipment, carpeting; and for help with general household cleanliness including issues with the presence of a number of animals within the home. The delay was partially explained by midwives not always having time to read up on records at clinic and the fact that the family moved to a different area. It did mean however that there was no co-ordinated multi- agency community support offered to the parents during the important second trimester. Assessments   5.5.12 There is no foundation for assuming that parents with learning disabilities will inevitably neglect or abuse their children. Most available research suggests that the majority of learning-disabled parents can provide adequate care, and that, with sufficient support, parental learning disability does not affect child outcomes. However, the presence of learning disability is a risk factor, especially when it is associated with difficulties such as a shortage of money, chronic housing problems, and fraught relationships. Some parents, like MD and FD, will have difficult experiences of being parented themselves thus limiting their opportunities to learn how to be a parent. In such circumstances, assessments are the means by which risks can be identified, support needs recognised, and future planning secured.  5.5.13 Despite the involvement of many professionals during MD’s pregnancy and after the birth of Baby D, there were no formal assessments undertaken to determine the nature and extent of the family’s support needs, although the fact they needed support was clearly evident from the number of professionals involved and the frequency of their contact with the couple.  5.5.14 The importance of timely assessments is highlighted in a wealth of literature and emerges as a key feature in many serious case reviews. Key research findings relating to the assessment of parents’ capacity to meet the needs of their children include the importance of assessing the extent to which parents understand the basic requirements of parenting and of considering parents’ ability to learn and change their behaviours.                                                               10 A business system in midwifery, which allows the tracking of information so practitioners can be alerted when actions are required or overdue.     19 There was evidence in this review that professionals over- estimated the abilities of both MD and FD to understand professional concerns and to make and sustain the necessary changes.   5.5.15 There were many different individual practitioners and services having high levels of contact with, and providing higher than normal levels of help and support to the family during MD’s pregnancy and after the birth of Baby D. It was apparent to the review team, and to the practitioners involved, once all of the single agency information had been gathered together and compiled for this review, that a single, or multi-agency, assessment of the family’s support needs, and of their strengths and difficulties, would have been helpful in this case. While all practitioners working with a child, young person and family are responsible for contributing to the multi-agency assessment and plan, when a child/young person needs a package of support, experience shows that they and their families benefit from having one person who can help them through the system, ensure that they get the right service at the right time and that agencies/ organisations communicate effectively with each other. This person is known as the lead practitioner and will normally be the person responsible for undertaking an assessment. Had a lead practitioner been identified, the ensuing assessment would have helped to ensure that information was shared and needs identified and this might have led to a coordinated support plan for the family. 5.5.16  A good multi-agency plan would have clearly set out goals, including assessing the motivation and abilities of MD and FD to make and sustain changes which demonstrated their capacity to consistently meet Baby D’s needs. No such assessment was however undertaken and the review team was keen to explore this issue further.  5.5.17 Where an unborn baby is considered to be at risk of harm or likely to be in need of services from children's social care when born, partners from any agency are required to make an immediate, timely referral to CSC or make contact with that agency to discuss whether such a referral would be appropriate. Midwifery clearly believed they had made this contact but neither they, nor any other professional, considered that the threshold for harm was met. Whilst the decision to undertake a pre-birth assessment lies with CSC, it remains within the scope of any partner agency to request that such an assessment is undertaken but the need for this was not considered as it was ‘understood’ that CSC were aware of the situation and had no concerns.  5.5.18 SW1 did think a pre-birth assessment might have been useful but this was not communicated to anyone outside of the CTLD team. When a parent is unable to adequately care for and meet their own basic needs they are likely to be challenged in their abilities to adequately care for and meet the needs of another, especially one that is very young and highly dependent. There is however no evidence that the need for an assessment of MD and FDs parenting capability was ever considered or discussed by any of the professionals working with the family and this was explained by professionals as, despite concerns about the couple’s need for a high level of support, they engaged with services, continually sought advice and each agency assumed that CSC were ‘somewhere there in the background’ and would have instigated an assessment had one been necessary.      20 5.5.19 Children’s centres lie at the ‘hub’ of a continuum of support where emerging difficulties can often be first spotted and where families turn to for extra help. They are often the most appropriate settings within which the extra help to families can be sourced and delivered. Children’s centre practitioners told the review team that the role of CC practitioners has, by design, changed – the role is expected to do more in-depth supportive work with families who in the past may well have been allocated a social worker.  5.5.20 Both parents willingly engaged with the children’s centre. There was however no well- developed early help framework in place at the time, within which to assess the needs of families referred to them. This meant that the children’s centre practitioner (CCP1) responded to the needs of the family, as identified in the midwife’s referral and as they observed them. Help and support to the family continued on a very practical level. When discussing the application of thresholds of need with regard to this family, CCP1 stated that, with the information they held, and from their observations of the parents, they did not consider at any point, either during the pregnancy or in the post-natal period, that the threshold for referral to children’s social care was met. This judgement was not based upon a formal assessment but on their understanding of thresholds of need and their observations and interactions with the family. The review team agreed with this judgement.  5.5.21 What did emerge however was recognition that the parents were overly anxious about the pending birth and they needed considerable help and support, including with budgeting and household chores. They had to be frequently ‘prompted’ by practitioners about the importance of certain tasks being undertaken on a regular if not a daily basis and they would often contact the children’s centre practitioner, sometimes up to 5 times per week, to seek advice or ask for assistance.  5.5.22 Practitioners acknowledged that the circumstances of the family as they were presented to individual agencies did not trigger any child protection concerns. However, when taken in the context of historical assessments and/or observations of MD and FD’s functioning, professionals agreed that an early help assessment of MD and FD’s parenting capabilities and capacities may have improved multi-agency understanding of what agencies needed to put in place in order to support parents with the care of Baby D when born. It may also have alerted each professional to the nature and extent of the support the family were receiving from individual practitioners, including those from adult services.  5.5.23 Practitioners have described that if they had been in receipt of all known information about the parents it would have made a ‘fundamental difference’ in the way in which they would have approached their work with the family. However at no point did any agency consider the need for an early help assessment. This could have been completed by any of the practitioners involved with MD and FD and would have pulled together the information that was known to agencies about the strengths and difficulties within the family. It certainly would have supported a more co-ordinated and multi-agency approach to work with the family. Despite the concerns of health professionals and children’s centre workers about how MD and FD would cope as parents, there was no one professional who coordinated work with the family, although professionals continued to assume that the CTLD worker was, as MD repeatedly stated, the social worker involved with the family.     21 5.5.24 This unchecked assumption allowed work with the family to remain uncoordinated, which meant that professionals worked alone to support the family rather than as part of a multi-agency plan. The integrated chronology highlights one day where the family received two home visits, one by the health visitor, and one by the children’s centre practitioner. They also attended a midwifery appointment at the local children’s centre and a GP appointment at the local health centre. The following day, CC1 took the family to a drop in appointment to look at housing needs. Each individual agency was unaware that the other had contact with the family within such a short period. Whilst these visits may have been welcomed by the family, more might have been achieved had professionals collaborated and communicated more effectively.  5.5.25 There is general agreement in literature that IQ is not necessarily predictive of parental competency except when perhaps it falls below 55-60.11 Above this level, the evidence suggests that decisions about whether a person is an effective parent ‘will need to rest upon a case by case judgment of abilities relevant to the rearing of children rather than IQ level alone’. Given that information was not shared about MD’s early assessments, professionals with whom MD came into contact during her pregnancy and after the birth of Baby D were therefore basing their concerns purely on their observations and the extent to which both parents were able to act on advice and maintain improvements in the home.  5.5.26 Key research findings relating to the assessment of parents’ capacity to meet the needs of their children include the importance of understanding the basic requirements of parenting and of considering parents’ ability to change. 12 On occasions, professionals have over- estimated the ability of some parents to understand professional concerns and make the necessary changes. In such cases, psychological assessment can be valuable to assess parental capacity, including sometimes their IQ but it has also been suggested that one way of assessing capacity to change is by giving parents ‘managed’ opportunities to change. In these cases, it is important to be clear what needs to change, how change will be assessed or measured, and over what time scale, how parents are to be supported, and the consequences if no or insufficient changes are made. Had a parenting capability assessment been undertaken, it would have helpfully drawn on the knowledge and expertise from adult services in relation to MD’s learning disability and might have elicited information about how practitioners could best communicate with both parents.                                                                  11 ‘Local Authority duties to parents with learning disabilities: G, Taylor Barrister November 2016; University of Bristol, Parenting Assessments for Parents with Learning Disabilities (2013),  12 Rachel Jones, (2009) "The therapeutic relationship in psychological therapy for individuals with learning disabilities: a review of existing literature", Advances in Mental Health and Learning Disabilities     22 5.5.27 The review team found that FD’s learning difficulties, which he self-reported during conversations with the reviewers, were not understood or fully explored, despite the fact that he was constantly present for the ante natal and medical appointments and took a caring role for Baby D after his birth. Unlike many other males who feature in SCRs, FD was described as a supportive partner and an interested father. In the absence of a formal assessment of either MD or FD’s parenting capability, it is unclear whether FD had any support needs of his own in coping with the demands of the role that he had adopted.  5.5.28 There is a wealth of research which acknowledges that fathers, or father figures, can play a key role in ensuring children’s development needs are met in families where the mother has a learning disability. Professionals observed and described that FD was ‘a hands on dad’ and the main carer for Baby D when born, feeding, and changing, etc., completing most domestic tasks and taking on a carer role for MD. FD was present during all planned sessions and was actively engaged and welcoming of agency support. Practitioners have reflected that FD had appeared to adopt a carer role within their relationship and that MD responded positively to this.  5.5.29 Situation now: Learning from local inspections and reviews has since led to the development of a pre-birth vulnerability pathway, which was established in March 2016. Since implementation of the pathway, the pre-birth vulnerability-screening tool has supported midwives in the assessment and care of vulnerable women who are pregnant. Practitioners reflected that if MD had presented to maternity services today then she would have been assessed as vulnerable and referred internally into the vulnerability midwife led ‘Haven clinic’. There would also have been liaison with the learning disability nurse within the hospital for advice and support and a referral, based on clearly identified vulnerabilities, would have been made to children’s social care.  Learning Point 9:  Whilst multi-agency guidelines now provide a clear framework for greater collaboration between agencies in meeting the needs of parents and unborn babies, HSCB should consider to what extent it can be confident that the agreed pathways are effective in identifying and responding to the needs of vulnerable parents.  Joint Working 5.5.30 By its very nature, joint working brings together professionals with different roles and responsibilities as well as divergent professional cultures and these differences can act as barriers to effective joint working. Understanding the roles and responsibilities of colleagues from different disciplines and respecting their expertise is critical to the success of joint working. Professionals in both children’s services and adult services said they knew very little about each other’s roles and remits. For example, CC1 was perceived to be the ‘lead practitioner’ by other professionals working with the family who repeatedly described her as their ‘social worker’.   5.5.31 Practitioners also reflected that as CC1 was perceived to be a specialist CTLD social worker, an assumption was made that any impact of MD’s learning disability on her parenting capability would have been assessed and considered. CC1 was however very clear throughout this review that she saw her role as providing ‘support’ to MD notwithstanding the fact that the case was closed to adult services.      23 Whilst the extent, status and purpose of that support was never clarified it did lead to a false sense of confidence in practitioners that one agency had a good understanding of the strengths and support needs of MD and FD and an understanding of how these would in turn impact on their parenting capability.  5.5.32 This way of working leads to what can be described as ‘silo practice’. The triennial review highlights that ‘silo’ working does not necessarily mean that professionals are working in isolation. ‘It can equally arise in the midst of multi-agency working’ where professionals viewed aspects of [an individual] or family’s need and level of risk, solely from the perspective of their own discipline.’  5.5.33 The importance of an integrated professional group being accountable for safeguarding children rather than confining the responsibility to children’s social care was stressed in Eileen Munro’s13 first two reports on the child protection system (2010, 2011). A collaborative approach is meant to ensure that not only are parents recognised as having needs in their own right, but also the impact of those needs on their children should be part of a multi-agency response with key professionals sharing information and deciding how best the family could be supported.  5.5.34 It was only after contributing to this review that the GP became aware of the involvement of other agencies. The GP had minimal contact with the family prior to or after the birth of Baby D and at no point were any safeguarding concerns noted. Medical records referred to FD’s depression for which he was offered counselling but records do not indicate whether he attended any sessions. The review team learnt that only if there was a presenting issue or specific contact would a GP review a patient file, but it was acknowledged that MD’s learning disability should have been included on the disability register held at the practice and this may have prompted the GP to ensure the couple were receiving support. 5.5.35 The ‘disconnect’ highlighted in this review, between services for children and adults is not only a local issue. The legislative framework for adult social care places its emphasis on supporting parents with disabilities and parenting roles have not been treated as a central issue within the adult social care policy framework. While these frameworks have emphasised the need for inter-agency cooperation, it is only relatively recently that there has been recognition of the need for children's and adults' services to work together’.14 Learning Point 10: Although It is acknowledged that MD’s learning disability was ‘mild’ and the environment in which she grew up impacted on her ability to care for herself, this review has highlighted the need for practitioners in both specialist and non-specialist services to better understand how they can work together to assess the potential impact of learning disability on parenting capability and capacity to change and the concept of “parenting with support”.                                                                  13 The Munro Review of Child Protection: Part 1: A Systems Analysis, 2010; Part 2:The Child’s Journey 2011 14 SCIE Knowledge review 11: Supporting disabled parents and parents with additional support needs By Jenny Morris and Michele Wates Published: November 2006    24 Learning Point: 11: The contribution of practitioners working in specialist adult services to multi-agency assessments and plans for children and families is essential to helping with this understanding and more work is required in Hull to support quality and effective collaboration between adult and children’s services.   5.5.36 The learning, nationally and locally, that timely and purposeful multi-agency meetings support good planning and, with regular review, can improve how services are provided in order to improve outcomes for children and families, is not new. In this review, practitioners acknowledged a belief that ‘another’ was taking the lead or making decisions and agreed that without recourse to any multi-agency meetings, work with the family was fragmented with little to evidence any change in the parents’ functioning. There were three specific missed opportunities when multi-agency meetings could have contributed to a more coordinated approach:   When MD first left the shared lives placement to live with FD;   When MD’s pregnancy was first confirmed    When Baby D was due to be discharged home from hospital.   5.5.37 Whilst practitioners acknowledged the value of working more collaboratively with partner agencies, they also described what they saw as some very real barriers in organising and attending multi-agency meetings, including:   A lack of confidence that they are the ‘right’ person to pull a meeting together  A lack of confidence that other agencies will attend the meeting especially if they are not called by CSC  A view that multi-agency working takes up too much time and is not always seen as a priority.  5.5.38 There is a plethora of research, which confirms that coordinated and well-timed early intervention with families leads to better outcomes for children. The importance of agencies working in partnership lies at the heart of recent changes in early intervention services in Hull. However, whilst there has been considerable progress made in relation to inter-agency working, further work is clearly needed by all agencies to support worker confidence and capacity to take on the lead practitioner role and to coordinate and support multi-agency working, particularly where children’s social care are not the lead agency.    5.5.39 The challenges for all public services, in terms of diminishing resources and workforce pressures, are also well documented. The triennial report of SCRs reflects concerns of competing demands in a number of reviews and describes the reality of ‘a steady increase in child protection activity year on year since 2009’. This increase is matched by an equal increase in child in need activity, and extends back now over several years. All this has occurred during a time when many services have remained static or been cut, thus leading to increased workloads for individual practitioners.     25 5.5.40 These demands are not without impact on professionals but, even in such a challenging climate, multi-agency working continues to offer scope for better joined up services to enhance and improve outcomes for children. Working together avoids duplication of processes across agencies, allows a practitioner to have access to peer support which in turn better supports step-up and step-down processes and thus contributes to more effective allocation of resources. The scope of activities that are needed to work effectively with some families means it is almost impossible for any one agency to deliver those services. For partnership working to be effective however, strong leadership and commitment is required to promote multi-agency collaboration and ensure  ‘think family’ practice is accepted, promoted and supported across the continuum of need as not only a cross- partnership responsibility but also a more effective and efficient way of working to support families.  Management Supervision  5.5.41 The importance of effective supervision is frequently highlighted in serious case reviews. When functioning well it is seen as a positive and empowering system by practitioners and managers alike; it facilitates reflective practice and continuous improvement, along with a more proactive approach to case management.   5.5.42 The children’s centre practitioner described having easy access to both informal support and formal supervision processes from the children’s centre during the period under review but suggested that, compared to other families with whom they were working, they were far less concerned about how the couple were managing and saw no need to discuss the family or the impending birth with their manager.  5.5.43 Midwives are encouraged to have regular safeguarding supervision regarding their caseloads, but they also did not see a need to discuss this family with their manager or with the Safeguarding Midwife. Had concerns about this family been discussed in supervision, it may have provided an opportunity to review the case, which in turn may have led to a new referral to CSC. In 2014, implementation of safeguarding supervision within midwifery service was however in its early stages. It is now well embedded into current practice.  5.5.44 Within health visiting services, Baby D’s case was being managed at a Universal Partnership plus level. CHCP have a staff supervision policy, which described the importance of supervision for all staff working with families who are in need of family support, or with families where there are child welfare concerns. Safeguarding supervision takes place on a minimum of 3 monthly basis (but can be more frequent as required) for those health practitioners working with families who have been assessed at a partnership plus basis. The health visitor in this case said that she was aware that she could access these supervision processes, however she did not feel that there were any child protection or significant safeguarding concerns in relation to Baby D either prior to, or following, the birth. 5.5.45 Professionals described widely different experiences of supervision. CN1 described how he discussed his concerns about MD with a ‘modern matron’, whilst CC1 could not recall the last time she accessed supervision.      26 Other professionals advised the review team that they did not feel the need to escalate their concerns about this family to their respective managers: both parents engaged with services and actively sought the advice and support of professionals; they were considered to be serious in their attempts to prepare for the birth of their baby and, once born, there were no safeguarding concerns identified and the baby appeared loved and well cared for.  5.5.46 Given the complexity of family situations, relationships and emotional dynamics, research15 suggests it is easy for practitioners working under pressure to lose focus or to get stuck in a particular way of thinking. Professionals need a safe and ‘containing’ space to be able to think about what they are doing and how they make sense of the practical and emotional pressures of the work. It is here where good supervision can make a difference, but the review team was told that busy caseloads and competing priorities often meant that only the most pressing cases were taken to supervision and none of the professionals considered this family sat within that category.  5.5.47 The review team concluded that if professionals had discussed the needs of this family with their respective managers, advice may have been given to liaise with other agencies but a decision to refer to CSC would have been unlikely given what was known about the family at the time.  5.6. ASP 3: The effectiveness of communications with the family In the same way that hearing the voice of the child is central to good assessments, good and clear communication with parents is central to effective safeguarding interventions. Effective partnership with parents requires their engagement, cooperation, and full understanding of what is expected of them and what they can expect of professionals. It is also a legal requirement under the Human Rights Act 1998 that parents should be able to participate fully in any process which relates to the safety and wellbeing of children in their family. The review team wanted to explore how well professionals worked and communicated with the parents and how confident they were that both parents were able to understand and act upon their concerns.  Supporting parents with learning disabilities  5.6.1 Although there was a growing awareness of MD’s vulnerabilities and her difficulties in understanding and retaining information, some practitioners were unaware that a formal ‘borderline’ diagnosis of a learning disability had been made and said that even if they had known about the assessment, they were not sufficiently aware of what this meant in terms of MD as a vulnerable adult, as a pregnant women and as a future parent.    5.6.2 Whilst parental learning disability is identified as one of several known factors that can have impact on parents’ capacity to safeguard and promote the welfare of children, parents with learning disabilities, like any other group, are diverse with regard to their parenting skills.                                                                15 SCIE Research briefing 43: Effective supervision in social work and social care (2013)     27 There is little to evidence that any of the practitioners working with this family throughout the pregnancy and after the birth of Baby D thought of MD’s ‘learning disability’ in itself as being a sufficient basis upon which to infer poor parenting, but the need for the parents to have access to information about caring for a baby was well recognised. MD’s ‘mild learning disability’ was however a constant feature in discussions with practitioners during the SCR process.  5.6.3 The family described to the reviewers the feeling that services ‘backed off’ following the birth of Baby D, however practitioner recollection and agency records indicates a continued high level of contact with services. Both MD and FD described the importance of the practical and, sometimes daily, support offered by the maternal grandfather and his family who on several occasions cared for Baby D overnight in order to give the couple a rest when they were ‘walking around like zombies’. The extent of the family support given to the parents emerged only after Baby D had died and was perhaps not recognised by professionals at the time as being so extensive.  5.6.4 The parents told the reviewers that they and CC1 were expecting a ‘support package’ to be put in place after Baby D was born but this had never materialised. Neither they nor CC1 were able to offer any more details about what the package entailed but the parents suggested it was to do with helping them in the house. The parents described that the two types of ‘support’ they received were practical support, such as helping them to obtain kitchen equipment and ‘sort out the house’, and the other was the presence of professionals who offered reassurance when they were worried about doing things right. Although they had agreed to attend a special course for new parents, (BUMPS) they told the reviewers that it didn’t happen because there was no local course and when one did become available, it was too near the birth for the couple to attend. Neither parent was able to think of any additional support that would have been of benefit. Learning Point 12:  The term ’support’ can be used too readily to describe the work being undertaken or offered to families. Professionals should ensure that there is always a clear purpose to any support being given to families and that they in turn understand what they can expect from the ‘support’ offered.  5.6.5 When talking with practitioners about working with the family, a challenge, which was continually repeated, was the perception that the couple ‘did not seem to retain information’ and often required almost daily prompting about what to do. There was a view that this was linked to not always remembering what they had been told rather than a lack of motivation or willingness to do things better or differently. However, without an assessment of their capacity to change or learn, such views were based purely on professional observations but left midwives, CCP1 and the health visitor concerned about the best way to communicate important safety messages.  5.6.6 Baby D’s death was attributed to sudden death in infancy in association with non-compaction of the left ventricle. There are several factors known to be associated with sudden deaths in young babies and these were evident when Baby D died: MD’s age; winter weather conditions and the fact that Baby D was male. FD was also known to smoke which is considered as another contributory factor for sudden death in infancy. One of the most significant and modifiable risks however is the baby’s sleeping position and advice to all parents is that babies should be placed on their backs to sleep.     28 5.6.7 Records indicate that safer sleeping advice was given by the midwives, the health visitor and by CCP1. However, there was little to evidence following the birth of Baby D that this information was fully understood by MD or FD; a midwife on the maternity ward noted that despite advice, Baby D was found sleeping on MD’s chest whilst in hospital and a side cot was provided for the baby. The family have described to the lead reviewers that they were advised to ‘prop’ Baby D between two towels as he did not like to sleep on his back, but such advice is at odds with what practitioners know about safer sleeping and there is a possibility that parents either did not follow the advice they were given or did not understand why the baby’s sleeping position was so important.  5.6.8 Practitioners felt that they had a good relationship with the family and that there was a good level of communication between themselves and the parents but the review highlighted that professionals were left assuming that safety messages were being taken on board by the parents, despite their observations that the parents found it difficult to retain information. There is verbal and recorded evidence from this review that practitioners delivered consistent messages about safety to MD and FD, in particular the dangers of smoking near the baby, hygiene in relation to caring for the pet iguana and the dangers of cross infection, and safer sleeping. Practitioners describe that they felt that these messages seem to have been taken on board by the family at the time but were often forgotten when professionals visited a few days later.  5.6.9 Both CP1 and HV1 used some creative visual techniques to try to explain abstract concepts to the couple. When it was known that MD and FD would not be accessing the BUMPs programme, CCP1 worked with both parents on a pack specifically designed to help them better understand their parenting roles. This was a bespoke package which CCP1 prepared and reflected the worker’s response in ‘going above and beyond’ what might be expected of a children’s centre worker. Similarly, HV1 made some illustrated laminated cards for the couple to use to remind them of the importance of hand washing when handling pets and their baby.  5.6.10 Cleaver and Nicholson in their 2011 research 16 found that parents with learning disabilities were more likely to respond affirmatively to professionals and this possibly encouraged over-optimistic assumptions about the extent to which the parents actually understood what was being advised. Even without an assessment of the parents’ capacity to do things differently, professionals had already concluded over a period of several months, that both MD and FD struggled to fully comprehend what was being asked of them and why.  Learning Point 13: Practitioners understood that there was a need to communicate with the couple in a different way in order to help them understand key information; however this was not informed by a formal assessment of their communication needs or the use of an advocacy service to ensure that parents fully understood what professionals were communicating.                                                                 16 Cleaver and Nicholson: Parental Learning Disability and Children’s Needs: family experiences and effective practice 2011    29 5.6.11 Situation now: A review of how parenting support is offered is currently being undertaken by the local authority in order to ensure that the right support is in place across all services and that families have access to sufficient, accessible and timely parenting support provision which is appropriate to their needs. From April 2017 NHS Hull CCG commissioned the local maternity services provider HEYHT to deliver the Birth Preparation and Antenatal Education service. The aim of this service is to improve accessibility to birth preparation and parent education in order to support readiness for birth and parenting and positive pregnancy outcomes. The programme is midwifery led and offers a personalised approach with a mixture of one to one and group work sessions. Parents are given information about the service at their initial midwifery booking appointment and subsequent appointments.   6. Concluding remarks 6.1. This SCR has not identified a significant contravention or action by any professional that was a critical factor in the death of Baby D in December 2014. Indeed there was evidence of some practitioners going ‘above and beyond’ what was expected and offering extensive support to the family almost on a daily basis during the pregnancy and after the birth. This was a wanted child who appeared to be well cared for and was highly visible to professionals. The parents were, each in their own way, known by professionals to be vulnerable, although the extent to which these vulnerabilities impacted on their parenting roles was never assessed.  6.2. The learning from the SCR does however invite and require a better understanding by managers and practitioners in adult services, children’s centres and health services about the interplay between adult vulnerabilities and parenting especially in terms of shared responsibilities and assessments, multi-agency planning and the effective management of concerns.   7. Summary of Learning and Recommendations   Learning Point 1: (Page 10) At key transition points in the lives of vulnerable adults, their future needs should be considered alongside a review of the existing service provision.    Learning Point 2: (Page 11) The importance of ‘professional curiosity’ does not only sit in relation to work with families it also applies to conversations between professionals to ensure that roles and remits are well understood.  Learning Point 3 (Page 12) Where a learning disabled woman becomes pregnant (or has other children) it is essential that professionals who are in contact with her consider to what extent her disabilities or vulnerabilities could impact on her ability to care for her children and they should liaise with children’s services accordingly.     30 Learning Point 4: (Page 13) This review has highlighted that some practitioners in adult services require a deeper understanding about the roles and responsibilities of colleagues in other agencies but also need to better understand their safeguarding responsibilities to work collaboratively with other agencies to safeguard and protect children and vulnerable adults. The comments of practitioners suggest that some practitioners in adult services may be reluctant to communicate and share information with other professionals because they view the wellbeing of the adult as being their primary concern.  Learning Point 5: (Page 14) There would be benefit in HSCB seeking clarification from partners in adult services whether these views are held by a minority of practitioners and managers or are representative of a service-wide issue which requires immediate attention.  Learning Point 6: (Page 14) It would be helpful if HSCB sought assurance from senior managers that there are effective systems in place which encourage practitioners in adult services to ‘Think Family’ and which also support managers to monitor those cases which involve dependent children. Where both LA adults' and children's social care are providing services to a family, practitioners need to be better supported to share information in a timely way, undertake joint assessments and agree interventions.  Learning Point 7: (Page 15) It seems clear that professionals should work together for the benefit of the child and there are policy imperatives to ensure that agencies work together to provide better services. However, doing so raises a number of challenges. One challenge lies in finding effective ways to manage different professional perspectives and cultures and to promote better ‘joined up’ working between adult and children’s services. If practitioners in adult services have access to high quality training, good supervision, which fosters a culture of respect for staff in different disciplines, and access to multi- disciplinary discussions, they are more likely to consider the safety and development needs of children/unborn babies in their work with vulnerable parents.  Learning Point 8: (Page 17) Assumptions can sabotage effective communication and have the potential to lead people down unintended paths. The finding from this review highlights the importance of professionals communicating with each other to verify information given to them by family members rather making assumptions about the role and remit of other colleagues in contact with the family.  Learning Point 9: (Page 22) Whilst multi-agency guidelines now provide a clear framework for greater collaboration between agencies in meeting the needs of parents and unborn babies, HSCB should consider to what extent it can be confident that the agreed pathways are effective in identifying and responding to the needs of vulnerable parents. Learning Point 10: (Page 23) Although It is acknowledged that MD’s learning disability was ‘mild’ and the environment in which she grew up impacted on her ability to care for herself, this review has highlighted the need for practitioners in both specialist and non-specialist services to better understand how they can work together to assess the potential impact of learning disability on parenting capability and capacity to change and the concept of ‘parenting with support’.   Learning Point: 11: (Page 23) The contribution of practitioners working in specialist adult services to multi-agency assessments and plans for children and families is essential to helping with this understanding and more work is required in Hull to support quality and effective collaboration between adult and children’s services.     31 Learning Point 12: (Page 26) The use of the term ’support’ can be used too readily to describe the work being undertaken or offered to families. Professionals should ensure that there is always a clear purpose to any support being given to families and that they in turn understand what they can expect from the ‘support’ offered.  Learning Point 13: (Page 28) Practitioners understood that there was a need to communicate with the couple in a different way in order to help them understand key information; however this was not informed by a formal assessment of their communication needs or the use of an advocacy service to ensure that parents fully understood what professionals were communicating.    Recommendations Recommendation 1: That HSCB leads on the development of a local partnership-wide “Think Family” strategy which clearly describes agreed expectations about joint working and lines of communication between adult and children services to further improve outcomes for children and families. HSCB will nominate an from its team to lead on taking this work forward. Recommendation 2: That Hull City Council Adults Social Care provides assurance to the Board about the measures it takes and will take to promote and embed a safeguarding children culture and practices. Recommendation 3: That relevant Hull City Council Adults and Children, young people and family service managers meet together to develop a shared approach to “parenting with support” in relation to parents with a learning disability, in a way which secures a better shared understanding of each other’s roles and responsibilities and creates the conditions for more effective joint working. Recommendation 4: That HSCB ensures that the importance of “professional curiosity” as it was identified in this review is addressed in the Board’s safeguarding training (level 1) and within the equivalent ‘in-house’ single agency training in Hull Recommendation 5: That HSCB leads on a process to test and audit the effectiveness of the agreed pre-birth vulnerability pathway. Recommendation 6: That HSCB seeks assurance about the effectiveness of multi-agency ‘early help’ work and in particular, the use of the agreed early help assessment tool and planning process and the cross partnership responsibility for undertaking the lead practitioner role.  Recommendation 7: That HSCB prepares learning materials from this SCR to be cascaded to front-line staff across the partnership by means of bespoke briefings. End/   32 Appendix 1 Serious Case Reviews  1. Working Together 2015 outlines specific criteria under which a Serious Case Review must always be undertaken by applying Regulation 5 of the LSCB Regulations 2006. For this Serious Case Review Regulation 5(2)(a) and 5(2)(b)(i) applied, that being that the child had died and abuse or neglect of the child is known or suspected. 2. A Serious Case Review is one where: ‘a) abuse or neglect of a child is known or suspected: and b) either – (i) the Child Has died; or (ii) the Child has been seriously harmed and there is cause for concern as to the way in which the Authority, their Board partners or other relevant persons have worked together to safeguard the child.’ Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 require LSCBs to undertake reviews of serious cases in these specified circumstances and to ‘advise the authority and their Board partners on lessons to be learnt’  3. Working Together 2015 requires that Serious Case Reviews are conducted in such a way which:  1. recognises the complex circumstances in which professionals work together to safeguard children; 2. seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  3. seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight; 4. is transparent about the way that data is collected and analysed; and  5. makes use of relevant research and case evidence to inform the findings.    