Non-accidental injuries to an 8-week-old infant. Child L collapsed at home; medical investigation found a severe brain bleed and extensive retinal bleeding. Learning includes: bruising in a pre-mobile baby must always be considered of concern and be investigated further; professional judgement needs to be supported with specific guidance; information for parents is an important part of supporting professionals to deliver clear information regarding processes when bruising in pre-mobile babies is found; commissioners' contractual requirements of a service can be a barrier to professional judgement and exploration of history to inform assessment; fathers play an important role in family life, and should be included in universal services offer as the norm; an environment for safe disclosure, alongside an embedded culture of professional curiosity provides robust evidence that the issue of domestic abuse has been thoroughly assessed; learning can be gained from cases that have had good outcomes as well as those that become serious case reviews. Makes a number of recommendations including: ensure that during a child and family assessment, social workers asks direct question about experiences of domestic abuse, where the case has not been referred due to domestic abuse; seek assurance from health visiting providers and commissioners that the impact of data collection that inform key performance indicators (KPIs) does not impact on the ability and capacity for health visitors to exercise professional judgement; ensure that fathers' needs are considered and met in services.
      
    Serious Case Review No: 2022/C9493  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.     1             Serious Case Review    A Review of Learning Related to Safeguarding Pre-Mobile Children Who Present with Bruising       Author: Karen Rees   Presented to a Safeguarding Children Board 14 August 2019        2 CONTENTS  1  INTRODUCTION 3 2 PROCESS AND SCOPE  3 3  THE REVIEWER 3 4 CHILD L AND FAMILY 4 5 BRUISING IN PRE-MOBILE BABIES 7 6 CHALLENGES AND LEARNING  8 7 CONCLUSION 20 8 RECOMMENDATIONS 21  APPENDICES Appendix One: Terms of Reference Appendix Two: Answers to Generic Questions; Learning from SCRs  23 26                  3 1. INTRODUCTION  1.1. A Safeguarding Children Board were alerted to a serious incident related to Child L, an eight-week-old baby who collapsed at home. Following medical investigation, Child L was found to have a severe brain bleed and extensive retinal bleeding believed to be the result of a non-accidental injury. Child L made a full recovery and there are no apparent remaining symptoms from the injury.  1.2. The Community Health NHS Foundation Trust has undertaken an extensive Serious Incident Investigation using Root Cause Analysis, as practitioners within the Trust had contact with Child L, noted the visible markings but did not recognise the need to undertake safeguarding referrals. This report takes into consideration the learning from that review but will not reinvestigate those findings.  1.3. The Safeguarding Board discussed the case and following consultation with the Chair of the Board and Child Safeguarding Practice Review Panel, it was agreed that there was potential for serious harm and that the case met the criteria for a Serious Case Review (SCR). Due to the investigations that had already taken place, it was identified that it would be appropriate to undertake a proportionate review.  1.4. The Safeguarding Board undertook this review in order to identify further learning and blocks and barriers to implementation of best practice when considering bruising to pre mobile children.   2. THE REVIEWER  2.1. The Safeguarding Board commissioned an independent reviewer as chair and author of the review. Karen Rees is an Independent Safeguarding Consultant with a paediatric nursing background. Karen worked in Safeguarding roles in the NHS for a number of years. Karen is completely independent of the Safeguarding Board and its partner agencies.   3. PROCESS AND SCOPE  3.1. The Safeguarding Board formed a panel to oversee the SCR process. The panel set the Terms of Reference and identified that an alternative methodology to that more usual for a SCR would best fit the circumstances. It was identified that the main practitioners involved in the case were not available to be involved in the review. It was therefore not possible to discuss with those practitioners why decisions had been made in the way that they had. The panel agreed to a methodology that would provide a window on the system, using Child L as a case study, that identifies any learning or gaps in the systems that support professionals to assess risk and safeguard pre mobile babies who present with bruising.   3.2. The author reviewed summary reports presented from involved organisations and identified themes for learning. These themes were presented along with a series of questions at a multi-agency workshop. The workshop was moved from the original timeframe in order to engage enough practitioners to enable full and collaborative learning. Full Terms of Reference are included in Appendix One.  3.3. The workshop was attended by relevant professionals who may be in the situation to recognise risk of bruising in a pre-mobile baby.  The attendees at the workshop were asked to work in multi-agency groups to debate the issues and challenges that the various areas of practice presented to frontline practitioners.  3.4. The direct work from the multi-agency workshop informed the responses in each section that led to learning and recommendations. The report is therefore written in a style that reflects this different approach to   4 gathering learning in the form often akin to a thematic review. The review therefore retained the use of a collaborative approach.  3.5. In order to include checks and balances, the panel then reviewed the learning to ensure that it met with the understanding of processes and expected practice in organisations and that more senior managers were appraised of the issues, barriers and challenges that the workshop had identified. The panel then supported the formulation of recommendations to improve practice.  4. CHILD L AND FAMILY   4.1. The genogram below provides the context of Child L’s family. In order that genders of the children are anonymised, they are represented by non-gender specific symbols.  Ages are denoted as at the time of the incident.     4.2. It is not known when Mother separated from her previous partner, but it is known that Mother and Father had been in a relationship for about two years at the time of the incident. Sibling one and two had contact with their Father. Fifteen months prior to the injury to Child L, following a visit, the Father of Sibling 1 and 2 contacted Children’s social care expressing concerns about the care of his children as Sibling 1 had been noted to have a sore to the leg. A child and family assessment was carried out and no concerns were identified.  4.3. When children’s social care contacted the health visiting team as part of their agency check, the health visiting team indicated that the family were not known to them. The family were new to the area having moved from another county.  4.4. The health visiting team visited the family, undertaking a ‘movement in contact’. The family were deemed as having needs at Universal Services as per the Health Child Programme (HCP)1. The health visiting team requested the records from the previous health visitor, but these were never received. This assessment did not take account of the recent social care investigation or missing history. There was no further communication  1 The HCP offers every family a programme of screening tests, immunisations, developmental reviews, and information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.27 Oct 2009 Healthy Child Programme - Gov.uk    5 between children’s social care or the health visiting team regarding the outcomes of assessments and visits that related to the referral that had been received.   4.5. Both siblings were in receipt of speech and language therapy input during the timescale of this review.  Sibling 2 was investigated for headaches. There were two minor injury unit attendances, one for each sibling. Both of these were assessed in MIU in accordance with safeguarding procedures and no concerns were identified for either attendance. The siblings did not come to the attention of any other services.  4.6. When Mother became pregnant with Child L, she received routine antenatal care from the midwifery service and attended all appointments with midwives and for associated screening appointments. Labour and delivery were normal, midwifery services discharged Mother and baby on day fifteen as is usual for uncomplicated post-natal care. Midwifery services were aware of the social care assessment but did not identify any concerns at the time of their involvement.  4.7. The heath visitor was notified of the birth of Child L four days after birth and competed the new birth visit in line with timescales set out in the HCP.  The health visitor saw Child L, Mother and Sibling 2 at this visit. There were no concerns noted by Mother or the health visitor and Universal Health visiting services were offered, the six-week check was booked, and Mother was reminded to register the birth of Child L and to register with the GP. Father was not present at this visit and there is little documentation related to him as Father of the new baby or as a step parent to the other two children. Universal screening for domestic abuse was not undertaken as the sibling was present.  4.8. Three weeks later Mother contacted the health visiting duty line regarding concerns that Child L was constipated. On discussion it was assessed that Child L was not constipated and appropriate advice was given including what to do if Mother was still concerned.   4.9. Ten days later, the health visitor saw Child L and Mother for the planned six-week home visit. No one else in family was recorded to be present during visit. Mother reiterated the symptoms of constipation and again, on assessment Child L was not found to be constipated and further advice was given. Child L had gained weight and was seen to be clean, appropriately dressed, and interacting positively with Mother. Child L was reported by Mother to be smiling. Mother had registered Child L with the GP and booked a post-natal check.   4.10. There is no clear recording that the Domestic Abuse question was asked and no documentation regarding other members of the family. It is not clear who was present at the visit.   4.11. Four weeks later, Mother contacted the health visiting duty line to report that she had noticed a purple mark originating on the side of Child L’s neck now radiating down the arm and side. The health visitor on response to questioning of Mother, recorded that the baby had not fallen or been dropped. Mother also reported that although the baby had not been lethargic, Child L was noted to have been irritable the previous night. The health visitor advised Mother to make an appointment with the GP that day and to call back if that was not possible. The health visitor told Mother that she would inform her allocated health visitor and ask her to make contact.   4.12. Mother contacted the GP and made an appointment as requested.   4.13. Mother took Child L to the GP complaining of a rash. The Mother had noticed marks on the chest the previous week and on the arm that day. The GP ascertained that Child L’s delivery was normal and following the birth, was gaining weight and all examination checks were detailed and reported that baby was developing well. The   6 GP considered that the marks appeared to be bruising. It was agreed to follow up on the rash/bruise a week following the examination to be reviewed and possibly referred to paediatrics.   4.14. Mother took Child L to baby clinic the next day. The summary from the HV service states that Mother told the health visitor that the GP had said that marks were consistent with bruising. It was noted in the red book that Child L had been seen in clinic two weeks earlier and that a bruise had been noted on the sacral2 area. The health visitor noted a new bruise to the cheek of Child L. The health visitor liaised with the GP for an update.  4.15. It is of note that Mother had therefore presented Child L on three occasions to different professionals with concerns about marks to the body that could have been bruising. This possibly indicated that she was concerned.  4.16. Other than what was presented previously there have been no issues reported with the other children that would give rise for concern.   4.17. Apart from a couple of Minor Injury Unit attendances for non-related matters, there has been no reported involvement of services with Father. Father is listed within health assessments by the health visiting team as being Mother’s current partner.   4.18. Child L collapsed at home in the evening following the last clinic attendance. Child L was resuscitated following rescue breaths given by Father on instruction from the ambulance service. On admission to the Emergency department, Child L received recovery treatment. Despite Mother giving a history of the bruising this does not appear to have been taken into account either in the ED or on initial admission to the paediatric ward. It should be noted however, that at this stage the primary concern would be immediate preservation of life and stabilisation of Child L’s condition. The history of bruising was noted as part of the overall assessment, the significance of this was unknown at this point in Child L’s journey  4.19. As is the case where causation of presentation is not immediately obvious, safeguarding procedures were commenced following review by the paediatrician later the next day when physiological causes for Child L’s presentation were being excluded.   5. BRUISING IN PRE-MOBILE BABIES  5.1. The evidence of the link between child abuse and presentation of bruising in pre-mobile children is compelling. A systematic review on bruising3 that included scientific research from 1950-2016 identified that bruising is the most common feature of abuse in children. Of the studies included, it was identified that one had emphasised the need to investigate all pre-mobile children with unexplained bruising and another indicated that three infants found with bruising who were not investigated as child protection concerns, all presented later with severe abuse, two of which were fatal.    2 Sacrum (Sacral Region) The sacral region (sacrum) is at the bottom of the spine and lies between the fifth segment of the lumbar spine (L5) and the coccyx (tailbone). The sacrum is a triangular-shaped bone and consists of five segments (S1-S5) that are fused together.  3 The Royal College of Paediatrics and Child Health (RCPCH) (2017) Child Protection Evidence: Systematic review on Bruising.   Cardiff University, funded by NSPCC Published by RCPCH July 2017 https://www.rcpch.ac.uk/sites/default/files/Child_Protection_Evidence-_Chapter_Bruising_Update_Final_020817.pdf      7 5.2. The implications for practice are laid out within the Systematic Review:  “A bruise must never be interpreted in isolation and must always be assessed in the context of medical and social history, developmental stage, explanation given, full clinical examination and relevant investigations”. Pp9  5.3. Bruising in babies and especially those who are pre-mobile should always raise a concern and be investigated, not only because of child abuse but other undiagnosed clinical conditions and causes.  5.4. Similarly, NICE guidance for healthcare professionals, states that that child maltreatment should be suspected if there is bruising or petechiae (tiny red or purple spots) that are not caused by a medical condition and if the explanation for the bruising is unsuitable i.e. implausible, inadequate or inconsistent.  This includes bruising in a child who is not independently mobile.   5.5. There are a variety of guidance documents in use across several areas of the country, offering specific guidance and flow charts for expected responses to bruising in non-mobile children as well as references in Thresholds and Levels of Need Documents. Currently there is no specific guidance in this county and the Support Levels Guidance does not specifically reference bruising to non-mobile children.  5.6. Child L had presented with bruising in three areas of the body on three occasions to different professionals and was 8 weeks old at the time of collapse. There was no explanation sought by professionals or given by parents; the areas of bruising would be of concern even in a mobile child as they are not areas that usually bruise accidentally. The author would therefore argue, notwithstanding hindsight, that the presentation should have raised significant concern and been referred to children’s social care and a paediatrician.   6. CHALLENGES & LEARNING  6.1. Based on how this case unfolded and the evidence-based information, there are several challenges that this case presents that require consideration for the Safeguarding Children Board (and its successor) and across all multi agency partners.   6.2. The issues that this case has presented were formulated into areas for learning and improvement.  Questions and considerations were framed using the following model (based on Hampshire Safeguarding Adult Board Reflective Learning Framework) at the multi-agency workshop. Responses from the multi-agency partners who attended the workshop has led to learning points and recommendations in the following sections.     6.3. It is of note that whilst this was a multi-agency workshop, due to the nature of services, the issues of this case are particularly pertinent to those universal services such as health visiting, midwifery and GPs. The learning, however, is applicable to all services who work with children and families.      8         Understanding and Application of Procedures in cases of bruising in pre mobile babies.  6.4. There is no evidence in this case that safeguarding procedures were considered at any stage until Child L was reviewed by a paediatrician the day following collapse, despite presenting with rash and marks thought to be bruising for which there was no explanation.   6.5. On research of several LSCB websites, there is a wide variance of not only what procedures, protocols and guidance there are, but also what is contained within them. Most importantly there is a wide range of how much professional judgement is allowed for within guidance. Some areas stipulate that all bruising in pre-mobile babies must be referred to a paediatrician AND children’s social care. Some guidance states that if, on professional judgement, there are continued concerns, then there is a requirement to refer. Some areas also provide leaflets to be given to parents when bruising is found. Leaflets explain why referral is necessary and what parents can expect to happen next.    Response  6.6. Partners attending the workshop had the opportunity to view some of the protocols and guidance that the author had researched from various areas of the country.  What is supposed to happen?What is evidence telling us is actually happening?Why is there a difference?What needs to change & how will we achieve it?Barriers to ImprovementQuestions for Multi Agency Partners:  • What procedures are available across this county? • Is there specific multi agency protocols and/or guidance regarding bruising in pre-mobile babies? • Are procedures easily accessible? • Are procedures clear on the process to follow? • How is professional judgement accounted for in procedures? • Do we need additional procedure/guidance as per examples? • Are procedures based on current best practice? How will we know when we have achieved it?   9 6.7. Multi agency partners considered that there were no specific procedures for bruising in pre mobile babies across this county. The procedures that are in place are the standard Child Protection procedures that identify what to do in cases of suspected Non-Accidental Injury (NAI). Procedures do identify that bruising in pre mobile babies should be considered as non-accidental unless there is evidence, or an adequate explanation provided. The procedures do not go further as to how to gather evidence or an adequate explanation and what expected practice should be. In the case in question there was no explanation for the bruising.  6.8. This county’s Levels of Support Guidance and the single page overview of the document is widely accessible but does not make specific reference to bruising in pre mobile babies, although that partners at the event felt that the guidance is generic enough to be applied in relevant situations, feedback from GPs find that it is too generic.   6.9. It was felt that professionals need more guidance on what is expected when a bruise is found. There are concerns that if professional judgment is left to an individual practitioner in isolation of any other information, this could lead to biased and non-evidence-based decision making. ‘Checks and balances’ are required in the system.  On the other hand, if guidance is too prescriptive it may limit professional judgement and conversations and managerial/peer support with decision making.  6.10. There was also a question raised as to whether the creation of a social care record for children and families, where there were no concerns found on investigation, was the right way forward. There was also concerns expressed about swamping the system with referrals where there was reasonable explanation for the bruising.   6.11. The author would argue that the RCPH research previously referenced3 is compelling and that a presentation of bruising in a pre-mobile baby remains rare. Evidence from areas that have introduced mandatory referral to children’s social care has not led to excessive referrals. What it does mean though, is that practitioners have clarity on exactly what needs to happen in these cases. It must also be remembered that in many cases where physical abuse is or has happened, that the bruise is often only an indicator and other injuries have been found on further specialist paediatric examination, many of these leading to the death or lifechanging injuries for those the infants.  6.12. Medical conditions that result in bruising are rare but equally need thorough paediatric specialist investigation which would be part of any investigation into bruising in this and any age group of children.  6.13. In this case, Child L did survive with no adverse effects of the injuries, but the bruise was not the only injury.  6.14. Partners considered that a single flow chart, to support practitioners, alongside a leaflet for parents, would be helpful alongside relevant training and briefings.    6.15. The Community Health Trust has introduced an incident reporting flow chart for NAI in the health visiting service. The author notes that this is not a safeguarding flow chart but an internal tool to aid managers to identify good practice and where there may be lessons in the reporting and practice regarding NAI. The tool is not a child focussed safeguarding tool to aid decision making and onward referral to Children’s Social Care.   6.16. As a result of this case, there is a protocol being written for all agencies that come into contact with families in this county. The author has reviewed this document and believes it is the start of having a robust procedure. The draft document does indicate there will be a leaflet for parents, which the author strongly recommends. The draft document would benefit from a clear one sheet flowchart of the process.   10  History Informing Assessment  6.17. This family were new to this county. There is very little evidence that services knew very much about their history. Health visiting records were not received from the previous area and it is not clear if the GP had received the previous records for the whole family. The social care assessment in 2016 does not indicate if checks were undertaken in the previous area.  6.18. It is clear in the case of bruising in pre-mobile babies, that context and parental explanations are important to understand. It is also of note that understanding history can be key to safeguarding. Several Serious Case reviews as well as analysis and research indicate the importance of history informing assessment.4,5, 6 . The latest analysis of Serious Case Reviews7 indicates from one case:      Response   6.19. Partners first discussed how information is gathered about families who are new to an area as it is relevant in this case. Partners noted that there are many mechanisms to health visiting teams becoming aware that a family has moved into their area. This may be at the time that the family registers with a new GP (although this is problematic if families do not register as soon as they move). Families may come to the attention of agencies by attendance at A & E or other clinics. On occasion a health visitor from another area will make contact to inform the new health visitor that a family is moving.  6.20. A visit by the health visitor is only offered if a child in the family is under one year old. Records from the previous area are requested by the child health department. It is of note that only electronic records are received, and that any information contained in older paper records may not be available. Within the  4 Child N Serious Case Review 5 Radford, L. et al. (2011) Child abuse and neglect in the UK today. London: NSPCC 6 Brandon, M., Belderson, P., et al (2008) Analysing child deaths and serious injury through abuse and neglect: What can we learn? A biennial analysis of serious case reviews 2003–5. London: Department for Children, Schools and Families.  7 Peter Sidebotham et al. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 London, Department for Education Questions for Multi Agency Partners:  • How do we gather history? • Do records/assessment protocols prompt what information is expected to be gathered in assessments of New to Area/new patient/client contacts? • Is there clear guidance on receiving in records from other areas? • Are our movement in procedures effective? • What is the process for ensuring assessments include history? Learning Points:  • Bruising in a pre-mobile baby must always be considered of concern and be investigated further • Professional judgement needs to be supported with specific guidance  • Information for parents is an important part of supporting professionals to deliver clear information regarding processes when bruising in pre mobile babies is found.  “This case has illustrated that in order to perform a child protection role effectively universal services need to be fully informed of the family ‘history’”     11 Community Health Trust there was a delay in uploading all paper records to electronic systems during the change process; this is now resolved.  6.21. Gathering information from older records can be difficult. The archiving process has led to inaccuracies in how data was recorded and in some cases information gaps have led to records not being able to be traced. It is of note that newer archiving systems are much more efficient with fewer records lost.  6.22. Police and social care systems, as non-universal services, record only information that has been made as a result of referrals and incidents and is therefore different. There are very clearly laid out procedures for transfer of information where children are subject to a Child Protection Plan. Where children have transferred from another area and they are not subject to Child Protection Plan but there is a referral to a new area may lead to a social worker having to travel to another area to read the records as information is not readily shared from another local authority area. This is deemed a barrier to gathering effective information.  6.23. Police systems are national and local. Recent improvements have led to police being able to access all relevant information across the country. Information would only be actively passed between policing areas where there is a serious incident e.g. cases that are subject to MARAC8, MAPPA9.   6.24. When it comes to gathering a history in a new assessment in universal services e.g. new to area or new birth visit there is a current reliance on the health visitor or midwife asking the right questions. Some of these are guided by proformas and assessment paperwork. Health visitors suggested that some of these assessments are based on information gathering that is a contractual requirement of the service from the commissioners. Practitioners argued that this can be overwhelming and leave little in the way of a framework for a health needs analysis for newer practitioners who do not have the experience of what was previously used in analysing family health needs. As this has been learning from another recent case review, the Family Health Needs Analysis Framework is about to be reintroduced which will provide a robust framework for information gathering and assessment.  6.25. Midwives stated that information is gathered over several appointments with a couple. This includes gathering a social history and any previous children of both partners and if they live with the couple. If there are children living elsewhere questions are asked about this. Any concerns are sent to the safeguarding team for further review of family members identified.  6.26. It is of note that this area links to other areas and especially professional curiosity discussed later in this report as it is often this that encourages professionals to seek out more history and make further enquiries when there is a need to understand history in more detail.   6.27. Previously, some detail within health visiting records was recorded in a family record. It was not deemed appropriate to transfer the family record but only the child’s. This is now not the case and individual records can be created for any carer or person that a health visitor is working with. This enables the transfer of records as appropriate.    8 MARAC stands for Multi-Agency Risk Assessment Conference. The Domestic Violence MARAC is a meeting where agencies talk about the risk of future harm to people experiencing domestic abuse and if necessary their children, and draw up an action plan to help manage that risk. 9 MAPPA stands for Multi-Agency Public Protection Arrangements. It is the process through which the Police, Probation and Prison Services work together with other agencies to manage the risks posed by violent and sexual offenders living in the community in order to protect the public.    12 6.28. It is of note that the front door for referrals into children’s social care has improved information sharing where referrals have been made. This can only be effective if assessments in universal services contain enough information to inform decision making should there be a need.  Due regard must be given to the family history in the gathering of information to inform assessment.    Involvement of Fathers  6.29. When reading all of the information that was provided for this review, there was very little recorded about Father. Father was registered at a different GP practice than Mother and the children. Information gathered during the review, is that Father had very little contact with the GP. He had been registered since 2013. There is no history of any significant illness including mental health. Father had no contact with the surgery in the timeframe that this review is looking at.  6.30. Engaging fathers has been the subject of focus in previous serious case reviews 10. When fathers are either not engaged or where their role in the family is not understood, professionals are left not knowing to what extent a father may be a risk or protective factor within a family. In this case, there was no assessment of Father’s history or wishes and feelings as a parent. It is not known if Child L was his first child or if he had other children.  6.31. Research by the University of Worcester and the Fatherhood Institute11 concluded that health visitors are well placed to include fathers in their work with families using the Healthy Child Programme. An evaluation of a training programme proved to have been positive in raising awareness in the importance of engaging with fathers and provided ideas of new and innovative ways to achieve this.   Response  6.32. In universal health visiting services, it is expected that that details of the father are recorded, a genogram should also be included in records and various other helpful data which includes if the father is resident in the household. Meeting with fathers, however, can be problematic due to working patterns of fathers and health  10 https://www.nspcc.org.uk/preventing-abuse/child-protection-system/case-reviews/learning/hidden-men/  11 Nolan, M (2014) Evaluation of a Training Programme and Toolkit to Assist Health Visitors and Community Practitioners to Engage with Fathers as Part of the Healthy Child Initiative: A developmental study using action research. University of Worcester Questions posed to Multi Agency Workshop:  • What is expected practice in engaging with Fathers? • Is there any guidance or training? • What are the challenges for professionals? • Is there any local learning regarding this issue? • Are there examples of good practice? Learning Points:  • Commissioners contractual requirements of a service can be a barrier to professional judgement and exploration of history to inform assessment • Assessment frameworks are required to ensure that there are prompts to gather the right information and history from a family, thus promoting professional curiosity. • Movement in procedures in universal services must be robust with checks and triggers to ensure that records are shared and received in a timely manner and pursued where necessary.     13 visitors.  6.33. Other services don’t have such an issue. Midwifery services often get to see Fathers as there are improved employment practices that allow fathers to attend antenatal appointments and this is encouraged. Children’s social care and the police in any referral they receive will go out of their way to see and engage with fathers as this is expected and vital to any investigation.   6.34. For midwifery and health visiting this appears to change after delivery though. Midwives and Health visitors report that fathers do not expect that they will be interested in seeing them and the belief is that interest moves to mother and baby.   6.35. When challenged why this is the case, it appears that although encouraged and invited to stay if the father would like, there is not a predisposed expectation that the midwife and health visitor will see the father with the mother and baby.  6.36. Where fathers are present, there is some good work undertaken now particularly with the recognition of mental health issues for fathers after a baby is born.  6.37. There is no specific guidance or training regarding this issue.   6.38. Practitioners feel that the pressure put on them by commissioning requirements mean that they have a lack of power and discretion over which areas a family needs to have input. The hours that the service operates is also dictated by commissioners and therefore the opportunity to work flexibly to incorporate fathers and indeed working mothers is not available. It does not appear that there has been any work done with fathers locally to understand what their needs are.  6.39. It is of interest to note that it was suggested that where a couple may be of the same sex and have had a baby, either by IVF, surrogacy or adoption, then the service received becomes less delineated and more flexible. i.e where there are two mothers, they both get the same service, and where there are two fathers, they would be offered a service on a par with if they were mothers. It only appears to be heterosexual couples where this is so much of an issue. It would be interesting to know if that was the case as policies and procedures do not include services for same sex couples who have a baby. Midwifery services suggested that they would concentrate on the partner that had given birth, or the surrogate mother who had given birth. There is little clarity regarding what services are offered to adoptive parents in same sex relationships. Records do not have the ability to record parents as other than mother and father.   6.40. Health visitors and other services also report that staffing levels are an issue and that the inclusion of fathers takes more time and therefore commissioners and mangers need to support decisions regarding increasing funding and or staffing or reducing other work in order to consider priorities better. It is of note that there has been a step change in the type of service offered now that Health visiting is commissioned by Public Health in that there is more requirement to gather information and deliver services more aligned to public health issues rather than addressing as a routine the broader social and safeguarding, but that expectations are that all areas will be covered.   6.41. There is a suggestion from some that this has led to increasing numbers of staff leaving the service.  6.42. It is also the case that families can decline the universal health visiting service, it is suggested that there may be two reasons for this, either the family do not want the professional to know of concerns or that they do not see   14 what the service has to offer and do not feel involved. Therefore, opting out of a service that it would be expected for families to accept should be challenged to ensure that a rationale is recorded. This should be true of where a father actively opts out of engagement with a service.   6.43. Another issue was thought to be the gender of most health professionals in midwifery and health visiting services, i.e. would more males in the workforce encourage more father involvement?   6.44. It has been noted by some that there are more fathers phoning the duty line and attending clinics in recent years. This may well indicate that fathers do want more inclusion with services that may have been historically perceived to be for mothers and babies alone. It is felt that in the first instance that fathers’ feelings about a service and what would encourage them to attend should be considered before services change to address the gap that is perceived by professionals. It is reported that there used to be fathers’ groups, but these no longer exist.  6.45. Without clarity from universal services that fathers’ health, well-being and role as a parent is as important as mothers’ it is not possible to know if perceived non engagement of a father would or should indicate a risk or if there is other rationale.    Screening for Domestic Abuse   6.46. There is no evidence that domestic abuse was a feature in this relationship. Due to the prevalence of domestic abuse being estimated at 1 in 4 women and that domestic abuse often starts or escalates in pregnancy12, it has long been advocated that all pregnant women should be screened for domestic abuse in a safe environment with access offered to support networks should they be required.  This is reiterated in more recent NICE Guidance (2014)13 and NICE Pathway (2016)14  6.47. There is no record of successfully screening for domestic abuse in midwifery, GP or health visiting services.  12 Department of Health (December 2005) Responding to domestic abuse: a handbook for health professionals  13 https://www.nice.org.uk/guidance/ph50  14 http://pathways.nice.org.uk/pathways/domestic-violence-and-abuse   Learning Points: • Fathers play an important role in family life, and therefore should be included in Universal Services offer as the norm. • Good understanding of the role that a father plays within a family can help the understanding as to whether father plays a positive supporting role and is a positive role model for growing and developing children or whether they are likely to be considered as posing a risk • Knowledge of the role that fathers play can further inform level of service need rather than basing that purely on assessment of mother. • The above is true whether father is resident within the household or not.   15 The absence of any thorough assessment of elements of domestic abuse as a feature within this relationship in line with NICE guidance and pathways, means it could not be ruled out. Research shows that it often takes several opportunities and enquiries before some victims will disclose, and some never do, suggesting that asking once is probably not enough to allow for a victim to come forward for support. Creating space to allow for screening and disclosure may have been an important aspect.    Response  6.48. There were various responses to this element of the review. For universal health visiting and midwifery services there is an expectation that routine enquiry to screen for domestic abuse will be undertaken at several contacts.  It does appear though that there are various issues with this. The question does need to be asked of a woman on her own. Midwifery colleagues state that they try and screen on two occasions by seeing the woman alone.   6.49. This is not always possible in health visiting services and there are varying degrees of how far practitioners will go to ensure this has happened. There are also issues where the majority of health visiting contacts, and now often the six weeks follow up, are conducted in an open clinic setting. This makes asking the question more difficult and more importantly, responding to any disclosures, challenging. Guidance also states that the question should not be asked if a child over two is present, therefore again adding to limits to situations where the question can be asked.   6.50. The Community Health Trust are currently reviewing the Domestic Abuse and Violence policy. There will be more guidance on expectations if the routine enquiry question has not been asked i.e. ensuring that other methods and opportunities are made to ask the question if there are reasons that it has not been asked.   6.51. The Royal College of General Practitioners provides guidance to GPs regarding domestic abuse. This does not advocate routine enquiry but does state that GPs should enquire sensitively where any indicators may be suggestive of violence or abuse. GPs who responded across this county indicated that this is their usual practice.  6.52. For non-universal services, the system is different. Children’s social care and police are often responding to referrals where domestic abuse may already have been disclosed or is a known feature in a relationship with specific processes to follow upon disclosure or incident.   6.53. Children’s social care identified that if assessing a family, where domestic abuse is not known about, then assessing the relationship would routinely include gleaning information about family history and relationships and therefore a specific question is not prompted in assessment paperwork and nor is it thought to be specifically necessary.  6.54. The author would argue that whilst this may be the case, it does leave this to individual practice, particularly in recording and flagging if domestic abuse has been disclosed, there are indicators of domestic abuse, or Questions posed to Multi Agency Partners:  • What is usual practice for screening across agencies? • What is the guidance/policy? • How do we record screening to ensure completed? • What are the challenges? • How are we assured that practice keeps up to date?   16 domestic abuse has been denied.    6.55. The Child and Family Assessment proforma does require an answer regarding if there are factors regarding any domestic abuse. Research leading to the compilation of NICE Guidance would suggest that it is necessary to ask the specific question rather than gleaning information in a ‘round about’ way when frontline professionals are meeting with patients/clients etc. The guidance was reassessed by NICE in 2018 did not identify that any changes were required.   6.56. Partners felt that there were different practices across this county. Some of this was believed to be regarding how much exposure staff may have to cases of domestic abuse but also due to different expectations and leadership styles. It is recognised that NICE Guidance is associated with guidance for health and social care staff. Due to the extensive research methods of gathering best practice, it is useful guidance for all organisations to consider when thinking about their own policies on the subject. The following were also cited as barriers to whether screening using routine enquiry was successfully undertaken and recorded:  • Training needs • Policy  • Clarity in records as to whether question has been asked/answered.   • Confidence to ask the question  • Access to regular supervision  • Language barriers and difficulties accessing interpreting services  • Time pressures • Bank staff and staff turnover   Authoritative Practice  6.57. An issue that has come to light at this point of the review is an apparent absence of authoritative practice. Authoritative practice covers skills and competence, child centred practice, support and supervision.   6.58. Previous studies regarding learning from SCRs, the more up to date Triennial Analysis of Serious Case Reviews15  and Lord Laming in his review into the death of Victoria Climbié16, have indicated that it is important to maintain a respectful uncertainty of parents.  It is suggested that it is possible to do this without affecting the professional/patient/client relationship.    15 Peter Sidebotham et al. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 London, Department for Education 16 The Lord Laming, (2003), The Victoria Climbié Enquiry   Learning Point: • NICE Guidance indicates that routine enquiry into domestic abuse should be undertaken.  An environment for safe disclosure, alongside an embedded culture of professional curiosity that encourages opportunistic exploration of indicators, provides robust evidence that the issue has been thoroughly assessed. The outcome should be carefully and safely recorded. Without this, any possible impact on the lived experience of the children is not possible.  Practitioners should be supported to apply these principles with policies and training that underpin practice.   17 6.59. In order to ensure that assessment is comprehensive, robust and child centred, professional curiosity is needed whilst maintaining a healthy scepticism of the issues that are being presented.  Sidebotham (2013)17 identified that this is only possible if professionals are able to adopt authoritative practice. This authority comes from competence and confidence whilst practising.  It requires empathy to keep the child at the centre whilst considering the needs of the parents. This then necessitates humility from professionals who are willing to accept the limitations that they may have in their knowledge and skills to seek advice, supervision and guidance.  6.60. The author would suggest that many of the practice issues that the case has highlighted may have been more thoroughly addressed if practitioners had displayed professional curiosity and applied professional challenge. The ability to practice in this way comes when practitioners are authoritative in their practice.  6.61. Agencies therefore need to promote a culture of authoritative practice and provide the systems and mechanisms of training advice and supervision. In agencies where those cultures are in place and there is clear support and mechanisms for robust supervision and training in child protection, these skills are transferrable to all practice.  Child L presented with a rash/bruising. There was no clear collaboration between the GP and Health Visiting service. The confidence and competence to apply evidence base to the presenting features, empathy with Mother who was presenting concerns did not follow through with actions to protect, nor accepting that there was at the very least a need to seek guidance and support.    Response  6.62. Partners agreed that they knew about authoritative practice but were not clear that it is an embedded culture across all agencies and services. Partners felt that there needed to be clear policies and guidance to support practice to give confidence to practitioners. It was felt that there should be structured time for supervision and specifically safeguarding supervision that should be prioritised. Staff felt that other pressures often meant that supervision was overlooked.  6.63. In response to this the Community Health Trust indicated that there are two types of supervision, clinical and safeguarding supervision. Safeguarding supervision for health visitors is mandatory with non-attendance and cancellations monitored and exception reported to the CCG. Safeguarding supervision is also audited to ensure that it is taking place as required. The Trust have agreed to undertake a further audit to ensure that this is still the case. The Safeguarding team in the Community Health Trust also operates a consultation line that is available during working hours. Supervision for social workers is also mandatory and takes priority unless there is an initial child protection conference or other agreed priority work.     17 Sidebotham, P. (2013) Authoritative Child Protection. Child Abuse Review, 22(1): 1-4   Questions for Multi Agency Partners:  • How do we embed a culture of authoritative practice? • How do we ensure collaborative working? • How are we assured that the workforce is competent? • Can we be assured that supervision is targeted at the right cases?  • How do we embed messages from SCRs locally and nationally? • How do we engage with authority and maintain sensitivity with parents when there is a concern?    18 6.64. It was also thought that being in receipt of good quality information sharing also helped authoritative practice from robust handovers and information between agencies.   6.65. Practitioners cited that the reasons why authoritative practice is not happening is because there is not enough time in the system to allow for good quality training and reflection. There is not enough training and often training gets fully booked. It is felt that there is not enough multi agency training and reflection. Some services felt that more weight is given to ensuring that KPI’s (Key Performance Indicators) are met than unmeasurable qualitative elements of the service like outcomes from good supervision and reflective practice.  6.66. Other issues that were felt to be barriers to effective authoritative practice were cited as:  • Serious Case Reviews can be seen to be a fearful motivator rather than a learning exercise • Fear of raising sensitive issues with families • Lack of time • Staffing issues/turnover and Bank staff • Fear of stepping on the toes of other professionals and lack of confidence to challenge • Putting policy into practice due to focus on KPIs  6.67. Partners also felt that there was value in shadowing other agencies to gain and understanding and appreciation of how other services work and that this would improve collaborative and multi-agency working. It was also indicated that multi agency reflection and supervision. Making use of mentoring for less experienced staff was also felt to be a way of improving confidence and competence in practice.   Generic Questions  6.68. There were also some generic questions considered by partners in order to identify how learning from SCRs is embedded in organisations. These are identified in Appendix Two  7. CONCLUSIONS.  7.1. Reviewing the systems that were available to the practitioners in the case of Child L, a ‘window’ on those systems has been viewed. it has been possible to identify areas for learning within the systems, that might afford practitioners the authoritative practice to manage cases where a pre mobile baby presents with bruising. The learning may also give practitioners the skills to identify those that may be at heightened risk of NAI.   7.2. It is apparent that there are no specific multi agency guidance and processes in this county for practitioners who identify markings that may be bruises in pre mobile babies. There is a reliance on the use of usual safeguarding processes for physical abuse and a heavy reliance on professional judgement to know how to respond in each Learning Points • Too much focus on KPIs can be a barrier to authoritative practice • Staff need adequate access to good quality policies and guidance that are readily accessible, supported by appropriate training and reflective supervision. • Learning can be gained from cases that have had good outcomes as well as those that become Serious Case Reviews. • Increasing authoritative practice can be gained from mentoring, shadowing and utilising multi-agency supervision   19 case.   7.3. There is enough evidence to indicate that there should always be a concern when a baby presents with a bruise and therefore, in order to ensure a consistent response, guidance and accompanying information for parents is seen as needed for this county. Due to the numbers of cases of this nature that lead to a Serious Case Review, many LSCBs have produced specific guidance.   7.4. How prescriptive that guidance needs to be will be a matter for the Board to consider; contact with other boards who have considered the pros and cons of very specific guidance may be of help. It is of note that although the case of Child L was related to a pre mobile baby, that any guidance will need to inclusive of all non-mobile children who present with bruising as those situations must also be of concern.  7.5. Alongside guidance, the issues of ensuring that family history is understood also provides early indicators of risk, especially where a family moves to a new area. Inclusion of fathers in gathering that history as well as delivering services to families as a whole have been explored and recognised as important when understanding risks and ensuring equitable services.  7.6. The issue of ability to undertake routine enquiry for domestic abuse has been explored and challenged.  7.7. On all of the associated assessment and risk gathering elements of this review, services have cited consistent themes of that are seen as barriers; workload pressures to ensure that KPIs are delivered and  staffing issues of high vacancies and bank staff. These coupled with changes to record keeping and assessment tools are also seen specifically in health visiting as not helpful.  7.8. This review has raised the issue of equity of services in same sex parenting and ensuring that services consider the needs of 21st century families when commissioning and delivering universal services. Do services offer a different service based on gender of parent whether that be in same sex or heterosexual parenting relationships?  7.9. It could be argued that services should be commissioned and offered based on needs of the individuals in the population and a recognition that it is not always easy to identify short term outcomes where it is a qualitative service being delivered.  7.10. Finally, it will be important to ensure that the recommendations from this review lead to the required improvements and it is therefore necessary to make use of audit and appreciative enquiry to evidence that improvements are working in practice and to assess areas that need ongoing work.  8. RECOMMENDATIONS   8.1. This review makes the following recommendations for this Safeguarding Board; Recommendations are made under several main themes and require this Safeguarding Board to ensure that the following are addressed:   1. Policy  • This Safeguarding Board should continue to pursue and ratify the protocol that is currently in draft “Protocol for the management of actual or suspected bruising in infants & children who are not independently mobile” This must include the provision of an information leaflet for parents and a clear one page flow chart of the process.   20  • This Safeguarding Board must review the Support Levels Guidance to ensure that it references bruising in non-mobile babies and children and cross references the specific protocol once ratified. A review should also consider feedback from partners on any further amendments that would be helpful.  • This Safeguarding Board should request that the local Domestic Abuse Strategy Group ensure that the newly ratified guidelines take account of NICE Guidance that evidences best practice.  • The Community Health Trust must assure this Safeguarding Board that their ‘movement in’ guidelines and policies ensure robust information sharing in a timely manner and that there are guidelines to ensure appropriate pursuance and escalation of non-received records.  • This county’s Children’s Social Work Services to assure this Safeguarding Board that during a child and family assessment, social workers ask a direct question about experiences of domestic abuse, where the case has not been referred due to domestic abuse.  2. Information informing assessment  • This Safeguarding Board to seek assurance that all services who assess families’ needs have assessment frameworks and documentation that has a section to record history of family and household members.   3. Capacity in the system  • This Safeguarding Board should seek assurance from Health Visiting providers and commissioners that the impact of data collection that inform KPIs does not impact on the ability and capacity for health visitors to exercise professional judgement.  There must be time allowed for relationship building and assessment that may safeguard children.  • Commissioners and providers should consider how much the movement away from more traditional health visiting models has impacted on sickness, recruitment and retention of health visitors.   4. Engaging with Fathers   • This Safeguarding Board should ask commissioners and providers to ensure that Fathers’ needs are considered and met in services. This is to ensure that full consideration is given to the need to offer services that are inclusive of all parents and carers.  • This Safeguarding Board should provide a briefing on the importance of inclusion of Fathers and all carers in assessments and service offers. This topic should feature in all this Safeguarding Board’s core safeguarding training programmes.  5. Authoritative Practice   In order that the learning can be addressed there is a need for specific programmes of activities to improve and embed a culture where authoritative practice becomes the norm in practice. Activities need to cover the workforce who work with families.     21 Elements should consist of:  • Ensuring all guidance is available, up to date and relevant • Safeguarding Children core training is Multi Agency and includes understanding of authoritative practice. • Supervision in agencies evidences supportive respectful challenge. (Multi-agency Safeguarding Supervisor Training should be considered) • Ongoing safeguarding audit programmes of Board and within agencies include these issues.  • Appreciative enquiry is used to identify good practice both at Board and within single agency safeguarding/board meetings/staff meetings (as relevant to each agency).        22 Appendix One: Terms of Reference (Redacted)   SERIOUS CASE REVIEW TERMS OF REFERENCE AND PROJECT PLAN SUBJECT: Child L  1. Introduction:  1.1 This Serious Case Review (SCR) has been commissioned by the Safeguarding Children Board because the child has suffered serious harm as a result of abuse or neglect.   2. Legal Framework:  2.1 SCRs and other case reviews should be conducted in a way that: • recognises the complex circumstances in which professionals work together to safeguard children;  • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;  • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;  • is transparent about the way data is collected and analysed; and  • makes use of relevant research and case evidence to inform the findings.    3. Methodology:  3.1 This SCR will be conducted using a systems approach, which reflects on multi-agency work systemically and aims to answer the question why things happened.  Importantly it recognises good practice and strengths that can be built on, as well as things that need to be done differently to encourage improvements.  The model engages frontline practitioners and their managers in the review of the case, focussing on why those involved acted in a certain way at that time. It is a collaborative and analytical process which combines written agency reports with a ‘window on the system’ practitioner workshop.  3.2 This model is based on the expectation that serious case reviews are conducted in a way that recognises the complex circumstances in which professionals work together and seeks to understand practice from the viewpoint of the individuals and organisations involved at the time, minimising hindsight bias.  3.3 The review model adheres to the principles of: • Proportionality • Learning from good practice • Active engagement of practitioners • Engagement with families • Systems methodology  4. Scope of SCR:  4.1 Timescale of the review from 1st August 2016 to 1st November 2017. In addition, agencies are asked to provide a brief background of any significant events and safeguarding issues in respect of Child L’s immediate family.  This will include any significant event that falls outside the timeframe if agencies consider that it would add value and learning to the review.   5. Agency Reports:  5.1 Addendum Agency Reports will be requested from:  • Police   23 • Children’s Social Work Services and Early Help  • The Hospital Foundation Trust  • The Community Health NHS Foundation Trust,  • GP  5.2 Agencies are requested to use this Safeguarding Board ‘s Report Template.    6. Areas for consideration:  6.1 Agency report authors should consider the following:   What was life like for the child in this family? • How was this captured? • How was it acted upon?  What was the impact of Single-Agency and Multi-Agency working? • What was known by agencies? • What information was shared?   • How was it shared?  How were assessments, including risk assessments, undertaken? • What single agency assessments were undertaken? • What agency perspectives were of the risk posed to the child by his parents? • What interagency discussions, if any, took place regarding assessments and risks?   7. Engagement with the family  7.1 A key element of any review is engagement with family members, in order that their views can be sought and integrated into the learning.  This Safeguarding Board will inform the family that this review is being undertaken and will offer the child’s parents the opportunity to meet with the Lead Reviewer.  7.2 Their contributions will be included in the Overview Report and they will be offered feedback at the end of the process.  8. Timetable for Case Review:  Deadline for agency addendum reports 22nd February 2019 Meeting with family (if accepted) TBC Draft report produced 18th March 2019 Draft report shared with attendees of Practitioners’ event 19th March 2019 ‘Window on the system’ practitioners event 26th March 2019 14th May 2019 Draft report to be presented to the SCR Panel  25th June 2019 Final report to Panel (virtual) TBC Report presented to the Safeguarding Board TBC                                 24 Appendix Two: Generic Questions; Leaning from SCRs   Question Learning points  How do we ensure that learning from SCRs reaches everyone in each organisation?  There is a need for varying methods of availability of feedback from SCRs to meet all learning styles and to access large numbers of staff e.g.  • Bitesize briefings,  • Away days • Multi agency inclusion of staff in SCR process (such as this SCR) • Addition of key themes in mandatory safeguarding training  How do we know that learning from SCRs is effective?  • Supervision • Feedback to board  • Peer reviews • Further SCR shows improved practice • Appreciative enquiry at Board and agency meetings.  What does our multi agency case file audit process tell us?  • Can be important indicator of improvement as long as appropriate topic area is identified. • Appreciative enquiry and multi-agency review of a case that has positive outcomes is an alternative way to evidence what works well when working with families. 