Death of a 7-week-old infant from non-accidental injuries caused by shaking in February 2016. His father was convicted of manslaughter in March 2018. Baby C lived with both parents. His mother had lived in the UK for around 20 years and worked as a nanny. The pregnancy was uneventful and the mother attended all routine antenatal appointments. No concerns were identified regarding her physical or mental health. Records from postnatal visits by midwives and health visitors reported no concerns. Health visitor identified that the mother had no family or local social support so made a referral to baby massage and a course for parents with young babies. On the day of Baby C's death the father was caring for him alone. He called emergency services and reported that Baby D had fallen out of his bouncer and was bleeding. When the ambulance service arrived Baby D was not breathing, and he died in hospital four days later. The review concluded that the death could not have been prevented since there were no warning signs that Baby C was at risk. Learning include: there is no specific universal programme of work with fathers in the antenatal or postnatal period. Recommendations include: contact with fathers should be routinely recorded in midwifery and health visitor records; information about the link between crying babies and non-accidental head injury should be included in the core health promotion package offered to new parents.
      
 Title:  Serious case review report: ‘Baby C’: born: 2016: died: aged 7 weeks. LSCB: Camden Safeguarding Children Board Author: Anne Morgan Date of publication: 2018  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                            1     Camden Safeguarding Children Board  Serious Case Review Report   ‘Baby C’ Born: 2016 Died: Aged 7 weeks     PUBLISHED: 04.05.2018          2   Author: Anne Morgan Independent Safeguarding Children Consultant    CONTENTS   PAGE  1.0   FOREWORD BY LSCB CHAIR   3  2.0   INTRODUCTION   4  3.0   RATIONALE FOR CARRYING OUT A SCR   4  4.0   REVIEW PROCESS   4  5.0   CASE SUMMARY   7  6.0   ANALYSIS OF PRACTICE   9  7.0   FINDINGS    14  8.0   RECOMMENDATIONS    17  9.0   CONCLUSION   17             3  1.0 FOREWORD BY CAMDEN LSCB CHAIR  Services provided for Child C and his family.  On the morning of 20 February 2016 Baby C was rushed to the Royal Free Hospital suffering an unexplained, non accidental trauma. At the time the injuries occurred Baby C was in the care of his father, his mother was attending a dental appointment. Later that day Baby C’s condition deteriorated and he was transferred to Great Ormond Street Hospital. He was treated there until his death on 24 February 2016.  The circumstances surrounding the death of Baby C determined that a Serious Case Review be undertaken. I am grateful to Anne Morgan, the Independent author of this report and Jane Doherty the Independent chair of the Serious Case Review panel and indeed the panel members themselves who continue to oversee the process.   I am also grateful for the cooperation of everyone who has supported the work of this review over the last year. I acknowledge the constructive way in which staff and managers in all of the services involved have participated in the review, recognising that there are always lessons to be learnt from such circumstances. The delay in this report being published was necessary in order not to prejudice the criminal investigation which is ongoing.  The purpose of a Serious Case Review is to provide a rigorous analysis of the actions and decisions of the professionals involved and to identify ways in which services for other children can be improved. It is not an investigation to apportion blame or determine who is culpable. These are matters for coroners and criminal courts, respectively. We must never forget, however, that this review follows from the tragic death of an innocent child and we owe it to Baby C and his family to ensure the recommendations outlined at the conclusion of this report are implemented into everyday practice. The report itself is relatively short because of the very few agencies involved with the family.  The Camden Safeguarding Children Board having agreed and accepted the report has agreed that Public Health Camden lead on the implementation plan overseen by Jason Strelitz (Assistant Director Public Health Camden), he has already drawn together an appropriate multi-agency panel, under the auspices of the First1001 days Public Health programme, to implement these recommendations. Progress will be monitored by both the Serious Case Review panel and the Safeguarding Board and updated on the Camden Safeguarding Children Board website.          Dominic Clout 10.01.17        4   2.0 INTRODUCTION   2.1 This serious case review has taken place following the death of baby C. Baby C is thought to have suffered non-accidental accidental injuries, as a result of being shaken on the morning of 20 February 2016. At the time the injuries occurred he was being cared for by his father, his mother being at the dentist. Baby C was admitted to the Royal Free Hospital (RFH), and then transferred to Great Ormond Street Hospital (GOSH) later that day. He was treated there until his death on the 24 February 2016.  2.2 Baby C’s father was arrested and on the 22/02/2016.  Following further investigation, a decision was made by the Crown Prosecution Service to change the initial charge of GBH to manslaughter. On the 28th March 2018, the father of baby C was convicted of manslaughter at Blackfriars Crown Court and was given a custodial sentence of 8.5 years.  Medical professionals stated that evidence showed that baby C’s injuries were "most likely caused by being shaken and or thrown".  3.0 RATIONALE FOR CARRYING OUT A SCR 3.1 A meeting of Camden Safeguarding Children Board’s Serious Case Review (SCR) Panel was held on the 16th March 2016 and a decision made to carry out a SCR. This decision was based on the criteria as laid out in Working Together to Safeguard Children 2015 (Working Together)1, which refers to  Regulation 5 of the LSCB Regulations 2006. Regulation 5 (2) states that;  “a serious case is one where:  (a) abuse or neglect of a child is known or suspected; and  (b) either ;    (b)(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… (agencies)… have worked   together to safeguard the child”.   “Cases which meet one of the criteria (i.e., regulation 5(2)(a) and (b)(i) or 5(2)(a) and  (b)(ii) must always trigger an SCR”. Baby C’s death met regulation 5(2) (a), abuse is suspected, and 5(2) (b) (i), the child has died 4.2 There was a discussion about amount of agency contact (health agencies only) with the family prior to baby C’s death and that SCRs are normally by their nature multi-agency.  However in view of the criteria identified in Working Together 2015 it was clear that a SCR was required. The review is therefore focusing primarily on health services provided to the family prior to the incident, whilst using the opportunity to include in the terms of reference areas of concern that had been identified in recent serious case reviews in Camden, providing the opportunity to see how well recommendations have been embedded.   4.0 REVIEW PROCESS 4.1 Scope and focus of the SCR   The panel identified the following key areas to be explored as part of the review. They were:                                                              1 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children March 2015 p 75:   5  1) Were there any warning signs that could have been missed?  2) What specific work was carried out with father both during antenatal and postnatal periods? 3) Were there any areas of good practice?  4) Were there any issues arising from ethnicity and diversity (in respect of isolation)? 5) Analysis on the rapid response period  The review panel were asked to incorporate the following lines of enquiry into the report: to attempt to provide a better understanding of the following aspect of service provision;  Information provided to ante-natal services by GP when booking  Understand the wider level of compliance with the expectation of DV screening.  How effective was the identification of previous “paternal depression” (2010) and the response of professionals?  How thorough was the new birth visit on the family?   How did the professionals perceive the parents’ behaviour both during antenatal and postnatal period– risks and protective factors – and did this impact on professional responses?  4.2 Organisations Involved in the Review 4.2.1 It was agreed that the following organisations would be required to contribute to the serious case review; o Camden GP practice o University College London Hospital (UCLL) NHS Foundation Trust (maternity services; antenatal period) o  Royal Free London NHS Foundation Trust, (RFH) (community midwifery; postnatal period)   o Central and North West London NHS Trust (CNWL) (Health Visiting)  o London Ambulance Service NHS Trust (LAS) (Records only) o Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH) (post injury period to date of death) o Metropolitan Police Service (period between incident and date of death) (Records only)  4.2.2 The panel was made up of senior representatives from the following organisations with an independent chairperson and SCR author. Ms Jane Doherty was appointed to be the Independent Chair of the SCR panel. Jane is an Independent Social Work Consultant with a considerable background in Child Protection and Quality Assurance. As an independent consultant she now specialises in multi-agency learning reviews including partnership reviews and SCRs. The independent author was Anne Morgan, an Independent Safeguarding Children Consultant with a health background in paediatrics and safeguarding. She has extensive experience in carrying out reviews and is trained in the use of a systems approach. The following table illustrates the panel members:  Independent Social Work Consultant Chair of Panel Jane Doherty Independent Safeguarding Children Consultant SCR Author Anne Morgan LB Camden Children’s Social Care Director, Children’s Safeguarding and Social Work  6  LB Camden Children’s Social Care Head of Children’s Quality Assurance, CSSW Metropolitan Police Service DS, Specialist Crime Review Group Great Ormond Street Hospital for Children NHS Foundation Trust Executive Lead for Safeguarding Camden CCG NHS Trust Designated Nurse for Safeguarding Children Camden CCG NHS Trust Designated Doctor for Safeguarding Children  4.3 Time period to be covered 5.3.1 The period of the review is from May 2015 when baby C’s mother presented for ante-natal care to baby C’s death on the 24.02.2016. It does not include subsequent events in detail; however it takes into account additional information obtained in enquiries and assessments that took place after baby C’s death. 4.4 Methodology   5.4.1 Working Together identifies the purpose of a SCR is to undertake a ‘rigorous, objective analysis…in order to improve services and reduce the risk of future harm to children’. The LSCB is required to ‘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’.2  This review was carried out in line with those principles and is proportionate to the incident.    4.4.2 A chronology was produced by the agencies involved and the professionals working with the family identified.   4.4.3 The model used was based on a broad systems approach. Professionals were involved through focus groups and individual conversations (when not able to attend a group). The final meeting being used as an opportunity for them to review the findings and consider recommendations.  4.4.4 Due to the very limited and routine contact professionals had with this family a decision was made to meet with the professionals as a large group for an initial discussion and to explain the process. This was followed by four small group meetings to enable practitioners to talk through their contact with the family and consider the scope and focus of the SCR in relation to their agencies’ involvement. One of these focus groups was with professionals who had involvement with the family following baby C’s injury to identify whether there was any additional learning that would be relevant to the review process. A final group meeting was held where a draft report was shared with the professionals’ involved where they provided input into the report’s findings and recommendations.   4.4.5 The process was supported by panel members who were a part of the initial and final group discussions as well as the smaller groups.    4.4.6 Unfortunately neither parent felt able to be involved in the process and therefore information which they may have been able to provide to help the review panel in looking at                                                              2 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of March 2015 children p.75     7  lessons to be learnt was not available. The panel was satisfied that appropriate attempts were made to try and get parents to engage in the SCR process however due to the traumatic circumstances of the case the parents did not feel they could take part. Should they wish to participate at a later date their views will be incorporated into the SCR learning.  4.4.7 Some of the learning identified was outside of the TOR and was not directly relevant to this review. The learning has, however, been included in the findings along with the practice changes that have occurred.   5.0 CASE SUMMARY 5.1 Family Composition   Name/ Relationship Baby C – Subject  Mother Father  5.2 Narrative  5.2.1  On the 19.05.2015 the Mother attended the GP for an initial appointment in regards to a planned pregnancy. She reported to be pleased that she was pregnant and had self-referred to UCLH for her maternity care. Mother reported she had lived in the UK for fifteen years. 5.2.2  On the 12.06.2015 the Mother attended her midwifery booking appointment. Parents were reported to be living together. The Mother was working as a nanny and the Father as an investment assistant. Health and Social assessment identified no concerns and the Mother reported no domestic abuse within the relationship. Between that appointment and the 11.12.2016 the Mother attended a further six routine appointments, with no concerns identified with either her physical or emotional health. Questioning for domestic abuse does not occur at other times during the pregnancy unless there are concerns identified which make it a possibility. 5.2.3  On the 29.12.15 the Father registered with the same GP practice as his partner.  5.2.4  On the morning of January 2016, the Mother attended hospital and baby C was born; gestation 39 weeks 2 days. His birth weight was 3.620 kg (50th centile) and head circumference 35cms. The birth was uncomplicated and routine care was provided. The Father was present at the birth and reported to be supportive.                                                                          5.2.5  The next day Baby C was examined by a paediatrician (neonatal examination) prior to discharge. No abnormalities were identified, Mongolian blue spots3 were noted and recorded on the baby’s notes. Both the Mother and baby C were discharged from hospital into the                                                              3 Mongolian spots are blue-grey or bruised-looking birthmarks that are present from birth. They're more commonly seen in darker-skinned people and usually occur over the lower back or buttocks. However, they can also appear elsewhere on the body or limbs. Mongolian spots may last for months or years, but they usually disappear by the time a child reaches four years of age. They're completely harmless and don't need treatment. They may sometimes be mistaken for a bruise (NHS Choices 2016).  8  care of the community midwives (RFH) and the discharge notification sent to the health visiting service. 5.2.6  On the 08.01.2016 Mum and baby seen by community midwife. She was advised re the role of the community midwifery service. Advice re breast feeding was provided and mother was observed breast feeding Baby C. The Mother said she was well supported. The midwife offered a visit the following day but this was declined by the Mother and a visit was arranged for the 11.0.2016. There is no recording of anyone else being present at this visit.  5.2.7  On the 11.01.2016 and 12.01.2016 midwife 2 visited. Baby C’s was noted to have jaundice at the visit on the 11th. It is not recorded whether the Father was present on these occasions but notes record in relation to the jaundice that “they know when to take baby to A&E” suggesting that both parents were present. It was also recorded that “mum is happy and well supported”. The Mother and baby C were discharged from midwifery care on the 18.01.2016. 5.2.8  On the 21.01.2016 the health visitor undertook the new-birth visit. She carried out an assessment of the family’s health and environment; the Mother’s profession was recorded as a nanny with twenty years’ experience. Father’s profession was also recorded. The health visitor discussed baby blues and post-natal depression. The Mother was recorded as “being relaxed and talking about baby with ease and emotional warmth”. The health visitor recorded that there was little family support but that the Mother was well supported by father and friends. The health visitor provided health promotion advice in relation to SIDS, accident prevention, immunisation and environmental safety. Baby C was asleep during the visit. Domestic abuse was not discussed as the Father was asleep in the next room, however had there been any concerns identified in relation to this she would have booked a follow up visit or asked the Mother to attend clinic.  Due to the lack of family within the UK the health visitor made a referral to Little Connections Group Little Connections is a course for parents with babies aged 0-8 months. Topics relevant to the review which are covered in the sessions include managing crying and stress management for parents. She also referred her to baby massage which is good for bonding and attachment and also good for parental networking to make new friends. This does not start however until the baby has had his/her six week developmental assessment.  The health visitor assigned the family to Universal Services (a service provided to all children and families with under 5s)4 and arranged a postnatal review for the 02/03/2016. She completed the registration form for the Children’s Centre for Integrated Early Years Support with the Mother and provided information in relation to the breast feeding support group. 5.2.9  On the 15.02.2016 the Mother took baby C to a local baby clinic. Baby C was weighed (this would have been unclothed). He had gained weight; 5.44kg (75th centile) and noted as “well with good tone”.  5.2.10 On the 16/02/16 the Mother and baby C attended the GP surgery and had their post-natal appointment and six week check respectively. Routine discussion about domestic abuse was discussed as part of the assessment and none was reported. No concerns were identified in relation to the Mother or baby C’s health or development.   5.2.11 On the 20.02.2016 the Father was caring for baby C alone whilst the Mother attended the dentist for a 10am appointment (she left house at 9am). At 11.15am the Father called 999 and asked for the London Ambulance Service (LAS). He reported that his son had fallen                                                              4 DH; Healthy Child Programme Pregnancy and the first five years of life; DH 2009   9  out of the bouncer when he turned his back (the bouncer was on the sofa bed) and that he (baby C) was bleeding from his nose and mouth. When LAS arrived at the home at 11.20am baby C was blue and not breathing. CPR was started and his airway cleared. Basic life support was administered in the ambulance and baby C was transferred to the Royal Free hospital (RFH) where he was intubated and ventilated. There were no obvious lacerations but there was bleeding from the mouth and nose. The Father’s account of the accident did not fit with the type of injuries baby C had received and the London Ambulance staff raised their suspicion of non-accidental head injury with the hospital immediately on arrival.  5.2.12 A scan of baby C’s skull was undertaken at the RFH, This showed bleeding and baby C was transferred to Great Ormond Street hospital. The Mother had returned from the dentist and went to the RFH and then to GOSH with the Father. Following baby C’s admission the head injury protocol was followed. This is based on current good practice guidance. As part of the history provided to the hospital by the Mother she reported that “Baby C sometimes screamed a lot”. Parents were resident. 5.2.13 On the 21.02.2016 the consultants responsible for baby C’s care explained to baby C’s parents the gravity of his condition.  5.2.14 On the 22.02.16, following a referral from PICU a social worker from GOSH was allocated and met both parents. She explained her liaison role with the local Children’s Social Care and the police. A strategy meeting was held that same day, and one of the actions agreed was that the Father would be arrested that afternoon and the Mother was to be interviewed if she gave consent for that to happen. It was recorded that the Mother had been resident in the UK for fifteen years the Father for twelve years and they had lived together in rented accommodation since 2013. It was also reported to the strategy meeting that there were several over the counter medicines to aid sleeping and ear plugs found at the home. It was agreed that the GOSH social worker would provide bereavement support to the family.    5.2.15 The social worker met with the Father at his request following the strategy meeting to talk about family circumstances, the birth of baby C, his reported history of mental ill health in the family and bereavement support available.   5.2.15 Following his arrest the Mother was seen by a social worker and offered support.   5.2.16 On the 23.02.2016 baby C’s consultant met with the Mother to explain that baby C’s condition was incompatible with life and treatment would be withdrawn the next day. On the 24.02.2016 baby C’s treatment was withdrawn and he died at 3pm. Both parents were in attendance as was the social worker (in line with the Father’s bail conditions).  5.2.17 The Father was charged with manslaughter on 11.01.17 and is awaiting trial on 09.02.2017.  6.0 ANALYSIS OF PRACTICE   6.1     University College London Hospital 6.1.1  The Mother self-referred to the hospital for her maternity care. She was working as a nanny at the time of booking. She attended the booking clinic and received routine care. She was asked about domestic abuse and none was reported. It is not clear how embedded screening about domestic abuse is at UCLH and after the booking visit it is not clear that it was asked on any other occasion. In a previous Camden SCR in 2014 it was recommended that the Trust “review their Domestic Abuse Policies and Procedures and ensure there are  10  robust arrangements for screening women on their in order to meet national guidance5. UCLH report they have reviewed these procedures and that routine screening is taking place. In order to provide further assurance they plan to perform an audit on domestic abuse screening across Midwifery Services. This will be carried out by December 2016.  6.1.2  The author was asked to consider the support and service offered to fathers as a part of this review. At antenatal contact the Mother was noted not to need an interpreter and no concerns were identified in the family history. This was appropriate practice. It is not routine practice at UCLH or the RFH to identify additional attendees at this visit nor any other (nor is this common practice amongst midwives across the country) therefore it is not clear whether he attended or not. Discussion in the focus group about the role of fathers during the antenatal period focused around the need to involve them but also the need to identify domestic abuse which midwives couldn’t do if fathers were present. The midwives see their client as the woman and baby whilst Government policy and the Healthy Child Programme6 reflect the need to support the needs of the family unit and fathers in particular. The Healthy Child Programme. Current midwifery records have no place for the involvement of fathers that following this policy would require; neither are they commissioned to do so. It is unlikely that had they done so this would have altered the outcome for baby C.  6.1.3  Further routine antenatal contact occurred and the Mother was invited to attend antenatal classes. This is a verbal request and aimed at mothers’ and their partners. They are required to confirm attendance and identify which venue they will go to. The classes are held both during the week and at the weekend and cover pregnancy, birth and the post-natal period. An additional classes covering breastfeeding is also offered. Health promotion in relation to SIDS is covered and advice provided on managing crying. The mother’s attendance is recorded for statistical purposes but not in their records. Partner’s attendance is not routinely recorded.  This practice of inviting the mother verbally and not providing a specific invitation to the partner is similar to that in many areas of the country. It can however give a message that partners are not important and does not follow the ethos of the Healthy Child Programme7. The Healthy Child Programme is the early intervention and prevention public health programme that lies at the heart of a universal service for children and families in the UK. The Healthy Child Programme’s universal reach provides an invaluable opportunity to identify families that are in need of additional support and children who are at risk of poor outcomes; the level of provision being based on the level of need. The introduction of the 1001 day programme which will include preparation for parenting will further support families; and aims to involve fathers’ more pro-actively, however the recording of father’s involvement will not necessarily be addressed. 6.1.4   Baby C was born on the 16.01.2016. The Father was present at Baby C’s birth. Baby C was handed to the Mother to hold immediately. This was good practice.   6.1.5   On the 17.01.2016 baby C was examined by a paediatrician for his pre discharge neonatal examination and Mongolian blue spots noted on his buttocks. These were recorded in his hospital records and on the discharge notification. The Mother and baby C were discharged from UCLH into the care of the community midwives at the RLH. Transfer of care to the midwives at the RFH and to the health visitor was timely and followed good practice.                                                               5NICE Guidelines Domestic Violence and abuse; how health services, social care and organisations they work with can respond effectively guidelines NICE(PH50) February 2014   6 DH; Healthy Child Programme Pregnancy and the first five years of life, p26; DH 2009 see Appendix 1 7 DH; Healthy Child Programme Pregnancy and the first five years of life, p33; DH 2009   11  6.2    The Royal Free Hospital 6.2.1  The community midwifery service provided four visits prior to discharge from their service at twelve days. The first visit was timely and the midwife spent time providing advice in relation to breast feeding, observing a feed and offering advice. The midwife discussed post –natal depression with the Mother and said in the practitioner forum that it was her practice to talk about the emotional changes having a baby can bring to both parents and how fathers can also be affected by the birth of their baby. There is no routine expectation that this should occur and fathers’ are not routinely involved in this contact, nor is this discussion routinely recorded. Domestic abuse is routinely discussed at this contact.  6.2.2  The Mother declined a visit the next day and when a midwife next visited as arranged (11.01.2016) the Mother was offering a mixture of breast and formula. There was no discussion recorded in the notes as to the Mother’s thoughts or feelings about not continuing with breast feeding. Breast feeding or not being able to breast feed can be quite an emotive subject and it would have been good practice to explore this. Baby C was slightly jaundiced at this visit and appropriate advice was given and a follow up visit arranged for the next day when the jaundice was resolved. The notes infer that the Father was at home during the visit but it is not noted specifically. The Mother and baby C were discharged from the midwifery service on the 18.01.2016, baby C having regained his birthweight and no concerns had been identified The midwives assessed the family as one that was managing well with good mother baby interaction and support being offered by the Father. 6.2.3  The Mother and baby C received appropriate care by all three midwives. The RFH attempt to have no more than two midwives visiting post-natally however the team providing the Mother and baby C’s care were extremely busy on the day of discharge and a colleague from another team carried out that visit.  6.2.4 The midwives from the RFH were very clear about their role in identifying domestic abuse during pregnancy and appeared confident in that aspect of their role. A recent internal audit had identified an increased level of compliance in their screening for domestic abuse. 6.3 Health-visiting Service 6.3.1 The health visitor visited on the fourteenth day post-delivery which was within the normal limits for carrying out a new birth visit. This visit enables the health visitor to carry out a holistic assessment of all family members and identify the level of support that may be required. It is also an opportunity to explain the health visitor role and service provided and how the health visitor will work in partnership with the family.  6.3.2 The visit covered mother and baby’s physical and emotional health, social and family history and health promotion around SIDS, immunisations, environmental safety and use of the Personalised Child Health Record (PCHR). Assessment in relation to fathers is carried out but not routinely recorded.  6.3.3 The health visitor was not able to ask about domestic abuse as the Father was asleep in the next room. Not asking in this instance was good practice in this case as asking about domestic abuse can potentially put women at further risk if done in the perpetrator’s hearing. The health visitor did however ask about more general questions and the Mother was positive about her partner and the support he was giving. She said that head she been concerned she would have carried out a follow up visit or asked the Mother to attend clinic to enable her to discuss this. 6.3.4  The health visitor referred the Mother to the Little Connexions and baby massage as she had no immediate family in the UK although it was identified that she had support and it  12  is not unusual for families in the UK to have no immediate family to help with the new born baby. This referral however would have provided back up and support for the Mother and was good practice. It is often assumed that because one works with children as the Mother did that there is no need for support but working with children and having one of your own can be two very different experiences. In this instance it was recognised that whilst the Mother had been a nanny for many years she may have need of support. This was recognised and support offered. This was good practice.     6.3.5  The health visitor assigned the family to universal services8, registered her with the Children’s Centre and advised the Mother about local clinics. She also made an appointment for the Mother and baby C to be seen at eight weeks for a post-natal health visiting contact.  The family were not identified as one that required additional support and had the knowledge and skills to access services should they require help. Universal services provision is made up of a:  New Birth Visit BV between 10-14 days post delivery  Post natal Maternal Mental Health review by six to eight weeks post-natally  One year developmental review  Two year developmental review and   allocation to a corporate caseload  Where families need additional support a more intensive programme is provided “universal plus”. Universal plus services include all the provision of universal services but the family is allocated to a named health visitor and the following additional contacts are provided:  An ante natal contact and additional contacts determined by health visitor frequency according to need/concern. 6.3.6  Changes to the commissioning and provision of health visiting services and the introduction of electronic records has resulted in health visiting becoming a much more of a mother and child service than a family service despite government policy aimed at a more inclusive approach to fathers. Many electronic records have a mother’s record rather than a family record and drop down menus which can sometimes restrict the practitioners’ ability to easily record all aspects of their contact.  6.4 General Practice  6.4.1  Both parents and baby C were registered with the GP practice, the Mother since 2000 and the Father since December 2015 when he registered as a new patient. He was not seen by any of the clinical staff until after baby C’s admission to GOSH in February 2016. Following the death of baby C, the Father’s records were accessed as part of the review. There was nothing of note in relation to mental health in his records. The Father had one episode of reactive depression, caused by a life event in 2010, when counselling was offered and refused.  6.4.2  The Mother saw her GP for an initial consultation once she became pregnant. This was a planned pregnancy and GP records state that the Mother was self-referring herself to UCLH. There were no social or health concerns and therefore no liaison to the maternity department re the pregnancy was required.  There is no evidence that the midwives                                                              8 DH Healthy Child Programme Pregnancy and the first five years of life DH 2009  13  informed the GP of this self- referral. Whilst not relevant in this case it is an agreed protocol and should have happened. 6.4.3  The next consultation was the post-natal contact. This was a combined post- natal check for the Mother and baby C. The hour’s consultation was put in place several years previously as the GPs were finding that routine appointment times did not allow them the time to satisfactorily cover all the issues required. Domestic abuse is covered at this contact as part of the wider health promotion package offered. The opportunity for a mother to have an hour’s consultation is excellent practice and provides an opportunity for a relationship to be built up between a mother and the GP which will have benefits during future consultations.  6.4.4  In discussion with the GP practice they were asked about whether they saw a place for fathers to be involved in children’s reviews as identified in the Healthy Child Programme 2009. They were also asked about whether they provided specific information about crying babies or the risk of baby’s being shaken bearing in mind that the peak time for crying babies is seven weeks9. The GP practice do not routinely invite both parents to children’s developmental assessments, but in light of this review and previous SCRs within the last year in Camden they are looking at how they can pro-actively include partners’ and provide them with the same information (including crying babies) and support in relation to their child’s needs.  6.4.5  Health promotion advice provided at this contact routinely covers information in relation to SIDS, as a cause of infant death however advice in relation to crying is usually only provided when there is a problem and even then unlikely to include the risk of shaken baby syndrome. Current literature available provides advice around the management of crying suggests a variety of ways to manage it including walking away from the baby for a period of time, however the link between crying and non-accidental head injury is rarely mentioned despite it being one of the biggest causes for injury and death for children under two years of age10. Crying in babies reaches a peak at about seven weeks it would therefore be an ideal opportunity to discuss with parents the risks around shaking at that six week contact.  6.5    Child Death Panel Process  6.5.1 “An unexpected death is defined as the death of an infant or child which was not anticipated as a significant possibility for example 24 hours before the death; or where there was an unexpected collapse or incident leading to or precipitating the events which lead to  the death” 11.  When professionals are uncertain about whether the death is an unexpected death the designated paediatrician responsible for child deaths should be consulted12.                                                              9 NHS Choices website 8 Barlow, K. M., and Minns, R. A. (2000) Annual incidence of shaken impact syndrome in young children. Lancet 356(9241): 1571. 10 Ibid 11 HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children p 85: March 2015 12 Ibid 13HM Government: Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children Flow chart 8, p91: March 2015      14  6.5.2  In this instance baby C died four days after the initial injury and could be said to fit the definition of an unexpected death, however a strategy meeting had been held with many of the people present who would have been involved in a rapid response meeting. Had the death occurred earlier the strategy meeting would probably have taken place immediately following the rapid response meeting. The initial post-mortem result showed nothing unexpected and reflected the causal effects already identified. i.e. non-accidental head injury. The death also occurred four days after the initial police investigation had started and examination of the house had occurred, therefore it is not clear what could have been gained by a paediatrician or other health professional doing a joint visit (another aspect of the rapid response process) or a rapid response meeting being held.   6.5.3  The rapid response process flowchart includes the need for a second meeting13 following the final post-mortem results to update professionals and review the circumstances of the death. As this death had been immediately identified as a SCR, and a strategy meeting held prior to baby C’s death it was agreed to follow the SCR process and that a second rapid response meeting was not required.   7.0 FINDINGS  7.1    Were there any warning signs that could have been missed?  7.1.1. This was a planned pregnancy. On examination of the Father’s GP records there was an episode of reactive depression in 2010 when the Father was offered counselling which he declined, but no evidence of an ongoing significant mental illness, substance misuse or domestic abuse. When seen by professionals’ no concerns were identified and the Mother reported that the Father was supportive.  7.1.2   From the evidence available at the time there were no warning signs missed. 7.2   What specific work was carried out with father both during antenatal and postnatal periods? 7.2.1 The Healthy Child Programme states that: “The contribution that fathers make to their children’s development, health and wellbeing is important, but services do not do enough to recognise or support them. Research shows that a father’s behaviour, beliefs and aspirations can profoundly influence the health and wellbeing of both mother and child in positive and negative ways.’ Maternity and child health services are used to working mainly with mothers, and this has an impact on their ability to engage with fathers. Fathers should be routinely invited to participate in child health reviews, and should have their needs assessed.’  7.2.2.  Whilst the Healthy Child Programme and government policy both encourage the active involvement of fathers both ante-natally and post-natally this has not always transferred into practice either in Camden or elsewhere in the country apart from specific services available for teenage fathers.  7.2.3  Within Camden partners are not routinely invited to antenatal appointments and are not seen by the midwife unless they attend appointments with the mother. Their role is seen as secondary to the mothers who is identified as the midwife’s main client. Fathers are invited to antenatal classes via the mother but there are no sessions specifically for them.                                                                15  This is contrary to the guidance offered in the Healthy Child Programme; Preparation for parenthood p33, which identifies the need   “To begin early in pregnancy and to include: …social support using group-based antenatal classes in community or healthcare settings that respond to the priorities of parents and cover: the transition to parenthood (particularly for first-time parents); relationship issues and preparation for new roles and responsibilities; the parent–infant relationship; problem-solving skills (based on programmes such as Preparation for Parenting, First Steps in Parenting, One Plus One; the specific concerns of fathers, including advice about supporting their partner during pregnancy and labour, care of infants, emotional and practical preparation for fatherhood (particularly for first-time fathers); discussion on breastfeeding using interactive group work and/or peer support programmes; and standard health promotion”  Whilst the commissioning of services being provided are becoming more family focused this is not currently reflected by practice 7.2.4   Post-natal health visitor contact; fathers are seen and involved if they are present at the new birth visit or any other contact in relation to mother and baby. There are no electronic family records and fathers’ information is recorded in mother’s health visiting record when there is any pertinent information provided. This does not encourage professionals involving father’s as part of the family. Similarly the six week post-natal check by the GP and the health visitor assessment at six to eight weeks is aimed at mother and baby and this provides the opportunity to discuss their relationship with their partner and the new baby.  7.2.5   Attendance at Little Connections is for both parents as are activities at the children’s centre. The attendance by fathers remains low  partly because of work patterns but also the perception that professionals still see mothers’ as the main carers leading to fathers not feeling that these activities are for them. 7.2.6 Currently there is no specific universal programme of work with fathers’ either in the antenatal or postnatal period  7.3     Were there any areas of good practice?  7.3.1  In the post-natal period the health visitor appropriately identified that the Mother had no family support and no friends locally with children and made a referral to Little Connections and baby massage. 7.3.2  The GP practice provided an excellent service at the six week post-natal check for the Mother and baby C providing adequate opportunity for mothers’ to discuss areas of concern.  7.3.3 There was evidence of good solid work, with sensitivity to ethnicity and cultural needs by both the midwives and health visitors and excellent provision of care by the GP practice.  7.4   Were there any issues arising from ethnicity and diversity (in respect of isolation)?  16  7.4.1 Social isolation is defined as having little or no contact with other people. It usually lasts for extended periods of time. Social isolation is different from loneliness, in that loneliness is a state of emotion that is felt by individuals who are not satisfied with their social connections which can last anywhere from a few weeks to years14.  7.4.2  In 2013 Camden had an estimated resident population of 225,140 people and like many other London boroughs has an ethnically diverse community. Nearly 35% of Camden’s overall population is estimated to be from a black minority ethnic (BME) group. This figure excludes the white Irish community and other non-British white residents who make up 22% of the population15.  7.4.3  Both baby C’s parents were born outside of the UK. The Mother had lived in the UK for over twenty years working as a nanny and the Father for twelve years. The Mother has no family in the UK, the Father has an aunt and cousins who live in London. Although English is not their first language they both are able to speak and communicate well in English and the Mother reported that she had friends and a supportive social network. This was evidenced by the number of people who provided support while baby C was in hospital. She did not however have many friends at home with children. Lack of family support following the birth of a baby is something that can affect both British born as well as the immigrant population as identified in the research carried out in 201516. However many families from ethnic minority backgrounds also found negotiating the healthcare system the differing child rearing practices and cultural aspects of child rearing to be a factor which could increase their social isolation. Those who attended ante-natal classes and post-natal support were less likely to be affected17. The Mother had worked as a nanny prior to baby C being born, she had self-referred to the midwifery department and attended ante-natal classes, and one could presume that she was aware of and able to negotiate the system and manage the differences in culture. It is not clear however whether this was an area that was discussed with her or the Father who may have been less aware of and able to adapt to cultural differences and more in need of support. Neither parent wanted to be part of the review, she was therefore not able to identify whether this was a concern for them. The Father was back at work at the time of Baby C’s injury and whilst his social life would have been affected it is not clear whether he was experiencing social isolation. 7.4.4  It would appear that there were no specific areas identified in relation to ethnicity and diversity in respect of social isolation that were unique to the Mother’s ethnicity however this does not mean that she was not socially isolated.  7.5.   Analysis on the rapid response period 7.5.1  Working Together definition of an unexpected death can be open to interpretation in that baby C’s death was expected within the previous 24 hours. It was however a death caused following a significant incident, it was also clear that the cause of injury was non- accidental and therefore a strategy meeting was appropriate. The CDOP named paediatrician was at the strategy meeting as were all the professionals who would have been at the rapid response meeting.  Whilst the process did not explicitly followed all aspects of the first rapid response meeting they were covered within the strategy meeting  7.5.2 The response was appropriate in this instance                                                              14 Dictionary definition 15 Greater London Authority 2012 “ Camden Development v2” Interim 2011 Census based report 16 AXA PPP healthcare and Netmums; Social isolation putting first time mums at risk: Posted February 13th 2015.  17 Helen Brookes and Denise Coster NSPCC Evaluation department; Baby Steps: perspectives of Parents from a minority ethnic background: NSPCC 2015   17   8.0  RECOMMENDATIONS  8.1  Fathers’ Engagement  8.1.1. The Board identify what services are currently provided for fathers’ in Camden and how relevant they are. Once evaluated consider ways in which these services could be improved, both by commissioner and provider organisations18.  8.1.2 Contact with fathers should be routinely recorded in midwifery and health visitor records   8.1.3 Future commissioning of antenatal education should include the opportunity for men only sessions within standard ante natal classes19.  8.2 Crying Babies and Non accidental head injury 8.2.1  Public Health include information about the link between crying babies and non-accidental head injury into the core package of health promotion package offered to new parents in the way that SIDS is currently.  8.3 Good Practice 8.3.1 The Board review how post-natal services are currently provided within Camden and how the good practice identified by this GP could be publicised and aspects of it replicated in other practices.  9.0 CONCLUSION 9.1  There were no specific findings from this review that would appear to have had an impact in relation to baby C’s death. The death could not have been prevented as they were no warning signs that suggested that baby C was at risk, however there are lessons that can be learnt which are discussed. This review has also provided the opportunity to explore areas that have been identified in other similar SCRs in Camden which the Board will address; in particular the involvement of fathers, and health promotion advice in relation to non-accidental head injury. It has also provided the opportunity to highlight good practice, from the midwives, health visitor and in particular the GP.       REPORT END.                                                              18 Examples of good practice can be found in:The Healthy Child Programme Pregnancy and the first five years of life, DH 2009, Engaging fathers in child and family services Bridget Tehan and Myfanwy McDonald CAFCA Practice Sheet September 2010.   19 Rapid Review to Update Evidence for the Healthy Child Programme 0–5 Summary. Public Health England 2015 review-level evidence of the impact of antenatal classes on men’s preparation for their partner’s labour, birth, and early fatherhood, shows that fathers-to-be benefit from participation in adjunctive, men-only sessions within standard antenatal classes. 