Death of an infant in November 2017 from injuries linked to being shaken three months earlier. Father was convicted of murder. Charlie was the youngest of three children and lived with mother and father. Father had history of significant domestic abuse in a previous relationship and violence towards his sister and partner. GP records showed that he sought support for anger issues in 2004. Father suffered a significant brain injury from a fall at work in December 2015; he was supported by various services; Mother became his primary carer. In June 2017 Sibling 1 made disclosures at school about Father being angry and rough play indicative of risk to injury. Call made to Multi Agency Safeguarding Hub; children's social care stated that threshold was not met for a Family and Child Assessment. Mother declined Early Help support. On the day of the incident Charlie was left in the care of Father along with Sibling 2; he suffered significant injuries linked to being shaken. Learning includes: professional curiosity may lead to a fuller understanding of the lived experiences of children; accurate recording of assessments is vital for understanding risk; when children talk about their lived experience there should be adequate credence given; information held by agencies that indicate risk to children should be shared regardless of how or why that information is known. Recommendations include: specific programmes of activities to improve and embed a culture where Think Family and authoritative practice and supervision become the norm in practice considerations.
      
 Title:  Serious case review case 7: Charlie (assigned pseudonym): overview report. LSCB: Walsall Safeguarding Children Board Author: Karen Rees 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.                            1 Walsall Safeguarding Children Board       Better Together for Children www.wlscb.org.uk     Serious Case Review  Case 7  Charlie (Assigned Pseudonym)        Overview Report   Author: Karen Rees   Presented to Walsall Safeguarding Children Board (WSCB) 3rd October 2018  2 CONTENTS  1 Introduction 3 2 Circumstances leading to the review 3 3 Methodology 3 4 Reviewer 5 5 Process and Scope 5 6 Parallel Processes and Family Engagement 5 7 Background Prior to Scoping 6 8 Key Phases 6 9 Thematic Analysis 14 10 Good Practice 27 11 Conclusion and Learning 27 12 Recommendations 29  Appendix 1: Terms of Reference (Redacted for publication) 31  Appendix 2: Pathways to Harm, Pathways to protection 35    3 1. Introduction   1.1. This Serious Case Review is undertaken following a referral to the Serious Case Review Sub Group on 21/09/2017 related to a childcare incident in August 2017.   1.2. Regulation 5 of the Local Safeguarding Children Boards (LSCB) Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances.   1.3. Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely:   5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.   (2) For the purposes of paragraph (1) (e) a serious case is one where:  abuse or neglect of a child is known or suspected; and  either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.   1.4. The request for a Serious Case Review was agreed by the Independent Chair of the WSCB on 26/09/2017  2. Circumstances Leading to the Review  2.1. Charlie was the youngest of three children and lived at home with parents and siblings. Charlie was left in the care of Father along with Sibling 2.  Mother and Sibling 1 were absent from the home.  Whilst in the care of Father, Charlie suffered significant injuries that are presently being linked to shaken baby.    2.2. Charlie was initially cared for in the Intensive Care Unit at the Local Children’s Hospital on life support.  Charlie’s long term prognosis was poor and medical professionals indicated that Charlie would not survive the injuries. Following consent from the family, the life support was discontinued in November and Charlie died.   2.3. Father had previously suffered a significant brain injury as a result of an industrial accident.  This resulted in him being disabled with a support and rehabilitation plan implemented; he was supported by various services.   3. Methodology  3.1. Working Together to Safeguard Children 20151 does not prescribe a fixed methodology for Serious Case Reviews, but states that reviews should be conducted in a way in which;                                                       1 HM Government (2015) Working Together to Safeguard Children  4   recognises the complex circumstances in which professionals work together to safeguard children;   seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   is transparent about the way data is collected and analysed; and   makes use of relevant research and case evidence to inform the findings.   3.2. This serious case review used a mixed methods approach based on systems methodology. Agency Review Reports were requested from the agencies that had provided services to Charlie and the family.   Agency Review Reports and other written reports were received from:   Local Authority Adult Social Care  Clinical Commissioning Group (CCG) Area A on behalf of GPs  Hospital Trust Area A (Health Visiting, Inpatient and community midwifery post-delivery, ante natal outpatients, Community Rehabilitation Services to Father, Accident and Emergency)  Hospital Trust Area B (Accident and Emergency, Hospital Midwifery)  Hospital Trust Area C (Specialist Health Services to Father)  Mental Health Trust   Local Authority Children’s Services (Children’s Social Care and Education)  Police  Ambulance Service  Housing   Privately Funded Specialist Epilepsy Nurse for Father    Privately Funded Occupational Therapist/Case Manager for Father  (NB Area A denotes area of residence, whilst Areas B and C denote alternative local authority areas)  3.3. Members of the panel, practitioners and their line managers, report authors and safeguarding leads came together for two Practitioner Learning and Reflection Workshops (PLRW). Attendees at the first PLRW had an opportunity to review all the Agency Review Reports prior to and during the day.  The PLRW also included group work whereby attendees identified areas where learning had occurred.   The second workshop enabled a review of the emerging themes, learning and recommendations. In keeping with Working Together 2015 guidance, the PLRWs ensured full engagement from agencies who had provided services to the family. This was to enable an understanding of the systems that practitioners were working within with a view to ascertaining why practitioners practiced in the way that they did and how they made decisions.   5 4. The Reviewer  4.1. Karen Rees is an Independent Safeguarding Consultant with a nursing background. Karen worked in safeguarding roles in the NHS for a number of years. Karen is completely independent of WSCB and its partner agencies.  5. Process and Scope  5.1. Full Terms of Reference and Project Plan were agreed at a meeting of the Serious Case Review Sub Group on 9 November 2017 and are attached as Appendix 1. The review has considered agency involvement with Charlie, siblings and parents from September 2014, (the start of the school year just prior to Mother’s pregnancy with her second child), until the date of the serious childcare incident. 6. Parallel Processes and Family Engagement  6.1. At the time of conducting this review there was an open coroner’s inquest and ongoing criminal investigations. The Coroner was made aware of the Serious Case Review. As the criminal proceedings progressed to charges, the coroner closed the case.   6.2. Due to the ongoing investigation, Police asked that the family were not approached at that stage. This decision was respected and therefore arrangements to meet with the family were not possible until after the conclusion of the criminal processes.  The family were therefore informed about the review in writing and sent a leaflet about the method of conducting the review including the use of family records.  6.3. The criminal proceedings concluded with Father being convicted of murder.   Mother and Father were then invited to contribute to the review. Father cancelled the appointment; Mother was not at home for a pre-arranged meeting. As it was not possible to engage with the parents, there are some gaps in information and therefore the review does not contain family perspectives of the lives of themselves or their children and the services that they received.  6.4. For the purposes of this review, the family will be known in the following way: Family member To be called Mother of Charlie Mother Father of Charlie Father 1st Child of Mother/Stepchild to Father Sibling 1 2nd Child Sibling 2  6 7. Background Prior to Scoping Period 7.1. Information available to the review would indicate that Mother and Father had been in a relationship for about 5-6 years at the time of the incident. Father has two children from a previous relationship. Mother has one child from a previous relationship (Sibling 1). 7.2. The Police provided some historical information to the review that reflected significant domestic abuse perpetrated by Father in a previous relationship and evidence of violence towards his sister and partner. GP records indicate that Father sought support for anger issues in 2004. In 2012 Father self-referred to Primary Care Mental Health services but did not meet the criteria for services and was discharged. 7.3. Mother was seen once in mental health services for anxiety and depression in 2013. This was attributed to her mother’s house being burgled and that Mother lived on her own with a child (Sibling 1). 8. Key Phases  8.1. For the purposes of this review the children’s story will be highlighted using relevant information in key phases that inform the areas for analysis in section nine of this report. Relevant information from the Agency Review Reports was extracted and discussed in the PLRW seeking to understand the multiagency working and learning.    Key Phase 1: September 2014- August 2015 (Birth of Sibling 2)  8.2. During this phase, Sibling 1 was attending School 1. There were no concerns expressed with attendance, behaviour or academic ability.   8.3. The family were living in private rented accommodation; records suggest that Mother and Father had their own tenancies initially.   8.4. In December 2014, Mother booked for antenatal care at the GP Practice. At the home visit by the community midwife that followed, it was noted that parents were living together with Sibling 1. No risks or concerns were identified. Routine domestic abuse enquiry was undertaken at various points with no disclosures made. Ante natal care was noted to be shared between Area A Hospital Trust community midwifery services and Area B Hospital consultant and midwifery staff.   8.5. In May 2015, Father attended his GP stating that he had difficulties controlling his temper. He indicated that he was affected by issues from his childhood. He advised the GP that he had been violent and aggressive in the past. He reported that his partner was supportive. The GP referred Father to Primary Care Mental Health Services. It is confirmed that Mother and children were registered at the same practice as Father.   8.6. Father was seen by Primary Care Mental Health Services from the Mental Health Trust at the GP practice in June 2015. Mother accompanied him to the appointment. It was noted that Mother was pregnant at the time of this consultation although the name of Mother is not recorded. The  7 information disclosed by Father led to a discussion of treatment options with a suggestion of contact with an external counselling service for support with anger management.   8.7. Following this consultation, Father was discharged by Mental Health Services. No risks were identified and no information was shared with any other services. This will be subject to further analysis in section nine of this report.  8.8.  Mother attended all her ante natal appointments and was seen on a self-referral basis for varied concerns during pregnancy. None of these concerns were reported to be out of the ordinary. Pregnancy progressed well. Sibling 2 was born following a planned induction of labour for medical reasons (attributed to pelvic girdle pain that is not an uncommon pregnancy complication).       Key Phase 2: August 2015 (Birth of Sibling 2) - Pregnancy Booking Charlie (August 2016)  8.9. Mother and Sibling 2 were discharged the day after the birth. No risks or concerns were identified.    8.10. Routine post-natal care was undertaken at home by the community midwives. Routine maternal mental health screening did not highlight any concerns. Community midwifery services handed over care to the health visiting service within the same Hospital NHS Trust (Area A).  8.11. The health visitor undertook the new birth visit in line with the Healthy Child Programme (HCP)2. Father was not present at this visit. Details of family members were recorded.  No risks or concerns were identified. Routine domestic abuse screening was undertaken with no disclosures made. The level of service identified that was required to meet the needs of the family was Universal i.e. indicating that there were no additional needs; the family required routine screening appointments only.   8.12. Sibling 2 was seen with Mother by the health visiting service on two further occasions. The first was for the follow up visit secondary to the new birth visit, the second was for the 6-8 week check at home. Nothing of note was recorded and the family remained subject to Universal level of intervention. It is noted that the required routine maternal mental health screening was not undertaken at this visit.  8.13. Sibling 2 was not brought for the routine introduction to solids appointment in early December 2015 (pre-Father’s accident).   8.14. The family moved into a social housing tenancy in October 2015.  A welcome visit was made by a housing officer after ten days; no welfare or safeguarding concerns were noted.  8.15. It was noted that neighbour disputes started soon after the family moved but appeared to be of a ‘tit for tat’ nature with both the family and neighbour reporting concerns about noise and disruption. One of the concerns was the neighbour reporting that he heard a baby crying and verbal                                                       2 The HCP offers every family a programme of screening tests, immunisations, developmental reviews, and information and guidance to support parenting and healthy choices – all services that children and families need to receive if they are to achieve their optimum health and wellbeing.27 Oct 2009 Healthy Child Programme - Gov.uk  8 abuse being shouted at the baby. This was at the time that Father was in hospital. The housing officer visited to investigate on the same day but there was no reply. Father was still in hospital when the visit took place six days later. At this visit it was noted that the baby was in the bouncer, was content and had no visible marks. The property was clean, warm and well ventilated.  The disputes appeared to be ongoing until the family moved in May 2016.  8.16. Father sustained a traumatic brain injury from a fall at work in early December 2015; he remained in Area C Hospital until the end of January 2016. He was referred to Area A Hospital’s Community Neurological Rehabilitation Team (CNRT)3 for follow up. He also remained under the care of a Neurologist at Area C Hospital.   8.17. It is recorded in GP records in December 2015 that Grandmother was looking after the baby (Sibling 2) as Father was in hospital in a coma following a fall at work.   8.18. In April 2016, Sibling 2 was seen at clinic for a 9-12 month review as per HCP. No concerns were noted with health or development. There is no evidence that Mother’s mental health was assessed as would be standard at this appointment. It is not recorded that there was any knowledge of the circumstances of Father’s injury at this appointment.  8.19. CNRT noted concerns related to Father’s condition and that Mother had become his carer. Concerns related to behaviour change as a result of his brain injury and that he was displaying angry outbursts of a verbal and occasionally physical nature. Both parents stated that there was no physical violence to her or the children. How this information was shared and with whom will be subject to further analysis in section nine. In May, sessions with a clinical psychologist commenced to include support with anger and irritation.  8.20. In May 2016, the family were rehoused on medical grounds due to Father’s brain injury.  8.21. In June 2016, an ambulance was called as Father had slurred speech. Father was conveyed to Area A Hospital where he complained of head pains. Father was admitted and underwent tests and observations. CT scans of his head showed no changes. Father demanded to be discharged the following morning.  8.22. It was also in June that Mother contacted Adult Social Care to request psychiatric support for Father. This was declined as it was not the role of Adult Social Care; Mother was appropriately signposted to the GP.   8.23. In July, an ambulance was called for Father who was fitting. He was conveyed to Area A hospital. It was noted that Father had a pre-arranged consultation with a neuro clinician a few days later and he was discharged.                                                        3 Community Neurological Rehabilitation Team consists of a multidisciplinary team of a range of professionals to offer rehabilitation and support services dependant on a patient’s assessed need.   9 8.24. At the end of this phase, an Independent Occupational Therapist (OT) Case Manager received a referral from the solicitors and insurers related to Father’s injury claim. This was to provide input around Father’s rehabilitation needs. This was in addition to the input being received from NHS services. The extent of the understanding of this role and the dimensions it added will be analysed further in section nine.  8.25. Sibling 1 had moved school in February. Neither School 1 or 2 appeared to have knowledge of Father’s brain injury and reported no concerns during this phase.  8.26. It is of note that all the professionals working with Father, knew of his status as a Father and many had contact with the children in the course of their work.  Key Phase 3: August 2016- Birth of Charlie (March 2017)   8.27. In August 2016, Mother attended an antenatal booking appointment with the community midwife at the GP surgery. Father was in attendance. Mother and Father were asked about family health and there was no information given about the brain injury and any impact. There were no risks identified at this contact.   8.28. In September, the Community Midwife undertook a home booking visit. Father was present. At this visit, Mother stated that her occupation was a full-time carer for Father. There is no entry in the records to indicate that this was explored further.  8.29. During this phase, it was arranged that taxis could be funded through the injury claim in order that parents could get to appointments.  8.30. In October 2016, an Independent Epilepsy Nurse was funded through the injury claim as it was recognised that there was currently no NHS provision available. The Epilepsy Nurse visited the family on several occasions and supported them in managing childcare safely as well as other aspects of epilepsy management.  8.31. In November, Father suffered a further seizure. On this occasion he recovered whilst the ambulance crew were in attendance and he remained at home.   8.32. This phase is characterised with significant involvement from the CNRT offering support and rehabilitation to Father and increasing notes in records regarding the nature of Father’s anger and frustration.   8.33. When Mother’s maternal mental health was assessed by the community midwife, it is reported that she expressed that she was stressed and answered ‘yes’ to both Whooley questions4. The patient                                                       4 The Whooley Questions (see below) are used as a screening tool for major depressive disorder. A no response to both questions (negative test) essentially rules out depression, and a yes response to one or both questions (positive test) identifies virtually all persons who may benefit from further evaluation.  1) During the past month, have you often been bothered by little interest or pleasure in doing things? (Yes/No)  10 held records record this as ‘stressed’; in the electronic records ‘anxiety’ is ticked. There was no further action recorded regarding this. At a later appointment this no longer appeared to be a feature.   8.34. Two episodes in this phase indicate the ongoing stress for Mother. In October, she complained about the current midwife and requested a change. In December, Mother was reported to be angry and agitated at the time it took to book the next hospital appointment whilst at the GP surgery. There was no further exploration of this recorded.  8.35. In December, letters within the GP records for Father from Area A Hospital and Area C Hospital indicate ongoing concerns.  These indicated anger and frustration that included displays of physical aggression albeit no reports of direct violence against persons.  8.36. The Independent OT case manager referred Father to Adult Social Care for a Care and Support Assessment. Father’s needs were assessed not to be significant from an Adult Social Care perspective. Needs were mainly noted to be housing and financial. Adult Social Care were informed by the Epilepsy Nurse that there were significant concerns regarding safety in the home because of the number of seizures Father was having. There was an indication that Mother could not leave him on his own and he needed 24-hour monitoring.   8.37. In November, Sibling 2 was seen in the paediatric assessment unit at Area B Hospital for a rash. During questions about family health, Father was reported to be well. There was no mention of Father’s brain injury or epilepsy. Also in November, Sibling 1 was admitted to Area B Hospital for an elective tonsillectomy.   8.38. In December, Mother presented with Sibling 2 in Accident and Emergency at Area B Hospital   with a tiny bruise and scratch mark in the ear. The injury was reviewed by a paediatric consultant and no safeguarding issues observed. Sibling 2 was diagnosed with acute tonsillitis.  8.39. None of these attendances resulted in knowledge of Father’s condition or the stressors that were present for Mother.  8.40. In mid-January, Adult Social Care social worker referred Father for an assessment for Continuing Healthcare funding. The assessment took place two weeks later. It was noted that as part of this assessment Father required constant support and supervision in terms of his own needs. This assessment documents anger due to tiredness, that Father is not able to look after the children on his own, that he feels a burden and was very low in mood. This assessment did not include his role as a Father, it was purely to assess his need for any further funded healthcare. The impact of this and origin of these stated issues is further analysed in section nine.                                                          2) During the past month, have you often been bothered by feeling down, depressed or hopeless? (Yes/No) http://whooleyquestions.ucsf.edu/content/home accessed 23 April 2018   11 8.41. The day before the CHC assessment, Adult Social Care contacted Children’s Social Care to inform them of the circumstances the family were in and to seek support for getting Sibling 1 to school. Sibling 1 was still attending school in the previous area following their house move. Support was declined as there were no additional needs in respect of Sibling 1. Children’s social care have no record of this contact. The continued difficulty in getting Sibling 1 to school eventually resulted in funding of Taxis through the injury claim. This was arranged by the Independent OT in addition to the already agreed use of taxis for appointments. Adult Social Care were not advised of this. During the CHC assessment it was agreed that the Adult Social worker would contact Children’s Social Care to update them. There is no record that this second contact took place in either Adult Social Care or Children’s Social Care records. If it did take place and was not recorded, there was no ensuing action from Children’s Social Care.   8.42. Adult Social Care provided Telecare services and signposted Father for support services from Headway5. A carers assessment commenced for Mother, but this was never completed. Adult Social Care supported an application for rehousing and school transfer for Sibling 1.  8.43. During the final stages of Mother’s pregnancy with Charlie, the Independent OT arranged for private funding for the family to pay for two days per week additional childcare (nursery and then subsequently a childminder) for Sibling 2. This was in order to reduce the burden of childcare and replace the support Father would have given if not for his brain injury.  8.44. In February, there is a record that the health visitor attempted an antenatal visit as required by the HCP. It is not known if this was a booked appointment but there was no reply at the address. There was no record that this visit was rescheduled.  8.45. Area B Hospital maternity records indicated that labour was to be induced in this pregnancy due to social reasons. There is no further indication as to why this was. Community midwifery services in Area A were not aware of this information. Once labour had been induced, Mother asked if things could be speeded up as she was concerned for Father as exhaustion could be a factor for seizures. This information did not feature in the discharge summary.   Key Phase 4: March 2017 (Birth of Charlie- Date of Incident (August 2017)  8.46. Charlie was born following the planned induction and was well at birth. Mother and Charlie were discharged the following day.  8.47. The community midwife carried out a routine post-natal visit the day after discharge and reported no concerns. A physical assessment of Mother and Charlie was undertaken. Emotional well-being was reported to be normal. A further contact was made on day 5 at the GP surgery. No concerns were reported and emotional well-being was again noted to be good.  Mother did not attend a further planned appointment at the children’s centre. This was the day after the family moved. An appointment was left with Father but this contact did not take place.                                                        5 Headway is a registered charity that supports people affected by brain injury to improves their lives  12 8.48. When Charlie was nine days old the family moved to a privately rented bungalow. When housing attended the previous tenancy to prepare it for re letting, they found two doors internally had been damaged. The housing report for this review indicated that photographic evidence confirmed that the doors appeared to have been punched (at a height consistent with an adult rather than a child). This information was not shared with any other agency.  8.49. The health visiting service received the birth notification in a timely manner. There were difficulties arranging the new birth visit as the family had just moved, were busy settling in to the new home and stated it was not convenient to have the health visitor there. Due to the change in address, the health visitor handed over to a new health visiting team and the new birth visit was undertaken on day 15 (one day outside of recommended timescale for the visit).   8.50. At the new birth visit parents and both siblings were present. Health for both parents was reported and recorded as good. The Whooley questions were asked with a negative response from Mother. The domestic abuse routine enquiry undertaken when Father was out of the room resulted in no disclosures. The result of this visit was that health visiting care plan would be as per the Universal Service with the next contact being at 6-8 weeks.  8.51. The 6-8 week home visit appointment was not carried out; the health visitor was met on the doorstep as Charlie was reported to be asleep and generally unwell. The appointment was rearranged for three days later at the clinic. Mother reported that she had changed Charlie’s milk feed on advice of the GP as Charlie had been vomiting after feeds.  8.52. Although Adult Social Care had an open case for Father, there was little activity in this phase. The social worker had been off sick and left, leading to  the case awaiting reallocation. The carer’s assessment in respect of Mother was closed as it was not completed. The family did not make any contact with Adult Social Care requesting any further support. No contact was received from any other agency requesting further input for the family.  8.53. In this phase, the GP received further letters from the Psychologist in the CNRT detailing the circumstances of concern at home. This related to the ongoing anger and frustration and detailed issues where Father had indicated a wish to end his life.  Father had declined respite care. There were also reports in this phase that parents had stated that they had had enough of all the different professionals involved and that they just wanted to be left alone. They felt that they had enough support from the Independent OT.   8.54. The GP followed up this information with a review appointment. Father denied any current thoughts of suicide and declined the offer of support from a community psychiatric nurse.   8.55. As a result of the ongoing concerns that Father’s rehabilitation was not progressing, alongside about the difficulties consistency in engagement from the family, there was consideration of a multi-disciplinary team (MDT) meeting. This meeting took place in May. The meeting was attended by the Independent OT, the Independent Epilepsy Nurse and the Psychologist. The focus was related to the role of Mother as carer, to set rehabilitation goals and identifying seizure and medication management. Minutes of the meeting were sent by the Independent OT to those involved. The Area  13 A hospital does not have a record of the minutes. Anger and frustration at the level that it was being discussed in letters and in notes was not discussed at this meeting.   8.56. In June, Sibling 1 (aged 8 ½ years) arrived at School 3 (where he had moved two months previously), crying. Sibling 1 disclosed that Father had been throwing coins towards Sibling 1’s head as a result of asking for money for a school trip. Sibling 1 went on further to disclose that Father often gets angry when they play fight and that the punches can be really hard and that it hurt. Sibling 1 stated that Father only stops when he gets bored. On making time to listen to Sibling 1 further in a ‘Time to Talk’ session, Sibling 1 made significant disclosures regarding various aspects of home life that included arguments between parents and anger in Father that made Sibling 1 feel scared. Sibling 1 also disclosed that Father hurts Mother and says mean things to her. Sibling 1 gave more details of other rough play that was indicative of risk of injury to the children in the home. Sibling 1 asked that Father was not told about what had been disclosed to school.  8.57. As a result of this information a call was made to the Multi Agency Safeguarding Hub6. The response from Children’s Social Care was that the threshold was not met for a Child and Family Assessment and Mother should be offered Early Help support. When school staff spoke to Mother she declined Early Help stating that they had lots of help and support. Mother was seen to respond appropriately to Sibling 1 and hugged and provided reassurance. Prior to this incident, Sibling 1 had not mentioned anything to School 3 about Father’s brain injury or fits; they had no knowledge of this. School 3 continued to undertake well being checks and monitored Sibling 1 for signs of abuse or distress. None were noted. School 3 took no further action regarding the threshold decision by Children’s Social Care or to speak to any other professionals that Mother had indicated were supporting them.    8.58. The Epilepsy Nurse visited in this phase and continued to offer advice to Father about safe childcare e.g changing Charlie’s nappy on the floor and feeding sitting on the floor. He was also advised not to bath the children but to top and tail only. There is no record of any communication with the health visitors or midwives regarding this advice or the reasons for the epilepsy nurse involvement.   8.59. In July, an ambulance was called for Charlie who was reported to be vomiting blood. The ambulance crew found all physical examinations to be normal and conveyed Charlie to Area A Hospital Accident and Emergency. The GP received information from Accident and Emergency that Charlie was transferred to the Urgent Care Centre following triage, suggesting that this was not a critical emergency. The outcome of this attendance is recorded on GP records as ‘discharged with advice’.  This was not known to the health visiting team as information is not shared from these attendances with the paediatric liaison service or the health visitors.   8.60. In August, Charlie was in the care of Father and collapsed. Injuries identified were consistent with having been shaken. Charlie was transferred to the regional intensive care unit where life support was maintained. A decision was made that the Charlie could not survive the injuries and life support                                                       6 Multi-agency safeguarding hubs Multi-agency safeguarding hubs are structures designed to facilitate information-sharing and decision-making on a multi-agency basis often, though not always, through co-locating staff from the local authority, health agencies and the police.    14 was withdrawn three months later and Charlie died.   9. Thematic analysis  9.1. By analysing the agency review reports and using the information gathered at the Practitioner Learning and Reflection Workshops, it is possible to identify areas where there is learning that can lead to recommendations and improvement.  9.2. It was stark in this case how much information was known to those working with Father and Mother as his carer.  All of those working with the children as their focus, had no knowledge of the situation and difficulties that the family had found themselves in following Father’s Accident in December 2015.   9.3. It was very difficult to find the voice of the child in the many reports that were received or at the PLRW’s and therefore leads to the first area for analysis.  THE VOICE OF THE CHILD IN ASSESSMENT AND UNDERSTANDING RISK  Opportunities for hearing the voice of the child: Children’s workforce  9.4. Due to information not being known to midwifery services and the health visitor, Father’s anger and later accident did not feature in the assessment or understanding of risk by these practitioners in either pregnancy.  The family were identified as requiring universal services only. The domestic abuse questions were asked of Mother by both midwifery and health visiting staff and no disclosures were made.   9.5. This routine enquiry regarding domestic abuse was good practice and shows evidence that learning from previous SCRs in the locality appear to have been applied.  9.6. The information regarding the outcome of primary care mental health services assessment in May 2015 was recorded in the GP records for Father. Fathers’ records are not routinely accessed by community midwives during ante natal and post-natal services within GP practices.   9.7. Midwives stated that the reason that fathers’ records are not accessed is that it is the Mother that is their patient and not the Father. Consent to access fathers’ records is cited as an issue. It can be seen from the work of the Fatherhood Institute7 and in advice to midwives from the Royal College of Midwives8 that full and meaningful engagement with fathers should be encouraged. This is because of the positive impact not only on fathers, but on mother and baby. Consent can be gained to access and document in fathers’ records.  Most fathers would see this as positive inclusion in whole family ante natal care. In this case, Father was registered at the same practice. This may be more of a challenge where a father is not registered at the same practice. If inclusion of Father and recording                                                       7 The Fatherhood Institute. http://www.fatherhoodinstitute.org/ Accessed 25 May 2018 8 Reaching out: Involving Fathers in Maternity Care https://www.rcm.org.uk/sites/default/files/Father%27s%20Guides%20A4_3_0.pdf Accessed 25 My 2018   15 in Father’s records had been routine, the midwifery service would have become aware of the brain injury to Father. Fathers who decline consent to be included could invoke a professional curiosity as to why that may be and in some cases, identify potential risk factors.      9.8. The assessment of maternal mental health, during second pregnancy, was not robust. Mother had answered positively to the Whooley questions which may have been indicative of how things were at home. This was within the period following Father’s accident. This information was not effectively documented and therefore was not available to those undertaking maternal mental health assessments in the post-natal period. The actual recording of the answers to the Whooley questions was not obviously apparent within the records.  However, the patient held records state that mother was stressed and the electronic records indicate anxiety was present. It is not clear why neither of these issues led to further assessment and support. The Area A Hospital Trust have evidenced this as learning and made single agency recommendations regarding this.  9.9. In the ante natal period for Charlie, the issue of the agreed induction of labour for social reasons and the ensuing request to speed things up so that Father did not get tired, was not known to community midwifery. This was because it was not recorded in the shared patient held midwifery notes. This had only been recorded in the obstetric notes of Area B Hospital.  9.10. Community midwifery services in Area A and hospital midwifery services in Area B have traditionally shared information across their services via email communication and within the maternal patient held records. There is a recent development of the installation of new records software at Area B Hospital that will enable Area A midwifery services access to view all electronic hospital notes. The improvements to communication and the efficacy of this will form part of WSCB assurance seeking recommendations from this review.   9.11. When the community midwifery service then asked about maternal mental health in the post natal period, it was reported to be good. It is not clear why this had changed. The author would suggest that as there was no action on disclosure antenatally, there was not much mileage in disclosing anything further as it did not lead to further questioning or understanding.  9.12. It is also clear that Mother told community midwifery services that she was a full-time carer to Father. This did not elicit any further questioning about what this meant and any impact this would have. The Area A Hospital Trust have not been able to identify why this was. It is possible that a culture of professional curiosity is not embedded this is discussed later.  9.13. There was a further attendance that may have been suggestive of requiring further exploration and possible support. In December 2016 Mother attended Accident and Emergency with Sibling 2. The presenting condition was regarding a bruise in the ear. It was felt by all at the PLRW that this was not a usual concern to be presented at an emergency department. Although procedures were followed and a paediatric opinion was sought, there was no documented exploration of why Mother had been so concerned about such a tiny mark to cause her to present Sibling 2 to Accident and Emergency. This may have been a further missed opportunity to hear the voice of the child.     16 9.14. In terms of understanding what these incidences would mean for any children in the household and any impact on them, practice did not consider the voice of the child. These missed opportunities to apply professional curiosity may have been the reason that those professionals did not know of the situation regarding Father’s injury and epilepsy.  Child focussed professionals did not know about the large number of professionals working with Father and Mother from half way through Key Phase 2.  9.15. It does have to be acknowledged, however, that on being asked about family health on several occasions post Father’s accident, there was no information made available to professionals by Mother or Father.    9.16. There was one very clear indicator of the lived experience of the children and the voice of the child. In June 2017 Sibling 1 made clear disclosures regarding what constituted physical child abuse and domestic abuse and violence. School 3 responded appropriately and gave time to listen to what Sibling 1 was saying. When this was referred to Children’s Social Care through the MASH, it was seen as an advice call. The call is not documented by Children’s Social Care and therefore it is not possible to understand why a direct disclosure of abuse and violence by an 8-year-old child was not subject to any further assessment.  9.17. It could be argued that even if it was felt that the threshold for Child and Family Assessment by Children’s social care was not met, the issues that were disclosed could have been subject to some agency checks. That may well have alerted the GP that the issues that were recorded in Father’s records were having a direct impact in the home and on the children. Sibling 1 was not a child who had ever disclosed at previous schools about Father’s brain injury or epilepsy. This then, was out of character. It is important to note that at the time of the disclosure, Sibling 1 had only been at School 3 for five weeks. School 3 listened and offered very good care after Sibling 1 chose to tell them what was happening at home.  The impact of not being heard by and responded to by the system to effect change and protection may well have prevented any further disclosure.  9.18. When spoken to by school staff, Mother played down what was happening and staff saw her respond appropriately to Sibling 1. In the context of any domestic abuse she may have been experiencing, this would not be an unexpected response.   9.19. The previous contact by Adult Social Care about the difficulties Mother was experiencing in managing childcare were also not documented by Children’s Social Care, so this further piece of the jigsaw did not add to the picture that was emerging.   9.20. School 3 recognise that they could have done more to challenge the Children’s Social Care response. They could have searched out more information from Mother when she indicated that there were many professionals supporting them. This could have led to further information being shared.   Education services have made appropriate recommendations to address this in their own agency review.   9.21. The previous information regarding Father’s historic violence was only known by the Police. The issues related to a previous relationship and would not have been flagged to those working with the  17 family in the timeframe for this review. It is the case, however, that if the referral regarding Sibling 1’s disclosure had resulted in any background checks, then this evidence would have come to light and would have led to a different understanding of risk.  Opportunities for hearing the voice of the child: Adults’ workforce  9.22. This then moves us to thinking about how those working with the adults heard the voice of the child and understood risk to the children in their assessments of the adults.  9.23. The first time that there is an indication of risk to children by those assessing Father is in June 2015 in the first key phase. Sibling 1 was six years old and Mother was seven months pregnant with Sibling 2. Father had attended the GP practice with concerns over managing his anger. Having been duly referred to Primary Care Mental Health Services he was seen and assessed.   9.24. This assessment appointment took place at the GP practice. Father was accompanied by Mother and it was understood by the mental health worker that she was pregnant. The severity of depression was recorded from the completed questionnaire as low. Disclosures were made, however, of significant anger and that Father indicated he knew he was capable of harming himself or others when he loses his temper and it gets out of control. It is further documented that there were no safeguarding concerns. Although the record indicates that his partner’s baby was due soon, there was no recording of Mother’s name.   9.25. The outcome was for referral for an external counselling service that was funded by commissioners for those with a GP in the locality. It is not known if this service was accessed by Father. It is not recorded how the financial pressures that were also disclosed were going to be supported or if any advice was given regarding this possible trigger for his symptoms. The practitioner who undertook the assessment is not able to recall the consultation.   9.26. The Mental Health Trust has recognised this as an issue for their services. This assessment does not consider the voice of the child and no other checks or balances were made regarding what was being disclosed. There was information in the GP records regarding historical anger issues and the previous attendances regarding this. Had this been known, the current presentation may have been viewed differently.   9.27. Since this time there are new procedures within the Mental Health Trust that include undertaking checks within their agency to ascertain any history. There is now an electronic system for reporting and flagging concerns that links to seeking safeguarding advice. There is also a system of professionals meeting where there may be concerns for unborn babies. These meetings are attended by the safeguarding midwives. Had this system been in place at the time, the Mental Health Trust have indicated that this family would have been discussed.   9.28. Clarity was sought at the PLRW regarding the assessed need of Father.  This was to try and understand the impact that this would have had on Mother as his carer, as well as being a mother of a growing family. It is apparent that there were no physically assessed needs in that he was able to manage activities of daily living. The independent OT has informed the review that Father was not  18 one to be involved in housework before the accident and therefore it was not a requirement to re teach him skills. There was an indication that it was more about motivation to undertake tasks post injury that was the issue. Father had lost confidence in himself and required support to go out of the house.  9.29. Tensions appeared to increase after the seizures started. Father could no longer drive and Mother did not drive. There was significant information in the CHC assessment regarding Father’s needs that indicated that risk to the children and the baby that was due within six weeks needed to be assessed. Issues such as anger, not being able to care for the children alone, feeling a burden and low in mood may have had an impact on Mother’s ability to cope, Father’s mental health and well-being as well as possible risks to the children.   9.30. There is no clarity in the recording of the CHC assessment as to why it was recorded that Father could not care for the children alone. i.e. whether it was Father and/or Mother who had stated that Father could not care for the children alone. A review of what is documented as well as discussion with the assessor, has resulted in knowledge that it was discussed but not who had stated it.   9.31. It was issues of this nature though, along with the fear of seizures happening resulting in either injury to himself or the children that led to the decision, possibly by Mother, that Father could not care for the children on his own. No professional documented any assessment that stated that Father should not be left alone with the children because he was a risk. Records do indicate that, as he struggled to manage his own care, he would not be able to provide adequate care for his children on his own.  This issue may become clearer when the author is able to speak to parents.  9.32. Adult Social Care attempted to get support for Mother from Children’s Social Care. Mother was struggling to get Sibling 1 to School 2. The whole family had to travel some distance to school on a bus as Mother could not drive and could not leave Sibling 2 alone with Father. This referral was rejected and is not recorded by Children’s Social Care. Adult Social Care were not given any advice as to how to proceed. When there may have been evidence that there was recognition of the need to support the family further during the CHC assessment, there is no record of a call to Children’s Social Care. There is therefore no evidence that any information from the CHC assessment was shared with Children’s Social Care.  If it was, it did not result in any action or advice from Children’s Social Care. Notwithstanding this, it is a hypothesis from this review, that largely, the issues that parents presented to adult workers were seen in terms of meeting Father’s needs. The impact on children living within these circumstances, both historical and current was not seen as a possible risk.  9.33. Adult Social Care did not contact the school to see if there was any support that the school could give. Mother was seven months pregnant at this point, but Adult Social Care did not contact either the GP, the community midwife or the health visitor. This was another missed opportunity for adult and children’s workers to share information.  9.34. The CHC assessor contacted the GP during the assessment process; it does not appear that the GP shared any historical information related to violence or aggression.   19 9.35. Adult Social Care has identified that as a negative response was received from Children’s Social Care, on the day before the CHC assessment, they took that to mean that there was nothing further that could be done. There were two issues here. Firstly, Children’s Social Care did not offer any further advice and guidance to Adult Social Care about other options for family support that they might try. Secondly, there was information within the CHC assessment that was significant. With the negative response from Children’s Social Care and the further information from the CHC assessment, Adult Social Care could have made use of the Thresholds Guidance9 to identify what level the needs of the children were at.  This may have prompted  contact with school, health visitor GP etc. These were the professionals who would be supporting children below the threshold for Children’s Social Care interventions (i.e. at levels 1-3).  This has led to a single agency recommendation by Adult Social Care regarding training and use of the Thresholds Guidance.   9.36. Further indicators of risk for the children were missed due to the incomplete carer’s assessment for Mother. It has been stated that Mother was ambivalent to the assessment and gave different responses regarding her needs. This lack of engagement from Mother, meant that the assessment was not completed and was closed as a piece of work. The author would argue that it is possible that Mother may have been more engaged with the assessment if there had been more contact with the social worker. The case was left unallocated when the social worker went off sick. Had Mother understood what the outcomes might have been and had an opportunity to build a relationship with the social worker, she might have engaged more. This may well have had a positive impact on the children. One of the stated reasons for not having more involvement was the belief by the social worker that the Independent OT was undertaking the lead role.   9.37. The Independent OT informed the review that the role was regarding the rehabilitation of Father and does not have the statutory duty to undertake a carer’s assessment as identified within the Care Act 2014. That responsibility lies with the Local Authority Adult Social Care. The communication issues here are discussed in the next section.   9.38. Adult Social Care now have regular ‘share meetings’ at GP practices and this would be an opportunity to discuss cases of this nature. Had this been in place at the time it may have led to wider information being shared with the health visitor and/or midwife. The Local Authority are also in the process of producing a Corporate Safeguarding Policy (Adult and Children). This will cover all directorates in the council and will ensure that everyone has access to information regarding referral and escalation pathways. The policy will also reference Thresholds Guidance for safeguarding children.   9.39. As more information was being disclosed to professionals working with Father, no one spoke to Sibling 1 to understand any impact on him. Books and information were given to Father to read to Sibling 1 regarding a parent with a brain injury.  There was also work planned with Sibling 1 by the                                                       9  MULTI - AGENCY THRESHOLD GUIDANCE Identifying Need and Analysing Risk when working with Children in Walsall  available at http://westmidlands.procedures.org.uk/assets/clients/6/Walsall%20Downloads/Multi-agency%20threshold%20guidance%20(PDF%201MB).pdf  accesssed 26 April 2018    20 Epilepsy Nurse regarding seizures; parents declined this stating that they did not want Sibling 1 to be upset.   9.40. There did not appear to be an understanding of the impact of living in an environment of constant stress and displays of aggression would have on young children or the risk that could ensue from this. Moreover, the unpredictable nature of Father’s outbursts must have been very difficult for the children and Mother.  9.41. It is noted that some of those working with the adults did not have information related to the level of aggression e.g. the Independent OT has stated that there was knowledge of frustration and irritability but not of any physical aggression that is seen in the Psychology reports. Further issues related to how this was understood and communicated will be discussed later in this review.  9.42. Father did indicate to one of the psychologists, that he had previously had some anger issues but stated that this was of a verbal nature and was minimised by Father. It is of note, however, that the problems being presented were largely considered by most professionals working with Father to be new and out of character for him. This may go some way to explaining the inability to understand risk. There was a degree of empathy being applied by those working with Father and trying to support him to rehabilitate back to his pre-accident demeanour. What they were not aware of, was that Father had historic anger issues, some of those being significant violence to others.   9.43. Those whose primary focus were the adults, knew of Sibling 1 and 2 initially and then of the pregnancy and birth of Charlie. Whilst only some of those professionals were aware of the level of anger that was being displayed, none of them knew that anger was not a new issue post brain injury and that in fact, this was documented in GP records back as far as 2004.  9.44. In sessions with the CNRT and at appointments with the neurology service at Area C Hospital, issues and concerns related to anger and frustration were being disclosed. These services did not consider that there was enough concern or evidence that the children were at risk and therefore did not share this information.  Several reasons were put forward for why this was the case.   As there had been no reports of violence against the children the risk was not recognised.  There was concern expressed that it was important to keep the professional relationship with the parents and that to share that information may cause parents to disengage.   9.45. Housing staff also had indicators of the stress that the family were under. Whilst Father was in hospital after his accident, housing received a report of an adult shouting at a baby. When they visited, there were no safeguarding concerns noted and therefore information was not shared.  The significance of Father’s hospitalisation was not fully understood and the information was not shared with those that may have been able to offer assessment and further support.  9.46. Housing staff also had more evidence of possible violence when they reported that doors needed repair due to adult punch marks. This was not shared with any other agency, because its significance was not recognised. Housing services have made a recommendation about this issue in their agency  21 review report.  9.47. There is very clear research regarding the impact of witnessing domestic violence on children and this is now accepted in all professional fields as child abuse10. Domestic abuse cannot be ruled out in this case despite the non-disclosures by Mother. Sibling 1 indicated this in his disclosure at school.  As Mother denied this when challenged it would have been very difficult to evidence and support.  It is less clear in research and less well understood by some professionals, of the impact of other displays of irritability and aggression. There is some research11 to suggest that displays of anger appear to be stressful for young children and that if that anger becomes physical then the level of stress increases.   9.48. The GP practices involved from when Father’s accident occurred had comprehensive information detailing the behaviour that Father was displaying and that was causing issues at home. This did not lead to any understanding of the impact this was having on any children and any risk. All family members were registered at the same practice throughout the period under review. The GP practice also had some information that this aggression was not unique to post Father’s accident.  The reasons for the previous referral from the GP to the mental health team, along with the outcome was documented within the GP records. This was not shared with others.   9.49. The reasons cited that the GP practice did not assess the impact of the information that they were in receipt of, was that none of the letters indicated that the GP was required to do anything with this information. The author would challenge this as the GP practice was the only place that had details that this patient was a father who was displaying historic and current anger. This should have been recognised and information should have been shared. It was argued by the author of the GP Agency Review, that it would not be possible with the number of patients and time constraints to have acted on this information without a clear mandate to do so from those sharing the information. Those who wrote the letters had indicated that they would have a professional respect for the GP and would not always add instructions to their letters unless it be for a change of medication.   9.50. It is, however, the case that all those who knew this information had responsibility to share it. It appears that there are misconceptions regarding roles. The GPs have acted as passive recipients of information. Those writing letters have assumed that GPs will act on the information that they receive. It is indefensible to not understand the risk that was apparent and to at least have a conversation with the health visitor. The Children Act 1989 established that the welfare of the child is paramount and that it is everybody’s responsibility to safeguard children.  9.51. When the family transferred to a new GP practice in April 2017, they transferred as a family. On receipt in the new practice the records are read by the practice manager and any important issues are flagged to the GP. Any specific problem is coded and added to the electronic record. Records do not flag family links unless there is an identified risk (e.g. domestic abuse) therefore each record is viewed in isolation. This is a significant task as many records are copious. There does need, however                                                       10 NSPCC Domestic Abuse https://www.nspcc.org.uk/preventing-abuse/child-abuse-and-neglect/domestic-abuse/  accessed 26 April 201 11 Cummings, E. M., Zahn-Waxler, C.& Radke-Yarrow, M. (1981) Young Children's Responses to Expressions of Anger and Affection by Others in the Family. Child Development. Vol. 52, No. 4 pp. 1274-1282   22 to be a robust system of the new practice understanding the issues of new patients. Without this in place the risks regarding what may not be known to the new practice are considerable.  Single agency recommendations have been made regarding this issue.   COMMUNICATION AND COORDINATION   9.52. When there are many services working with a family it is important that each service recognises the number of other services and professionals involved, as well as their roles and responsibilities. It is also important that the care being delivered is done so in a coordinated way.  9.53. Many of the services offered to the family were health services or services allied to health. A unique feature of this case was that some of the services were being privately funded through Father’s injury claim against his employers. It was not until all the agency review reports were received that it began to become clear how many professionals were involved. Indeed, when initial reports were received it was clear that there were other services that agency review authors had not initially known about.  9.54. This leads to consideration of how services can work together more effectively. It is a fact that there could have been more professional curiosity at several points by those whose primary focus was the children. This has been explored in the previous section.   Opportunities for coordinated support in children’s workforce   Learning Point 1: Application of Professional curiosity may lead to a fuller understanding of the lived experiences of children  Learning Point 2: Accurate recording of assessments is vital for understanding risk   Learning Point 3: Professionals undertaking assessments in the ante natal and post-natal periods benefit from actively engaging with Fathers accessing and recording in records.  Single Agency Recommendation. Learning Point 4: Where midwifery and/or health visiting services are divided across organisations, effective use of shared records is vital to ensure relevant and timely information sharing.   Learning Point 5: When children talk about their lived experience there should be adequate credence given.  Learning Point 6: The impact of the system not acting on what a child has disclosed may prevent further disclosures.  Learning Point 7: Those being asked for advice should signpost and advise next steps  Learning Point 8: Defensible decision making can only be evidenced by recording decisions.  Learning Point 9: The 1989 Children Act principle regarding the welfare of the child being paramount must be adhered to by ALL professionals.  Learning Point 10: Information held by agencies that indicate risk to children should be shared regardless of how or why that information is known.    23 9.55. It could be argued that as parents did not share any information when being asked about family health by the child focussed professionals, it was not overtly obvious that Father had health issues and was being seen by a multitude of professionals. Those child focussed professionals did not recognise Father as a man who required full time care or had the issues that were being discussed in assessment of his needs in the adult focused services.   9.56. Opportunities to understand that there was more to this family than was being presented are linked to those opportunities for application of professional curiosity discussed previously. If there had been more enquiry of the family at various points, then those professionals may well have considered other levels of service and support. Frameworks for communication and coordination are aligned to the level of need of a child and family. These are set out in the WSCB Thresholds Guidance IBID. Had the level of need been assessed using all the information that was knowable, it may have led to an Early Help single agency response at level two or a multi-agency early help offer at level three according to the WSCB Thresholds Guidance.   9.57. If the disclosure made by Sibling 1 had led to a Child and Family Assessment by Children’s Social Care or an Early Help Assessment, then the above frameworks would have been applied. Children’s Social Care did not feel that this met the threshold for level four and therefore was not opened for assessment; Mother declined Early Help.  This should have triggered a challenge and possible escalation.   9.58. It has been identified in a previous SCR in the locality, that the Thresholds Guidance is clear regarding a parent refusing an Early Help offer.  This should be discussed and considered as to whether the needs of the child would escalate which would then result in a referral to Children’s Social Care.   9.59. As it was, this did not happen and therefore the opportunity for coordinated support was missed. One of the reasons that this did not happen was highlighted at the workshops. Staff from School 3 indicated that they have many children who make disclosures in their setting. This has led to the employment of a full-time family support worker. They have the facilities to support families and children. Sibling 1 was being monitored and supported. They also saw a positive response from Mother and this lessened their concerns. School staff indicated that they may not always get that reaction from parents so this again added to their reassurance that all was well. This meant that escalation and challenge to Children’s Social Care was not seen as necessary.   Opportunities for coordinated support in Adult’s workforce  9.60. The reasons for not identifying risk in the adult workforce were discussed in the previous section. There were several opportunities to identify frameworks for communication by those working with the adults. Even without the complexity of any risk to the children, there were many professionals working with the adults that required more robust communication.   9.61. Adult Social Care perceived that the Independent OT was the main coordinator of care and therefore did not take a lead role. The Independent OT states that this was a misunderstanding and that was not what the role was about.  There needed to be more communication regarding these two roles  24 that may have led to a clearer understanding of roles and responsibilities. The MDT meeting discussed below would have been an ideal opportunity to rectify this misunderstanding.  9.62. The Independent OT stated that there was no working relationship formed with the CNRT Psychologist as the practitioner left the post just after the OT became involved. The CNRT records do not indicate any contact between those two professionals at this time.  It is of note that the Independent OT stated that this changed when a new psychologist became involved.  The CNRT records indicate that it was five months after the new psychologist became involved before contact was made by the Independent OT. This was because the Independent OT believed there to be a gap in service and that the post remained vacant. In fact, the gap was two months.  Much of this information sharing from the OT was undertaken via email and telephone conversations. This information is recorded in CNRT and other records. It is therefore not easy to understand why the Independent OT was not aware of the level of physical aggression that was known to the Psychologist. The independent OT and the Independent Epilepsy Nurse saw no evidence of children who were at risk and did not have the benefit of the information that was known to others working with Father.  9.63.  The Independent OT wrote regular reports to update the GP. These are not filed within the GP record despite a consent form signed by Father being evident. It has not been possible to understand why these reports are not available in the records. The Independent OT has stated that reports were sent to the GP. The GP practice has no record of these reports.  9.64. The MDT meeting that was convened was for a limited purpose. There needed to be an earlier consideration of this meeting to include the GP, Adult Social Care, the independent practitioners as well as those from both Hospital Trusts (A and C). Use of the MDT meeting framework would have meant a much earlier sharing of information and clarity regarding information that all held. It is known that parents were presenting different issues to different professionals. This would have been an opportunity for the agreement as to who was going to be a key worker for the adults.   9.65. This framework would also have aided an understanding of the different roles that professionals were undertaking. The Independent Epilepsy Nurse and OT have indicated that they often struggle to be accepted as part of the MDT in cases where they have been instructed as part of an injury claim. These professionals offer a service that is privately funded through the injury claim but offer a professional service to the clients. It is in everyone’s best interests for all professionals to work effectively together, however they are commissioned. In fact, these professionals were having contact and supporting the whole family throughout their involvement.  9.66. It is possible that with all the information gathered, there would have been a better understanding of the complexities and the possibility of including the children’s workforce in the sharing of information.   9.67.  It has been discussed earlier in this review that there was an issue of concern by some that there is a potential for people to disengage if information is shared.  There is an acceptance now that, in this case, there should have been advice sought by CNRT from the hospital safeguarding leads. This would have enabled supporting information sharing in a way that would not alienate the family. It  25 was important for those professionals to understand the paramountcy principle in the Children Act and that the welfare of the children overrides any concerns regarding adult engagement. It is acknowledged that there were mixed messages by Mother who at times indicated that they were getting lots of help and support and at others that they were not getting the help they needed. This needed further exploration and understanding and could have resulted in finding help that was acceptable to parents. It was known that Mother was struggling and asking for help on some occasions from some professionals.   Think Family  9.68. Whilst the frameworks above (Thresholds Guidance and MDT meetings) were not applied for the reasons stated, what was required was a whole ‘Think Family’ approach. This further framework could have provided a more coordinated approach across those working with the parents and the children.   9.69. The Think Family framework12 was originally identified as a useful toolkit when working in cases where parental mental health was an issue. It has been recognised that this framework is useful when it is identified that any issues affecting parents result in services working with adults (e.g. physical health, learning disabilities etc.). This framework recognises that no parent or child exists in isolation and that when an issue affects an adult it has an impact on the child and vice versa.   9.70. Think Family approaches can support all those offering services to each member of the family to think about the services as a whole family intervention. This ensures that information regarding service levels and interventions are shared. The model recognises that there may be risks and vulnerabilities in families who have additional needs but also that there are often protective and resilience factors that can be built on. This framework, if used, could have included an assessment of the role Mother played as a carer to understand if this provided protective and resilience factors or if in fact this was an added stressor. The needs of both parents would have been considered by use of a Think Family approach.   9.71. In this case, it was of concern that those working with the children had no knowledge of the brain injury and seizures that Father was experiencing and the cited anger and frustration. A Think Family approach would ensure that all services working with various family members were in touch with each other.  Services could then be offered cognisant of all the other services. This would ensure that there was no duplication of, or gap in support being offered to the family. More importantly, the family themselves would be very clear on who was undertaking what role, where their support was coming from and who was coordinating that support. Identification of strengths and resilience factors would also have helped the family as well as professionals to realise where the positive aspects lay.  9.72. Using a whole family approach could have led to wider MDT meetings that would include the children’s workforce alongside those working with the adults. It could be argued that this might have                                                       12 SCIE 2014 Think child, think parent, think family: a guide to parental mental health and child welfare http://www.scie.org.uk/publications/guides/guide30/files/guide30.pdf    26 commenced as far back as Father’s discharge from hospital.  9.73. It is recognised that it would be unusual to include those working with a child and family in the discharge of an adult.  This case, however, was unusual in the complexities that the family were facing. At the very least it would have shown the family that their needs were being considered and that they were receiving a coordinated and seamless approach to having those needs met.   9.74. A recent SCR in the same locality identified that Think Family approaches are not well embedded in Walsall. Further recommendations are therefore made within this review.  Professional curiosity and authoritative practice: The role of supervision  9.75. A clear theme that has emerged within this review is the lack of application of professional curiosity. This theme though, is broader than that.  9.76. Previous studies regarding learning from SCRs, the more up to date Triennial Analysis of Serious Case Reviews13  and Lord Laming in his review into the death of Victoria Climbié14, have indicated that it is important to maintain a respectful uncertainty of parents.  It is suggested that it is possible to do this without affecting the professional/patient/client relationship.   9.77. It is noted in these documents that serious case reviews often feature families that are of a complex nature with multiple vulnerabilities that emerge over several years. SCRs also often feature cases where the children and family are being seen by multiple professionals in multiple settings across different localities. This SCR has all those features.  9.78. In order to ensure that assessment is able to be comprehensive, robust and is child centred, professional curiosity is needed whilst maintaining a healthy scepticism of the issues that are being presented.  Sidebotham (2013)15 identified that this is only possible if professionals are able to adopt authoritative practice. This authority comes from competence and confidence whilst practising.  It requires empathy to keep the child at the centre whilst considering the needs of the parents. This then necessitates humility from professionals who are willing to accept the limitations that they may have in their knowledge and skills to seek advice, supervision and guidance.  9.79. Agencies therefore need to promote a culture of authoritative practice and provide the systems and mechanisms of training advice and supervision. In this case, it can be argued that there were no ongoing overt child protection concerns leading to a lack of seeking of advice and support. In agencies where those cultures are in place and there is clear support and mechanisms for robust supervision and training in child protection, these skills are transferrable to all practice.  This supports practitioners to apply the skills that are needed to sift through the myriad of information. This may have enabled professionals to see that Charlie and siblings were at risk of harm and required protection.                                                        13 Peter Sidebotham et al. (2016) Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014 London, Department for Education 14 The Lord Laming, (2003), The Victoria Climbié Enquiry   15 Sidebotham, P. (2013) Authoritative Child Protection. Child Abuse Review, 22(1): 1-4    27   10. Good Practice  10.1. This case featured a plethora of good practice from knowledgeable and dedicated practitioners that have been included in the body of the report where appropriate. Further good practice was identified as follows:   In the main agencies followed their own procedures.  Those working with Father ensured the GP was appraised of the issues and progress.  Domestic abuse routine enquiry appeared to be well embedded in health visiting and midwifery services.   Action contained within a letter to the GP regarding Father’s needs were followed up with a consultation with Father.  There were elements of good record keeping in several services.  Adult Psychology Services and Independent OT arranged a MDT meeting.  Concerns regarding the family from Adult Social Care and School resulted in contact with Children’s Social Care.  The family were supported with housing needs by various professionals.  There was a key worker in school for children and time set aside for children to talk.  GP records show aspects of the voice of the child in documenting how sibling 2 appeared when presented at the practice.  11. Conclusion and Learning  11.1. Charlie was the youngest of three children whose Father had suffered a brain injury fifteen months before Charlie was born. Father was a man who had struggled to manage his anger and had a history of violence to others. This was not known to the majority of professionals working with the family. Those that knew of his current anger issues largely attributed them to his brain injury. It is fair to say  Learning Point 11: Application of Thresholds guidance ensures that services are offered according to level of need.  Learning Point 12: Professionals need to ensure that Thresholds are applied effectively. Decisions that appear to be at odds with what guidance states must be challenged.   Learning Point 13: Where there are many professionals involved, there is a benefit from ensuring MDT meetings take place at the earliest opportunity and are inclusive of all professionals involved.  Learning Point 14: ‘Think Family’ frameworks ensure that the needs of the whole family are considered in light of what is known by all. Think family frameworks prevent professionals working in isolation.  Learning Point 15: Effective supervision and training can support a culture of authoritative practice. Learning Point 16: Children and families benefit from inclusion of all health and social care professionals in communication and coordination of support regardless of how they are commissioned.     28 that there is every possibility that his anger and frustration became more intense as a result of his injury and ensuing seizures.  This was, however, not a man who became angry following a brain injury but man with anger and violence issues in his past who went on to suffer a brain injury.   11.2. What Charlie and his siblings needed to stay safe, was a comprehensive package of support that was coordinated and communicated to all involved with the family. Charlie needed to have parents supported to offer the best care that they could in the circumstances.  The effects and impacts of the stressors on them needed to be understood by thorough ongoing and dynamic assessment of need.  Risk needed minimising by assessment of vulnerabilities; resilience factors needed recognising and increasing.  11.3. By using the Terms of Reference and the model put forward in the Triennial Analysis of Serious Case Reviews (depicted in Appendix Two), it is possible to draw conclusions and learning in terms of ‘Pathways to Harm and Pathways to Protection’  11.4. The events leading up to the injuries to Charlie are unknown by professionals and therefore it is difficult to identify exactly which focus might have provided more insight into Pathways to Harm.  11.5. In terms of Pathways to Harm model, it can be identified that the background context of Charlie’s family was initially one where Father had a history of anger and violence. They were initially a couple  with an older child of Mother’s from a previous relationship expecting their first baby together. What is very clear is that the vulnerabilities increased as time progressed.  Father’s accident happened when Sibling 2 was four months old. From that time, mother became a carer and vulnerabilities for the children increased.  Charlie was then born which created increased pressure to manage Father with his anger issues and a new baby. Application of systems to aid prevention and protection related to these vulnerabilities was required.   11.6. The thresholds for intervention were not fully understood and applied.  This was because the full extent of the vulnerabilities had not been assessed therefore risk was not understood across those working with either an adult or a child focus. The identified level of need remained at Universal (Level 1) rather than Early Help Additional Support (Level 3) or Complex Needs (Level 4).   11.7. The system of a whole ‘Think Family’ approach was not applied by any professionals.  This too has preventative and protective factors within it as it encourages all those working with both adults and children to offer a coordinated service and a sharing of information. Those working with the adults did not understand the whole family approach and therefore worked independently of those offering services to the children.   11.8. This review found that there was a wealth of information about Father and the struggles that Mother was reporting but very little information about the children. The focus within this family was very clearly on the adults and not the children for the reasons that this review has identified.   11.9. Most of those working with the children as their focus were not aware of the head injury to Father and therefore could not effectively assess the vulnerabilities. In part, this was because parents did not disclose anything regarding Father’s health to those professionals.   29  11.10. Vulnerabilities were not discussed in a multidisciplinary forum. This meant that all professionals had elements of information that they knew but that were not known to everyone else. Had information been shared in a coordinated manner it is possible that the risks and vulnerabilities may have been viewed holistically. This may then have led to a multi-agency package of support to wrap around the family.  This package should have had the needs of Charlie and siblings as the central focus i.e. provision of safe and effective care from both parents.   11.1. Professionals did not display authority in their practice when considering the needs of the children, this led to a lack of professional curiosity, empathy to seek the voice of the children and ultimately the services offered to the family remained at the wrong level to deliver the protection from harm that Charlie and siblings needed. 12. Recommendations  12.1 This Serious Case Review has identified several learning points. WSCB will include all of these learning points with a synopsis of the case in their ongoing learning and improvement briefings. These will provide valuable information for use in training and supervision as well as a topic for agendas within individual safeguarding committees and wider workforce briefings.  12.2  The issues raised within this Serious Case Review are similar to those found in a previous SCR in Walsall and that are also found nationally.  WSCB therefore need to understand more deeply how these issues can be embedded in practice.   12.3  Two other Area LSCBs have agencies that were involved within this review. WSCB will need to ensure that relevant learning is shared with those Boards  12.4  Issues regarding Thresholds and associated decision making are being addressed in ongoing work related to improving and enhancing the Multi Agency Safeguarding Hub processes and responses. Further recommendations are therefore not made here.   12.5  The main themes that arise appear to be ones of the culture within organisations regarding two main areas:   Think Family  Authoritative Practice and Supervision  In order that the learning can be addressed both of these areas need specific programmes of activities to improve and embed a culture where these become the norm in practice considerations.  Activities on both of these areas need to cover the Child and Adult Workforce who work with families. Elements should consist of:   1. Ensuring Guidance is available, up to date and relevant 2. Mandatory Safeguarding Children training is Multi Agency and includes Think Family and understanding of authoritative practice. 3. Supervision in agencies evidences supportive respectful challenge of these areas. (Multi-agency Safeguarding Supervisor Training should be considered)  30 4. Ongoing safeguarding audit programmes of Board and within agencies include these issues.  5. Appreciative enquiry is used to identify good practice both at Board and within single agency safeguarding/board meetings/staff meetings (as relevant to each agency).    31 Appendix One:   Terms of Reference and Planning Document  1. Introduction  The request for a Serious Case Review was agreed by the Independent Chair of WLSCB on 26/09/2017.  Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 sets out the functions of LSCBs. This includes the requirement for LSCBs to undertake reviews of serious cases in specified circumstances.   Regulation 5(1)(e) and (2) set out an LSCB’s function in relation to serious case reviews, namely:   5(1)(e) undertaking reviews of serious cases and advising the authority and their Board partners on lessons to be learned.   (2) For the purposes of paragraph (1) (e) a serious case is one where:  (a) abuse or neglect of a child is known or suspected; and  (b) either — (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child.   Serious Case Reviews and other case reviews should be conducted in a way in which :  recognises the complex circumstances in which professionals work together to safeguard children;   seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did;   seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight;   is transparent about the way data is collected and analysed; and   makes use of relevant research and case evidence to inform the findings.    (Working Together Chapter 4 para 11, March 2015)  2. Case summary  Charlie is the youngest of three children and lived at home with parents and siblings. Charlie  was left in the care of father along with one sibling.  Mother and other sibling were absent from the home address.  Whilst in the care of father Charlie has suffered significant catastrophic injuries that are presently being linked to shaken baby.   Charlie was initially cared for in the ICU and was supported on life support. long term prognosis was poor and medical professionals indicated that CHARLIE would not survive the injuries. Following consent from the family, the life support was discontinued on and Charlie died.  Father is being treated as a suspect in relation to this investigation.  Father had previously suffered a significant head injury as a result of an industrial accident that resulted in him being disabled with a support and rehabilitation plan implemented and supported by adult social care.    3. Scope of the Review  The review will consider agency involvement with Charlie, siblings and parents from September  32 2014, (the start of the School Year just prior to mother’s pregnancy with second child), until the date of the serious childcare incident, unless there is specific relevant information post incident.   4. Methodology  This Serious Case Review will be undertaken using a hybrid methodology that will analyse the complex circumstances that practitioners work in and provide opportunities for shared learning and lead to improvements in the way in which agencies understand their roles and responsibilities and work together to promote the safety and well being of children. Agencies will be asked to review their own involvement with the family and to produce an Agency Review Report. This will be followed by the sharing of the written material in order that learning can be shared in and analysed taking into account the view of the professionals that were involved at the time. This process will involve 2 round table Practitioner Reflection and Learning Workshops to ensure practitioner and first line manager involvement in the review. This methodology takes into account the requirements in Sec. 1 above.  5. Areas of consideration to be addressed by all agencies:  Agencies will be required to use the Agency Review Report Template provided. The report should be written for publication without the need for redaction.   In addition to the scoping period, agencies are asked to provide any relevant background information that they consider will be important in setting the context for the later family situation.   a. Please critically evaluate the quality of known information, assessments and decision making. Was the risk to Charlie fully understood and acted upon? How was the family history incorporated into assessments (including any knowledge of domestic abuse)?   b. Please analyse the actions taken and the support that was put in place for the family following the accident to Father.    c. Please comment on the assessments that were undertaken in relation to father as a parent and partner? What support network was there to support the family and how was this assessed and understood?  d. What preparation, assessment and planning was undertaken during the pregnancies in the scope of this review?  How well was this communicated to other professionals?  e. Please comment on assessment, planning & support regarding the implementation of the rehabilitation for Father. How were the needs of the children incorporated into these plans?  f. Did practice within your service meet the required standard in this case? (Please expand on your answer providing evidence).  g. Please comment on liaison between professionals and record keeping in the case generally. h. Please identify examples of good practice, both single and multi-agency. 6. Agency Review Reports are required from the following organisations/agencies:   Hospital NHS Trust Area A:  33 o Health Visiting o School Nursing o Midwifery o Other hospital Departments e.g. Out patients and A & E in respect of Charlie, parents and Siblings. o Any service associated with Father’s healthcare and rehabilitation post-accident.   General Practitioner (via Clinical Commissioning Groups) for siblings and parents   The Mental Health NHS Trust   The Metropolitan Borough Council  o Children’s Social Care o Children’s Centres/Early Help o Education o Adult Social Care   Police  Housing   Ambulance Service  Occupational Therapist and any other professionals appointed by Injury Solicitors   7. Family Engagement  An important part of a Serious Case Review is the involvement of family members so that their thoughts and viewpoints can be incorporated both to the review itself and any learning. The Board will need to consider the appropriate point at which to inform the family of the review that takes into account the current circumstances. The overview author will make contact with relevant family members once authorised. The family will be offered feedback at the end of the Serous Case Review process.  8. Overview Author  Walsall Safeguarding Children Board have commissioned Karen Rees, an Independent Safeguarding Consultant from 402k Consultancy Ltd. to undertake this SCR  9. Timeline for Review (NB Due to severe weather the first Workshop had to be reconvened hence delays ensued)   Safeguarding Board decision and commissioning discussion  26 September 2017 Scoping Meeting 9 November 2017 Letters to Agencies/Authors etc. 14 November 2017 Authors’ Briefing 1 December 2017 Agency Reviews submitted to WSCB 15 February 2018 Quality Assurance of Agency Reviews by Lead Reviewer                           16-18 February 2018 Agency Reviews distributed 19 February 2018 Practitioner Learning and Reflection Workshop (Whole Day)  2 March 2018  19 April 2018  34 1st Draft of Overview Report Distributed to all attendees 6 April 2018 17th May 2018 2nd Review Learning and Reflection workshop (½ Day)  19 April 2018 (AM)  24 May 2018 V2 Overview Report Distributed to all attendees 27 April 2018 8 June 2018 Comments on V2 latest by  4 May 2018 15th June 2018 Version 3 to SCR Sub Group members TBC  Final Draft Overview report presented to SCSIC Subgroup and/or LSCB (arrangements tbc) 26 September 2018       35 Appendix Two: Pathways to Harm; Pathways to Protection    