Serious, non-accidental injury of a 4 1/2-week-old child in November 2012. Child X was admitted to hospital with injuries including: up to eight rib fractures, retinal haemorrhages, traumatic subdural haematoma, and leg and foot fractures. Mother and father were convicted in relation to the injuries. Bruises and haemorrhages were seen by a number of professionals in the days prior to the incident including: hospital staff, during two separate admissions; GP; and health visitor. Mother was 18-years-old when Child X was born; maternal grandmother reported that mother had witnessed sexual abuse against her sister by her father and was physically abused by her father as a young child. Identifies issues including: insufficient knowledge of parental history; administrative weaknesses including the loss of papers regarding the targeted status of the family in transit between health visitors and delayed transfer of information between hospital and community health services; insufficiently robust assessments; inadequate recording of injuries; failure to follow procedures in relation to bruises in non-mobile children; optimistic thinking, failure to revise judgments and insufficient professional challenge; invisible fathers; and failure to undertake multiagency discussions. Makes recommendations covering Surrey Safeguarding Children Board, health services and children's services.
      
 Title:  Overview report on the serious case review relating to Child X. LSCB: Surrey Safeguarding Children Board Author: Alan Bedford Date of publication: 2013  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           Overview report on the   SERIOUS CASE REVIEW   relating to   Child X     Independent Author: Alan Bedford   October 2013       Update November 2014 2 INDEX  Section  Page  SUMMARY 4  1 INTRODUCTION 7 1.1 Rationale for a Serious Case Review (SCR) 7 1.2 Anonymity 8 1.3 Family Details 8 1.4 Summary of circumstances leading to the SCR 9 1.5 Terms of Reference 10 1.6 SCR Process 10 1.7 Individual Management Reviews 11 1.9 Methodology 12 1.10 Publication 12 1.11 Family Involvement with Review 12 1.12 Surrey Safeguarding Children Board Approval 13  2 THE FACTS 14 2.2 Up to the birth of Child X 14 2.3 After Child X’s birth to the major injuries 16 2.4 The hospitalisation that lead to the diagnosis of traumatic injury 24 2.5 Diagnosis 26  3 ANALYSIS and APPRAISAL 28 3.3 Was there sufficient information about either parent by the time of pregnancy that might have affected the supervision of, or help provided to, the family? 28 3.4 Health visiting in the antenatal period 30 3.5 Birth 30 3.6 Midwifery care post birth 30 3.7 Guidance on Bruising 32 3.8 Hospitalisation Days 10-14 34 3.9 Health Visiting Services 34 3.10 GP Involvement 37 3.11 Hospital attendance Day 21 38 3 Section  Page 3.12 Communications with community health services 40 3.13 Summary up to admission on Day 30 40 3.14 The admission of the seriously unwell X on Day 30 to ASPH 41 3.15 The transfer to St George’s 43 3.16 Race, religion, language, culture 45 3.17 Capacity and Climate 45 3.18 Fathers 45 3.19 Involved relative 45 3.20 Diagnosis of fractures 46 3.21 Summary 47  4 WHY DID THIS SEQUENCE OF EVENTS OCCUR? 49 4.2 Administrative weaknesses 49 4.3 Interagency referrals 49 4.4 Why bruising was not taken more seriously, and an assessment of real risk not made sooner 50 4.5 Why there were no multiagency meetings 53  5 CONCLUSION 54  6 RECOMMENDATIONS 55   APPENDICES  App 1 Recommendations from IMRs 58 App 2 Appraisal of IMRs 61 App 3 Key dates 62 App 4 Bruising in Children who are Not Independently Mobile: multi agency guidance 63 App 5 Terms of Reference 66 App 6 Acronyms 69  4 SUMMARY  i. This Report is the overview of the Serious Case Review (SCR) which was commissioned by the Surrey Safeguarding Children Board (SSCB) as statutorily required when a child has suffered a serious injury, and there is concern about the way agencies worked together.  The Report and recommendations were accepted by the SSCB on 26.09.13.  In this case, a four and a half week old baby, born to young parents, was admitted to hospital and eventually found to have brain haemorrhages, several leg and foot fractures, and multiple rib fractures – all of which are thought to have been caused by abuse.  In the previous 3 weeks several bruises and eye haemorrhages had been seen but none had been deemed to be from abuse.  It is likely that some of the marks were seen after fractures had started.  Both parents were convicted in relation to the injuries.  ii. Despite the SSCB having a policy in place (see appendix 4) that says that any bruise to a baby who is non-mobile of its own accord must be referred to social care and then referred on for paediatric examination, five different disciplines did not follow that policy.  Midwives and health visitors knew of the policy but accepted parental explanation and did not refer on, nor did they discuss it as potential abuse with their managers/advisers.  The local hospital (nurses and doctors) similarly accepted explanations, or assumed wrongly that there was “easy bruising”.  Paediatricians did not think the policy applied to them, and that they could use their clinical judgement as to whether it was abuse or not before any referral to social care.  The GP was unaware of the policy and the GP’s clinical assessment concluded that the marks seen did not constitute abuse.  iii. This failure to follow the bruising policy may have been related to the fact that the general SSCB policy about referral of injuries to social care did allow a judgement to be made on the likelihood of abuse before a referral is required.  Recommendations in this Review ask the SSCB to explore why professionals did not follow the bruising policy, and to make any necessary adjustments to the policy, provide associated training, and monitor through case audit the compliance with guidance on the reporting of bruising and injuries.   iv. Throughout the case – over the baby’s life of less than five weeks – there were numerous examples of poor recording and communications.  Midwives and health visitors did not record drawings of bruises, making comparison over time difficult.  The first injury seen was recorded as being seen five days earlier than it was actually seen, and other agencies in good faith repeated this record on their own notes.  Communications from the local hospital were inconsistent and sometimes incorrect, and often delayed.  A GP for example examined the baby with a bruise, having not yet been told by the hospital of two prior A&E attendances, or a four day admission which had ended six days earlier – and thus had no knowledge that many professionals had already seen the bruise.  Information about A&E attendances that community health services glean from A&E records and then forward to appropriate community staff 5 sometimes took weeks to arrive.  Key information between health visitors was either not sent, or not received.  v. This Review has made recommendations in relation to all suspicious marks being drawn on body maps, tardy communication processes being reviewed and improved, SSCB auditing case files to monitor improvements in recording and communication following this review, and emphasising just how important are accurate records.  There are recommendations for the community health services to ensure health visitors always discuss suspicious marks with more senior staff, and for the SSCB to be assured about GP compliance with safeguarding training requirements.  vi. There were four home visits by midwives – each by a different midwife.  The Review makes a number of recommendations about community midwifery to the NHS Trust concerned, including a review of continuity of care, and making arrangements so that midwives are informed of any A&E attendances of babies they are visiting.  vii. There were no obvious warning factors prior to birth, but midwives did refer the pregnant mother to social care, concerned about her vulnerability after having to leave her then home.  Had social care explored all old records they would have identified that the mother herself had experienced abuse in her own family, which might have added to the assessment of vulnerability.  There was lack of clarity about what the midwife referral was actually for, and this probably contributed to social care taking no further action.  The Review recommends that the SSCB should ensure there are effective processes in place so that the purpose of referrals is clear.  viii. It took some time for the fractures and head injuries to be identified after admission.  The local hospital did not locate records of the baby’s prior attendances on the first day of admission and so the records of three prior bruises seen as an inpatient and outpatient were not known.  Nor was any professional outside the hospital contacted for background information.  This contributed to there being no record of suspicion of abuse, and a working hypothesis of overwhelming infection was the focus, even when blood was found in the spinal fluid.  When the history was identified the next day, a chest x-ray and the MRI scan were thought to be clear, although a CT scan may have been a better test.   ix. When the baby was so ill that a transfer to a specialist hospital was required, the receiving hospital was given no information about prior bruising, and knew that tests had been ‘clear’, so continued to focus on a medical rather than traumatic cause.  Again there were no discussions with anyone outside the hospital.  It was only when their specialists re-examined the local hospital tests that rib fractures and brain haemorrhages were seen, and abuse diagnosed.  Sight of those tests was delayed as admin reasons prevented them being available quickly.  A later full body x ray identified further leg and foot fractures.  x. There are recommendations for the local hospital about reviewing its arrangements for ensuring rare or unusual images can be assessed by doctors with sufficient expertise, and for the specialist hospital about ensuring that test results transferred from referring hospitals can be more promptly seen. 6  xi. Throughout this case, until the injuries were diagnosed, there were no multiagency meetings to pool thoughts about the growing number of concerns.  This was because no one thought abuse was occurring, but this was often in the absence of knowing what other people knew.  The purpose of the policy about babies who are not independently mobile is to ensure that staff do not makes decisions on their own, but this is what often happened.   xii. The Review explores why bruising was not taken more seriously, and fuller assessments of risk not undertaken.  The answer lies in dynamics within and between professional staff which are seen in SCR after SCR, and which will often occur if there is not the strongest system of management, supervision and training in place to mitigate the risks involved.  The first is a rule of optimism, where there is an innate hope for the best that can overtake any evidence to the contrary.  Reasons why something might not be abuse are given stronger weight than sceptical inquiry.  xiii. Secondly, there is another human tendency which is not to change one’s mind having reached an initial conclusion – again in face of evidence.  An example was the local hospital believing that a propensity to bruise easily was the key explanation, with no consideration that a baby might for example bruise easily and be abused.  The view, not backed by any incontrovertible evidence, was so strong that even when the old bruises were eventually recalled after the baby’s admission and when the baby was seriously unwell, abuse was never really considered as a cause, and the hospital that the baby was then referred on to was told nothing about previous marks.  xiv. The SSCB is asked to ensure that the human tendency towards optimism and unchanging views is addressed in training, and that its member agencies examine their processes to ensure management and supervision arrangements are robust enough to assist staff with these tendencies.  xv. The third and related dynamic is a lack of challenge – either to parents or to professional colleagues.  Sometimes staff feel that ‘challenge’ is too confrontational, rather than seeing it to be simply requiring good answers.  In this case, with the exception of one junior doctor, staff did not challenge each other as no one thought abuse likely.  However by not discussing bruises with managers or safeguarding advisers they were denied the challenge that such more distant and objective staff might have made.  Nevertheless, it is surprising that only one of the numerous doctors, nurses or midwives formed a more sceptical view and acted in a way that would challenge the thinking about what might be going on.  The Review asks the SSCB to review whether it thinks there is a sufficient culture of challenge in Surrey, and that challenge is seen as a highly valued professional activity.  xvi. It is important to recognise that, with so many staff making what look in hindsight to be errors, it is unlikely to be just a simple matter of individual responsibility.  Whilst agencies may form a view about individual performance, the answer to improvement is much more likely to be found in addressing the systematic issues described.  Improving administrative processes and commitment to them, clarity about the expectations of the bruising policy, and in ensuring that systems support staff with any 7 tendency to optimism, unchanging views and reluctance to challenge, is the heart of improvements for the local health and social care community.  xvii. It cannot be concluded that the major injuries could definitely have been prevented, although best practice may well have done so.  The Review identifies: many failures to follow agreed policy; missed opportunities to have shared concerns with other agencies, more senior staff and safeguarding advisers; a lack of any process that would have weighed up the whole picture.  Had this been done much better, there may well have been more monitoring, more support for the family, and more professional scepticism and query about what was happening.  Unless the baby had been removed from home after one or other of the bruises – which may not have happened – the more serious injuries could still have occurred.  However, had there been an x-ray when the baby was seen in hospital with the bruises, then it is possible that rib fractures would have been evident –in which case intervention could have prevented subsequent injuries.  xviii. Whether the injuries were preventable or not, there is very significant learning from this review which should help babies in a similar position in future.   1. INTRODUCTION 1.1. Rationale for serious case reviews (SCR). 1.1.1. Regulation 5 of the Local Safeguarding Children Board Regulations 2006 requires Local Safeguarding Children Boards (LSCBs) to undertake reviews of serious cases in accordance with procedures set out in chapter 8 of ‘Working Together to Safeguard Children’ (HM Government, 2010), referred to here as WT2010.  The SCR was commenced several months before the publication of the 2013 version of Working Together (WT2013), and was concluded using the WT2010 guidance.  1.1.2. When a child dies or is seriously hurt, and abuse or neglect is known or suspected to be a factor, the LSCB should conduct a Serious Case Review (SCR) into the involvement that organisations and professionals had with that child and their family.  The purpose of an SCR as defined by ‘Working Together’ is to:    establish whether there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children   identify clearly what those lessons are, how they will be acted upon, and what is expected to change as a result; and   as a consequence, improve inter-agency working, and better safeguard and promote the welfare of children  1.1.3. The Surrey Safeguarding Children Board (SSCB) Chair, having heard the advice of the Strategic Case Review Group, decided in December 2012 to 8 commission an SCR because the child had suffered a serious injury and the case gave cause for concern about the way professionals and services worked together.  1.2. Anonymity:   1.2.1. The details relating to the family and individuals are anonymised. Specific dates, and dates of birth, are omitted to aid anonymity  1.3. Family Details  1.3.1. All are white British  Mother:   Mother of Child X aged 18 at X’s birth Father :   Father of Child X aged 20 at X’s birth Child X    Their baby born autumn 2012  Maternal grandmother Maternal grandfather Paternal grandmother A     The aunt of X and younger sister of the mother  The family structure is set out in the genogram below, referring only to those family members mentioned in this report  9  FAMILY TREE                          1.4 Summary of Circumstances leading to the Serious Case Review  1.4.1 Child X was admitted to hospital at 30 days old and was eventually diagnosed with up to 8 fractured ribs, retinal haemorrhages, traumatic subdural haematoma (bleeding in the brain) and several leg and foot fractures.  In the SSCB’s early consideration of the case, information emerged about the vulnerability of the young mother, and about a number of bruises and other symptoms prior to the major injuries – which may have indicated prior abuse.  In addition, the baby was hospitalised for several days for apparently medical reasons.   1.4.2 Child X was seen at hospital at 5 days old for constipation/blood in stool.  An abdominal bruise was seen by a midwife at 10 days old, and X was later hospitalised from 10-14 days old after symptoms including blood stained vomit, and the bruise were seen.  A facial bruise was seen by the GP, and then the health visitor at 20 days old, along with an old linear abdominal bruise.  The facial bruise was also seen, with an additional thigh bruise, on a hospital visit at 21 days old.  At 27 days old the health visitor noticed haemorrhages in both eyes.  The admission which led to the identification of the major injuries was at day 30.  Female Male   Enduring relationship e.g. marriage or cohabitation Divorced Paternal Grand-father Paternal Grand mother Mother’s Step - Father Maternal Grand Mother Paternal Grand-father  Deceased  Father  Mother  A  Sister  Baby X Separated 10 1.4.3 The matter was investigated by Surrey Police and both parents were charged and later convicted in relation to the injuries  1.5 Terms of Reference (TOR)   1.5.1 The full TOR are contained in appendix 5. These contain more specific questions to be answered in addition to overall aims which are as in 1.1.2 above.  1.5.2 The timeframe of the review is from pregnancy to the Strategy Meeting after the injuries were diagnosed, although historical information that may have informed professional assessments and decisions during the time frame could be considered.  1.6 The SCR Process   1.6.1 The LSCB appointed Fergus Smith as the independent chair of the SCR Panel.  He is an independent consultant and director of Children Act Enterprises Ltd, and has no connection with the agencies in this Review.  Alan Bedford was appointed as the independent overview author.  He has a background both as a child protection social worker and manager, and many years as a CEO in the NHS.  He had 4 years’ experience as an LSCB chair, has written overview reports, and is an accredited SCIE systems reviewer (although the SCIE methodology is not used here).  He has no connection with agencies in Surrey.  1.6.2 The process was set up under the national guidance: Working Together to Safeguard Children 2010 (WT2010) but influenced later by the 2013 successor version.  Under WT2010 an SCR Panel was set up to oversee the process.  This consisted of:  Post Organisation Independent Chair CAE Ltd DI Central Referrals Unit Surrey Police Designated Nurse Child Protection Guildford & Waverley CCG Area Head of Children’s Social Care NW Surrey County Council Safeguarding Advisor Adult Services Surrey County Council Group Manager: Team Lawyer Surrey County Council  Independent Safeguarding Adviser Alan Bedford Consulting Quality Assurance Officer Surrey Safeguarding Children Board. Serious Case Review Administrator Surrey Safeguarding Children Board. 11 The panel was convened under Working Together 2010 and this report is in line with that guidance.  The publication of Working Together 2013 has since removed the requirement for an SCR panel.   1.6.3 The Panel met on 7 occasions, including on one occasion with the IMR writers from the involved agencies.  The IMR writers also had their own briefing session.  1.7 Individual Management Reviews  1.7.1 IMRs were produced by the following agencies, plus brief statements from Elmbridge Council, Surrey Education, and SE Coast Ambulance NHS  Foundation Trust   Ashford and St Peter’s Hospitals NHS Foundation Trust (A&E, Paediatrics, Maternity) – referred to in this report as ASPH  St George’s Healthcare NHS Trust (Paediatric Intensive Care)  Surrey County Council Children’s Social Care (Children’s Social Care)  Surrey Police  Virgin Care Services Ltd (Health visiting, School nursing)   General Practice (IMR led by the Surrey Named Safeguarding GP)  Guildford and Waveney CCG – a Health Overview Report  1.8 IMRs were produced by each agency by someone not involved in the case and signed off by a senior manager.  Ongoing dialogue between the Panel, overview author, and the IMR writers ensured that issues the Panel needed to understand, some of which emerged during the process, were fully addressed.  There is a brief appraisal of each IMR at appendix 2  IMR Authors  Post Organisation Named Nurse for Safeguarding Children Virgin Care Services Ltd Deputy Chief Nurse  Named Nurse Ashford & St Peter’s Hospitals NHS Foundation Trust CAMHS Service Development Manager Surrey County Council -  Children’s Services Review Investigator, Major Crime Review Team Surrey Police Named Nurse for Safeguarding Children St George’s Healthcare NHS Trust Named GP for Safeguarding Children, Surrey Guildford & Waverley CCG (for the GP Practice) Designated Nurse Child Protection Guildford & Waverley CCG (The Health Overview) 12 1.9 Methodology   1.9.1 The methodology was as described in WT2010: LSCB Chair approved terms of reference, IMRs provided by involved agencies, a Panel of uninvolved agency representatives overseeing the process, and an independent Panel Chair and Overview Author.  In addition, the overview author met the paternal grandmother, the lead GP at the involved Practice (with the IMR author), and the named doctor and midwife at ASPH.  1.9.2 Towards the end of the Review the Court made available to the SCR the Finding of Fact made by the Judge in the care proceedings.  This is referred to in this report as the ‘Judgement’.  These findings, which are made on the balance of probabilities, are incorporated into this report where relevant.  This is mainly in relation to the extent, cause, and age of injuries.  In the criminal proceedings, a higher standard of proof (beyond reasonable doubt) was used.  1.9.3 The SCR Panel accepted the level of detail used in this Review as necessary to maximise learning about compliance with procedures, opportunities for better practice, and to show how much knowledge can be available but not brought together.  1.10 Publication:  1.10.1 Both before and after WT2013 was published, there is an expectation that the reports of SCRs will be published, unless to do so would harm any children involved.  This is so that the professional community can see the lessons that emerge for their work, and so that the public can see that the LSCB and agencies have looked closely at the case and taken responsibility for the findings.  The emphasis is primarily on learning, so SCRs are produced in a way that anonymises child and family identity, and individual staff identity, wherever possible.  Care is taken to include only information that is relevant to the terms of reference. Publication of the approved report was not possible until the criminal process had been concluded  1.11 Family Involvement  1.11.1 Both parents were approached separately through their representatives to invite them to contribute to the review.  It was made clear that the discussion would be about services they had received, not matters of culpability but neither parent accepted the invitation.  Through his legal representative, the father declined to be seen.  Both through solicitors, and directly, the mother was offered the opportunity to give her views to the SCR but the invitation was not accepted.  The paternal grandmother did agree to discuss her views about how the case was managed, and this is described in the report. After the convictions and before publication, family members were offered the opportunity to hear about the SCR findings.  The author met the paternal grandmother, and the LSCB Chair and Partnership Support Manager met the father. The mother did not accept the invitation. 13  1.12 Surrey Safeguarding Children Board Approval  1.12.1 This SCR Report and its recommendations were accepted by the SSCB at its meeting on 26.09.13.  14 2. THE FACTS 2.1. Background  2.1.1. This section describes what happened in the case, and includes events or knowledge that was or may have been relevant to looking at whether what happened might have been prevented, and to looking at the quality of services to the family.   2.1.2. The facts are deliberately described in some detail as they demonstrate what was known to whom, and how complicated the story became without any central coordination or assessment to pull it together.  The period from birth to diagnosis of the injuries was just 5 weeks.  The picture described below was put together with some difficulty given the problems with the accuracy, timeliness and consistency of records.  No apology is given for the complexity below as it helps to illustrate how unclear the professional picture was at the time, and the difficulty caused by the lack of any collective view that might have led to different conclusions.  2.1.3. Headline dates are charted in appendix 3  2.2. Up to the birth of Child X    This section covers events up until the birth in hospital of Child X.  2.2.1. There is not a great deal known about the mother-to-be’s childhood, but when she was 5 her birth father (now deceased) was imprisoned for sexual offences against one of her sisters.  Records of a 2009 Children’s Service assessment quote the maternal grandmother as saying her daughter – the mother-to-be in this case – witnessed the offences, and that all her daughters were abused.  There is also a suggestion that the mother-to-be was hit by her father, Child X’s maternal grandfather.  The maternal grandmother remarried.  There is only some knowledge of schooling, where the mother to be was noted as having some learning and social difficulties and, for a period up to 17 months before the baby’s birth, was being supervised by the school nurse for safeguarding concerns.  The SCR has sought, but not obtained, the reason for this.   2.2.2. It is also unclear why a school nurse was involved, as Education informed the SCR that the mother-to-be’s schooling ended in 2010.  Surrey Children’s Social Care was aware of the mother as her sister A has been looked after since 2009 as a result of challenging behaviour and a breakdown of relationships in the home.  Some aggression from the mother to be to her sister A was noted.  Social work assessments at that time suggested a rather chaotic and unstable home life, but the initial assessment of the mother to be concluded there were no issues for her.  Prior to Child X’s birth the mother to be had two jobs in nurseries: one ended 3 months before the birth, and she was on maternity leave from the other.  Little is known about the father (age 15 20 at Child X’s birth).  There are records indicating that at school he had some learning difficulties, and Children’s Social Care have a record of some minor involvement with the police as a teenager (no convictions) in relation to alcohol or being a potential victim of links with older drinkers.  This was not known to professionals working with him as a prospective / new parent.  The father’s name appeared in obstetric records, but was then crossed out.  2.2.3. The mother-to-be (hereafter described as ‘mother’ unless referring to pre pregnancy) became pregnant in late 2011 and was referred early in 2012 by the GP to maternity services, which are part of Ashford and St Peters NHS FT (ASPH).  Both parents were seen in the following month by the community midwife and no concerns were noted.  As it was a teenage pregnancy (the mother was 18) she was offered, but refused, parent education, and the opportunity for an assessment under the Common Assessment Framework.  She was noted as having housing and financial problems, and not being known to Children’s Social Care.  (She was actually known, as an initial assessment had been done on her in 2009).  Two months before the birth she again refused teenage parenting classes.  Routine antenatal appointments when she was in Surrey were kept.  Ante-natally she saw (at least once) two of the midwives who later visited her at home post-natally, plus other midwives.  She attended A&E and the labour ward on two occasions in the early stages of pregnancy with sickness and inability to tolerate food and drink.  On the second occasion she was admitted overnight.    2.2.4. In mid-summer, the mother reported being ejected from her own parental home.  Housing had been arranged in Hounslow.  The midwife suggested booking into Wexham Park Hospital for the delivery.  The midwife, on the advice of her team leader, notified Children’s Social Care in Surrey of the mother’s problems, although it is unclear what was expected from the communication.  The midwife (MW1) told Children’s Social Care that there had been no previous problems and that she was advising for information only.  The Virgin Care IMR describes the midwife contact with social care as ‘escalation’.  No further action was taken.  There is no indication, in the notes of the referral, that Children’s Social Care made the link with A or the information about the then mother-to-be in A’s assessment and from her Looked After records about the childhood abuse.  The IT audit system shows the record was accessed that day, but it does not show which elements were looked at.  The school nursing service would have known that the mother-to-be was on a ‘targeted’ list by the school nurse only a year before because of concerns about her well-being at home.  The midwifery service knew none of this.  The mother told midwifery a few weeks later that she was returning to Weybridge.  2.2.5. The same month the maternal grandmother told Children’s Social Care (visiting in relation to a sister) about the physical abuse her daughters had experienced from their late father when they were very young.  The sister’s social worker was not aware of the midwife’s ‘referral’ about the mother. 16 2.2.6. The SCR has been supplied with no information about antenatal care in the two months mother lived elsewhere.  On her return, a health visitor from one part of the county (HV1) called to make an antenatal visit at the maternal grandmother’s home but was told she had now moved.  This visit was under the policy to provide targeted antenatal health visitor support for mothers with additional needs.  Health visitors could have seen from community nursing electronic records, had they looked, that the mother to be had been a school nurse safeguarding concern.  Although the original health visiting team say the targeted status was passed on, the new team say nothing was received and, in not being aware of it, the case was allocated to a bank health visitor (HV2) rather than a regular staff member.  There was no discussion between the two areas about transferring a targeted case between them.  No antenatal visit was made by a health visitor.   2.2.7. A month before the birth, the mother referred herself to maternity at St Peter’s with reduced foetal movement.  (In this report “St Peter’s” is used rather than ‘ASPH’ if it refers to something specific that happened there, as opposed to corporate Trust issues where ‘ASPH’ is used).  She was reassured and discharged.  She saw the GP for an ante-natal check 4 days before giving birth.  This was the second of two antenatal GP contacts described by the Practice as ‘unremarkable’.  (She had only registered with the GP 7 weeks before she gave birth).  She referred herself to hospital for reduced foetal movement 2 days before birth, but was seen as normal, and she was discharged to come back the next day, was admitted and Child X was born with father present.  The care proceedings Judgement determined that no injuries later seen were caused in the birth process.  Mother and baby were discharged at 9pm on the day of birth, although the hospital discharge summary says the discharge was the following day.  No problems were identified with Child X.  A maternity record says that the mother had experienced one prior neonatal death (death within 28 days of birth) but this does not appear to be correct.  2.3. After Child X’s birth to the major injuries  This section covers the events from Child X’s arrival home after birth to admission to hospital in November with what proved to be life threatening injuries.  The events are described chronologically as they show the growing number of opportunities for concerns to be formed.  These are analysed in Section 3 ‘Analysis’.  The baby’s age in days is given, with 0 being the day of birth.  Day 1   A midwife (MW2) visit was unsuccessful.  The paternal grandmother says it is very hard for people in the flat to hear visitors.  The mobile number the midwife had was wrong.  The correct number was obtained, and the mother was called and she said all was well.  No visit was made.  The paternal grandmother says that on the day after birth her son told her about hearing a click in the baby’s leg when changing her, and advised they tell the midwife.  There is no record that they did.  When relating 17 the click story to a paediatrician, after the last injuries, it was described as a ‘massive crack’ but the Judgement said this day predated the earliest time fractures were thought to have occurred.  Day 2   A midwife (MW3) visited, and the ASPH chronology says ‘no concerns’ were noted.  The Judgement said that this was likely to be the very earliest date the rib fractures which were discovered later could have occurred.  Day 5   The paternal grandmother took the baby with both parents to St Peter’s A&E at 2.26am for constipation and blood in the stool.  The A&E record said only father attended.  No concerns were noted by the Paediatric Registrar or nursing staff.  Health visitors were unaware of this attendance until Day 20 as the paediatric liaison nurse did not see the attendance record until Day 10 and the forwarding by internal mail took until Day 20.  There is no record at the GP Practice of A&E notifying the GP of this attendance, and the first time it was mentioned was in a letter on another matter received on Day 20.  Later on Day 5 another midwife (MW4) did a home visit and there were no concerns.  She was aware from the parents that Child X had been taken to A&E earlier that day.  The Strategy meeting after the injuries were diagnosed was told the parents declined this visit as they were going out, but this appears not to have been the case.    See also Day 10 below, as much of what happened then was recorded as happening on Day 5.  Day 8   There is no record of the following, nor of any action in response in hospital records, but on this day the paternal grandmother says she saw a left, linear abdominal bruise which she said the parents had found on waking.  The parents indicated this may have been caused by a car baby-seat belt when Child X was being transported by a relative.  The Review was told that the mother tried to call the community midwife but did not succeed, so the paternal grandmother says she called the maternity ward and other numbers at the hospital to see if they could get the community midwife to call.  The reason given was because of the bruise.  The paternal grandmother says that maternity said they could not do this and to ‘keep trying’.  She had expected the hospital to locate the community midwife or ask to see the baby.  As the baby seemed well, and as they perceived they were getting no help, they decided to wait for the next midwife visit which they knew would be in the next day or so.  No ASPH record has been found of these calls, to confirm the information provided to the SCR. 18 Day 10   Possibly the previous night, the Judgement said the parents had given evidence of a cut lip on X and a high pitched scream.  When MW2 visited, her first home visit to the family, father was waiting outside and told her about a left abdominal bruise, saying it was caused by too tight a car seat belt.  It is not mentioned in the mother’s notes, but in the baby’s notes the midwife record of the visit says there was a bruise on the left side.  The notes do not describe or draw it, or specify where on the left side it was.  It was later, after the major injuries were identified, described as round, brown, and of 1cm diameter – in an unspecified place.  The midwife later told a hospital doctor she reviewed the seat and found the story acceptable.  Advice was given about doing up the belt.  The baby was said to have been wearing thick clothes which had made the strap tight.  No drawing was made.  No medical examination was sought.  The bruise was not reported to the midwifery supervisor or to the named safeguarding midwife.  A medical note by a hospital doctor about a Day 13 phone call with MW3 says the midwife indicated the parents had been trying to contact her about the bruise before her visit, but that is not in midwifery notes.  The description of the bruise is quite different from that described by the paternal grandmother two days earlier, or by the hospital the next day.   The mother’s hand held midwifery record written by MW2, which mother later showed hospital staff, showed this incident happening on Day 5.  The SCR pursued this and identified that the ‘Day 5’ had been changed to the ‘Day 10’ only after the injuries and the midwife looked at the records for the IMR.  Day 10 is likely to be the correct date as a different midwife went on Day 5.  The paternal grandmother recalls the mother saying the midwife was not worried about the bruise and was ready to ‘sign her off’.  Later on Day 10, in the afternoon at 14.52, Child X was taken to St Peter’s A&E by parents and paternal grandmother with blood-stained vomit and being unsettled.  There is no mention of the abdominal bruise on the A&E record or in the summary sent to the GP, although the paternal grandmother says it was discussed while the baby was still in A&E.  The hospital was unaware that a midwife had seen a bruise earlier that day.    The paternal grandmother says that she was concerned there might be a link between the bruise and the blood stained vomit, and suggested to a doctor there ought to be an X ray to rule out a traumatic cause (although not thinking it might be NAI).  She says the reply was that the baby was too well for that to be justified.  There is no hospital record of this exchange.  Child X was admitted to a ward as her white cell count was raised.  A blood test gave a preliminary indication that clotting was normal.  The paediatric liaison nurse (who links the hospital and community nursing services) saw the A&E record on Day 14 19 and it was received by health visitors on Day 31.  The hospital nursing assessment made no reference to the bruise.      The GP was not sent a notification of this Day 10 A&E attendance until Day 26.  The notification was dated Day 12 and said that the presenting complaint was that the baby had vomited blood.  Midwifery notes, but not in the ASPH IMR, show a message left by mother at 6pm to report the baby’s attendance at A&E and subsequent admission.  The Judgement in the care proceedings found that the car seat belt was not the cause of the linear bruise seen by the midwife and hospital.  The Judge concluded that the bruise was associated with the squeezing which led to the rib fractures.  The Judgement also concluded that blood in X’s throat and mouth was associated with the squeezing that was so hard the ribs fractured.  Day 11   On the second day in hospital, a consultant led ward round identified an infection of the umbilicus and a staphylococcus infection and intravenous antibiotics were administered.  A junior doctor identified the bruise (which it was said was not unlike a birth mark), and was to contact the health visitor and midwife.  In that doctor’s statement for the IMR, the mark was described as on the chest and on the right, although there are many records of it being on the left and on the abdomen.  This appears to be an erroneous recollection.  It is possible that the ‘bruise’ seen by the doctor was different from that seen by the midwife the day before as the midwife saw a very small round bruise, while the St Peter’s drawing shows something larger, more linear with some small marks around it.    The IMR says the health visitor was contacted, and the doctor discussed the bruise with the parents.  An SHO (a senior house officer) recorded that ‘we cannot be certain that (the bruise) is not NAI’. (Non-accidental injury)  The doctor called midwifery.  The midwife who had seen the bruise was not available, and the colleague spoken to would not have known about the bruise seen the day before as it was only recorded on notes held by the mother.  They told the doctor that there was no record of social concerns or incidents documented on the visit sheet at the office.  Her colleague reported that on the Day 10, Child X’s skin was intact.  Day 12  The ASPH IMR suggests a midwife visited the ward, but the SCR was later told this did not happen.  20 Day 13   MW2, unavailable on Day 11, returned the hospital doctor’s calls, and said she was aware of the bruise and described the car seat story.  She told the doctor that the parents had tried to contact her as soon as they saw the bruise.  The hospital notes about this discussion refer to the bruise being from Day 5 as that is what it said on the parent held record, but the midwife knew it to be Day 10.  It is possible neither doctor nor midwife mentioned the date and assumed they were discussing the same date.  Day 14   At a ward round, consultant 2 considered the bruise and considered it likely to have been caused by friction in the way explained.  The junior doctor told midwifery.  No inquiry was made of the GP by the hospital during this admission.  Child X was discharged but the wrong discharge letter was sent to the GP.  It arrived on Day 20.  It was the right name but the wrong patient’s details.  Midwifery was informed of the discharge.  The health visitors (who had not yet started visiting) received the discharge summary Day 17.  This would probably have been the wrong one.  The incorrect, and then a correct, discharge letter were faxed to the GP six days later on Day 20.   Day 15   A midwife (MW5) visited the day after Child X left hospital and discharged the baby from midwifery care.  Nothing of concern was noted.  Day 16   The Judgement concludes this was the last point at which the rib fractures could have happened.  Day 17    The health visitors received the hospital discharge summary from Child X’s birth.  Day 19   The ASPH named nurse for safeguarding contacted a health visitor (HV3) after liaison with the midwife regarding the bruise.  On the same day, HV3 met MW2.  This was not planned, and is described as an informal meeting when the midwife dropped in.  HV3 was told that midwifery had discharged the baby, and that there had been a bruise on the right abdomen on Day 2.  This does not match the ASPH IMR (and any other reference) which says the bruise was on the left on Day 10 (although it was also erroneously recorded by a midwife as occurring on Day 5). The midwife was concerned in case the health visitors were not aware of the bruise.  The midwife also reported the hospital 21 attendances, and that she had spoken to the hospital about the bruise.  HV3 also phoned the Paediatric liaison nurse about Child X’s hospital attendances.  No written handover was done by midwifery.  Day 20    The GP saw Child X in the morning (for the only time) as mother wanted Child X checked before stopping antibiotics.  The morning appointment was before the hospital discharge letters arrived later in the day.  The GP notes record the Day 10-14 hospital stay from mother’s self-report, and the GP saw a linear purple mark on the abdomen – ‘could be a pinch mark from car seat as stated by father.  Observe’.  The GP, who has forensic experience, examined the mark carefully with the baby undressed, and also handled the baby to assess if there was any discomfort – there was not.  The GP did not see it as a typical bruise, and was not sufficiently concerned to refer the matter on.  The GP was not aware of the LSCB policy requiring any bruise on a non-mobile baby to be referred.  The GP also saw a mark on the baby’s face which he said he would not describe as a bruise, but a small mark of undetermined origin.  St Peter’s sent a discharge letter from the Day 10-14 admission later that morning, but realised that the contents were wrong so the GP was called by a junior doctor.  The GP was told about the car seat bruise.  He was asked not to exclude non accidental injury (NAI), and to refer to A&E if ‘any new bruising/suspected injuries/possible signs of NAI’.  The hospital doctor asked if Children’s Social Care were involved but the GP was not aware of this.  The ASPH IMR says the GP said he had seen the baby with no evidence of ‘further bruising’.  By this he meant nothing further to the abdominal bruise.  This appears inconsistent with the health visiting notes which record the GP telling her, after her visit described below, that he was aware of the facial bruise – but as noted above the GP did not see it as a ‘bruise’.  The junior doctor noted on the medical file, ‘how do we check whether known to social services now?’  A bank (not permanently employed) health visitor (HV2) visited the home to make a new birth assessment within the target 21 days, but the formal Family Needs Assessment was not started as per policy.  Weight was satisfactory.  There was a ‘bruise’ on Child X’s right cheek.  There was also an area of flaky skin above the umbilicus and a 5cm linear bruise on the abdomen ‘still visible’.  The bruises were discussed with mother by the health visitor who said Child X had sensitive skin and bruised easily.  She was advised to draw the bruise to the paediatrician’s attention at the hospital appointment the next day.  The health visitor did not alert the paediatrician to this or make any follow up to ensure that happened.  No drawing of the bruising on a body map was done.  The family was invited to the drop in baby clinic or call the health visitor as needed.  The next visit was scheduled for Day 41.  The facial bruise was not discussed by HV2 with her supervisor or the named safeguarding nurse, but was recorded.  The HV2 did discuss the visit with the 22 GP, who had seen the baby earlier that day for an antibiotic review.  The health visitor says the GP was aware of the facial bruise.  The ASPH named nurse, who was curious about the case, and the registrar – who saw the baby on Day 10 and was to see her again on Day 21 – discussed the case.  The note of this discussion in the medical notes says the bruise and story were consistent, but does not mention ‘easy bruising’.  It said the named nurse should be contacted when the family arrived the next day (by bleep as she would be on leave).  Virgin Care received notification of Child X’s Day 5 A&E attendance.  At the end of the day, at 17.37, the corrected discharge letter arrived at the GP Practice, confirming what had been said about the body bruise and any further bruising in the earlier phone call from the hospital.  The GP saw it the following day.  The GP did not refer the new bruise to A&E as requested by the hospital (not seeing it as a bruise).  Day 21    Child X was taken to the paediatric day ward at St Peter’s for a follow up, and a paediatric registrar was called.  Two new bruises were identified, additional to the abdominal bruise seen before.  The cheek bruise, and a small discoloured area on the right thigh.  They were recorded as unexplained, with the parents accompanied by the paternal grandmother saying Child X had a habit of pushing a finger into her cheek, and the thigh marking came from a nappy edge.  The linear abdominal bruise was now faint.  The skin lesions from the infection had gone.  The registrar’s statement says that mother said that the facial bruise had been present at her hospital admission over a week before, but there is no record of that.  The paternal grandmother who worked at the hospital said that Child X bruised easily as she did.  She also said she had done safeguarding training and had no concerns about the mother.  Her views on her son were not recorded.    A haematologist was consulted who suggested that the staphylococcal infection which Child X had earlier can lead to easier bruising.  The registrar considered that Child X had bruised easily when blood was taken for a clotting study, and considered the bruising at that site something she had not seen before in her practice.  She said in a later statement that the child had bruised where the doctor’s finger had pressed against her.  The baby was discharged shortly afterwards, so there is no evidence of how permanent was any mark.  Full clotting studies take several weeks, and in due course these all came back as normal.  The ASPH IMR says the registrar discussed with the on-call consultant 3, who was not at the hospital, who suggested talking to the named safeguarding nurse.  There was a discussion.  The named nurse did not refer the baby as per the bruising policy for babies who are not independently mobile.  Child X was discharged home by the registrar without a formal conclusion, or any referral to Children’s Social Care or discussion with outside professionals.  Child X was not seen by a consultant. 23 The medical record says, ‘Letter to GP’ but the GP did not receive one.  The GP was therefore unaware of the hospital’s thoughts about the facial bruise, or the existence of the thigh bruise.  The same day, the paternal grandmother called the health visiting office to speak to bank health visitor, and spoke to HV3.  The paternal grandmother was annoyed at what had happened at the hospital (i.e. the querying of the bruises).  HV3 said she would ask HV 2 to discuss the concerns with the parents, and that she could not discuss confidential patient details with the grandmother  Day 22   The GP notes record a notification that mother called the GP out of hours service Harmoni as Child X was crying continually.  The paternal grandmother said this was early afternoon and was because the mother was worried that Child X was not feeding.  Harmoni advised Child X be taken to A&E.  The Harmoni nurse recorded ‘mother non-committal, asking if it can wait until tomorrow’.  The nurse reiterated the advice.  Day 24   The registrar emailed the ASPH named safeguarding nurse ‘as the health visitor was talking to you about the bruising’.  The email reported that the registrar and a consultant had been ‘happy’ with the car seat explanation of the first bruise.  It explained about the mother and paternal grandmother talking about easy bruising and her own observations about redness when she held the baby’s arm.  It says the mother said that one of her health visitors had seen the baby push her finger into her cheek.  The mother had only ever seen one health visitor, the day before, so there was some confusion between midwives and health visitors in her comment.      Day 26   The GP received the notification from A&E of the baby’s attendance there on Day 10  Day 27   Child X was taken to the health visitor drop in clinic.  The IMR says the weight had increased 131 grams in a week.  Health visitors at these clinics do not have access to prior records, but HV3 who knew about the bruising seen to date was there.  Weight gain was about 5 ounces compared to the expected 7.  HV3 saw from the parental hand held record that the weight was being monitored by the hospital.  Child X also had a right conjunctival haemorrhage the parents said had been there a week, and a left one said to have been a few days old.  The health visitor suggested the baby was taken to the GP for an assessment.  No check was made to see if an appointment was made or kept.  The baby’s GP record shows no such appointment was made.  The paternal grandmother, who had also seen a ‘blood shot eye’, confirmed that the mother told her the health visitor advised going to see the GP.  24 HV3 knew from paternal grandmother about the bruising seen in hospital on Day 21.  She was also aware of the abdominal bruise from the midwife handover.  The health visitor did not consider the sequence of bruises and eye haemorrhages as a safeguarding issue and did not record or discuss them as such.  Health visitors had no concerns about any parental handling of Child X that they had witnessed.  Day 28   HV3 returned a call to the paternal grandmother who had left a message, very annoyed about the contents of the baby’s discharge letter from the Day10-14 admission which the heath visiting team told her they did not receive.  The health visitor said she could not discuss any detail with her and advised that her son should raise issues with HV2.  This discharge letter refers to the car seat bruise being seen on Day 5, and neither the mother nor paternal grandmother pointed out this date was wrong.  The discharge letter does not mention NAI and is tactfully written, only saying that if there were more bruises Child X should be brought to A&E for assessment.  2.4. The hospitalisation that led to the diagnosis of traumatic injury  This looks at what happened from Child X’s arrival at St Peter’s A&E when Child X was 30 days old until the multiagency strategy meeting held to discuss the diagnosis 4 days later.  Day 30   The baby’s father called the ambulance service at 00.12 on the advice of the paternal grandmother after he had found her pale and floppy, jerking, with a twitching hand and face.  The baby arrived at A&E at 00.44.  The ambulance service had no concerns about NAI and their working assumption was epilepsy.  No bruising was noted at A&E.  Full testing for sepsis (a life threatening condition where the body over reacts to infection) was undertaken and intravenous antibiotics commenced.  She had a high pitched scream and her eyes looked a little red.  Cerebral spinal fluid was blood stained.  A chest X ray for a heart murmur was ordered.  The mother told consultant 4 that both her sisters had epilepsy.  There was no recorded evidence that NAI was considered as a possibility and on that first day medical records, which would have shown a history of at least 3 bruises and eye haemorrhages, were not located.  Bruising was though referred to on the electronic inpatient list which was accessible.  Day 31  The case was handed over to consultant 5 the next day, Day 31, with a working diagnosis of infection e.g. meningitis.  A junior doctor at the ward round identified the history of bruising and querying of NAI, and also the prior retinal haemorrhages.  Consultant 5 discussed with Consultant 4 a brain CT scan to exclude subdural haematoma (bleeding in the brain that can indicate trauma).  Consultant 5 declined the CT on the grounds of radiation risk to a neonate and an MRI was ordered.  The 25 chest X ray which was looked at for heart irregularities, and the MRI came back as ‘normal’.  On this day the health visiting service received information about Child X’s Day 10 attendance at St Peter’s.   Day 32   Consultant 6, who is the named doctor for safeguarding, contacted consultant 5 to see if any social concerns had been identified and to ensure that a subdural haematoma had been excluded.  She was advised there were no safeguarding concerns.  The nursing assessment record made no reference to prior bruising.  Nursing records for the Day 10 admission, and this one, are described as fairly minimal and ineffective with no nursing care plans in place, and no social history.  St Peter’s doctors were becoming very concerned about Child X’s well-being and started discussions with St George’s Hospital, a specialist tertiary hospital about a transfer.  She was transferred in the afternoon to St George’s Paediatric ICU.  No reference to any prior bruising or NAI suspicion in the information transferred verbally or in writing from St Peter’s to St George’s.  The transfer letter was written by a SHO.  The focus of transfer information was on the management of her fitting.  During her stay at St Peter’s, no inquiries were made by the hospital with midwifery, health visitors, or the GP.  At St George’s: The baby was ventilated and sedated.  St George’s doctors tried to access the chest X ray and MRI taken at ASPH but although sent they had not been uploaded, and the relevant office was closed delaying the neurological review until the next day.  There is no record that trauma or NAI was being considered as a possible cause, but St George’s’ doctors say that it was.  Day 33    The next morning at St George’s, their medical staff were able to examine the X-ray and MRI taken at St Peter’s.  Although the parents identified no trauma, the MRI was seen to evidence subdural haemorrhages.  The paediatric neurologist spoke to the parents who identified the red eyes a week before admission.  An ophthalmology review was also requested, as the eyes can display evidence of head trauma.  A clotting test was ordered – unaware that St Peter’s had done a negative test three weeks before, or that St Peter’s knew about bruising.  A consultant paediatric intensivist then saw the parents and specifically asked about trauma which was denied.  After this, the intensivist noted that a radiologist, looking at the St Peter’s chest X-ray had found a rib fracture and after further examination 4 rib fractures at least a week old had been diagnosed.  On this day, the father and HV 2 spoke on the phone.  He told her about Child X being in hospital.  She had heard this from neither St Peter’s nor St George’s.  She said she had tried to contact the St George’s named nurse but had been unable to 26 speak to her.  The named nurse was on leave, but the deputy was available and no message has been traced.  Due to the almost certain indications of trauma, consideration was given at St George’s to referring the matter to Children’s Social Care or the Police that evening, but it was decided to wait until the following day when the diagnostic information to raise with the parents would be more detailed.  No inquiries had been made from St George’s to the GP, midwife or health visitor for background information which may have aided a diagnosis.  Day 34    The paediatric intensivist informed the parents of the acute and chronic subdural haemorrhages and four fractured ribs, told them he would tell Surrey Children’s Social Care and the Police and what further tests would be done.  Later that day the ophthalmologists confirmed retinal haemorrhages to both eyes.  A Strategy Meeting, which is a preliminary multiagency meeting to assess the evidence and plan immediate steps, was called for that afternoon.  The Strategy Meeting was attended by staff from the hospital, Surrey Children’s Social Care and the Police.  Background information was exchanged, a definitive diagnosis was given, and various actions and inquiries were agreed.  Parental access to the child was to be supervised, to which the parents agreed in writing.  Children Social Care say the notes of the meeting were circulated, but not all present saw them.  For example, they refer to shoulder bruising and the professional said to have reported this has told the SCR that this was not said, and no evidence for such bruising has been found.  Also other inaccuracies were reported when they were re-circulated for an accuracy check at the request of the SCR Panel.  The outcome of the meeting was not recorded in the medical notes.  2.5. Diagnosis  Child X was transferred out of the intensive care unit on Day 35 with the following diagnoses   Traumatic subdural haematoma  Retinal haemorrhages  Bi-lateral rib fractures  Refractory seizures, query cause  2.5.1. Subsequent to the original diagnosis as above, further X rays and re-X rays at St. George’s identified    further rib fractures,  a femur fracture   two tibia fractures 27   foot fracture.   Dating fractures is a not a precise exercise, but the Judgement concluded the following:   2.5.2. The Judge at the care proceedings concluded that the injuries were non-accidental in origin, with none related to birth or any bone deficiency.  The injuries listed in the Judgement and the conclusions on dates were as follows.  They are in this report as they put professional decisions during the baby’s life into the context of what the baby may have been suffering. The SCR was concluded before the criminal trial.  Injury Approximate date of causation 8 rib fractures  Day 2-16 Metaphyseal fractures*: femur and 2x tibia Day 11-25. Unlikely, but possibly after  Metatarsal fracture ? but from Day 1 Retinal haemorrhages From Day 28 Brain haemorrhages Possibly Day 24-28 , Probably day 29 Face bruise On or before Day 15 Abdominal bruise On or before Day 10 Thigh bruise On or before Day 21 Cut lip  Sometime around Day 10 * changes to the ends of long bones typically caused by pulling or swinging 28 3. ANALYSIS AND APPRAISAL   3.1 This section analyses the events that occurred up to diagnosis of non-accidental injuries, and looks at why actions or decisions were made, trying to identify when practice strayed from what was expected, or was significantly good.  It is always easy in hindsight to say what might have happened, and where anything looks inexplicable evidence of what staff thought processes were at the time is sought.  Although this SCR will appraise practice, the overall purpose is to identify areas of practice that can be improved or from which others can learn.  The analysis is done chronologically, where practical, as that is the easiest way to consider whether a difference could have been made in this case, although each of the questions in the TOR is borne in mind during the analysis.  Showing areas of concern in the context of the actual case story, demonstrates real risks and not just theoretical learning points.  Recommendations from this SCR overview are in bold italics  3.2 In section 4 the key issues are summarised and where possible errors are noted, the SCR looks at ‘why’ this happened and any systems issues which impacted on professional performance.  3.3 Was there information about either parent by the time of the pregnancy that might have affected the supervision of, of help provided to, the family?   The SCR found it hard to piece together historical information about the parental background, and so it was likely that identifying what information existed was hard for professionals at the time.  3.3.1 ‘Referral’ to Children’s Social Care by Midwifery: About 3 months before the baby was due, the midwife, concerned about the mother being ejected from her home, and moving to another area with housing and financial worries, called Surrey Children’s Social Care.  This incident has raised issues which will need more thought if in future such conversations are to be more clearly understood by both sides.   3.3.2 Despite the mother being a teenager, there is no reference in the ASPH IMR to ASPH midwifery making any contact with the area to which she was to move.  She was asked to make all the arrangements herself, even though she was such a young mother, and there was enough concern to call Children’s Social Care.  Maternity services should clarify the circumstances in which a handover should be given to the area where a vulnerable client has moved, and checks made that a vulnerable client has indeed locked into services after moving.  The ASPH IMR also concludes that the midwifery documentation was insufficiently detailed about the social factors, and that the risk factors were not sufficiently acted upon.  3.3.3 The ASPH IMR expressed concern that midwifery did not follow up with Children’s Social Care to find out the outcome of the ‘referral’.  Children’s Social Care understood the call from the midwife to be for information only ‘as the community midwifery services were monitoring mother and would refer if 29 appropriate’.  The Children’s Social Care IMR says it is unclear what were the expectations of the midwife, especially as the midwife said there were no prior problems before the pregnancy was booked in.  Children’s Social Care said to the SCR that they receive large numbers of ‘information only’ calls and further checks are only made if the referrer indicates specific risks.  If not, the ‘referrals’ are recorded with a no further action (NFA) conclusion.  Their IMR said this happened in this case.  The risks are clear: social work time is taken up dealing with information that is simply noted, when there are higher priorities getting less time, or, there is ‘no further action’ on cases which might really have more needs but are hidden by ‘information only’.  The SSCB should ensure that there are effective processes in place to ensure that the purpose of referrals (and this does not just apply to referrals to social work) is clear.  The Children’s Social Care IMR says that recent work had been done on the multiagency referral form to make the expectation clearer and this is about to be implemented.  Its success will need to be monitored.  3.3.4 There are also lessons to be learned from how Children’s Social Care handled the call.  Although there is evidence that old records were accessed there is no evidence from the write up of the referral that a link was discovered with the mother’s Looked After sister or the initial assessment on the mother to be in 2009 (or if it was, that it was perceived to have any relevance).  Had this connection been made (the midwife was unaware) information would have been identified about mother’s earlier years where she is said to have been a witness to a sexual offence against her sister by her now late father, leading to his imprisonment 14 years ago.  It would also have said that the mother was physically abused as a young child by her father.  It would have given some indication of her social difficulties.  The sister’s social worker was unaware of the midwife’s concerns.  The importance of this is shown by the Children’s Social Care IMR conclusion that had the information been known, it should have led at least to an initial assessment to see if further assessment or support was needed.    3.3.5 This emphasises the importance of the quality of the exchange between referrer and referred to.  The Children’s Social Care IMR concludes that their Contact Centre who received the call should have initiated further checks about mother’s background, and recommends that the Centre reviews how it checks and shares information with area teams who are working with close relatives.  The IMR concludes that whilst this would be good practice, it does not mean that if it had been done at the time the later tragic events would necessarily have been avoided.  This event is a good example of how a system issue affects decisions.  3.3.6 The Health Overview wonders if the knowledge that the mother worked in a nursery, and presumably had been CRB checked, may have led to a view that she could not be a risk to a baby.  The paternal grandmother also wondered if the mother overestimated her abilities as she had an NVQ child care qualification. 30  3.4 Health visiting in the antenatal period  3.4.1 In the summer of 2012 HV1 attempted an antenatal visit, but the maternal grandmother said her daughter had moved.  In the IMR process, that health visitor could not recall why the case was targeted (only targeted cases get an antenatal visit).  The new health visiting team reported that they never received the targeted antenatal forms from HV1 although their transmission was recorded, and as a result the case was allocated to a non-permanent member of staff.  The Virgin Care IMR describes this as an opportunity lost, and there was never an antenatal assessment.  It suggests that a verbal handover is a protection against lost records.  The IMR rightly recommends that the process of midwife to health visitor communications, and health visiting team to team communications be reviewed to create a more robust process.  There is no guarantee that had there been an antenatal assessment, and a greater understanding of the family’s status as targeted, that the later injuries would have been prevented, but there would have been a higher chance that later signs might have been taken a little more seriously.  3.4.2 The Virgin Care IMR is justifiably recommending that the criteria for antenatal visits are reviewed and rolled out effectively to staff.  3.5 Birth  3.5.1 There were no obvious lessons from the mother’s self- referral up to maternity services before birth with apparent reduced foetal movement, or the birth process, and mother had father’s support at the birth itself.  The mother and baby’s discharge home at 9pm on the day of birth does not seem unusual these days, but the paternal grandmother said she did not think it was appropriate and that it reflected the intense pressure in the hospital that day.   3.6 Midwifery care post birth  3.6.1 The ASPH IMR indicates that baby was visited at home on Days 2, 5, 10, and 15. The baby was in hospital on Days 10-14.  The visit on Day 2 was unsuccessful but later phone contact was made to hear progress.  The case was handed over to HV3 informally on day 19 (see above) and the HV2 visited on Day 20.  The final midwife visit was on Day 15.   3.6.2 The IMR appraises the midwifery work and says that there should have been a risk assessment to assess the risk level, but this was not done.  3.6.3 The ASPH IMR found the quality of midwifery notes and assessment not of sufficient standard.  It said they were ‘not completed appropriately, were scant and minimal with many omissions’ and makes three recommendations:  To audit and improve documentation, to ensure there is a proper record of social history, and to develop a risk assessment process to ensure high risk mothers are identified and appropriate action is taken. 31  3.6.4 The author of this report found midwifery records hard to grasp – with at least a parent held mother’s file, a parent held child’s file, and another file held at the office. There can be a lack of consistency between them, and as seen in this case the office file did not contain a record of a bruise when the hospital called, even though a midwife had seen one.  The fact that the internally written ASPH IMR originally made a number of factual errors from reading the notes suggests there is indeed an issue.  ASPH should review midwifery record keeping systems to ensure a tighter arrangement with key events known at the office and not just patient held records   3.6.5 The midwife was unaware of the A&E attendance which happened when Child X was 5 days old, and although the attendance is not deemed to have any safeguarding implications, it would seem sensible that midwives are informed when a baby, who is being visited by them at home regularly, attends A&E.  She was aware of the admission on day 10 as her team was contacted by the hospital.  Although a health visitor eventually heard about the A&E attendance of a baby in their care, it seems that midwives are not routinely told, even in the early days when only a midwife would be visiting at home.  ASPH should consider when and how their midwives are informed about the attendance at A&E of a baby under their care.  3.6.6 It is of concern that the phone call to the hospital maternity ward about a bruise on an 8 day old baby appears to have led to nothing more than being told to keep trying to contact the community midwife.  Leaving it solely to a relative to take appropriate action was not appropriate – even had it turned out to have had a benign cause.  Any call received which describes bruising to a baby, especially a non-mobile one, should have been recorded and passed on to a relevant colleague.  3.6.7 The Day 10 bruise seen by MW2 was the first occasion when the baby was seen to be marked by staff allocated to her.  There is no indication in records that the midwife was aware her service had been told about the bruise 2 days earlier.  The fact that the events of Day 10 were recorded in the maternity notes as happening on Day 5 when they must have been written on Day 10 is inexplicable, and this led the hospital to believe that was indeed when the seatbelt incident was noted.  The GP was also given the ‘Day 5’ date in Child X’s hospital discharge note.  The Day 34 Strategy Meeting Minutes also recorded the bruise as happening on the day 5, and even after the minutes were re-circulated for an accuracy check in May 2013 the revised minutes still said the car seat bruise was on day 5.  3.6.8 There is also the issue of recording injuries fully.  As no drawing was made by the midwife of the ‘small round’ bruise she saw on Day 10, such as on a body map, there was no record of its exact location or appearance, and it cannot therefore be compared with the drawing made at ASPH two days later, or what HV2 saw as ‘still visible’ on day 20 – a 5cm linear bruise.  Was it even the same bruise?  Whilst not suggesting that pursuing a very small bruise with 32 a clear explanation is necessarily easy, the standard of service in these episodes was not acceptable, and the ASPH IMR recommendations (see App3) on non-mobile bruising are supported by the SCR.  3.6.9 The significance of the procedure on bruising not being followed on Day 10 is that, according the Judgement in the care proceedings, the rib fractures had been caused the previous day and that the bruise was caused in that squeezing incident.  One cannot, of course, be sure of what would have happened, but at the very least had the procedure have been followed, the parents would have known the family was under scrutiny.  3.6.10 There must be a question about continuity of care.  On the 4 occasions the baby was seen at home, the visit was undertaken by a different midwife.  The midwife who visited on the Day 15 would have seen the hand held records saying the car seat bruise was on Day 5, and may or may not have known it was actually the Day 10.  (She might have done if she had spotted there was another quite different entry for day 10.)  It is recommended that ASPH review continuity of care in community midwifery, especially for potentially vulnerable families.  3.6.11 The handover to health visiting is also an issue.  The HV said this was informal rather than formal (although there was the benefit of it being face to face).  There was no written material, eg information about the bruise.  This would have been good, not least because HV3 recorded the handover as describing a right sided bruise.  The midwife told the health visitor she had discharged Child X.  There were 5 days between the last midwife visit and the first health visitor visit despite the bruise incident.  ASPH and VCSL should set out clear expectations on the nature of midwife to health visitor handover.  3.6.12 The ASPH IMR also suggests that the knowledge that mother had turned down special support, such as parenting education classes should have been highlighted to the community team to ensure ‘more support was available such as daily visits by the community midwifery team’.  3.6.13 The GP says that there is a very positive relationship with the midwife who is the formal link with the Practice.  However, given that a number of different midwives might see one baby, the GP view was that the relationship with midwifery beyond the formal link is poor, with GPs ‘kept at arm’s length’ and less information shared.   3.7 Guidance on Bruising   3.7.1 The handling of the abdominal bruise, and the later bruises, is a significant issue for the SCR.  The LSCB guidance says that “Children can have accidental bruising, but the following must be considered as non-accidental unless there is evidence or an adequate explanation provided….. Any bruising to a pre-crawling or pre-walking baby”.  The midwife who saw them 33 could be said therefore not to have been in breach of procedures in not treating it as NAI as she accepted the story.  There is no guidance in the SSCB Safeguarding Procedures Manual which requires a medical examination of bruising in a non-mobile baby.  However, there is a separate Feb 2012 policy (Bruising in Children who are Not Independently mobile–Multi agency Guidance- see appendix 5) that is on the SSCB web site – but in a not immediately obvious place – which says “Bruising in a child not independently mobile (any child who is not yet crawling, bottom shuffling, pulling to stand, cruising or walking independently: Includes all children under 6 months even if they are rolling, or children with significant disabilities resulting in immobility) should raise suspicion of maltreatment and should result in an immediate referral to Children’s Social Care”.  The ASPH IMR concluded that this guidance is not well known, and has a plan to circulate to all relevant professional staff.  3.7.2 This means that there is contradictory guidance: one saying there is discretion in judging something non accidental, and the other mandating a referral to Children’s Social Care for any bruise in a non-mobile baby.   3.7.3 The bruising guidance regarding babies who are not independently mobile also says “wherever possible discussion of the case with a senior colleague is expected”.  This did not happen with community nursing/midwifery re the abdominal bruise seen on Day 10 or the facial bruise on the Day 20 and only in a limited way by the hospital re the face and thigh bruises on Day 21.  Regardless of the guidance, the judgement to accept the parental explanation (a judgement repeated at consultant level later) is questionable.  The car seat was seen, but (and this is not a hindsight view, and would have been  the author’s view if no other incident happened) it is hard to believe how a car seat strap could cause a small round bruise, or the longer one – whichever it was – through thick clothes and against a soft tummy.  Indeed, if despite the clothes etc, the belt was so tight as to bruise a baby one would be questioning parental judgement anyway.  The level of suspicion should have been much higher.   3.7.4 Even if the story was believed, and no action taken immediately, or even if it had proved true, the whole point of the guidance to talk to someone else about it is so that there is a chance for another objective view to be involved.  This is crucial as it is hard for even experienced professionals to raise such a fundamental issue with parents as possible deliberate injury.  Abusing families can be very manipulative in trying to get concern played down.  Also, as no one else was told about the ‘seat belt’ bruise, Children’s Social Care would not have known had they been referred the family on another matter, and the GP and health visitor did not know until they heard from different routes on Days 19 and 20.  The Judgement concluded that the car seat story was not the explanation and quotes a parent as accepting this.  3.7.5 Recommendations about the bruising policy are at 3.12.3 below  34  3.8 Hospitalisation days 10-14  3.8.1 The importance of sharing information can be seen when Child X was taken to St Peter’s A&E later on the day the midwife saw the bruise.  The presenting issue was blood stained vomit.  The A&E card makes no reference to the bruise, so the child was either not fully examined, or if the bruise was seen it was regarded as of no consequence, or it was seen and not recorded.  Given that the baby was only 10 days old this is of concern.  She was admitted, and the next day the bruise was seen by a junior doctor.  A drawing was made which was good practice.  The midwife did return a call to say she was aware of the bruise.  The IMR suggests it took 3 days (days 11-14) until consultant 2 considered the bruise, and the consultant considered it to be friction (accepting the parental story as plausible). Child X was discharged.    3.8.2 It is possible that a paediatric doctor did in fact see the bruise in A&E but this was only recorded in paediatric notes.  This would not be appropriate as should there have been a future A&E attendance the A&E notes would not have indicated that any bruise was seen at that attendance.  3.8.3 Consultants and junior colleagues also failed to follow the bruising guidance, by not referring to Children’s Social Care.  ASPH’s planned action on ensuring all relevant staff are clear on the guidance is described above.  The GP being sent a discharge letter on the wrong baby did not help.  Positively, the junior doctor did the right thing in making inquiries of the midwife and health visitor.  The hospital re-did the letter and spoke to the GP on day 20 to find that the GP said he had seen the baby, well, with no evidence of any more bruises.  3.8.4 It is interesting that the corrected discharge letter describes the abdominal bruise as one of two ‘presenting’ complaints when the bruise was, according to what is recorded, not noticed until the second day in hospital.   3.8.5 In 3.12.2 below it is described how the paediatric departments apparently thought the non-mobile bruising policy did not apply to the Hospital.  3.8.6 The significance of not following the bruising policy can be seen by the Court conclusion that the rib fractures had been done before the baby’s admission, and that the abdomen bruise was caused in the same incident.  Had there been an X ray because the bruise was viewed with more suspicion (perhaps along with the blood stained vomit) injuries might have been seen.  3.9 Health Visiting services  3.9.1 Having made one attempt to visit ante-natally, as the case was ‘targeted’, the loss of this status in transit to another part of Surrey meant that no visit was made before birth.  The new birth visit at 20 days was within the 21 day target.  The required Family Needs Assessment was not started at this visit 35 made by a bank health visitor.  As above, had the health visitors realised earlier concerns, a regular member of staff would have handled the case.  There were no medical concerns but a bruise was seen on Child X’s cheek, in addition to the old abdomen bruise seen on the left, and two small areas of flaky skin by the umbilicus.   3.9.2 The day 20 facial bruise: Despite being aware of the guidance on bruising on non-mobile babies, the health visitor made the same error of judgement as midwifery and hospital in not making a referral.  This time there was not even an explanation, other than easy bruising, and a check with ASPH would have shown at least a preliminary normal clotting test.  There had been a suggestion that the skin infection diagnosed on day 10 when Child X was in hospital could cause easier bruising but it is unlikely the health visitor knew that when she took no action on the facial bruise.  The fact that the parents were asked to ask a hospital doctor about the bruise the next day, with no alert to ASPH, or follow up check, compounded the situation.  There must have been at least some concern (or why else say show the hospital tomorrow?).  No professional should ever assume, when there is some possibility of NAI, that parents will do what they are advised, or that other staff will jump into child protection mode unless they are alerted to concerns.  The health visitor thought that as she was not concerned about NAI she did not have to do anything else.  No drawing was made on a body map.  No supervisor was consulted.  Virgin Care should ensure that any possible NAI or bruising in non-mobile babies seen by health visitors is shared with a manager or the named nurse.  3.9.3 As this was the fifth consecutive profession (Midwifery, hospital nursing, hospital doctor, GP and health visiting) which did not follow guidance, it is beyond coincidence that this relates just to individual competence.  The likely explanation is a systemic one – that staff are just not clear about the guidance, or find it too hard to implement as written or, for example, referral of minor bruising in the past has been dismissed. (see recommendations  at 3.12.3)  3.9.4 It is also relevant that the mother was a child care worker herself, and told the health visitor that she was therefore aware of safeguarding issues.  The Virgin Care IMR makes reference to the lack of robust challenge being a feature of many SCRs, and the mother’s work, plus the suggestion of easy bruising and sensitive skin was allowed to deflect focus.  It is of note that had there been a check with ASPH they had a record of preliminary clotting tests being normal.  3.9.5 Despite the bruise being the second bruise the health visitor was aware of on a non-mobile baby, no further visit was planned until Day 41.  The Day 27 clinic attendance was a ‘drop in’.  There seems to have been an assumption that, as the baby was being followed up in hospital, it would be looked at there, but this was not checked.  It is not possible to conclude that if the health visitor had referred on the bruises on the non-mobile baby, the baby would have been protected.  This is because the hospital to which she would 36 have referred the baby did itself not refer the bruises when seeing the baby the following day.  However had Child X been referred in the context of possible abuse it is probable she would have been seen by a consultant, and maybe an X ray would have been done.  Social Care would have been told and their outside perspective may have highlighted potential risks.  3.9.6 When Child X was taken to the health visiting drop in clinic on Day 27 her weight had increased, but not by as much as hoped.  A right conjunctival haemorrhage was seen which the parents said had been there a week, and a left one for a few days.  Such haemorrhages can be indicative of head injury, but even with an abdomen bruise, facial bruise and thigh bruise (the health visitor may have known of the thigh from the paternal grandmother) there was still no concern that the cumulative picture was one of possible concern.  The health visitor also asked the parents to consult the GP about the eyes, but did not alert the GP and no appointment was made.  This is risky in safeguarding, but the Clinic did not see it in that context so never considered that risk.  It is also important, in analysing this episode, that the health visitor knew on day 21 from the paternal grandmother that there had been hospital questions about possible deliberate harm after the face and thigh bruising, but the retinal haemorrhages still did not trigger any alarm bells.  A further paternal grandmother call to the health visitor on Day 28 did not lead to any inquiry about what other agencies might be conveying to the family.  3.9.7 IMR writers were asked to report on capacity or climate issues which might affect performance.  The health visiting team concerned had a safeguarding caseload on a par with the rest of Surrey.  However team functioning was of concern with vacancies and long term sickness.  HV3 was one of only 2 qualified staff in the team at the end of October 2012.  The staffing of the wider locality within which the team as based had been on the risk register since 2011, and was 21% under establishment in the summer 2012.  The team have to submit breach forms when mandatory visits or missed or recording behind, and in October 2012 the return showed 4 targeted antenatal visits, 3 new birth visits, a one year developmental check, and 129 incidents of record keeping not to timescale.  These breaches were not reviewed that month.  The Virgin IMR reported that additional staff were redeployed to the team pending the arrival in January 2013 of a permanent 1wte health visitor.  3.9.8 It is clear the team was under pressure, and that can lead to hurried work or insufficient attention per case.  However, as other professionals also failed to follow LSCB procedure on bruising in non-mobile babies there is likely to be another cause.  It is possible that their work pressure made it easier for health visitors’ knowledge that the baby had been seen at length in hospital, and was being followed up, to allow them to think nothing could be wrong and not to intensify visits. 3.9.9 The IMR reported that work had started on updating the database which monitors the training and supervision of bank (ie non-permanent) staff, and that the database is to be monitored by team managers.  The health needs 37 assessment guidelines are being updated to reflect lessons from SCRs.  Also that 0-19 guidelines and record keeping standards are being updated, and work is in hand to improve communications between midwives and health visitors.  3.9.10 The GP reported the working relationship with health visitors (who are, unusually these days, co-located with the Practice) as excellent with good information sharing.  3.10 GP Involvement  3.10.1 The baby was only seen by the Practice on one occasion – when the mother requested a review of the baby’s antibiotics.  This was on day 20 and at that point the GP had no record of the A&E attendance on day 5, nor the A&E attendance on day 10, nor the hospital admission from days 10-14.  The GP therefore learned any history from the mother who told him about the abdominal bruise being seen during the day10-14 admission.  The GP appropriately undressed the baby to examine the mark and also handled the baby to see if there was any sign of discomfort which might therefore indicate a deeper injury.  The GP concluded that it seemed superficial, that the explanation was possible, and that the action was just to observe.  The GP was not aware of the policy that all bruises on non-mobile babies should be referred, and like the hospital, considered it normal practice to form a conclusion about a bruise before deciding if a referral was necessary.  The rib fractures had almost certainly happened before this examination, and possibly the leg fractures too.  3.10.2 The call from the hospital doctor later in the day to explain about the wrong discharge letter being sent did not change the GP’s plan.  The hospital doctor asking that NAI not be ruled out was not recorded by the GP, who accepted in hindsight that it should have been.  The GP told the hospital that no bruising, further to the abdominal bruise, and did not mention the facial mark as he did not see it as a bruise.  This raises as an interesting issue about terminology as the health visitor described it as a bruise later that day as did the hospital the next day.  3.10.3 It was appropriate that the health visitor who had seen the bruises earlier on day 20 discussed them with the GP – something made easier by co-location.  However, neither saw a need to refer on to children’s care.  They both knew the baby would be seen in the paediatric department of St Peter’s the next day, and this is likely to have reduced any concern they had.  Neither spoke to paediatrics to make sure the marks were considered (the appointment was a routine follow up to the recent 5 day admission).  3.10.4 The GP IMR expresses concerns about ‘a lack of reliability’ regarding information from St Peter’s to the GP Practice, and its author (the Named GP for Safeguarding) commits to exploring this through the Health Subgroup of the SSCB and identifying improvements. 38  3.10.5 The Practice did not have a ‘lead GP’ for safeguarding as was the policy of the PCT.  It was argued that there are too many special issues for which a ‘lead GP’ is demanded.  Whilst it is not obvious that the lack of a lead GP made a difference in this case, it might have been more likely that the February 2012 policy about how to respond to bruising in non-mobile babies had been known about or understood. The GP says that, in any case, having to trawl through numerous policies on web sites to locate the one needed in relation to a patient in front of the GP is an unrealistic expectation and he recommended there was a one page summary of key principles that GPs could have easily available.  3.10.6 The IMR author regards the GP suggestion as a useful one, and she has committed to working with the designated nurse to draft such headline guidance, for consideration by the local named professionals and SSCB Health Subgroup.   3.10.7 The GPs at the Practice had had no recent update training on safeguarding.  In fact the GP could not remember ever being offered training.  3.10.8 However subsequent to the GP IMR interview, the Surrey Named GP for safeguarding reports that this practice has identified a safeguarding lead, and that all Practices in the local CCG area now have safeguarding leads.  The Practice is now clear about local and national training requirements, and all Practices have been made aware of dates for level 3 training.  It is recommended that the SSCB receives on-going reports from the relevant NHS body on compliance with required training for GPs.  3.11 Hospital attendance on day 21  3.11.1 Child X was taken for review at the day ward at ASPH and was seen by a paediatric registrar.  The cheek bruise was seen, plus a thigh bruise.  The paternal grandmother, who is a health professional, said Child X bruised easily as she did, and was upset at the potential accusation.  The Registrar sensibly consulted a haematologist who said that the infection at the Day 10 admission can lead to easier bruising.  Despite the concern, and lack of definitive explanation, Child X was discharged home without specific consultant approval, partly because on call arrangements were either unclear or not followed.  It is good practice for a consultant to confirm the discharge when NAI has been considered.  By this day, at least three separate bruises had been identified in a non-mobile baby who had just reached 16 days old.  It is likely from estimates made on fractures that Child X had suffered the rib fractures before this appointment, so had an X ray been done that day there might have been sufficient evidence for intervention.  The ASPH IMR has recommended review of safeguarding arrangements on the day ward to ensure consultant leadership of safeguarding issues and this is supported by the SCR.  39 3.11.2 This was another illustration of the non-mobile bruising procedure not being followed as Children’s Social Care were not involved as required.  In this instance there were two causes.  Firstly, the ease by which the ‘easy bruising’ possibility became almost the conventional wisdom.  The combination of what mother said, what the professional paternal grandmother said, and what the registrar saw when taking blood became so strongly held as to stop any serious consideration of anything else – and certainly no consideration of referral to Children’s Social Care.  In a submission to the hospital IMR, the registrar said she was ‘convinced that the child did bruise easily’.  The full clotting studies later came back normal, and even if they had not, a child who bruises easily could also be the victim of abuse.  Throughout the treatment of Child X, there seems to have been no consideration that a child, if she did bruise easily, might also have been abused.  What had become the, actually unproven, conventional wisdom may also have been behind why the hospital did not mention any prior bruising when transferring Child X to St George’s.  3.11.3 Secondly, the policy might not be seen as practical by hospital doctors, and one senior doctor speaking to the SCR suggested that the hospital did not think the mandatory referral rule applied there.  This is because, for example, an A&E would see many bruises on non-mobile babies and to refer all might be deemed impractical.  Instead, judgement is used to form a view of the likelihood of something being NAI and then a decision is made about referral.  (As seen above, this is how midwives and health visitors operated too).  It is clearly a risk if the policy says something and professionals implement it differently, and in doing so undermine its purpose.  The SCR strongly recommends that the SSCB facilitates discussions with a wide range of professionals about the implementation of guidance on bruising to children who are not independently mobile to understand why it has been so poorly implemented, and to make any adjustments and training necessary.   3.11.4 Also that the SSCB should monitor the circulation and take up of any revised guidance on bruising, and undertake case audits with partners to ensure that guidance is followed and recording of injuries is as expected.   3.11.5 Thirdly that the SSCB should review its web site and how procedures are linked to ensure there is a much simpler way of staff identifying what guidance they must follow.  3.11.6 The Cambridgeshire Safeguarding Board has a very useful line in its 2012 policy on non-mobile babies.  It says “This protocol is necessarily directive.  While it recognises that professional judgment and responsibility have to be exercised at all times, it errs on the side of safety by requiring that all pre-mobile babies with bruising be referred to Children’s Social Care and for a senior paediatric opinion where there is no obvious medical cause.”  This could be added to the Surrey policy as it would remove any doubt about its mandatory nature. 40  3.11.7 This SCR has been made aware that another Surrey SCR on child ‘S’ has also made a recommendation about bruising to babies who are not independently mobile, after two different professionals did not report injuries and accepted parental explanation.  Even though the Feb 2012 policy in appendix 4 was not then in place, the other Review believed that the injuries should have been reported/actioned, and it makes a recommendation similar to the first one in 3.11.2 above.  The fact that this issue had been highlighted in two local SCRs only emphasizes the importance of these recommendations.  3.12 Communications with community health services  3.12.1 Paediatric liaison services are highly valued as a link between acute and community services, and as a potential to break down barriers to information sharing.  In this case communications did not work effectively given the delay in information reaching community staff.  The A&E report of Child X’s attendance when she was 5 days old was not collected by the paediatric liaison nurse until 10 days later, and was not sent on to health visitors for a further 7 days – by internal post as no safeguarding concerns.  It arrived 3 days after that.  The same process after the day 10 A&E attendance arrived on day 31, after Child X’s injuries.  Neither form made any reference to bruising (as noted above, A&E did not see the abdominal bruise on day 10).    3.12.2 The Virgin Care IMR recommends the production of a flow chart describing the flow of information from hospital to community staff dealing with children and young people.  This is supported and it is recommended that ASPH and community health care organisations review information flows and processes to ensure that community staff are informed as quickly as necessary about events happening to children under their care.  3.12.3 It is also concerning that when Child X was discharged from the 4 day admission at which the thigh bruise was seen the discharge letter to the GP was not sent for 6 days, even when GP cooperation in case of further bruising was sought, and the Day 10 A&E attendance notification was not sent for 16 days after that attendance.  3.13 Summary up to admission on day 30  3.13.1 Prior to admission at least 3 bruises had been seen on a non-mobile baby, plus haemorrhages in both eyes.  The parents were young and first time parents, with the mother having experienced some abuse herself.  None of the hospital or community staff, be they hospital doctors, GP, nurses or midwives had referred any of bruises to Children’s Social Care.  Parental explanation was accepted, and where there was no explanation, a propensity to “easy bruising” was assumed to be the cause – despite no recorded evidence of this.  As no one had any significant concern about the bruises there were no multiagency meetings where information could be pooled and 41 an overview could be formed.  There was no central pool where all the information could be found, and no one agency or individual was taking responsibility for the baby’s safety.  Some information that might not have been critical but which would have improved the overall picture took a very long time to be transferred.   3.13.2 There had been no full medical examination including X-rays as no one’s concern had reached that level.  Had there more scepticism about the, by then, several marks on the baby’s body and the eye haemorrhages, they might have been seen in the context of prior marks and a worrying pattern recognised.  It is likely that by the time the baby was last seen in the community on Day 27 the rib fractures would have occurred, the leg fractures may well have occurred, and only the foot fractures were yet to come.  When the child was last seen in hospital on Day 21 the rib fractures at least would have occurred.   3.13.3 As no one saw the bruises in the context of abuse; there was no referral to social care nor for a formal child protection examination.  This made it easier for parental explanations to be accepted and non-explanations seen insufficiently seriously.  3.14 The admission of the seriously unwell Child X on day 30 to ASPH  3.14.1 The analysis of this admission takes into account what was subsequently found at St George’s Hospital.  There are issues at ASPH about missed diagnosis, but it is unlikely that this made any significant difference to X medically as her life saving treatment would have been similar.  It did however mean the parents had full access to the baby as they were not under any suspicion.  3.14.2 Child X was taken to ASPH A&E by the parents after becoming very unwell, floppy, twitching, and with a high pitched cry.  Although the ASPH IMR author was told verbally that trauma/NAI was considered there is no recorded evidence that this was the case, and all tests seem to be to identify a medical cause such as infection or epilepsy.  Although blood was found in the spinal fluid (which can have several causes) no one at this stage on the first day had knowledge of prior bruising or retinal haemorrhages, as prior records were not located and no one who would have known was contacted (e.g. health visitor).  As on previous visits, the child protection part of the A&E record was not completed.  The prior abdominal bruise was available electronically on the ‘inpatient list’, but this was probably not looked at.  This SCR strongly supports the ASPH IMR intention to review the current process, improve it and ensure discharge letters are available.  Consultant 4, who spoke to the parents on admission day, was aware the baby had been admitted before.  3.14.3 A chest X-ray was ordered, not to look for trauma, but in relation to a heart murmur, and no skeletal survey was done as NAI was not suspected.  It was reported as normal.  St George’s identified 4 rib fractures from the same x-ray; although it should be pointed out their radiologists say they are not easy 42 to spot.  The ASPH IMR rightly proposes that the protocol on when to do skeletal surveys of non-mobile babies should be reviewed and clarified.  3.14.4 The next day, at a ward round, a junior doctor documented the history of prior bruising and alludes to query NAI.  ASPH reports that the on call consultant 7 giving advice on managing Child X’s seizures was unable to contact the attending consultant 5 that morning for a detailed handover.  Later, after consultant 5’s arrival, the consultant spoke to consultant 4 who suggested the spinal blood might relate to a brain bleed and suggested a CT scan to exclude a subdural haematoma.  The junior doctor also reported the eye haemorrhages to consultant 5.  He spoke to radiologists who suggested a CT scan but this recommendation was declined by consultant 5.  The ASPH IMR says that was because Child X’s seizures were epileptic in nature, there being some family history of epilepsy – although the chronology says the argument was about radiation risk.  An MRI was done instead and was reported as normal by two radiologists.  When the same MRI scan was examined at St George’s subdural haemorrhages were identified.  The ASPH IMR concludes that the advice to do a CT scan should have been considered as it was most likely this would have identified the intra- cranial bleeding and NAI.  3.14.5 In considering why ASPH radiologists failed to see the brain bleeding, the ASPH IMR points out that the radiologists see very few brain scans on children that age, adding that a second opinion of a neuro-radiologist was suggested but did not happen.  This illustrates a risk for babies at a general hospital like St Peter’s.  Although the delayed diagnosis is unlikely to have harmed this baby, on another occasion there might be other children at risk in the family where a delayed diagnosis might delay their protection.  Taken together with the missed rib fractures, ASPH should review arrangements for reporting on rare or unusual scans, and be satisfied that there is access to appropriate specialist/subspecialist advice.  In this digital age such access should be possible to arrange even at a distance.  The ASPH IMR proposes developing an on-site radiology and orthopaedic expertise in reading paediatric x rays and scans   3.14.6 No indication has been provided to this review that, whilst Child X was at St Peters on her last admission there, any outside professionals such as GP, former midwife, and health visitors were called to see if they could throw any light on what was still a medical mystery.  By the end of the second day the hospital was aware of previous bruising, had seen an eye haemorrhage, was aware of blood in spinal fluid, but still did not seek further information from clinical colleagues, a skeletal X-ray or check with Children’s Social Care.  On the third day in hospital, day 32, the named nurse and doctor were aware and the named doctor (consultant 6) asked consultant 5 if there were any safeguarding concerns.  He advised there were not.  3.14.7 The Health Overview notes that it is a junior doctor rather than consultants who raises the possibility of NAI.  It also points out that given the concerns being of a medical nature, there are references to discussions with the named nurse rather than doctor, or the designated doctor in the named doctor’s 43 absence.  The thought processes which limit the range of options being considered will be discussed in 4.  3.15 The transfer to St George’s  3.15.1 On Day 32 Child X’s condition was worsening with increased fitting, discussions commenced with St George’s Hospital in London about a transfer to a paediatric intensive care unit (PICU).  In the course of preliminary discussions, practical arrangements, and more formal handover, at no time was any reference made to previous bruising, or any prior querying of NAI.  The X-ray and MRI were described as normal.  The notes of a third NHS Trust which handled the baby’s transfer did not mention anything to do with NAI. The St George’s IMR says that there is no written record at St George’s of the discussions between the two hospitals which preceded the transfer.  A number of transfer documents were identified.  None mention safeguarding.  This meant that St George’s clinicians had no idea that earlier bruising had been identified, nor retinal haemorrhages (by the health visitors), nor that ASPH had actually considered NAI twice – at an earlier admission and a ward attendance.  It also meant, as at ASPH, that the parents had full access to the baby.  This was not a major risk as in PICU nurse monitoring is very intensiv).  The parents did not report any trauma or old injuries when the history was taken.  3.15.2 St George’s reports that the form which is used to record information from other healthcare settings has already been redesigned to include safeguarding information and the name/designation of the person recording the information.  The St George’s IMR has an action in place to ensure transfer discussions are summarised in the records as soon as possible after the child’s arrival.  3.15.3 The medical staff were put at a disadvantage by the ASPH MRI scan being said to be normal, which effectively ruled out brain trauma.  The IMR had verbal reports that trauma/NAI was being considered, but there is nothing in the records to confirm this was considered on the first day at St George’s.  The staff did want however to review the ASPH X-ray and MRI Scan, but were unable to do so because although sent from ASPH they had not been uploaded and the technical office which could have done this was closed.  The IMR points out that access to specialist opinion on children’s brain scans is often delayed to the following day when such a specialist is unavailable. St George’s should have a system in place to ensure important test results are always available, and that access to specialist advice can be reaches in urgent situations.  3.15.4 They were able to review them the next day, and the subdural haemorrhages were identified.  This triggered appropriate action such as further discussion with the parents, when on this occasion mother reported the ‘red eyes’ seen by the clinic on day 27.  The hospital also realised the significance of this not being volunteered before.  Eye examinations for retinal haemorrhages, 44 clotting studies, and a skeletal survey were appropriately ordered and NAI became a prime focus.  Later the rib fractures were seen.   3.15.5 Although the medical team was now rigorously exploring an NAI diagnosis, the St George’s IMR describes how no inquiries were made of any professionals outside the hospital, when this would be good practice when a baby is admitted to PICU with an uncertain diagnosis.  The IMR rightly has planned to ensure such early contact, by earlier completion of the nursing assessment tool, improving the system of access to contact details and PICU teams to emphasise to staff the importance of these discussions.  3.15.6 Although by early evening on the second day the brain bleeding had been identified, and some of the fractures had been found (and so NAI was most likely) the medical staff decided not to inform Children’s Social Care until the next day when the test results would have been more formally reported, and this could be better discussed with the parents.  The IMR debates at length, without coming to a conclusion, the benefits of early referral against the risks that diagnosis might be premature and relationship with the parents could have been compromised, also pointing out that Children’s Social Care would probably not have acted that evening.  The view of this SCR is that it would have been better to report it and an agreement reached about handling, rather than deny Children’s Service (or indeed the police) any input until the next day.  With subdural haematoma and fractures, the chance of it not being NAI was by then very slim.  Also Children’s Social Care may have had important information or views.  No one knew that they didn’t.   3.15.7 Having said that, the following morning, Day 34, all appropriate internal and external notifications were made and by the afternoon a multiagency Strategy Meeting had been convened and held, and a plan of action reached on the, by then, definitive diagnosis.  There are however issues with that meeting in that although the extensive notes are reported as being circulated (not all seem to have received them), errors in them were only identified when queried by this SCR and the notes were re-sent for an accuracy check in 2013.  There was a limited response to this which led to the SCR Chair writing again to attendees.  The attendance list did not show which agency any of the ten attendees came from, and in five instances not even what role they held.  This may be related to the electronic template used. Surrey Children’s Social Care should review the Strategy Meeting record so the proper designation and agency of each attendee is clear.  The SSCB must require agencies to read minutes carefully and submit corrections promptly.   45 3.16 Race, religion, language, culture  3.16.1 No issues on this in relation to the family have been identified.  3.17 Capacity and Climate  3.17.1 Each agency was asked to review whether there were organisational issues such as staffing, resources, infrastructure, and organisational climate which may have affected this case.  Other than the report on health visiting staffing and capacity, agencies reported there were no such issues.  3.18 Fathers  3.18.1 This section has been deliberately left to the end of the analysis as it will be clear by this point in the SCR overview that there is almost nothing in it about the father.  There is hardly any reference to him in IMRs, it is not even clear whether the couple were together throughout the period, nor any view of him as a parent.  Other SCRs have found a similar ‘shadowy’ understanding of fathers who have then shown themselves to be a risk to their child.  Fathers could also be a protective factor.  IMRs noted that neither the midwifery or health visiting assessments (which may have looked at the father) were completed or to time.  On the other hand, the vast majority of parents cope well with their babies and fathers are often not assessed, indeed they may hardly ever be seen, if at all, by community staff.  However, in this case where the parents were young, where at least one had experienced abuse themselves, and where injuries started to appear, the justification for looking at the father is more obvious.  The problem is that there was, rightly or wrongly, hardly any concern in a safeguarding context (and parental handling seen appeared satisfactory).  Also in this case the influential presence of his professional mother must have made it even more difficult to focus on him.   3.19 Involved Relative   3.19.1 In this case, the paternal grandmother was active in supporting the baby and parents, and clearly took her responsibilities as grandparent seriously. As noted above, she had a professional background and staff found her comments and questions, which often were on technical matters, difficult and intrusive, something which in hindsight she understands.  However, she would have thought it negligent had she not used her professional knowledge in providing support to the family, and in querying what might be happening in hospital.  This was not an easy dynamic for either grandmother or staff.  3.19.2 Whilst she did, when interviewed, think there was abuse, she told the Review that when staff asked questions about that being a possibility she would rather they had been more up front about it and done standard tests for injuries e.g. X-rays………‘if you are going to do safeguarding, do it properly’ was her opinion.  She said the family would have found it easier if the possibility of NAI had been tested to the hilt to conclude one way or another, 46 rather than leaving it open and vague by raising issues and no conclusion being formed – which they found difficult.  This has some resonance with this SCR’s conclusions about insufficient steps being taken when there were injuries.  3.19.3 There is no recommendation on this but staff might consider the possibility that acting more robustly might not always lead to a negative family reaction.  3.19.4 No relative, regardless of professional standing, other than the parents has any right to know anything about a child patient regardless of professional standing (unless parental permission is given).  3.20 Diagnosis of Fractures  3.20.1 Outside the time period of the SCR, learning has been identified in relation to the arrangements for diagnosing and dating fractures.  NAI had been identified by Day 34, but during the Review it was identified that a week after this further and more extensive X rays had taken place and further injuries found.  There was some uncertainty whether what everything which might have been a fracture was indeed so, and a repeat X ray two weeks later would have shown more evidence of the bone healing which indicates the fracture.  Exploration by the St George’s IMR author found that the discharge plan requiring the repeat X-ray was not followed up, and the appropriate appointments not made.  The IMR author also identified that there was insufficient reference in the clinical notes about this plan.  It was not for a month after the first skeletal survey that the error was identified, and it was done two days later – but at a much less helpful interval.  3.20.2 The IMR has identified that there was a lack of clarity of role in relation to ordering the follow up test between the consultant responsible for the safeguarding aspects of the case, and the consultant who handled the baby’s discharge.  St George’s have clarified to paediatricians that it is the consultant responsible for actually discharging the child who must ensure subsequent required appointments are identified and made.  3.21 Summary  3.21.1 There is no way of knowing if the serious injuries found on Child X would have been prevented by different assessments and decisions in this case.  It is probable that at least some might have been incurred before the clinic visit on Day 27 or even the hospital visit in Day 21.  Unless there had been enough evidence to remove the baby she would still have been in her parents’ care and the injuries might still have happened.  However, the above analysis/appraisal, shows that a sequence of events and decisions across several professions and agencies were handled in a less than optimal way, and that if handled differently there might have been either more intensive supervision, more multiagency discussion of risk, more awareness of risk, and possible protective action.  These opportunities are listed below, and it is 47 their cumulative impact, rather than any single action which shows that there was an opportunity to make more of an intervention:   There might have been a more robust assessment of the risks with this young mother if links with her Looked After sister had been made when the midwife referred  Attention to the family might have been greater had the targeted status of the family not been lost in transit between health visitor teams, and antenatal visit/s done, and the health visitors had seen the recent concern of their school nurse colleagues  The assessment of the family might have been robust had midwifery and health visiting done the required formal assessments   If any of the numerous professionals who saw bruises on days 10-14, 20, 21 and 27 had followed procedures and informed Children’s Social Care there might have been a fuller assessment  If the bruises seen by midwives and health visitors had been discussed with managers or safeguarding experts as would be expected, it may have led to more thorough assessment or multiagency discussion  If there had been more professional curiosity about the car seat story, or the absence of explanations for the later bruises, it may have led to referral and multiagency discussion  If when eye haemorrhages appeared on day 27, they had been added to the 3-4 previous bruises and the picture seen as of concern, there might have been an immediate NAI focussed medical examination  If “easy bruising” had remained just a possibility, rather than becoming so firmly ingrained as likely, there would have been a more open mind and referrals to Children’s Social Care may have been made  Had the pattern of marks raised enough concern for a skeletal X-ray it is possible at least some of the injuries would have been seen and later ones avoided  The points below could not have prevented the injuries   Had old records been available when Child X arrived at ASPH, it is probable that NAI would have been much more of a focus, as prior bruising was known, and especially when blood was seen in the spinal fluid.   Had the ASPH X ray and scan been seen by doctors of greater subspecialty expertise the trauma would have been diagnosed before the transfer to St George’s.  Had there been a more open mind at St Peter’s on the last admission about possible causes (the ‘clear’ X-ray and MRI scan, which later proved not to be clear, did focus attention away from NAI) and had contact been made with GP, health visitor or midwife for background information as the diagnosis was still unclear, then it would have been much more likely that NAI would have been a consideration, and the whole picture might finally have been put together. 48  At St George’s similarly – had professionals who knew the family been contacted there would have been information to balance the transfer information from ASPH that made no mention of possible NAI, or at least brought forward the eventual diagnosis.  3.22 There were many opportunities which might have led to a different outcome.  The other conclusion is that, while individual errors were made, the cumulative picture involves so many professionals who either did not follow recommended practice or were insufficiently curious, that one has to look at the systemic context to understand the case enough to make improvements.   49 4. WHY DID THIS SEQUENCE OF EVENTS OCCUR?  4.1. There is no single reason, and this section looks at some key issues that bring together thoughts on why.  They are grouped to show they are system wide issues, cannot be just left with individual agencies, and need Safeguarding Board oversight.  4.2. Administrative weaknesses  4.2.1. There are some events such as the loss of papers in transit, or delayed transfer of information from hospital to the community, or a wrong discharge letter being sent, which are just down to poor, or ill thought through, processes.  Absence of prior medical records when a child arrives in an emergency can be another example.  Agencies will have already given thought to these things, and will have added impetus to do so when they see how such practice made a contribution in this case to risks emerging too slowly.  Getting these things right is not just a managerial responsibility, but front line professionals who share in or experience these processes must also take responsibility for ensuring they are not just accepted as normal, but press for resolution.  The number of illustrations across agencies suggests that there could be a sharpening of the approach to ensuring administration works well, rather than an assumption that it will, or pessimism about change.  There needs to be a commitment that these things matter.  4.2.2. Record keeping in safeguarding work is crucial, and in this case one can see how poor recording affected the work of others and compounded problems.  Some IMRs are critical of the recording standards in files they saw.  One wrong date of a midwife visiting and seeing the first injury was subsequently recorded in other agency records as a fact, and the absence of drawings of injuries by midwives and health visitors means even now there is no clarity of the number of injuries, and if what one worker saw was the same as next worker what saw.  The SSCB should reiterate for all agencies that any suspicious marks must be recorded on a body map in order that there is a permanent record, and one which can help build a picture over time.  4.2.3. The SSCB, through the promulgation of findings from this SCR should emphasise the importance of administration processes and record keeping, and through case audits monitor their quality.  4.3. Interagency Referrals  4.3.1. There is a more fundamental issue about referrals to Children’s Social Care, which applies to any interagency referral.  Although it was not a major turning point in this case, the need for both parties to be clear about the purpose of the conversation is very important.  Children’s Social Care can find themselves in receipt of numerous pieces of information where it is not clear what is wanted from them, or which on receipt do not identify any obvious action.  Whilst there is an important place for Children’s Social Care to 50 provide advice on handling of cases that do not seem to meet their threshold, exchanges without a clear purpose can end up not being looked at as thoroughly as they might be, and referring agencies can step back because they think that something will be done.  Alternatively it can also make agencies reluctant to refer as if they do not get what they expect – even if they were not clear what was wanted.  The midwifery – Children’s Social Care ‘referral’ illustrates some of these risks.  4.3.2. Children’s Social Care concluded that there was enough information available to have justified an initial assessment, and why this did not happen was for a combination of the reasons which conspired to create an atmosphere where limited checks were deemed necessary.  A recommendation was made above which is aimed at the SSCB as this is a general theme which needs county wide oversight and monitoring.  4.4. Why bruising was not taken more seriously, and an assessment of real risk not made sooner  4.4.1. This is at the heart of this SCR.  Although individuals did not follow guidance on bruising in young babies, the individuals were many and from different employers and professions, so there is a general not individual cause (although of course individuals can vary in how good they are at their role).  The possible confusion about the bruising policy about babies who cannot move themselves has already been discussed and the SSCB will need to understand how that came to be and put it right.  Some people may not have been very aware of it, but some who were aware still did not follow it.  This points to 3 dynamics which the SSCB, and its member agencies must assess and address, through their collective work.  They are not new issues to SCRs, but their continued relevance in subsequent SCRs shows how powerful they are and how organisations should assume their presence when designing training, supervision and audit.  4.4.2. There are three related dynamics between professionals and clients, which professionals have as human beings.   A rule of optimism (described in Brandon et al, 20121, as a ‘common and previously identified theme’ in their biennial review of learning from SCRs).  Failure to revise judgements. (Fish, Munro and Bairstow, 20092, say that ‘One of the most common, problematic tendencies in human cognition … is our failure to review judgements and plans – once we have formed a                                                            1 DFE Research Report  DFE-RR226: Marian Brandon, Peter Sidebotham, Sue Bailey, Pippa Belderson, Carol Hawley, Catherine Ellis & Matthew Megson (2012) ‘New learning from serious case reviews: a two year report for 2009-2011’  2Fish, S., Munro, E. and Bairstow, S. (2008) ‘Learning together to safeguard children: developing a multi-agency systems approach for case reviews’, London: Social Care Institute for Excellence.  51 view on what is going on, we often fail to notice or to dismiss evidence that challenges that picture’).  Lack of challenge- of parents and fellow professionals (Brandon et al, 20123, describe numerous lessons from lack of challenge and critical thinking in SCRs).  4.4.3. The rule of optimism is where professionals wrongly assume positive outcomes for children.  It rationalises evidence that contradicts progress – so even where the facts show that risk is on-going or increasing, professionals tell themselves that the opposite is true.  It is more likely to exist when staff feel under pressure, or when staff find it hard to face up to potentially life changing decisions.  In this case, not just one mark of unproven origin was seen not to demonstrate risk, but at least 3 plus eye haemorrhages and not one professional thought it of enough concern to alert Children’s Social Care.  The “easy bruising” theory was just that, and there was a natural reaction to accept it and not see the parents as a threat.   4.4.4. The on-going evidence did indeed contradict progress, as by that time there were at least 3 bruises, and retinal haemorrhages, and although there are one or two records of the ‘let’s keep an eye on things’ type no one had any serious concern.  In hindsight, it all seems alarming, but because of the innate tendency to want to believe the best, without the strongest systems of training support and supervision, and multiagency review, the optimistic stance can continue.   4.4.5. A feature of this is what E. Munro (‘Improving reasoning in supervision’, Social Work Now, 40, 6) describes: “The single most pervasive bias in human reasoning is that people like to hold on to their beliefs”.  This leads to a failure to revise judgements whatever the evidence.  This was illustrated at St Peter’s when the “easy bruising” theory, once thought to be the explanation, was so strongly ingrained that bruising was not mentioned at all when the baby was transferred for more specialist care at St George’s.  Also, to look at it in a different way, once the assessment of the very ill Child X started at St Peter’s without knowledge of prior bruising, and working diagnosis of epilepsy or infection was pursued, NAI was never seriously considered, even when some knowledge of prior bruising emerged.  This in turn influenced the initial approach at St George’s, and as described earlier, the sort of outside checks which a hospital would make to help recognise risks were not made.  4.4.6. This is not an issue just for the hospitals in this case.  The author of this Report reviewed a very similar case where very considerably more injuries were not seen by the first general hospital nor immediately found by the specialist hospital, as a hypothesis of a medical illness was the overwhelming focus.                                                             3 op.cit 52 4.4.7. A feature of these dynamics is a lack of challenge – both professional to parent and professional to professional.  A dictionary definition of challenge includes ‘summons to engage in a contest’ and ‘demand an explanation’.  Often it can be the fear of coming over as engaging in a contest that stops professionals demanding explanations.  This can apply to work with families (like not challenging parents too much in case it lessens their motivation or impacts on relationships with staff).  Also, it can be hard for workers to challenge parents, when certain of their answers might lead to life changing decisions about the family such as the removal of a child, and the consequential pain for parents.  In this case parents were asked for explanations, but even vague ones were accepted as the number of incidents grew.  Also, in this case, the regular presence of the professional paternal grandmother made challenge even harder, as she gave strong views apparently from an informed perspective.  The SCR saw in IMRs how some staff felt intimidated by this, and this can weaken challenge.  4.4.8. Another way this applied was that even though clinical staff did ask questions, none made it possible for those trained in investigation to meet the parents as no referrals to agencies with statutory powers were made.   4.4.9. There was little challenge evident between professionals.  In part, this was because some staff, eg the midwives and health visitors seeing the bruises on day 10, day 20 and haemorrhages on day 27, did not tell anyone such as a supervisor or named professional who might have taken a challenging stance.  Although this was because they did not think there was abuse to report, the agencies concerned should review managerial arrangements to see if there is any inhibition to reporting concerns upwards or to advisers.   4.4.10. There may have been opportunities for health visiting to be more challenging of the car seat story they inherited, or for the GP and community staff to engage in more robust discussions about whether explanations were really believable.  There were opportunities for doctors to be more challenging of each other.  In the sense that challenge is seeking an explanation, it is about ensuring minds stay open.   4.4.11. The SSCB and its member agencies should consider the degree to which ‘challenge’ is encouraged as an important part of professional work, and valued as something in the interests of children.  4.4.12. The SSCB should ensure that the human tendency to optimism in the face of evidence and reluctance to change judgements are understood in training, and that member agencies examine their processes to be sure that there are appropriate management and supervisory structures in place to minimise the impact of such tendencies.  SCR after SCR shows that even though these issues are known they continue to apply and affect cases, so there should be no easy assumption that everything is all right. 53   4.5. Why there were no multiagency discussions  4.5.1. There is a simple answer.  No one ever triggered one.  No one referred any bruise to Children’s Social Care so no assessment was done which might pull together the views of a range of agencies.  No one thought that there had been abuse so no strategy meeting was held.  There was not even an informal get together to ask what was happening by the time there had been at least 3 bruises plus the eye haemorrhages in the baby’s first 4 weeks.  And neither St Peter’s nor St George’s called other agencies when dealing with life threatening, unexplained illness.  4.5.2. This was the consequence of staff and even teams being affected by the rule of optimism, not revising judgements and the lack of challenge – so much so that no one thought it worth invoking child protection processes before the final diagnosis.  This just emphasises the importance of agencies singly and collectively having arrangements in place where staff are supported to be more curious, challenging, and helped to ward off the underlying human tendency to hope for the best-despite growing evidence to the contrary.  54 5. CONCLUSION  5.1. This conclusion needs to be seen in the context that unless Child X had been removed from home the major injuries may still have occurred.  Even if the family had been placed under close supervision as marks appeared, they could still have happened.  After at least 3 bruises to a non-mobile baby were seen between days 10 and 21 it could be argued that an X–ray would have been justified and some of the fractures may well have been present.  This would almost certainly have triggered protective action.  5.2. The sequence of events described in this SCR, summarised at 3.21, suggests that, had so many things been done better and had there been stronger checks and balances in place to guard against undue optimism and fixed views, there were indeed opportunities to have made a difference.  The illustrations of slow or non-communication, absent or inaccurately/poorly completed records, failure to follow SSCB procedure, insufficient curiosity or challenge, and the fact that at no stage was there any multiagency consideration of what was developing, are all of concern and will provide considerable food for thought for the SSCB and member agencies.  5.3. Although there were examples of individual poor practice, it is too easy to say that individual performance was the root cause.  This SCR has shown clearly how many people in a number of agencies acted in a similar way.  Also, individual performance can often reflect the support arrangements in their organisation, the priorities of agencies, and the degree to which agencies and or the SSCB monitor the effectiveness of local arrangements.  For these reasons many of the recommendations are for those responsible for the effectiveness of the whole system, and not just for single agencies. 55 6. RECOMMENDATIONS    6.1. There are two sets of recommendations.  Firstly, those made by the agencies who have written individual management reviews.  These reflect the conclusions reached by involved agencies when they looked at their own performance for the SCR.  These recommendations are in Appendix 1. Each agency has an action plan, which will be monitored by the SSCB, containing their own actions, and any below stemming from this SCR.    6.2. Secondly, there are those additional recommendations which are made from the conclusions of this SCR.  They are supported by the SSCB’s SCR Panel.  The paragraph in which the recommendations appear is stated.   Surrey Safeguarding Children Board  1. The SSCB should ensure that there are effective processes in place to ensure that the purpose of referrals (and this does not just apply to referrals to social work) is clear (3.3.3)  2. The SSCB should facilitate discussions with a wide range of professionals about the implementation of guidance on bruising to children who are not independently mobile to understand why it has been so poorly implemented, and to make any adjustments and training necessary (3.11.3)  3. The SSCB should monitor the circulation and take up of any revised guidance on bruising, and undertake case audits with partners to ensure that guidance is followed and recording of injuries is as expected (3.11.3)  4. The SSCB should review its web site and how procedures are linked to ensure there is a much simpler way of staff identifying what guidance they must follow (3.11.3)  5. The SSCB should reiterate for all agencies that any suspicious marks must be recorded on a body map in order that there is a permanent record, and one which can help build a picture over time (4.2.2)  6. The SSCB should receive on-going reports from the relevant NHS body on compliance with required training for GPs (3.10.8)  7. The SSCB, through the promulgation of findings from this SCR should emphasise the importance of admin processes and record keeping, and through case audits monitor their quality (4.2.3)  8. The SSCB and its member agencies should consider the degree to which ‘challenge’ is encouraged as an important part of professional work, and valued as something in the interests of children (4.4.11)  56 9. The SSCB should ensure that the human tendency to optimism in the face of evidence and reluctance to change judgements are understood in training, and that member agencies examine their processes to be sure that there are appropriate management and supervisory structures in place to minimise the impact of such tendencies. (4.4.12)   Ashford St Peter’s Hospitals’ NHS FT  10. ASPH should clarify the circumstances in which a handover should be given to the area where a targeted midwifery client has moved, and checks made that a vulnerable client has indeed locked into services after moving. (3.3.2)  11. ASPH should review midwifery record keeping systems to ensure a tighter arrangement with key events known at the office and not just patient held records (3.6.4)  12. ASPH should consider when and how their midwives are informed about the attendance at A&E of a baby under their care (3.6.5)  13. ASPH should review continuity of care in community midwifery, especially for potentially vulnerable families (3.6.10)  14. ASPH should review arrangements for reporting on rare or unusual scans, and be satisfied that there is sufficiently quick access to appropriate specialist/subspecialist advice (3.14.5)   Ashford St Peter’s NHS FT and Virgin Care Services Ltd  15. ASPH and Virgin Care should set out clear expectations on the nature of midwife to health visitor handover (3.6.11  16. ASPH (midwifery) services and Virgin Care (health visiting) should review managerial arrangements to see if there is any inhibition to reporting concerns upwards or to advisers. (4.4.9)   Ashford St Peter’s Hospitals NHS FT and Community Health providers  17. ASPH and community health care organisations review information flows and processes to ensure that community staff are informed as quickly as necessary about events happening to children under their care (3.12.2)   57 Virgin Care Services Ltd   18. Virgin Care should ensure that any possible NAI, or bruising in non-mobile babies, seen by health visitors is shared with a manager or the named nurse (3.9.2)   St George’s Hospital NHS Trust  19. St George’s should have a system in place to ensure important test results are always available, and that access to specialist advice can be reached in urgent situations (3.15.3)  Surrey County Council Children’s Services  20. Surrey Children’s Social Care should review the Strategy Meeting record so the proper designation and agency of each attendee is clear.  The SSCB must require agencies to read the minutes carefully and submit corrections promptly (3.15.7)                                 AB Sep 2013                                        58 Appendix 1 Recommendations from Individual Management Reviews  The following are the recommendations as they appear in the IMRs submitted to the SCR.  The Surrey Safeguarding Children Board will monitor the progress of the associated action plans   Ashford and St Peter’s NHS FT  Recommendations  1. Staff receive an appropriate level of safeguarding training that will assist them in analysis of information when making decisions about bruising in non-mobile children, and to support good recording practice and working with family members, having difficult conversations  2. Staff to have access to all relevant information in a timely way to support decision-making, including policy guidance and information to support the above in a timely fashion e.g. NICE guidance on bruising and immobile babies, hospital pathways and Working Together and local multi-agency guidance.   3. Staff to have access to patient documentation to support decision-making.  Staff are trained to ensure this documentation is fit for purpose, for sharing and accessible at time required.   4. A review of the safeguarding structure and capacity within the Trust, to ensure safeguarding leads are available to all staff.   5. Safeguarding supervision to be available to all staff in accordance with hospital policy and safeguarding supervision to challenge the current culture of the organisation regarding responsibilities to safeguarding.  6. A directory of guidance on the management of specific medical conditions where there is no access to expertise within the department, available to all levels of staff.    GP IMR (this IMR identified issues mainly for GPs in general rather than the Practice concerned).  It recommended that:   1. The Named GP raises with the health sub-group of the SSCB, the issue of robust communication and information sharing between the hospital and GP practices (and vice versa where necessary).  2. An update regarding the GP-specific level 3 training programme, with the 2013-14 dates, is circulated immediately. 3. Guidance is drafted in conjunction with the designated nurse for Surrey for consideration by the named professionals group and SSCB Health sub group59 Health Overview Report (on behalf of Guildford and Waverley CCG)  Recommendations for Action:  Each Health Provider has made their own recommendations which are endorsed.  In addition the following recommendations are made:  1. G&W CCG as lead commissioner for safeguarding needs to ensure that lessons from this review and provider action plans developed in response to this review are monitored by the appropriate CCG to ensure that lessons are being embedded into practice  2. G&W CCG as lead commissioner for safeguarding needs to assure themselves that the named doctor capacity is sufficient and that there are robust cover arrangements to ensure safeguarding advice at times when the presentation is of a medical arrangement  3. G&W CCG as lead commissioner for safeguarding needs to review education provision across the health economy including GP Practices to ensure the protocol for bruising in pre-mobile babies is embedded in practice.   St George’s Healthcare NHS Trust  Learning for St George’s Healthcare NHS Trust  1. Information shared between St George’s professionals and other healthcare providers prior to transfer should be recorded and this then should be available in the child’s records.   2. Early contact to be made with community professionals such as health visitors, school nurses, GP’s or midwives for all children who are admitted to PICU to inform of the admission and to also seek information.  3. Paediatric Consultants and teams to be reminded that the Consultant and team actually discharging the child on the day are responsible for arranging follow up of the child’s health needs as well as the safeguarding aspects of the child’s care.   Surrey Police  No recommendations  Surrey County Council Children’s Services  Recommendations for Action  1. Point 6.10.2 to be brought to the attention of the Contact Centre to consider how they appropriately check and share relevant information with SCS area teams where there is active involvement by the area teams with other close family members. 60  2. To further the work with agencies referring to Children’s Services with regard to their establishing greater clarity of their purpose for referring i.e. whether it is for information sharing, consultation or action and that all identified risks and concerns are clearly stated and recorded.  Virgin Care Services Ltd  1. Review the effectiveness of the joint SMART action plan which was created with St Peter’s Hospital as part of this review.  2. Upgrade the database which monitors training and supervision for the Bank 0-19 practitioner’s, and implement monitoring by the team line manager and service manager for action breaches.    3. Investigate the options to improve the flow of timely information from the acute hospitals into the Virgin Care community.    4. Update the 0-19 team’s guidelines to clearly define “targeted ante-natal criteria”, and specify the documentation to be written on RIO (electronic health records).    5. Update all relevant 0-19 team’s guidelines and record keeping standards to mandate that the practitioners obtain a history of the client, including filtering from first contact on RIO, and retrieving any old child/family health records if there is a concern highlighted by outside agencies or seen on RIO.    6. Recommend that the communication procedures between the midwives and the 0-19 team are updated to ensure that a robust system is put in place.  7. Recommend that the Paediatric Liaison criteria and standards be reviewed and updated.  8. Health needs assessment guidelines and tools be updated to reflect lessons learnt from SCR’s, and be communicated to 0-19 practitioners’ so they are aware of the guidelines and timelines for completion.    9. Implement a more robust system to confirm transfer of records internally, and include the use of nhs.net team accounts to alert teams of transfers within the organisation.    10. Provide additional training for Health Visitors to improve skills when assessing parenting and include specific training for the 0-19 team on the RIO system.   61 Appendix 2: Appraisal of Individual Management Reviews  1. Ashford and St Peter’s NHS FT  This IMR required considerable re analysis and revision.  A number of key facts proved to be incorrect, or presented in a misleading way, around midwifery.  It is hard to tell the degree that this was due to insufficient rigour in the original IMR, or was due to poor and confusing recording by front line staff which would make it hard for any reviewer.  There were also some additional facts around the hospital service that the SCR later identified.  When the SCR raised many queries about the SCR the Trust cooperated well in clarifying the detail.  The analysis, although a little hampered by the confusion over some facts, was generally sound.  The detailed action plan, developed after they had conducted a serious untoward incident review is quite comprehensive.  2. General Practice  This was relatively short as the family were new to the Practice and only saw the baby once.  It was clearly written, contained all the key facts, and identified the issues – with actions which were progressed immediately.  3. St George’s Healthcare NHS FT  This was a well written IMR, with good detail and analysis.   4. Surrey Police  This was a very brief IMR as most police knowledge came after the event.  Prior knowledge of the relevant family members was appropriately identified.  5. Surrey County Council Children’s Services  The difficulty in being clear who could have known what was reflected in the redrafts of the IMR.  However, going through this process clarified for CSC the learning points about access to historical information which are well set out.  6. Virgin Care Services Ltd A well written IMR with the facts set out, a robust analysis and a good, well referenced learning section.  7. South East Coast Ambulance Service NHS FT  Not an IMR but the information was not received until the review was near complete.  A December 2012 request from the SSCB to the Service led to a response that the case could not be identified.  In May 2013 the records were easily found.  It seems the Service can only track through an accurate not partial address, and not for example a patient name.  However a correct address is believed to have been given so the original ‘no discovery’ seems inexplicable.  It would appear that better search facilities would be useful. 62 Appendix 3: Key dates  DAY  0 Baby born 1 Abortive midwife visits 2 Midwife home visit 5 A&E attendance for constipation, blood in stool Midwife home visit 8 Parents see abdominal bruise and paternal  grandmother reports this to midwifery 10 Midwife home visit.  Abdominal bruise seen by midwife A&E attendance for blood in vomit, and admitted with infection.  A&E records do not refer to bruise, but it is seen on ward the next day 14 Baby discharged home 15 Midwife visits home and discharges mother and baby 20 GP sees abdominal bruise, and mark on face Health visitor makes first home visit and sees both 21 Baby taken to paediatric ward for follow up appointment.  Facial and thigh bruising seen 22 Mother speaks to out of hours GP service as baby very distressed 27 Baby taken to drop in health visitor clinic.  Eye haemorrhages seen 30 Baby admitted to local hospital via ambulance in small hours 32 Transferred to tertiary hospital with no diagnosis of injury or mention of prior bruising 33 Local hospital tests are reviewed at the tertiary hospital and fractures and traumatic brain haemorrhages found  63 Appendix 4: Bruising in Children who are Not Independently Mobile: Multi Agency Guidance  1. Introduction  This Guidance provides all professionals with a knowledge base and awareness for the management of children who are Not Independently Mobile (NIM) who present with bruising or otherwise suspicious marks.  Children with disabilities who are not mobile should also be considered within this guidance.  2. Definition   Bruising is the commonest presenting feature of physical abuse in children.  The younger the child, the greater the risk that bruising is non-accidental.  Any bruising or mark that might be bruising, in a child of any age, should be taken as a matter for inquiry and concern.  Bruising in a child not independently mobile (any child who is not yet crawling, bottom shuffling, pulling to stand, cruising or walking independently: Includes  all children under 6 months even if they are rolling, or children with significant disabilities resulting in immobility) should raise suspicion of maltreatment and should result in an immediate referral to Children's Services.  It is the responsibility of the examining paediatrician to decide whether bruising is consistent with an innocent cause or not, even if a plausible explanation is given by the carer.  3. Immediate response  Any child who is found to be seriously ill or injured, or in need of urgent treatment, should be referred immediately to hospital before referral to Children’s Services. All other cases should be first referred to social care.  4. Making a referral  Where a decision to refer to social care is made, it is the responsibility of the first professional to learn of, or observe the bruising, to ensure that a referral is made to social care.  Wherever possible, discussion of the case with a senior colleague is recommended.  Children should not be medically examined by any professional other than a medical practitioner.  Referrals should be made via Contact Centre for Children’s Services and/or via the main Police Switch board for Police (Telephone referral).  All telephone referrals to social care via Contact Centre should be followed up within 48 hours, with a written referral using the appropriate interagency referral form.  Social care and Police will follow SSCB 64 procedures in making a referral to locality Paediatric Teams for medical examination (Managing individual cases).  5. Medical Examination: (Only to be undertaken by a suitably trained Paediatrician)   A bruise must never be interpreted in isolation and must always be assessed in the context of medical and social care history, developmental stage and explanation given. The examining medical practitioner should obtain relevant information from all available sources e.g.: health visitor, GP, hospital records, social services nursery etc. which helps in informed decision making.   A full clinical examination of the whole body of the child or young person should be undertaken. Haematological and biochemical studies including a clotting screen should be done to exclude possible medical causes resulting in bruising.   Any child under 2 years presenting with unexplained bruising should have full skeletal survey, including a CT Brain scan (see guidelines for requesting, repeating and reporting on skeletal surveys).  Retinal examination by an experienced ophthalmologist is essential to exclude eye injury including retinal haemorrhages.  6. Recording  The importance of signed, timed, dated, accurate, comprehensive and contemporaneous records cannot be overemphasised.  The completed medical examination record form should be circulated within the ‘Gold’ standard time scales to GP, HV, and other involved professionals (refer to Multi agency guidelines to follow when a child is referred for medical examination).  7. Contact details  Contact Centre (0800 -1800)   0300 200 100 6 EDT (out of hours 1700 – 0900)   01483 517898 Police: 101  For medical advice  Weekdays 09:00 to 17:00 – Community Paediatric Team Surrey Community Health (Except Epsom area covered by Epsom General Hospital)  Surrey Community Health North West     01483 728201 South West     01483 783211 East      01737 768511  After working hours, weekends and Bank holidays – On call paediatrician at nearest hospital  65 ASPH       01932 872000  East Surrey Hospital    01737 768511 Royal Surrey County Hospital  01483 571122  Epsom & St Heliers Hospital  01372 735735 Frimley Park Hospital   01276 604604  February 2012 66 Appendix 5: Terms of Reference  Scope and Terms of reference for the Serious Case Review (SCR) in relation to child X aged 5 weeks when injuries identified  Date Independent Chair agreed to hold SCR December 2012  1. Terms of reference of the SCR  Terms of reference relating to the overall purpose of the SCR  1.1 to establish what lessons are to be learned from the case about the way in which professionals and organisations work individually and together to safeguard and promote the welfare of children  1.2. to identify clearly what those lessons are both within and between agencies, how and within what timescales they will be acted on, and what is expected to change as a result; and improve intra-agency and inter-agency working and better safeguard and promote the welfare of children.  Specific issues that should be considered arising from the review of information available to the SCR Panel  1. The level and extent of agency engagement and intervention and whether this was appropriate to the assessment of the parents’ ability to provide adequate care and supervision of Child X 2. The recognition of safeguarding issues by all agencies and how these were addressed.  Was sufficient consideration given to the fact that this was a pre mobile baby?  How were concern and or issues communicated between professionals within each agency or team and between agencies?  Were concerns discussed with supervisors and safeguarding advisors  3. The quality of assessments on which decisions and actions were taken 4. The existence of any mental health issues or issues of substance which may have impacted on parenting capacity. 5. Whether there are any factors in the history of any adults that indicated that they may pose a risk to children.  What was known to agencies about either parents prior to the birth of Child X and whether there were any indications there could be an impact on their parenting ability? 6. Whether race, religion, language, or culture was a factor in this case and had been considered fully 7. The extent and quality of partnership working between and among key agencies. 8. The effectiveness of working arrangements (including information sharing and communication) between all professionals  9. The existence of any factors relating to the “capacity and climate” within agencies which may have impacted on practice in this case. 10.  The degree to which the admitting hospital considered the possibility that the child’s injuries were caused deliberately and in particular how the injuries later diagnosed at a Specialist hospital were not seen in the X-rays and scans which were undertaken at the admitting hospital.  67 11. In addition to the above the review should consider learning both for the individual agency and for how agencies work together through the LSCB   Authors of individual management reviews, SCR panel members and the author of the overview report should also bring to the attention of the SCR panel chair any other matters falling within the scope of the review if they think that there are lessons to be learnt either for an individual agency or for the LSCB.  Authors of individual management reviews who identify other significant issues not falling within the scope of the review should bring them to the attention of a senior manager within the agency.  These are provisional terms of reference, which may be amended if new information comes to light.   2. Time period for review  1. The principal focus of the serious case review will be from the booking of the pregnancy to the Strategy meeting after NAI was identified.  2. The review will invite all agencies to provide family history outside the specific scope and timescale which may have had an impact on parenting capacity or family functioning  3. Parental and family involvement in the review  The SCR panel will seek to involve the parents (and other family members where this is identified as relevant) in the review in order to obtain their perspective on the services offered.  The mother and father of Child X will be notified about the decision to hold the review in an appropriate way and at an early point, via legal representatives if appropriate.  The SCR panel will seek to involve the parents and other family members as fully as possible.  In view of the current criminal investigation all contacts with family members will take place within a framework to be agreed by the SCR panel based on legal advice and advice from Surrey Police.  4. SCR panel membership  The SCR panel will be chaired by Fergus Smith The following agencies will be asked to provide a senior manager with expertise in relevant aspects of children’s safeguarding to sit as a member of the SCR panel: Surrey Police Surrey Children’s Services Surrey NHS - Designated Nurse Adult Social Care  5. Agencies currently believed to be involved within Surrey  The following agencies are known to have been involved at this point and will be asked to contribute Internal Management Reviews  Surrey Children’s Service 68  Virgin Care Services Ltd  GP/ Guildford and Waveney CCG  Ashford and St Peter’s Hospitals NHS FT  Surrey Police  Agencies currently believed to be involved outside Surrey  St George’s Hospital NHS Trust   If other agencies are identified they will be asked to contribute as appropriate.  6. Managing public, family and media interest  Family interest in the review will be considered by the SCR and the panel chair in keeping with the approach set out in section on parental involvement above.  Media and other public interest in the review will be managed in line with the SSCB press / media strategy.   The children and other family members will not be identified by the SSCB and all agencies will take whatever steps are appropriate to reduce the likelihood of identification in criminal proceedings if these occur. ------------------------------ 69 Appendix 6: ACRONYMS  ASPH Ashford and St Peter’s NHS Foundation Trust CEO Chief Executive Officer GP General Practitioner HV Health Visitor IMR Individual Management Review LSCB Local Safeguarding Children Board MW Midwife NAI Non Accidental Injury PICU Paediatric Intensive Care Unit SCR Serious Case Review SSCB Surrey Safeguarding Children Board TOR Terms of Reference WT 2010 Working Together to Safeguard Children 2010 WT 2013 Working Together to Safeguard Children 2013  