Death of a 2-year-old boy by choking. Child C1 had been left alone with his older sibling when he swallowed and choked on a small item. He later died in hospital. Following his death some unexplained bruising was identified and Child C1's sibling was made subject to an interim care order. No charges were made against either parent. Mother had a history of depression and suicide attempts. Father had a history of domestic abuse and substance misuse. Mother and children had spent some time in a homeless family unit following disclosure of domestic abuse by the father. Social workers had conducted two initial assessments of the family, but did not identify any concerns. Issues identified include: parents were interviewed together during social work assessments despite allegations of domestic abuse; the overwhelming focus on Child C1's medical care distracted attention from potential safeguarding concerns and police reluctance to share information from the criminal investigation with social services to help with care proceedings for Child C1's sibling. Recommendations include: the common assessment framework should be actively pursued for homeless families with no formal social work intervention; the safeguarding children board should discuss with the crown prosecution service the possibility of children's services providing advice on complex child protection cases and NHS trusts should review first aid education for parents.
      
Title: Child C1: serious case review [overview]. LSCB: Manchester Safeguarding Children Board Author: Sian Griffiths and David Hunter Date of publication: 2014 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.                CHILD C1  SERIOUS CASE REVIEW This report has been commissioned and prepared on behalf of Manchester Safeguarding Children Board and is available for publication on the 15th December 2014.         INDEPENDENT LEAD REVIEWERS:  Sian Griffiths  David Hunter August 2014Page 1 of 36 Child C1 SCR Published Report 151214.doc  CONTENTS  1.   Introduction: 1.1. The circumstances leading to this Serious Case Review              Page 2 1.2. Family Composition         Page 3 1.3. Brief summary of the case        Page 3  2. Methodology                     Page 4  3. Key Dates Table          Page 7  4.  How professionals understood the case                 Page 11  5. Appraisal of Practice and Analysis 5.1. Introduction          Page 15 5.2. The referrals to Children’s Services in early 2012    Page 16 5.3. Accommodation with Homeless Families 2012-2013    Page 19 5.4. Emergency Presentation at Children’s Hospital 2013              Page 21 5.5. Actions taken consequent to Child C1’s death     Page 25 5.6. Concluding comments        Page 26  6. Findings and Recommendations for the Board      Page 27  Bibliography          Page 29  Appendix A: Individual Agency Actions       Page 30  Appendix B: Multi Agency Actions       Page 32  Appendix C:   Acronyms         Page 36   Page 2 of 36 Child C1 SCR Published Report 151214.doc  1. INTRODUCTION   1.1   The circumstances that led to undertaking this Review  1.1.1  In the summer of 2013 Child C1, who was aged under 2 years old, died after choking on a small item at his home in Manchester, whilst in the care of one of his parents. The Post Mortem examinations subsequently identified unexplained injuries. 1.1.2  The Manchester Safeguarding Children Board’s Serious Case Review (SCR) Sub Group concluded that the case  had met the criteria for a Serious Case Review as identified in Working Together to Safeguard Children 20131, in that there was information that: (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. At the time of this decision, the cause of injuries, including that which led to Child C1’s death had not yet been resolved, however the SCR Sub-Group concluded there were signs of suspected neglect, including:  parental supervision; dangerous home circumstances; the children having been left with an adult about whom the extended family had previous concerns; historical information regarding drug and alcohol use by the parents. 1.1.3   A full Home Office Post Mortem was undertaken and an Inquest took place during the course of this Review.  The Inquest verdict was Accidental Death and the Coroner referred to Child C1’s death as a ‘tragic accident’.   1.1.4  A Police investigation also took place and a file was sent to the Crown Prosecution Service seeking consideration of offences of neglect.  However the CPS advice was that there was insufficient evidence to charge either parent with any offences. 1.1.5   Care proceedings were initiated in relation to Child C1’s older sibling who is now subject to a Care Order.                                                                      1 Working Together: HM Govt 2013  Page 3 of 36 Child C1 SCR Published Report 151214.doc 1.2   Family Composition  The family members referred to in this review have been anonymised as follows:  Family member Anonymisation Age at Summer 2013 (date of ChildC1’s death) Mother MC1  Father FC1  Subject’s older sibling Sibling C1 Under 4 years SUBJECT Child C1 Under two years Maternal grandmother MGM  Maternal grandfather MGF  Paternal grandmother PGM  Paternal grandfather PGF   1.3   Brief Summary of the case  1.3.1. Child C1 lived with his2 mother, MC1 and older sibling, Sibling C1. The mother and children had recently moved into a Housing Association tenancy having previously been living in Homeless Families accommodation for over a year following allegations of domestic abuse involving the father, FC1.  At the time of Child C1’s death the parents were reconciled and FC1 was caring for the children whilst MC1 was out for the evening.  1.3.2. During the course of the evening the two children were left in a downstairs room while FC1 went upstairs to iron some of his clothes.  The period of time FC1 was upstairs cannot be accurately established.  FC1 has stated that it was only a few minutes, although MC1 questions whether he would have been that quick and a longer period appears to have been likely.  FC1 described being aware that the children had become quiet and went downstairs to find Child C1 apparently choking on a small item and unable to breathe.  FC1 attempted to remove the item but could not do so and ran with the child to his grandparents’ home a few doors away.  As it was a very short distance from the hospital, FC1’s grandparents drove him and Child C1 to the A&E department and FC1 carried him inside.  1.3.3.  Child C1 was given Cardio Pulmonary Resuscitation.  Removal of the small item was extremely difficult but was eventually successful and Child C1 was transferred to the Paediatric Intensive Care Unit (PICU), where he was placed on a ventilator.  The parents were informed that it was likely that Child C1 would not survive.  Of particular significance to this Review is that there was no safeguarding referral made by hospital staff on admittance.  Three days later, with the agreement of his parents, Child C1’s life support was discontinued and he died shortly afterwards.                                                              2 To protect children’s anonymity they are both referred to using the male pronoun.  Page 4 of 36 Child C1 SCR Published Report 151214.doc 1.3.4. Prior to Child C1’s death there had been involvement with a number of services.  The parents had met in 2010, but had periods of separation.  There was evidence of domestic abuse including an allegation of physical assault by FC1 on MC1 during her pregnancy with Sibling C1.  This led to a referral to Children’s Services and an Initial Assessment (IA) being undertaken in June 2011.  The IA concluded that no further action was required as the parents were reconciled and living with paternal grandparents who were considered to be protective.  After a short period of reconciliation MC1 disclosed further domestic abuse to health professionals and moved with Sibling C1 to live in Homeless Families accommodation.  At the time MC1 believed that she could manage the domestic abuse, which she says was more verbal than it was physical.  1.3.5. Historically the mother was known to have had periods of depression and suicide attempts.  The maternal grandmother had serious health issues and there were difficulties in family relationships.  In early 2011 the police had been called to a disturbance at the maternal grandmother’s house after an allegation that the Mother, who was pregnant with Sibling C1, had taken her own mother’s prescribed morphine and threatened to kill herself.  1.3.6. The children are of dual heritage.  FC1 is dual heritage, Black Caribbean and White British.  MC1 has identified as White Northern Irish/English.   Both parents have well established connections with their local area.  FC1’s grandparents, with whom he lived as a child, lived in the same street as MC1 and the children.  The family lived in a long established, racially diverse area of the city. No other information regarding issues of diversity has been provided to the Review.   2. METHODOLOGY  2.1.1. Statutory guidance within Working Together requires Local Safeguarding Children Boards to have in place a framework for learning and improvement, which includes the completion of Serious Case Reviews.  The guidance establishes the purpose as follows: Reviews are not ends in themselves. The purpose of these reviews is to identify improvements which are needed and to consolidate good practice. LSCBs and their partner organisations should translate the findings from reviews into programmes of action which lead to sustainable improvements and the prevention of death, serious injury or harm to children. (Working Together, 2013:66) 2.1.2. The statutory guidance requires reviews to consider: “what happened in a case, and why, and what action will be taken”.  In particular,  case reviews should be conducted in a way which: • recognises the complex circumstances in which professionals work together to safeguard children;   Page 5 of 36 Child C1 SCR Published Report 151214.doc • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  • is transparent about the way data is collected and analysed; and  • makes use of relevant research and case evidence to inform the findings.  2.1.3. In order to meet these requirements the model adopted in undertaking this review uses a ‘systems approach’ which draws significantly on the work undertaken by Professor Munro3 and SCIE [Social Care Institute for Excellence].  A ‘systems approach’ to learning recognises the limitations inherent in simply identifying what may have gone wrong and who might be ‘to blame’. Instead it is designed to identify which factors in the wider work environment support good practice, and which create unsafe conditions in which poor safeguarding practice is more likely.  The purpose therefore is to move beyond the individual case to a greater understanding of safeguarding practice more widely.  2.1.4. The process was led by two Independent Reviewers working with a Review team and included:  • Consideration of chronologies and learning summaries produced by 6 key agencies. • 6 meetings of the Review team. • 2 meetings with the ‘Case Group’ – key practitioners involved in the case. • Conversations with 12 of the key practitioners. • Specialist advice from the Consultant Paediatrician and SUDC4 Lead for Greater Manchester.  2.1.5. Two Independent Lead Reviewers, Sian Griffiths and David Hunter, were commissioned to lead the review.   The Review was authored by Sian Griffiths, an independent consultant who has significant experience in undertaking Serious Case Reviews and is an Accredited SCIE Learning Together Reviewer5.   David Hunter is an independent practitioner and author and chair of child Serious Case Reviews, Domestic Homicide Reviews and kindred matters. Both the Lead Reviewers were independent of the case and of all the agencies involved.    2.1.6. The Review Team was comprised of the Independent Lead Reviewers, and the following senior managers/senior professional leads who were independent of the case:                                                             3 See Munro, 2011 Chapter 4 4 Sudden Unexplained Death in Childhood 5 Whilst this Review has used many of the principles of the SCIE model, it has not been undertake as a SCIE Learning Together Review  Page 6 of 36 Child C1 SCR Published Report 151214.doc   Modern Matron for Safeguarding/Child Protection- Saint Mary's Hospital  Central Manchester University Hospitals NHS Foundation Trust  Detective Sergeant Serious Case Review Team  Specialist Protective Services Greater Manchester Police Consultant Paediatrician Community Child Health Designated Dr Safeguarding Children  Manchester NHS Citywide Clinical Commissioning Group  Designated Nurse Manchester NHS Citywide Clinical Commissioning Group  Team Leader  Homelessness Division  Children & Families Directorate  Manchester City Council  Central Locality Manager (Children’s Services) Children & Families Directorate  Manchester City Council  2.1.7.  A Team Manager from the NSPCC took part in the panel in order to offer further independent challenge.  This manager left the NSPCC during the process, but continued her involvement with the panel.  The MSCB Business and Performance Manager, Policy and Performance Officer and Business Support Officer also contributed to Review Team meetings.    2.1.8.  The Case Group consisted of front line practitioners and first line managers who had worked with the family in various capacities.  Individual conversations took place with 12 of these practitioners in order to obtain a detailed picture of what happened in this case, with a particular focus on establishing what the practitioners knew at the time the events unfolded in order to minimise hindsight.  The members of the Case Group were also invited to a briefing meeting at the outset of the Review and to a Learning event at which the emerging analysis was discussed with the Review team.  2.1.9.   As well as the individual agency chronologies and learning summaries, the Review requested and had access to a range of other documentation, including Pathology reports and Children’s Services Initial Assessments.     2.1.10. The timeframe under consideration for this Review was:  1st December 2011 – 31st December 2013.  The starting point was chosen as this was shortly after MC1 and Sibling C1 moved into Homeless Families accommodation, and also the time when a referral was made to Children’s Services.  The end point was chosen to allow consideration of actions taken to protect Sibling C1 following the death of Child C1.   Page 7 of 36 Child C1 SCR Published Report 151214.doc 2.1.11. In order to minimise the risk of pre-judging any learning, the Review did not set out specific terms of Reference, but did identify four issues that were of particular interest to the Board.  The Board were particularly keen to identify whether learning had been embedded in practice following a previous Serious Case Review (Child V) in which Sudden Unexpected Death in Childhood (SUDC) procedures also were a key feature:    1 To consider the effectiveness of the interface between the police, health professionals and HM Coroner in undertaking the child death investigation.   2 To consider to what degree the agencies, individually and collectively, identified any safeguarding implications in relation to surviving or future siblings.   3 To consider what actions were taken as a result of any identified safeguarding concerns arising out of the child death investigation.  4 To consider the role of family members in identifying and responding to child safeguarding concerns.  2.1.12. Family involvement.  The involvement of key family members in a Review can provide particularly helpful insights into the experience of receiving or seeking services.  Both the mother and the father agreed to speak to one of the Lead Reviewers during the course of the Review.  Their comments, where relevant to the purpose of this Review are woven in to the report.   3. Key dates table  Dec 2011 MC1 and Sibling C1 move into Homeless Families accommodation following allegations of Domestic Abuse (DA). Mother reports she is 10 weeks pregnant and it is unplanned. 07.12.11 Pre-assessment MCAF6 checklist completed by HV [health visitor]. January 2012 MC1 fails to attend two antenatal booking appointments. 17.01.12 FC1 attempts to see MC1 at Homeless Families Unit, police called. 29.01.12 FC1 issued with a harassment warning following an incident when he followed MC1 around a supermarket. Police make referral to Children’s Services who conclude no further action.  31.01.12 Referral received by Children’s Services from hospital midwives due to Domestic Abuse.  No further action taken as concluded that Mother was effectively safeguarding the children. 31.02.12 MC1 attends antenatal booking appointment.                                                            6 MCAF  Manchester Common Assessment Framework   Page 8 of 36 Child C1 SCR Published Report 151214.doc MAY 2012 CHILD C1 BORN May/June 2012 HV has difficulty contacting and seeing MC1 and the children.  HV contacts staff to follow up Over the following months there were several health referrals made for both children and appointments were generally missed or there was a delay attending. August 2012 HV visit. Sibling C1 referred to Paediatrician due to difficulty walking – feet turning inwards and to the orthoptist because of a squint. Referred Child C1 to Ear Nose and Throat [ENT] for tongue tie.  Immunisations overdue for both C1 and Sib C1. September 2012 MC1 and FC1 seen arguing at door of Homeless Families accommodation. September 2012 HV refers Child C1 to hospital as poor feeder and faltering growth. MCAF completed by HV due to homelessness and health concerns re both children. October 2012 Police called to incident.  FC1 at his grandfather’s address, abusive, refusing to leave. C1 given first immunisations 10 weeks late and had 8 week baby check, also 10 weeks overdue. Nov 2012 Two appointments for Child C1 failed with Paediatric ENT. GP informed, would require re-referral. Dec 2012 Child C1 brought for immunisations. March 2013 MC1 informs Homeless Families accommodation staff that she will be staying out overnight with FC1.   Agreed that FC1 be allowed to visit as a day visitor. 18 April 2013 MC1 asks for FC1 to be allowed as overnight guest. 22 April 2013 Phone call to Homeless Families accommodation from MC1’s mother.  Wanting her keys back from MC1, describing her as abusive and stealing her morphine.  Stated concerns about FC1’s violence and therefore concerns about the children. 22 April 2013 Permission given by Homeless Families for FC1 to stay as overnight guest. May  2013 MC1 moves into own tenancy with Child C1 and Sibling C1. Day 1, (Sunday) Summer 2013 21.10hrs Child C1 brought into Paediatric Emergency Department by FC1. Explained he had found Child C1 choking on a small object, was unable to remove it.  Ran to his grandparents nearby who brought them into the hospital. Object removed with difficulty in A&E and C1 transferred to Paediatric Intensive Care Unit [PICU].  Child C1 critical recognised he might not survive. Day 2 (Monday)  Scan identifies brain damage.  PICU Consultant prepares parents for possibility Child C1 may not survive. Day 3 (Tuesday)  Further review, PICU Consultant explains that life support cannot continue indefinitely. Staff Nurse contacts Central Manchester University Hospitals NHS Foundation Trust [CMFT] Safeguarding Children’s Nurses informing of admission. Safeguarding Nurse contacts Named Doctor who advises no  Page 9 of 36 Child C1 SCR Published Report 151214.doc child protection concerns about the way C1 was transported to hospital. Day 4 (Wednesday) 10.40 hrs Parents give consent to life support being removed. 13:00hrs Staff Nurse records concerns just raised by maternal grandmother about care provided by FC1 and an incident when Child C1 allegedly fell down stairs.  MGM asking for Sibling C1 to be scanned.  Information shared with PICU Consultant who attempted contact with Consultant Paediatrician for Safeguarding who was not available and the GP. PICU took further advice from duty Paediatrician and then contacted SUDC doctor and Police. 13.10 hrs Police informed by hospital of Child C1 admission and plan to remove life support that afternoon.  Police SIO identified and SUDC Paediatrician informed. Children’s Services informed. 15:30hrs Child C1 pronounced dead.  2 Strategy meetings take place – SUDC Paediatrician, Police, Children’s Services.  Early view that this was tragic accident, but possible issue with FC1’s supervision of children.   Information shared about allegations made by maternal family to hospital staff regarding FC1’s care of Child C1. Allegations of occasional unexplained bruising/accidents in the past.  Agreed S47 assessment, Sibling C1 staying with family. Police and SUDC Paediatrician undertake initial investigation; meet with PICU Staff nurse and family 18:30hrs Child C1 examined by SUDC paediatrician in the presence of Det Inspector1.  Some bruising noted, difficult to determine significance. 19:00 hrs Police and SUDC team request notes from ward.  They were told that the request would have to go to Clinical Governance the next day. 19:30 hrs Police and SUDC Paediatrician undertake visit to home. Day 5 (Thursday) 12.18 hrs Children’s Services Team Manager contacted by Coroner’s Officer.  Informed that Post Mortem had been stopped and a Home Office Post Mortem was to be completed.  Unexplained bruising had been found on Child C1.  Hospital also had the information. Strategy meeting arranged with police. 14.24 hrs Post mortem skeletal survey takes place. 15.30 hrs Strategy meeting takes place with Social Worker, SW Team manager, DI and DC.  Police inform of possible fracture to arm.  Agreed Police Protection for Sibling C1, to be placed in foster care.  Child Protection medical for Sibling C1 booked for later that day.  Further strategy meeting booked. Video interviews undertaken with parents Police and C/S working closely together.  16.50 hrs Hospital Cashier contacts Named Nurse/Matron for Safeguarding Children re concerns shared with her by MGM.  Page 10 of 36 Child C1 SCR Published Report 151214.doc 20.10hrs Sibling C1 taken to foster placement under police powers of protection7. Day 6 (Friday) Child Protection Medical undertaken; Sibling C1.  No non accidental injuries or concerns identified. 09:00  Home Office Post Mortem takes place. Joint briefing undertaken by DI. Possibility of other injuries, further tests required. 15:15hrs Strategy meeting held at the Hospital.  SUDC Paediatrician, SW, DC, HV and DI.  Section 20 [Children Act 1989] Accommodation agreed with parents, but Emergency Protection Order/Interim Care Order would be sought if parental consent withdrawn. Day 9 Domestic Abuse referral sent to Women’s Aid by police requesting support for MC1. Day 12 Strategy Meeting - Police and C/S. Agreed that Skeletal survey will take place for Sibling C1. C/S will be initiating Care Proceedings. Disagreement between Police and C/S regarding what information Police willing to disclose for use in Care Proceedings due to consequent need to disclose to parents C/S find an alternative source, unbeknown to police.  Rapid Response8 Report provided by SUDC Paediatrician to Coroner. Day 18 Sibling C1 – skeletal survey undertaken. No evidence of injuries. Following month Looked After Children Review  Following month Police called by family member following argument between Mother and Father in the street. Forwarded to PPIU.  Domestic Abuse Stalking and Harassment [DASH] risk assessment undertaken.  Risk Medium.  Officer in case informed. Following month Multi-agency planning meeting.  Police, C/S and Local Authority Legal.  Continued dispute about disclosure of information by police to C/S. November 2013 Sibling C1 made subject to Interim Care Order. December 2013 Police submit pre-charge decision form to CPS.  CPS advice- insufficient evidence to charge either parent. December 2013 Police inform C/S that no charges against the parents following advice from CPS.                                                             7 Police Protection: When a police officer has reasonable cause to believe that a child would be at risk of significant harm unless action is taken immediately they may: [Section 46 Children Act 1989] • remove the child from the situation and take them to a place of safety  • Take action to prevent the child's removal from a place of safety. 8 Rapid Response is the process that is followed by agencies as detailed within the Greater Manchester Procedure for The Management Of Sudden Unexpected Death In Childhood  Page 11 of 36 Child C1 SCR Published Report 151214.doc  4. How professionals understood the case at the time  The following section is a summary reconstructing how professionals understood the children’s experience and their situation at the time. It is produced in the present tense in order to ensure focus on what was known at the time, rather than what we know with hindsight. This enables us to gain a better understanding of the context in which professionals worked and therefore what either helped them or got in the way of their safeguarding practice.  4.1. The Review period begins soon after Mother moves into the Homeless Families Unit following disclosures of domestic abuse against Father.   At this point the professionals who have routine contact with the family are the staff at the Unit and the Homeless Team Health Visitor.  All the practitioners experience Mother as a private person who is ‘compliant’, but they do not feel they know her or the children particularly well. In the Health Visitor’s description “there was something intangible about her”. The Mother spends most of the daytime out of the accommodation, reportedly caring for her own mother who is terminally ill with cancer.  The Mother informs staff that she is no longer having contact with the Father and the relationship is over. Staff are aware of the Father’s grandparents visiting but there is no direct recording of their relationship with Mother C1 and Sibling C1 or what the arrangements are for contact between father and child.    4.2. The role of the staff at the Unit is to provide general housing related support for families who have been referred to this accommodation as a result of their vulnerability.  Staff refer to specialists when they identify a particular need, which does not appear to them to be necessary in this case.  There are some concerns about Mother’s health, but Sibling C1’s development and the care he receives do not give cause for concern.    4.3. In early 2012 the Police are involved on a couple of occasions as a result of Father harassing the Mother.  On both occasions the officers identify that these are domestic incidents and refer to the PPIU9. The father is issued with a harassment warning. On the second occasion the PPIU make a referral to Children’s Services. At the end of January the Mother is booked in to the Ante-natal clinic and tells staff that she has experienced Domestic Violence and has a court order preventing the Father from contacting her, but not from having contact with Sibling C1. The information is not recorded on the Neonatal Record, the reasons for which are not known, however, a referral is made to Children’s Services. It is not known if Mother had such a court order.  4.4. Both Referrals are dealt with by the same Social Worker in the First Response Team.  The Social Worker accesses the 2 Initial Assessments prepared the previous year both of which had judged there were no concerns. She experiences the mother as ‘very accommodating’ and assesses she is able to protect the children, as evidenced by her leaving the Father and promptly                                                            9 The PPIU is the Public Protection Investigation Unit of the police which is staffed by specialist officers responding to cases involving Child Protection, Domestic Abuse and safeguarding Vulnerable Adults.  Page 12 of 36 Child C1 SCR Published Report 151214.doc reporting his behaviour.  The Social Worker notes there are no concerns about the care of Sibling C1 from the Health Visitor.   The Social Worker therefore concludes that there is no need for further action.      4.5. The Health Visitor refers the Mother to the Community Nursery Nurse for extra support as well as to the GP as she is worried that the Mother is very underweight.  On several occasions the Health Visitor reminds the Mother to ensure that Sibling C1’s immunisations are undertaken.  The Health Visitor and Unit staff have regular communication, all are aware that the Father should not be allowed access to the building and there are no pressing concerns.  4.6. Child C1 is born in May 2012 and discharged home with his Mother to the Homeless Families Unit.  Whilst hospital staff speak to the Mother at different times both about her mental health and domestic abuse, the Hospital records contain limited information about these issues and again, the reasons for this are not known.  4.7. Both the Health Visitor and the Midwife record a number of missed appointments with the Mother and Child C1, but this does not cause excessive concern and they are reassured by the fact that she is being seen regularly by staff in the Unit. She is felt to be “disorganised with appointments and routines”.  When the Health Visitor does see the Mother and children, she has no significant concerns about Child C1, but does again remind the Mother about ensuring Sibling C1’s immunisations are completed.  Overall the Health Visitor and Community Nursery Nurse are happy with Child C1’s progress.  He is described as “alert and sociable”.  Other appointments with health specialists for the children are missed over the next few months.  The Health Visitor tries to encourage the Mother to take the children to the crèche/playgroup, but she does not do so.  4.8. In March 2013 the Mother tells Unit staff that she is seeing the Father again.  She asks if he can now visit the accommodation.  Initially the ban on him visiting is upheld.  But as she openly continues to see him, often returning very late with the children, a decision is made by the team leader that he can be a day visitor, on the basis that at least this provides some level of monitoring.  It is unclear what consideration, if any, is given to whether Father might present a risk to the children, staff presuming the mother will be able to protect them.  There does not appear to be any discussion of this decision with the Health Visitor or Children’s Services.  4.9. In April 2013 the Mother is informed she will be allocated her own tenancy.  At this point she asks staff in the Unit if the Father can be allowed to stay as an overnight guest “to support her ahead of the move”.  The same month one of the Support Workers at the Unit takes a phone call from maternal grandmother, who alleges that Mother has been stealing her morphine, can be verbally abusive and will not return her house keys.  She also says that the Father is violent and she is worried about the children’s safety.  The Support Worker who takes this call describes being told by a more senior member of staff that this is not their concern, although this is firmly denied by the  Page 13 of 36 Child C1 SCR Published Report 151214.doc individual concerned.  The Support Worker documents the conversation with maternal grandmother in the running record, but does not take any other action.  The Support Worker believes that based on previous history there is little point in doing so as she feels from previous experience her concerns would not be taken seriously.  On the same day it is agreed at an operational level that Father can stay as an overnight guest.  4.10. By late spring 2013 Mother and the two children are living in their new property, which is in the same street as the paternal grandparents.     A local Health Visitor is now allocated to the family and meets them for the first time shortly afterwards.  She describes Sibling C1 as being active and appearing well and that Child C1 is now walking unaided (which had previously been slow in development).  The Health Visitor finds Mother to be friendly.  4.11. At 9.10 in the evening on a Sunday in summer 2013 Child C1 is brought into the A&E department of the Children’s Hospital by his Father.  The father explains that he was caring for the children and had gone upstairs for 5 minutes. When he returned he saw that Child C1 was choking on a small item.  He was not able to remove it so ran with Child C1 to his grandparents’ house down the street and they drove Father and Child C1 to the hospital.  Child C1 is unresponsive and in cardiac arrest.  It proves difficult for A&E staff to remove the item which is eventually achieved by the surgical registrar.  Child C1 is transferred to the PICU but it is clear that he is critically ill and may not survive.  His parents are informed of the seriousness of the situation.  4.12. A significant amount of highly skilled work is required to treat Child C1 and ensure he has the best care.  He remains on a ventilator in Paediatric Intensive Care and is regularly reviewed during Monday and Tuesday. Following the review on Tuesday afternoon, it is explained to the parents that Child C1 has irreversible brain damage and that ventilation will need to be ceased.  It is agreed with the parents that they will have 24 hours to think about what they have been told.   4.13. During the afternoon of Tuesday (Day 3), a Paediatric Nurse on the PICU, is surprised on checking Child C1’s notes that no-one has spoken to the Safeguarding Team at the hospital.  She feels that the presentation of a young child with a cardiac arrest outside of hospital and the delay in his presentation at hospital should have led to a safeguarding referral.  The nurse therefore contacts the Hospital Safeguarding Children’s Nurses and informs them. They in turn speak to the Named Doctor for Child Protection who advises that there are no child protection concerns at this time regarding the way Child C1 was brought into hospital. A member of the hospital Safeguarding Unit also telephones the Health Visitor and leaves a message in her absence.  A message is then left for the PICU nurse quoting the Named Doctor’s response that there are ‘no concerns’ although the context is not detailed in the message that the nurse receives.  4.14. The following day, Wednesday, the parents agree to withdrawal of life support for Child C1.  The maternal grandmother then speaks to the same Nurse and tells her that there is a history of domestic violence from Father; that Child C1  Page 14 of 36 Child C1 SCR Published Report 151214.doc had previously fallen down the stairs and had unexplained bruising whilst in the care of his father who also became aggressive after smoking cannabis.  The Nurse ‘feels sick’ when she hears these allegations and immediately shares the information with the Consultant Paediatrician. The Consultant Paediatrician is unable to contact either of the Named Doctors for Safeguarding, but does speak to the duty Paediatrician who advises him to contact the SUDC team and the police, which he does. He has great difficulty in finding the right police officer to speak with.   4.15. The police immediately contact Children’s Services and the SUDC Paediatrician and Rapid Response/Strategy Meetings take place.  The Children’s Services Team Manager is surprised that they have not previously been told about Child C1 by the hospital.  The initial view of professionals is that this is a tragic accident, although there is some concern about the Father’s supervision of the children.  It is therefore agreed that there should be a Section 47 assessment10, and that Sibling C1 should be cared for by the maternal family. The Police and Children’s Services work well together in managing the decision making and working with the family.  The Children’s Service Team manager maintains an open mind throughout but is satisfied at this point that there is no evidence to justify any other course of action.   4.16. Child C1’s life support is withdrawn that afternoon.  This marks a particularly distressing outcome not only for the family but for practitioners who have been providing Child C1’s care.  4.17. The Police and SUDC paediatrician undertake the expected inquiries in line with the protocol, including visiting the home.  4.18. The following day, Thursday, the Children’s Services Team Manager receives a call from the Coroner’s Officer who informs her that the post mortem has been halted as unexplained bruising has been found.  The Team Manager identifies immediately that this raises the possibility that Sibling C1 may be currently at risk.  A Strategy Meeting is put in place that day and all necessary actions to protect Sibling C1 and video interview the parents are initiated and completed.  By the end of the day Sibling C1 is placed with foster carers.  4.19. The same afternoon, a Hospital Cashier contacts the Named Nurse to tell her that maternal grandmother had spoken to her about concerns regarding the Father.  The cashier’s personality and the nature of her work environment allow her to engage with the grandmother and respond to her distress without distraction.  The cashier feels strongly about the importance of everyone taking responsibility for safeguarding children and has never forgotten the image of Jamie Bulger being walked out of a busy shopping centre with no-one intervening.                                                             10 Section 47 of the Children Act 1989 places a duty on LAs to investigate and  make inquiries into the circumstances of children considered to be at risk of ‘significant harm’ and, to decide what action, if any, it may need to take to safeguard and promote the child’s welfare.  This is also referred to as a Core Assessment.  Page 15 of 36 Child C1 SCR Published Report 151214.doc 4.20. From this point onwards Police, Health and Children’s Services all work together to fully assess any risk to Sibling C1 and investigate the circumstances around Child C1’s death.    4.21. The only difficulty that arises in relation to the multi-agency approach is that some time later there is disagreement between the Police and Children’s Services regarding what information should be shared by the Police in order to inform the Care Proceedings underway in relation to Sibling C1.  The Police do not feel able to provide information about some aspects of their investigation as they are aware that this would become disclosable within the Care Proceedings and therefore known to the parents who had not yet been interviewed under caution because the specialist medical opinion on the cause of the injuries was not ready.  However, the police do provide a written disclosure document to Children’s Services.  The outcome is that Children’s Services Legal Department access the information themselves through another route.  The fact that the Senior Investigating Officer was not a part of the Strategy meetings and also that the Police have had some previous negative experience of Children’s Services in other similar circumstances appears to contribute to the inability to resolve this jointly.   5. Appraisal  of practice and analysis  5.1       Introduction. 5.1.1.  This section of the Review assesses the quality of multi-agency practice at those key points which were considered to provide the most significant learning.  In doing so, it takes into account both the contemporary required standards and also the information that was known, or could have been known at the time of the events.  Where there is information about why practice may not have met required standards these are explained.  By understanding why things happened in the way that they did, rather than simply what happened, the Review is seeking to achieve a greater depth of learning about safeguarding systems within Manchester beyond this individual case.  Where learning in relation to individual agencies’ practice has been identified within the agency learning summaries it is not repeated here.  The recommendations for individual agencies which were produced at the outset of this Review are included in Appendix A.  5.1.2.   It is important to note that no legal judgement has been made as to whether either parent caused any harm to Child C1, either by the inquest, which has no role in identifying individual responsibility for a death, or arising out of criminal proceedings. Nevertheless, as a result of the circumstances around Child C1’s death, Children’s Services concluded that there was evidence that Sibling C1 could be at risk of significant harm and therefore reached the threshold for statutory intervention.  Sibling C1 was subsequently made subject to an Interim Care Order by the Family Court.  The long term plans are for Sibling C1 to be returned to his mother’s care.  Page 16 of 36 Child C1 SCR Published Report 151214.doc 5.1.3.  The Review has reached the clear conclusion that no causative link could reasonably be made between the responses of agencies at the time and the outcome for Child C1. Nothing in the information available to this Review suggests that agencies could have anticipated Child C1’s death within his family in these, or other, circumstances.  Nevertheless in analysing agency actions it is possible to identify potential strengths and weaknesses in safeguarding practice as part of overall learning.  5.2 The referrals to Children’s Services in early 2012    5.2.1.   In January 2012 two referrals were made by the police to Children’s Services regarding domestic violence.  At the end of the month a hospital midwife also made a referral to Children’s Services due to the history of domestic violence and the fact that the mother and Sibling C1 were living in homeless accommodation.  The referrals, which were all appropriately made, went to the First Response team.  The team which is staffed by Social Workers responds to all new contacts coming in to Children’s Services; undertakes initial enquiries and where the case requires a statutory social work response forwards it to a locality social work team for further assessment.  The required standard is that each contact will be considered and responded to within 24 hours.  5.2.2.   In this case the Social Worker assessed that there was no need for further action. The Social Worker had access to two previous assessments undertaken in the preceding 6 months which had also concluded that no further action was required.  The Social Worker in reflecting on her response felt that she had adequate information to make this judgement and that the previous assessments were of a good quality.    She did not question the previous Initial Assessments, which included some unresolved information that could reasonably have triggered concern about the Mother’s history.   She gave significant weight to the mother’s separation from the father and her ability to protect her children. The manager who signed off the Initial Assessment accepted this assessment.  5.2.3.   It is the conclusion of this Review that there was enough information to indicate the need either for a MCAF or for a fuller social work assessment of both Sibling C1 and unborn Child C1’s needs. The Review Team identified a number of aspects of the two previous Initial Assessments which were of concern.  Despite the allegations of Domestic Abuse the parents had been interviewed together and there is no evidence of MC1 being seen on her own.  There had by this point been 7 referrals to Children’s Services and this was clearly a vulnerable family, although not a family that was displaying evidence of high or increasing risk. The Social Worker was explicit during her conversation with Review team members that she did not feel that she was working under unreasonable pressures at this particular time and she did not identify any other work factors that had an impact on her decision making. This suggests that her response to this case was not untypical.  It cannot be discounted that the approach and assessment skills of a particular individual may have been a significant factor.  However, focussing on this alone will not provide adequate insight into the factors that impact on work  Page 17 of 36 Child C1 SCR Published Report 151214.doc within the First Response team and in what way practice might be strengthened and risks minimised.    5.2.4.   In reflecting on this episode of practice it is possible to identify a number of common ‘error traps’ which are increasingly recognised as familiar factors in child protection practice. The individual referrals relating to this family largely repeated similar concerns from different agencies at different times.  There was no explicit information suggesting an increase in the level of concern over time.  This is a familiar pattern from practice experience both locally and nationally.  Because the referrals appear to be repeating the same information, there is a tendency to assume that the previous assessment of the situation remains unchanged.  As a result, the potential cumulative impact for a child of living in what may be a damaging environment may not be recognised.  5.2.5.   A second common error trap when working in complex environments11 is a failure to revise assessments or reconsider initial judgements. This was demonstrated in this case by the absence of challenge about the previous Initial Assessments, despite further information and changing circumstances, such as further evidence of domestic abuse and the impending birth of another child.  The Social Worker was explicit that as the team manager had signed off these previous assessments there was no reason for them to be revisited or questioned. This approach points towards the need for greater willingness to challenge and be challenged on decision making throughout the organisation.  Lastly, the weight given in the assessment to the mother’s capacity to separate from the father and protect her child post separation was not balanced adequately against concrete evidence or tested out over time.   5.2.6.   Practitioners should not be judged as if they are working in a vacuum when reaching such decisions, as their work context will have a fundamental impact on how they respond to individual cases.  There is a body of knowledge about the particular difficulties of ensuring that teams at the ‘Front Door’ of Children’s Services are able to effectively manage the inevitable risks within this setting.12 Safeguards, such as time for reflection and comprehensive individual case supervision, are considerably harder to embed in this setting and therefore best practice which requires practitioners to routinely achieve a ‘constant balancing of opposing arguments, alternative hypotheses or conflicting versions of events”13 is particularly difficult. Practitioners working at the ‘front door’ of Children’s Services are required to reach quick judgements with limited information and as such there is a particular level of vulnerability built in to the practice. Research also suggests that such teams may be inclined to ‘filter out’ referrals, particularly where there is no information of immediate significant harm to a child.14                                                             11 Munro (2008: 137) 12 Broadhurst et al (2009) 13 Reder and Duncan, cited in Burton, S (2009 :7) 14 Broadhurst et al (2009)  Page 18 of 36 Child C1 SCR Published Report 151214.doc 5.2.7.  The First Response team is responsible for assessing all the first contacts for the whole of Manchester.  It manages a very high throughput of work and by its nature is an intense work environment.  It will therefore not be possible to achieve absolute certainty that every decision made will stand the test of a subsequent detailed examination.    “Child protection inevitably involves working with uncertainties and making difficult decisions and complex judgements on the basis of incomplete information in rapidly evolving, often hostile and highly stressful contexts.” 15               Nevertheless the expectations of good, defensible, decision making are rightly high and practitioners need good quality support and assessment so that the organisation can be confident in the standards that are achieved. This Review recognises that ensuring best practice at this early point is a continuing area of priority for Children’s Services and the Board.  It has been subject to critique within OFSTED inspections, audits, a peer review and reports to the Council’s Scrutiny Committee.  Planning is in place to develop a Multi Agency Safeguarding Hub [MASH] as the first point of contact by 2015.  The recommendation to the Board regarding this aspect of practice is therefore made clearly within this context and framed to ensure that focus on the particular vulnerabilities of assessment practice within this setting is given priority in both current and future developments.   (Recommendation 1)  5.2.8. It is also of note that despite the concerns of agencies and the repeat referrals, the option of undertaking a MCAF was not pursued by the referring agencies or recommended by Children’s Services. Standards and practice at the time were intended to ensure that contacts not requiring statutory social work intervention were followed up with appropriate community resources for immediate support to the child and family, which would often entail a MCAF.   The Social Worker stated that she had informed the Homeless Families Unit that they should make a further referral if the mother restarted her relationship with the father.  However, there is no evidence of this advice in the records of either agency and no reference to a MCAF.  5.2.9. The experience of this case again underlines the continuing work required to ensure the appropriate use of MCAFs when working with families with additional needs who are below the threshold for Children’s Services’ intervention.  The experience of this Review provides further case evidence as to the comparatively low use of MCAFs at that time, something which was already recognised by Children’s Services and the Board following an unannounced OFSTED inspection in 2009.  It has further raised the question as to the effectiveness of the Pre-CAF questionnaire, intended to identify whether a MCAF is needed.  In this case, it is unclear why the Pre-CAF which was undertaken did not lead to a MCAF, something which the practitioner concerned has clearly recognised themselves.  Good practice would be to include an explanation as to why the Pre-CAF did not result in                                                            15 Burton (2009:4)  Page 19 of 36 Child C1 SCR Published Report 151214.doc the initiation of a MCAF. Responding to this concern within the Early Help programme has been identified as a continuing priority for the Board, and therefore this Review does not consider there is significant value to producing a general recommendation in relation to MCAFs.  However, what has been recognised as a result of this review is that the normal expectation for homeless families where there is no formal social work intervention would be that a MCAF is actively pursued with the family. (Recommendation 2)   5.3 Mother, Child C1 and Sibling C1’s accommodation in Homeless Families Accommodation 2012-2013    5.3.1. The Mother and Sibling C1 lived in the Homeless Families Unit for approximately 18 months with Child C1 being born during this period.  Mother was experienced by staff as ‘a private person, who took control of her own affairs’.  She was considered to be co-operative but did not actively seek or take up professionals’ time in the way that was more typical of residents in this setting.  MC1 describes herself as someone who ‘likes to get on with things’ and did not present problems to the staff.  The children were mainly seen by staff when the mother was arriving or leaving and there was nothing of concern about their presentation. It would appear that the fact that the Mother presented as quite able and self-contained had the impact of dampening professional curiosity or concern.  There was no evidence during their time in the Unit that the children were suffering harm.  Nevertheless, the story of this family has been recognised by Homeless Families as providing some important learning about the way in which families who do not present as chaotic or high risk may remain fundamentally unknown to professionals, or their problems underestimated.   5.3.2. One of the factors that have been identified as having impacted on the way in which the service was provided to the families living within the unit was the staff grading system in place at this time.  Support workers were appointed at two different pay grades without clarity as to the different roles or skills required to fill those roles.  There was direct evidence provided to the review of the negative impact it had had on some practitioner’s perception of their worth and their responsibility. This system has since been redesigned in recognition that it was counterproductive.  To some extent, a culture developed whereby those staff at the lower grade may not have felt they were able to, or should engage with the residents other than at the most practical level, which was not the intention of the service.    5.3.3. A particular concern was the response to maternal grandmother’s allegations regarding MC1’s drug use, FC1’s aggressive behaviour and her fears for the children.  The Support Worker (Support Worker A) who received the call stated that she had informed a Support Worker at the higher grade (Support Worker B) about what had been said, but was told that this was not their business.  Support Worker B denies absolutely that this conversation took place and there is nothing in Support Worker A’s contemporaneous record to confirm that it did. Support Worker A did note the conversation with maternal grandmother in the running records, but she took no further action, as in her view, there was little point escalating concerns, because she believed  Page 20 of 36 Child C1 SCR Published Report 151214.doc nothing would be done. Clearly this represents unacceptable safeguarding practice. Support Worker A described personal disputes between some workers, linked in part to the grading system, as well as a sense of disaffection with senior management.  An investigation into this incident has taken place, but the only conclusive evidence is that Support Worker A did not escalate her concerns and that if any other staff members read the record they did not consider taking action either.  Support Worker A no longer works in this setting and relevant staff in the Unit have been made aware of the agency expectations regarding safeguarding.  The Service has identified no evidence to consider that this episode was typical of practice.  5.3.4. The most significant area of learning which is judged to have wider relevance to practice in the Homeless Families Unit is the response to the risks of domestic abuse to the mother and children.  The mother, and any risk to her, had been assessed prior to moving to the Unit and she had contact with an IDVA (Independent Domestic Violence Advisor).  The reason for her move into the unit was specifically because she had been made homeless following allegations of domestic abuse and this was known to staff.  5.3.5. The Father was not allowed in the unit and on a couple of occasions when he attempted to gain access, appropriate action, including calling the police, was taken. However, until the spring of 2013 Mother stated that she was not in contact with FC1.  5.3.6. Then, in early 2013 it became apparent that MC1 was meeting with FC1 and a pragmatic decision was made by a team leader in the unit to allow him to visit and subsequently stay overnight.  There was, and is, no evidence that either the mother or children were subject to abuse as a result of this decision.  However the Review team were concerned about the decision in principle and as a result it was further investigated by a senior manager within the Homeless Families Division. It has been judged that whilst the thinking behind this decision was well intentioned, it was nevertheless flawed. It was based initially on the fact that as the unit could not prevent MC1 from seeing FC1, it was safer that she did so where there might be some oversight.   5.3.7. On reflection it becomes apparent that taking this approach could place children at risk and may send an unintended message to victims and perpetrators about the seriousness of domestic abuse.  Staff noted they had followed the policy that children should always be accompanied by a parent, but had not taken into account the possibility that the parent might not be in a position to protect.  Given the Unit’s specific role in housing families as a result of Domestic Abuse this is of some concern. In attempting to understand why this was the case the Review has considered  four  significant issues for the unit:  • The professional perception of MC1 as not presenting any concerns for herself or her children.  Page 21 of 36 Child C1 SCR Published Report 151214.doc • The degree to which adherence to policies may provide a false sense of security that the correct actions have been taken. • The degree to which staff understand the dynamics of domestic abuse and its relationship to safeguarding children.  • The risk of focussing on the adult perspective of risk, rather than the child’s experience.  5.3.8. The Homeless Families Service has made procedural changes as a result of this Review, but has also made a commitment to work with staff to develop their reflective skills, through supervision and training. This is subject to a recommendation. In particular this Review has highlighted a potential skills deficit, which the Review team felt had relevance across agencies more generally.  Practitioners who contributed to this review were able to articulate the principles of safeguarding.  However, this left an unanswered question about practitioners’ confidence or skills in engaging parents in difficult discussions about issues such as domestic violence.  This was also reflected in some of the records from health workers.  From their wider experience Review Team members felt that skills, as opposed to knowledge, in working with adults, were often an area of vulnerability across services.  For example, although protocols or procedures in some situations require questions about domestic abuse to be asked, there was a concern that due to varied staff confidence or experience, this was not infrequently done in a formulaic manner and was therefore limited in its effectiveness. (Recommendation 3)  5.4 Emergency Presentation of Child C1 at the Children’s Hospital, summer 2013   5.4.1. The medical care provided to Child C1 when he was taken into A&E at the Children’s Hospital met the high standards expected.   Considerable difficulties were met in removing the object from his throat and this will have been both professionally and personally demanding for the medical staff concerned.  Similarly the care that Child C1 received on the Paediatric Intensive Care Unit, and the response to the family, has been assessed as being of a high quality. Again, the professional and personal demands on staff of working with children in this setting should not be underestimated.  “Few of us can imagine a greater nightmare than facing the death of a child.  The professionals who work with families through such a tragedy – doctors, nurses, policemen and social workers – deal with the rawest of emotions”16   What has however been identified in relation to Child C1 is that safeguarding concerns had not been recognised at the earliest possible stage following his admission to hospital.  The potential implications of this are twofold:                                                             16  Foreword by  Baroness Helena Kennedy QC in Sidebotham & Fleming, (2008)  Page 22 of 36 Child C1 SCR Published Report 151214.doc • Sibling C1’s safety could have been compromised, although there is no evidence that he did experience any harm as a result. • Access to evidence that would have contributed towards the police investigation was compromised.  The learning arising out of this episode of practice therefore reflects one of the issues of interest identified at the outset of this Review and requires priority consideration by the Board. 5.4.2.  Child C1 had experienced an unusual, serious medical trauma, which should have triggered concern from a much earlier point of admission.  Whilst this is understandable in the early hours, during which time significant medical input was required to attempt to stabilise him, the Review Team were concerned that there was no consideration of a referral to the Safeguarding team in the hospital until Day 3 when a new member of staff came on to the unit.    The Consultant Paediatrician in discussion with the Review Team identified that the focus in the PICU was very much on the end of life care in relation to Child C1.  He recognised that whilst safeguarding should be considered automatically, in reality this was dependant on the medical presentation of the child, which in Child C1’s case did not trigger any concerns.    Whilst in complex work environments, it can be difficult to identify signs of concern, this mirrors the comment by Lord Laming in the Victoria Climbie enquiry that:               “Child protection does not come labelled as such”17.    The result of the overwhelming focus on the child’s medical care had the effect of distracting attention from other information which might have led to consideration that there were safeguarding concerns.  5.4.3.  That a staff nurse who arrived on shift on Day 3 was immediately concerned that the safeguarding team had not been consulted for advice about Child C1, illustrates that there were indicators of potential concern present.  The nurse was surprised that given: the method by which the Father had brought Child C1 into hospital; the confusion as to whether or not the parents were separated; recognition of the mother’s previous address as being a hostel; and that this was a cardiac arrest of a child which in itself is unusual, she believed that advice should have been sought from the safeguarding team in the hospital.  The apparent reasons for this  difference in approach include:  • The nurse concerned had a particular interest in safeguarding and was studying a Safeguarding module in a Masters Degree. • The nurse was able to bring a fresh perspective after the point of crisis management when staff would have been under particular pressure. • The safeguarding team would not have been available for consultation at the weekend.                                                             17 Laming  (2003: p60)  Page 23 of 36 Child C1 SCR Published Report 151214.doc 5.4.4. The absence of the safeguarding team at the weekend has been raised by hospital staff as a potential weakness in the system.  However, in this case there is no evidence from those involved that consideration was explicitly given to seeking safeguarding advice over the weekend and therefore this would not appear to have been a critical factor. The alternative route for advice would be through the on call Consultant Paediatrician in any event.  Whilst the principle of the availability of working hours has been accepted by the Trust, nevertheless, it is the conclusion of this Review that the underpinning focus on safeguarding within the PICU setting needs further development.  The evidence provided to this Review would suggest that safeguarding is not firmly ingrained in thinking within this setting, something which has been commented on by other paediatricians who have safeguarding explicitly as part of their role.  Whilst there may be benefits to identifying a named member of staff  with a safeguarding remit for all children in the unit, if this were to be considered it should be additional to, not instead of, a strong commitment to developing a mindset that ‘safeguarding is everyone’s business’ being developed in specialist paediatric settings. (Recommendation 4)  5.4.5.   It is also the case that the possibility of seeking safeguarding advice could have been considered whilst Child C1 was in Accident and Emergency.  Information provided by the Named Doctor for Safeguarding was that typically systems at A&E for contact Safeguarding were well followed.  Two possible factors may have influenced why this did not take place on this occasion. Firstly, that the child was transferred from A&E into the PICU and therefore A&E staff may have assumed that once the child was stabilised any safeguarding concerns would be managed within that unit. Secondly, the fact that Child C1 was carried into A&E by a parent, rather than brought in by ambulance meant that the more typical response, i.e. that paramedics or accompanying police officers would have raised a safeguarding concern, was not available. Given that this is an unusual set of circumstances, it would not appear proportionate to suggest significant changes in policy or procedure at A& E as a result, however, a recommendation is made that the learning from this review is shared with key staff at A&E. (Recommendation 5).  The response of the cashier in sharing her concerns is a potent reminder that safeguarding is very significantly an attitude of mind, rather than a function of a particular role.  5.4.6.   The day after the Staff Nurse contacted the safeguarding team for advice she was also told by the maternal grandmother of concerns about domestic violence and that Child C1 had previously suffered accidents in FC1’s care.  This disclosure was immediately passed to the Consultant Paediatrician who attempted to speak to a member of the Safeguarding team, but was not able to do so. The Consultant Paediatrician gave a powerful description of the frustration of having to make a number of phone calls before finding the right person to speak to and this procedural gap will require attention by the Trust. (Recommendation 4) The Consultant Paediatrician’s response at this point then led to the SUDC procedures being initiated.   Page 24 of 36 Child C1 SCR Published Report 151214.doc 5.4.7.  Clear procedures have been developed over recent years to respond to sudden unexpected deaths in childhood.  The Greater Manchester Procedure18 has been revised and updated since its introduction in 2009, most recently including specific learning from a Serious Case Review (Child V, 2013).  This Review was specifically asked to consider whether the processes which were undertaken following Child C1’s death were in keeping with the expected procedures and particularly whether there was evidence from Child C1’s experience that learning from Child V had been embedded.  5.4.8.   Child V’s case had identified that there were gaps in the SUDC procedures at the time.  In particular it had revealed that if a child died from natural causes, yet the post mortem examinations identified unexplained injuries which did not relate to the cause of death, there was no requirement or  trigger to ensure that safeguarding services were informed, potentially leaving other children at risk now, or in the future.  In Child C1’s case, when information was received by the Coroner’s office that he had unexplained injuries, not related to the cause of death, the Police and Children’s Services were informed immediately by the Coroner’s Officer. The Social Work manager concerned was particularly impressed at this response, which was her first experience of such information being shared by the Coroner’s office and clearly demonstrates learning from Child V.  5.4.9.  The actions taken by those involved in the SUDC procedures, health, Police, Coroner’s Office, were timely and met the required standards both in the letter and the spirit of the procedures.  All steps were taken in order to ensure that the safety of the remaining sibling was secured, the family were supported appropriately and necessary investigations were initiated. Professionals from different disciplines worked together co-operatively, for example police and social work staff spoke to each other most days.     5.4.10. The effectiveness of this period of practice was to a significant degree a consequence of the professionals concerned having a good mix of relevant experience. There was an experienced police Senior Investigating Officer, who had very recently completed SUDC training and another experienced DI was appointed to focus on the safeguarding role.  The Social Worker and her manager were both experienced and confident in their roles.  Although neither had previously had experience of the SUDC procedures they had a very clear view about their role and were very focussed on the safeguarding of Sibling C1.  The SUDC paediatrician was also very experienced, with a strong commitment to multi-agency approach to safeguarding.  The Social Work team manager was highly self-critical about her assessment that there was no reason to consider immediate protective actions for Sibling C1 on Day 3 and that she had accepted the view that the injury was the result of a ‘tragic accident’.  She was then ‘devastated’ when she was informed of both the allegations about the father and the unexplained post mortem injuries.                                                             18 Greater Manchester Procedure For The Management Of Sudden Unexpected Death In Childhood (Rapid Response) Version 4 ()1.07.13)       Page 25 of 36 Child C1 SCR Published Report 151214.doc However until Day 4 there was no evidence that could reasonably have led to Children’s Services intervening to protect Sibling C1 and no reason to criticise the practice of the Social Worker or her manager.  5.4.11. The sequence of events in Child C1’s case has however exposed an anomaly in the SUDC procedure which requires considered, but urgent resolution.  It was recognised within hours of Child C1’s admission to hospital that he would not be able to survive independently without continued life support and therefore that his life would end within the foreseeable future.   As such the need for the SUDC procedures was predictable.  However, because the child’s death followed a planned process within the hospital, there was in effect a built in delay.  This raises the question as to why there is not a clear trigger or professional mindset that initiates such a procedure when the death of a child in such circumstances is recognised as inevitable.  5.4.12. The SUDC lead for Greater Manchester has been working with a group of colleagues for some time in an attempt to develop a protocol to respond to children who present following an Acute Life Threatening Event linking this with the SUDC procedures.  As a result of this Review, which again has highlighted potential vulnerabilities in safeguarding practice for this group of children, a further meeting has been arranged to try to progress this work.  It is therefore the recommendation of this Review that this work is completed urgently. (Recommendation 6)    5.5 Actions taken consequent to Child C1’s death  5.5.1. Joint working between the Police and Children’s Services in investigating Child C1’s death and safeguarding Sibling C1 was predominantly of a high standard.  However there was one aspect which did cause difficulty.  During the course of the Police investigation there was a dispute between the Police and the Local Authority as to what information about that investigation could be shared.  A decision was made by the Police not to share information about some details of the investigation which the Local Authority legal advisors considered were crucial as part of their application to the Family Court for an Interim Care Order.  This was not resolved, leading to the Local Authority obtaining the information from another source, which was evidently not good practice from either agency’s perspective.   5.5.2. That there was an impasse between these two services was not acceptable. Such difficulties in managing information are not unusual in these cases and require a constructive problem solving approach on both sides, with escalation to more senior levels if necessary.  It is therefore the Recommendation of this Review that the experience identified in this case is shared with the multi-agency Child Protection Investigation Steering Group for further consideration. (Recommendation 7)  5.5.3. A detailed analysis of decisions made by the police and CPS as whether to bring criminal charges in an individual case is outside the remit of this Review.  Information provided to the Review was that consideration was  Page 26 of 36 Child C1 SCR Published Report 151214.doc given by the police both as to whether there were grounds for a criminal charge relating to the cause of Child C1’s death, either due to a deliberate action, or a failure to act, by either of his parents.  Based on the file of evidence prepared by the Police the CPS subsequently concluded that they could not authorise charges on the evidence available.   5.5.4. This Review is not challenging either the Police or CPS decision in this case. However, the Review team were in wide agreement that in some cases involving questions of possible neglect, the involvement of other key professionals in an advisory role, particularly those from Children’s Services, might provide extremely helpful to the CPS in weighing up the evidence.  The CPS has recently identified the need for a change in its approach in other circumstances where there are questions about abusive behaviour by adults, particularly cases of Child Sexual Exploitation.  The Review team felt strongly that in complex child protection cases, there was merit in exploring this further with the CPS.  (Recommendation 8)     5.5.5. The physical vulnerability of young children and the degree to which parental knowledge about the actions that should be taken when a child experiences some critical accident has been given consideration within this Review.  It is important to note that Child C1’s mother believes that had the father had better knowledge of First Aid there was a possibility that the outcome for Child C1 might have been different.  Similarly the importance of calling 999, and therefore receiving immediate medical advice, even when the distance to a hospital is a very short one, has also been highlighted.  In these circumstances this Review recommends that a proportionate piece of work is undertaken to consider whether there is the means to provide First Aid advice or training for new parents. (Recommendation 9)  5.6 Concluding comments  5.6.1. At the outset of this Review four issues were identified as of particular interest, however, these were not intended to define or constrict the learning for this Review (see page 7). Each of these has been considered within this report, however it is of significance that a number of other issues have emerged as having been of particular importance for safeguarding within Manchester and these have led to three key recommendations.   5.6.2. Issue 1:  The interface between police, health professionals and HM Coroner in undertaking the child death investigation.  The Review has reached a clear conclusion the practice following the initiation of the SUDC procedures was of a good standard and demonstrated learning from previous incidents.  5.6.3. Issue 2: Agency response to safeguarding implications for surviving or future children. The Review has undertaken a detailed analysis of the response of agencies in recognising the potential safeguarding issues for future children and where this has identified weaknesses in safeguarding practice, recommendations have been made.   Page 27 of 36 Child C1 SCR Published Report 151214.doc 5.6.4. Issue 3: Actions taken as a result of any identified safeguarding concerns arising out of the child death investigation. The review has reached the conclusion that actions taken when safeguarding issues were identified were timely and appropriate.  5.6.5. Issue 4:  The role of family members in identifying and responding to safeguarding concerns.  Given the information provided by family members about their concerns following Child C1’s admission to hospital, and the particular circumstances of his being brought into hospital, the Review was keen to consider whether there was any wider learning from the family’s perspective.  This has led to a recommendation regarding the provision of First Aid information to new parents.     6  Findings for the Board and Recommendations  This section brings together the recommendations arising out of the learning from Child C1’s experience which will require further consideration and prioritisation by the Board.  The recommendations are not framed primarily to meet the SMART19 criteria as whilst some have comparatively straightforward solutions, others may trigger a range of responses at a multi and individual agency level and may also benefit from being linked to and incorporated with other ongoing work-streams.   Similarly Action Plans are not incorporated within this report in recognition of the growing awareness of the importance of ownership by the Board of the learning arising out of Serious Case Reviews and the often limited effectiveness of SCR Recommendations where this ownership has not been clearly established20.     1. The Board to consider how the role of Reflective Supervision in strengthening assessment practice can be developed and enhanced as a key tool in safeguarding children, both in relation to Children’s Services and to other partners.    2. Learning from this Review to be incorporated into the development of the role of MCAF within Early Help.  This to include:  • Where families placed in homeless families’ accommodation are not subject to formal intervention from Children’s Services, there should be a normal expectation that a MCAF is actively considered with the family.                                                            19 SMART  criteria for setting goals , are (with occasional variations in the words used) Specific, Measurable, Achievable, Realistic, Timely 20 See Brandon et al (Sept 2011)  Page 28 of 36 Child C1 SCR Published Report 151214.doc • Where a pre-CAF does not lead to a MCAF, the reasons for this should be identified.  3. The Board to consider what support or multi-agency training could be provided to enable partner agencies to assess and/or develop staff skills in working effectively with adults, particularly, but not exclusively with regard to experiences of domestic abuse.  4. CMFT to evaluate the degree to which awareness of safeguarding is evidenced in practice within the Paediatric Intensive Care Unit and identify any supportive processes or other  steps which need to be taken as a result, including clear routes for contacting other agencies.  5. Information from this Review to be shared with A&E staff and consideration to be given to any changes in safeguarding practice as a result.  6. The Board to ensure that a safeguarding protocol for responding to children presenting with an Acute Life Threatening Event is completed and implemented as a matter of urgency.  7. At the earliest opportunity, the Board to share this report with the Child Protection Investigation Steering Group.  That group to review the practice relating to information sharing between the police and Local Authority as this impacts on criminal and family court processes.  8. The Board to seek discussions with the CPS regarding the possibility in some complex child protection cases of the involvement of Children’s Services in an advisory capacity.  9. The Board to request a focussed and time limited review by the relevant NHS Trusts regarding First Aid information provided to new parents and for any achievable improvements to current provisions to be identified.    Page 29 of 36 Child C1 SCR Published Report 151214.doc  BIBLIOGRAPHY  Brandon et al (Sept 2011) A study of recommendations arising from serious case reviews 2009-2010  Broadhurst et al (Nov 2010) Ten Pitfalls and How to avoid them.  NSPCC  Burton, S (2009) C4EOSafeguarding Briefing:   The oversight and review of cases in the light of changing circumstances and new information    HM Government (2013) Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. London   Lord Laming, The Victoria Climbié Inquiry, London: The Stationery Office, 2003  Munro, E Effective Child Protection.  2008  Sidebotham, P and Fleming, P (2008) Unexpected Death in Childhood: A Handbook for practitioners  Page 30 of 36 Child C1 SCR Published Report 151214.doc APPENDIX A:  Individual Agency Actions  The following actions were identified by individual agencies at the outset of the Review based on their initial analysis of the practice. Central Manchester NHS Foundation Trust 1. Health Visitors should demonstrate that a process is in place to ensure that medical referrals are not delayed, and that the responsibility for making a referral is clearly documented. 2. Vulnerable Babies team should provide regular bespoke training to Health Visitors and Midwives to ensure that the referral process for MCAF and Vulnerable Babies is commenced at the earliest possible opportunity.  3. Health Visitors and Midwives should clearly document within the child’s records why an MCAF has been rejected by them when faced with obvious concerns.  4. Rotational Midwives to antenatal clinic continue to have their booking history taking “peer reviewed” to ensure that local guidance is being adhered to and that errors have not been made.  However, core staff should be regularly reminded of referral process and guidance in order to ensure that the peer review process is fit for purpose.  5. All midwives receive documentation appraisal at their annual Supervisor of midwives review.  This should include documentation for the neonate.  6. An audit should be undertaken by the Safeguarding Midwifery Team in order to identify the percentage of information which is appropriately shared by the Neonatal record, which should be commenced at booking.  7. Midwives, Doctors and Health Visitors need to regularly review case notes and correspondence to ensure that all social concerns are regularly addressed, as circumstances could deteriorate throughout the pregnancy and following delivery of the baby.  8. Antenatal care and post natal care guidelines for midwives and medical staff and health visitor guidance should direct all staff to readdress social care issues regularly, especially where there has been an increased risk of concern identified earlier.  9. Provision for documentation should be made for any attendance into the hospital with regard to who is caring for the other children.  10. Provision for documentation to be made with regard to who is present in labour and at delivery.  11. Provision for documentation to be made when estranged partners visit or attend the post natal ward or are present during community home visits.  Page 31 of 36 Child C1 SCR Published Report 151214.doc  Manchester City Council - Homelessness 1. Safeguarding children training refresher to be provided for staff.  GP Services 1. Review the process of patient record transfer and consider ways to minimise the journey time and optimise communication of patient care issues between practices as a patient changes registration, particularly in the case of a safeguarding concern.  Children and Families - Children’s Services 1. Summary of learning from this case in relation to the need for good quality assessments that include gathering information from all agencies involved, to be presented to all Social Work teams. 2.  All Social Workers to attend training on domestic abuse within 6 months.   Page 32 of 36 Child C1 SCR Published Report 151214.doc APPENDIX B:  Multi Agency Actions The finding identified by the SCR Do MSCB accept the finding? If MSCB accepts the finding how will it be taken forward? Who is best placed to take this forward and in what timescale? Timescale for responding to the finding and how will it be reported? 1. The Board to consider how the role of Reflective Supervision in strengthening assessment practice can be developed and enhanced as a key tool in safeguarding children, both in relation to Children’s Services and to other partners.  Yes   1. MSCB will take this forward by tasking  the Quality & Performance Improvement Sub-Group to assess & evaluate the impact of the Multi-Agency Supervision Policy implemented and published following the Child U SCR. 1. Quality & Performance Improvement Sub-Group by the end of February 2015. (Chair SPIG RW) 1. Via a report to MSCB by the end of February 2015.  2. Learning from this Review to be incorporated into the development of the role of MCAF within Early Help.  This to include: • Where families placed in homeless families’ accommodation are not subject to formal intervention from Children’s Services, there should be a normal expectation that a MCAF is actively considered with the family. • Where a pre-CAF does not lead to a MCAF, the reasons for this should be identified.  Yes    2. MSCB will take this forward by requiring the Early Help Strategy Group to produce a plan of action.   2. Early Help Strategy Group.(Lead EM)  2.1 Initial plan of action by the end of November 2014.  2.2 Report on completed plan of action by the end of February 2015  Via report to MSCB in two phases:  2.1 End of November 2014.  2.2 End of February 2015.  Page 33 of 36 Child C1 SCR Published Report 151214.doc APPENDIX B:  Multi Agency Actions The finding identified by the SCR Do MSCB accept the finding? If MSCB accepts the finding how will it be taken forward? Who is best placed to take this forward and in what timescale? Timescale for responding to the finding and how will it be reported?  3. The Board to consider what support or multi-agency training could be provided to enable partner agencies to assess and/or develop staff skills in working effectively with adults, particularly, but not exclusively with regard to experiences of domestic abuse.  Yes  3.1 MSCB will take this forward by linking with recommendation 1.1 from the Child B1 SCR requiring the CSP  to provide assurances to MSCB that the ‘Delivering  Differently’ response to domestic abuse  will incorporate strengthened arrangements for safeguarding children; including the monitoring of the new arrangements by the Safeguarding  Children Practice Development Sub-Group. 3.2 The Learning & Development Sub-Group will ensure that the outcomes from this activity are integrated into relevant Multi-Agency training. AS SCR B1: 3.1.1 Letter to CSP end Sept 2014. (Business Manager AMc)   3.1.2 SCPD SG monitoring by end Jan 2015 (Chair tbc)  3.2 Learning & Development Sub-Group. By the end of February 2015. (Chair AMc tbc)  3.1 By report to MSCB by the end of January 2015.    3.2 By report to MSCB by the end of February 2015.  4. CMFT to evaluate the degree to which awareness of safeguarding is evidenced in practice within the Paediatric Intensive Care Unit and identify any supportive processes or other  steps which need to be taken as a result, including clear routes for  Yes     4. MSCB will take this forward by requiring a report from the Head of Safeguarding CMFT.    4. Head of Safeguarding CMFT (KK) by the end of December 2014   4. Report to MSCB by the end of December 2014.   Page 34 of 36 Child C1 SCR Published Report 151214.doc APPENDIX B:  Multi Agency Actions The finding identified by the SCR Do MSCB accept the finding? If MSCB accepts the finding how will it be taken forward? Who is best placed to take this forward and in what timescale? Timescale for responding to the finding and how will it be reported? contacting other agencies.   5. Information from this Review to be shared with A&E staff and consideration to be given to any changes in safeguarding practice as a result.  Yes  5. MSCB will take this forward by requiring a report from the Head of Safeguarding CMFT.  5. Head of Safeguarding CMFT  (KK) by the end of December 2014  5. Report to MSCB by the end of December 2014.  6. The Board to ensure that a safeguarding protocol for responding to children presenting with an Acute Life Threatening Event is completed and implemented as a matter of urgency.  Yes  6. MSCB will take this forward by requiring a report from the Head of Safeguarding CMFT.  6. Head of Safeguarding CMFT (KK) by the end of November 2014.  6. Report and protocol presented to MSCB by the end of November 2014.  7. At the earliest opportunity, the Board to share this report with the Child Protection Investigation Steering Group.  That group to review the practice relating to information sharing between the police and Local Authority as these impacts on criminal  Yes  7. MSCB will take this forward by tasking the Child Protection Investigation Steering Group to review existing joint/Multi-Agency Practice with a view to producing a protocol, which addresses the issues indentified in this review and promotes effective child protection investigations.  7. Child Protection Investigation Steering Group by the end of January 2014 (Chair HJ)  7. Protocol presented to MSCB by end of January 2015.  Page 35 of 36 Child C1 SCR Published Report 151214.doc APPENDIX B:  Multi Agency Actions The finding identified by the SCR Do MSCB accept the finding? If MSCB accepts the finding how will it be taken forward? Who is best placed to take this forward and in what timescale? Timescale for responding to the finding and how will it be reported? and family court processes.  8. The Board to seek discussions with the CPS regarding the possibility in some complex child protection cases of the involvement of Children’s Services in an advisory capacity.  Yes  8. MSCB will take this forward by tasking the Superintendent, South Manchester Division, GMP and Strategic Lead Children’s, CSC to convene a meeting with CPS with a view to involving an independent Child Care expert in CPS’s review of complex child protection cases.   8. Superintendent South Manchester Division, GMP (WC) & Strategic Lead Children’s, CSC (RP) by the end of December 2014.  8. Via report to MSCB by the end of December 2014.  9. The Board to request a focussed and time limited review by the relevant NHS Trusts regarding First Aid information provided to new parents and for any achievable improvements to current provisions to be identified.  Yes  9. MSCB will take this forward by requesting a review facilitated by Head of Safeguarding, Pennine Acute Hospitals Trust; Divisional Head of Nursing, University Hospitals South Manchester NHS Foundation Trust and Head Of Safeguarding Central Manchester Foundation Trust.  9. Head of PAHT (LM for SS), Head of Nursing UHSM (HT) and Head of Safeguarding CMFT (KK) by the end of January 2015.  9. Report to MSCB by end of January 2015.   Page 36 of 36 Child C1 SCR Published Report 151214.doc APPENDIX C: Acronyms       A & E Accident and Emergency ALTE Acute Life Threatening Event CMFT Central Manchester University Hospitals NHS Foundation Trust CPS Crown Prosecution Service C/S Children’s Services DASH Domestic Abuse Stalking and Harassment  DC Detective Constable DI Detective Inspector GP General Practitioner HV Health Visitor IA Initial Assessment IDVA Independent Domestic Violence Advisor LSCB Local Safeguarding Children’s Board MASH Multi Agency Safeguarding Hub MCAF Manchester Common Assessment Framework PCT Primary Care Trust PICU Paediatric Intensive Care Unit PPIU Public Protection Investigation Unit SCR Serious Case Review SCRP Serious Case Review Panel SIO Senior Investigating Officer SUDC Sudden Unexplained Death in Childhood 