Death of a 2-month-old baby girl in January 2017. A post-mortem found eight rib fractures sustained over a 24-hour to twenty-day period. Baby's mother was found guilty of manslaughter and received a custodial sentence. Baby lived with her mother and was the subject of a Child Protection Plan from birth due to concerns based on her mother's past parenting difficulties, alcohol and substance misuse and previous abusive relationships. Mother chose not to say who the father was. An older sibling born in 2008 was cared for by the maternal grandparents who obtained a Special Guardianship Order. The family is of white British heritage. Baby was born pre-term and was seen frequently by health and social work professionals from two local authority areas - she was viewed as making good progress and being well cared for. Evidence of mother drinking and taking drugs during her pregnancy; continued use of alcohol and cocaine after the baby's birth was successfully hidden from professionals. Lessons learnt include: the need for effective liaison and communication between local authority social care teams; professionals should understand the addictive nature of drug and alcohol dependency and that non-attendance at substance misuse appointments could be an indicator of abuse; professionals need to be mindful of disguised compliance and an over optimistic mind set. Recommends that an appropriate action and implementation plan should be devised to ensure lasting improvements to practice and services aimed at safeguarding and promoting the welfare of children.
      
 Title:  Serious case review: BSCB 2017-18/01. LSCB: Birmingham Safeguarding Children Partnership Author: Paul Sharkey Date of publication: 2019  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           Serious Case Review  BSCB 2017‐18/01 Independent Lead Reviewer:  Paul Sharkey MPA Publication date: 19th December 2019 2 Contents Page Part 1 Introduction 3 Part 2 Aims, Key Issues for Analysis and Review Processes (Appendix 1) 5 Part 3 Case Background and Overview of Agencies’ Involvement: The Facts 9 Part 4 Analysis 23 Part 5 The Mother’s Views 40 Part 6 Key Findings and Lessons 41 Part 7 Professional Challenge and Action Planning 45 Glossary 46 References 48 Appendices 49 3 Part 1: Introduction 1.The subject of this Serious Case Review (SCR) is a baby who was born in late October2016 in a Birmingham hospital and was the mother’s second child. Due to concernsabout the mother’s substance misuse, history of domestic abuse and the removal of herfirst child some years previously, the baby was made the subject of a child protectionplan under the category of neglect, the day after birth.2.The plan entailed multi-agency intervention with the pair from a range of social care,health, family support and substance misuse professionals to support them and reducerisk of harm to the baby. The mother’s parents, who lived nearby, also had a supportiverole in the plan.3.Mother and baby were discharged from hospital in early November and, being registeredhomeless (albeit having hostel accommodation in Birmingham), stayed with a friend inBirmingham, prior to moving to temporary accommodation in Solihull in mid-November.The move resulted in a change of professionals from Birmingham to Solihull andarrangements were made for a receiving-in Initial Child Protection Conference in Solihullfor the 05.01.17. Birmingham Children’s Services held case responsibility and oversawthe child protection plan over the Christmas and New Year period. However, to assistBirmingham Children’s Services a visit was made by a Solihull social worker on the30.12.16 when no concerns were noted.4.The baby, aged two months, was taken by ambulance on the afternoon of the 02.01.17to the emergency department of a Birmingham hospital, suffering from cardiac arrest,where tragically, the baby died.  On post-mortem examination the baby was found tohave eight rib fractures sustained over a twenty-four hour to twenty-day period. Sevenoccurred between 4-12 hours and one between 10-20 days before death.5.The baby was aged just two months old and was not independently mobile and was thusnot able to injure itself. Subsequent medical examinations concluded that the injurieswere traumatic in origin and caused by significant force. The mother told the police thatshe (the mother) had fallen asleep during the daytime of the 02.01.17 with the baby onher chest and that no one else had had care of the baby during that time. She said thatthe baby was never out of her sight or mishandled by her or anyone else. She wasarrested on suspicion of neglect and a criminal investigation was started by WestMidlands Police (WMP).6.In the light of the baby’s immobility and age, the mother’s account of events was thoughtto be implausible as an explanation for accidental injury or medical cause. The presenceof multiple unexplained rib fractures on a baby of two months, sustained on multipleoccasions, was thought to be indicative of abusive and/or deliberately inflicted injury.7.Subsequent expert medical evidence as part of the Police enquiry, suggested that therib fractures sustained by the baby on the 02.01.17 contributed to the baby’s deaththrough progressive respiratory failure caused by shallow, ineffective breathing, leadingto a lack of oxygen to the brain, asphyxia and cardiac arrest.48.Following a very thorough police inquiry, the mother was subsequently charged in lateAugust 2018 with manslaughter and two counts of grievous bodily harm in respect of thebaby. Following a trial in March 2019, the mother was found guilty at Birmingham CrownCourt in early April 2019 of the said offences and given a custodial sentence of thirteen-and-a-half years.9.In compliance with statutory guidance1 and regulations, the Birmingham SafeguardingChildren Board (BSCB) commissioned a SCR on the 10.10.17. An independent jointreview chair/Lead Reviewer was appointed in late December 2017 and work started onthe SCR in February 2018.10.The SCR was temporarily halted in October 2018 to allow for the conclusion of the trialin April 2019. The SCR Review Team was aware from the police representative that theongoing criminal enquiry contained some very salient and significant evidence regardingthe mother’s involvement in the death of the baby, which was not available to the reviewat the time. This could only be shared and used by the SCR after the trial’s conclusion.An interim overview report was provided in October 2018 by the chair/Lead Reviewer tothe BSCB SCR sub-group which considered it at the meeting of the 12.10.18. Feedbackcomments were made by the sub-group which led to additional amendments by the LeadReviewer that were included in a later (February 2019) version of the interim report. Afinal version was completed following the conclusion of the trial and sentencing of themother in early April 2019.11.There was no information or evidence available to the agencies and professionalsinvolved at the time that would have led them to be able to predict the tragic outcome inthis case.  The mother must take full responsibility for the tragic death of her baby.1 Local Safeguarding Children Board Regulations 2006; 5(1) and (2), see also ‘Working Together’ 2015, Chapter 4. This was the version current at the time of the death. A revised version was published in June 2018.5 Part 2: Aims, Key Issues for Analysis and Review Processes (see Appendix 1) Family Involvement 12.The maternal grandparents were written to on two occasions following the conclusion ofthe trial in early April 2019, regarding a meeting with the Lead Reviewer. There was noresponse.  The baby’s mother was seen by the Lead reviewer and a review teammember on the 29th May 2019. Her views are set out on page 40.Race, Religion, Language and Culture 13.The family are English speakers of white British heritage.Parallel Proceedings: The Police Enquiry 14.West Midlands Police completed a very thorough inquiry into the death of the baby.2This resulted in the decision of late August 2018, by the Criminal Prosecution Service,to charge the mother with manslaughter and two counts of grievous bodily harm inregard to the baby’s death.15.The Lead Reviewer and review team received an update on the Police inquiry from thepolice representative at the review meeting of the 14.09.18. The information sharedsuggested that the mother had continued to engage in substance and alcohol misuseduring the period prior to her baby’s death and had hidden the fact from theprofessionals. Moreover, that alcohol and substance abuse had played a very significantpart in the death of the child. This information was not known to the professionalsinvolved with the mother and baby prior to the latter’s tragic death. Of significance to thisSCR, no such information was mentioned in the agency reports and documentationmade available (at the time of the interim report of October 2018) to the Lead Reviewerand review team during 2018.16.The advice from the review team police representative in September 2018 was that noneof the detailed material from the criminal enquiry could be used in the interim reportpending the conclusion of the later trial. Moreover, it was not possible to interview themother or her parents until after the trial. On this basis the Lead Reviewer recommendedto the BSCB Independent Char and BSCB Business Manager that the review betemporarily halted, pending the completion of the trial in April 2019.Meeting between the Lead Reviewer and the WMP enquiry team (05.04.19) 17.The meeting agreed that an addendum to the initial police report of April 2018 would beprovided from sources used in the Police enquiry and the trial of the mother to cover thefollowing themes:2 The enquiry team are to be commended on the diligence, professionalism and commitment shown in the conduct of a very complex investigation.  6 •The timing, nature and context of the injuries sustained by the baby (seeappendix 2 for risk of serious injury to and vulnerability of infants under 12months old).•The events between mother and baby between 22.12.16 and 02.01.17 with afocus on the final seventy-two hours leading up to the child’s death on the02.01.17.•Any evidence of substance and/or alcohol use by the mother from thebeginning of her pregnancy to the baby’s death, with reference to her contactand dealings with professionals.•Any evidence of contact between the mother and adult males in the periodbetween the 22.12.16 and the 02.01.17.Key Findings Likely cause of death 18.As previously mentioned, the consensus of expert medical opinion provided at the trialin relation to the likely mechanism of the cause of death of the baby was as follows. Thebaby sustained multiple rib fractures some four to twelve hours prior to death at around15:00 hours3 on the 02.01.17 by way of a non-accidental traumatic event. The eventinvolved a compressive significant force being deliberately inflicted on the baby; possiblya squeezing of the chest, amounting to non-accidental injury and assault when the babywas crying, leading to the rib fractures.19.The traumatic event (namely, the non-accidental assault) probably caused the baby’sbreathing to be temporarily impaired or to cease for a period of time, leading to adecrease in oxygen supply to the vital organs, including the brain; resulting in hypoxic-ischaemic brain injury and setting up the conditions for a subsequent deterioration incardiovascular function and ultimately, death.20.In short, the evidence suggested that the assault by the mother had resulted in the deathof her baby.Timing of Injuries 21.On examination the baby was found to have eight rib fractures sustained over a twenty-four hour to twenty-day period. Seven occurred between 4-12 hours (between 03:00 and11:00 hours on the 02.01.17) and one between 10-20 days before death (between the13.12.16 and the 20.12.16).Events Prior to the Death 22.CCTV evidence obtained by the Police enquiry showed that at 17:50 hours on the22.12.16 the mother, along with the baby in a pushchair, was recorded furtively drinkingwine from a glass in a Solihull public house. She left an hour and fifteen minutes later at19:05 hours. This was a very significant event as the day before (21.12.16) she hadbeen visited by the Solihull social worker when a discussion ensued with her regarding3 The baby’s death was formally declared at 16:06 in hospital. 7 the details and expectations of both the existing child protection and the pre-proceeding plans, including the importance of abstaining from alcohol.  23.The mother was visited by the Solihull social worker on Friday 30.12.16. The baby wasasleep in a car seat, wrapped in a blanket and wearing a hat. The mother was challengedabout reported sightings of her drinking in the pub on the 22.12.16, despite having givenassurances that she had understood the importance of not drinking alcohol andpromising to abide by the terms of the child protection and pre-proceedings plans. Shesaid that she had drunk only one glass of wine and thought she was allowed to have adrink over the Christmas period. She was advised that the child protection plan wouldremain in place.24.Evidence from the Police enquiry established that the mother had been visited by somefriends on the evening of the 31.12.16 (New Year’s Eve) who had stayed the night at theflat. They had brought some alcohol (two lagers, a bottle of Cava and half a bottle of redwine) and a wrap of cocaine. It was apparent that the mother already had some cocaineand later took three or four lines along with her friends. She also admitted to the policeto having drunk a glass of champagne.25.Other police witnesses stated that the mother and baby had arrived at a public houseon New Year’s Day (01.01.17) at around 16:30-17:00 hours to attend a birthday party.The witnesses recalled that the mother had drunk around four or five pints of cider andblackcurrant and ‘didn’t have much time for the baby’, who appeared to have a cold. Themother told another witness that her baby was not very well. She and the baby left thepublic house at 22:30 hours, five and a half to six hours after having arrived and wasestimated by the witness as being ‘six or seven out of ten on a scale of drunkenness’.26.Another witness stated that the mother continued to drink cider during her pregnancyand would have ‘a can of an evening, a few times a week’.27.One of the witnesses arranged for the mother and baby to be taken home from the partyby taxi in the company of a male adult mutual friend. The male friend had noticed thatthe baby looked pale and ‘not very well’ whilst in the public house. He said that themother ‘was desperate for cocaine’ and that he believed that she had spoken to hersupplier on the telephone4 but no-one had turned up. He could not say whether themother had used cocaine at the public house and did not see her use it at the house.He said that the baby appeared very unsettled until around 4:00 hours, when the motherwent into the living room and lay on the sofa with the baby on her chest and both fellasleep in that position. The male witness lay on another sofa and slept for a short timebefore leaving the property at around 6:30 hours. He said that mother and babyremained in the same position when he left. He did not see the mother do anything tothe baby that might have caused the baby an injury.28.The enquiry evidence would therefore suggest that the baby was seriously injured bythe mother sometime between 6:30 and 11:00 hours.4 Between 01:00 and 02:50 hours according to the Police enquiry. 8 Substance and alcohol misuse 29.As previously noted, the enquiry evidenced that the mother drank cider during herpregnancy, drank wine on the 22.12.16, took cocaine on the 31.12.16 and drank severalpints of cider over a five to six hour period on the 01.01.17, in addition to contacting hercocaine supplier. Save for the 22.12.16 event, none of the other occasions of alcoholand cocaine use5 were known to any professional.30.As part of the criminal enquiry, police found two almost empty bottles of alcohol spiritsin the mother’s fridge on the 02.01.17. She was also noted on the way to the hospital onthe same day to have been smelling of alcohol on her breath. There was telephoneevidence that she had sent a text message to a friend on the 22.12.16 which includedthe words ‘I’ll just quit fags and booze till I get paid next week’. A message extract of the29.11.16 said “I’m not allowed to drink alcohol but have on weekends (but) they don’tvisit over weekends lol!!!! I was gonna get some tonight and maybe a livener but (the)social worker has just told me she’s gonna arrange me to be drug/alcohol tested asaphaha-grrr”.31.The police seized the mother’s phone during the course of the criminal enquiry andexamined it for various communications. It transpired that ‘behind closed doors and inthe company of her inner circle of friends she was continuing to use alcohol and cocaineand would not, or could not, give up drink and drugs for the sake of the baby’.32.The Police enquiry concluded that ‘the mother had been presenting a different face toher family, to some of her friends, and to social and healthcare workers, intending togive them a false impression that she was a responsible and caring parent takingseriously her role as mother to a new born baby’.Contact between adult males and the mother from 22.12.16 to the 02.01.17 33.The Police enquiry evidenced that the mother and baby had been brought home by anadult male friend from the party at the public house on the night and morning of the01/02.01.17. Apart from that occasion, there was no evidence of the mother and babybeing in the sole company at home of any adult male.Dissemination of Learning 34.The Independent Lead Reviewer presented the final report to the Executive Board of theBirmingham Safeguarding Children Partnership in September 2019, for ratification andeffective dissemination of the learning.  The partnership will commission a series oflearning events to share the emerging learning with frontline practitioners and managersacross the safeguarding partnership in Birmingham.   The Executive Board will alsooversee the arrangements for publication of the full report on the partnership’s website,together with a Learning Lessons Briefing Note aimed at frontline practitioners, and amanagers’ briefing pack for use in team meetings and supervision sessions to maximisethe opportunity to cascade the learning from this case.5 Save for the May 2016 positive cocaine test. 9 Part 3: Case Background and Overview of Agencies’ Involvement: The Facts Social History Prior to May 2016  35.The baby’s mother was born in 1986; she comes from the West Midlands and wasadopted at the age of eighteen months, along with her older sister. The motherreportedly had a difficult relationship with her parents and described her childhood as‘up and down’.36.As a young adult in her late teens and twenties, she had a history of mental healthdifficulties (self-harming and depressive feelings), substance misuse (cocaine andalcohol) and subjection to serious domestic abuse and violence from various ex-partnersdating back to 2007.37.The mother had a child by her then violent partner in early 2008, whilst living in Solihull.Prior to the birth she wanted the child to be adopted, which involved Solihull Children’sServices. However, she changed her mind during the adoption process and the localauthority undertook an assessment which identified several risk factors, including,domestic violence from her partner, debt, her own depression/low mood and substancemisuse. Attempts were made by Solihull Children’s Services to work with the parentsthat aimed to support them in providing ‘good enough’ care for the child, in a safe familyenvironment.38.However, the situation deteriorated quickly with emerging serious concerns aroundcontinued domestic abuse, substance misuse (cocaine and alcohol), the child being leftwith other family members for long periods of time, the child’s parents prioritising theirown needs before those of the child and the breaching of the working agreementregarding the mother’s partner having supervised contact with the child.39.An Initial Child Protection Conference (ICPC) was held in June 2008 which resulted inthe child being made the subject of a child protection plan under the category of neglect.At around the same time, the mother left the child in the care of her parents and did notreturn. The child became a Looked After Child under Section 20 of the Children Act 1989to Solihull Council and further parenting assessments were undertaken on both parentswho by this time had separated.40.The mother was not able to show the local authority that she could meet the child’sneeds and was disregarded as a potential carer. The mother’s partner successfullycompleted his parenting assessment and the child was returned to his care in early 2009,still subject to the child protection plan. Father and the child moved to Coventry and areceiving-in ICPC was held in April 2009. There was a further domestic abuse incidentbetween the parents in October 2009. In February 2010, the partner decided that hecould no longer manage the child’s care and left the child with the maternalgrandparents. Solihull Children’s Services again took responsibility for the case.41.The child became cared for by the maternal grandparents but continued contact with themother who provided some of the care during the day. The child became, once again,the subject of a child protection plan with Solihull who had concerns about the mother’scontinuing substance misuse, albeit no issues concerning her parents. A further10 parenting assessment of the mother started in December 2010 and ended in January 2011 due to concerns about her commitment to the assessment and reported issues of domestic abuse with a new male partner.  42.The child remained in grandparents’ care under Section 20 of the Children Act 1989.They applied for and obtained a Special Guardianship Order (SGO) in January 2012,under the auspices of Solihull Children’s Services and the child has remained with themsince that time. Solihull ended its involvement with the child and the maternalgrandparents in March 2012, albeit that there have been annual visits in line with theSGO allowance being paid to the grandparents.May 2016 to January 2017. 43.The mother attended at the Birmingham Heartlands hospital for an ante-natal bookingwith the community midwife (CMW1) on the 09.03.16, when six weeks pregnant. Themother’s history of substance misuse was noted. She declined a referral to the perinatalmental health clinic. On the 04.05.16 she attended an ante-natal appointment at Solihullhospital at 12 weeks pregnant. An extensive history was noted of substance misuse,earlier Solihull Children’s Services involvement, a previous child living with her parentsand high blood pressure. A referral was made to the specialist midwife for substancemisuse (SMW1) for the 11.05.16 which the mother did not attend.44.The mother saw the specialist midwife on the 24.05.16 at 15 weeks pregnant. At thatpoint her expected date of delivery was the 11.11.16. A full history was taken when shestated that she was not currently in a relationship, denied any current domestic abuseor substance misuse but admitted to some cider drinking whilst pregnant. She had drunkthe day before and was informed by SMW1 of the dangers of foetal alcohol syndrome.She said that she intended not to drink alcohol for the rest of her pregnancy. SMW1 saidthat because of her previous history of substance misuse a referral would be made toSolihull Children’s Services at 20 weeks gestation to which she agreed.45.On the 27.05.16, the urine toxicology indicated that the mother had tested positive forcocaine thus gainsaying her previous denial of use. SMW1 completed a referral toSolihull Children’s Services which was received by the Multi-Agency Safeguarding Hub(MASH) on the same day.6 SMW1 followed up the referral on the 01.06.16 with theMASH and was told that referrals were not accepted until the mother was 20 weekspregnant. SWM1 emphasised the seriousness of the mother’s history of substancemisuse and the referral was accepted. The MASH informed SMW1 on the 02.06.16 thatthe case was awaiting allocation and the pre-birth assessment started on the 16.06.16.46.On acceptance, it was believed by Solihull MASH that the mother was resident in theborough, as per the information from the midwifery referral. No checks were maderegarding the location of the mother’s tenancy which was a hostel in Birmingham,although, as previously mentioned, she had been living temporarily with a male friend inSolihull, whose address had been given by the midwifery referral to the MASH. The male6 N.B The mother had given her male friend’s address in Solihull to the midwifery service as her address. By the time of the midwifery referral to Solihull Children’s Service at the end of May 2016, her male friend had died in the interim period and the mother chose to live with her female friend in Birmingham.  11 friend died and the mother, despite having the hostel place remaining open to her7, chose to stay with a female friend in Birmingham, where she continued to live during the time of Solihull MBC’s involvement, prior to the later case transfer to Birmingham on the 31.08.16.  47.On the 15.07.16 SMW1 was informed by a Solihull social worker (SSW1)8, that thereferral on the unborn baby was likely to proceed to an ICPC. The mother did not attendan appointment with SMW1 on the 18.07.16. The social worker was informed and thecommunity midwife was asked to visit and seek to re-engage the mother with SMW1.The mother gave a urine sample to SMW1 on the 28.08.16 which, on the 01.09.16,proved to be negative with no drugs being detected.48.By mid-August SSW1 had completed the pre-birth assessment on the mother. In thecourse of the assessment SSW1 had established that the mother was, in fact, residingin Birmingham (Sheldon) with her female friend and her children, notwithstanding thather Birmingham hostel placement remained open. Following a contact with the motherby SSW1 in late August, it was recorded that the mother had no intention of getting herown property in Solihull before the birth of the baby. After some discussion betweenSolihull and Birmingham Children’s Services a referral was made to the latter on the31.08.16. Case responsibility was commendably and promptly taken up by BirminghamChildren’s Services on the 01.09.16 when a social worker (BSW1, an agency worker)was allocated to start a social work assessment. SSW1 provided the Birmingham MASHwith a copy of her completed pre-birth assessment on the 02.09.16 and closed the caseto Solihull soon after.49.On the 29.09.16 SMW1 told BSW1 that the mother had provided two negative drug testson 26.08.16 and 23.09.16. However, she had previously tested positive for cocaine on24.05.16. Following that positive test, she then missed four subsequent appointments inJuly and August. SMW1 told BSW1 following the negative September drug test that theunborn baby’s growth was not progressing. There was a possibility that the mother mayhave had to be induced with an early birth, such were the concerns for foetal wellbeingbecause of the poor progress. BSW1 asked that SMW1 make a referral to a substancemisuse agency (in this case Change Grow Live) for rehabilitation support andfortnightly/weekly drug testing.50.BSW1 commenced the assessment on the 05.09.16 and completed it on the 21.10.16.Visits were made (at the mother’s female friend’s home) on the 26.09.16 and the19.10.16 to inform the assessment. At the former visit no concerns were noted by BSW1;the mother had bought several items in preparation for the birth. She gave no identifyinginformation save to say that the father was a married man who wished to have noinvolvement with the birth or any future contact with the mother or the baby. In the eventof any change in the situation she would let the Birmingham Children’s Services know.51.Police checks on the female friend were requested by BSW1 on the 29.09.16. Anelectronic request for a strategy discussion was reportedly made to the Police on the06.10.16 which resulted in a nil response. However, West Midlands Police had no record7 Her belongings were still at the hostel.  8 At this time, SSW1 believed that the mother was staying with her friend in Solihull. 12 of receiving a request on the 06.10.16 for a strategy discussion. Additional calls were made to chase up the matter but to no avail and on this basis the team manager (BSWTM1) decided to hold the strategy meeting on the 17.10.16. In consultation with Solihull Children’s Services and Health (SMW1) the team manager decided to proceed to a Section 47 enquiry and the holding of an Initial Child Protection Conference (ICPC). The Police were asked to provide any relevant information on the mother and her female friend, to inform the enquiry which started on the 09.10.16.  52.The mother registered with a Birmingham GP practice on the 11.10.16 and was seen onthe 14.10.16 by a practice nurse for a New Patient health check. The mother told herthat she smoked and was tee-total. Family and general history were discussed andrecorded with no concerns noted, although nothing was mentioned about the pregnancy.53.On the 18.10.16, BSW1 spoke by telephone to the maternal grandfather who informedthe social worker of the mother’s first child having been placed with him and his wifeunder a Special Guardianship Order since 2012 and the reasons for this. He said thathe was happy to attend a family group conference if necessary but would not have thecapacity to look after another child. He added that the mother had regular, supervised(at her request) contact with the first child at her parent’s home with no concerns noted.54.Again, on the 18.10.16, the mother attended an appointment with her communitymidwife whom she had first met on the 09.03.16 at six weeks pregnant. The unborn babywas recorded at below the 5th centile.55.BSW1 visited the mother on the 19.10.16 to complete the social work assessment. Hesaid that a recommendation would be made to the Area Resource Panel meeting thenext day for the start of public law outline9 pre-proceedings on the unborn baby. Thiswas necessary because of the mother’s previous non-cooperation with Solihullsubstance misuse and family support services as mentioned in the Solihull Children’sServices pre-birth assessment. The mother was recorded as saying that she wouldengage with any drug misuse and parenting support services in Birmingham, albeit shewould struggle to attend sessions in the community immediately after the birth of thebaby.56.Consequent to the completion of the social work assessment on the 21.10.16 the teammanager (BSWTM1) decided to: proceed to an ICPC; implement a child protection planunder the neglect category; hold a legal planning meeting with a view to starting pre-proceedings on the unborn child and, if necessary; escalate to care proceedings in theevent of parental non-co-operation and/or a breach of the former.57.The Area Resource Panel meeting - chaired by the Head of Service (HoS) - held on the20.10.16, agreed to the team manager’s proposal for a pre-proceedings plan, given theknown risks and needs of the unborn child and the requirement for multi-agency riskmanagement arrangements. Progression to a Legal Planning Meeting (LPM) was given.On the 21.10.16 BSW1 made a referral for a community based parental assessment9 The Public Law Outline (PLO) is a means by which, through meetings between a local authority and parents, an agreed plan is produced regarding the care of children that seeks to avoid the local authority starting care proceedings. Thus, it is a pre-proceedings device.  13 with ‘Think Family’ and sent an email to SMW1 confirming that the mother and her baby were not to be discharged from hospital until after a discharge meeting to be held by the midwifery service, Birmingham Children’s Services and the receipt of legal advice regarding pre-proceedings. There was a request for a further drug test on the mother at the birth. 58.The community midwife passed on information to the mother’s GP on the 21.10.16 thather baby was due the coming weekend and that there was an ICPC arranged for the26.10.16. BSW1’s name was shared with the GP although there was no subsequentcontact made with the social worker. BSW1 visited the mother on the 21.10.16 to informher of the outcome of the social work assessment and decisions made by the AreaResource Panel, and to complete a genogram. The mother said she was aware of thehistorical concerns but was now in a better position and wanted to care for her new baby.She was informed of the forthcoming ICPC but was unlikely to attend due to the plannedlabour on the 25.10.16. She was reluctant to share any information on the paternity ofthe baby.59.A referral was made on the 24.10.16 to ‘Think Family’ by BSW1 for community-basedsupport to start in mid-December. There were concerns that the mother had failed threeprevious parenting assessments in relation to her first child. BSW1 would be visitingdaily post birth with the support of health and other partners.60.A legal planning meeting was held on the same day involving the team manager, theHead of Service and the local authority solicitor. The current situation and contents ofthe social work assessment were considered, it being the case that the mother had goneinto hospital on the 22.10.16 to be induced, such were the professional concerns for thewellbeing of the unborn baby. The overall post birth plan for a community assessment,the mother’s engagement with substance misuse, midwifery and health visiting, familysupport services and daily social work visits prior to the start of the communityassessment in mid-December was agreed, as was the move towards locating it within apre-proceeding planning framework. A LPM review was scheduled for the 12.12.1661.On the 25.10.16, the baby was born (some two weeks before the EDD of the 11.11.16)to the mother by normal delivery following induction for intrauterine growth retardation,due to the baby being small for its gestational age.10 The Emergency Duty Team wasnotified by the hospital of the birth and the hospital implemented the child protection planpreviously agreed with by Birmingham Children’s Services. This included no dischargeuntil after a multi-agency discharge meeting and the sharing of the local authority’s pre-proceedings initiative. A decision was also made for a urine toxicology test to beconducted (with the mother’s consent) in line with the local authority’s request.62.Observations at the baby’s birth were satisfactory: the baby was a well baby, albeit itwas noted that the baby was of a small birth weight for gestational age (10th centile) witha head circumference on the 1st centile.10 See appendix 3 for effects of maternal cocaine and alcohol use on the foetus, new-born children and beyond.  14 63.The ICPC held on the 26.10.16 made the baby the subject of a child protection planunder the category of neglect. In attendance were the social worker (BSW1), a civilianpolice representative and a specialist midwife (SMW2).11 Unfortunately, the Solihullsocial worker received an invitation the day before the ICPC and, because of the shortnotice, was unable to attend. The plan included the undertaking of a community-basedassessment, intensive multi-agency support and daily social work visits under a pre-proceedings initiative. A net safety score12 of 2 (from the three professionals inattendance) was given which indicated a very low level of safety and high professionalconcerns regarding the wellbeing of the baby whilst in the mother’s care.64.The prescient comment was made by the principal officer child protection1 (POCP1) andnoted in the ICPC minutes that:‘There is a risk of professionals being over optimistic in this case. [The baby] is a very small and vulnerable baby13 who may need more than good enough parenting’. 65.Moreover, there were concerns from the ICPC about the mother and the baby beingdischarged to the mother’s female friend because of police information concerningprevious domestic violence calls to the premises and logs for drug dealing. An emailfrom the ICPC Chair (principal officer child protection - POCP1) was sent immediatelyafter the conference to the team manager, social worker, Head of Service and theprincipal social worker at Solihull setting out these concerns.66.The mother was informed at hospital by BSW1 of the case conference outcomes,decisions and concerns about her returning to her female friend’s home. Three optionswere considered. Firstly, that the mother and the baby could stay with the maternalgrandparents pending the provision of their own accommodation and the start of thecommunity-based assessment in mid-December. Secondly, that the mother and thebaby should go to an allocated temporary accommodation, and thirdly, a return to thefemale friend’s home.67.The principal officer child protection (POCP1) discussed the options regarding thedischarge plan with the covering team manager (BSWTM2) on the same day. The optionof staying with maternal grandparents was not viable as they were not in a position totake mother and baby. The risks of mother and baby going to an emergency hostel weretoo high and the option was therefore rejected. The third option was for mother and babyto return to the female friend’s house.68.BSWTM2 had looked at the concerns around the female friend and established that thedomestic violence report related to an incident in December 2015 when her sibling hadattacked her with a snooker cue but had since returned to his country of origin. Thefemale friend had contacted the Police to report the incident and seek protection. Therehad been no reported incidents of domestic violence since that time. In relation to thesuggestion of drug dealing this was at the level of uncorroborated intelligence which did11 Not SWM1 12 Where Zero (0) is no safety and ten (10) is a high level of safety – Birmingham Children’s Trust – Process for Child Protection Conferences June 2019.  13 See appendix 2 on vulnerable infants and risk of non-accidental-injury.  15 not result in any police action or charges brought against her. Moreover, she had two children of her own and there were no concerns about their safety or wellbeing.  69.On this basis a decision was made by Birmingham Children’s Services to allow themother and baby to return to the female friend’s home in the short term, under a highlystructured safety plan, pending the provision of longer term accommodation in theSolihull area as the mother had previously strongly indicated that she wanted to berehoused there, given her parents lived there. Birmingham Children’s Services felt thatthe discharge should take place the following week (in early November) to allowarrangements to be put in place for the safety plan, which was communicated to thehospital who were content with the proposal.70.The specialist midwife (SMW1) challenged the discharge plan with the principal officerchild protection on the 28.10.16 for the mother and baby to go to the female friend’shome and received an email setting out how the risk was to be managed.71.The mother tested negative for drugs on the 28.10.16 whilst in hospital. Staff reportsfrom the ward noted that she was attending to her baby’s needs and that there were noconcerns. The maternal grandparents and the mother’s first child had visited the motherand baby on the ward. The mother was told by BSW1 that the discharge date would beearly the following week. The baby was noted over the next few days to be feeding andsleeping well with no concerns recorded.72.BSW1 made a referral on the 31.10.16 to Change Grow Live (a Birmingham substancemisuse and support agency) to undertake drug and alcohol work with the motherrequiring  weekly drug/alcohol testing and an exploration with her of the serious risksassociated with substance misuse on parenting and the potential impact on the baby.BSW1 visited the female friend on the same day to ensure that suitable arrangementswere in place for the discharge the next day. No concerns were noted regarding theproperty or a shortage of essentials for the baby.73.The discharge planning meeting was held at the hospital on the 01.11.16 attended bythe mother, the community midwife (CMW1), hospital midwife (HMW1) and BSW1.SMW1 was not in attendance. The baby was noted to have made a noticeable weightgain with no concerns identified regarding growth. The mother was observed to beattending to the baby’s needs well and a ‘loving attachment’ noted. All was in place atthe female friend’s home and the community midwife would undertake daily visits for thefirst five days and review frequency after this. BSW1 was also to undertake daily visits.74.The mother said that her parents would be visiting at least once a week to providesupport. She was reminded that no one else should care for the baby and in the eventof others, especially male friends (in view of her history of associating with risky males)wanting contact with the baby, she should notify BSW1 who would undertake checks.The mother informed the meeting that the baby’s father did not want to play a part in thebaby’s life. However, should he wish to do so in the future she should notify BirminghamChildren’s Services. She was reminded of the pre-proceedings and advised to obtain asolicitor.16 75.The baby and mother were discharged from hospital and into the care of the communitymidwife at 17:05 on the 01.11.16. Various checks were completed including, importantsymptoms information given, along with a cot death leaflet and an explanation of riskfactors. GP registration of the baby and the role of the health visitor were explained, anda full physical examination of the new-born was completed.76.A copy of the child protection plan was received on the 01.11.16 by the mother’s(Birmingham) GP who reviewed it. There was no notification received of the baby’s birth.77.On the 02.11.16 a working agreement between the mother and Family Action (a familysupport agency) was completed which included work around domestic abuse/violenceawareness, help with a housing application (the mother was several thousand poundsin debt to a previous social landlord in Solihull) and benefits, self-esteem andconfidence, coping with stressful situations without recourse to drugs and alcohol andparenting support. The Family Action worker (FAW1) would visit twice weekly for up tonine months. The mother said she was happy with this level of intervention.78.Change Grow Live (CGL) received the referral from BSW1 for help in addressing themother’s substance misuse issues and the potential impact on parenting and the baby’swellbeing on the 02.11.16 and uploaded it onto the agency’s case record. The referralhighlighted historical substance abuse and did not indicate that ongoing abuse wassuspected. A key condition for being accepted onto a CGL programme was that thereshould be ongoing substance abuse. In the mother’s case there was no evidence forthis, albeit self-reported.79.BSW1 visited mother and baby at the female friend’s home on the 03.11.16. The motherstill needed to get a solicitor to assist her with the pre-proceedings meeting which wasscheduled for the next day but believed she was not eligible for legal aid. The baby wasobserved to be suitably dressed for the cold weather.80.The mother’s situation was triaged by CGL on the 03.11.16 who assessed that she wasnot eligible for its service as the grounds were not met for intervention, namely that therewas no evidence for contemporaneous substance abuse. She had self-reported nothaving taken alcohol since September 2015, cocaine since May 2016 and had obtainedseveral negative drug tests since then. With hindsight, evidence from the Police enquiryand trial demonstrated that she was in fact continuing to misuse drugs (cocaine) andalcohol both during the pregnancy and post the baby’s birth.81.In any event, she was informed that she would not be offered any structuredinterventions but would be referred to ‘Emerging Futures’, an aftercare service. A workerwould be in contact with her in due course to discuss options. The result of the triagemeant that the mother would not be subject to any drug testing or receive interventionto understand the impact on her parenting of the baby, two key elements of the childprotection plan.82.BSW1 was informed by e-mail on the same day by CGL that the mother was beingreferred to the Aftercare, Phase 5 service.17 83.Daily visits by the social worker and the community midwife in early November notedsatisfactory progress being made by the mother in her care of the baby with nosignificant concerns noted. The mother attended a pre-proceedings meeting withBirmingham Children’s Trust on the 04.11.16. She accepted the concerns andunderstood the expectations as set out in the letter before proceedings. She confirmedthat she was willing to engage in the plan. BSW1 undertook a visit on the 07.11.16 andobserved positive parenting from the mother. The baby appeared alert and relaxed inmother’s arms and was putting on weight. Both the midwife and the (Solihull) healthvisitor (SHV1) had visited, as had the worker from Family Action. No concerns werenoted by the midwife who observed that the baby had gained weight steadily; all babychecks were satisfactory and the baby was noted as ‘pink and alert’.84.SHV1 told BSW1 on the 07.11.16 that the mother would be allocated a Birminghamhealth visitor given that she was living at a Birmingham address. This person wouldattend the first core group meeting scheduled for the 09.11.16. The category of care wasUniversal Partnership Plus.14 SHV1 had completed a safe sleeping assessment and theplace of sleeping observed (a Moses basket beside a double bed). She advised themother to remove a soft toy from the Moses basket. SHV1 noted no concerns regardingthe baby or the mother. She shared all of the details with the allocated Birminghamhealth visitor (BHV1) via a telephone call immediately after the visit and the notes weretransferred via child health to BHV1.85.The mother cancelled the planned first contact with the Birmingham health visitor(BHV1) on the 08.11.16 with no reason given. A second visit was made the next daywhen BHV1 noted that the baby was 15 days old, was dressed appropriately andhandled with care by the mother. The midwife was still visiting. BHV1 said that she wasgoing to attend the first core group meeting but that it had been moved forward by anhour, unbeknown to her. BSW1 visited at the same time and confirmed that mother andbaby would be moving to a temporary Solihull address, pending consideration by Solihullhousing agency of a permanent move to a home within the local authority. BHV1 saidthat this would mean another transfer to the Solihull health visiting service in due course.86.The first core group meeting was held on the 09.11.16 and attended by the social worker,the mother and the community midwife. CGL was not present because it had previouslyassessed on the 03.11.16 that the mother did not meet the criteria for a service and wastherefore not a member of the core group. Mother and baby’s imminent move plannedfor the next day to Solihull was referred to. There were no concerns noted about anyaspects of the baby’s care or development whilst in the care of the mother. Neither healthvisitor was present due to a mix up in times. Meanwhile a handover had again takenplace between the Birmingham and Solihull health visiting services, the second time inonly a few days. The new health visitor from Solihull was SHV2. BSW1 was notified ofthe change.14 This is part of the Healthy Child Programme (HCP) delivered by health visitors during pregnancy and the first five years of a child’s life. There are four levels of service delivery. Universal partnership plus provides ongoing support from the health visiting team and a range of local services to deal with more complex issues over a period of time. These include services from Sure Start Children’s Centres, other community services including charities and where appropriate, the Family Nurse Partnership. 18 87.Mother and baby moved to the temporary Solihull accommodation on the 10.11.16,supported by the maternal grandfather. BSW1 visited the new accommodation the sameday and spoke with the mother and the maternal grandfather about the move. Thecommunity midwife also visited and noted the mother to be coping with the support inplace. Baby was gaining weight steadily. BSW1 visited the next day and said that hewould assist the mother with the application to Solihull Community Housing forpermanent accommodation. She had got into debt with her previous home because ofthe housing benefit change regarding having a two-bedroom property (when she wasbeing assessed to care for her first child) and only her being in the home.88.On the 12.11.16 CMW1 visited and noted the baby to be sleeping in the Moses basketwith a regular and appropriate feeding pattern. Baby was examined with all checksnormal.89.A Birmingham social work assistant (BSWA1) visited on the 14.11.16 and saw the babyand the mother. The home was noted as clean, warm and tidy with no concerns raised.90.On the 15.11.16 the GP (Birmingham/Sheldon) and the two health visitors from Solihulland Birmingham discussed the case at a GP liaison meeting. CMW1 visited on the16.11.16 and noted that baby was ‘pink and warm’, with no concerns noted. CMW1planned a full review for the next week. An entry was made on the 17.11.16 in the Solihullhealth visiting records that the baby was the subject of a child protection plan under thecategory of neglect to Birmingham.91.The Solihull Multi-Agency Safeguarding Hub (MASH) received a referral on the 17.11.16from Birmingham Children’s Services requesting a receiving-in ICPC in regard to babyand mother, who were now living in Solihull. The request was initially refused becausea housing assessment was being completed which provided for some uncertainty as towhether mother and baby would be eventually housed in the area. The later advice givento Birmingham on the 22.11.16 by the assistant manager of the Solihull ChildAssessment Team was to wait until the outcome of the housing assessment, when itwould be clear whether mother and baby were to become permanent residents inSolihull. Consequent to this, a decision would then be made by Solihull about a transfer.92.BSW1 visited on the 18.11.16 and noted no concerns. The mother presented well withthe baby asleep in the Moses basket. Family Action was due to visit that day to continuetheir work with the mother. Maternal grandfather had visited as per the safety plan andwould continue to do so on a weekly basis. BSW1 mentioned that he had been in contactwith Solihull Children’s Services about transferring the case, given that mother and babywere now residing in Solihull and had applied for permanent accommodation in theauthority. The mother was reminded that if she wanted any of her friends to have contactwith the baby she should notify BSW1 so that he could carry out checks.93.CMW1 made a final visit to baby and mother on the 23.11.16. No concerns were notedand the baby was recorded to be gaining weight. Checks were made and recorded asnormal and baby was discharged into the care of the Solihull health visitor (SHV2).94.On the same day BSW1 undertook an unannounced visit and noted that the mother hadmade some progress but that it was ‘early days’ and she needed to sustain it. She had19 not yet started work with the substance misuse team in undertaking random drug testing and understanding the impact of drug abuse on the baby. It would seem that BSW1 was under the impression that this was still on offer from CGL. This was not the case as noted at the first core group meeting.  95.Mother and baby were seen by SHV2 on the 24.11.16. They were noted to be onUniversal Partnership Plus and subject to a child protection plan. Passive smoking andsafe sleeping were discussed. Baby was noted to be appropriately clothed with goodemotional warmth between baby and mother observed.96.On the same day, Birmingham Children’s Services made a change of social worker fromBSW1 to a senior practitioner, BSP1, due to the former deciding to leave at short notice.97.On the 25.11.16 a statutory visit was done by a Birmingham social worker (BSW2) anda student social worker (BSSW1). The next core group was arranged for the 09.12.16at the maternal grandparents’ home. A pre-proceedings meeting was arranged at a localchildren’s centre for the 14.12.16. Positive signs of care for the baby were noted. Themother was asked if she had heard from the drugs worker and replied no. BSW2 agreedto chase this up. It was noted by Birmingham Children’s Services on the 27.11.16 thatmother and baby had had several changes of professionals over the period.98.BSW2 spoke on the telephone to a drugs worker (DW1) at CGL on the 29.11.16 andwas told that the mother had been triaged on the 03.11.16. She had not been acceptedfor service or drug tested because she had claimed not to be using drugs or alcohol.She had been referred to ‘Phase Five’ aftercare.99.SHV2 visited on the 30.11.16 and noted the baby to be sleeping on its back in the Mosesbasket and breathing regularly. BSW2 visited on the 02.12.16 and recorded that thehome environment was clean and warm. The mother mentioned having seen her heathvisitor a few days earlier and also the family support worker. Christmas plans werediscussed when the mother asked BSW2 whether it would be possible to have a glassof wine over the festive season, albeit she knew that it was not part of the childprotection/pre-proceedings plan. BSW2 said she would consult with her team manager.No concerns were noted about the baby’s care. The mother was continuing to engagewith professionals and provide for the baby’s basic care needs, with evidence ofprovision of age appropriate stimulation via a baby play mat/gym in the living area.100. BSW2 noted the following actions: firstly to contact CGL as a matter of urgency todetermine when random drug tests could be carried out. This was despite being told byDW1 that drug testing was not agency policy for clients who claimed to be drug andalcohol free, and was made clear at the first core group meeting of the 09.11.16Secondly, to ask the mother what her plans were about attending a drug support serviceand to signpost her to the ‘Freedom Project’15, regarding awareness around domesticabuse.101. On the 06.12.16 the mother spoke by telephone with her GP (Solihull) about the baby’sprojectile vomiting after feeds and was later examined by GP1 who advised the mother15 A Birmingham domestic abuse/violence project. 20 to take baby to the paediatric assessment unit (PAU). The baby attended the PAU with mother (at Birmingham Heartlands Hospital) around 6 p.m. and was admitted overnight. The initial assessment of the baby omitted the check for safeguarding alerts despite being the subject of a child protection plan, although it was established that there was social work involvement with the family and that mother’s first child lived with maternal grandparents. The accompanying GP letter did not mention that the baby was on a child protection plan.16  102. On discussion it appeared that the baby was being overfed, with additional features ofreflux. A new plan was suggested of feeding two ounces every three hours withGaviscon mixed into the feeds. Baby tolerated this well, was stable overnight anddischarged the next day with a follow up on the weight by the health visitor. A GP anddischarge letter was completed. The mother had previously text messaged BSW2 lettingher know about the baby’s vomiting and admission to the PAU.103. SHV2 visited on the 08.12.16 and recorded that the baby was gaining weight along the0.4 centile and feeding well. Baby was clean and dressed appropriately in a baby growand had recently been registered with a local (Solihull) GP. Mother and baby were notedas making good eye contact and mother was observed as handling baby in a warm andloving manner with kisses and cuddles. There were no signs of the baby being in distressor injuries recorded. There was no mention made of the child protection plan.104. On the 08.12.16 Solihull Children Services received confirmation that SolihullCommunity Housing had completed its assessment and had decided to assist themother with obtaining permanent accommodation in the area. It was agreed by SolihullChildren’s Services management to convene a receiving-in ICPC for the 05.01.17.17 Thecase was re-allocated to SSW1 (who had completed the original pre-birth assessment)to prepare an assessment for the conference. On the 15.12.16 SSW1 was informed byBSP1 that the case had progressed to pre-proceedings.105. The second core group meeting was held on the 09.12.16. Baby was reported to beprogressing well with no concerns noted. Mother was engaging well with agenciesalthough Family Action announced that they would be finishing their involvement asmother was no longer a Birmingham resident. She was disappointed at this decision asshe felt well supported by them. It also meant that the domestic abuse work - which wasin its early stage - would finish. The meeting gave a safety score of 4 which indicated adegree of caution and remaining risk in the minds of the professionals.106. The mother was not involved with a substance misuse agency to address her drug andalcohol issues since CGL had stated at the beginning of November that she did not meettheir criteria for intervention. She agreed to refer herself to Solihull Drug Support16 Since June 2017, there has been a link between Heath and Birmingham Children’s Services (now Birmingham Children’s Trust (BCT)) records via CPIS (Child Protection Information Sharing), which provides for real time data sharing between health services and children’s services. The information link enables any health professional to know when a child subject to a child protection plan or is looked after presents at a health resource. Additionally, for those children, an alert is sent out to the BCT social worker when an unscheduled health appointment is attended such as an accident and emergency or walk in clinic attendance.  17 This was within the 15 working day timescale when weekends, public holidays over the Christmas and New Year period and the two extra Solihull Council days are taken into consideration.  21 Services (SIAS). The proposed Birmingham based community parenting assessment scheduled for mid-December was cancelled given the transfer of case responsibility to Solihull set for the receiving-in ICPC of the 05.01.17. No date was set for a further core group given the forthcoming ICPC in Solihull.  107. There was no evidence that the baby had been cared by anyone other than mother andmaternal grandparents. However, it remained a concern that she was unwilling to sharethe identity of the baby’s father, stating that he had chosen not to become part of thebaby’s life.108. Baby and mother attended at the GP surgery on the 13.12.16 for the routine six -weekmedical examination. This is a thorough and essential part of the Healthy ChildProgramme that includes a physical examination, a review of development, anopportunity to give health promotional advice and an opportunity for the parent toexpress concerns. The baby’s weight, height and head circumference measurementsand centiles are recorded. The mother volunteered information about her history of drugmisuse, domestic abuse, her first child being with grandparents and the child protectionplan for the baby. The examination was satisfactory in all areas with no contra-indications for immunisation or any evidence of injuries or fractures to the baby.109. The pre-proceedings plan review meeting was held on the 14.12.16 chaired by the teammanager at Birmingham (BTM1). Progress with the plan was noted as was thewithdrawal of services due to the move to Solihull and the lack of any involvement withdrug services. The planned parenting assessment by Birmingham would now nothappen due to the move to Solihull. No concerns were noted by professionals or thegrandparents - with whom she had improved her relationship – in regards to the baby’scare and development whilst with the mother, who had engaged well with agencies.There had been both announced and unannounced weekly visits by the social workerwho had observed good attachment between mother and baby, who seemed to bethriving. Frequency of visits would lessen to once a fortnight, although still involve someunannounced ones prior to the transfer in early January 2017.110. BSP1 undertook an unannounced visit on the 16.12.16 and reported positively regardinggood care from mother to baby with a close attachment observed. The mother said thata good friend with alcohol problems had recently died and that she had thought abouthaving a drink but had not. It was suggested that she refer to ‘Healthy Minds’. The gapin services over the Christmas/New Year period was noted as was the intended closureby Birmingham Children’s Services on case acceptance by Solihull on the 05.01.17.111. BSP1 sent all relevant information via e-mail to Solihull Children’s Services on the17.12.16 in preparation for the ICPC of the 05.01.17. The baby received scheduledimmunisations on the 21.12.16 as per the Healthy Child Programme. That afternoonSHV2 visited, noted the immunisations and weighed the baby who continued along the0.4th centile. Given the timing of the medical evidence presented in court, it is possiblethat baby had already suffered one rib fracture prior to this time, albeit, as stated by themedical experts later in the trial, rib fractures can occur without any external signs. Noconcerns were noted and the ICPC of the 05.01.17 was mentioned.22 112. On the 22.12.16 the GP contacted SHV2 to seek confirmation that the baby was still thesubject of a child protection plan, having previously been notified to this effect by a letterfrom SHV2 on the 12.12.16. On the same day BSP1 undertook an unannounced visitand saw baby and mother to check on the baby’s welfare and confirm the mother’sarrangements over the Christmas period. The visit by SHV2 was mentioned by themother as was the baby’s weight gain. There were no concerns noted regarding thebaby’s health and development. Baby had been immunised, with the grandfather beingin attendance along with the mother. Evidence of good attachment was noted by BSP1.113. There were no concerns about home conditions although there was an ashtray full ofcigarette stubs in the kitchen evidencing that the mother was smoking quite a lot. Shesaid that she ensured adequate ventilation when smoking and kept the kitchen doorshut. She mentioned receiving a visit from a Solihull social worker (SSW1) and familysupport worker (SFSW1) the previous day (21.12.16) to start the assessment. They hadnoted no concerns with evidence of generally positive care and attentive parenting. Themother said that she and baby would be spending Christmas day at her parents beforereturning home that evening. A key and very significant part of the meeting involveddiscussion with the mother regarding the details and expectations of the pre-proceedings plan, including the importance of abstaining from alcohol.114. On Friday the 23 December, the last day of work before the Christmas/New Yearholiday, SSW1 telephoned the Birmingham senior practitioner (BSP1) at 10.55 hours tosay that she had started the assessment and had no concerns arising from the visit ofthe 21.12.16. However, she advised that an off-duty Solihull family support worker whohad previously worked with the mother (during the assessments with her first child) hadseen her on the 22.12.16 with the baby in a pub, drinking wine. She did not appear tobe intoxicated although the incident was in breach of the pre-proceedings plan.Significantly, it happened only one day after she had given assurances to SSW1 thatshe understood the importance of not drinking alcohol and had promised to abide by theterms of the pre-proceedings and child protection plans.115. SSW1 was advised at 16:00 hours by BSP1 that there were no concerns about themother’s day to day parenting. The family support worker would need to put her accountin writing and that her observations could not substantiate that the mother was drinkingalcohol. Nonetheless, it was concerning that she was visiting a pub, given her previousissues with alcohol. It was agreed that SSW1 would make a visit sometime the followingweek.116. SSW1 visited mother and baby unannounced on Friday 30.12.16 on behalf of theBirmingham social worker, who was on leave. The mother said that the plan to beabstinent over the holidays was unrealistic, that she had drunk only one glass of wineand she had thought that she was allowed to have a drink over the Christmas period.Despite this, there were no other concerns identified by SSW1. This was the last visit bya professional prior to the baby’s death.117. The mother became registered with her Solihull GP on the 30.12.16.118. On the 02.01.17 the baby was taken by ambulance at 15:06 hours to the emergencydepartment of Heartlands hospital with a cardiac arrest. Resuscitation attempts were23 unsuccessful, and the baby sadly died. The mother said that she had fallen asleep with baby on her chest and that she was not sure how long she had been asleep. She was arrested by the Police on suspicion of neglect of her baby and a criminal inquiry was started.     Part 4: Analysis 119. What follows, by reference to the fifteen key issues cited in Appendix 1, is an analysisof agencies’ practice, decision making and actions taken that sought to protect the babyfrom harm and promote its wellbeing. It is informed by the available agencydocumentation, including the WMP addendum, in addition to the learning gained fromthe practitioners’ learning event.  Relevant findings, themes, conclusions and learningare set out in Part 6 below.What was the quality of agency intervention in the pre-birth period? 120. Overall, there was good quality work done by the midwifery service as evidenced by theearly noting, at six weeks pregnancy, of the mother’s history of substance misuse and afull social and medical history taken at 12 weeks of her previous involvement with SolihullChildren’s Services regarding her first child, domestic abuse and substance misuse. Themother’s risks to the unborn baby were well recognised by the midwifery service whichresulted in the timely referral to the specialist midwife for substance abuse (SMW1).121. The mother was advised of the dangers of foetal alcohol syndrome arising from hermisuse of alcohol and SMW1 made an appropriate safeguarding referral to SolihullChildren’s Services. SMW1 was rightly persistent in her challenge made to the SolihullMASH regarding the referral and was successful in getting it accepted on the 01.06.16.The then existing policy of referral of the unborn child at 20 weeks has (according toinformation given at the practitioner’s learning event) since been changed to a 12 weeksthreshold; which in the Lead Reviewer’s opinion, marks a significant positive practicedevelopment.122. The mother’s early denial of substance abuse was proven to be false by the positiveurine toxicology test of the 27.05.16 which prompted SMW1’s timely referral to SolihullChildren’s Services.  This prescient act should have alerted professionals post thebaby’s birth to the need for regular substance misuse testing, which for various reasons,was not undertaken and thus presented a significant flaw in the child protection and pre-proceedings planning. Testing could have alerted professionals to the mother’sdeceitfulness.123. Although having a place in a Birmingham hostel, the mother had given the midwiferyservice the address of a friend in Solihull where she had been temporarily staying. Thiswas the address provided to the Solihull social worker (SSW1) who accepted the referraland started the pre-birth assessment on that basis. The friend subsequently died andthe mother then moved in with a female friend and her two children in Birmingham, ona temporary basis. It was a month later, well into the assessment, that SSW1 establishedthat the mother was staying with her female friend at the Birmingham address.24 124. The evidence suggests that a thorough pre-birth assessment was completed by SSW1who considered all of the mother’s previous background history around substancemisuse, domestic abuse, mental health issues and the three failed parentingassessments in regard to her first child. Contemporaneous risk factors around her useof cocaine, missed appointments with the specialist midwife, no fixed abode and herreluctance to name the father were also included and considered. In recognition of thesubstantive risks to the unborn baby of significant harm, SSW1 appropriatelyrecommended the need for an ICPC and child protection plan. This was communicatedin a timely manner on the 15.07.16 to SMW1.125. SSW1 finished the assessment in mid-August which was signed off by her assistantteam manager (SATM1) who concurred with the need for an ICPC and a child protectionplan. However, given that the mother was living in Birmingham at the time of theassessment, had an open placement in the Birmingham hostel, had told SSW1 that shehad no intention of obtaining a property in Solihull prior to the baby’s birth and was indebt to the Solihull housing agency of £18,000 (and therefore not a good candidate forrehousing consideration), it was the collective view of SATM1, the local police and theSolihull Child Protection Unit that she was unlikely to be rehoused in Solihull. Moreover,there had been no involvement with the mother since her first child had been placed withthe grandparents, some four years previously. By this rationale they came to thereasonable view that they had no professional or statutory authority to make the babythe subject of a Solihull child protection plan, hence the referral to their Birminghamcounterparts.126. Therefore, SSW1, having established that the mother was living in Birmingham with herfemale friend, made a referral to (the then) Birmingham Children’s Services on the31.08.16. The latter promptly accepted case responsibility on the 01.09.16, withoutdemur and in a child-focused manner. A fresh assessment was started by BSW1 on the05.09.16. SSW1 provided her pre-birth assessment to the Birmingham MASH on the02.09.16 and closed the case shortly after. At the request of BSW1, SSW1 re-sent acopy of her pre-birth assessment on the 16.09.16.127. By the 21.10.16, BSW1 had completed a good standard pre-birth assessment18 thatidentified all of the relevant historical and contemporaneous risk factors19, albeitapparently without sight of the earlier Solihull version as there was a delay in thedocument being sent to the social worker by Birmingham Children’s ServicesInformation and Advice Support Service (IASS). This was unfortunate as timely use ofthe Solihull document could probably have resulted in a Solihull Children’s Servicespresence (SSW1) at the ICPC and, arguably, the Birmingham assessment could havebeen finished at the end of September. This would have given BSW1 more time to havearranged for an earlier ICPC and subsequent planning prior to the baby’s birth, thusallowing suitable safeguarding and support arrangements to be in place, rather thanholding the conference the day after the birth.18 Which, the Lead Reviewer learnt, was nearly exactly the same as the Solihull pre-birth assessment 19 BCT Information report. 25 128. Albeit that the baby was born prematurely, child protection arrangements and pre-proceedings planning were somewhat rushed20, which resulted in delays in the settingup of support services and drug testing arrangements for the mother. In this respect itwould have been useful to have known the referral criteria for CGL, given the importanceof drug testing for the mother and her self-reported abstinence which precludedintervention from CGL21 and no drug testing. This proved to be a significant flaw in thelater safeguarding plan.129. In addition, the apparent difficulty in communication between Birmingham Children’sServices and the Police in the request to hold a strategy meeting on the 06.10.16 didnot help matters, albeit that intelligence on the mother’s female friend was later providedby the Police for the ICPC.130. In summary, the two local authority pre-birth assessments were of a good standard thataccurately identified the risks and needs for the baby and the mother. However, therewas a delay in IASS forwarding the pre-birth assessment to BSW1, this contributed todelays in holding the ICPC (this was a key recommendation from the Solihull pre-birthassessment), safeguarding planning, timely arrangements for support and riskmanagement and SSW1’s absence at the ICPC on the 26.10.16.22131. The Review identified that BSW1 could have used the Solihull pre-birth assessment asthe basis of his assessment given its inclusion of the known historical and contemporaryrisk factors for the baby. In short, the Birmingham assessment could have beencompleted quicker and in a timelier manner. The delays had knock on effects for thelater safeguarding arrangements, particularly around robust drug testing for the mother.132. A key lesson from this practice episode (and notwithstanding the problem of IT withinBirmingham Children’s Services at the time), is the need for effective liaison andcommunication between the two local authority social care teams in the timely  sharingof, in this case, pre-birth assessments and working towards the making of timelysafeguarding arrangements for the unborn child.What were the reasons the substance misuse midwife objected to discharge planning? How was the situation resolved? 133. SMW1 objected to the discharge plan because of (i) Police intelligence suggestingprevious domestic abuse and drug dealing at the home, and (ii) the very low conferencesafety score of 2 and high professional concerns (including those of the safeguardingmidwife who was at the conference) arising from the ICPC.2320 Ideally, the pre-birth ICPC should be held at least 10 weeks prior to the date of the child’s estimated date of delivery to enable sufficient time to be given to setting up suitable assessment and support services 21 See appendix 3: National Institute on Drug Abuse, UK.  22 The Review was told by the Birmingham Children’s Trust review team representative that there were I.T communication problems within Birmingham at the time.  23 No conferences are now held on a Friday because of the weekend risk possibility. Now, if the score is lower than 3 discussions are held with the relevant team manager and child protection manager.  26 134. The situation was resolved by SMW1 receiving an explanatory e-mail from the principalofficer child protection, setting out the case and rationale made by the BirminghamChildren’s Services for the baby and the mother’s discharge to the mother’s femalefriend’s home (see paragraphs 68-70). The community and hospital midwives werepresent at the discharge meeting and raised no concerns, agreeing to the plan. Therewas no further challenge from SMW1 who had recourse to the BSCB escalation process,but did not feel the need to use it.Did agencies fully recognise the impact that drug and alcohol misuse and domestic abuse might have on day-to-day parenting capacity? Did members of the core group have a good understanding of domestic abuse and coercive control? 135. The mother’s substance abuse issues and the potential impact on her parenting werewell recognised both by the two local authority pre-birth assessments and at the ICPC.The minutes state that,‘[The baby’s] health and development could be affected by the mother’s drug use and[the baby] may begin to suffer withdrawal symptoms in the next day or so. [The baby]was born with a very low birth weight and this could be a result of the mother usingcocaine during the pregnancy. Further risks to [the baby] include exposure to risky adultswho are dealing cocaine to [the mother], a lack of finances available to provide for [thebaby] and the impact of drug use upon [the mother’s] capacity to safely care for andparent [the baby].’136. The ICPC minutes asked:‘Has [the mother] had intervention from drug/alcohol agencies? Is this needed now? Is[the mother] currently using drugs now?’The resulting outline child protection plan in its harm statement cited that:‘We are also worried that [the mother] sometimes drinks too much alcohol and takesillegal drugs which will affect her ability to make sure that [the baby] is looked after wellenough and always has everything it needs’.137. However, despite the clear recognition of the mother’s substance and alcohol abuse askey risk factors (which was so tragically shown to be the case by the later evidence ofthe WMP enquiry-see above at paragraphs 24-31) to the baby, there was no explicitlyspecific agreed action set out in the child protection plan to address this factor, albeitthere was a passing reference in the ‘Safety Goal/Wellbeing Goal’ section:‘It would be safer for [the baby] if [the mother] was working openly and honestly witheveryone, including drug and alcohol support agencies and the mental health serviceand if [the mother] was making safer choices in respect of her relationships’.138. As previously mentioned in paragraph 64, the ICPC resulted in a net safety score of 2from the three professionals in attendance. Guidance at the time (Chair’s Handbook –A Guide for Chairs for Child Protection Conferences and Other Meetings to Using the27 Strengthening Families Framework. (2016)) did not give Chairs any specific direction regarding action to be taken on low scores. This guidance was updated in June 2019 and states that ‘Where the score is 0-3 (very little safety) the Chair will need to have an immediate conversation with the Team Manager to address the level of risk and, where appropriate, request immediate safeguarding action to be taken.’ Subsequent discussion by the Review Team felt that guidance should be revised to make it more explicit on the need to consider seeking legal advice. 139. In the event, a referral was made to Change Grow Live, a Birmingham substance misusesupport agency, by BSW1 on the 02.11.16. However, as previously mentioned(paragraph 81), the mother’s self-report to the triage worker indicated that she was notcurrently taking illegal drugs (cocaine) or drinking alcohol, which did not meet theacceptance criteria for a service,24 thus precluding her from any structured interventionand drug testing, two key elements of the child protection plan.140. BSW1 was advised via email (following a telephone call from the CGL worker who wasunable to get an answer from BSW1) of the situation. Namely, that the mother hadpresented at the assessment as abstinent, thus indicating that a referral to an aftercareservice for ongoing support to maintain recovery was the most appropriate serviceprovision. In the referral from BSW1, it was stated that the mother had consented to drugtesting. However, the CGL triage worker had highlighted in the email to BSW1 that themother would not be subject to any drug testing from CGL or the aftercare service(Emerging Futures - the sub-contractor for delivery of aftercare provision and on-goingrecovery support), given that she would not be receiving any structured treatment.25141. In a follow up conversation (December 2018) between the CGL report author and theworker, the latter said that had he spoken directly with BSW1, he could have explainedthe outcome of the triage assessment in greater detail. He could have asked the referrerabout the specific concerns regarding the mother and discussed the service offerregarding aftercare. However, this did not happen as no further contact was made byBSW1.26142. The CGL worker’s assessment was confined to a focus on the mother’s substanceabuse issues and whether these fitted the service criteria. In retrospect27 the worker, tohis credit, has acknowledged that he should have shown more professional curiosity andexplored what impact having a baby was having on the mother’s abstinence andrecovery, and explored in general how she was managing in her current circumstances.143. In any event, the CGL worker made a referral to the aftercare service (Emerging Futures)on the 03.11.16 who stated that they did not receive the request; albeit that apparently,the mother’s name was on the agency’s client database and was contacted on the19.01.17. Notwithstanding the referral, the mother’s move to Solihull on the 10.11.16,24 CGL’s decision not to accept the mother for a programme of structured treatment because she did not meet the service criteria was in line with the agency’s commissioning agreement with Public Health (additional report dated 24.12.18 from CGL) 25 Additional report from CGL dated 24.12.18 26 Ibid. 27 Ibid. 28 precluded her from receiving a service from Emerging Futures, given it was a Birmingham agency. Her Solihull location involved a self-referral to Solihull Integrated Addiction Service (SIAS) which she did not pursue, albeit she had had some previous involvement with Aquarius Action, part of SIAS.  144. The issue of relapse by individuals with substance misuse histories was usefully raisedfor the SCR Review Team by the author of the Heart of England NHS Foundation Trustinformation report. The author cited estimated rates of relapse for alcohol misuse atbetween 30% to 70% and other substances at above 60% (Drug Treatment in England:The road to recovery: National Treatment Agency: 2012).145. Scientific and professional consensus suggests that alcohol and drug addiction cannotbe cured but rather managed by a structured programme of intervention, involving theindividual being sufficiently motivated to control their behaviour and being subject toregular unannounced drug testing. Without involvement in such programmes thelikelihood of an individual modifying their behaviour and successfully controlling theiraddiction is minimal. Moreover, life stresses are acknowledged factors in eithermaintaining substance abuse or prompting relapse, with the birth of a baby being aknown stressor.146. The mother had received no intervention (during the period under investigation) from asubstance misuse agency to address her drug and alcohol misuse, nor was she subjectto regular drug tests. Therefore, the likelihood, in the opinion of the Lead Reviewer, ofher not using alcohol or drugs before and after the baby’s birth was minimal, despite the(apparent) negative testing for cocaine on discharge from hospital. Her two failedappointments with the substance misuse midwife in October 2016 were of concern andshould have raised questions about her veracity regarding abstinence, particularly withregards to her history of non-attendance on eight previous occasions. In the opinion ofthe Review Team, this pattern of missed appointments should have raised professionalcuriosity around the rationale for non-attendance and the implications for the potentialrisk to the unborn child. A key learning point from this episode is that a missedappointment could be an indicator of substance misuse.147. This issue has since been reinforced by the evidence from the Police enquiry of themother’s continuing misuse of cocaine and alcohol during the period under examination.Up until the 22.12.16 (when she was seen drinking wine in the public house) the motherwas clearly adept at convincing professionals that she was not substance misusing.148. Given the importance of the mother’s involvement in a structured drug and alcoholprogramme and regular random drug testing as key elements in the child protection/pre-proceedings plans and their function as mitigating mechanisms in the management ofrisk to the baby, it is the Lead Reviewer’s opinion that Birmingham Children’s Servicesshould have taken a more pro-active approach to the issue. Birmingham Children’sServices should have ascertained beforehand whether CGL was a suitable agency towork with the mother, given its acceptance criteria and the decision not to take her inearly November. Likewise, CGL should have been clearer about informing BirminghamChildren’s Services of its referral and client engagement criteria (viz, that it would notaccept a client who self-reported drug abstinence). On learning of her move to Solihull,Birmingham Children’s Services should have taken timely action to link her in with a29 suitable agency (possibly SIAS) in order for the mother to show her willingness to change, address her substance misuse issues and agree to regular and unannounced drug testing.  149. However, the review learnt that the funding of drug testing was, at the time and continuesto be, problematic in so far as social workers and team managers are required to seekagreement for such a resource request through an Area Resource Panel.28 Theapparent rationale for not doing so was an anticipation that the Panel would havedeclined random drug testing on the basis that the mother had had three negative tests(albeit, she had missed two), that there was no evidence from her presentation in regardto caring for her baby of any relapse, and that the case was due to be transferred toSolihull in early January 2017.150. Notwithstanding the above, this SCR would agree with the statement from theBirmingham Children’s Services (now Birmingham Children’s Trust) agency report writerthat ‘if drug and alcohol testing had been carried out, it may have provided a differentpicture in terms of [the mother’s]  substance misuse’ and the attendant risks to the baby.Such knowledge could have been factored in to the overall risk assessment regardingthe baby and informed future risk management planning and the pre-proceedingsprocess.151. In this regard, it is important for Area Resource Panels to be mindful (see paragraphs144-147) of the extent to which parents and carers who claim not to be engaging insubstance misuse may be in denial and cover up. Absence of evidence is not necessarilyevidence of absence. A key lesson is for Area Resource Panels to be cognisant of theprofessional evidence of denial, dissembling and relapse by people with longstandingand entrenched substance misuse behaviour and adopt a robust, albeit proportionate,approach to practitioner requests for drug and alcohol testing.152. Since the time of the baby’s death, significant improvements have been introducedbetween Birmingham Children’s Trust and CGL. These are that there is an effectivetriage which includes liaison between the social worker and the CGL triage worker, toexplore and identify in detail, risk and need of the individual child. There are closeworking relationships between the child protection conference chair(s) and CGL, toensure that any concerns raised at conference, including drug testing, are addressed.153. Regarding the mother’s history of being a victim of domestic abuse this was also wellrecognised by the ICPC as a key potential risk factor for the baby. It was explicitly notedin the ICPC minutes and an agreed action was included in the outline child protectionplan that BSW1 was to make a referral to an appropriate domestic violence agency withthe aim of engaging the mother in work that increased her awareness of domestic abuseand its impact on the baby.154. This action was ineffectively implemented as the Child Protection Plan required thesocial worker to make a referral to an appropriate domestic abuse agency such asBirmingham & Solihull Women’s Aid, and the referral was not made. Family Action hadagreed to undertake work to increase the mother’s understanding of domestic abuse to28 A panel of senior managers that gate-keeps access to private sector services such as random drug testing. 30 ensure that some support in this area was provided. Four out of the six sessions undertaken by Family Action were focused on the mother’s needs and included discussion around domestic abuse and healthy relationships. Current relationships were not explored by Family Action as part of this work or by any other agency involved with the family, albeit that there is no evidence to suggest that the mother was in a current relationship. Additionally, there was no evidence of work done with the mother around exploring the impact of domestic abuse on the baby.  155. Family Action by its own admission should not have allocated a very complex case to astudent social worker with limited skills around domestic abuse. Nevertheless, FamilyAction was not expected to continue with any domestic abuse work beyond the first twoto three weeks of their involvement as the expectation was that a specialist domesticabuse agency was to take on this element of the Child Protection Plan. The FamilyAction report noted that a specialist domestic abuse agency could have been particularlyhelpful in this case and would have ensured that highly trained staff were leading on thisarea of the Child Protection Plan. Particularly, as Family Action had been allocated thecase in order to provide support across a range of other issues with this family.156. Indeed, this SCR submits that on this occasion, with this case Family Action (and CGL29in regard to substance misuse) was not the appropriate agency to undertake a complexpiece of domestic abuse work with the mother30. Arguably, BSW1, should have ensuredthat the referral to a specialist agency was made, as required by the Child ProtectionPlan. However, it should be noted that at the time the resources offered were decidedby the Area Resource Panel. This tended to allocate services based on existingavailability and not necessarily on the basis of the identified need of a particular childand family. Arguably, these arrangements acted as a systemic barrier to matching thechild’s identified need with the appropriate resource. In the Lead Reviewer’s opinion andwithin the context of the above analysis regarding Area Resource Panels, the serviceallocation of CGL and Family Action did not meet the needs of the baby and the motherwithin the context of substance misuse and domestic abuse.157. Since then, the SCR Review Team understands that improvements have been maderegarding a more needs-led service, as acknowledged in a recent Ofsted inspection:“Assessments carried out by the ASTI service are completed within children’stimescales, and in most cases are thorough, exploring background history, presentingissues and information from partners. When analysing children’s needs, social workersmake effective use of practice methodology, clearly identifying risk and protectivefactors, danger statements and safety goals that appropriately inform future actions.Management overview is evident, and the majority of assessments contain clearrationale for recommended action that is proportionate to children’s levels of need.”Heads of Service reportedly now have a better grasp of the most concerning cases intheir area. They are better placed to have discussions with social workers and managers29 The SCR learnt from the CGL Review Team member that the agency was undergoing some significant organisational change in 2016, involving the bringing together of around thirty separate drug and alcohol agencies in Birmingham, all under one umbrella. These changes may have led to a degree of misunderstanding in the mind of BSW1 and his manager regarding the role and remit of CGL in relation to drug testing and risk assessment of parenting.  30 Family Action provides quality services for families experiencing complex domestic abuse. 31 to understand the child’s individual identified need and match the appropriate agency resource that will meet the need and any risks and facilitate improved family engagement.  158. Likewise, there was an onus on agencies31 to set out clearly to BSW1 (and BirminghamChildren’s Services) their respective competencies, expertise and referral criteria inrelation to addressing the requisite risk issues identified at the ICPC and contained inthe subsequent child protection plan.159. The Review Team noted that the child protection plan involved manifold agencyinterventions taking place at the same time, which for someone like the mother with herhistory of difficulties and the fact of having just given birth to her baby, possibly put herin a position of feeling relatively overwhelmed by the demands of the plan.160. In this case, how reasonable and realistic was it to have expected her (and others in asimilar situation) to have engaged simultaneously with all of the strands of the childprotection plan? In hindsight, perhaps some consideration could have been given to theaction sequencing and prioritisation of the plan within a reasonable timetable. One thatthe parent could cope with and be more likely to engage in, rather than expect them totake on all of the actions at once and perhaps, in doing so, inadvertently setting parentsup to fail.161. Arguably, the identification of many risk factors that require change and resultingmitigating actions does beg the question as to whether it is actually unsafe for the childto be living with a parent without a better safety plan, including possible pre-proceedingsand removal under a court order. In short, is the child protection plan safe?162. Therefore, learning points from this episode suggests agency requirement to haveproportionate and realistic expectations of parents, dependent on circumstances; andthe need, where appropriate, for a degree of appropriate sequencing in theimplementation of the child protection plan. Alternatively, is the presence of a plethoraof risk factors and resulting actions an indication that it is inherently unsafe for a child tobe with its parents/carers?163. In relation to the core group there were no written records of the first meeting held onthe 09.11.16 which is of concern. However, the evidence suggests from the two previouspre-birth assessments and the minutes of the Birmingham ICPC that there was a goodappreciation and understanding of the potential risk for domestic abuse and the impacton parenting, which (as was noted in the minutes of the second core group meeting ofthe 09.12.16) had begun to be addressed by Family Action.Did members of the core group consider mother’s parenting skills and history in determining whether she would work openly and honestly with agencies? 164. The minutes of the second core group of the 09.12.16, noted that, since the baby’s birth,there had been no concerns identified in relation to the care given by the mother. Indeed,the latter was noted to have presented as ‘an attentive parent and has created a warm31 See note 29 in regard to CGL. 32 and comfortable home for (the baby) and herself’. It also noted a remaining concern that the mother had not been willing to share the identity of the father, stating that he had chosen not to become involved with the child’s life. Whilst noting that the mother had started making significant changes to her lifestyle and associations ‘the concerning history cannot be ignored and (the baby) should continue to be subject to a child protection plan/pre-proceedings plan, whilst (the mother) continues to engage with support services to address the concerns and evidence her parenting capacity’. There may have been some significance to the scoring of 4 by the review, thus indicating a degree of continuing professional caution and risk that was, arguably, not reflected accurately in the later risk management arrangements over the fateful Christmas and New Year period. 165. The evidence thus suggests that the professionals remained mindful of the potentialrisks to the baby, whilst being encouraged by the mother’s apparent progress andengagement with aspects of the child protection plan. In retrospect, the evidence fromthe Police enquiry and trial showed that the mother was not adhering to a crucialcondition, namely continued abstinence from drugs and alcohol. Arguably, the lack ofregular drug testing went some way in enabling her ‘to control the narrative’ byconstructing an image of an attentive parent meeting the needs of her baby andcomplying with the wishes and expectations of the professionals and the child protectionplan. In that sense she was able to show a degree of disguised compliance towards theprofessionals. Her continuing concealed substance and alcohol misuse proved,tragically, to have been a critical factor in the death of her baby.166. The core group was informed by the Family Action representative that the agency wouldfinish its involvement with the mother due to the impending case transfer to Solihull32,albeit that it would attend the receiving-in ICPC scheduled for the 05.01.17. FamilyAction’s work with the mother and baby had been of some significance to the formerwho had, according to reports, engaged well, attended all of the seven sessions andexperienced the intervention as supportive. The mother was reported to have beendisappointed with this decision as she had developed a positive working relationshipwith the support worker and was keen to finish the programme of work.33167. The ending of the service marked a withdrawal of an important source of support to andmonitoring of the mother, thus increasing the potential risk to the baby, compounded bythe additional potential risk34 for the mother to engage in drug and alcohol misuse overthe Christmas and New Year period.168. The in-house (Birmingham Children’s Services) parenting assessment was due to startin mid-December but did not happen due to the mother and baby’s move to Solihull onthe 10.11.16. There was an intention for a parenting assessment to be done by Solihullonce the case had been taken on by them after the receiving-in ICPC set for the 05.01.17which, due to the baby’s tragic death, did not happen.169. Thus, a third key element in the original Birmingham child protection plan did not happen.32 Family Action was not contracted to work in Solihull. 33 See Part 5, Mother’s views.  34 Tragically, an actual risk.  33 What efforts were made to establish the paternity of the baby? 170. Enquiries were made with the mother regarding the baby’s paternity by thoseundertaking pre-birth assessments in Solihull and Birmingham and also explored withinthe ICPC and pre-proceedings processes. The mother chose not to say who the fatherwas although Birmingham Children’s Services understood that there were twopossibilities, including a married man who was said by the mother not to want anyinvolvement with the baby. Birmingham Children’s Services was keen to undertake aDNA paternity test but without confirmation about the father’s identity was unable to doso.Did mother give any indication that her relationship with the baby’s father may still be ongoing? If so, how did agencies respond? Were agencies curious enough around this? 171. The evidence from agencies’ reports and the subsequent Police enquiry did not indicatethat the mother was in an on-going relationship with the baby’s father or any other male,albeit that she was in the company of a male acquaintance on the day of the baby’sdeath. 35 However, given her long-standing history of involvement in abusiverelationships, there were continuing concerns from the Birmingham Children’s Servicessocial work team that she might enter into a future relationship where domestic abuseand coercive control were risk factors to the baby, thus needing to be assessed andmanaged. Hence, the condition in the child protection and pre-proceedings plans for themother to inform Birmingham Children’s Services of any new relationships.Was there anything about the baby’s presentation that indicated she was distressed or suffering abuse? If so, how did agencies respond? 172. There was no evidence presented to the SCR Review Team36 to suggest that the babyshowed any distress or had suffered any abuse up to the end of December 2016. Thebaby had been subject to frequent and regular visits from the Birmingham Children’sServices social workers, latterly, the Solihull social worker, and the community midwifeand health visitors from Birmingham and Solihull. The professional view was that thebaby was developing within normal limits with good attachment and bonding to themother who seemed to be coping reasonably well with her baby’s care. At no time werethere any professional concerns noted.173. The baby’s visits to the GP and Heartlands hospital in early December 2016 did not elicitany undue concerns around development, safety or wellbeing. The health visitor on thefollow up visit noted that the baby was gaining weight along the 0.4 centile and feedingwell. The second core group meeting of the 09.12.16 noted that the baby wasprogressing well with no concerns. No concerns were noted by the GP when the babyattended the surgery for a routine six-week examination on the 13.12.16. The baby wasgiven immunisations on the 21.12.16 and seen by SHV2 in the afternoon with no35 N.B. The Police enquiry ruled out any involvement of the male in the baby’s death.  36 Notwithstanding the later Police enquiry and trial evidence that the baby had suffered a rib fracture sometime between the 13 to the 20 December 2016.  34 concerns observed. The baby was last seen by BSP1 on the 22.12.16 and SSW1 on the 30.12.16 with no concerns noted.  174. The Police enquiry and trial evidence suggested that the baby sustained a single lateralfracture to the 7th rib between the 13th and 20th December 2016, some ten to twenty daysbefore death. The baby was therefore subject to an assault by the mother during thistime for which the latter was found guilty of a S.20 wounding.  These dates would haveincluded the baby having been seen by several professionals during this period.However, there was no evidence that the baby presented with any obvious signs ofdistress to professionals and the rib fracture would not have manifested itself by anyexternal signs of injury.Did professionals consider the lived experience of the baby? Were they professionally curious? 175. ‘Lived experience’ is defined as ‘Personal knowledge about the world gained throughdirect, first hand involvement in everyday events rather than through representationsconstructed through other people. It may also refer to knowledge of people gained fromdirect face to face interaction rather than through a technological medium’ (OxfordEnglish Dictionary).176. Clearly, the baby was not old enough to communicate to the various professionals aboutits experience of being cared for by the mother. Therefore, the baby’s lived experiencewas mediated through the mother’s self-reporting, which was positive. Arguably, it wasin the mother’s interests to have provided a positive narrative to the professionals. Asshown by the later Police enquiry, the evidence (in hindsight) was that she pursued aconvincing and successful ‘disguised compliance’ strategy regarding her substance andalcohol misuse.177. As previously noted, there was frequent and regular visiting from and contacts withprofessionals in line with the child protection and pre-proceedings plans. These weremainly focused on the baby’s health and development and how well (or not) the motherwas managing her baby’s needs and safety. There was no evidence of the motherhaving contact with any males and her parents who were seen to be supportive did notidentify any concerns about the baby’s care. The overall professional perception of thebaby’s care and development was positive as described in previous paragraphs. Aspreviously mentioned, the mother had successfully masked her drug and alcohol misusefrom the professionals and in hindsight had, to some extent, pursued a strategy ofdisguised compliance by presenting as a plausible individual.178. As previously mentioned, there should have been more professional curiosity andchallenge in respect of the mother’s substance misuse, for both illegal drugs and alcohol.Suitable arrangements should have been made as part of the child protection and pre-proceedings plans for the mother to have undertaken a structured substance misuseand robust drug testing programme that was not dependent on self-reporting in regardto current use. There was no evidence of any challenge or response by BirminghamChildren’s Services social workers to the mother’s request of having a glass of wine(made on the 02.12.16, see paragraph 99 above) over the festive season, albeit thatthere had only recently been a change in the social worker. The report of her drinking35 wine in the pub on the 23.12.16 (see paragraphs 114-115 above) should have been addressed by the management of Birmingham Children’s Services, albeit the timing of the pre-Christmas weekend was problematic.   179. There was a lack of professional curiosity shown at the baby’s attendance at thePaediatric Assessment Unit (see paragraphs 102-103) regarding checks being made forsafeguarding alerts. The baby was subject of a child protection plan at this time. Despitethe mother informing staff of the involvement of a social worker no questions were askedabout why and what for?Were there any issues around communication, information sharing or service delivery that impeded agencies working with the family? 180. As previously mentioned at paragraphs 128-132, there was a delay in IASS sharing theSolihull pre-birth assessment in a timely way with BSW1. This contributed to delays inholding the ICPC (this was a key recommendation from the Solihull pre-birthassessment), safeguarding planning, and timely arrangements for support and riskmanagement.181. As mentioned at paragraph 64, the Solihull social worker (SSW1) did not attend theICPC held on 26.10.16 due to the late receipt of the invitation. This was despite havingmade the transfer referral on the 31.08.16, sending a copy of her pre-birth assessmenton the 02.09.16 and, at BSW1’s request, resending it on the 16.09.16.  is not fullyknown37 why there were problems in BSW138 receiving SSW1’s pre-birth assessmentand the late invitation. SSW1’s presence at the ICPC would have afforded an opportunityto have given the full historical background and findings of her assessment; albeit thatthese were similar to the Birmingham assessment provided for the ICPC.182. There was a twenty-day gap between the ICPC and partner agencies (particularlyhealth) receiving the outline child protection plan, which should have been done in fivedays and the minutes in ten days.39183. A key issue was the mother’s two moves between Solihull and Birmingham and backagain. The resultant inter-local authority case transfers caused significant disruption inregard to the continuation and consistency of effective implementation of the childprotection plan. Her move to Solihull on the 10.11.16, some nine days after the dischargefrom hospital, meant a change in health visitor and the later discontinuation of importantBirmingham services such as Family Action who finished on the 12.12.16. The motherhad found this service very supportive and it was not around during the criticalChristmas/New Year period. The proposed Birmingham CS family assessmentscheduled for mid-December, a key element in the overall child protection plan, did notoccur due to the move. The absence of drug intervention and testing for the mother was37 Reportedly related to IASS (now CASS) transition and communication processes which were poor in 2016.   Remedial action has since been reportedly taken within the CASS that has seen improvements, evidenced by frequent internal and multi-agency audits and Ofsted inspections.  38 BSW1 was an agency worker who left Birmingham Children’s Services on the 24.11.16. It has not been possible to speak with BSW1 to clarify the reasons why SSW1 did not receive a timely invitation to the ICPC.  39 Now 48 hours for child protection plans and under negotiation for circulation of minutes.  36 in part a function of the transfer of case responsibility between the two local authorities and as already alluded to, was a very significant missing element in the child protection plan.  184. Compounding these difficulties was the precipitate departure of BSW1 on the 24.11.17.This would have added to the sense of discontinuity and lack of consistency in the caseregarding trust relationships with professionals and the mother, the cohesiveness andknowledge of the core group and effectiveness of services in managing risk to the baby,albeit that there was adequate management case oversight.185. Thus, the transfer from Birmingham to Solihull led to the cessation of services forcontractual reasons40, changes in key professionals at a critical time in the childprotection plan and the diminution of its potential effectiveness.186. In short, the Birmingham child protection plan never really took off, given BSW1’sdeparture, the absence and withdrawal of the key elements mentioned above due to theproposed transfer to Solihull agreed on the 08.12.16 and the scheduling of the receiving-in ICPC for the 05.01.17. Between these two dates the plan essentially consisted ofmonitoring visits by BSP1, SHV2 and SSW1 pending the transfer of case responsibilityto Solihull on the 05.01.17.187. This case demonstrates the difficulties for agencies in safeguarding children in familieswho move rapidly across local authority and organisational boundaries. Differences inthreshold and eligibility criteria for resources, service priorities and differing contractingarrangements with private and third sector agencies, within a context of financialconstraints, can make for problematic case management and militate against theavoidance of delay, drift and disruption in assessment, planning and intervention.188. Self-evidently, what is needed is a clear and effective transfer protocol, underpinned bya set of framework principles41 that inform agreed inter-authority arrangements,protocols and processes that are child-centred,42 promote case continuity, effectivesafeguarding, and minimise case transfer, disruption and delay.Were the decisions taken in relation to case work by the two children’s services departments’ child-focused or resource led? Was the referral to Solihull Children’s Services made at an appropriate time? 189. Solihull Children’s Services acted in good faith by accepting the referral for a pre-birthassessment from the specialist substance misuse midwife (SMW1) in late May 2016.The mother had originally given the address of her male friend in Solihull to SMW1 whohad passed this on to Solihull Children’s Services, but at the time was actually stayingwith her female friend in Sheldon, Birmingham. This only became known to SolihullChildren’s Services some four weeks later on making actual contact with the mother inearly July, by which time the pre-birth assessment had started. In the Lead Reviewer’s40 i.e. The important family support service from Family Action. 41 Ideally, West Midlands wide although it is recognised that this would be a very complex exercise. 42 Ideally, the framework would also include vulnerable adults.  37 opinion, the decision to accept the referral (given the mother had stated a Solihull address) was both procedurally compliant and child-focused.  190. With the benefit of hindsight, it would clearly have been in the interests of the baby forthe case to have remained with Solihull Children’s Services rather than have beentransferred to Birmingham in early September 2016. However, this SCR has sought tounderstand the rationale for decisions and actions taken by professionals within theprevailing circumstances of the time. On that basis, this Review would contend that thedecision by Solihull Children’s Services to transfer the case to Birmingham Children’sServices in late August 2016 was reasonable and defensible.191. An alternative, albeit in hindsight, scenario/option was that the pre-birth assessmentwould only have started in early July on making physical contact with the mother whowas staying on a temporary basis with her female friend in Birmingham. Moreover, shehad told SSW1 that she was not minded at that time to be rehoused in Solihull, hadextensive housing debts and had had no involvement with Solihull Children’s Servicesfor four years. Given these circumstances with her location, arguably, Solihull could havecontacted the Birmingham IASS and the two departments could have agreed thataccording to existing policy Birmingham would accept case responsibility for the pre-birth assessment and any subsequent follow up safeguarding actions. The mother’sexpected date of delivery was November and in early July there was a significant degreeof uncertainty as to where she would eventually be living. Thus, it would have beenreasonable for Solihull Children’s Services to have made a referral to BirminghamChildren’s Services in early July. This may have led to an earlier ICPC and sufficienttime for suitable safeguarding arrangements to be in place prior to the baby’s birth inlate October, rather than holding the ICPC the day after the birth.192. However, even if this option had been pursued, the mother and baby’s move to Solihullon the 10.11.16, the subsequent referral to Solihull Children’s Services and itsacceptance on the 08.12.16, cut short the Birmingham child protection plan and ledinexorably to the disruptive outcomes mentioned above in paragraphs 186-188. Giventhese developments and (the then) existing inter-local authority arrangements, it is hardto see how continuity and consistency in implementing the original child protection planand service delivery (mindful of the contractual arrangements of some agencies) couldhave been maintained and disruption avoided.193. Once it became clear on the 08.12.16 that the mother and baby had been accepted bySolihull Community Housing for permanent accommodation in the district, SolihullChildren’s Services was obliged by regional procedures43 to accept case responsibilityand duly arranged a receiving-in ICPC for the 05.01.17, within the 15 working daysrequirement.194. Therefore, within the terms of the existing regional framework, the referral byBirmingham Children’s Services to Solihull Children’s Services was procedurallycompliant and timely. Whether it was child-focused remains a moot point and highlightsthe need to review the current regional transfer framework that locates the welfare of the43 Viz, West Midlands Regional Safeguarding Network, ‘Protecting Children Who Move Across Local Authority Borders’ (revised, January 2013). See chapters 8, 9 and 10.  38 child as paramount, particularly around the necessity for continuity and consistency of service.  Was the level of planned support and intervention during the period of transfer to Solihull in readiness for the ‘receiving-in’ Initial Child Protection Conference on the 05.01.17, appropriate for the level of need identified? Did the plan of support and intervention for mother over the Christmas/New Year period consider the maternal grandparents? 195. Mindful of hindsight and outcome bias, the complexities of child protection and thesubsequent revelations of the Police enquiry regarding the circumstances leading up toand accounting for the baby’s manner of death, this SCR submits that in relation to theChristmas/New Year period, the planned level of support underestimated the level ofneed and risk. The reasons are as follows:196. Firstly, in the opinion of the Lead Reviewer there were several potential risk factors thatobjectively could have indicated the probability of raised risk levels over the said period.These included the possibility of the mother using drugs and engaging in alcohol overthe Christmas/New Year period, at a time of reduced contact with agency professionals.This eventuality (which tragically actually happened) was compounded by the lack ofany random drug testing, reliance on the mother’s self-reporting of substance abstinenceand no evidence of having taken any concrete steps to address her substance misusethrough involvement in a structured programme. The contractual arrangements notallowing Family Action to continue working with the mother once she had moved toSolihull, the reduced social work and health visiting cover and the lack of a detailedsafety plan over the Christmas/New Year period, also constituted additional risks andthe raised possibility of an adverse incident arising for the baby. Compounding this wasthe crucial factor of the case being in a state of transfer between the two local authoritiesand the attendant risks this could present. Additionally, the objective research evidence(see Appendix 3) on the link between infants under one year old and the risk of non-accidental injury was never considered and factored in to the overall risk matrix.197. Secondly, in all of the circumstances, it would have been reasonable to think that adynamic multi-agency risk assessment44 taking into consideration all of these factors,could have been undertaken by Birmingham Children’s Services professionals and thecore group. Such an assessment, in addition to considering the above, could have beenunderpinned by including the possibility of mother’s disguised compliance45, especiallyin light of her request on the 02.12.16 to drink over Christmas and the report of herdrinking wine in the public house on the 22.12.16.  On this basis, appropriate steps couldhave been taken to mitigate any identified risks to the baby by way of a risk managementplan. There was no evidence that this took place, nor that the grandparents had beenactively involved in the support arrangements over the period.44 Defined as ‘The continuous process of identifying hazards, assessing risk, taking action to eliminate or reduce risk, monitoring and reviewing, in the rapidly changing circumstances of an operational incident’, (Thornton. D (2002); Constructing and Testing a Framework for Dynamic Risk Assessment; A Journal of Research and Treatment; 139-153 45 Albeit, in hindsight she was very plausible in giving the appearance of co-operation with the agencies.  39 198. In the opinion of the Lead Reviewer the safety plan should have involved enhancedmulti-agency support and monitoring oversight by Birmingham Children’s Services andthe core group, including:•Giving the mother a very clear follow up (from her query to BSW2 on the02.12.16, see paragraph 99) message that under no circumstances was itacceptable for her to drink any alcohol or use illicit drugs over the holidayperiod. Any evidence of substance/alcohol misuse would be a breach of thepre-proceedings agreement and could result in the start of care proceedings.•Family Action being enabled to continue its service provision until thereceiving-in ICPC in early January 2017.•Arrange for unannounced visits by Birmingham Children’s Servicesprofessionals (if not the social worker then EDT) over the period until theSolihull receiving-in conference.•Having a clear agreement with the maternal grandparents setting out in detailwhat their involvement would be over the period.•Consideration by the Birmingham Children’s Services/Solihull Children’sServices team managers of the report of the mother drinking wine in the pubon the 22.12.16 and timely follow up.199. Thirdly, the support and intervention level over the said time period was based upon aninaccurate perception of need and risk. It did not consider the prescient words of theprincipal officer child protection (POCP1) at the ICPC in the previous October (seeparagraph 64 above). It was perhaps shaped by the succession of positive professionalreports that led to an underestimation in the perception of risk to the baby.200. That said, in the opinion of the lead Reviewer, it would have been unrealistic andunreasonable to have concluded that in all of the circumstances, the level of risk wassuch as to result in the death of the baby whilst in the care of the mother. There were noknown antecedent indicators or evidence that this was a likely outcome and the mother’scontrol of the narrative gave a convincing perception of an attentive parent who wasmeeting her baby’s needs.201. As later shown by the Police enquiry, the baby sustained the mortal injuries(notwithstanding the earlier serious, albeit non-mortal, rib fracture incurred between tenand twenty days prior to the death) some four to twelve hours before death, followingthe mother’s imbibing of alcohol in the public house on the night of the 01.01.17 andlater probable cocaine use. The combined effect of alcohol and cocaine can lead toviolent behaviour, lack of impulse control, disinhibition and the taking of careless risks,depression; and the production of a poisonous bodily substance called cocaethylene.‘The combination of the disinhibiting effect of alcohol and confidence inducing cocaine with the addition of cocaethylene leads to a heightened possibility of impulsive or reckless behaviour and even violence.’ (http://www.substance.org.uk/harm-reduction-information/cocaethylene-cocaine-alcohol)46 46 See appendix 3 for details 40 Such a totally unsuitable situation combined with the demands of a two-month-old baby produced a set of highly dangerous circumstances that led to the catastrophic event of the assault and eventual tragic death of the baby.   202. The Police enquiry report included the opinion of the prosecuting barrister that “Theassault on [the baby] that caused [its] death undoubtedly represented an escalation ofviolence, perhaps reflecting the deterioration in [the mother’s] emotional resilience,undermined by successive bouts of heavy drinking and cocaine abuse”. This SCR wouldconcur with this view.Part 5: The Mother’s Views 203. In response to being asked by the Lead Reviewer what she thought of the servicesprovided to her, the mother said that she could not fault them and that she had hadprevious experience of similar services during the time with her first child. She said thatfrom the period when she was pregnant with the baby and involved with the midwiferyservice she understood why social services would have to be involved and that she wasfine with that.204. She felt that the First Birmingham social worker was good and supportive when she wasin hospital at the baby’s birth. It was a bit of shock when he left suddenly in November,one day he was there, then he was gone the next day.205. The mother was asked about the issues around her drug and alcohol misuse. She saidthat alcohol was her main issue, although she admitted to ‘dabbling’ with cocaine. Thatwas eight years ago and she did it as a way of coping with the domestic violence whenshe was with her first child’s father. She said that she stopped drugs after her first childwas taken away from her. She claimed also to have been teetotal for 18 months beforethe death of the baby and didn’t have a problem with drink; she was able to drink socially.She had worked with an alcohol agency in Solihull for two to three years and has neverhad a problem since. She admitted to taking cocaine once in her pregnancy in May 2016.She did this to cope with the death of her male friend who was like a father to her.206. She said that if social services had got her to undergo regular drug testing as they shouldhave, they would have seen that she was not using. She had brought up the subject atevery meeting and claimed not to have known why it did not happen.207. Regarding the glass of wine at Christmas she said that this was agreed by one of thelocal authority children’s services, but was not sure which one said yes and the othersaid no.208. In regard to agency support she found ‘Family Action’ to have been very good and goton well with the allocated worker, particularly around her past history with men andissues of safety for her and the baby. ‘It was gutting to have to stop it’. She felt sufficientlysupported in the transition from Birmingham to Solihull services, in addition to her familyand friends and ‘never lacked support’.41 209. In response to a question about the child protection plan she said that everything wasok and that she was willing to follow the plan. She said that she was open and honestwith the professionals and that she worked with everyone as she did not want to loseher baby. She did miss a couple of appointments for drug testing but claimed to havebeen on holiday for one and was unwell for the other. If they had tested her, they wouldhave known that there were no problems. She felt let down that the testing was notcompleted.210. The mother said that drugs and alcohol were not a problem; otherwise she would haveexperienced prison by withdrawing and needing medication which was not the case.She did a slow reduction programme with the Solihull drugs programme involving oneto one and group work, drinks diary, work on why we drank and completed a gradualreduction. She was told that if she did not stop drinking she would be dead by the ageof 26.Part 6: Key Findings and Lessons 211. There was no information or evidence available to the agencies and professionalsinvolved at the time that would have led them to be able to predict the tragic outcome inthis case.  The mother must take full responsibility for the tragic death of her baby.212. Effective work was done by the midwifery service in identifying the mother’s substancemisuse history and other early risk factors. A timely safeguarding referral was made toSolihull Children’s Services who conducted a thorough pre-birth assessment thatidentified all of the relevant risk factors and appropriately recommended the need for anICPC and a child protection plan.Effective Inter-Authority Early Communication and Co-ordination Regarding Case Transfers 213. The two local authority pre-birth assessments were of a good standard that accuratelyidentified the risks and needs for the baby and the mother. However, the lack of earlyand effective information sharing between Solihull Children’s Services and BirminghamChildren’s Services, lead to  a delay in the IASS forwarding the pre-birth assessment toBSW1. This contributed to delays in holding the ICPC (this was a key recommendationfrom the Solihull pre-birth assessment), safeguarding planning, timely arrangements forsupport and risk management and SSW1’s absence at the ICPC on the 26.10.16.214. The Review identified that Birmingham Children’s Services staff could have used theSolihull pre-birth assessment at an earlier stage of the Birmingham assessment, giventhe latter’s  inclusion of the known historical and contemporary risk factors for the baby.If this had been done the assessment could have been completed quicker and in atimelier manner. The delays had knock on effects for the later safeguardingarrangements, particularly around robust drug testing for the mother.215. Solihull Children’s Services, believing that the mother was residing in Solihull, actedappropriately, in good faith and in a child-focused way in both accepting the referral from42 the specialist substance misuse midwife (SMW1) in late May 2016 and completing the pre-birth assessment in late August 2016.  216. Birmingham Children’s Services, in early September 2016, promptly accepted withoutdemur and commendably took responsibility for, the mother and the unborn baby, in achild-focused manner.217. A timely referral was made by Birmingham Children’s Services to Solihull Children’sServices in December 2016 which was child-focused and procedurally correct. SolihullChildren’s Services made a defensible decision to wait until the outcome of the housingdecision on the 08.12.16 before accepting the referral.218. Key Learning Point 1: There is a need for effective liaison and communication betweenthe two local authority social care teams in the early sharing of pre-birth assessmentsand the resultant working towards the making of timely safeguarding arrangements forthe unborn child.219. The mother’s moves between Solihull and Birmingham caused significant disruption tothe continuity and effectiveness of the baby’s child protection plan. The planned casetransfer from Birmingham to Solihull in early January 2017 led to the cessation ofimportant supportive services for contractual reasons and changes in key professionalsat a critical time in the child protection plan.220. This case shows the difficulties for agencies in safeguarding children where familiesmove frequently and rapidly across local authority boundaries.  Differences in thresholdcriteria for resources, service priorities, diversity in contracting arrangements with privateand voluntary sector agencies and financial pressures, all make for a degree ofcomplexity that result in a myriad of challenges to effective case management,especially regarding the avoidance of delay, drift and disruption in assessment, planningand implementation of child protection plans.221. Key Learning Point 2: The current (2013) regional transfer protocol did not meet therequirements of this case. An effective inter-authority transfer protocol should bedeveloped that is child centred, promotes case continuity, effective safeguarding andavoids disruption and delay.222. In this regard, the review team understand that Birmingham Children’s Trust and SolihullChildren’s Services are progressing a piece of work clarifying the arrangements fortransfer across authority borders. It will seek to address the principles of sucharrangements as well as agreed practice guidance. This will be further strengthened byregular liaison work at team manager level. These arrangements will apply to childrenin need and in care as well as those subject to child protection plans. When finalised, itis hoped that the arrangements will be adopted at regional level.43 Professional Scepticism Regarding Substance-Misusing Carers and the Need for Structured Intervention and Clarity about Agency Referral Criteria and Regular Drug Testing 223. The mother’s substance abuse issues and the potential impact on her parenting werewell recognised at an early stage, both by the two local authority pre-birth assessmentsand at the ICPC.224. Because of CGL’s acceptance criteria, the mother did not receive any structuredsubstance misuse intervention or drug testing, two very key elements of the childprotection plan. She was expected to self-refer to SIAS on moving to Solihull, whichgiven the lack of any intervention to address her substance misuse, was unlikely tomotivate her into doing this.225. A more proactive and robust approach within both the child protection plan and the pre-proceedings process should have been taken in ensuring that the mother engaged witha structured substance misuse programme that included regular and unannounced drugtesting.226. Caution should be taken by professionals when accepting the veracity or otherwise ofparents/carers who self-report abstinence from drug and alcohol without any evidence,such as a successful completion of a structured substance intervention programme(along with a robust risk assessment) and/or regular, unannounced drug testing. In thesecases, it is legitimate for professionals to be respectfully challenging with parents/carers.227. The Area Resource Panel system was insufficiently needs-focused at the time ofresource allocation regarding the child protection plan, particularly in relation to thecommissioning of robust drug and substance intervention and testing for the mother.This has now been addressed whereby identified need and risk are matched byappropriate agency resource.228. Key Learning Point 3: Professionals and service commissioners should understandthe addictive nature of drug and alcohol dependency and consider that withoutstructured intervention and regular testing from an agency with clear referral criteria, thechances of a substance-misusing individual controlling such behaviour is minimal.229. Key Learning Point 4: Effective partnership intervention for drug and alcoholdependent parents requires professionals to closely monitor parental engagement instructured intervention and the outcome of regular testing. Patterns of non-attendanceat substance misuse appointments could be an indicator of substance misuse.230. Key Learning Point 5: There was a breakdown in the continuity of substance misuseintervention and family support during the transfer between local authorities in late 2016.There is an opportunity to explore whether regional commissioning could enhancesupport for drug and alcohol dependent families.44 231. There was no parenting assessment done by Birmingham Children’s Services in mid-December 2016 as per the child protection plan because the mother and baby were bythen living in Solihull and awaiting a receiving-in ICPC.232. Reasonable efforts were made by the two local authorities to try and establish thepaternity of the baby. The mother chose not to disclose this. There was no evidence tosuggest that the mother was in an ongoing relationship with the baby’s father.233. There was no evidence to indicate to the visiting professionals that the baby was indistress or was suffering abuse prior to 31.12.16.Professional Curiosity, Respectful Challenge and Disguised Compliance 234. The baby was not old enough to communicate its lived experience to professionals,which was mediated through the mother’s positive self-reporting. Professionals couldhave been more curious regarding the baby’s admission to the PAU and being subjectof a child protection plan. More robust challenges should have been made in regard tobeing tested for substance and alcohol misuse, particularly following eight missedappointments with the substance misuse midwife, not attending a structured programmeand reports of her wine drinking before Christmas.235. Key Learning Point 6: The mother was able to plausibly present and project a narrativeof an attentive parent who was meeting her child’s needs. She successfully masked herdrug and alcohol misuse from the professionals (albeit she had failed a drug test in May2016 and missed six subsequent appointments for testing) and was able to pursue astrategy of disguised compliance.Dynamic Risk Assessment and Mitigatory Risk Management 236. Over the Christmas/New Year period the planned level of support, monitoring and riskmanagement was not appropriate. It was based upon an inaccurate and staticperception of need and risk and overly influenced by the positive professional reportsthat led to an underestimation in the perception of risk to the baby.237. The ending of Family Action’s support due to contractual reasons beyond their control,at a period of heightened risk just before the Christmas/New Year break, added to thediscontinuity of support and monitoring, coming at a crucial time in the evolution of thiscase.47238. Key Learning Point 7: Social workers and other relevant professionals need to bemindful of disguised compliance and an over optimistic mind set. They need to becognisant that risk and need in child protection are dynamic, contextual entities that arecontingent on changing circumstances and of the need to develop suitable riskmanagement plans commensurate with the assessed and accurate degree of perceivedrisk.47 N.B See paragraph 230 above regarding pan regional commissioning. 45 Part 7: Professional Challenge and Action Planning 239. The Birmingham and Solihull Safeguarding Children Partnerships and relevant agenciesshould consider the above key findings and lessons. An appropriate action andimplementation plan should be devised that results in lasting improvements to practiceand services aimed at safeguarding and promoting the welfare of children in Birminghamand Solihull.46 Glossary BSCB/P Birmingham Safeguarding Children Board/Partnership BHV1 Birmingham health visitor 1 BSW1 Birmingham social worker 1 BSW2 Birmingham social worker 2  BSSW1 Birmingham student social worker 1 BSWTM1 Birmingham social work manager 1 BSWTM2 Birmingham social work manager 2 (covering manager) BSP1 Birmingham Senior Practitioner 1 CMW1 Community midwife 1 CGL Change Grow Live (substance misuse agency) DW1 Drugs worker 1 (CGL) DfE Department for Education FAW1 Family Action worker 1 BP General Practitioner (doctor) HMW1 Hospital midwife 1 IASS Information Advice and Support Service ICPC Initial Child Protection Conference LPM Legal Planning Meeting  MASH Multi-Agency Safeguarding Hub MBC Metropolitan Borough Council PAU Paediatric Assessment Unit PLO Public Law Outline POCP1 Principal Officer Child Protection (Chair of ICPC) SATM1 Solihull Assistant Team Manager SCR Serious Case Review SGO Special Guardianship Order SIAS Solihull Integrated Addiction Services SHV1 Solihull health visitor 1 SHV2 Solihull health visitor 2 SFSW1 Solihull Family Support Worker 1 SMW1 Specialist midwife 1 for substance abuse SMW2 Specialist midwife 2 47 SSCB Solihull Safeguarding Children Board SSW1 Solihull social worker WMP West Midlands Police 48 References Brandon, M. et al (May 2016): ‘Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011-2014’: Department for Education Davies, F. et al: ‘A profile of suspected child abuse as a subgroup of major trauma patients’: www.emj.bmj.com/content/32/12/921 Drug Treatment in England (2012): ‘The Road to Recovery’: National Treatment Agency Thornton, D. (2002): ‘Constructing and Testing a Framework for Dynamic Risk Assessment; A Journal of Research and Treatment’. RCPCH (February 2017): ‘Child Protection Evidence; Systematic review on Fractures’ West Midlands Regional Safeguarding Network (January 2013): ‘Protecting Children Who Move Across Local Authority Borders’.  Working Together to Safeguard Children: Department for Education: 2015 Process for Child Protection Conferences: Birmingham Children’s Trust: June 2019 Escalation Guidance: Birmingham Children’s Trust: June 2019 49 Appendices Appendix 1 2.1 Purpose The overall purpose of this SCR is set out in Government Guidance48, namely to undertake a rigorous, objective analysis that will: •“Look at what happened in this case, and why, and what action needs to betaken to learn from the Review findings.•Action results in the lasting improvements to services which safeguard andpromote the welfare of children and help protect them from harm.•There is transparency about the issues arising from this case and actions whichthe organisations are taking in response to them.•Including sharing the overview report with the public”(Working Together 2015, 72) 2.2 Key Issues for Analysis 1.What was the quality of intervention pre-birth?2.What were the reasons why the substance misuse midwife objected todischarge planning? How was the situation resolved?3.Did agencies fully recognise the impact that drug and alcohol misuse anddomestic abuse might have on day to day parenting capacity?4.Did members of the core group have a good understanding of domesticabuse and coercive control?5.Did members of the core group consider mother’s parenting skills and historyin determining whether she would work openly and honestly with agencies?6.What efforts were made to establish the paternity of the baby?7.Did mother give any indication that her relationship with the baby’s fathermay still be on-going? If so, how did agencies respond?8.Were agencies curious enough around this?9.Was there anything about the baby’s presentation that indicated it wasdistressed or suffering abuse? If so, how did agencies respond?10.Did professionals consider the lived experience of the baby? Were theyprofessionally curious?11.Were there any issues around communication, information sharing or servicedelivery that impeded agencies working with the family?12.Were the decisions taken in relation to casework by the two Children’sServices Department’s child-focused or resource-led?13.Was the referral to Solihull Children’s Services made at an appropriate time?14.Was the level of planned support and intervention during the period oftransfer to Solihull in readiness for the ‘receiving-in’ Conference on the 5thJanuary 2017, appropriate for the level of need identified?15.Did the plan of support and intervention for mother over the Christmas / NewYear period consider the maternal grandparents?48 Working Together to Safeguard Children (2015): HM Government/Department for Education 50 2.3 Scope of SCR The timeframe under examination was from 01.05.16, which included the pre-birth assessment process, to mid-January 2017, when the case was closed by Birmingham CS. The SCR was undertaken under the ‘Working Together’ 2015 statutory guidance as it was commissioned by the Birmingham Safeguarding Children Board (BSCB) in October 2017, prior to the publication of the current edition of ‘Working Together’, June 2018.  2.4 Methodology The following documents, meetings and events have informed and underpinned this SCR: •An integrated chronology of agencies’ involvement and significant events;•A briefing by the SCR Lead Reviewer/chair for the agency report writers;•A reading and analysis of ten agency information reports by the LeadReviewer and review team along with report writers on the 17/18 April 2018;•Discussion and analysis at four review team meetings held in 2018 and May2019;•Learning event involving front line practitioners and managers held on 24May 2018;•Conversation with the mother;•Reference to the fifteen key issues;•A meeting on the 05.04.19 between the SCR chair and the WMP enquiryteam to discuss the findings of the enquiry post-trial and agree onarrangements for the production of a written addendum to the original WMPinformation report of February 2018;•Sight of all relevant documents;•The adoption of a broadly systemic approach to the understanding andanalysis of the case within an organisational context of professionals’ actionsand decision making at the time;•Being mindful of hindsight and outcome bias; and•A focus on learning and not blame.2.5 The Review Team The Review Team comprised of senior representatives from the following agencies: SCR Review Team Independent Chair and Lead Reviewer Mr Paul Sharkey Change Grow Live Safeguarding Lead University Hospitals Birmingham NHS Foundation Trust Head of Safeguarding 51 Birmingham Children’s Trust Head of Service – Child Protection Solihull Children’s Services Acting Head of Service  Safeguards and Quality Assurance West Midlands Police Detective Inspector Birmingham Child Abuse Investigation Unit Women’s Aid Operations Manager 2.6 Lead Reviewer/Chair The Independent Lead Reviewer and joint Review Team Chair was Mr. Paul Sharkey, MPA49. Mr. Sharkey undertook an SCR for BSCB in 2014/15 but since then has had no involvement with the BSCB or any partner agencies, including those involved in the SCR. He has a professional background in statutory and third sector safeguarding of over thirty years at senior management level. He has authored/chaired seventeen SCRs since 2002 and has attended several DfE/NSPCC courses on improving the quality of SCRs over recent years.   2.7 Confidentiality  In compliance with Government guidance, this SCR has respected the right to anonymity of the child, the family and the professionals involved in the case. 49 Master’s in Public Administration (2007) from Warwick University Business School. 52 Appendix 2: Risk of serious injury to and vulnerability of infants under 12 months old. 1.An omission in this case was any consideration of the very informative research into theraised risk of non-accidental injury to babies under one year old. One authoritative study(RCPCH: 2017) states that abusive fractures are more common in children less than 18months of age than those older than 18 months. That multiple fractures are moresuspicious of abuse than non-abuse and that rib fractures in the absence of majortrauma, birth injury or underlying bone disease have a high predictive value for abuse.80% of abusive fractures occurred in children younger than 18 months and that inchildren less than one year 25-56% of all fractures were abusive.2.Another study (Davies, C. et al: 2018) identified non accidental injury (NAI) as asignificant cause of injury in children under 2 years old,  with 76.3% of severely injuredchildren suffering trauma because of suspected child abuse, occurring in infants underthe age of one. Brandon et al (2016) found that ‘infancy remains the period of highestrisk for serious and fatal child maltreatment; there is a particular risk of fatality for bothboys and girls during infancy’ (p.40). 74% of the fifty cases on non-fatal physical abuseincluded in the Brandon study were aged under one year. (p62)Appendix 3: National Institute on Drug Abuse, UK Cocaine use during pregnancy is associated with maternal migraines and seizures, premature membrane rupture, and separation of the placental lining from the uterus prior to delivery. Pregnancy is accompanied by normal cardiovascular changes, and cocaine use exacerbates these—sometimes leading to serious problems with high blood pressure (hypertensive crises), spontaneous miscarriage, preterm labor, and difficult delivery. Cocaine-using pregnant women must receive appropriate medical and psychological care—including addiction treatment—to reduce these risks. Babies born to mothers who use cocaine during pregnancy are often prematurely delivered, have low birth weights and smaller head circumferences, and are shorter in length than babies born to mothers who do not use cocaine. Dire predictions of reduced intelligence and social skills in babies born to mothers who used crack cocaine while pregnant during the 1980s—so-called "crack babies"—were grossly exaggerated. However, the fact that most of these children do not show serious overt deficits should not be over interpreted to indicate that there is no cause for concern. Using sophisticated technologies, scientists are now finding that exposure to cocaine during foetal development may lead to subtle, yet significant, later deficits in some children. These include behaviour problems (e.g., difficulties with self-regulation) and deficits in some aspects of cognitive performance, information processing, and sustained attention to tasks—abilities that are important for the realization of a child’s full potential. Some deficits persist into the later years, with prenatally exposed adolescents showing increased risk for subtle problems with language and memory. Brain scans in teens suggests that at-rest functioning of some brain regions—including areas involved in attention, planning, and language—may differ from that of non-exposed peers. More research is needed on the long-term effects of prenatal cocaine exposure. 53 Impact of Cocaine use on Individual: Information from Frank UK – advice site for Substance Misuse Powder cocaine (also called coke), freebase and crack are all forms of cocaine. They’re all powerful stimulants, with short-lived effects – which means that they temporarily speed up the way your mind and body work, but the effects are short-lived. Both ‘freebase’ cocaine (powder cocaine that’s been prepared for smoking) and ‘crack’ cocaine (a ‘rock’ like form of cocaine) can be smoked. This means that they reach the brain very quickly, while snorted powder cocaine gets to the brain more slowly. All types of cocaine are addictive, but by reaching the brain very quickly freebase or crack tend to have a much stronger effect and be more addictive than snorted powder cocaine. Injecting any form of cocaine will also reach the brain more quickly but this has serious additional risks, including damaging veins and spreading blood borne viruses, such as HIV and Hepatitis C. Here are the main effects and risks of taking cocaine: •It can make you feel on top of the world, very confident, alert and awake, butsome people can get over-confident, arrogant and aggressive and end uptaking very careless risks.•It raises the body’s temperature, makes the heart beat faster and reduces yourappetite.•When the effects start to wear off, people experience a long ‘comedown’, whenthey feel depressed and run down. This crash can happen for days afterwards.Information from NHS, England regarding Alcohol misuse in pregnancy •When you drink, alcohol passes from your blood through the placenta and toyour baby.•A baby's liver is one of the last organs to develop and doesn't mature until thelater stages of pregnancy.•Your baby cannot process alcohol as well as you can, and too much exposureto alcohol can seriously affect their development.•Drinking alcohol, especially in the first three months of pregnancy, increasesthe risk of miscarriage, premature birth and your baby having a low birthweight.•Drinking after the first three months of your pregnancy could affect your babyafter they're born.•The risks are greater the more you drink. The effects include learningdifficulties and behavioural problems.•Drinking heavily throughout pregnancy can cause your baby to develop aserious condition called foetal alcohol syndrome (FAS).•Children with FAS have:opoor growthofacial abnormalitiesolearning and behavioural problems•Drinking less heavily, and even drinking heavily on single occasions, may beassociated with lesser forms of FAS. The risk is likely to be greater the moreyou drink54 Impact of Alcohol use on the Individual The effects of alcohol can include: •Reduced feelings of anxiety and inhibitions, which can help you feel moresociable.•An exaggeration of whatever mood you're in when you start drinking.•A wide range of physical health problems, either as a result of binge drinkingor from more regular drinking. The problems caused by alcohol include highblood pressure, stroke, liver disease, cancers and falls and other accidents.Mixing cocaine and alcohol This combination can produce a poisonous substance in the body called coca-ethylene that may affect your heart and stays in your system longer than cocaine alone. Mixing cocaine, a stimulant, with a depressant like alcohol can hide some of the other effects of the cocaine. This makes it easier to overdose as you take more to achieve the same high. 