Death of a 3-year-old girl in November 2011, as the result of a traumatic head injury. Child D's injuries occurred whilst she was in the care of a neighbour. Subsequent care proceedings for Child D's sibling found that the neighbour inflicted Child D's injuries but no judgement was made as to whether deliberately or accidently. Neighbour pleaded guilty to child neglect and was sentenced to two years ten months imprisonment. Mother and neighbour's wife pleaded guilty to perverting the cause of justice and both received a suspended sentence. Family were known to universal services only prior to the incident. Mother came to the UK from Pakistan in 2008 after marrying father, who was born in the UK; mother did not speak English. Identifies good practice in the support services offered to mother and use of interpreters to communicate with mother. Concludes that there are no lessons to be learned from the case and makes no recommendations.
      
 Title:  This is an independent overview report of the serious case review concerning the death of Child D: date of serious incident: November 2011. LSCB: Coventry Safeguarding Children Board Author: Mark Dalton Date of publication: 2014  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                          COVENTRY SAFEGUARDING CHILDREN BOARD SERIOUS CASE REVIEW This is an Independent overview report of the Serious Case Review concerning the death of Child D  DATE OF SERIOUS INCIDENT: NOVEMBER 2011   References relating to the subject child, family members, organisations professionals and places have been coded and anonymised.   Independent Lead Reviewer    Mark Dalton Independent Chair, CSCB     Amy Weir       Date of report: May 2014  Agreed by Coventry Safeguarding Children Board: 28th May 2014      Contents   page  Introduction  2   Serious Case Review process 2   Involvement of the family in the process 4   Key factual information 4   Analysis 6   Conclusion 7                             2  INTRODUCTION This review was commissioned in March 2013 following the death of child D in November 2011. The precise circumstances leading to the death have never been fully established. The child died as a result of a traumatic head injury which occurred whilst she was in the care of a neighbour. The child and her family were not in receipt of any services at the time of her death. One of the unusual features of this case review is the paucity of any external assessment as to welfare of the child or family functioning. Apart from admission to the local hospital for the birth of the family’s two children and routine community health contact the family were unknown to any other agencies in the City. SERIOUS CASE REVIEW PROCESS The circumstances of the child’s death were first noted by the Serious Case Review subcommittee Coventry Local Children Safeguarding Board in December 2011. The decision as to whether the case met the criteria for a Serious Case Review was delayed awaiting the conclusion of a police enquiry and post-mortem reports. This proved to be a complex investigation, which was delayed by the need for extensive post-mortem tests and attempts to obstruct the investigation by some of the individuals concerned. Despite the practical difficulty of having little professional practice to review and comment on, the regulations and statutory guidance contained in “Working Together to Safeguard Children 2010” were strictly applied: “When a child dies (including death by suspected suicide) and abuse or neglect is known or suspected to be a factor in the death, the LSCB should always conduct a SCR into the involvement of organisations and professionals in the lives of the child and the family” (Working Together 2010 para 8.9) The LSCB were finally able to make the decision to undertake a Serious Case Review on 14th March 2013 at the conclusion of the Police investigation. The scope of the Review and Terms of Reference were agreed on 25th March.  The LSCB agreed to the appointment of Mark Dalton, the independent chair of the Serious Case Review Subcommittee, as overview report author. The primary purpose of a Serious Case Review is to enable agencies to learn lessons from the practice. Clearly in this case, where there was no agency involvement apart from universal services, there are correspondingly no lessons to learn from previous involvement with the family. However, if this family were typical of a type of family structure within one of the communities within the city there may be lessons for agencies about the way such isolation is addressed and services are publicised to potential users. All agencies within the city were notified of the intention to undertake this case review. With the exception of health agencies, other services within the city confirmed a nil response. The family were known to a GP practice, the Health 2  Visiting Service and the Hospital in connection with the birth of the two siblings. IMR’s were commissioned from the individual health agencies as follows: Coventry and Rugby CCG – GP services Coventry and Warwickshire NHS Partnership Trust – Health Visiting Services University Hospital Coventry and Warwickshire NHS trust – Antenatal care The panel also have the benefit of the information and analysis contained in the Judgment from the care proceedings held in relation to the child’s surviving sibling, this information remains confidential to the panel but was invaluable in providing background information about the family that would not have been available through any other means. Following care proceeding in which findings were made for child D’s sibling, the child was rehabilitated back to the care of the parents.  A SCR panel met on two occasions to consider the IMR’s and to consider whether there were any lessons to be learned from the tragic circumstances of the child’s death. The Panel comprised: Mark Dalton      Lead Reviewer Named Doctor    University Hospital of Coventry and        Warwickshire (IMR author) Head of Safeguarding     Coventry City Council Deputy Director of Nursing   Coventry and Warwickshire NHS Trust Designated Nurse  Coventry and Warwickshire CCG           (IMR author) Safeguarding Business Manager  Coventry LSCB Head of Service    Early Years’ Service Coventry City Council Senior Probation Officer.    Staffordshire and West Midlands Probation       Trust Also attending: Lead Nurse for Safeguarding Children  Coventry and Warwickshire NHS Trust and Adults at risk     (IMR Author )  Legal Adviser to Panel   Finance and Legal Services Coventry City       Council Lead Professional for Safeguarding  Coventry and Warwickshire NHS Trust Children and Vulnerable Adults,   (Observing)        3   Within a month of the decision to undertake the Review the new version of Working Together to Safeguard Children was published that would have allowed the possibility of alternative proportionate review processes being considered. To avoid confusion panel resolved to continue following the 2010 guidance under which the review was commissioned. The review was presented to the Coventry Safeguarding Children Board in July 2013 where it was agreed that publication would be delayed until after any criminal proceedings had been concluded.  INVOLVEMENT OF THE FAMILY IN THE PROCESS The family were notified that a serious case review was being undertaken following the death of the child. The family’s involvement in the Serious Case Review process was constrained by the impending prosecution of the mother, the neighbour who was caring for her at the time and his wife.  Social Care and other agencies have become more heavily involved in their family life and their attention focused on the care of their remaining child.  The mother of the child does not speak English and the purpose of the review was explained to her through an interpreter, her initial comments were that she has found the process confusing.  In reality there are only three specific points of concern that the panel would want to direct towards the parents; namely: • Did the mother consider herself to be socially isolated?  • Was she aware of the community resources available for young mothers like her in the community?  • Where there any factors which prevented her from accessing such resources? The limited involvement with the family by agencies means that there is very little for the family to comment upon in terms of the quality of service they received. However the review has speculated on whether the lack of uptake of services was an informed choice or because the mother was unaware of what was available. The mother of the child, the neighbour and his wife were facing prosecution for offences directly relating to the death of the child and their subsequent attempts to cover up the true facts. The impending court action also inhibited their involvement at the time of this review. Once the court processes were over parents were offered an opportunity to meet and discuss their view of agency work with their family and the findings of the review, unfortunately they declined this offer.   KEY FACTUAL INFORMATION 4  Both the child’s parents’ families of origin come from Pakistan, but whereas the child’s father was born and brought up in the UK, the child’s mother lived in rural Pakistan and came to the UK in 2008 following her marriage in 2007. This appears to be a traditional arranged marriage and the couple are first cousins. The family made their home in an area of Coventry where the father has many relatives and a community where there were many others of similar faith and beliefs. The paternal extended family were significantly involved in providing support and practical help. It is known that the child’s father worked long hours; working shifts during the night at a local factory. He would work as a volunteer at a local bookshop and taught Arabic in his time off and at the weekends.  The child was born in 2008 and was just over three years old at the time of her death. There is nothing in the medical records to indicate that she was anything other than a normal healthy child.  The family’s needs where identified as being met by Care Pathway 2 by the Health Visitor, because of the mother’s difficulty in communicating in English and additional support for feeding the child. The child saw the GP a total of 11 times during her life; these were for minor issues and indicated responsible parenting. The mother saw three different GP’s who all spoke a language the mother was fluent in; there were never any safeguarding concerns.  The sibling was born in May 2011 five weeks prematurely and it has been suggested that he may have more complex health needs. However there has never been any concern with how the family have used the health services.  The parents have always used these services appropriately and up to the child’s death sought help from their GP as and when it was necessary. A friendship developed between the mother and a male neighbour who lived opposite the family home in 2011. This relationship would be considered inappropriate and breaking the religious and social conventions of the orthodox Muslim community. The neighbour was older, married and male and for the mother to be alone with this person without her husband’s knowledge or permission would be considered unacceptable.  The relationship is relevant to this review because the neighbour began the practice of looking after the child once or twice a week in order for her to play with the neighbour’s children and do things which she was not allowed to do at home; such as watch TV or eat sweets and crisps. It is during one such visit at the neighbour’s house that the incident occurred which resulted in the child’s tragic death. The post-mortem has established that the child received a traumatic head injury whilst in the care of the neighbour. There is no credible accidental explanation for how such an injury could have been caused; equally there has been no admission of responsibility by either the mother or the neighbour. The police investigation has proven that there was a delay summoning an ambulance as the neighbour attempted to persuade the mother to avoid mentioning 5  that he had been caring for the child. The post-mortem has established that the child would not in any event have been saved. Despite extensive Police investigations the events leading up to the child’s death have not been ascertained. Within the care proceedings in relation to the child’s sibling it was found that the neighbour inflicted the injuries from which the child died; whatever the mechanism for the death and whether it was accidental or deliberate, given the age of the child it was undoubtedly negligent.  Subsequently the neighbour, his wife and the child’s mother were charged with perverting the course of justice. The neighbour was also charged with the offence of child cruelty. They all pleaded guilty to perverting the cause of justice, in addition at a later date the neighbour pleaded guilty to child neglect. Both the mother and neighbours wife received a suspended sentence and the neighbour was sentence to 2 years and 10 months imprisonment in February 2014.  ANALYSIS There is nothing known about this family that marks them out from tens and possibly hundreds of similar families in the city. The family were given the same level of service that thousands of other families receive from community health. This review has prompted a scrutiny of the services that are available and how they are offered. In hindsight it seems that an argument could be made for describing the mother as socially isolated; although this is not a problem she ever complained of or was seriously considered by those who worked with her.  On the contrary, where this was ever commented on by the professionals involved with her it is in terms of mother being supported by her extended family. However her social isolation may have been the reason for her reliance on the neighbour and her allowing her child to spend extended time within his care. Community Support: There is an Asian Women’s Support organisation in the area where the family live, which is well established and well used. It would seem to be an appropriate resource for the mother.  She was informed of the service in April 2008 when she first booked with the midwife when pregnant, but declined the offer of support.  The mother was often seen by health professionals, including hospital or clinic appointments or during home visits with her sisters’ in-law. They helped with translation and their presence was seen as helpful and evidence of a supportive family network. The possibility that the mother was feeling isolated, or was facing difficulties which could be addressed through wider community support was never a formal consideration for the agencies that knew her and the family.  All the evidence suggested that she was adequately support by her own family. Accessibility of information: While written communication cannot be provided in every language spoken in the city community health services were able to provide Punjabi or Urdu speaking staff or have interpreters available in order to communicate with the mother during clinic appointments and home visits. Health Visitors record showed that they considered the language needs and took steps to work with an interpreter r or provide a Health Visitor with the requisite language skills. This was 6  good practice in ensuring direct communication between the health professionals and mother given it is estimated that 140 different languages spoken in the City.1 In addition mother attended all health appointments made showing that not having translated written communication did not prevent her from understanding she or her children had medical appointments to attend.      CONCLUSION A fundamental question for a Serious Case Review is whether the death of a child was predictable and preventable. The lack of involvement from external agencies means that no one had sufficient information about the care arrangements to raise any concerns.  Even if these arrangements had been known they would not have raised any suspicions as the neighbours had children of their own who appeared well cared for. The conclusion of the Serious Case Review is that the tragic death of child D could not have been predicted or prevented. The responsibility for the child’s death remains with the neighbour as she received the fatal injuries whilst in his care.  Therefore, unless any intervention could be conceived that would have prevented this neighbour having care of the child, the death cannot be considered either preventable or avoidable.  To undertake a review and reach the conclusion that there are no lessons to be learned and no suggestions for improvement is an unusual one in a Serious Case Review process. Equally the tragic and as yet unexplained death of a child does not seem an appropriate juncture to celebrate good practice.   However in this case there is evidence that different sectors within Health worked together well in that information about mother and child was communicated from the Hospital to the community midwife and thence to the Health Visitor and GP. Several recent reviews have commented on how complex health arrangements have become, so it is important to acknowledge it when it works well.  The family’s cultural and language needs were dealt with in an appropriate way.  This question is specifically asked in the terms of reference and the individual management reviews all comment positively on how their part of the service was able to meet this family’s needs.  There are no recommendations from this case; either from the individual management reviews or from the Serious Case Review process for inter-agency working.   Mark Dalton Overview Report Author 1 Coventry People and…Race and Ethnicity file:///C:/Users/Mark/Downloads/Race_and_Ethnicity_factsheet_update_Sep13.pdf  7                                               8  