Serious injury of a baby girl in late 2011. Child F was stabbed by her father who was described as suffering a severe psychotic episode at the time. Father was arrested and subsequently received psychiatric care in a secure setting. Father had intermittent contact with mental health services from his late teens onwards, which included episodes of drug-induced psychosis. He received a four year prison sentence for a serious violent crime prior to the birth of Child G. Issues identified include: lack of access to significant history contained in court and prison psychiatric reports and prison health records; pattern of agency involvement with the family by two distinct sets of professionals, focusing separately on the father and on mother and children; overreliance on self-disclosure in assessing risk; and lack of agency knowledge about degree to which father was involved in care of children. Identifies learning, including: the need for GPs to 'think family'; and the need for the probation service to improve its approach to notifying social care of the birth of children to supervisees. Makes various recommendations covering GPs, probation services, accident and emergency services, mental health and health services. Review was undertaken using elements of a systems approach.
      
   Serious Case Review No:  2014/C5017  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.        Child F Serious Case Review Overview Report  Services provided for Child F and Child G and members of their family from January 2009 – October 2011   Serious Case Review Overview Report Author Keith Ibbetson     1 Services provided for Child F and Child G and members of their family from January 2009 – October 2011  CONTENTS Section  Serious Case Review Findings Page  1. Arrangements for the Serious Case Review (SCR) 2-9 2. Details of family members  10 3. Narrative of agency involvement with the children and their family 11-25 4. Evaluation of the services provided  26-57 5. Key findings and conclusions 58-62 6. Additional recommendations of the SCR overview report and SCR panel 63-65  Appendices  I  Terms of reference of SCR  66 II  Membership of the SCR panel 67 III  Background documents and references 68 IV  Excerpt from Healthy Child programme on engagement of fathers 69 V  The response of emergency services 70 VI  Recommendations of individual management reviews 71-73     2 1 ARRANGEMENTS FOR CONDUCTING THE SERIOUS CASE REVIEW Introduction 1.1 This report was prepared for (TEXT REDACTED) Local Safeguarding Children Board (LSCB) in order to fulfil the requirements of Chapter 8 of the Working Together guidance.1 The guidance sets out the arrangements for the local interagency review of cases which have given rise to serious concerns about the safeguarding of children and where there may be important lessons for the local network of agencies with child protection responsibilities. The purpose of this report is to highlight the most important findings of the review with the objective of improving local child protection practice.  1.2 (TEXT REDACTED) The terms of reference of this Serious Case Review (SCR) were agreed in January 2012 in line with the statutory guidance published on 1 April 2010. 1.3 This document is the LSCB overview report on the SCR. It summarises and complements the findings of the individual management reviews conducted by the agencies that were directly involved. The guidance under which the SCR conducted its work provides for the SCR overview report to be published in full. The child who is the focus of the review was seriously injured but is now well. She has an older brother. Before publishing the report the LSCB has a responsibility to remove from it any information that might lead to the identification of the children or cause an unnecessary intrusion into the privacy of the children or other family members.  1.4 An Executive Summary will be published which sets out the circumstances of the case (without publishing anything that would risk identifying the children involved) and the lessons of the review. The SCR completed its initial work in June 2012. At that time the events which led to the SCR were still the subject of a criminal investigation. The completion of this report has been delayed until the conclusion of the criminal proceedings in order to take full account of information from the criminal proceedings and also to ensure that premature publication of the SCR findings did not prejudice the criminal trial. 1.5 The review concerns services that were provided to two children and the members of their family: Child G was aged 2 and Child F was (TEXT REDACTED) an infant in late 2011, when Child F was stabbed by her father. At the time he was suffering from what has been described in psychiatric reports as a ‘severe psychotic episode’. 1.6 The children lived with (TEXT REDACTED) other members of their family at an address in (TEXT REDACTED). Their father lived at this address for some of the time and at the home of his own mother which is also in (TEXT REDACTED). Child F suffered a number of stab wounds before her father could be (TEXT REDACTED) arrested by police officers who had been sent to the family home following a 999                                                            1 HM Government, Working Together to Safeguard Children – 2010..   3 call (TEXT REDACTED). The children’s father was detained in custody after the incident but subsequently received psychiatric care in a secure setting. (TEXT REDACTED) The scope, focus and terms of reference of the Serious Case Review bearing in mind the circumstances in which Child F was injured and the involvement of agencies with the family 1.7 The Working Together guidance states that the LSCB in the area where the child lived should consider conducting a SCR when a child sustains a life threatening injury and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard and promote the welfare of children (Working Together Section 8.11). Initial reports indicated that the injuries had been life threatening and so the LSCB decided to conduct a SCR.  1.8 It is part of the function of the SCR to judge whether there are concerns about the way in which agencies and professionals had carried out their child protection responsibilities. In reaching the decision the LSCB noted the following background information which would require attention in the review: • The children’s father had been in intermittent contact with mental health services for a number of years – both in (TEXT REDACTED) and when he was in prison (TEXT REDACTED) • He had a number of criminal convictions and he had been supervised by the probation service (TEXT REDACTED) • A number of agencies and professionals had been involved with the family but had not identified any concerns about the children • The father and members of his family had sought help from local health services about his mental health in the days prior to the incident. Neither of the children had ever been referred to the local authority or been the subject of a child protection investigation or child protection plan. 1.9 The recommendation to hold the SCR was made on 21 November 2011. The independent chair of (TEXT REDACTED) LSCB made the decision to undertake the SCR on the same day. Work began at that point to agree the scope and terms of reference of the review. Following early meetings, formal notifications of the review and the methodology for its conduct were sent to all LSCB member agencies. Through a review of agency records the LSCB determined which agencies needed to contribute individual management reviews. A full list of the agencies involved in the review is set out in section 1.14 below. 1.10 The Working Together guidance makes the LSCB responsible for determining the scope and terms of reference for the SCR taking into account the circumstances of the particular case. Consideration was given to this within the SCR panel and there was also consultation with participating agencies. The general terms of reference for the SCR adhere to the objectives for SCRs set out in the Working Together to Safeguard Children 2010:   4  to draw together a full picture of the services provided   to establish whether there are lessons to be learned from a case about the way in which local professionals and agencies work together to safeguard children   to identify clearly what those lessons are, how they will be acted upon and what is expected to change as a result, and hence improve interagency working and better safeguard children 1.9 The terms of reference agreed for this review are contained a separate document which contains family details. Key sections highlighting the focus of the review are reproduced as Appendix 1 to this document. The scope of the SCR covered a period of nearly three years, beginning in January 2009 and ending when Child F was stabbed.  1.10 The Terms of Reference address issues identified in Working Together to Safeguard Children 2010 as being of general relevance and also issues specific to the case history. The terms of reference were followed by the authors of individual management reviews and the independent author of this overview report. Section 3 of this report provides a chronological account of agency involvement with the family. Section 4 of the report focuses on the following questions and themes:   Historical information (prior to 1 January 2009) on the family members about factors that may have led to risk to the children or impacted on the parenting capacity of either the mother or the father  The quality of assessment undertaken, particularly the assessment of risk and parenting ability  The plans made following assessments, whether they were consistent with the assessments undertaken and whether plans were fully implemented?  The quality of information sharing within and between agencies  Whether the focus of agencies‘ activities focus on the needs of children  Whether agencies responded appropriately to any risk factors identified in the course of their work with the family  Were the diversity needs (ethnicity, religion or any disability) of the family were recognised and responded to?  Did staff have the knowledge, skills and experience to respond to the needs identified in the case?  Were staff appropriately supervised and supported in their work with the family?  Did any issues or capacity or resources within agencies limit the ability of the agency to meet the needs of the family?  1.11 The overview report also makes recommendations on changes that need to be made to implement the lessons of the SCR. These take account of the recommendations contained in individual management reviews and developments in services that have occurred since the events in question took place. The SCR   5 either makes recommendations on matters that are not already part of the work programme of individual agencies and the LSCB, or in some matters it makes recommendations to strengthen work that is already taking place. Critical periods of agency involvement covered by the SCR 1.12 The scope of the SCR runs from the beginning of the mother’s pregnancy with Child G to the incident in which Child F was stabbed. Agencies were asked to scrutinise any earlier information in their records. Agency files showed that the children’s father had had a significant amount of earlier involvement with health, education and criminal justice agencies. This has been provided as background information because it demonstrates the long standing nature of many of the difficulties that he experienced. However it was agreed by the SCR panel and the overview report author that the focus of the review should be on current and recent service provision. Agencies involved  1.13 The following agencies and contracted professionals provided services to the children and to other family members within the period covered by the review and have provided a full chronology of their work with the family and an individual management review:   (TEXT REDACTED) Hospitals NHS Trust Integrated Care Organisation (which provides community health visiting services in (TEXT REDACTED))  (TEXT REDACTED) NHS Foundation Trust (which provided community mental health services)  (TEXT REDACTED) Hospitals NHS Trust (which provides hospital services at (TEXT REDACTED)  NHS (TEXT REDACTED) (in relation to GP services)  (TEXT REDACTED) NHS Trust (antenatal services in relation to Child F)  (TEXT REDACTED) Police Service   (TEXT REDACTED) Probation Trust  1.14 A number of other agencies had very limited involvement in the case history and were therefore either asked to provide chronologies, background information and reports or to contribute via additional discussions with SCR panel members:  (TEXT REDACTED) Ambulance Service  A substance misuse service involved with the father  Limited information was also obtained from the father’s school records and Connexions records (referred to in section 3 of the report).   No faith, voluntary or community groups were identified as having been involved in relation to the welfare of the children. 1.15 The Working Together guidance stipulates that a health overview report should be prepared on behalf of the commissioning Primary Care Trust (from 1 April 2013 Clinical Commissioning Group). Its purpose is to provide an overview of health   6 provision and to identify the key findings from the SCR which have implications for NHS commissioning of health services. The Designated Doctor for Safeguarding for NHS (TEXT REDACTED) prepared this report. The findings of the health overview have contributed to the findings of this SCR overview report. 1.16 At the point when the SCR began the government was actively considering how best to respond to the recommendation made by Professor Eileen Munro that a ‘systems’ model should be used to conduct SCRs. 2 The LSCB Chair had brief discussions with the Department for Education and with the Social Care Institute for Excellence (SCIE) about whether it would be possible to seek dispensation from the current statutory guidance in order to use this review as a ‘pilot’ systems SCR. For a number of practical reasons it was not possible to do this. However a decision was made to try to use elements of the systems approach in the way in which the SCR was conducted while adhering to existing guidance. This has resulted in a much greater level of direct involvement of staff in the SCR than would normally occur giving them an opportunity to add important detail to the findings and to test them against their own experience of their work with the family. This has been a useful experience which the LSCB will evaluate as part of its wider learning and preparation for the revised statutory guidance published in draft in June 2012. Staff accounts of their involvement are taken in to account as part of the overall information evaluated by the SCR. Availability of records 1.17 With the exception of the mother’s antenatal records in relation to her first child all of the relevant health and medical records were accessed for the SCR. (TEXT REDACTED) Council was asked to locate educational records for the father because it became clear that he had experienced difficulties going back to his childhood and he had been educated in part in (TEXT REDACTED). (TEXT REDACTED) was unable to locate these records because school records from the relevant period have not been fully archived and indexed. Some limited records were found. Although the inability to locate records is always a concern, neither of these records is likely to contain information which would significantly alter the findings of the SCR.  1.18 All of the other relevant agency records were available for the review and so far as could be established there were no significant gaps in the records.  Appointment of the SCR panel, the SCR panel chair and the appointment and role of the independent overview report author 1.19 (TEXT REDACTED). SCR panel members are senior managers in member agencies or designated professionals with substantial experience of safeguarding children.                                                             2 The Munro Review of Child Protection: Final Report: A Child centred system, Cm 8062, May 2011, The Stationery Office   7 1.20 The SCR panel was chaired by (TEXT REDACTED). This arrangement is consistent with the statutory guidance. He is not employed by any of the agencies involved in the review. He has substantial experience and expertise in child protection services. (TEXT REDACTED). 1.21 The SCR overview report was prepared by Keith Ibbetson. He has no relationship of any kind with any of the agencies involved in the review or to anyone involved in the case or the SCR. He has not previously worked for (TEXT REDACTED) LSCB. He is an experienced author of SCRs and chair of SCR panels. The independent author has not been a decision making member of the panel but has taken the following roles:  to attend meetings of the SCR panel and provide professional advice as required  to review the agency management reviews and to seek out and evaluate along with the SCR panel additional relevant material to corroborate or develop the findings made by agencies  to meet with staff members who were involved in two health agencies in order to discuss their role in the case  to assist the panel in improving the quality of the agency management reviews  to prepare the overview report on behalf of the panel  to present an outline of provisional findings to staff who were involved and receive their feedback and comments  to meet with family members to discuss their views of the services provided  to finalise the overview report taking into account the views of professionals involved, the views of family members and the discussions at the panel  to prepare the executive summary on behalf of the LSCB 1.22 The SCR panel has met on six occasions in order to:   make decisions on the conduct of the review  manage the review so as to ensure that it complied with the statutory guidance  consider progress in the production of agency individual management reviews and chronologies   receive and consider an initial draft of this overview report and of the health overview report  to decide when and how it would be best to engage members of the family in the review  to consider and agree recommendations   to consider a draft action plan  to agree the overview report, the recommendations and action plan and to agree the executive summary for recommendation to the LSCB    8 Quality of Individual Management Reviews and steps taken to improve their quality 1.23 The SCR panel and the overview report writer have scrutinised the quality of the individual management reviews to ensure that they provide a full and objective evaluation of the work of each agency. The quality of the individual reviews has largely been good and some are considered to be of a very high quality. They have all made an important contribution to the findings of the SCR. All of the review writers were asked to clarify points of detail in their reports. The SCR asked for a small number of the reviews to be amended and resubmitted because they did not adequately cover areas that were considered essential. There has been a high level of cooperation in that process and support from all of the participating agencies.  Parallel processes that have impacted on the conduct of the SCR 1.24 The (TEXT REDACTED) Police Service conducted a criminal investigation into the wounding of Child F. The individual management review prepared by the police contains some details of the police investigation and the progress of criminal proceedings. The criminal proceedings have now been concluded and relevant information has been taken into account by the SCR. Agreed extensions to the normal timescale for completion of the SCR 1.25 Chapter 8 of Working Together (April 2010) makes the Chair of the LSCB responsible for determining what action to take when the SCR panel considers that it is necessary to exceed the six month timescale laid down in the statutory guidance for the completion of SCRs. 3 The SCR has over run the timescale by approximately four weeks because of the practical difficulty of starting the review during the Christmas period and because of the additional steps taken (described above) to build some additional aspects of the ‘systems’ approach into the process. 1.26 The SCR panel has been mindful of the need for member agencies to take action in the meanwhile in order implement recommendations while the review continued. The progress made in the implementation of recommendations is reflected in the agency action plans linked to the SCR. Involvement of family members 1.27 It is normal practice in SCRs to seek the views of family members who have been in receipt of services or closely involved with the child. Often this is not possible because of the parallel criminal investigation. In this case it was agreed that it would be possible to do this because, despite the continuing police investigation, as there was no risk that discussion with family members would prejudice any criminal trial.                                                             3 Section 8.23 – 8.24   9 1.28 Unfortunately it has not been possible to obtain the views of the children’s father (who is referred to in the report as Mr B) because it was judged that he remained too ill to understand the purpose of the SCR and to contribute to it in a meaningful way. Individual meetings were held between the SCR overview author and three family members (one of whom was assisted by a close family friend). The purpose of these meetings was to seek the views of family members about the services that were provided and to seek additional information from family members in order to understand the involvement of professionals more fully. The SCR is grateful that family members were able to make a contribution over a recent event that continues to have a severe impact. 1.29 It was apparent that family members were dissatisfied with a number of aspects of the services that were provided and family members have expressed the view that Mr B was badly let down by professionals and that this has had a devastating effect on the family. The views of family members are reflected at a number of points in this report and have influenced its findings. There are however points at which the report reaches a different final understanding of some events than the one held by family members because it has taken into account of all of the information that is available in agency records. (TEXT REDACTED). 1.30 Family members were made aware of the findings of the SCR before they were published. (TEXT REDACTED) The papers constituting the SCR and arrangements for publication 1.31 The SCR consists of the following reports and documents:  the overview report  the combined chronology of agency contacts  the individual management reviews (and background reports from agencies with very limited involvement)  the integrated multi-agency action plan  the draft executive summary     10 2 DETAILS OF FAMILY MEMBERS 2.1 Child F was under a year old when she was injured. She lived with her older brother, her mother, her aunt and her maternal grandmother. 2.2 Child F’s father lived for part of the time in this household and for some of the time with his own mother and her family. 2.3 The father’s own family consisted of his mother, father and four brothers and sisters (three of whom are adults). 2.4 The ethnicity of family members is recorded in different agency records as Black British or Black Caribbean. Records do not identify the religion of family members. The approach taken by agencies to respond to the specific needs of service users from a minority ethnic background are set out in detail in Section 4.7. (TEXT REDACTED)   11 3. Narrative of key events and professional involvement 3.1. Key events and professional involvement in the case history prior to the start date of this review (January 2009) The children’s mother - Ms A 3.1.1. Ms A is in her late twenties. (TEXT REDACTED). She had routine contacts with health professionals, but no significant health concerns. None of the background information obtained by the SCR about Ms A gives any indication of potential risk to her children.  The children’s father - Mr B 3.1.2. Mr B is also in his late twenties. Initial review of his records indicated that he had experienced significant adversity in his childhood and adolescence, including problems in health, mental health, substance misuse and education. The SCR therefore obtained and considered background information about his childhood in order to understand how his earlier difficulties had been addressed by professionals, what his experience of services had been and whether professionals who were in contact with Mr B more recently had had access to relevant information about his past. 3.1.3. Mr B’s GP records were available to the review because along with other members of his family he had attended the same GP practice for many years. Only a very brief summary of school and education records has been obtained because there are difficulties in retrieving some archived education records in (TEXT REDACTED) which the authority has undertaken to investigate further. Mr B also attended schools outside of (TEXT REDACTED) and these records were not sought. 3.1.4. (TEXT REDACTED) Mr B experienced difficulties at school from the age of 8.  3.1.5. (TEXT REDACTED).  3.1.6. It is not the focus of this review to comment in any detail on these childhood adversities or to evaluate the response of services to them. However it is apparent that Mr B did not complete his education and left school with no academic qualifications. Although he later tried to obtain some vocational skills it is evident that his early problems severely limited his later life opportunities.  3.1.7. Mr B was cautioned by police for causing damage to property at the age of 14 and for receiving stolen goods at the age of 15. From age 17 - 21 he was convicted of (TEXT REDACTED) (including the possession and supply of drugs), (TEXT REDACTED). Initial contact with mental health services 3.1.8. Mr B had his first contact with mental health services in his late teens when his parents brought him to A&E. (TEXT REDACTED). He was prescribed an antipsychotic medication as well as medication to reduce anxiety and referred for an urgent outpatient appointment    12 with the Community Mental Health Team (CMHT). He was encouraged to make a self-referral to a substance misuse service. 3.1.9. As a result of the referral Mr B was assessed by a community psychiatric nurse in the mental health intake service. (TEXT REDACTED). The assessment made a referral to a young people’s mental health service and recommended him to continue taking medication, under the care of his GP. Subsequent GP records indicate that Mr B’s mother continued to collect prescriptions for him for a further two years. Later probation records indicate that Mr B would not take his medication on a regular basis despite support from his mother and other family members. He never attended the young people’s mental health centre.  3.1.10. This pattern of contact with mental health services was to be repeated later in the case history:  Mr B’s parents or other family members sought medical help for him  Mental health assessment in the community did not identify any psychotic symptoms or underlying mental illness  Mr B did not engage with mental health services offered   His mother remained motivated to help him and keep up his treatment by collecting prescriptions and medication.  Violent assault in 2006 leading to a lengthy prison sentence 3.1.11. In mid-2006 Mr B violently assaulted another male following a confrontation in the street. (TEXT REDACTED).He received a four year prison sentence.  3.1.12. There are contradictory accounts and judgements as to the role that mental illness played in this episode. On arrest Mr B reported that he had suffered from psychosis for two years and that he had been taking medication. He was medically examined and there were no concerns about his fitness to be interviewed by the police. Mr B linked his actions to perceived threats from the victim and his own involvement in criminal activity. He stated that (TEXT REDACTED) he had acted in self-defence in fear of his life. (TEXT REDACTED) 3.1.13. It is not certain whether family members knew all of the details of this offence or interpreted them in the same way. (TEXT REDACTED) 3.1.14. Whilst on remand at a Young Offender Institution (YOI) Mr B’s mental health deteriorated leading to contact with prison health service health and he was again treated with anti-psychotic medication. A psychiatric report was prepared, though the contents are not known.  3.1.15. At sentencing (TEXT REDACTED) a report commissioned by Mr B’s solicitors and prepared by a Consultant Forensic Psychiatrist was presented to the court. This (TEXT REDACTED) concluded that Mr B’s actions in committing the assault might have been influenced by his mental state, leading him to overestimate the threat posed by his victim. (TEXT    13 REDACTED). The report pointed to the potential for the development of a ‘severe and enduring mental illness such as schizophrenia’. The judge’s sentencing took into account the fact that Mr B had (TEXT REDACTED) been suffering from a mental illness.  3.1.16. Section 4.1 of the SCR overview report comments on the differing diagnoses of Mr B’s condition and his engagement with mental health services over the 8 years before he stabbed his daughter. At this stage it is most significant to note that the reports referred to in the preceding paragraphs were used and known about only in the court arena. The information in the report and the tentative diagnosis that Mr B had an underlying mental illness were not provided to Mr B’s GP or to the mental health trust, despite drawing on local records in compiling the report. The health service had no access to information about health care of Mr B whilst in the YOI. The probation service – which subsequently supervised Mr B for almost two years – had no knowledge of this report. This is a clearly a concern and it is the subject of recommendations in this report.  3.1.17. In 2008 Mr B was released at mid-point of his sentence. His licence condition was the normal one that if he breached the licence he would be returned to prison to serve the remainder of his full sentence. Prior to release he had had had a series of overnight and week-long home visits. (TEXT REDACTED).There appear to have been no concerns about these stays.  3.1.18. On release Mr B reported to his probation officer and was assessed as being a Tier Four (high) risk, required to report weekly to his supervising officer The following areas were identified for work during the supervision period which if not addressed would lead to a heightened risk of reoffending: overall risk, lack of accommodation and employment, substance misuse (cannabis and alcohol) and mental health. Mr B was referred to the multi-agency risk assessment panel (MAPPA) which coordinates the supervision of offenders judged to pose a risk. The case was discussed at two MAPPA meetings. The main focus was on the potential risk of conflict between Mr B and his victim, but professionals believed that this had receded. The second MAPPA meeting agreed that case management would be by the single agency involved (probation) and that there was no need to refer the case back for further multi-agency discussion, unless there were significant new developments.  3.1.19. Probation records state that during his prison sentence Mr B had ‘engaged with mental health services’ so that by the time he was released he was stable and did not require medication. He was strongly warned not to return to cannabis use because it was detrimental to his health. 3.1.20. As part of the supervision arrangement the probation officer referred Mr B to a substance abuse service. This provided an assessment and individual counselling sessions which continued until 2008. In all Mr B attended five sessions. This was a voluntary arrangement and at this time service users’ progress was not reported back to the probation service. During his assessment the father said that he had attended courses in prison designed to reduce substance misuse. Mr B did report having suffered from depression and drug    14 related psychosis, but he did not specifically state when this had been. He reported that he had been abstinent from cannabis for two years (coinciding with his imprisonment) and he reported currently using alcohol, drinking occasionally only.  3.1.21. Information provided by a substance misuse service indicates that Mr B (TEXT REDACTED) does appear to have been genuinely motivated to remain drug free (or to show that at that point he was drug free) and at one point he asked for a drug test. At that time the probation service would not have commissioned a drug test in these circumstances. During this period Mr B had no children or caring responsibilities and this was reported correctly by Mr B to a substance misuse service as part of the assessment. (TEXT REDACTED) 3.1.22. In order to understand his current mental health status and to ensure that he had access to relevant services the probation officer also referred Mr B to the mental health trust. He was assessed by an experienced psychiatrist who noted that Mr B had recently been released from prison (TEXT REDACTED). Mr B reported that he had been monitored and tested for drug use and that he had been clear of cannabis use for 2½ years. At the time of the assessment Mr B had been off all medication for the previous seven months. The assessment did not reveal any signs of a psychotic illness. It described a man motivated to engage in his probation supervision and to attend a substance misuse service. Mr B was discharged back to the care of his GP which appears to be in keeping with the fact there was no evidence of psychotic symptoms despite taking no medication for the previous seven months. 3.1.23. For six months Mr B reported to his probation officer regularly and in compliance with the requirements of his licence. No home visit was made after his release. There is no evidence of offending or contact with the police during this period. The probation officer discussed all of the matters identified in the risk assessment with Mr B and he was believed to be benefiting from the various support services and referrals made. He completed programmes commissioned or provided by the probation service focused on victim empathy and an offending behaviour programme. Training opportunities were arranged in order to promote Mr B’s future prospects for employment. (TEXT REDACTED).Mr B remained under supervision under the terms of his licence until mid-2010. 3.2. Key episodes during the period under review (January 2009 onwards)and their significance in the development of the case history 3.2.1. During March and April 2009 the father reported to his probation officer that he was keeping busy helping family members with informal jobs. (TEXT REDACTED). His probation officer believed him to be drug free and not suffering any mental health problems. 3.2.2. At the end of April 2009 Child F’s mother attended her GP her because of her pregnancy. (TEXT REDACTED) She was seen routinely (TEXT REDACTED) during the pregnancy and there were no concerns. (TEXT REDACTED).  3.2.3. The father continued to report to his probation officer. He spoke of continuing efforts to find work and training. At this point he did not give any information about his partner’s    15 pregnancy. (TEXT REDACTED). During June and July the father attended a number of courses and applied for training opportunities. He attended a further Offending Behaviour Programme which met weekly and as a consequence his reporting requirement in relation to this probation officer was reduced. 3.2.4. In August 2009 the father’s probation officer left her post and he was allocated a new supervisor. The father continued to report regularly. The new probation officer did not consider making a home visit because it was assumed that her predecessor would have done so, but in fact no home visit was ever made. 3.2.5. In September 2009 Mr B told a probation group that (TEXT REDACTED) his girlfriend was pregnant. (TEXT REDACTED) He stated that he was looking forward to fatherhood. He said that he was aware of the extra responsibility and that he would need to earn money. (TEXT REDACTED)  Key events between the birth of Child G in September 2009 and August 2010 when the father reported a deterioration in his mental health to his GP 3.2.6. Child G was born (TEXT REDACTED) in early September 2009. The pregnancy had been without complications. The delivery and post natal period were routine and mother and baby were discharged the following day. 3.2.7. Shortly after the birth of Child G the father reported to his probation officer that he had given up college and was actively seeking work. A week after the birth the father reported that he was adjusting to life with a baby and that it had completely changed his life. He stated that he was fully involved in all aspects of child care intending to seek temporary work to earn more money.  3.2.8. The health visitor’s new birth visit took place at the end of September 2009 at the home of the children’s maternal grandmother and the mother. Health visitor 1 completed the Family Health Assessment with the mother who identified her own health, housing and finances as her main concerns. Child G was reported to be alert and well. The health visitor recorded the details of the father who stated that he lived elsewhere. The health visitor recalled that the father was present at this visit though she did not note this in the records at the time. There was no detailed discussion with either parent about expectations in relation to the father’s role, except that he would be involved and supportive. No information was provided about the father’s history of mental health, drug misuse or offending. The health visitor did not know that the father was under the supervision of a probation officer.  3.2.9. In early October 2009 the father told his probation officer that he (TEXT REDACTED) was abstaining from cannabis. 3.2.10. Shortly after Ms A brought Child G to the child health clinic (TEXT REDACTED). There were no identified concerns and the baby (TEXT REDACTED) was growing steadily and thriving. The mother was advised to attend clinic again in four weeks and to attend her own post    16 natal GP check. The GP post natal checks of mother and baby were routine and satisfactory. Subsequently Child G was taken for clinic checks, immunisations and doctors’ appointments in an entirely routine way and there were never concerns about her health or development. 3.2.11. In late November 2009 the probation service sent a notification to the local authority social care service giving details of the father, mother, Child G and the mother’s address. This was a standard probation trust procedure when an offender under supervision notified the birth of a child with whom he had a close connection. It was not a referral because of concern about the child and it was not asking the local authority to take any action. The notification was received and checked by a social care administrator who confirmed that the individuals concerned were not known and that Child G was not subject to a child protection plan. The address was also checked and it was confirmed that social care were not involved with any child at that address. As the response had not identified child protection concerns or an involved social worker the probation officer took no further action because there was nothing to indicate that there were any risks to the child. No entry was made in relation to such checks on the local authority client index. The value of this notification procedure and subsequent changes in policy and practice are discussed further in section 4.6 below. 3.2.12. Records show that the probation officer used the last supervision session in November 2009 to discuss the father’s previous cannabis use. The father explained how this was no longer a risk factor for him stating that his best friend did not drink or smoke cannabis and therefore was a good influence. The father also stated that (TEXT REDACTED) he was caring for Child G at night and that this was (TEXT REDACTED) positive experience. 3.2.13. (TEXT REDACTED).  3.2.14. During December 2009 – January 2010 the father continued to attend at probation supervision sessions. He reported that at this point he had obtained a (TEXT REDACTED) job on a scheme for ex-offenders. He reported keeping this up for some months. The father continued to describe himself as being very involved in the care of his child (TEXT REDACTED). During February and March 2010 the father continued to report to his probation officer that his home life was settled and positive and he stated that he continued to have worked approximately 25 hours per week and was still seeking further ways to make himself more employable. 3.2.15. In mid-January 2010 the father’s GP records contain a report of mental health review and personal health plan. Mr B was noted to be coping well and working. His mental health was noted to be stable. 3.2.16. (TEXT REDACTED). 3.2.17. (TEXT REDACTED).     17 3.2.18. During April and May 2010 the father continued to report to his probation officer and asked for advice over housing. (TEXT REDACTED). Discussions began about ending the contact with probation as the licence period was due to expire shortly. 3.2.19. In mid-May police records show that the father’s family home was the location of an aggravated burglary during which (TEXT REDACTED) the father’s parents were robbed and threatened with serious violence. (TEXT REDACTED) In August 2010 Mr B told his GP that he had been threatened with a knife during a burglary and that this event had triggered deterioration in his mental health. (TEXT REDACTED). 3.2.20. During May - July 2010 the father had six further contacts with his probation officer. He cited his desire to care for his son as being a motivation not to reoffend and discussed further ways to avoid reoffending with his probation officer. The father continued to be unemployed (TEXT REDACTED) but said that he had not signed for Jobseekers Allowance as he intended to get work as soon as possible.  3.2.21. The final probation appointment was in early July 2010. The review of progress noted that the father had stopped smoking cannabis and that his mental health problems had not recurred. He stated that he was aware of the risks of reoffending and the likelihood of a substantial sentence if he did. The records show that the probation officer believed that the father remained living with his partner’s mother. There were no reports of contact with the police during the licence period and so far as the probation officer was concerned the father had not reoffended. He had no employment but there was no evidence of a reoccurrence of mental illness or substance misuse - the other risk factors previously linked to his offending.  3.2.22. (TEXT REDACTED). August 2010 – deterioration in the father’s mental health 3.2.23. It is not possible to know if there was any connection but within a short time of his probation supervision ending the father reported evidence of renewed substance misuse and deterioration in his mental health. 3.2.24. In mid-August 2010 the father attended his GP with his partner. He said that his mental health had been stable for 2 years. (TEXT REDACTED). 3.2.25. (TEXT REDACTED) Since the recent burglary he had started smoking cannabis and had developed paranoid thoughts that people were talking about him. He said that he had started to avoid going out and that he had been unable to sleep. He said that he lived with his partner. He appeared to be withdrawn and was emotionally ‘flat’ giving vague responses to questions. He denied hearing voices and he was not aggressive. The father’s GP made a detailed referral to the mental health services. (TEXT REDACTED). The GP had prescribed an antipsychotic medication and (TEXT REDACTED) asked the father to return to the surgery if his condition deteriorated. This referral makes no reference to Child G. There is no indication in the records that the GP knew that Mr B shared responsibility for a child.    18 The SCR has established that the GP who knew the family best did know that Mr B had become a father through his general knowledge of the family, but it is not certain whether he knew this at this time. This is discussed in section 4.3. 3.2.26. The mental health trust notes contain no detailed record of this referral. However there is evidence that Mr B was offered an outpatient appointment because there is a copy of a letter from the mental health trust in the GP records (dated late September) indicating that the father had failed to attend an appointment. It is not known why he did not attend. There was no further follow up in relation to the missed appointment by the mental health trust or the GP. The father also failed to attend a review appointment at the GP surgery. 3.2.27. A month after the initial appointment the father contacted the GP surgery seeking further medication (TEXT REDACTED) and he was offered an appointment that afternoon - which he did not keep. The next contact that the father had with professionals over his mental health was almost a year later in October 2011, approximately a week before he stabbed his daughter. Key events between October 2010 and October 2011 3.2.28. In late 2010 the mother attended her GP to seek confirmation of her second pregnancy. The mother was (TEXT REDACTED) given advice about some minor health concerns. (TEXT REDACTED) She did not provide the GP with any information about the identity of the father or his circumstances. This is considered further in section 4.3. As a result and because the mother and father had different GPs the antenatal referral contained no information about the father or any potential risk related to him. 3.2.29. The mother attended the scheduled maternity ‘booking appointment’ in late October 2010 when it was documented that (TEXT REDACTED) she lived alone with her one year old son. (TEXT REDACTED) No details of the father were provided. (TEXT REDACTED). Notification of the pregnancy was sent to the community health service including a midwife risk assessment and proposed shared ante natal care arrangements. As the only risk factors identified were (TEXT REDACTED) minor medical ones there was no reason for an antenatal visit to me made by the health visitor and no action was taken until after the birth. There were no later concerns about the mother or baby in the antenatal period. 3.2.30. (TEXT REDACTED). 3.2.31. There were no significant events involving the father during the pregnancy, though he began to have a number of minor contacts with the police. (TEXT REDACTED). No arrest or prosecution arose from these episodes. 3.2.32. Child F was born in early 2011. The delivery was routine. The following day a hospital notification of birth was received in the (TEXT REDACTED) Child Health Department and forwarded to the local health visiting team (TEXT REDACTED). The new birth visit was allocated to a new Health Visitor and took place at age 13 days, (TEXT REDACTED).     19 3.2.33. During the home visit both children were seen along with Ms A and the children’s maternal grandmother. The father was not present but his details were recorded. The health visitor was told that the father lived elsewhere, but that he continued to be supportive. Both children were well and the health visitor had no significant concerns. The health visitor (TEXT REDACTED) gave advice about (TEXT REDACTED) the heightened risk of cot death associated with smoking (TEXT REDACTED). The Family Health Assessment was undertaken. This was a booklet which the mother completed asking for self-reported information about both parents. It was recorded that the general health of both parents was good. No details of the father’s mental health problems or of his cannabis use were provided by the mother when she completed the family health assessment, although the document has sections that refer to these issues. The mother reported that she had a good network of family support. The outcome of the new birth visit was that no specific risks were identified and the mother was invited to attend child health clinics and to seek additional advice if needed. 3.2.34. (TEXT REDACTED) Section 4 considers the approach taken by professionals to obtaining information about fathers. 3.2.35. Over the following six months the mother was offered four clinic appointments for Child F and she attended twice. On each occasion there were no concerns about Child F’s health and development and she continued to gain weight in line with normal expectations. Advice was given in relation to a number of routine health matters. The mother made and kept GP appointments for developmental checks, primary immunisations and her own post natal check. No significant concerns were noted. (TEXT REDACTED). 3.2.36. The last health visitor contact with the mother and Child F was in late May. Child F was not brought to a scheduled clinic appointment in July 2011. Child F was not brought to the GP for second primary immunisations at the GP surgery in June, but these were given at an appointment in August 2011. This was the last contact that primary care professionals had with Child F prior to the incident in which she was injured in October 2011. A GP appointment for the third primary immunisations was missed on 19 September. There was no immediate follow up by the GP. 3.2.37. In late May 2011 the father was stopped on two further occasions by police. On both occasions his behaviour had given rise to strong suspicion about possible drug possession. (TEXT REDACTED) Family contact with professionals in the week prior to Child F being injured 3.2.38. In mid-October 2011 Mr B was taken to an appointment at his GP by a member of his family who was concerned that he was (TEXT REDACTED) smoking drugs again and as a result behaving oddly. (TEXT REDACTED) This was four days before Child F was stabbed. 3.2.39. (TEXT REDACTED) When asked about his mental health Mr B stated that there was nothing wrong and that he had no paranoid thoughts. However he mentioned that everyone was    20 ‘saying things about him’ or (TEXT REDACTED) had ‘bad thoughts about him’. (TEXT REDACTED). The family member described how Mr B was locking himself in his room. He confirmed the information in the GP records that the father had taken medication in prison but that he had not taken anti-psychotic medication for some two years. 3.2.40. The father agreed to be referred to the mental health trust Primary Care Liaison Team and it was noted that his mother could be contacted over the appointment if needed. The GP requested an urgent appointment within the next two weeks. There is no evidence that Mr B was asked any questions about any caring responsibilities towards children or children with whom he might have contact. This GP did not know from the records that Mr B was a parent and was viewing him as part of his own family of origin. Family members told (TEXT REDACTED) the SCR that they were disappointed that Mr B had not been given medication. They say that they were advised that the appointment would come in 7-10 days. There is no confirmation of this in the GP records. 3.2.41. Later records in the mental health trust show that the referral letter was sent by post (rather than being faxed) arriving on the morning that Child F was injured. The referral was acknowledged to the GP immediately and Mr B was offered an appointment approximately four weeks later. The mental health team did not know that Child F had been injured when they dealt with the referral. 3.2.42. Two days after the GP appointment Mr B’s mother telephoned his GP again because her son was not sleeping at night and ‘his mind was racing’. He was awaiting the mental health service appointment but she said that she was unsure if he would be able to take it up as he might not pick up calls on his mobile phone because he was anxious and suspicious. This was 36 hours before Child F was stabbed. 3.2.43. Mr B’s mother spoke to another GP who agreed to prescribe a small dose of sleeping tablets for the next seven days. The family’s account is that the grandmother went to the surgery to collect this prescription urgently and it was agreed that she would also call Mr B’s own GP the next day to explain the circumstances and ask the GP to chase up the referral that had been made to the Primary Care Liaison Team by phoning the on call mental health worker. Subsequent records show that Mr B’s partner did go to the GP the following morning, but there is no evidence that any contact was made with the mental health trust to hurry up the appointment. Mr B’s attendance and mental health assessment at A&E 3.2.44. That evening the father presented at A&E (TEXT REDACTED), initially with his mother and joined shortly afterwards by his partner. This episode began approximately 30 hours before Child F was stabbed.  3.2.45. Mr B was first seen by a triage nurse. (TEXT REDACTED). The nurse took (TEXT REDACTED) samples and requested a medical assessment. She noted that Mr B had not slept and that he had been very anxious for two days and she noted the medication prescribed by the GP. The notes include the term ‘PMH (previous medical history) – induce psychosis’. The senior    21 nurse recorded the reasons for referral to the psychiatric team as ‘?drug induced psychosis’. 3.2.46. 30 minutes later Mr B was seen by an A&E doctor who (TEXT REDACTED)noted that he had been exhibiting paranoid, angry and erratic behaviour; he was also noted to be tearful and suffering from insomnia, based on the history given by his mother. The A&E doctor noted that Mr B had suffered from ‘induced psychosis in 2004’ and that he had been treated with (TEXT REDACTED) medication for two years. Mr B stated that he was ‘scared of gangs’ and that he had ‘lost a lot of family over the last year’. The medical record states that he ‘denied hearing voices or seeing things’ and the risk assessment recorded was that he was ‘no risk to others’, no risk to self – not suicidal’ and ‘no risk from others but paranoid’. 3.2.47. Mr B attributed his condition to smoking too much ’weed or skunk’. According to his mother, he had had similar episodes earlier in the year (2011). She reported that ‘when he is like this’ he could smoke up to 40 cigarettes a day and drink up to 2 bottles of brandy, ‘but not most days’. Mr B said that he had not smoked skunk (TEXT REDACTED) for about four weeks. The family’s account is that the doctor said that she did not believe this and told him, though that is not recorded in the notes. It was recorded in the A&E notes that Mr B lived with his girlfriend and their children.  3.2.48. The A&E doctor prescribed antibiotics for a chest infection and told Mr B to return to A&E or to go to his GP if (TEXT REDACTED) his physical health deteriorated. His family say that he was reticent to take this medication as he was worried about his state of mind, rather than any infection. Mr B was also referred to the (TEXT REDACTED) Mental Health Crisis Resolution Team (which as part of its function provides a mental health assessment service within the A&E department) noting the possibility of a drug-induced psychosis. He was also strongly advised to reduce his consumption of alcohol and drugs. 3.2.49. The team which offered a service to the A&E department on this evening consisted of an experienced mental health worker on rota who had access to advice and support on call from a junior doctor in her second year post qualification who was undertaking her training in adult psychiatry. Mr B was seen shortly after midnight by them both which was the practice of the service in relation to new patients. Prior to seeing Mr B the mental health worker checked for records of Mr B on the mental health trust’s information system and recorded basic details of the referral.  3.2.50. As this was the last assessment and the last substantial professional contact with Mr B before he injured his daughter the records of this contact have been reviewed closely and the incident has been discussed with the staff involved. The contact has also been discussed fully with family members who are critical of the assessment that took place. The assessment is evaluated in detail in section 4.3 of this report. The following paragraphs set out (TEXT REDACTED) the best possible reconstruction of events, taking into account all of the sources of information available. Where there are discrepancies between the records,    22 the recollections of the professionals and the recollections of family members these are noted. 3.2.51. The mental health worker recorded the reason for the referral as follows: ‘drug induced psychosis – paranoid – scared of going out. Erratic, angry’. 3.2.52. The check made on the mental health trust electronic information system showed that Mr B had been a trust patient in the past but did not give details of contacts, assessments or diagnosis. This was because records of Mr B’s earlier contacts had not been transferred when the trust had adopted a new electronic recording system. This was because his previous contacts with the trust had only been very limited (as described earlier in this section of the report) and because as far as the mental health trust was concerned his mental health had not posed a risk of harm to himself or to others. This is discussed further in section 4. 3.2.53. The junior doctor and the mental health worker carried out a mental health assessment of Mr B. The professionals both recollect firstly briefly interviewing Mr B alone, then seeing him with his mother, until she left the interview and then with his partner. A very close family friend arrived separately but was not interviewed as part of the assessment. Family members told the SCR that they do not recall Mr B being seen on his own.  3.2.54. According to the doctor and the mental health worker Mr B was seen alone only briefly (for two to three minutes) and provided relatively little information before they decided that it would be best if his mother joined him. During discussions when his mother was present Mr B was very open about his recent very heavy use of drugs and alcohol. He said he had a ‘spliff’ for breakfast and continued to smoke cannabis (including very potent ‘skunk’ that he said people called ‘Amnesia’) and drink throughout the day. According to the mental health records he was also very frank about his involvement in the supply of illegal drugs and the money he made from this. Mr B’s mother said that he had used cannabis for the last 6 years. Mr B said that he felt his symptoms were due to his drug use and he added that he did not suffer from any mental illness. Mr B’s mother said that it was important for him to be very frank about everything that was going on. 3.2.55.  It was noted that in the past Mr B had been diagnosed with drug induced psychosis on three occasions and treated with medication. The doctor states that she quizzed Mr B and his mother as to where this diagnosis had been made (whether it was by the GP, a psychiatrist or in prison) but Mr B did not provide any details. She was aware that he had been in prison and formed the impression that this had been because he had been involved in a fight. 3.2.56. The assessment was not able to elicit any symptoms of psychosis or other mental illness (such as depression) arising either from Mr B’s recent drug misuse or from an underlying mental illness. The mental state examination indicated that there was no formal thought disorder and no evidence of auditory or visual hallucinations. Mr B showed no evidence of    23 thoughts of harming himself or others. He was noted to have ‘full’ insight, suggesting that at this point the clinicians believed that there was a rational connection between his explanation for his symptoms and his account of his own behaviour. 3.2.57. Mr B’s mood was recorded by the doctor to be ‘objectively slightly paranoid and anxious’ but ‘subjectively paranoid’ (which is taken to mean that Mr B said that he felt paranoid but that in psychiatric terms he was not experiencing paranoid delusions). The assessment noted that his paranoia was ‘exacerbated by weed use’ and that the basis for his fear and suspicion of others was in good part grounded in reality. It was recorded that ‘he often feels paranoid in public, as well as in the area that he lives, which he describes as being unsafe (shootings etc.)’. Subsequently the mental health worker has confirmed that insofar as Mr B was anxious and erratic in his behaviour she believed that it was due to the large amount of cannabis and alcohol that he was consuming and the stress and insecurity caused by being involved in risky criminal activity. 3.2.58. The clinicians say that family members were also very surprised by his account of the extent of his drug use (TEXT REDACTED). They state that family members did not provide any additional information about Mr B’s paranoid behaviour or other psychiatric symptoms.  3.2.59. The outcome of the assessment was that Mr B was believed to be experiencing symptoms consistent with heavy drug and alcohol use (TEXT REDACTED). The judgement was that there was no indication that he presented any immediate risk to himself or others and that he had very good family support at home. The medical records state that Mr B indicated that he had no thoughts about harming himself or others and that at that point he had ‘full insight’ into his circumstances (i.e. he himself had a very good idea what it was that was making him feel paranoid). In contrast Mr B’s partner told the SCR that she remembers Mr B saying he had suicidal intent. However there is nothing in the medical record to support this and the written records state the opposite. 3.2.60. The management plan formulated was for Mr B to be allowed home and discharged back to the care of his GP who had already made a referral to the (TEXT REDACTED) Primary Care Liaison Team. Mr B and the family were given up to date information leaflets about local drug and alcohol services. The clinicians state that they felt that this plan had involved Mr B and his family and that they were in agreement with it. Mr B was given (TEXT REDACTED) one dose of a medication to help him sleep that night and the mental health worker agreed to expedite the referral that was already in place to the mental health service. Family members say that they questioned whether more needed to be done. 3.2.61. The assessment was documented on the trust electronic record system. The mental health trust risk documentation was not fully completed at the time of the assessment. Family members state that when he returned home Mr B took the medication (TEXT REDACTED) prescribed by the doctor at the hospital and the one earlier prescribed by the GP. (TEXT REDACTED). This was some 24 hours before Child B was stabbed.    24 3.2.62. For their part family members have expressed frustration and disappointment to the SCR about this assessment (and also directly to the mental health trust). They have expressed concerns about some remarks made by the doctor and the mental health worker which they feel conveyed a negative attitude towards the family. Mr B’s partner did not think that there was sufficient probing in depth of his mental and emotional state and how he was feeling. The close family friend was present at the hospital though she did not sit in during any of the assessment. She has had some experience of mental health assessments before and states that she was surprised how short a time the assessment lasted. The children’s maternal grandmother was not present at the hospital. However she states that she believes that there should have been a longer assessment. With hindsight all family members feel that too much emphasis was placed on Mr B’s self-reported misuse of cannabis and alcohol. They now state that they find the extent of his reported consumption to be implausible and feel that this detracted from a fuller exploration of his mental health needs. Family members state that Mr B was willing to be admitted to hospital and that this is what should have happened. (TEXT REDACTED) Family members believe that they did everything that was possible to get help for Mr B in the days before he stabbed his daughter.  The assessment of potential risk to the children at A&E 3.2.63. The A&E doctor recorded that Mr B lived ‘with girlfriend and children’. The doctor who undertook the psychiatric assessment recorded that Mr B was ‘currently in a relationship with girlfriend with whom he had two children’ correctly noting their ages. (TEXT REDACTED) Based on the records available and interviews with the staff involved it is agreed that no specific information was recorded about exactly where the children lived or the nature and extent of Mr B’s contact with them or his caring responsibilities.  3.2.64. No one present during the assessment perceived there to be any risk at all to the children or stated any concern in relation to this. The doctor and the mental health worker say that they were reassured about the welfare of his children by the following factors: 1) Mr B was not being aggressive or violent at all 2) He was affectionate to other family members, particularly his partner 3) Mr B spoke about his children in a very positive way and he specifically cited his desire to be a better father as his main reason for wanting to stop taking drugs and drinking 4) The clinicians were reassured by the presence of key members of the extended family who they felt mitigated any potential risk –both in relation to Mr B’s mental health and in relation to the care of the children. The mental health trust provides a format for recording the risk assessment in relation to patients and service users who have contact with children. This was not completed at the time of the assessment. The wounding of Child F 3.2.65. Mr B’s partner told the SCR that (TEXT REDACTED) although he had taken the medication she did not believe that Mr B slept that night. Later that day Mr B’s partner telephoned Mr B’s GP surgery. She explained that Mr B had been seen at A&E (TEXT REDACTED) and had    25 been told to contact the GP surgery to ask for a further prescription. She states that she did not know what dose had been given to Mr B by the doctor. Additional medication was prescribed to help Mr B sleep. This was the last professional contact with any family member before Child F was stabbed.  3.2.66. Ms A describes Mr B as being calmer the next day, but emotional, clingy and very childlike. She states that Mr B was in all day and so far as she is aware he did not take any drugs or consume any alcohol. She recalls that before he went to bed he spoke to her about winning the lottery. (TEXT REDACTED). This was based on a story in the newspaper, but Mr B genuinely believed it related to him.  3.2.67. The account provided by family members is that Mr B woke family members in the small hours (TEXT REDACTED). After a few minutes it was clear to everyone that he was becoming more agitated and behaving and speaking in a very odd way and Mr B’s partner called 999 speaking first to the emergency call handling centre and then to the police operator. (TEXT REDACTED). Ms B’s partner told the operator that he had mental health problems (TEXT REDACTED). At the time of the call Mr B was not holding a weapon. Police officers and an ambulance were dispatched – the police officers to attend the home as quickly as possible and the ambulance was asked to wait at a rendezvous point 200 yards away which it did. Both responded to the children’s mother’s request not to use their lights and sirens as this would frighten and agitate Mr B further. 3.2.68. After initially being calm Mr B had become more agitated and grabbed Child F, holding her to his chest. Before the first two police officers directly approached Mr B (TEXT REDACTED) they were told by family members that he was now holding his child and behaving in a threatening way with a knife. Given the potential seriousness of the circumstances approximately ten more police officers arrived at the scene. When police officers entered the room Mr B was holding Child F, holding a knife in a menacing way and speaking in a deluded way. In the course of a brief standoff it became apparent from blood on her clothing that Child F had been stabbed.  3.2.69. Mr B had also cut himself (TEXT REDACTED) and he was restrained and arrested. Child F was noted to have suddenly gone very quiet and because of the urgency of the circumstances she was conveyed immediately to the nearest A&E department (which is a very short distance from the family home) in the police car. This was with the agreement of her grandmother who accompanied her. (TEXT REDACTED). During the journey there was dialogue between the police operator, the ambulance service and the helicopter emergency medical service (HEMS) which had also been dispatched. HEMS asked the police to keep Child F at the scene as they believed that they could provide better immediate care than the hospital. Police records show that this message did not reach the police until they were 800 yards from the hospital, so a decision was made to continue. Child F was treated in A&E at the hospital before being transferred by HEMS to another hospital.    26 3.2.70. Child F’s grandmother was interviewed by the A&E sister at the hospital who recorded the following her account about Mr B in the medical notes as follows: ‘Grandmother informed me before mother’s arrival that (Mr B) had been @ A&E yesterday after a 4 day history of not sleeping with associated agitation… ?Secondary to smoking skunk / cannabis. Was discharged home. ? plan of Rx (plan of care)’ and then described the incident in which the infant had been injured. (TEXT REDACTED).  3.2.71. According to police records Mr B was arrested for attempted murder and treated by the ambulance service at the scene where his self-inflicted cuts were found to be superficial. (TEXT REDACTED). He was taken to hospital for further medical assessment and then to a police station where he was taken into police custody where a mental health assessment was arranged. 3.2.72. (TEXT REDACTED) The descriptions of Mr B’s behaviour given by those who were present (TEXT REDACTED) when he injured his daughter indicate that he was floridly psychotic (TEXT REDACTED) and that there had been a significant deterioration in his mental state since he was seen at A&E.  4 Evaluation of practice 4.1 Structure of the findings of the SCR Introduction 4.1.1 This chapter of the SCR overview report evaluates the effectiveness of the services provided to the children and other family members and the actions taken by professionals in order to identify any possible risks to the children and to safeguard the children. It examines the provision made by agencies individually and by the network of professionals who have responsibilities to safeguard children as a whole. The findings of this report draw on the individual management reviews. This summary has also taken full account of the overview of the case made possible through the scrutiny of all of the available information as well as discussions in the SCR panel meetings and discussions with the authors of individual agency reviews. Relevant documents were made available by participating agencies to the author and the SCR panel.  4.1.2 The evaluation contained in sections 4.2 – 4.10 provides the best account that can currently be given of the effectiveness of the services provided to the children, based on the information available from all agencies and the views of family members. It has not been possible to interview Mr B about this because during the time when the SCR was being carried out he remained too ill to make a meaningful contribution to the review. 4.1.3 In this SCR the evaluation in the overview report serves two functions. First it evaluates whether the actions and decisions of agencies with child protection responsibilities had any bearing on the episode in which Child F was wounded. The SCR has sought to establish    27 whether agencies had any evidence to suspect that the children were at risk of suffering serious harm and whether the incident involving Child F could have been prevented if agencies had been able to take different decisions or act differently. Second the SCR provides a wider evaluation of the services provided to the children and their family during key episodes in the case history. The objective is to identify whether there are any lessons that can be learnt so as to improve safeguarding services, independently of any possible link to the harm caused to Child F. Judgements about the actions and decisions made by professionals 4.1.4 The Working Together guidance requires that the SCR should bring hindsight to bear in evaluating the actions of professionals and public bodies.4 Self-evidently there is value in seeking to look back objectively at a case history, knowing the outcome and with a fuller knowledge of the events and the actions taken by all of the professionals who were involved. However as well as the insight that comes from hindsight the SCR is aware of the danger of what is termed ‘hindsight bias’. 5 This arises when the evaluation is unduly influenced by knowledge of the outcome. 4.1.5 So far as is possible the SCR has therefore sought to avoid hindsight bias. In some circumstances it is easy to criticise the decisions and actions of professionals because it can now be seen that they were part of a chain of events that had a tragic outcome and they are judged out of the context in which they occurred. Much more valuable learning can be obtained by seeking to understand and explain why actions were taken and decisions were made and to consider the influences over professionals arising from the context within which they were working. It is only possible to learn lessons that are relevant to other professionals who may be working in similar circumstances if hindsight bias is set aside. 4.1.6 When evaluating the actions of individual practitioners and managers and groups of professionals and agencies the SCR has taken the following approach. Judgements about actions and decisions take into account the information that was available to those who took them. At certain points it is necessary to evaluate the overall service provision in relation to information that was known to the network of child protection professionals as a whole and would have been available if relevant information had been sought and provided. The review has sought to judge the actions of professionals and agencies against established standards of good practice as they were believed to apply at the time when the events in question took place. The evaluation will distinguish and outline the influence of individual and wider organisational factors in the decisions and actions taken by individuals as well as focusing on the individuals themselves. Structure of the evaluation                                                            4 Working Together to Safeguard Children 2010, Chapter 8 describes the evaluation in the overview report as being ‘the part of the report where reviewers can consider, with the benefit of hindsight, whether different decisions or actions may have led to an alternative course of events.  5 David Woods et al, Behind Human Error, Ashgate (2010) second edition;  Sidney Dekker, The Field Guide To Understanding Human Error, Ashgate (2006)    28 4.1.7 This chapter of the SCR overview report addresses all of the matters set out in the specific terms of reference of this review and others that all SCRs are required by Working Together to Safeguard Children to address. The evaluation in this chapter begins by describing the roles of different professionals working with different family members. The remainder of the evaluation is presented as follows:  Was there evidence of risk factors from the period prior to January 2009? Did information about them inform later professional contacts with the family?  What assessments were undertaken and what was the quality of those assessments?  Were plans made to provide services consistent with assessments and were they fully implemented?  Did agencies respond appropriately to any risk factors identified in the course of their work with the family?  Did the activity of agencies focus on the needs of children?  What was the quality of information sharing and joint working within and between agencies?  Did any issues arise in the work with the family that prompted, or should have prompted, agencies to seek information from agencies involved before the start date of the review?  Were the specific racial, cultural and religious needs of the family recognised and responded to? Were any other matters relating to diversity addressed?  Did staff have the knowledge, skills, and experience to respond to the needs identified in the case?  Were staff appropriately supervised and supported in their work with the family?  Did any capacity issues within the agency limit the ability of the agency to meet the needs of the family? The section concludes with a summary of the key findings and learning and an assessment of whether the wounding of Child F could have been anticipated or prevented? Preliminary theme arising from an overview of the narrative of events – the separation of professional attention on different family members 4.1.8 The evaluation will consider all of the matters arising from the terms of reference in detail. However there is one key pattern that is easily discernible from the narrative and underpins many of the other review findings. The narrative shows how across all of the key events there were two distinct groups of professionals who had contact with different members of the family. 6 As this strongly influences many other aspect of the evaluation it is useful to set out a brief overview of the pattern of services provided to the different                                                            6 The following paragraphs give only a broad overview. Section 4.6 focuses on the joint working and information sharing between professionals in detail. In particular it will examine the points in the case history at which there were opportunities for individuals to share information and collaborate across the professional network.     29 members of the family before evaluating specific issues such as risk assessment and service provision.  4.1.9 A small number of professionals were in contact with the children’s mother. She had contact with her own GP and midwives in relation to her own health and her antenatal care. She then had contact with health visitors and the same family GPs over the health of her children. The father had a different GP. The mother’s family GP and the midwives did not know the identity of the father and they had no contact with him. The health visiting records show that health visitors asked for and recorded basic details of the father. Neither of the family health visitors recorded having direct contact with Mr B, though one recalled having met him on one occasion. Child F’s mother told the SCR that both health visitors met the father. The question of knowledge about the father is discussed in detail in section 4.3. 4.1.10 On his side the father had contact with a number of professionals arising from the offences that he had committed, his drug misuse and his mental health problems. His family GP knew him and treated him as part of a family unit in which the key people were his mother and his siblings, whom the GP had known for some years. Mr B’s GPs knew from his contact with Mr B’s mother that he was a father but he never recorded this fact in his notes and he never asked Mr B directly whether he had responsibility for any children. Other members of the practice did not know this.  4.1.11 Mr B had limited contacts with professionals in the mental health trust in 2004 and 2008. These contacts were all very brief as when he was examined in a community mental health setting he did not show signs of a serious or enduring mental health problem and so was never allocated to the service or appointed a care coordinator. On both occasions he was discharged back to the care of his GP and referred on to other services (the young people’s mental health service and drug services) which he did not attend. In 2010 a further referral was made but Mr B did not keep the appointment and it cannot be confirmed that he received it. In 2011 a further referral had been made by the family GP to the local mental health service shortly before Child F was wounded.  4.1.12 Mr B was supervised by two different probation officers during 2008 - 2010. They made referrals to the mental health trust focused on his possible mental health needs and for support from substance misuse services. Probation officers focused on work required to reduce the risk factors that they believed had contributed to his offending.  4.1.13 There was no contact between these two groups of professionals at all. There were a small number of times when it might have been possible for the professionals who were dealing with Mr B to bridge the gap between the two sets of professionals and to consider the potential impact of his behaviour on his children. A brief account of these shows that this did not happen for different reasons at different times. 4.1.14 The family health assessment format that was used by the health visitors during the two new birth visits invites the parents to offer information about themselves, their relationship and the wider family environment. The mother chose not to provide    30 information about his history or any current risk factors, either during the new birth visit or at any other time. As a consequence the health visitors did not know that Mr B had a conviction for a serious violent offence against an adult or that (until mid-2010) that he was in regular contact with a probation officer.  4.1.15 When his first probation officer became aware that Mr B had a child a notification was sent to the local authority to find out if the child was subject to a child protection plan or if the family were known. The replies were negative. Section 4.6 evaluates this contact. By the time Child F was born Mr B was no longer subject to licence requirements and no longer had contact with the probation service.  4.1.16 During the A&E assessment that took place 24 hours before the wounding of Child F, mental health service professionals were aware that Mr B had children and lived in the same household with them. They had only brief contact with him and the only information about his history of mental health problems was information provided by Mr B and his family. Their assessment was the first one which was able to any degree to take account of possible risks to the children arising from his mental health and substance misuse because they were the first to know of a direct connection at a time when he was not functioning well and seeking support. Section 4.3 evaluates this contact in detail. The most important factor that limited the extent to which this assessment could thoroughly assess potential risk to the children was that it took place within the A&E setting. This is explored further in section 4.3. 4.1.17 Having noted as an initial point of evaluation that discrete groups of professionals worked with different members of the family, it is important to note that this is not necessarily a criticism. This may have been entirely ‘normal’ and understandable. Given their roles and the nature of the risks identified it may not have been considered necessary for them to communicate with one another. This is discussed in detail in section 4.6. The evaluation of mental health services and the nature of Mr B’s mental health problems 4.1.18 The primary focus of the SCR is not on mental health or substance misuse services provided to Mr B. However given the key events in the case history the SCR panel and the overview author have considered these carefully, focusing on the implementation of the responsibilities of mental health services to safeguard and promote the welfare of children. Where this touches on the wider provision of mental health services the findings of the report have been discussed with senior representatives of the mental health trust who have both clinical expertise and relevant management responsibility.  4.1.19 At different points in the case history psychiatrists gave different diagnoses of Mr B’s mental health problems. When Mr B’s mental health was assessed in local community settings (2004, 2008 and 2011) his paranoia and anxiety were always understood to have been linked to or triggered by misuse of cannabis and alcohol. None of the assessments that took place elicited any clear evidence of psychotic thought patterns. When the extent of his criminal activity was factored in, this was identified as being an understandable    31 cause of real fear and anxiety for him. His strategy of smoking significant amounts of strong cannabis and drinking to reduce his anxiety are likely to have worsened his symptoms and his vulnerability. There were long periods when Mr B was not taking medication and he remained free from psychiatric symptoms. These usually coincided with times when he reported that he was not taking cannabis.  4.1.20 On the one occasion in 2006 when Mr B was assessed and treated within the prison system the psychiatrist arrived at a different view, stating that he believed that Mr B was suffering from an underlying psychotic illness and that there was the potential for the development of a ‘severe and enduring mental illness such as schizophrenia’. It has been noted that this assessment was only ever used in the court setting where it influenced sentencing to Mr B’s benefit. This finding, the assessment that it was based on and his health records while in prison were never made known to Mr B’s GP or to others in community mental health settings. 4.1.21 It is not the role of this report to judge which diagnosis was correct. Moreover it would be impossible to do so. Psychiatric diagnosis is often difficult and uncertain. Some patients closely and consistently fit diagnostic criteria. The behaviour of many others will fluctuate a great deal leading them to be given different diagnoses at different times. In some cases psychiatrists only feel able to offer a firm diagnosis after they have observed the impact or lack of impact of treatments. It would in any event never be possible to prove that Mr B did not have an underlying mental disorder. The role of cannabis as a trigger or a cause remains unclear. 4.1.22  It is clear that the nature of Mr B’s mental health problems did vary a great deal. In particular it is clear that his presentation and behaviour in the episode during which he wounded his daughter was drastically different from any account of his previous behaviour and drastically different from the way that he had presented to professionals 24 hours earlier.  4.1.23 The remainder of this report will refer to Mr B’s ‘mental health’ and his ‘mental health problems’ rather than to any specific psychiatric condition. The purpose is not to minimise the nature of his difficulties, but to underline that it is impossible to be certain what caused them. It is also important to underline that the primary focus of concern of this report is to understand whether the professionals who were aware of his mental health problems were sufficiently mindful of the potential impact on his children.  4.2 If there is evidence of risk factors from the period prior to January 2009 establish whether or not information about these risk factors informed later professional contacts with the family 4.2.1 There is no significant information about risk factors in relation to the mother or other members of her family during the period prior to the terms of reference of the SCR. There is no indication that any important information about risk in relation to the mother was not    32 known to professionals. No information about risk factors in relation to the mother or other members of her family has subsequently emerged. 4.2.2 Sections 3.1.2 – 3.1.22 above give an outline of the considerable difficulties that Mr B experienced during his childhood and adolescence. This included:   (TEXT REDACTED)   Chronic cannabis use which the family stated occurred from age 12 onwards  Educational and behavioural difficulties resulting in school moves and eventually permanent exclusion from secondary school  Involvement in petty offending and convictions associated with the illegal supply of drugs from age 16 onwards   The onset of anxiety disorders and psychosis associated with his sustained drug misuse, first recognised in late adolescence. 4.2.3 In 2006 Mr B committed a serious violent offence against another adult, by his own account this was linked to his involvement in the illegal supply of narcotics and at time when he was a heavy cannabis user. While he was on remand in a Young Offender Institution his mental health deteriorated. 4.2.4 Taken together the combination of violent offending, drug misuse and mental health difficulty (whatever its cause) might easily have had a significant negative impact on Mr B’s capacity to parent children in a safe way. The narrative indicates that - until Child F was injured - they did not. The reasons for this cannot be known fully but it is likely that the following are relevant:  When Mr B first became a parent he was on licence to the probation service and (according to his own accounts and some supporting evidence) he was not using cannabis and he was not committing offences. The evidence is that his pattern of cannabis use changed after his licence supervision ended  Although there is abundant evidence that Mr B cared deeply about what happened to his children, it is not possible to be absolutely certain how much day to day responsibility he had in caring for them  Had he behaved in a way that placed his children at risk it is very likely that other members of the family would have been concerned and acted to protect them against any risk. 4.2.5 The report is concerned to establish whether the professionals who were involved with the family knew about these potential risks.  4.2.6 The professionals who were most directly involved with the mother and the children knew little or nothing at all about Mr B. They were not in a position to assess the potential risk and relied on their observations and evaluation of the children to judge whether they were living in a safe environment and developing well. The evidence was that they were and that the mother was taking the steps necessary to promote their health and development. She missed a small number of appointments but this was not considered unusual or concerning.    33 4.2.7 The probation officers who supervised Mr B were aware of his criminal record and the general pattern of his behaviour and offending. Substance misuse and mental health were identified as risk factors when supervision began and updated assessments were requested and provided. At that point Mr B did not have children.  4.2.8 After the birth of Child G in 2009 the probation officer established from the local authority that the child and family were not known to the local authority. This is discussed in section 4.3 below. 4.2.9 The psychiatrist who assessed him in 2008 knew about key aspects of Mr B’s history and convictions, but again at that time he did not have children.  4.2.10 Mr B did not keep his appointment when his GP referred him to the mental health trust in 2010. Mr B did not attend the planned GP review and the GP did not re-refer him. At that time he had one child and the extent of his responsibility for the child could have been explored if a mental health assessment had taken place.  4.2.11 The mental health professionals who assessed him at the A&E department in 2011 established that he had children. They had no access to information about his mental health history or his previous offending though he gave a frank account of his current lifestyle and indicated that he had previously suffered from drug induced psychosis. Their assessment could not take full account of the historical indicators of potential risk. This assessment is discussed in detail in section 4.3. 4.2.12 The most significant aspect of the history that remained inaccessible to any professional who was working with Mr B or the children were the court and prison psychiatric reports prepared in 2006 and prison health records from 2006-2008. These were only used within the court and in the prison service and never made available to local professionals. It is not possible to know what effect it would have had if the GP, mental health trust and probation service had had these records. They showed what Mr B was like in a different setting at a particularly stressful time in his life and they offered a different opinion as to the nature of his mental health problem. Even though it cannot be said that access to these records and reports would have made a difference in this case it is clear that careful consideration needs to be given to making such records available in future.  4.2.13 The professional who had the best overview of Mr B’s background and relevant history was his GP, though he too had no access to prison and court records and reports. So far as the SCR can determine Mr B’s GP did know from his mother that he had children but he did not record this in the records so that colleagues could easily take account of it. None of the GPs established what the care arrangements for the children were. The GPs focused on Mr B’s current mental health problems, taking into account his past, but viewing him as part of his family of origin. This is likely to have been reinforced by the fact that he was often brought to the surgery by family members (although on at least one occasion the surgery had contact with Mr B’s partner) and his mother continued her role in collecting prescriptions and medication. GP contact with Mr B took account of his past, but did not establish the significant changes in his life and family network. This highlights important learning for GPs    34 about the need 1) to view patients in relation to their current life and not just their medical history, 2) to ask questions about whether patients have children and 3) in some instances to communicate with other GPs and health professionals who are responsible for other individuals in a patient’s network. Recommendations are made in relation to this. 4.3 What assessments were undertaken and what was the quality of those assessments 4.3.1 The pattern of assessments was shaped by the overall pattern of professional contact with different family members set out in section 4.1 above. This section of the report evaluates the key assessments undertaken. In some areas it also deals with the service provision that followed from this where the two are hard to separate. Probation assessment 4.3.2 The assessment carried out by the probation service was necessarily determined by the focus of the service on reducing the risk of reoffending. Assessments took place shortly after Mr B was released on licence and identified the factors that the probation officer believed to be likely to influence possible reoffending. Mr B was assessed as a high risk of reoffending and referred to the local multi-agency risk assessment panel (MAPPA). The probation supervisor commissioned additional assessments in relation to risks associated with mental health and substance misuse. All of these assessments were within the framework of probation responsibilities and correctly carried out. They occurred at a time when Mr B did not have responsibility for children. Additional referrals were made in relation to employment and training. The assessments and services were subject to review and areas of progress were noted. It was also noted that Mr B never demonstrated any genuine ‘victim empathy’.  4.3.3 It is impossible to tell how motivated Mr B was in relation to the services that he was offered. However the evidence is that he attended and complied with all of the requirements of his licence. There is no evidence of offences committed while Mr B was under probation supervision. 4.3.4 These assessments were undertaken at the beginning of his licence period when Mr B did not have children. When his probation officer became aware that he did have a child, she contacted the local authority to establish if the children were the subject of a child protection plan and if the family were known to social care staff. There was a negative response to both of these questions. As she saw no indications of possible risk to the children she did not seek additional information from any other professional. 4.3.5 The only shortcoming identified in the provision made by probation services is that no home visit was made in order to establish more about his family circumstances and verify the information given by Mr B. This would have been justified given the nature and circumstances of his offence, (TEXT REDACTED) and the repeated weight that Mr B placed on family members in supporting him and helping him not to reoffend. The potential value of a home visit would have been even greater once it was known that Mr B had a child.    35 4.3.6 At the time probation officers were expected to undertake a home visit shortly after release for high risk offenders. Current practice is to undertake a home visit for all offenders on licence. Midwifery assessments 4.3.7 Midwifery assessments were focused on the pregnancy. In booking and subsequent appointments midwives are required to follow up any information about risk highlighted in the GP antenatal referral and also to seek to identify any additional information about risk factors. There is no detailed information about the maternity care provided during the mother’s pregnancy with Child G. During her pregnancy with Child F she was seen at (TEXT REDACTED) hospital. No risk factors had been identified in the GP referral. (TEXT REDACTED). No social risk factors were identified. The mother said that she lived with her one year old infant. The mother indicated that she was well supported by family but no details of wider family circumstances were recorded. The identity of the father was not sought and no information was obtained about him. There is no evidence that standard, obligatory questions about domestic violence were asked though there was opportunity to do so because the mother attended her appointments alone. (TEXT REDACTED). 4.3.8 This was a limited assessment focused on the immediate medical and health needs of the mother and any medical issues that might impact on the pregnancy. It was led by the information provided by the GP and by the information that the mother was prepared to disclose.  4.3.9 The (TEXT REDACTED) NHS Trust does not issue specific guidance to staff working in antenatal clinics about identifying fathers, where they do not attend and where this information is not offered by the mother. Reliance is placed on the professional responsibility of the midwife to consider the care offered to the mother in the context of the whole family (whatever its composition). Recording formats offer space for information to be collected about fathers.  Health visitor assessments 4.3.10 Health visitors undertook family health assessments in relation to both of the children at the time of the new birth home visits. (TEXT REDACTED). The content of these assessments has been described in detail in the management review provided by (TEXT REDACTED) community health service. Both assessments led to the decision to allocate the children to the universal service because they had no additional needs that required a proactive health visitor intervention. This involves regular clinic appointments to track the children’s health and development, but otherwise the children’s mother was left to seek advice on the children from her GP and the health visitor. If factors pointing to heightened levels of need or potential risk had been identified then a higher level of provision would have been offered (‘universal plus’ or ‘partnership plus’) which would have involved more active monitoring and response by the health visitor.    36 4.3.11 The family health assessment at the new birth visits focused on the health and development of the two children, placing this within the wider context of the family circumstances. The assessments undertaken follow broadly the children in need assessment framework with a focus on 1) health and development of the infant, 2) parenting capacity and 3) environmental factors. The assessment has four components: observation and assessment of the infant; observation of the care provided; discussion with parents and carers and completion of a self-reported questionnaire which gives the parent an opportunity to provide information about the wider family circumstances and any risk factors, which the health visitor will then discuss further. In principle this offers the opportunity for information about domestic violence, parental drug misuse and mental health problems to be identified. Relevant background information may have been identified in relation to another child in the family or by the GP or midwife in the antenatal period. If this has not happened the health visitor is reliant on the information provided by the parent during the new birth visit. In this case the mother did not provide any detailed information about the father or her knowledge of any indicators of risk relating to him. 4.3.12 Based on the information provided there is no reason to suggest that it was not correct to assign both Child G and Child F to the universal level of health service. However two issues have been identified from which there is the potential for further learning: 1) the role of the father in the assessment and the knowledge that professionals had of him and 2) the response of health professionals when the children were not brought to appointments. The role of the father in the assessments and health professionals’ knowledge of him 4.3.13 The exact role of the father was not established. (TEXT REDACTED).  4.3.14 With hindsight it is apparent that in this case the strengths and protective factors in parenting came from the mother and members of the parents’ extended families, whereas the only risk factors were linked to the father’s substance misuse and mental health problems. These were not static throughout the lives of the children; they increased as time progressed particularly in the weeks before his final psychotic episode.  4.3.15 In the new birth visits nothing was said that would have caused the health visitor to seek more information about the father or to contact any other professional about him. The father was present during the first home visit and his details were taken. The health visitor states that he was not present at the second, but his details were confirmed. It was noted in general that he was playing a supportive role but not living in the household. The health visitors did not know this but this was at odds with the information that the father provided in many of his contacts with his probation officer which suggested that he was staying and living with his partner and her mother. It is very likely that if the health visitors or the midwives involved had had a better understanding of the role of the father and the potential risk factors in his background the overall assessment of need in relation to Child F would have been different.     37 4.3.16 Health visitors say that if it had been known that the father had a history of mental health problems, drug misuse and a conviction for a violent offence it is much more likely that the children would have been allocated a higher level of health visiting service, even if this was just to allow the health visitor to remain actively involved for a longer period until an assessment of any potential risks had been made. It is impossible to say whether this would have made a difference to the services offered by the point at which Child F was injured.  4.3.17 The SCR has tried to understand how much the mother knew about the risk factors that have been identified in relation to the father and why it is that she chose not to share information about the father’s history with the professionals that she was in contact with. (TEXT REDACTED). 4.3.18 (TEXT REDACTED). Both she and her own mother expressed the view that it was important not to judge people by what they had done when they were juveniles and that individuals could overcome past bad experiences.  4.3.19  Neither of the health visitors saw it as their responsibility to challenge the mother to provide more information about the father or to seek background information from other sources. This was consistent with the prevailing practice and culture of the health visiting service and this is an underlying pattern in practice that goes beyond the individual case. This is identified in the community health management review as an area of potential learning, given that recent government guidance places great stress on identifying fathers and encouraging the involvement of fathers in the care of their children. 7 4.3.20 At present it is clear that there is a gulf between the guidance produced by government and the implementation of this aspiration by many front line staff. Guidance sets very high expectations about the involvement of both resident and non-resident fathers highlighting the value of direct communication with fathers, assessment of fathers and arranging appointments at times when fathers can attend. Practitioners aspire to achieve this but know in practice that in many settings contacts will usually be with the mother and practitioners will rely on the information that the mother provides. The reasons for this will be shaped by different reasons in different health settings and in work with different communities. In practice it will often be most difficult to engage the fathers and other male carers who most need to be engaged because they engage in risky behaviour and are less likely to be cooperative. 4.3.21 If it is to be successful the work to engage fathers requires a significant change in culture, expectations and working practice. The management review of community health provision suggests that further training is required and makes a recommendation in relation to this. The reviews of midwifery practice do not address this aspect of practice. Guidance alone will not achieve significant changes. Training will be beneficial because it is clear that many practitioners find it hard to know how to broach the issue of father’s involvement with mothers and to find out more about fathers in a way which does not appear to be intrusive                                                            7 Department of Health (2009), Healthy Child Programme – pregnancy and the first five years of life. A key section is reproduced as Appendix 4 of this document    38 and threatening. However it is unlikely that in isolation training will make a significant difference and it is recommended that health trusts need to provide a much more comprehensive approach. This could include: issuing clear guidance; offering training; and monitoring the extent of engagement with fathers and the effectiveness of contacts. Staff will need to be consulted so that there is a shared understanding of why this aspect of practice is so difficult and to have an opportunity to contribute their own ideas. Many of the ideas suggested in guidance (such as offering appointments when it suits fathers) will clearly have resource implications and trusts need to decide at a senior level whether they are prepared and able to ask staff to prioritise this area of activity. This needs to be addressed by all health trusts providing midwifery and health visiting services.  4.3.22 It is recognised that there are particular practical difficulties in applying this approach in midwifery, not least because midwives are also expected to exclude male partners from part of the antenatal assessment while they ask obligatory questions about domestic violence. Notwithstanding these difficulties the full force of recommendations made in relation to this issue in this report and the health overview report should apply in relation to antenatal services.  The response when appointments were missed 4.3.23 The decision to offer contact within the universal provision framework, linked as has been explained to the lack of specific information about the father, shaped the response when the mother did not bring Child F to clinic appointments. As no specific risk factors had been identified the response of the health visiting teams was to send the mother a further appointment or to phone her with a reminder. This was left to the individual practitioners to undertake and the length of time between missed appointments and follow up varied. Usually this led to the mother attending some weeks later.  4.3.24 Had the health visitors been offering a targeted intervention in which specific needs or risk factors were being addressed through a planned series of contacts, they are likely to have taken a different stance when an appointment was missed because they would have wanted to establish the reasons and to ensure that appointments were rearranged as soon as possible. 4.3.25 Discussions with the individual management review author and with the staff directly involved in this case have shown that since the events under review the policy and practice of the trust have been changed so as to ensure that there is now a standard practice when any clinic appointment is missed (bearing in mind that attendance at such appointments is voluntary). The management reviews recommends that the need to implement this policy is reinforced through training and supervision. It is recommended in addition that is should be subject to audit. The use of the Family Health Assessment     39 4.3.26 Since the new birth visits in relation to these children the RIO electronic record keeping system has been introduced to the community health trust. This records the information gathered in new birth visits in a different format from the one currently used to collect it. In interviews with the health visitors it has been established that they place great value on the use of the family health assessment at new birth visits. There appears to be some uncertainty as to whether the introduction of RIO will lead to changed expectations about the role of the family health assessment. The strong positive feedback given by practitioners in this case review strongly suggests that the community health services should be extremely cautious about making any substantial change in the use of the family health assessment. It is recommended that there is a full consultation with front line staff before any significant change is made to the Family Health Assessment Mental health assessment in Accident & Emergency department Introduction 4.3.27 Paragraphs 3.2.44 - 62 above set out the best account that can be reconstructed of this episode. It has been evaluated in detail by the SCR panel and the overview report author because it was the last professional assessment of Mr B before Child F was wounded. Family members have also expressed concerns about the outcome of this assessment and the way in which it was conducted. 4.3.28 The SCR has sought to evaluate and learn from the assessment taking into account the evidence that was available to professionals at the time. The function of the SCR is to establish whether there were shortcomings in the assessment, whether these led to shortcomings in care and treatment, to establish whether as a result opportunities were missed to reduce risk from Mr B’s behaviour that could have been predicted and to learn from these findings. It is recognised that there may have been significant changes in Mr B’s mental state and behaviour after the assessment. It might not necessarily have been possible to predict these at the time of this assessment. 4.3.29 In order to evaluate the A&E assessment, the following have been considered:  Evidence of the involvement of the family at the time and the views of family members given to the SCR  The actions that the professionals took to try to elicit information from the Mr B and his family  The evidence that was presented and the quality of the assessment of Mr B’s mental health   The plan or service provision made by the professional in the A&E department  The assessment of the safety of the children The SCR has taken account of the management review provided by the mental health trust but the authors of the SCR overview report and the health overview report have also directly reviewed the relevant medical notes and held discussions with the staff involved.    40 4.3.30 The SCR obtained the views of family members, to set them out in a systematic way and to evaluate them alongside the evidence from the medical records and the additional information provided by the professionals who were involved.  The views of family members 4.3.31 It was not possible to interview Mr B to establish his views about this assessment because he remained too ill.  4.3.32 The following family members have given their views about the A&E assessment:  Mr B’s mother -who was present during part of the assessment  Mr B’s partner - who was present during part of the assessment  A close family friend who attended the hospital and drove Mr B home but was not present during the assessment  The children’s maternal grandmother -who was not present. 4.3.33 Taken together family members have expressed the following criticisms or concerns about the assessment:  Too much emphasis was placed on Mr B’s self-reported misuse of cannabis and alcohol   The extent of his self-reported consumption of drugs and alcohol was implausible and family members state that they have no evidence to support his account of being involved in criminal supply of drugs; family members feel that this may have been part of his deluded thinking  The ready acceptance of his account of his drug use and involvement in criminal activity led the doctor and the mental health worker not to make a full exploration of Mr B’s mental health needs.   There was insufficient probing in depth of Mr B’s mental and emotional state, how he was feeling and the extent of his unhappiness at recent deaths of people close to him.   They are surprised how short a time the assessment lasted; for example, drawing on experience in the ambulance service the family friend has noted how mental health assessments associated with compulsory detention in hospital sometimes take several hours   Mr B was willing to be admitted to hospital and this is what should have happened.   The children’s maternal grandmother believes that there is a specific 6 hour holding power under the Mental Health Act (1983 and 2007) that could have been used to secure his admission. 4.3.34 Family members have also expressed concern about what they feel was an abruptness and negative attitude in the way in which some aspects of the assessment were conducted. The perceptions of family members must be treated as genuine, though some have been disputed by the professionals involved. However this aspect of their account is impossible to address without knowledge of everything that was said during the assessment and exactly how it was said.  The findings of the A&E assessment of Mr B’s mental health     41 4.3.35 The evidence from the mental health trust records is that the interviews with Mr B and members of his family did attempt to explore the areas that should be included in a mental health assessment, including Mr B’s presenting symptoms, his mental state, his behaviour towards other people and his use of drugs and alcohol that might be influencing his mental state. The records show that the examination of Mr B’s mental state included recording of his mood, speech, perception of his circumstances and the level of his insight into his own circumstances. A view was formed based on observations made in the assessment about his risk of harm to himself and to others.  4.3.36 The formulation (explanation) of Mr B’s condition viewed drug and alcohol misuse as the cause of his current mental state rather than any underlying mental illness. The junior doctor and the mental health worker both independently arrived at this conclusion. This was because Mr B gave a great deal of information about his use of cannabis and alcohol and he was very frank about his involvement in criminal activity. The professionals who saw Mr B formed the view that his agitated state, his anxiety and his suspicion of other people could largely be explained by the combination of his heavy use of cannabis and alcohol and by realistic fears arising as a result his criminal lifestyle. They believed that he was taking cannabis and drinking heavily to calm his nerves to the extent that he had become dependent on both. Their judgement was that using them in this way had become counterproductive as one of the recognised effects of significant cannabis intake is that it can make the user suspicious and exacerbate feelings of paranoia.  4.3.37 In contrast, Mr B gave only very little specific information when asked about any psychiatric symptoms or history such as depression, anxiety or psychosis and about his history of mental health problems. The medical records show that Mr B’s mother was present when the doctor and the mental health worker tried to gather information about his history of mental health problems and to establish when and where he had previously been diagnosed as having drug induced psychosis. Mr B’s mother did urge him to be frank about everything but according to the records she did not provide any detailed additional information about his history of mental health problems. The records show that she left the assessment while this was being discussed. The professionals believe that this was because she was very upset to hear him talk about the extent of his recent drug use. 4.3.38 Based on the records made at the time the family members who were involved in the assessment did not provide any significant additional information about other psychiatric symptoms. It is clear that it was much more difficult to establish information about Mr B’s mental state and mental health history, but the evidence is that attempts were made to do this. There is no evidence that these factors were neglected or downplayed in the assessment.  4.3.39 Most of the symptoms of mental health concerns that family members have used to describe Mr B’s behaviour and emotional state coincide with the behaviour recorded in the mental health assessment. There is also considerable evidence that at a number of points family members had explained the deterioration in his mental health as being attributable to    42 drug use. For example: medical notes show that his partner was present in August 2010 when Mr B told his GP that he was smoking weed and becoming paranoid; GP records state that Mr B’s mother told the GP in October 2011 that he was ‘smoking drugs again and as a result behaving oddly’. In later discussions with psychiatrists who were preparing reports for the criminal proceedings Mr B and his father confirmed accounts of his significant use of drugs and alcohol and his involvement in offending at this time. It is of course very possible that different members of Mr B’s family had different information about his lifestyle and his use of cannabis. The plan made and discussion about possible admission 4.3.40 There are significant differences between the records and recollections of the professionals and the recollections of family members. Medical records written at the time indicate that the professionals attempted to engage the family in trying to gain further information and to explore whether Mr B presented a risk. The professionals believe that the family members present were involved in the assessment and discussed and agreed with the treatment plan. Family members state that their concerns were not taken into account and that they were surprised by the plan to discharge Mr B home without further active treatment or support and monitoring. It is impossible to be certain as to why such strong differences in perception exist.  4.3.41 The records indicate that family members were not seen on their own in the absence of Mr B. Had this happened it might have meant that family members were freer to provide more detailed information about their concerns. It is agreed by everyone that this was a weakness in the assessment.  4.3.42 The plan or service provision made by the professionals was in accord with the assessment that they made. Mr B and his family were given information about local drug and alcohol services; he was given medication (TEXT REDACTED) to help him sleep that night and he was discharged back to his GP in the knowledge that he had already referred him to the mental health trust Primary Care Liaison Team for a fuller psychiatric assessment. 4.3.43 The family have subsequently stated that their expectation was that Mr B would be admitted to hospital that evening as the strain of coping with him was proving too much for his mother. The records do indicate that the strain on Mr B’s mother and other family members was mentioned during the assessment. From the descriptions given of Mr B’s mental state and circumstances at the time of the assessment there is no indication that the professionals involved would have considered hospital admission to be necessary or justified. This has been considered in detail in the individual management review prepared by the mental health trust. The evaluation made in that report was prepared by an experienced consultant psychiatrist and the trust’s head of social work and social care. It states that: ‘Mr B’s presentation in A&E did not exhibit features of a clear psychotic episode to warrant his care being taken on by the Home Treatment Team. His presentation was also not    43 consistent with an admission to hospital being offered, not least given the principles of least restrictive practice we operate under. Thus someone, as in Mr B’s case, who is acknowledging a problem, seeking help for it and is accepting of advice and further treatment options, should be offered support in the community without recourse to the often disturbing environment of an acute admission ward.’ 4.3.44 The SCR accepts this judgement. Although subsequent events did not prove this to be correct, on the basis of the information that was available at the time the admission of Mr B to an acute psychiatric ward was not justified because on the basis of experience it would have been likely to have done him more harm than good.  4.3.45 The records show that approximately 30 minutes was spent with the family. Longer would have been spent if family members had been seen without Mr B. It is correct that – as family members have pointed out – when an assessment is taking place under Section 2 of the Mental Health Act in order to consider whether it is necessary to detain a patient in hospital can take considerably longer than the assessment of Mr B in the A&E department. This is not relevant to the circumstances of Mr B because these assessments require a very detailed scrutiny of the medical and legal grounds to admit a patient. There were no medical or legal grounds to detain or admit Mr B.  4.3.46 The children’s maternal grandmother has specifically suggested that there was a power to detain Mr B for 6 hours for an assessment. This most likely relates to Section 5.4 of the Mental Health Act (1983 and 2007) which enables a nurse to detain a patient in hospital who is already a hospital inpatient. This also was not a legal power that is relevant to the circumstances in which Mr B was being assessed. Assessment of the potential risk to the children 4.3.47 The trust mental health risk assessment framework contains a section dealing with risk to children. This should be completed when it has been identified that a patient lives with or has caring responsibilities towards children (or is a risk to children). Interviews with the professionals involved and review of the records demonstrate that an assessment of the potential risk to the children formed part of their thinking but that it relied on a series of assumptions being quickly formed based on impressions of the family, rather than there being based on a systematic assessment of the children’s circumstances. Details of the children were obtained and recorded but no specific information was recorded about the nature and extent of Mr B’s contact with children and his caring responsibilities. The component of the mental health trust risk assessment format focused on children was not completed. The clinicians say that they were reassured about the welfare of his children by the very positive way Mr B spoke about them and by the presence of key members of the extended family.  4.3.48 The details of the assessment and the thinking of the professionals in relation to this aspect of the assessment were not recorded. This means that it is impossible to be absolutely sure what was discussed and considered. However if a systematic and comprehensive    44 assessment had been undertaken it is almost certain that it would not have come to the conclusion that the children were at risk. There was no evidence that Mr B had ever posed any risk to the children in the past. Insofar as Mr B was noted to have any psychiatric symptoms there was no indication that he was focused on or preoccupied with the children. Had this been the case it would have led to a high level of concern and it is very likely that the clinicians would have recognised this. Potential risk to the children was not discussed with other family members but it is easy to understand how professionals could conclude in the circumstances that the other members of the family network would ensure that neither adults nor children would come to any harm. Members of the family did not think that Mr B could pose a risk to his children and it would have been extremely difficult to imagine circumstances in which the professionals involved would come to that conclusion. 4.3.49 Although family members say that they do not believe the account given by Mr B of his drug use, the doctor and the mental health worker did. It was therefore a shortcoming of the risk assessment that it did not consider in detail whether the misuse of drugs and alcohol might adversely impact on the care of the children. If a detailed assessment of this had been made it is very likely that it would have come to the same conclusion i.e. that the family members would be alert to any concerns and would be able to protect the children from any potential harm. 4.3.50 Although there is no evidence that it would have identified a high level of risk to the children the assessment illustrates that mental health trust staff were insufficiently aware of the need to make a specific assessment of risk to children. The individual management review prepared by the trust makes two recommendations in relation to this which the SCR endorses. Learning from the A&E assessment 4.3.51 The narrative in section 3.1 and the preceding analysis indicate that there were two important shortcomings in the assessment and in the way it was documented: there was no separate time given to interviews with family members without Mr B being present and the risk assessment of the children relied on an instinctive judgement rather than being the systematic. The SCR has highlighted the following as being most important factors contributing to these shortcomings.  4.3.52 The mental health trust’s internal information system did not allow the assessors access to previous records of Mr B’s mental health trust contacts in 2004 and 2008. The records would also have shown that his current presentation was consistent with the way in which Mr B had behaved, intermittently for at least 8 years. Knowledge of the length and severity of the problem would have been useful. Access to records of the mental health trust’s own 2008 psychiatric assessment (conducted following the probation referral after his release from prison) would have provided information about Mr B’s history of violence. It is very likely that if this information had been available it would have made it easier for the doctor and the mental health worker to explore the history with Mr B and with his family. This might have influenced the assessment of future risk. However had these records been accessible    45 they would have confirmed the information that Mr B’s previous psychotic symptoms were linked to cannabis use. This would have tended to reinforce the assessment that the professionals had made. 4.3.53 There was uncertainty between the clinicians involved in the A&E assessment about what risk assessment documentation needed to be completed and whose responsibility it was to complete it. There was a mistaken belief that if someone was not taken on by the crisis resolution service there was no need to complete the risk documentation, including the safeguarding children documentation. Completing this documentation would not have altered the assessment but not completing it would have hampered the assessment of other clinicians if Mr B had presented at A&E or in the mental health trust at a later point.  4.3.54 The case history highlights potential vulnerabilities in the way in which the mental health liaison services to the A&E department are designed and delivered. There are specific challenges for relatively junior or inexperienced staff in undertaking mental health risk assessment and the associated risk assessment of children in the A&E department. Rapid assessment is required and judgements are required about potential risks to children when there is often no opportunity for contact with children or with professionals who know them and little or no access to relevant records. Given this the actions and decisions of the individual professionals are likely to have been repeated if other individuals had been on duty that evening. They were not the result of wayward judgements by those involved.  4.3.55 Section 4.8 describes the level of training and experience of the staff members involved. It was broadly what would be expected. It is possible that if the assessment had been carried out by a psychiatrist with more experience it might have obtained more information from the patient or the family which would have led to different treatment options being considered. Although it is extremely unlikely that any psychiatrist would have considered admitting Mr B to hospital a more experienced psychiatrist who was aware of the full history might have prescribed Mr B antipsychotic medication. However even if this had happened it is impossible to say with any degree of certainty that it would have changed the course of events. The conclusion of the experienced consultant psychiatrist who has evaluated the case history is that ‘the speed of action of an anti-psychotic would not have altered his presentation the following day’. (Mental health trust individual management review) 4.3.56 Whether or not it would have made a difference to the management of this case, it is important for the mental health trust to explore further whether the training in mental health and safeguarding children that relatively inexperienced staff received prepares them adequately for the types of cases they would see when undertaking an acute assessment outside of normal working hours in the A&E department.  4.3.57 The mental health trust review states that the trust is currently developing trust-wide operational guidance on the work of staff which will address the skills, medical leadership, induction of staff and safeguarding training necessary for tailored to the task of assessment in A& E. The mental health trust review has made a series of recommendations in relation to    46 these matters. The SCR endorses these recommendations and the action plan developed by the trust which recognises that specific and urgent action is needed.  The conduct and professionalism of the staff involved in the A&E assessment 4.3.58 Taking into account all of the evidence available, the view of the SCR is that the assessment was undertaken in a professional way. The evidence is that it was conducted in good faith and to the best ability of the professionals who carried it out. Wider family contact with health professionals during this period 4.3.59 Family members went to great lengths to get help for Mr B in the days before he stabbed his daughter. In evaluating the service provision that was made the SCR has therefore considered the A&E assessment as part of the wider pattern of contacts that family members had with health professionals in the four days before Child F was stabbed. 4.3.60 There is no doubt that Mr B’s mother, his brother and his partner did everything that they could reasonably have done to obtain care and support for him during the four days leading up to the wounding of Child F, contacting his GP three times and taking him to A&E. However the evidence shows that there was a mismatch between what members of the family believed was happening and the action that professionals were taking. It also suggests that coordination of the involvement of different health professionals could have been better. 4.3.61 When Mr B was first seen by his GP he was told that an urgent referral would be made and (family members say) that this would lead to an appointment in 7 – 10 days. This could not have happened because the referral was sent by letter to the mental health trust and it arrived four days later, after Child F had been injured. The referral was screened immediately by the mental health trust. 4.3.62 Although the referral letter asks for an urgent appointment ‘within the next two weeks’ nothing else in the letter indicated that the circumstances required an urgent response because Mr B was seriously ill or a risk to himself or others. The key section of the letter refers to him as ‘a patient with known paranoid schizophrenia’ whose family ‘have recently become concerned about him’. The GP did not identify that Mr B’s circumstances had changed and that he now had responsibility for children. If this referral was genuinely urgent it is strongly suggested that it should have been faxed or sent electronically and followed up with a phone call.  4.3.63 Family members contacted the GP twice more in the following four days, and although it was suggested that there could be a follow up call to the mental health trust to hurry up the referral, no further contact was made with the trust. 4.3.64 The plan recorded at the end of the A&E assessment (written by the psychiatrist) indicates that the discharge letter to the GP would be used to expedite the existing referral to the mental health team. However the actual letter (which was written by the mental health    47 worker) does not do so and there is no indication that the Primary Care Liaison Team were contacted in order to provide information about the attendance at A&E. This might have altered the response of the Primary Care Liaison Team.  4.3.65 The SCR has established that (without any knowledge about what had happened to Child F) the Primary Care Liaison Team offered an appointment to Mr B for 23 November (5 weeks after the GP referral). The view of the mental health trust is that although the letter asked for an urgent appointment there was nothing in the referral letter that conveyed the need for urgency and that this time scale was justified. However before making this decision it would have been better for the members of the mental health team who decided how to respond to this referral to seek to clarify directly with the GP (i.e. on the phone) why he thought that the referral was urgent. 4.3.66 There is no evidence that these actions would have altered the outcome for Child F. However if such approaches are repeated in other cases confusion about whether a case is urgent or not and the failure to pass in information about developments in the case history may cause delay in referrals being made and dealt with.  4.3.67 It is also noted that Mr B was never referred by his GP to substance misuse services, even though this was always believed to be the cause of his mental health problems. Yet whenever he was assessed by the mental health service he was found not to have an underlying mental illness. This combination of approaches meant that he never received a service for his drug problem (except when he was referred to the drug service by the probation service). 4.3.68  It is therefore recommended that 1) the mental health trust and GPs in (TEXT REDACTED).rify criteria and arrangements for urgent mental health referrals, highlighting the responsibilities of GPs to follow up referrals as circumstances change and 2) that (TEXT REDACTED) GPs are asked to review how they respond to information in relation to heavy or sustained drug use and consider how they can make better use of local drug services. The deterioration in Mr B’s mental state after the assessment 4.3.69 As the description in sections 3.2.66 onwards above shows there was a sudden and severe deterioration in Mr B’s mental state some 24 hours later. The impact of Mr B’s mental state on his understanding of his actions and his criminal responsibility for his actions at the time when he stabbed his daughter has been determined by psychiatrists and the courts. However the observations that are available from family members and police statements strongly suggest that he was severely disturbed and psychotic. His behaviour and mental state at the time when he harmed his daughter were qualitatively different and markedly worse than when he was seen at A&E and at any other point where his mental state was documented in the case history. It is not possible to know exactly what caused this sudden deterioration. The description that has been provided by family members of his behaviour during the day before he stabbed his daughter indicates that he was not substantially worse than when he was taken to hospital. Their account is that he did not take any alcohol or    48 cannabis during this period and that this can be verified because at least one family member was with him the whole day. The evidence is that it was only when he woke up early in the morning that he was in a psychotic state.  4.3.70 This should serve to underline to clinicians from all agencies that there is always a risk of sudden deterioration in patients with a history of psychosis which needs to be taken into account in assessment and care planning and which needs to be explained to patients and carers. However in this case there is no evidence that either family members or professionals could have anticipated the rapid and drastic deterioration in Mr B’s mental state. The response of emergency services 4.3.71 Family members have raised a number of concerns about the response of emergency services to the incident in which Child F was injured. Whilst it was not the intention of the SCR to examine the response of the emergency services in detail additional information has been obtained from the (TEXT REDACTED) Ambulance Service and the (TEXT REDACTED) Police Service in order to address the questions posed by family members. This is set out separately in Appendix 5. 4.4 Were plans made to provide services consistent with assessments and were they fully implemented? Introduction 4.4.1 This section of the report will provide an overview of the findings in relation to this, looking at the work of the network of agencies with child protection responsibilities as a whole. It draws on the findings of the individual management reviews which evaluate in detail the provision made in individual agencies. Throughout the case history the provision made to Mr B and to the family was consistent with the assessments that were made and agencies implemented the plans that followed from the assessments that were undertaken.  4.4.2 In this case the main service provision in relation to Mr B was made by probation. The main provision made to the mother and the children was made by health trusts. Both parents were in contact with their GPs and the children shared a GP with their mother. The father received a number of assessments from the mental health trust but he missed some appointments and he did not take up an opportunity to attend a young people’s mental health service (in 2004). He was never allocated to a mental health team because throughout the history the finding of the assessments was that his problems were largely caused by his cannabis use and that he did not have a severe or enduring mental disorder. In relation to the mental health trust the key contact was the assessment in the A&E department shortly before Child F was injured. Findings about service provision from the mental health trust have been integrated into the findings on assessment in section 4.3 above.  4.4.3 There is no indication at all that lack of service provision or the nature of the service provision made was significant in relation to the injuries to Child F.    49 Probation provision 4.4.4 All the evidence is that service provision by the probation trust complied with all of the expected requirements. Mr B received a range of services that were related to the original assessment of the factors that put him at risk of offending. He complied with the terms of his licence attending individual supervision sessions regularly and attending at a number of programmes. He also attended at the substance misuse service for assessment and a number of individual sessions. 4.4.5 The provision made was effective insofar as Mr B did not reoffend or have any contact with the police during the time when he was under supervision, he reported being drug free and showed no adverse signs of substance misuse. It is impossible to know whether Mr B complied with the requirements because he was genuinely motivated to or whether he did so in order to avoid breaching his licence. By his own admission Mr B resumed his cannabis consumption and his associations suggestive of criminal activity soon after the end of his supervision Health visiting and antenatal provision to the mother and the children 4.4.6 The provision made was in keeping with the assessments of need made in relation to the mother and the children. Ms A missed a small number of antenatal and child health clinic appointments but attended sufficiently for professionals to be satisfied that health needs were being met. Section 4.3 has discussed the policies of health trusts in relation to missed appointments. There is no suggestion that any additional health provision to the mother or the children would have prevented the injuries to Child F. GP services 4.4.7 The family GPs separately provided services to the father and to the mother and children. Section 4.3 above has described how that the father’s GP did not identify the significant changes that had occurred when he became a father. 4.5 Did the activity of agencies focus on the needs of children? 4.5.1 This aspect of the terms of reference has also been addressed through the discussion on assessment in section 4.3 above.  4.5.2 Health visitors and midwives are required to have their main professional focus on the needs of children. The narrative and the evaluation of assessment and service provision indicate that this occurred. There were some weaknesses in the assessments carried out within these services (outlined above for example section 4.3). These largely arose because of the specific circumstances and difficulties of the case and not because the focus was not on the needs of children.  4.5.3 The father’s GP was primarily concerned with his mental health needs and the one GP who had knowledge that Mr B had responsibility for a child did not record it in his medical record. There is potential learning for all GPs in this.     50 4.5.4 The mother and children’s GP was focused on the children’s health and development in the small number of contacts with family members. Immunisation appointments were missed on a number of occasions and the GP practice offered follow up appointments. 4.5.5 The main focus of probation service activity was entirely appropriately on the task of reducing the risk of the father re-offending. However when the father acknowledged that his partner was pregnant the probation officer contacted the local authority to see if the family were known and if the children were subject to a child protection plan. This episode is discussed in detail in section 4.6. 4.5.6 The only contact that the father had with the mental health service when he had responsibility for children was shortly before he injured his daughter. This episode has been discussed in detail in section 4.3 above. It shows that mental health professionals were mindful of the children but did not take all of the steps expected to undertake a detailed assessment of possible risk to them. 4.6 What was the quality of information and joint working within and between agencies? 4.6.1 Individual agencies with a different role and focus were working with different members of the family. Sections 4.1.9 – 4.1.18 set out an overview of the agencies that were working with the father and with the mother and children. Prior to the incident in which Child F was injured there was never any reason to believe the children were at risk of harm or in need or additional services. As a result no formal information sharing arrangements – such as those that would occur during a child protection enquiry or plan - were in place. Information sharing was limited to the normal referral arrangements that exist between health professionals or the normal sharing of information that associated with discharge arrangements between antenatal care, GPs and community health services.  4.6.2 The lack of any concern about the children meant that the limited sharing of information between professionals that took place was understandable. However the case history has highlighted three specific areas in which there is the need to improve information sharing arrangements between agencies:  Notifications by the probation service when service users are known to be responsible for a child  Sharing of information about adults who may pose a risk with health staff working with children and   Sharing of medical information from the prison service and criminal justice system. Probation notifications to other agencies 4.6.3 The overview of agency involvement has established that there was only one active attempt to share information between the professionals working with the father and an agency that might have been working with the mother and children. This was when the probation officer notified social care of the birth of Child G with the intention of establishing if there was any local authority involvement with the children (see paragraph 3.2.11 above). This was an    51 established part of probation service procedures in order to enable probation officers to identify any concerns about a child and if necessary to open up lines of communication between the probation officer and the local authority. In this case there was no need for further communication because the family were not known to the local authority and the probation officer had no reason to believe that Child G was at risk. At that point Mr B was not offending, (by his own account) not misusing drugs and alcohol and he was showing no signs of mental health problems. Discussion in the SCR panel clarified that this was not intended as a referral to the local authority and confirmed that there was no reason for the probation officer to make a referral at that point. 4.6.4 The probation procedure to make a notification in these circumstances might safeguard the probation officer from working with the parent of a child who was at risk without being aware of it. This is of value. However in such circumstances there would have been more value in the probation officer identifying the child’s health visitor and notifying the community health service of the birth of a child and the link to a probation service user. This is for the simple reason that health visitors are to different degrees involved with all infants, whereas the local authority social care service works with a very limited number of families. Such communication would alert health professionals to important background information about the family and inform their assessment of the child’s circumstances and needs. In this case it would have been of particular assistance because the mother gave no background information to the health visitor about the father.  4.6.5 It is therefore recommended that the (TEXT REDACTED) Probation Trust should undertake a review of its procedures to widen the scope of information sharing about service users who have substantial contact and involvement with children to include key health professionals. Sharing of relevant information about adults who may pose a risk with front line health professionals 4.6.6 When the health visitors who were involved with the children were interviewed they indicated that they are often not aware of the involvement of adult services with the parents of children on their caseloads, including in some cases adults who it was subsequently revealed had been the subject of multi-agency risk assessment (MAPPA) discussions and plans. This was not relevant in this case because the father did not have responsibility for any children at the point of his release from prison and discussion at MAPPA. However in other circumstances this sharing of information could be very important.  4.6.7 It is therefore recommended that the local MAPPA coordinator and local health agencies should review the effectiveness of the current arrangements for health involvement in MAPPA panels and the sharing of information sharing within health agencies so as to ensure that front line health professionals are made aware when parents and carers are discussed in MAPPA panels in all cases where this is necessary.      52 The sharing of information about offenders from court reports and prison health services 4.6.8 Forensic psychiatrists and the prison health service both sought information from local health professionals in order to inform their assessment and treatment of Mr B. However the flow of information was only in one direction. Information contained in court and prison psychiatric reports and wider information from the prison health service were never shared with local health professionals – either the GP or mental health trust. This is not in the interests of offenders or the wider community because the discontinuity in health records that occurs when offenders are in prison reduces the effectiveness of health care to them making them more vulnerable and may add to the risk to others. There may be sound reasons why some court reports might not be shared outside of the court setting. However in general there is no logical reason why prison and court health records and reports should not be shared with a patient’s general practitioner.  4.6.9 In this specific case it is not known what information is contained in the prison health service records of Mr B so it is impossible to say whether access to them might have altered the approach of local health professionals. The forensic psychiatric report prepared on Mr B in 2006 was the most comprehensive report prepared on his mental health prior to the current incident. It only became known to local health professionals after the incident during the course of subsequent reviews. The report offers a different perspective on Mr B’s mental health, based on an assessment in different conditions. Regardless of whether the diagnosis suggested within it is correct or not, access to it would clearly have been of value to Mr B’s GP and to local mental health staff.  4.6.10 It is believed that the lack of information sharing from court and prison records is a national issue. There may be practical difficulties but it is a problem that should be resolved. It is recommended that local health commissioners take whatever steps are necessary, either at a local or a national level, to investigate and resolve this problem.  4.6.11 At present GPs do not necessarily realise that prison health records may contain important information. Regardless of the progress in resolving the wider policy in relation to this, (TEXT REDACTED) NHS should make local GPs aware of the issue and be encouraged to take steps to obtain prison health records for patients in every case. This is the subject of a recommendation in Section 6 below. 4.7 Were the specific ethnic, cultural and religious needs of the family recognised and responded to? Were any other matters relating to diversity addressed? Recording of ethnicity 4.7.1 The individual management reviews have listed how the ethnicity of family members is recorded in agency records. The children are consistently recorded as being ‘Black British’, except for the GP records which do not record the ethnicity of Child G at all. The mother is recorded as being ‘Black Caribbean’ except in midwifery records where she is recorded as being ‘Black British’. The father is recorded as being of Black Caribbean origin. It is not clear    53 whether these records arise from family members being asked to define their ethnicity, or whether these were assumptions made by professionals.  4.7.2 According to Mr B’s father (information provided to a forensic psychiatrist after the incident) Mr B has a much more complex ethnic heritage (TEXT REDACTED). There is no point in the agency records before Child F was stabbed that captures this information. The probation records identify Mr B as being of Black British Caribbean origin. Again it is not certain whether this was his self- definition.  The ethnicity of professionals providing services 4.7.3 The majority of the key professionals working with the family and managers of services (GP, junior doctor, mental health worker and two health visitors) were members of minority ethnic groups, underlining that at front line practitioner level the workforce in (TEXT REDACTED) is very diverse reflecting to a considerable degree the composition of the population of (TEXT REDACTED). Insofar as there were shortcomings in the services provided to these children and their family it is important to underline that they did not result from the services being provided or managed by individual workers who have no ordinary empathy with or connection to the day to day life experiences of the local population. Attention to ethnicity, culture and religion in assessment and service provision 4.7.4 There is no evidence that ethnicity, culture or religion were ever explored in detail in the assessments that were undertaken. To the extent that social factors were identified in relation to Mr B’s offending and drug misuse he attributed his difficulties to being associated with the area in which he grew up and the people he associated with as a young person. There is no suggestion in relation to the service to the children and their mother that there were any shortcomings in the assessment or provision made which resulted from lack of attention to ethnicity.  4.7.5  (TEXT REDACTED). 4.7.6 (TEXT REDACTED). Mental health and drug provision for Mr B 4.7.7 Although the overall mental health provision to Mr B is not the main focus of the SCR, the overview report has carefully considered its effectiveness - because there is no doubt that it was Mr B’s mental health problem that led him to harm his daughter.  4.7.8 The SCR has sought to understand whether some aspects of Mr B’s overall experience of service provision mirror the wider experience of mental health services of many young black men from his social background. The wider position is summarised by a recent review of    54 relevant research 8 which describes a how young black men are over-represented in some aspects of mental health services (such as compulsory detention and hospital admission) and under-represented in others (such as detection of mental health problems by GPs). It also notes that: ‘Black Caribbean, Black African and White/Black Caribbean mixed groups are 40 – 60 per cent more likely than average to be admitted to hospital from a criminal justice referral which means their mental health problems are often only detected when they come into contact with law enforcement agencies’.9 The research goes on to note that a combination of factors is believed to lead to ‘a high level of fear’ among service users ‘that they will receive inappropriate and poor treatment’. This results in a position where ‘those who are in most need of support are the least likely to access the services which provide this support (and) the provision of good medical care tends to vary inversely with the need for it in the population served’.  4.7.9 Whilst it true that Mr B has had two significant contacts with the criminal justice system linked with mental health problems and drug misuse, not all of the issues identified in the wider research apply in his case. For example his GP was clearly sensitive to his mental health from an early age, before he entered the adult criminal justice system. Mr B has never been compulsorily detained in hospital and has been referred on a number of occasions for voluntary assessments. At times he has engaged in treatment coordinated by his GP, largely because his mother and other family members have actively encouraged him and supported him by taking him for appointments and encouraging him to take medication. On one occasion (August 2010) he was offered an appointment but did not take it up.  4.7.10 Whenever Mr B was assessed in the community his mental health problems were attributed to his misuse of drugs. Unfortunately with the exception of the period when he was under probation supervision he has never attended or engaged with local drug services (in part because he has never been referred or self-referred). Although the professionals involved in the A&E assessment would not have known this from his history, Mr B was very unlikely to have attended the drug service that they suggested.  4.7.11 It is not clear whether Mr B had a fear that he would receive ‘inappropriate and poor treatment’ (as the wider research suggests). However it is clear that his mother and other family members went to considerable lengths to try to have his problems assessed and to keep him engaged with health services.                                                             8 The Centre for Social Justice (February 2011), Mental Health: Poverty, Ethnicity and Family Breakdown - Interim Policy Briefing http://www.centreforsocialjustice.org.uk/client/downloads/CSJMentalHealth_Final_20110205.pdf   9 The source given is the Care Quality Commission survey, Count Me in 2009: Results of the 2009 national census of inpatients and patients on supervised community treatment in mental health and learning disability services in England and Wales. Care Quality Commission, 2010     55 4.7.12 No additional recommendations arise from this aspect of the SCR. However the difficulty that professionals experience in engaging service users such as Mr B reinforces the need for the recommendations made in section 4.3.68 above. 4.8 Did staff have the knowledge, skills, and experience to respond to the needs identified in the case? 4.8.1 All of the individual management reviews examined this question.  4.8.2 The probation officers and health visitors had the necessary experience and knowledge to respond to the needs identified in the case. All of the professionals in these services had received relevant supplementary training on safeguarding. 4.8.3 The mother was seen by a student midwife and an experienced and qualified colleague at her antenatal booking appointment.  4.8.4 The level of knowledge, experience and training of the mental health professionals who assessed Mr B in the A&E department has been examined in detail by the mental health trust. The findings are summarised here. The mental health worker was a qualified Mental Health Nurse who had worked for many years in the local mental health service. This gave her a very good understanding of how the local mental health services and partner agencies worked together. Before undertaking the psychiatric assessment role in A&E she had undertaken a period of closely supervised work with senior mental health nursing staff and had undertaken a number of A&E assessments. She was judged by the trust to have the training and experience necessary to undertake this task. 4.8.5 The doctor involved in the assessment was a Foundation Year 2 doctor. She was in the second month of a four month post in psychiatry working across an inpatient and community mental health settings, supervised by an experienced psychiatrist. She had studied psychiatry and had knowledge of risk assessment and management and the role of substance misuse. This doctor has identified from discussion with other junior doctors that it is only within the (TEXT REDACTED) sector of the mental health trust that A&E psychiatric assessments are carried out by doctors of the F2 grade of post qualification training. It is much more common in other specialisms and in other sections of the trust for duty psychiatry cover to the A&E department to be provided by a CT1-3 doctor. This is a more experienced junior doctor, who has chosen to specialise in psychiatry. 4.8.6 Safeguarding children’s awareness training is part of the familiarisation with the trust’s key responsibilities that all mental health staff receive as part of their induction. However this provides only a brief overview and the mental health worker involved had been an employee for many years. She had received a small amount of additional training in safeguarding.  4.8.7 The junior doctor had received limited training in relation to safeguarding children during her induction. She received training in risk assessment and management and this included reference to related policies including safeguarding children which were left for her to access and read as part of her professional development. Given the weight which is now    56 placed on the need to evaluate potential risk to children when undertaking mental health risk assessments and the range of responsibilities facing junior doctors it is wrong to leave this to the initiative of individual doctors. The trust has recognised this and will in future make safeguarding training in relation to children and vulnerable adults a mandatory and fuller part of doctors’ induction. 4.8.8 It is recognised that there are a number of factors that make the task of mental health risk assessment in A&E department challenging, especially when the assessment has also to be mindful of the potential risk to children. The individual management review indicates that there may be benefits in future from implementing measures which make a closer link between the safeguarding training that staff receive and the implementation of that training in relation to the types of cases that staff are likely to see in the A&E department. This will ensure that potential risk to children is fully assessed and the findings of assessments are shared with other professionals. 4.8.9 In the mental health trust child protection training at level 2/3 is delivered by staff with specialist responsibilities for child protection is also part of the mandatory training requirement. It is recommended that the LSCB should seek an update from the trust on the provision and take up of this training provided. 4.8.10 Taken together the relative lack of training of key staff in children’s safeguarding must have contributed to the shortcomings in the risk assessment in relation to the children in the A&E department (set out in section 4.3 above). However the SCR has found that even if a fuller risk assessment had been carried out in relation to the welfare of the children it is very unlikely that it would have identified the severe risk that Mr B posed to the children 24 hours later.  4.9 Were staff appropriately supervised and supported in their work with the family? 4.9.1 Each individual agency has supervision arrangements for staff and specific arrangements that apply where there are child protection concerns. GPs are independent contracted professionals who do not receive supervision, but they may contact the named GP with responsibility for safeguarding or the designated doctor to seek advice on individual cases. Each of the individual management reviews has evaluated the use of supervision within individual agencies. The findings are summarised here. 4.9.2 Expectations about how supervision should be accessed vary according to the perceived level of risk and complexity of the case. Health professionals are expected to bring cases in which child protection concerns have been identified to the attention of their supervisor. The size of caseloads in universal services precludes supervision discussion of all cases. Part of the professional responsibility required of health professionals is to screen caseloads in order to identify cases that should be discussed with a supervisor. For the reasons described in section 4.3 and in the narrative section of this report no professional had had any reason to identify this as a case that merited or required supervision.    57 4.9.3 Particular attention has been paid to the supervisory arrangements that apply in relation to staff undertaking mental health assessments in A&E.  4.9.4 This report has noted at a number of points the particular challenges in undertaking a mental health assessment in A&E. Both of the professionals involved had access to more senior nursing and medical support, including support from the on call consultant psychiatrist. Neither believed that they needed to have access to this senior support in this assessment because they did not believe that it was a complicated assessment. Senior professionals in the mental health trust and the trust’s Executive Board have supported this judgement through fully endorsing the findings of the trust’s individual management review. 4.9.5 The Crisis Resolution Team which has responsibility for the psychiatric assessments in the A&E Department of the (TEXT REDACTED) Hospital also has structures in place to allow an opportunity for staff working in A&E to discuss assessments undertaken in this role at the next available multi-disciplinary meeting. In this case there was no opportunity for this to happen as Child F was injured within 24 hours of the assessment. 4.9.6 In addition all letters summarising mental health assessments and action plans that take place in A&E are reviewed by a manager before they are sent to the service user and their GP. The manager believes that this enables her to monitor quality and standards and gives her a good overview of the range of work that staff are undertaking. Both staff members received regular supervision and the mental health nurse had additional opportunities for informal and group support. The individual management review however noted that there was a lack of clarity about who was responsible for the clinical work undertaken by the junior doctor when she was a working as duty psychiatrist in the A&E service.  4.9.7 In summary there is no indication that   which Child F was injured. Some shortcomings have been identified in the arrangements for the supervision of staff undertaking mental health assessments in A&E and these arrangements will be strengthened. 4.10 Did any issue of capacity or lack of resources limit the ability of agencies to meet the needs of the family? 4.10.1 There is no evidence that lack of capacity or resources adversely affected the provision of services to any member of the family.  4.10.2 The health overview author has identified that some weeks after the father was assessed in A&E the department closed for a number of nights due to longstanding staffing problems. (TEXT REDACTED). However there is no indication that the concerns underlying this had any impact on the service provided to Mr B.    58 5. Summary of key findings and conclusions Key findings  5.1 There were two distinct sets of professionals who were involved with different family members. Mr B was under probation supervision for two years from 2008 – 2010. During this period Child G was born. Mr B’s family GP knew him well and had treated his mental health problems during 2004 – 2006. Mr B’s family GP also knew that he had become a parent but did not record this on the medical notes or refer to this in any referrals or correspondence.  5.2 Mr B had also had a number of contacts with mental health services, both in the community (in 2004 and 2008) and while he was in prison (during 2006-2008). He was referred to the (TEXT REDACTED) mental health service in 2010, but he did not attend the appointment. A week before Mr B injured his daughter his GP referred him to the mental health service again and he was waiting for an appointment. Mental health professionals saw Mr B in the A&E department 24 hours before he injured his daughter. 5.3 A separate group of professionals were in contact with the children and their mother. This group included midwives, health visitors and her family GP. Prior to the incident that triggered this review there had been no child protection concerns about the children. The children were in good health and developing well without the need for any additional services. They had missed some voluntary clinic appointments but this was not considered significant and the mother kept in touch with the family GP. The health visitors knew the identity of the children’s father but none of them knew any background information about him. The children’s mother did not disclose this to the professionals who were working with her. No professional knew how much involvement he had in the lives of his children.  5.4 As a result of this pattern of involvement the assessment of those professionals who were working with the children could only be based on their own observations of their health and development and the care provided to them by their mother, which was always observed to be positive. No account could be taken of the potential risk that the children’s father might pose if his substance misuse triggered a deterioration in his mental health or began to impair his parenting capacity.  5.5 The professionals who were in contact with the mother and the children and those who were working with the father did not communicate with one another. This was because there was no cause for concern about the children and no cause for professionals to be in touch with one another. In any event the probation officer ceased to be involved with Mr B before the birth of Child F and the mental health service was only intermittently involved. 5.6 The weight of all the evidence is that Mr B’s cannabis use began again and increased after his probation supervision ended in mid 2010. This led his family to be concerned about the deterioration in his mental health. His GP referred him to the community mental health service for assessment. This outpatient assessment had not taken place at the time when Child F was injured. 24 hours before she was injured Mr B was assessed in the accident and    59 emergency department. His anxiety, agitation and paranoia were attributed to his heavy cannabis and alcohol use and his involvement in criminal activities and there was no sign of any serious mental illness at that assessment.  Could the assault on Child F could have been anticipated or prevented? 5.7 There is a clear contrast between the view of the case history that it is possible to obtain looking back with the benefit of hindsight and the knowledge that professionals had of the case as it unfolded. As the case history developed it is easy to understand why separate groups of professionals worked with different family members and why there was never any reason for them to communicate to one another about potential risks. Regarding the case with the benefit of hindsight it is apparent that the health professionals who were in contact with the children and their mother would have benefited from knowing more about the background history of the father and the risks that he might pose if his mental health deteriorated.  5.8 When there is no evidence of risk to children or additional needs there is no system that enables all professionals who are working with children to know everything about the involvement of other professionals with the family. This depends entirely on parents sharing this information, which they may not choose to do. In this case the mother had some knowledge of her partner’s history of mental health problems and drug misuse but did not consider that it was relevant to discuss them with professionals because she did not feel that he presented any possible risk to the children.  5.9 From the professional perspective this means that there are cases - such as this one - when professionals will not know some information that later turns out to be significant. 5.10 Even if they had had background information about the father, the health visitors or other health professionals may not have acted very differently. Prior to the deterioration in Mr B’s mental health there were no concerns about the children. The family members who had the main responsibility for the children were viewed as competent and supportive and it would have been assessed that they would have protected the children if there had been any problems. There might have been a higher level of health visitor involvement in the family, but in this family there would never have been sufficient concern to trigger a child protection investigation or any other form of social care intervention. The professionals who were involved would not have been able to anticipate the very sudden and dramatic deterioration in Mr B’s mental health. In particular it would not have been possible to predict that when his mental health did deteriorate he would immediately pose such a serious risk of harm to his daughter. Neither the family nor the professionals had ever seen the slightest hint of this before. 5.11 Mr B had been referred for a community-based mental health assessment, four days before he injured his daughter. The GP asked for an urgent assessment, but did not provide the sort of information that would have triggered an urgent response or communicate the referral quickly enough to the mental health trust.    60 5.12 The psychiatric evaluation of the father that took place in the A&E department 24 hours before the father injured his daughter was a critical incident. Some shortcomings in this assessment have been identified. It would have been better if family members had been seen on their own without the father being present. There was no systematic assessment of potential risk to the children. However the SCR has found that there was no indication of psychotic illness shown during the assessment. The SCR is confident that if there had been evidence of psychosis or overt indicators of risk to the children they would have been recognised. The assessment of risk to the children was based on the observation that the father was not psychotic and not acting in an aggressive way and that he enjoyed a good level of family support. If that assessment had been completed in a more comprehensive and systematic way it is very likely to have come to the same conclusion. There was no reason for the professionals involved to believe that the children might be seriously harmed by the father because of the active concern and the level of involvement and engagement of the family. 5.13 24 hours after this assessment the evidence is that Mr B was in a severely psychotic state and suffering from delusions (TEXT REDACTED). So far as can be established this was completely unprecedented. 5.14 In his review of services to safeguard children in England in March 2009 Lord Laming recognised that it is not always possible to prevent the serious abuse of a child, noting that serious injuries and even deaths can arise from ‘the sudden and unpredictable outburst by an adult towards a child’. He notes that such circumstances are ‘entirely different from the failure to protect a child or young person already identified as being in danger of deliberate harm’. 10 The evidence is that this is such a case and that there was no indication to any professional (or indeed to members of the family) that the children were at risk of serious harm. Additional learning from the SCR 5.15 Although there is no indication that the injuries to Child F could have been anticipated or prevented a number of additional learning points arise from the evaluation in this report and in the individual management reviews.  5.16 The review has highlighted opportunities for better information sharing between the prison and criminal justice system and community based health professionals, both through the sharing of prison health records and court reports and through the greater engagement of health agencies in the multi-agency risk assessment arrangements (MAPPA).  5.17 The review has highlighted the complexity and difficulty of undertaking mental health risk assessments within the A&E service, particularly noting the difficulty of assessing potential risk to children especially when they are not present, contact with professionals who know them is not possible and there are often no records available. The mental health trust review                                                            10 The Lord Laming (March 2009), The Protection of Children in England – a Progress Report., HC330 Stationery Office    61 has made a recommendation in relation to this and the LSCB will closely monitor its implementation since this is a point of vulnerability within current services. 5.18 There are clearly grounds to refine and improve the approach taken by the probation service in notifying social care of the birth of children to probation service supervisees. Consideration need to be given to making this procedure more sensitive to individual circumstances and also to providing channels of communication from probation officers to GPs and other health professionals. 5.19 The case history underlines the need for GPs whose patients have mental health problems to actively ‘think family’. That means specifically: 1) asking whether their patients are parents or have substantial caring responsibilities towards children; 2) recording this in medical notes so that all members of the primary health care team have access to the information; and 3) emphasising it in all referrals and correspondence about the patient. 5.20 All of these areas are the subject of recommendations in this report or in the associated health overview report. Additional recommendations from individual management reviews 5.21 These recommendations stand in addition to the recommendations made in individual management reviews prepared by agencies that had direct involvement with the family. Additional recommendations have also been made in the health overview report prepared on behalf of commissioners of health services. These are set out in full in Appendix 6 and in the multi-agency action plan that accompanies this report. The deal with the following areas. 5.22 (TEXT REDACTED) NHS Trust Integrated Care Organisation   The use of the Family Health Assessment  The implementation of the ‘did not attend’ policy in child health services 5.23 (TEXT REDACTED) NHS Foundation Trust   A consistent trust wide operational policy for mental health assessments undertaken in A&E departments  A revised safeguarding children programme tailored to staff working within A&E  In future all junior doctors will have information about safeguarding children and adults as part of their risk assessment induction.  Clearer procedures for staff about documenting risk assessments and management plans  Improved access to records of service users with a historic history of severe risk that had been documented on previous recording systems   Better information sharing protocols between agencies involved in mental health services (such as the prison health service) to ensure that all relevant information and reports are shared 5.24 NHS (TEXT REDACTED) (in relation to GP services):  The need for GPs to have a proper family focus  Information sharing between GPs working with different members of the same family    62  The need for GPs to seek information about drug and alcohol use  GP working arrangements with the health visiting services 5.25 (TEXT REDACTED)NHS Trust:  Improving compliance with the audit of postnatal discharge documentation     63   6 Additional recommendations arising from the SCR overview report and SCR panel discussions   Why is a recommendation required? Recommendation made to Intended impact – local or national Recommendation 1.  Mr B’s GP did not record the fact that he had become a parent on his medical records or communicate it to colleagues and other professionals (TEXT REDACTED) GPs / health commissioners (TEXT REDACTED) (TEXT REDACTED) GPs should ensure that information about patients family details and their links with children are recorded in all relevant medical records and communicated to other professionals when this is relevant to the assessment of need and the provision of services 2.  The Healthy Child Programme sets high expectations about the involvement of fathers in maternity and early childhood health services. However the evidence is that staff do not have the confidence, training and necessary support to make the implementation of this aspiration meaningful (TEXT REDACTED) health commissioners and all health providers All health providers involved in the SCR Health trusts should create a clear expectation of staff that fathers are fully engaged in services and support staff in doing this through practice guidance, training, supervision and audit of services  3.  Health visitors told the SCR that they value the current Family Health Assessment tool and are uncertain whether its use will continue because of the introduction of new electronic recording systems including RIO Community health trust  (TEXT REDACTED) (TEXT REDACTED) NHS Trust should consult front line staff and managers fully before making any change to the use which might dilute the advantages of the use of the Family Health Assessment by health visitors and their teams.  4.  The family GP believed that he had made an urgent referral on Mr B, but the information (TEXT REDACTED) NHS Foundation Trust and (TEXT REDACTED) The mental health trust and GPs should jointly review criteria and arrangements for urgent mental    64  Why is a recommendation required? Recommendation made to Intended impact – local or national Recommendation provided and the way it was provided did not trigger the expected response from the mental health trust. There appears to be a mismatch in expectations (TEXT REDACTED) GPs health referrals to ensure that these are fully understood and effective 5.  Mr B was never referred by his GP for drug services, although this was believed by all the professionals involved to be the cause of his psychosis (TEXT REDACTED) health commissioners and all (TEXT REDACTED) GPs (TEXT REDACTED) (TEXT REDACTED) GPs should review how they respond to information about sustained drug use so as to make better use of local drug services  6.  The probation officer sought information from the local authority when he became aware of the birth of Child G. However it would have been more fruitful if communication had been with health colleagues as well (TEXT REDACTED) Probation Trust  (TEXT REDACTED)  (TEXT REDACTED) Probation Trust should undertake a review of its procedures to widen the scope of information sharing about service users who have substantial contact and involvement with children to include key health professionals 7.  Information from prison health service records and court reports was never made known to local health professionals, despite the fact that they had provided information to both forensic psychiatrists and the prison health service (TEXT REDACTED) health commissioners (TEXT REDACTED) / (TEXT REDACTED) Health commissioners should improve access of local health professionals to information in prison health records and court reports. 8.  Mental health professionals were generally aware of the need to be mindful of risks to children but did not systematically assess their circumstances. The trust has made recommendations on this and this is an additional recommendation (TEXT REDACTED) NHS Foundation Trust  (TEXT REDACTED) The mental health trust should provide an update to the LSCB on the provision and uptake of its level 2/3 training on the safeguarding of children    65  Why is a recommendation required? Recommendation made to Intended impact – local or national Recommendation 9.  Information about MAPPA discussions is not consistently communicated to front line health professionals. In 2008 it is known that there was insufficient health representation at the (TEXT REDACTED) MAPPA, this has been included as a recommendation because it was identified by health visitors as a wider problem which persists despite current guidance.  (TEXT REDACTED) Community Safety Partnership, (TEXT REDACTED) MAPPA co-ordinator and community health services (TEXT REDACTED) It is therefore recommended that the local MAPPA coordinator and local health agencies should review the effectiveness of the current arrangements for health involvement in MAPPA panels     66 Appendix 1 Terms of reference of the SCR  Specific Terms of Reference: 1. To establish what risk factors were known to agencies from their historical involvement with family members prior to the start date of this review, January 2009?  2. What assessments were undertaken and what was the quality of those assessments?  3. To what extent did assessments identify risk factors within the family?  4. Were plans consistent with assessments and were they fully implemented?  5. What was the quality of information sharing within and between agencies?  6. To what extent did the agencies’ activities focus on the needs of children?  7. To what extent did agencies identify the competencies and limitations of the parents in their parenting tasks.  8. Did agencies respond appropriately to any risk factors identified in the course of their work with the family?  9. Did any issues arise in the work with the family that promoted, or should have promoted, agencies to seek information from agencies involved before the start date of the review?  10. Were the diversity needs of the family recognised and responded to?  11. Did staff have the knowledge, skills, and experience to respond to the needs identified in the case?  12. Were staff appropriately supervised and supported in their work with the family?  13. Did any capacity issues within the agency limit the ability of the agency to meet the needs of the family?  14. (Overview report writer only) What were the key incidents/ practice episodes and what was the learning from them?      67 Appendix 2 Membership of the (TEXT REDACTED) LSCB SCR panel on Child F Independent Chair  (TEXT REDACTED) Council Social Care Head of Safeguarding  (TEXT REDACTED) Police Service Detective Inspector (TEXT REDACTED) Child Abuse Investigation Team NHS (TEXT REDACTED) Designated Nurse  (TEXT REDACTED) NHS Foundation Trust  Assistant Director of Operations       68 Appendix 3 Background documents and references Brandon et al, (2009), Understanding Serious Case Reviews and their Impact a Biennial Analysis of Serious Case Reviews 2005-07 DCSF  Brandon M, Belderson P, Warren C, Howe D, Gardner R, Dodsworth J, and Black J (2007) Analysing child deaths and serious cases through abuse and neglect: what can we learn? A biennial analysis of serious case reviews 2003-2005. DfES  Care Quality Commission survey, Count Me in 2009: Results of the 2009 national census of inpatients and patients on supervised community treatment in mental health and learning disability services in England and Wales. Care Quality Commission, 2010 The Centre for Social Justice (February 2011), Mental Health: Poverty, Ethnicity and Family Breakdown - Interim Policy Briefing, http://www.centreforsocialjustice.org.uk/client/downloads/CSJMentalHealth_Final_20110205.pdf  Sidney Dekker, The Field Guide To Understanding Human Error, Ashgate (2006) Department of Health (2010) Healthy Child Programme- Pregnancy and the First Five Years of Life. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118525.pdf  HM Government Working Together to Safeguard Children 2010,  The Lord Laming (March 2009), The Protection of Children in England – a Progress Report., HC330 Stationery Office The Munro Review of Child Protection: Final Report: A Child centred system, Cm 8062, May 2011, The Stationery Office Ofsted (2011) Ages of concern: learning lessons from serious case reviews - A thematic report of Ofsted’s evaluation of serious case reviews from 1 April 2007 to 31 March 2011 David Woods et al, Behind Human Error, Ashgate (2010) second edition; P Reder, S Duncan and M Gray, Beyond Blame – Child Abuse Tragedies Revisited, Routledge (1993)         69 Appendix 4 Good practice for engaging fathers in the Healthy Child Programme (HCP)   From the beginning, promote the father’s role as being important to his child’s outcomes.   Make it explicit that the HCP is there for the whole family – including the father – and demonstrate this by providing suitable seating for him as well as for the mother. Address him directly, encourage him to speak and make it clear that you are listening.   Arrange meetings, services, groups and reviews to maximise the possibility of fathers attending. Stress the importance of their presence to both them and the mother.   Include positive images of fathers from different ethnic groups and of different ages in the literature that you produce and display.   Record fathers’ details – including those of non-resident fathers. Most mothers will give this information willingly, and two in three pregnant women who are not living with the father of their child describe him as ‘a good friend’ or as their partner.   Include an assessment of the father’s needs as well as the mother’s, as these will have a direct impact on both the mother and the child.   Include an assessment of the father’s health behaviours (e.g. in relation to diet, smoking, and alcohol or drug use), asking him directly wherever possible. These behaviours have a direct impact on both the mother and the child, and specifically on the mother’s own health behaviours.   Signpost fathers to all of the relevant services.   Make sure that fathers (as well as mothers) are in possession of information about, for example, the benefits of stopping smoking and strategies for doing so. Where possible, provide fathers with this information directly (rather than secondhand, via the mother) and ensure that it also incorporates information on their role in relation to their child.   Offer antenatal preparation to fathers, including at times that will be convenient for working fathers (e.g. evenings). This will also make it easier for working mothers to attend.   For further information, see the Fatherhood Institute website at www.fatherhoodinstitute.org and Including New Fathers (Fathers Direct, 2007).  Department of Health (2009), Healthy Child Programme – pregnancy and the first five years of life  Page 26        70 Appendix 5 The response of emergency services The following information has been obtained in order to address specific concerns of family members about the response of emergency services. Dispatch of an ambulance  When police officers arrived at the home an ambulance was called to the house and asked to wait at a rendezvous point 200 yards from the house until it was certain that it was needed. Police records indicate that the ambulance had not arrived   Mr B was treated at the scene by the (TEXT REDACTED) Ambulance Service before being taken to hospital. The assessment and treatment of his self-inflicted wounds was impaired because his hands and feet were bound for his own safety and the protection of others Attendance of a doctor and psychiatrist  It is not the practice of the ambulance service to dispatch a doctor to the scene of an incident except in relation to the Helicopter Emergency Medical Service (HEMS)  HEMS was dispatched to the house but was not able to attend at the house before Child F had been taken directly to hospital because the incident developed so quickly  HEMS attended at the hospital and took responsibility for the care of Child F before she was transported to a hospital that was better equipped to stabilise and treat her condition  It is never possible to dispatch a psychiatrist in order to undertake an assessment of a mentally ill patient within the time that was available in this incident. When assessments take place under the Mental Health Act the psychiatrist becomes involved after any immediate risk to the individuals involved has been dealt with by the emergency services Actions and decisions of the police  The police are satisfied that it was necessary to deploy a large number of officers to the family home once it became clear that there was a potential threat to life. The account given by the police and family members is that Mr B was threatening Child F with a knife (and may have injured her) before police officers entered the room  The judgement of the officers dealing with the incident was that Mr B’s thinking was too disturbed to make him amenable to any negotiating strategy in the short term. However, the senior officer at the central control room decided that the on-call co-ordinator for negotiators should be alerted about the incident as he or she might have been able to give advice to the police officers on scene. The incident developed very rapidly and in 5 minutes it took for the co-ordinator to respond to the call, the incident was over. It is normally possible for a negotiator to be on the scene within one hour. The circumstances of the case did not permit this        71 Appendix 6 Recommendations from Internal Management Reviews (TEXT REDACTED) Hospitals NHS Trust  RECOMMENDATION  INTENDED OUTCOME  Audit compliance with completion of postnatal discharge documentation. Improved compliance and performance in postnatal discharge documentation to partner agencies.  GP should document any antenatal consultation in the hand held maternity record.  Effective multidisciplinary team communication   (TEXT REDACTED) NHS Trust (Community Services (TEXT REDACTED)) RECOMMENDATION  INTENDED OUTCOME  In order for health professionals to collaborate and work more effectively with parents/carers/agencies, it is vital that significant information is shared in relation to Family and Environmental Factors – in particular the Family History and Functioning; of all significant adult in the household and their role in the child’s life.  This can be achieved through single/multi-agency safeguarding levels two and three refresher training– using the Assessment Framework DOH (2000)  (TEXT REDACTED) NHS Foundation Trust  RECOMMENDATION  INTENDED OUTCOME  1.The Trust needs a Trust-wide operational policy for A&E assessments whether it has separate teams or distinct functions in one team carrying out this role  A Trust –wide operational policy will address staff skill set, medical leadership, induction and ongoing safeguarding training tailored to the needs of assessment in acute situations. It will clarify what risk documentation, including safeguarding of children and adults, is required for people assessed but discharged by the service. 2. (TEXT REDACTED) will deliver a training Safeguarding Children programme tailored to staff working within A&E Trust staff working in A&E settings will be able to translate child safeguarding into practice in acute situations. Children and Adult Safeguarding awareness training will be part of all junior doctor induction. 3. All junior doctors need to have safeguarding children and adults as part of their risk The Trust A&E operational policy will ensure that staff are clear what their specific role is with    72 assessment induction.  regard to documenting risk assessments and management plans 4. Staff must be clear what their specific role is with regard to documenting risk assessments and management plans Where the Trust has seen service users who have a conviction then information most be obtained via the Offender Care Service Line which will be entered onto the clinical patient system.  5. Information sharing systems  To look at information sharing protocols between agencies to ensure that all relevant information and reports are shared.  NHS (TEXT REDACTED) recommendations for GPs 1. All information held by a practitioner should be passed on, printed out in its entirety, to subsequent practitioners. 2. All newly registered patients should be given opportunities for disclosure of mental health, abuse of drugs and/or alcohol, past history of violence 3. When parents are on different GP lists, practitioners should have an overview of family dynamics composition both within and without the household. 4. GPs should link formally with the HVS. 5. All available details should be entered in the records of children, as well as in the maternal records - e.g. birth notifications, 6 week check up 6. Prison Medical Service records should be joined with GP records and vice versa when a patient moves from one jurisdiction to another.  Health Overview Report Mental health assessment and contact with patients A recommendation is that front line practitioners need standardised risk assessments for adults or mental health problems/drugs who are parents in line with CQC requirements. Assessments should include a history of violence and a past criminal record as specific questions to be documented and reviewed. A recommendation is that when patients and families seek attention for a mental health crisis, the patient and family’s expectations, coping strategies networks and safety nets for any children in the and support networks are explored and noted.  A recommendation is that GPs ask patients, especially ex prisoners, if they have accessed mental services and reports and records should be collated (with their consent).  Patient referrals:    73 A recommendation is that the rationale for an ‘urgent referral’ to a service is communicated per phone, by fax then post with a clear expectation of when the case is to be seen. Involvement of fathers A recommendation is that services commissioned for women and children should follow the Healthy Child Programme guidance, 2009, of including and promoting the father’s role in outcomes for children. (Ref: Healthy Child Programme guidance, 2009, Page3 25,6). Public Health A recommendation is that commissioners are advised of this review to include the recommendations in services for drug users. Hospital Liaison and A+E A recommendation is that A+E staff must be alert to the issues for children when they are providing services to adults who have contact or caring roles with children, and should refer to the Hospital1 liaison nurse as necessary.   